Category: Therapeutic Issue

A Universe Opens: Reflections On My First Session as a Therapist

Posted on by Psychotherapy.net Team

“Know all the theories, master all the techniques, but as you touch a human soul, be just another human soul.” —Carl G. Jung

As I stare down at the piece of paper holding a few clues to the vast mystery that will be my first-ever client, I feel a universe come into existence, a wide expanse full of potential and possibilities. The past year-and-a-half of didactic and experiential training has culminated here, in this very moment. All that I had previously read and thought about were finally lifting off the pages, out of my mind, and into the here-and-now in the form of a dynamic, real-life therapist-client relationship. As Sanmao, a Chinese feminist writer, put it, “What I learned on paper, I felt, was knowledge that had not yet been tested.” There I was — hours away from testing the knowledge I’d accumulated on a real-life, non-pretend client—sitting in the tension of opposing “what ifs:” “What if I forget everything I learned?,” “What if I’m terrible at being another human soul?,” “What if the theories are wrong?,” “What if none of the theories are applicable to me, or the client?,” “What if the theories are right?,” “What if it actually works?!”

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To alleviate some of the angst-citement—a cocktail of angst and excitement I was feeling, I decided to reach out to a handful of therapist friends—some licensed supervisors, some only a few months ahead of me—and solicit tips they might offer an intern who was about to go into their first-ever session, things they wish a mentor had told them as they were stepping into their role as a therapist for the first time. Here’s a mosaic of what they shared:

  • Check your excitement and adrenaline at the door. As exciting as it is, you are ultimately there for them.
  • Be genuine and be yourself. You don’t need to be a blank slate or do anything to prove yourself. If you’re an expressive person, allow yourself to be expressive!
  • Relate to the patient and be kind. If nothing else, focus on making yourself and the client comfortable. Validate however the client shows up in the therapy session—there’s no such thing as too much or not enough. Follow your curiosity and get to know them.
  • Ask them what they want to work on or change in their life, and then work on what they are ready and willing to work on.
  • Sit with them in their feelings. Don’t try to make them feel better. Instead, help them better feel by exploring and understanding their feelings.
  • Give them permission to feel. You can say, “I imagine if I were in your position, I might feel… Do you feel any of that?” This helps them feel less alone for something they might be feeling but are unable or afraid to name.
  • Don’t be afraid to create space. If you get flustered and don’t know what to say, you can say, “I just want to sit with this for a second before deciding where to go next or what else to explore.” You can also say, “I don’t know where to go from here,” and ask them if they have a sense of where they’d like to go next. Silence doesn’t always need to be filled. Space is comfortable and useful when it is intentional, and we make it intentional by acknowledging it: “I want to take a breath around that before saying anything. That’s a lot that you’ve been holding.”
  • Less is more. Provide a space for them to share. Bear witness to their unfolding. You don’t need to interpret, fix, advise, or do much.
  • Help your client cross the river by feeling the stones. Set small, achievable goals so they feel like progress can be made.
  • Take a moment to remember it afterwards. It’s your first one, and that’s exciting!

***

Upon wrapping up my first session, I felt a tremendous sense of relief—relief that my client hadn’t asked me whether this was my first session (though if they had, I was prepared to say something along the lines of, “If it were, what does that bring up for you?”), and relief that I’d made it to the other side of what felt like a tipping point in the evolution of this career and calling. Reflecting on the random scribbles I’d made during the session, a few twinkling stars began to emerge against the dark expanse of a nascent universe—the dawning of a new constellation, of a new relationship, with all its mystery and magic.

Laurie Helgoe on the Power and Challenges of Introversion

Posted on by rezendevknowfully.com

An Inner Laboratory

Lawrence Rubin: How would you, as a person, a clinician, a researcher, and a writer, define introversion?
Laurie Helgoe:
if you think of where you do your processing, where you work things out, where your laboratory is—it’s internal for an introvert
Introversion at its simplest is an inward orientation. If you think of where you do your processing, where you work things out, where your laboratory is—it’s internal for an introvert. In contrast, the extrovert’s laboratory is more external, and this difference translates to a lot of things. Introverts go inward to think things through. If there’s a question to be answered, like the one you just asked me, I might pause and kind of go inside myself to try to work out the answer before I speak. An extrovert might do that work interactively by giving you a partial answer and then engaging you in a back-and-forth until that answer is fully worked out. There’s not one “right” way, but the challenge for an introvert is if there’s not that space to go inside.

So, there’s a lot that goes with that. Many introverts talk about feeling energized through solitude. Part of that is just because they don’t have anything intruding on their thought process and kind of relax into it more easily.
LR: Being energized through solitude is interesting because we seem to live in a society in which we’re taught, or encouraged, or modeled, to seek energizing through connection, through activity, through accomplishment, through the immediacy of social media. So does that inherently place introverts against the current in our society?
LH: I think so, and that is why many introverts end up feeling bad about themselves or feeling that there’s something wrong, because we have these portrayals of the fun in life, the energizing aspects of life, as being social. I remember when one of the major phone carriers had this “friends and family” ad where one person was surrounded by this mob of people. That just sold me because it did just the opposite of what it intended because that looked like hell to me. Somehow, having that easy connection with this mob of friends and family was supposed to be what people wanted. And then when I think of the sitcom Friends, which just had a reunion show, there was the idea that people could just randomly pop into my space and I would always enjoy having them on the couch.

I think there are a lot of ways that introverts wonder things like, “Why aren’t I having fun at this party?” and “Why can’t I wait to get home and have what is considered fun for me?”
None of that fit for me, so I think there are a lot of ways that introverts wonder things like, “Why aren’t I having fun at this party?” and “Why can’t I wait to get home and have what is considered fun for me?” And in their case, that would mean getting back to a great book, or walking their dog, or just reading with space around them.
LR: I go back to that interesting analogy you made of the introvert having this internal laboratory. Is that contrasted with the extrovert, whose laboratory is the stage rather than a private enclave, and if so, does the introvert shy away from the public stage because that’s not where they process and how they process?
LH: Right. That’s an interesting question, because I happen to enjoy acting and I’m an introvert. But I think, and this is what reveals the complexity of introverts and extroverts, is that each may have different aspects, different ways in which people are introverted or extroverted. For example, public speaking is a common fear that is not confined to introverts. There are many extroverts who are terrified of public speaking despite the interest in and programming for obtaining external rewards—to get those smiles, to get those responses from others. In fact, there are dopaminergic pathways that reinforce external rewards, and these light up for the extrovert when they are socially stimulated.

I think introverts like me who enjoy the stage like teaching, acting, and performing in front of others, and particularly like the fact that they can do it in a structured way
There are fMRI findings and studies which show that introverts respond pretty much the same to images of flowers or people, whereas extroverts are very much more responsive to people-related stimuli. But while these positive, people-related stimuli can engage extroverts, they can also distract them from seeing the whole picture. Extroverts can in a way distort reality toward the positive because they really like these people-related rewards. It would be an extroverted kind of characteristic for someone to like the stage. That said, I think introverts like me who enjoy the stage like teaching, acting, and performing in front of others, and particularly like the fact that they can do it in a structured way, one that they planned and practiced for as opposed to being put on the spot. This is because when introverts are put on the spot, they don’t have time to go to their laboratory.

Misconceptions

LR: I’m fascinated by the notion of the inner laboratory—it has almost an Eastern sound to it. This makes me wonder if the so-called “extrovert ideal” is more of the dominant Western narrative, and that the benefits of introversion have only recently been recognized along with mindfulness practice and the integration of Buddhism into the clinical landscape.
LH:
in Eastern cultures, it can be the opposite, where extroverts are seen as a little weird or really out there
It’s so interesting you raise that, because there has been a lot of research suggesting just what you’re saying, which is that there is a very strong bias toward happiness in our culture—but a specific kind of happiness. Even the studies that have shown extroverts to be happier only tend to look at one facet of happiness, which is a high arousal-positive affect. But the research doesn’t look at low arousal-positive affect such as feeling tranquil and at peace, the chill feelings that are more valued by introverts. And so, you have this kind of culture-personality mismatch, which can lead introverts to feeling badly about themselves. In Eastern cultures, it can be the opposite, where extroverts are seen as a little weird or really out there. And there’s a puzzlement about this so-called American (extrovert) personality. So yes, I think there is some balance that is slowly being introduced as we look toward and value more contemplative practice in our society.
LR: Since we are this doing-connecting-running-accomplishing-externalizing type of culture, what misconceptions do clinicians need to know surrounding introversion and the introvert, such as the introvert and the schizoid personality are similar?
LH: I’m sure you were attuned to this when the DSM-5 was in development, but there was a proposal on the table to include the term “introversion” in a number of diagnostic categories as an indicator, as a symptom. But there was a loud outcry to that because what really was being referred to in the DSM was a kind of disengagement, and the problem with seeing introversion as disengagement is that it’s actually just the opposite. A healthy introvert may be quiet in a conversation, although not all introverts are disengaged. There is a continuum. Oftentimes, the reason why introverts are quiet is because we ARE engaged, because we’re processing, because we’re trying to make sense of what the other person is saying rather than the opposite, which is disengagement. We may put on good poker faces so that it seems that we’re kind of schizoid or not there. And sometimes introverts do need to make the point of narrating our process. Saying “Yeah, I’m thinking about this, just give me a second.”

so this idea that introversion is a pathological indicator is extremely problematic
So this idea that introversion is a pathological indicator is extremely problematic. I think most people who study introversion and extroversion see them as neutral categories and that there can be problems associated with either. If we look at mental health disorders, some of the impulse control disorders like substance use are more prevalent in extroverts, whereas for introverts, the internalizing disorders like depression and anxiety can be more prevalent.
LR: I am reminded of the Achenbach scales, which suggest that the externalizing disorders are more typically relegated to men and the internalizing disorders, like depression and anxiety, are more common among women. So, I wonder if there is a gender line that also contributes to the introversion/extroversion schism?
LH:
women have a harder time getting permission to be introverted
The gender differences aren’t as great as you might think. While I don’t have those figures right in front of me, one thing that’s notable is that women have a harder time getting permission to be introverted. We tend to think of the man as the strong, silent type, whereas a woman might just be considered the B-word or a snob if she’s not engaged. We have a lot of expectations on women to be the social kind of glue in our society. I think actually men are a little bit more prevalent in terms of the numbers, but they are not that different.
LR: I think I might have jumped ahead of myself. Can we go back and discuss other misconceptions around introversion?
LH: So, I think one is that there’s some kind of pathological disengagement. Another one is that introverts are shy, which is probably the most common misconception. While introverts can indeed be shy, so too can extroverts. The way that introversion is classically understood is that we are internally oriented, and our social way of engaging may be a bit different. We like a little more space in our interactions. We probably like fewer people. But all of that comes back to the level of stimulation. And I think of Hans Eysenck's level of cortical arousal and the idea that the sweet spot for everyone is in the middle, where we’re not too stimulated and we’re not bored. But extroverts tend to get cortically bored. They tend to crave more stimulation, so they’re trying to move in the direction of more stimulation to get to their middle, whereas introverts are trying to tone things down more to get to their middle.

So, for example, I’m at a party and I’m with a shy person. I, being pretty socially introverted, might be hanging on the sidelines because I kind of like being there. And there’s probably somebody there who’s a little quieter who I might want to talk to. I might really enjoy observing or just taking a break. A shy extrovert standing next to me might really, really want to be in there and just doesn’t know how. There might be a lot of self-consciousness and that kind of thing. Now again, these variables can overlap, but I think it’s much more helpful to see them as separate.
LR: This may be the pushy extroversive side of me, Laurie, but can you think of any others before we move?
LH:
there’s even a misconception or assumption that introverts really don’t have a personality—you know, that they’re kind of bland
Another one is that introverts are snobs. And this again might be due to the poker face. In the U.S., we love smile emojis, and we expect this very exuberant, outward-oriented evidence that a person is engaged, or present, or responsive. And if we don’t get that, the readiness is to assume that that person maybe doesn’t like me or is non-approving and stuck up. There’s even a misconception or assumption that introverts really don’t have a personality—you know, that they’re kind of bland. But if you just took a peek inside the laboratory, you’d find otherwise.
LR: I don’t know if this is a misconception, but there’s been a little bit of buzz in the literature about the overlap in some ways between introversion and autism. Is that a dangerous connection to make clinically?
LH: I know there has been talk that introversion is like [what used to be called] Asperger’s. I think if it helps us understand the autism spectrum in a different way, it may be useful. But I don’t know that it is the case and honestly, I haven’t gone that direction myself because we’re trying to link something up that may not be helpful and could be quite the opposite.

I’m all for the direction of us de-pathologizing most things, right? I think there is agreement around communication difficulties associated with autism spectrum disorders and there may also be some for some introverts. There may be some ways in which the spectrum would explain some aspects of their behavior.

LR: I can see what you’re saying in terms of this societal tendency to pathologize anything that’s considered different. We just tend to “other” the hell out of each other, so clinicians need to be very wary of looking for or building connections between introversion and pathology or problematic issues based upon misconceptions.

Introverts and COVID

LR: How did introverts fare during the isolation and social distancing of the COVID pandemic—heaven or hell?
LH: In fact, I was just looking at some recent findings on that, and introverts did for the most part thrive, although there certainly are variations. While extroverts had a hard time, with reported deterioration in their mental health, there were certain challenges that isolation created for introverts. Surprisingly, there was a time in history where all of a sudden, introverts were being asked, “How do you do this? How do you manage being alone? How do you manage this?” So, if nothing else, I think there was a sense that what we have is valued and has survival value—because we did. We all were safer because people stayed in their zones because they were able to socially distance themselves and to spend more time alone.
LR:
so, during this time of forced isolation, those who have historically been quite fine with solitary and internal lives became the experts in teaching the rest of society
So, during this time of forced isolation, those who have historically been quite fine with solitary and internal lives became the experts in teaching the rest of society. You mentioned the word “thrive,” and that introverts were called upon for their expertise.
LH: I can use myself as an example. I am still mostly working from home, where I teach and work with a lot of students. In my traditional face-to-face classrooms, we have an open office plan, which does not necessarily work well at all for having conversations and is overstimulating for introverts. But what is paradoxically true for me and others of my colleagues is that from home, I now engage better because I can have a conversation on-screen with a student or a colleague from the quiet of my home office. I don’t have to worry about privacy or having to find a special room because of that open floor plan. From home, I can be in a place that reflects me—we might even talk about my paintings that are sitting behind me or the view outside the student’s window, which might be snow, while I’m in Barbados. We get to connect in a more personal way because we have this home-to-home kind of connection. So I have actually found that this forced isolation has enhanced my relationships, because they have become a little more contained and kind of safe in cyberspace.
LR: Is safety a concern for introverts? And as I even ask the question, I wonder if some clinicians out there are wondering if this need for safety suggests some kind of earlier trauma.
LH:
introverts tend to be more guardians of privacy
What I mean by safety is the freedom from bombardment and overstimulation, but it can also mean the protection of privacy. Introverts tend to be more guardians of privacy, both for themselves and in relationships.
LR: Prior to COVID, I had a strict closed-door policy for that very reason, while other colleagues whose doors were always open seemed to spend far more time gabbing than working. Did you find any other differences in the ways that introverts and extroverts fared during the pandemic?
LH: One thing I know from academia is that there’s evidence that everybody’s working more since we’ve gone online. Introducing new platforms and having a lot of Zoom meetings can definitely result in social fatigue when you’re constantly on screen.

the introverts I know who have struggled the most are the ones who have extroverted family members at home
But the introverts I know who have struggled the most are the ones who have extroverted family members at home, or kids that they are locked in with and from whom they normally get a break from. I know I’ve missed some of my introvert haunts, like the coffee shop I go to work and the movie theater. I like places in the world where I can be quiet and where I can view, you know, kind of be a flâneur (I wish we had an English word equivalent). I like the idea of the passionate observer who is out and about, but not engaged in a direct way—I do get energized by that. So, I think there definitely are ways in which introverts have missed out. And certainly, we have close relationships, so it’s been very hard to be separated from family and friends, because introverts are not necessarily loners. I’ve talked to introverts who have grieved a loved one who they described as their “comfortable person.” For introverts, it’s hard work to do small talk, so we rely more on our comfortable people.

LR: And I would imagine that older people who have historically been accustomed to face-to-face contact don’t find the same level of comfort on the screen.

In Therapy

LR: I don’t imagine that people come to therapy because they are suffering from introversion. And while I was initially going to begin by asking about the challenges that introverts bring to therapy, I’d like instead to ask how therapy can tap into the strengths and resources that introverts possess?
LH:
analysis was a space where I could sort out the fact that I was at odds with the way my lifestyle was set up and how it wasn’t working for me
The first thing that came to mind when you said, “Introverts aren’t necessarily going to come in and say I’m suffering from introversion,” was that they might in some way say, “I’m suffering from society,” which is what was going on for me when I went through psychoanalysis. I talk about it in my book and how it really was the starting point for the book and for a lot of healing for me. Analysis was a space where I could sort out the fact that I was at odds with the way my lifestyle was set up and how it wasn’t working for me. It was important to finally put a name to it—that I was an introvert. I realized that I needed things that my life wasn’t providing, so I started to make some radical changes in my life.

So in therapy, you might have people saying things like they are getting hassled at work because they’re not outgoing enough, or who feel bad about themselves because they are at odds with society. It can be very, very helpful for clients to be able to put a name to it. I can point to so many people who have talked about that transformative moment when they said, “Ah, I’m an introvert. That’s why. Okay.” But, I think it typically depends on how that’s delivered.

That’s the beauty of a Myers-Briggs Type indicator, although some have criticized its psychometric properties. It really does describe each personality type in a strengths-oriented way, so people then can see themselves mirrored in that positive way. Instead of thinking that they are the problem that needs to be fixed, they have permission instead to engage in their lives in a way that works better for them.
LR: Do you ever feel compelled to point out to a client that they are introverted, or is that not always necessary?
LH: I would, and it may not even be that the word “introversion” is necessary. But I think it does help because there are a lot of characteristics that come with somebody who’s an internal processor. They might not think on their feet so well or they need space in conversations. If they have a spouse that always wants to do things or who always wants to talk, the introvert may wonder, “Why don’t I love my spouse or my partner because I don’t want to talk or do things all the time, and sometimes I want space for myself?” I might tell them, “Well, it sounds like you’re an introvert,” and they might say, “Oh, what’s that?” While most people know, I’m surprised that some people haven’t or don’t really reflect on being an introvert. I didn’t, and I’m a psychologist who didn’t really reflect on what that meant about me until well into my practice years.
LR: Do you find that it’s liberating for these clients once you tell them or suggest to them that they are introverted?
LH:
I get letters from readers all the time that say, “All I needed to know is that there really isn’t anything wrong with me, and there are other people like me.”
It’s tremendously liberating. I get letters from readers all the time that say, “All I needed to know is that there really isn’t anything wrong with me, and there are other people like me.” And there are people in our society who believe that the introvert is the rare person, kind of sitting down in the basement avoiding people, when in any given room introverts make up about half of the people in that room. So I think that knowing does shift a person’s thinking. They may finally understand, “That’s why I prefer to send an email than speaking my thoughts,” or “That might be why, after a meeting, I really feel like I need a break to think through what happened and write down some notes.” We get so much mirroring of what it means to be an extrovert, but don’t get that much about what it means to be an introvert.
LR: Would you necessarily treat a depressed, anxious or perhaps substance-abusing introvert differently than you would treat a non-introvert with similar symptomatology?
LH: I think a lot of the treatments apply well to both. But I think that for introverts, part of our treatment is to help them align their lives with what gives them joy, even though we need to be very careful about ascribing to them what we think that would be. That would be like the parent saying to the child, “You need to go out more to be with your friends,” when maybe that child simply relishes reading a book and living in this wonderful imaginative space. The parent would end up trying to pull that child out of that comfortable and happy place and telling them what their definition of happiness is. Similarly, we have to be very careful as therapists to not impose what we think the introvert’s happiness should be.
LR: I could see an overzealous introverted therapist trying to impose their expectations or beliefs on a client; sort of introversion-based countertransference?
LH:
introverts tend to be quite versatile because we bend and have to be psychologically bilingual, which is actually a strength
If the therapist had some kind of mission, that could definitely be a trap, because we do know that introverts can gain a good feeling through social engagement. Even acting like an extrovert can give you a lift. I think the difference with introverts is that it can be helpful for them to know about their introversion without feeling like they have to change who they are. Introverts tend to be quite versatile because we bend and have to be psychologically bilingual, which is actually a strength. It’s easier for introverts to act like extroverts in general than it is for extroverts to act like introverts. We saw this with COVID. It was not easy for those extroverts to flex in the introverted direction, while introverts have had to do it all their lives. Through my book and my activism, I have wanted to simply reinforce the idea that introversion is a viable option. That’s not to say that introverts have to be introverted all the time or that they won’t benefit, but the problem is that many haven’t gotten permission to be who they are in the first place. So, if you’re not who you are in the first place, how do you transcend that?
LR: Are there any other challenges or issues that introverts are more likely to bring to therapy?
LH:
maybe we introverts are entitled to a little bit of that juice that the extroverts are drinking
I think introverts, for better and for worse, can be self-scrutinizers. We are reflective. We think about our conversations. We reflect on events. And so, that may give us a more realistic view of things, and it also can induce anxiety and depression. I think this is where mindfulness techniques are so helpful—we can do that reflection without getting so attached to those thoughts and, as a result, can come back to the present. And at times, we can deliberately seek those joyful experiences and do what extroverts do. Maybe we introverts are entitled to a little bit of that juice that the extroverts are drinking.
LR: In addition to mindfulness, are there particular modalities of therapy that introverts might be more drawn to?
LH:
a very extroverted therapist who really wants a back-and-forth kind of dialogue may lose an introverted client
As an introvert myself, I always gravitated toward the psychodynamic psychotherapies in part because they provide so much space for the internal life. As number nine in a family of ten who was constantly overstimulated, I relished the luxury of having a person listen to me in a place where I got to lay back on the couch and just let my mind take up the whole room. In terms of space, that was a wonderful thing.

Not all introverts would necessarily like that. Some introverts do actually appreciate some structure or inquisitiveness from a therapist. I think that a general rule is that when working therapeutically with an introvert, there needs to be a certain level of patience to let the client consult with their inner laboratory and find out what they’re thinking. A very extroverted therapist who really wants a back-and-forth kind of dialogue may lose an introverted client.
LR: What about the opposite situation in which an introverted therapist has a very extroverted, performative, gregarious, energetic, over-stimulating client?
LH: I’ve actually had to contend with that because for me and a lot of introverts, interrupting is taboo. But some extroverts expect to be interrupted. They kind of like just letting go and knowing that you’re going to get your word in whether you want or not. Some extroverts love talking to introverts because the introvert gives the full space. But the introverted therapist may also have to be more active than they prefer with that type of client.
LR: I closed my physical practice a few years ago. It was so highly personalized, and some might argue overstimulating. If you were to be a consultant for designing therapy spaces for introverts, what tips might you offer?
LH: I love that question, because I think it’s a neglected one. One thing is that introverts are already likely coming into your office over-stimulated. If you have bright lights and a lot of clutter in your office, you’re probably not going to have somebody who’s going to be very able to settle into the space. I am very attentive to lighting so have a softly lit space, and because some introverts may not always want to make eye contact because they have to think and because sometimes our eyes will distract them, I do have some things that allow the patient or client to look away from me. They want to be oriented towards you. Introverts tend to be very absorbent of what’s going on around them. And so, they almost need to close themselves off. So, not facing the chair directly at them is helpful—kind of fanning them out so that the client can look off and go inside instead of always looking at you but can also easily enough look over at you. That kind of thing can really make an introvert feel more comfortable and open in this space.
LR: Maybe we can go into the office setup-for-introverts feng shui business.
LH: Love it.

Introverts at Home

LR: Do introverted parents bring unique challenges to therapy?
LH:
parents don’t often give permission and encouragement to help their child develop solitude skills
I do think parents feel a lot of pressure, from the whole playdate revolution, to having the most fun birthday party. I remember, and say this with a little bit of shame, but I was always relieved after Halloween was done because there was this pressure to create the best costume. One thing that I always note is that parents feel such a responsibility to help their child develop social skills, and certainly that is an important coping mechanism. But parents don’t often give permission and encouragement to help their child develop solitude skills. We can’t always entertain them. And if we are, we are developing a child who doesn’t have much resilience, because the reality is, we’re going to be alone for a good part of our lives. So, I think that it is important to help both introverted and extroverted parents foster that quiet space for their child(ren).

I remember the psychotherapy theorist, I think it was Fred Pine, who talked about the importance of quiet pleasures. Winnicott also talked about that. I like the idea that the child and you can be doing parallel things in this quiet space, and that child internalizes the ability to be alone, because they learn that they can be alone together. They learn that there is a sense of somebody who can tolerate their aloneness, which I think is such a beautiful but rare thing in parenting. That we can just do nothing together?

I was just watching the movie Christopher Robin. I love the way that Christopher Robin and Pooh talk about doing nothing because when you do nothing, something happens. I love when somebody asks me what I’m doing, and I say nothing, and then I do it. It is the idea of the generative, the fertile void. The way that boredom is a precursor to creativity. So I always ask, are we allowing kids boredom? If parents took some pressure off themselves to stop entertaining kids, kids might paradoxically end up being more self-entertained.
LR: I just wrote the introduction to a friend’s book on nature-based play therapy, and as we chat, Richard Louv’s work on the importance of nature in child development rings so loudly in my ears. I think kids (and adults) need to be in nature where there is quiet, and there is awe, and there is, like you said, an external space where they can be internal.
LH: Yes. I find for myself that having an evening walk when things are quiet is when I do feel that the laboratory is wide and vast, and I don’t have to tuck it away.
LR: Moving from parenting to relationships, what challenges have you found working with couples who are mismatched temperamentally?
LH:
an introvert/extrovert couple are going to have more conflict if they are going to be close, because they need to negotiate
I think there are a lot of introvert/extrovert couples that do quite well. But knowing from experience, an introvert/extrovert couple are going to have more conflict if they are going to be close, because they need to negotiate. So, if the extrovert wants to go out and be with friends, how often will the introvert be willing to do that? The introvert may indeed want to go to a movie or just have a quiet dinner or just stay at home and read together, which is a legitimate date, in my opinion.

There can be real advantages to that, because we might appreciate at times being pulled out of ourselves. Or pulled in, pulled back from ourselves. And so a couple that represents both those functions can become flexible in that way. What I notice is that there may be more of an ease in introvert/introvert couples. But that may also come with a lesser growth curve. The other thing can happen, though, is like with systems therapy, where one plays more of the function of introvert or extrovert. So, you have all different variations on the theme. But I think that naming this process becomes important in clinical work with couples, especially if their temperaments put them at odds. It took my husband and I twenty-five years and the writing of my book to discover that when I’m quiet, I’m not telling him he needs to explain things more.
LR: Or that you’re not withholding something from him or pushing him away.
LH: Instead, that he has been understood, and that I’m not telling him that I am disengaged. I’m actually thinking about what he says. So now when I’m quiet, he’ll say, “Oh, you’re thinking about it, right?” And I’m like, yes.
LR: So, your book in part was a marriage survival guide for yourself?
LH: Yeah, it’s very interesting to me that after writing the book, I found applications in my own life that I hadn’t yet discovered.
LR: Well, you probably were aware of those, but not consciously because you’re an introvert. They were bubbling up in some beaker deep in the back of your laboratory.
LH: There you go.
LR: As we come to an end, Laurie, what would you leave those clinicians out there who haven’t yet given too much thought to this whole introversion/extroversion area with?
LH: I think that we all benefit from having a richer world. And we have a richer world when we can embrace the internal and the external. I think too often we don’t, and we aren’t curious enough, or wait long enough to find out. I find in teaching interviewing skills to medical students that if they wait just a little bit longer, they’re going to find the story, the punchline, the meaning that, if they had spoken two seconds sooner, would have been missed. So keep in mind that the world is vast and wonderful out there. But it’s also vast and wonderful in there.
LR: If there are any questions that I wasn’t clear on, can I reach out to you after we finish today?
LH: Absolutely, because as an introvert, sometimes things get clearer later on.

Counseling Gifted Clients: Journeys through the Rainforest Mind

Posted on by Psychotherapy.net Team

“What do you do with the clients you suspect are super smart?” You know, those who talk fast, think fast, and ask probing questions; those who are so articulate and seemingly high functioning that you can’t understand why they say they are depressed and anxious. How do we begin to understand, let alone help, those clients who are paralyzed by fears of failure and the pressures of their “great potential”; who have exceedingly high standards and expectations for themselves and others? They change jobs frequently, are continually questioning themselves, and express frustration, impatience, and confusion with slower thinking co-workers. How can we walk alongside those clients who feel such deep and unrelenting loneliness, even if they have many friends and are in partnerships, and who were perhaps bullied and bored in schooling situations when they clearly have (or had) an enormous passion for learning? How can we fully and deeply assist those clients who have an unusual number of sensitivities to sounds, textures, visual stimulation, chemicals, and emotions? Or even begin to co-construct a meaningful treatment plan with clients who feel a responsibility for making a difference on the planet, have extraordinary empathy, and feel despair and idealism about the future? And how do we stay intimately attuned with clients who have experienced serious trauma in childhood but appear to be unscathed, those who are so tuned into us in therapy that they can sense when our attention is drifting, are afraid of overwhelming us, and who, in fact, do overwhelm us with their intensity, depth, intuition, and levels of awareness?

These are some of the challenges I experience working with gifted clients. Perhaps you do, too.

What is Giftedness?

Defining giftedness is difficult and controversial. There are many theories and definitions. Concerns over justice and equality can make this discussion tense and uncomfortable. Here is one way to think about it: all humans ought to be valued and appreciated and are worthy of love and respect. All humans differ in their strengths, weaknesses, learning styles, intellectual capacities, sensitivities, preferences, talents, temperaments, experiences, cultural backgrounds, and desires. It can get tricky when we talk about intellectual differences. And yet, intellectual differences exist. Giftedness exists—in all cultures, races, religions, and socio-economic groups.

It can be easier to see giftedness in children because they are often reaching typical childhood milestones earlier. Their precocity can be apparent in their language, curiosity, interests, and questions. They often read before they get to school and have abilities and wisdom beyond their years. I consult with parents of gifted kids. Here are some examples of children I have heard about: the eight-year-old who wants to be Richard Feynman for Halloween. The five-year-old reading The Chronicles of Narnia. The four-year-old who cries when listening to Mozart because the music moves him. The ten-year-old whose favorite pastime is watching BBC documentaries. The six-year-old who refuses to eat meat for ethical reasons. The nine-year-old who rescues the grasshoppers on the playground. The ten-year-old whose poetry breaks your heart. The fourteen-year-old who’d rather read David Foster Wallace than hang out on social media.

Notice I did not describe the child who performs well in school. Gifted children may test well and get high grades, and they may not.
So, defining giftedness is complicated. But we don’t actually need a clear, concise, undisputed definition to serve clients who fall into this category in one way or another. We don’t need to give them a label. We just need to understand what they may be dealing with due to their gifted traits and how to help them.

Traits of the Gifted Client

These are some of the characteristics of gifted clients with whom I’ve worked:

  • Advanced vocabulary, existential questions and concerns from an early age, multiple in-depth interests
  • A range of deeper-than-normal emotions and sensitivities (often underground in men), advanced analytical abilities, need for precision in fields of interest, perfectionism
  • Rapid thinking, talking, and learning
  • Excessive worry, great empathy for all living things, unusual insight into themselves
  • Avid reading, unending curiosity, and passion for learning (not necessarily for schooling)
  • More complex ethical, moral, and justice concerns, insight about things that others don’t notice, tendency to argue for fun or for intellectual stimulation
  • Idealism, wit, imagination, creativity, questioning authority, and needing to understand the meaning of life
  • Loneliness, anxiety (particularly when bored or during extreme bouts of thinking), existential depression, self-doubt even with seeming successes
  • Difficulty finding friends, serious schooling frustrations, uneven development

The Rainforest Mind

I have discovered that one way to manage discomfort with the label and definition of giftedness is to use the metaphor of the “rainforest mind.” I was a teacher of gifted children before becoming a therapist, and many educators were not happy about identifying them as such. I suggested we think of it this way: people are like ecosystems. Some are like meadows, some deserts, some volcanoes, and some rainforests, for example. They are all beautiful and valuable. One is not better than the other. The client with a rainforest mind is the most complex: multilayered, intense, overwhelming, colorful, highly sensitive, full of complicated creativity, and misunderstood. I have many clients who have read my blog/books and come to me saying “I’m not gifted, but I have a rainforest mind.” These clients are often uncomfortable with the label, too, and many deny they are gifted.

You may be using your most tried-and-true therapeutic methods with these clients but feel something is not quite working. You feel you are missing a very important piece of their puzzle but do not know what. Your client says they are struggling, but they seem to be capable, compassionate, and insightful. At times like these, I have found it useful to consider that my client has a rainforest mind.

Giftedness is a phenomenon that has its own set of complications. These clients desperately need us to see all of who they are and all of who they want to be. They need to be able to feel safe to be vulnerable and to trust that you can handle their exuberance, intense emotions, questions, contradictions, complexities, fears, intuitions, sensitivities, and, yes, their brilliance.

Some of the Issues

The gifted clients with whom I’ve worked come to therapy for the same reasons most clients do. They might be dealing with depression, anxiety, PTSD, attachment issues, addictions, or childhood trauma. But there will likely be other issues that will need your attention. The following are some of the concerns I see in my office every day:

  • Unhealthy perfectionism that stems from early intense pressure to achieve. Healthy perfectionism that is often misunderstood and stems from an innate desire for beauty, balance, harmony, justice, and precision.
  • Multipotentiality, which is a desire to pursue many career paths and multiple interests. This is often mistaken for irresponsibility, inability to focus, or even ADHD.
  • Extreme difficulty with decisions due to the ability to see too many options and to worry about the implications of every choice.
  • Existential depression and despair, particularly rooted in an early and ongoing sense of justice and social responsibility.
  • Difficulty finding friends and partners because of differences in intellectual capacity and in emotional depth and sensitivity.
  • A history of bullying in school and boredom over many years in a traditional classroom where they already know the material. Great frustration with coworkers and supervisors who are less competent or less conscientious.
  • Being given too much responsibility for siblings and parents in a dysfunctional family. The tendency to be the counselor for family and friends with no reciprocation. A capacity for resilience when raised with abuse, masking serious self-doubt, self-hatred, depression, and anxiety.

What Can a Therapist Do?

These are some of what I hope will be helpful hints and strategies I have found effective with these clients.

  • Get familiar with the traits that often accompany giftedness. Explain these to your clients. Learn to differentiate the issues that come with giftedness from the effects of growing up in a dysfunctional family. Explain how having a rainforest mind can be challenging. Suggest books, articles, and websites.
  • Look for ways your clients are masking their pain because they are used to practitioners who assume they are just fine and often their friends and family members overly rely on them because they are so capable.
  • Allow them to talk a lot without being linear or chronological; take notes if it helps you keep track. Create a very large container to hold what is likely to be a great deal of intensity. Love their difficult questions, big emotions, deep dives, and quests for justice and a better world.
  • Be authentic and sensitive. Listen deeply. They are often particularly intuitive and will be able to sense when you are irritated, not feeling well, or distracted.
  • Get your own therapy. If you are also gifted, take time to explore the resources for yourself.
  • Be careful that you don’t misdiagnose—giftedness can look like ADHD, ASD, OCD, and even bipolar disorder. (Note: Some clients can be gifted and also have a mental health diagnosis or learning disability, called twice-exceptional or 2e. It will be important for you to know about this as well.)
  • Know your limits and notice if you are intimidated by their intelligence. Refer if you are frequently overwhelmed or uncomfortable.

The Case of Marilyn

For the purposes of this article, this case example will focus mostly on psychoeducation around giftedness rather than the childhood trauma the client experienced. This case description is adapted from my book, Your Rainforest Mind.

Thirty-year-old Marilyn, a graduate student in anthropology and women’s studies came to counseling because, as she said, “I reached the end of my own abilities to fix myself.” Marilyn’s mother had died a year earlier, and her intimate relationship was “faltering.” In describing her goals in counseling, she wrote, “I want to stop carrying the weight of my family’s legacy, to untangle the mess in my head, to be free.” Marilyn had a history of difficult relationships with partners and trouble finding emotionally healthy friends. Like many of my clients, Marilyn did not initially know that she was gifted.

She described a bipolar, physically and sexually abusive mother. Her father was kind and loving to her but didn’t stand up to stop the abuse. According to Marilyn, her parents were “spectacularly unsuccessful in the real world.” And when Marilyn was twenty-two her father died suddenly.

As a child in school, Marilyn was bullied. She was excited about learning, academically ahead of her peers, and a talkative extravert whom teachers dismissed with impatience and children rejected.

As with most of my clients, we worked on two main tracks. Track one was the long road to healing from severe childhood trauma. Convincing Marilyn through lots of counseling processes based in attachment theory and somatic experiencing that the abuse wasn’t her fault, that she was, in fact, worthy of love, was the more complicated task. Over time, Marilyn felt more trust in me and allowed herself to grieve the losses she had experienced for so many years.

Marilyn, like many gifted folks, had shown a powerful resilience. In spite of her rejecting, critical, abusing mother, Marilyn was a kind, loving, competent woman. The damage was evident, though, in her distorted view of herself, her existential depression, somatic symptoms, and her inability to believe she was worthy of love. It took time for her to feel safe enough in therapy to allow herself to grieve and to trust.

Like many gifted clients, Marilyn did much self-examination. She particularly enjoyed art projects and used journaling and other art forms to delve deeper. She was a big reader and was always looking for resources that would expand her knowledge, particularly in the areas of body image and women’s issues.

The second track is simpler but essential. Even though Marilyn had experienced academic success, she did not identify as gifted or understand the traits. She wrote about this: “There were—and still are—so many times in my life I felt an unbridgeable distance between myself and others, like I fundamentally see the world in a different way that I can’t even explain because we don’t speak the same language.” Even though Marilyn found friends, she felt extremely lonely much of the time. She was often the caretaker in the relationship, giving much love and support but not getting much back. She wrote, “I get hungry for people who are socially competent and intellectual and curious about literally everything and creative and broad-minded and motivated by justice…People who care and feel deeply but also think in complex wide-ranging ways.”

Even though she was an optimist, Marilyn felt despair over finding a truly loving and kind, intimate relationship. And with both friends and partners, Marilyn had difficulty setting boundaries and asking for what she needed. Being gifted, this was even more challenging, because it wasn’t easy finding other sensitive, intelligent souls. I referred her to my blog, books, and other articles about giftedness to reinforce that her difficulties with peers and her enthusiasm for learning outside of school were also typical traits of the gifted.

As time passed in our work together, Marilyn graduated with her Master’s degree. Her advisor may have been the first teacher who recognized and appreciated her giftedness, telling her she was the brightest student she had ever worked with. This was an important acknowledgement. Marilyn and I continued therapy as she looked for employment. Fairly quickly she found a job that was not in her field of study but that suited her well.

Marilyn was employed in social services as a case manager and was wildly successful. The combination of her rainforest-minded traits of sensitivity, empathy, energy, attention to detail, and intelligence worked well with the population of families she helped. She often took on extra responsibilities to keep herself busy and mentally stimulated. In meetings, she saw the big picture and solutions long before her colleagues. So she was restless in the job when she had accomplished her goals and was not recognized for her skills. These can be the frustrations of many rainforest minds on the job. It was likely that Marilyn would find more challenging, financially rewarding work as her confidence grew, but this position was satisfying her need to make a difference.

In many of our sessions, as we talked about relationships both personal and professional, I would remind Marilyn that some of her struggles were due to her complex intellect, high level of sensitivity, multiple interests, divergent thinking, very high standards, fast learning abilities, and deep empathy. In other words, her rainforest mind.

Over our years together, Marilyn made enormous progress. She could acknowledge how severe her losses had been and grew more and more self-accepting. Her self-criticism had decreased significantly, and she became able to recognize her many strengths. She began to imagine that she would find deep friendships and a kind loving partner. Eventually, she accepted the idea that she was, indeed, gifted.

Marilyn described her experience this way: “I keep hoping to meet people with whom I can relax and be just me, all of me, unafraid to let them see who I really am, in all my dorky, questing, art loving, social justice-obsessed, bibliophile, rebellious, intersectional feminist, world-changing glory.”

***

Marilyn is but one example of the many fascinating gifted clients with whom I have been privileged to work. If you can identify who among your clients is gifted, has a rainforest mind, and if you can listen to, understand, and explain the particular challenges that these folks often face, it will make a big difference in the effectiveness of their therapy. You will be seeing and knowing them in a way that very few others, if any, have. And that will change everything.

Helpful Resources

Books/Articles
The gifted adult: A revolutionary guide for liberating everyday genius™.
The Social and Emotional Development of Gifted Children: What do we know?
Your Rainforest Mind: A guide to the well-being of gifted adults and youth.
Journey into your Rainforest Mind: A field guide for gifted adults and teens, book lovers, overthinkers, geeks, sensitives, braniacs, intuitives, procrastinators and perfectionists. .
Webb, J. T., & Amend, E. R. (2016). Misdiagnosis and dual diagnoses of gifted children and adults: ADHD, Bipolar, OCD, Aspergers and other disorders. Great Potential Press, Inc.

Websites
Supporting the Emotional Needs of the Gifted (SENG)
Your Rainforest Mind
Gifted Challenges
Puttylike

The Flash Technique: A Useful Tool in Treating Trauma

Posted on by Psychotherapy.net Team

I first heard of the Flash Technique (FT) in March 2019 when attending Dr. Philip Manfield’s therapy training on Eye Movement Desensitization and Reprocessing (EMDR) in Oakland, California. Unlike EMDR, FT does not require the client to commit to a lengthy process, nor does it require the client to focus on the traumatic memory for an extended period of time. The FT process starts with the client’s identifying a memory or fear and ranking the level of disturbance they are feeling in that moment. The scale, which is known as SUDS (Subjective Units of Distress), ranges from 0-10, with 10 being the most disturbing. Next, I ask the client to think of something positive or exciting that they can talk about for the next 10-15 minutes (i.e., a hobby, a pet, a movie, a trip). This is known as the Positive Engaging Focus (PEF). When FT was first developed, the therapist would say “flash” while the client discussed the PEF and instructed them to briefly think of the target memory. It later became evident that this was not necessary, and now when the therapist says “flash,” the client is instructed to blink instead of flash on the target memory. Once the PEF is identified, I demonstrate for the client how to cross their arms over their chest (a butterfly hug) and tap their arms. They tap while describing the PEF, during which time I periodically ask them to blink several times in rapid succession. After five or so sets of blinks, I ask them to pause and reflect on the target memory/fear. They rank the disturbance and tell me what they notice about the memory. Usually the target is less vivid and harder to pull up. Then we continue with the PEF accompanied by more blinking and tapping, after which we pull up the target again. This process continues until the target is no longer disturbing. FT can be used as a part of EMDR treatment or on its own. I thought FT was an interesting tool and started using it along with the standard EMDR protocol. Sometimes I use FT to lower the intensity of the target, and then process the remainder by using traditional EMDR. My practice has been both online and in person, and I have used FT with both virtual and in-office clients. I have found no major difference between in-person or virtual use of FT. I show the client how to cross their arms and tap the same way virtually as I would do in person. My interest in FT grew over time as I was observing positive results. As of this writing, I have used FT with dozens of clients for two years. I have found it easy to use and very effective when working on a variety of disturbing memories and fears. It usually takes about 15 minutes to implement FT, making it very easy to fit into the standard 50-minute session. In contrast to conventional trauma therapy interventions like EMDR, FT is minimally intrusive, in that it does not require the client to consciously engage with the traumatic memory. The client can therefore process traumatic memories without feeling distress. In the following session, usually a week later, I recheck the target memory or fear to see if there is still any disturbance. Some targets resolve in one session and the results hold over time. Typically, the easiest cases are single-incident traumas—an event that took place at one time and does not have any related memories. For example, someone who was in a car accident once and developed a fear of driving can often process the incident in one session without any need for additional work. In other cases, usually where there are many related memories, it generally requires additional sessions of FT or EMDR to fully resolve them. Multiple incidents can also be processed but may require additional sessions. I should note that FT, like EMDR, does not completely remove all fear. I would not want my clients to put themselves in unsafe situations following FT. Rather, FT and EMDR aim to relieve the extreme disturbance associated with a traumatic event. The client still remembers that the event took place and experiences a normal level of anxiety in appropriate situations. FT does not provide superpowers or magical thinking. It helps remove the irrational fear so that the client can comfortably engage in everyday activities. Below is a case example of my use of FT with a client who had been mugged. Della, a 33-year-old Caucasian female, was mugged seven years ago on the street. Since then, she had been unable to walk alone at night. She always had to have someone walk her places after dark, or she avoided going out altogether. Della lived in a safe suburb and did not have an urgent need to go anywhere at night. She stated, “I want to be able to walk alone at night if I need to.” Recently, Della’s company offered to relocate her to Paris. She was excited about the opportunity but realized that she needed to work on this fear if she was going to move to a big city. We discussed the mugging in more detail. The incident happened when she was in college. She was studying late at the library and drove home to her apartment at around 2 a.m. She had parked her car in a garage a block away from her apartment. As she was walking home, three people came up behind her, kicked her to the ground, grabbed her backpack containing a laptop, and drove away. When asked to rank the disturbance associated with this memory, Della stated it was a 9 on the SUD scale. For FT, we chose Paris as her PEF. “I’m excited to move there,” Della said. After five sets of FT which took about 10 minutes, Della ranked the SUD at 1 before the session ended. Two weeks later, Della reported that she had chosen a safe area in her suburb as a test for an evening walk. She walked alone at around 8 p.m. Della stated, “This is something I haven’t been able to do since the mugging seven years ago.” She said that it felt good to walk around and look at the lights. “This time, I didn’t have any physical symptoms,” said Della. She described that she did feel a little nervous, ranking the SUD at 1-2. However, it felt like a normal amount of anxiety compared to the paralyzing fear she had experienced previously. She felt good about the outcome. “I wanted to be able to walk alone at night if I had to, and now I can do that,” Della remarked.

***

In addition to the previous case, I have successfully used FT with other clients, focusing on a variety of negative memories and fears. Some examples include a parent’s suicide, childhood bullying, extreme fear of bugs, chronic pain with fear of becoming disabled, fear of contracting COVID-19, sexual assault, car accident/fear of driving, and near drowning/fear of swimming. In some cases, the problem resolved after only 15 minutes of FT, with no resurgence. In other cases, FT provided some benefit, but additional EMDR work was required to fully re-process the event and maintain results over time. To date, I haven’t observed any negative experiences with FT. Most clients have found FT to be helpful and enjoyable. I should note that FT, like any therapeutic intervention, may not be effective for every client or situation. Clients should be aware of potential risks and limitations of FT before starting therapeutic treatment. Useful Articles Related to the Flash Technique: EMDR and The Flash Technique: A Match Made in Heaven? Manfield, P., Lovett, J., Engel, L., & Manfield, D. (2017). Use of the flash technique in EMDR therapy: Four case examples. Journal of EMDR Practice and Research, 11(4), 195–205.

Sometimes I Also Feel Lazy: A Clinician Reflects on Self-Disclosure

Posted on by Psychotherapy.net Team

“Sometimes I also feel lazy,” I calmly mentioned to Chris. I noticed his chest instantly decompress with a sigh, as a slight smile took shape at the corner of his mouth. As a clinician, I make calculated decisions about how and when to disclose to my clients.

Chris is a Black man in his early 20s who struggles with symptoms associated with anxiety and persistent depressive disorder. He is currently living with his parents and saving to purchase a condominium. He works in the highly competitive industry of data analysis and takes an interest in both playing the guitar and learning new languages. However, Chris has ongoing thoughts and concerns associated with where he “should” be in life compared to his peers.

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My self-disclosure came after multiple sessions of hearing Chris berate himself, thinking he is not “doing anything with my life.” According to Chris, he should be earning more money and proactively searching out new places to live. We have all dealt with clients who appear to be doing better than most but seem to treat themselves as if they are the worst.

At the moment and in looking back, I felt conflicted. Should I have revealed how proud I was of him? No, that might be taken as gratuitous praise that he believes I “say to everyone.” Or should I have simply sat back and normalized his thoughts and concerns? Well, I tried that in previous sessions. This time I had a different idea.

I recalled how Chris had seemingly put me on a pedestal in the past. He had sometimes made remarks about how “you own your own business” and had “written books.” Now was a moment that I could come across as more relatable. I have noticed that power differentials present significant challenges when working with male clients.

Chris mentioned feeling “lazy” due to his perceived lack of initiative. I responded briefly with, “Sometimes I also feel lazy.” I aimed to be succinct so that my intervention was not taken as an attempt to monopolize his session.

Self-disclosure is not without controversy. Some colleagues argue that it helps, while others suggest that it may be harmful. With Chris, I wanted to convey that I go through periods of indolence as well. As it turned out, this led to a rich discussion about how routines might work better for him than relying on motivation.

One of my concerns prior to disclosing was my experience that mental health disorders are often associated with stigma, and this may delay clients from entering therapy. Chris could have suggested that it was “easy” for me to say that I go through periods of inactivity, as I don’t struggle with anxiety and depression (though inaccurate, I was not willing to take up his session with my issues).

I have found that self-disclosure —when used appropriately—has been a powerful tool in my practice to reduce some of the stigma associated with mental health issues and their treatment, normalize my client’s experience, offer different ways of thinking and behaving, and deepen the connection between me and them.

Below are some considerations for the appropriate use of self-disclosure that I have found in my clinical work:

Cultural Sensitivity

The use of self-disclosure can be problematic if I make assumptions about my clients based upon a real or perceived similarity with them. Culture goes beyond race and ethnicity. Chris and I are of the same race, but that does not mean we have the same worldview, so I must be careful to disclose only after having a thorough understanding of the cultural factors that impact his worldview.

Authenticity

My clients appreciate me when I am real, which is also when I think I am doing my best work. I fear that my professional licensure and other symbols of my presumptive clinical expertise sometimes create distance as opposed to allowing clients to connect with me. Sharing something about myself—when relevant—can help minimize this barrier. My clients come for the clinical interventions but stay for the relationship.
Client-Focus

My goal is always to help my clients meet their needs, as opposed to having my own needs met. The above-mentioned session could have easily become a discussion about me. However, this is not what Chris was there for.

Brevity

It is their session, not mine. I do not want to elicit a caretaking response from my clients. I have written elsewhere that good therapists are in therapy themselves. Another point is that disclosure should not happen frequently, for the same reason mentioned above.

Eliciting feedback

I have found it to be important to carefully observe my client’s reactions (facial expressions, tone of voice, and body language) in order to obtain a sense of how my self-disclosure affects them. It helps when I ask clients directly how they perceive my disclosure. I was able to pay close attention to Chris’ bodily response and noticed that he found comfort in my disclosure. Further, my observation was validated by asking him what the disclosure was like for him.

Some questions that I have found helpful prior to self-disclosing include:

  • What need is driving me to share this information (is it for me, or is it for the client)?
  • How might this information be helpful?
  • Is this helpful to share now (perhaps the disclosure may be better suited for a later time)?

I have also discovered that my use of self-disclosure has not always been as helpful as I had intended. One example stems from a time when I tried to normalize medication compliance with one of my clients who was diagnosed with schizophrenia. I mentioned the fact that I have asthma and am required to take my inhaler regularly in order to maintain optimal health. The client responded by saying that he would much “prefer asthma over schizophrenia.” I attempted to salvage the moment by admitting that it was not appropriate for me to compare asthma to his lived experience. I also allowed the client to give me feedback on how the disclosure made him feel (I learned that it came across as slightly dismissive). I have found that these lapses in clinical judgment have actually strengthened my alliance with clients when I am willing to admit them. Through self-awareness and honesty, these moments have become opportunities for a deepening in my therapeutic relationships and for my client’s self-awareness and growth.

***

In my clinical experience, carefully planned self-disclosure has been a transformative tool in the relationships with several of my clients. Chris viewed my personal revelation as a breath of fresh air, and it made our work together more effective. He respected and appreciated my authentic humanity—even if it meant I was sometimes lazy.
 

Long-Term Psychotherapy and BPD, Part 2: A Dialogue on Trust

Posted on by rezendevknowfully.com


Question: What do you call a homeless horse with a Borderline Personality Disorder?

Answer: Unstable.
 

Introduction: What We Did

In this, the second of a two-part essay, we (Anne, the client, and Trish, the therapist) seek to share multiple perspectives of our co-writing collaboration, a process that we developed to inform our long-term therapeutic relationship’s new focus on Anne’s diagnosis of borderline personality disorder (BPD). Following on from Part 1, in which we detail the ways in which long-term therapy with Trish has had a powerfully positive impact on Anne’s (treatment for) BPD, this second part—begun 5-6 months after the first—moves into the “how” of our co-authoring experience. Through collaborating, Anne is able to practice better interpersonal relationships, which we identified in Part 1 of this essay as crucial to “building a life worth living.” The epistolary dialogue format (as in Part 1) models the importance of trust in the therapist/client relationship, especially for those with BPD, which for us has been built in a range of ways through creative collaboration. In Part 2, we explore the risks and benefits of this dialogic trust-building collaboration, and recognise the investments of all parties involved in the treatment of those with BPD.

In mid-2020, in the midst of Australia’s COVID lockdown, Anne was asked by a friend who edits a psychotherapy journal to contribute an article on their recent diagnosis of Borderline Personality Disorder (BPD). That process is detailed in Part 1 of this essay. In Part 2, we unpack how collaborative writing is impacting our therapeutic relationship, and how humour has played a powerful role in building trust. Our creative collaboration has also raised a number of questions and negotiations, including: What risks were identified? How were these processed and resolved? How has maintaining our dual roles improved our therapeutic relationship?

We explore not only what has changed in our therapeutic relationship due to our creative collaboration, but also what has happened underneath the changes and how co-authoring (or other creative collaboration) might be useful to both therapist and client. We consider why we came to write together, the power of attuning and attending, and shifts in the therapeutic atmosphere that can result in increased trust—most powerfully, a more expansive view of each other that seems to enhance our work “in the room.” For us, humour is a “way in,” a way for us to extend the safe space of the therapeutic exchange into different kinds of relating, a movement that leads to increased trust.

We share memes and jokes about therapy, BPD, and any other topics that need to be decompressed, which establishes a common irreverent sense of humour that solidifies the trust built over time. Common factors theory suggests that the most important influence on therapeutic change is the strength of the alliance between therapist and client. Looking beyond technique and intervention, how does what happens in the room affect our co-authoring, and how does our co-authoring affect what happens for both of us in the room? As before, we use a dialogic approach to give voice to both perspectives.

Trish (she/her): I remember several months back, you had had a bad couple of days, and you were feeling particularly isolated. I wanted to reach out in some way, so I sent you a video clip showing Pepper (my therapy dog, who has been a part of our work together) magically being able to speak through a phone app, asking how you were feeling. I hesitated several times before I sent it but did it in the end. Ultimately I think it achieved what I hoped—a moment of connection through humour, extended by you, when you sent me a video of your dog replying. This happened before the idea of writing of our first article was even on the table, but there we were, extending our therapeutic alliance beyond the counselling room and into a creative/visual space.

Anne (they/them): Our psychotherapeutic relationship is predominantly a one-way listener relationship, framed by your professional training and the terms of our engagement. Is the incessant talking of the therapy client and the never-ending listening of the therapist a false centring of the client in a way the world doesn’t uphold? Like you said the other day, the few times your own selfness comes out in sessions, the client often overlooks it and is like, “Yeah, so anyway, back to me”—which, sadly, I can totally see myself doing! What if you were to say to me, in a session where I might do that, “Hey Anne! I just said something about myself, and you totally ignored it.” It might be hard for me to hear, but that is exactly what happens in real life. And what would that mean for you as a “therapist-ever-becoming” who considers what might be possible when a client is so caught up in their own woes that they miss the you-ness? A you-ness that might be able to push them further toward better interpersonal relationships?

Trish: You came in with your American swagger, already a devotee to New York style of psychotherapy, where not everyone there might have their very own barista (it’s a Melbourne thing), but they certainly have a therapist. You seemed to be willing to take a chance on me, despite some differences that might have gotten in the way. We seemed to click, conversation flowed and continued to flow in subsequent sessions. We discovered things that connected us in shared experiences in our lives apart from the mutual age bracket we found ourselves inhabiting, both having been high school teachers, both loving dogs in the same devotional kind of way. But maybe it was mostly that I really liked you as a person—your inquiring mind, your desire to make sense of things, your wry humour, your ability to narrate your life from the couch in such a way that I was drawn into the story and cared deeply about the author. Your paid work took you away on a regular basis, often for weeks or months at a time, but you would appear again at my office and we would resume. Before I knew it, we had been doing this for a couple of years and entering the realm of long-term therapy—not new to you, but not guaranteed for me, for two reasons: Australians are not so familiar with this way of receiving (long-term) psychological support, and for me as a therapist sitting outside of the Medicare system, there were no financial structures in place to subsidize the work, at times a disincentive for prospective clients. But it has always been my preferred way of working, as one who has found a fit with the relational emphasis of therapeutic work.

When therapists get together and wax lyrical about unconditional positive regard, they rarely see this as a reciprocal idea. It is considered as something bestowed on the client, flowing from a compassionate therapist. But when it is present in the therapeutic space in its fullest capacity, it emerges out of a mutual desire for the therapist and client to see each other as the best that they can be. I want to help you and I want to be seen as someone capable of that. You want help from me and need to believe that I will not let you down. I keep getting to show up again; I can say I won’t give up on you, and you give me the chance to do that through your own acceptance and trust of me. So is this shared unconditional positive regard?

Anne: I was not surprised to find out that you were a teacher—you remind me of the best teachers I knew during my 11 years teaching in high schools. I can see why the kids would be drawn to you: your sense of humor and down-to-earth vibe instantly put me at ease. Yet one thing I’m seeing in myself through the BPD diagnosis and range of treatments is how transactional I can be: i.e., you are my therapist, and because I pay you, you should be like x. Today when we were talking about you, it occurred to me that if we are talking about mutuality, it has to include a kind of benevolence in me for you, too. It doesn’t mean you have to disclose personal details as I do, but I think the interpersonal, relational mode I was talking about does mean our therapy sessions could be a space where I try out caring more about the other.

You are not just my therapist because you were there and I said yes. You also said yes. I have not just stayed—you have stayed. You have said that you feel you can help people and maybe there’s a question in there that goes beyond me just “feeling better.” I don’t literally affirm to you that you DO help me. You do. And I don’t think I affirm you or acknowledge that in the way that you do for me. What does that mean or look like coming from client to therapist? I think I would like to try some kind of “attending to” you in our next session, as a kind of practice of my learning better how to attend to others, in a non-transactional way. It feels freeing to think of improving my interpersonal skills through getting out of my own needs and trying to live more in others’ experiences or needs. I’m not sure exactly what that looks like in our therapy sessions, but I do think this is evolving in a direction in which I can practice caring for someone without it being based on my own needs, even in therapy. Which is still part of my growth in response to my BPD diagnosis.

But why did we keep writing together, and how has it increased each person’s feeling of “being seen” in a more fulsome manner? Initially, it made sense for Anne to ask Trish to co-write the article for the psychotherapy journal, given she is Anne’s therapist and had played such a profound role in Anne’s diagnostic journey. But what we found was something more than a narration of how long-term psychotherapy might help those with BPD.

Trish and Anne started co-writing online while maintaining fortnightly therapy sessions, as face-to-face sessions had been prohibited by home isolation. During this time Anne was also completing their Dialectical Behaviour Therapy (DBT) program remotely, which had life-changing effects. We also acknowledge that we are producing writing that is going to have a public audience, and that now that shapes our creative collaboration in important ways.

We have tried writing separately and then sharing what we had written at a later point, as Irvin Yalom and his client “Ginny” did in Every Day Gets a Little Closer (1), but ultimately returned to co-authoring in a shared Google doc that has a satisfying interactivity and vibrancy. One aspect of the collaboration that emerged from the beginning is the humorous banter that we both enjoy. It is present in our therapy sessions, too, but not to the extent that it has bloomed in our tracked comments while writing together. So alive was that back-and-forth that we tried to include the tracked comments in the final draft of that first article, but it didn’t feel right; the spontaneity was lost once the time stamps and overlaps in the marginalia were formalised into the body of the essay.

The fluidity of being able to write into the same document, and comment on each others’ and our own writing, seemed to form a big part of the energy of the shared work. Trish identified “rooftop moments” and other important insights that emerged in the writing. We both flagged passages that brought tears.

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(1) Every Day Gets a Little Closer

Trish: Anne, you pose such interesting questions about this creative process and why it works. It takes me back to our earlier discussions as we explored the issue of the power dynamic in the client-therapist relationship. It is a strange beast because it seems like it is both needed and rebelled against simultaneously. Sometimes, as a client, you want me to firmly take the reins and show you the way, and at other times you are aware that as you bare your life to me, I keep mine under wraps. You step into a vulnerable space and I have a boundary that keeps me safe. And I want to offer support and guidance but reject labels like “expert” and get cosy with terms like Yalom’s “fellow travellers.” “Do you think our writing together altered an established power dynamic?” For in that space I saw you as the authority and looked to you to have the answers on how the work would come together. I completely trusted that you would take us to where we needed to be with our first article. How does it feel for us to exchange leadership roles as we move from one space to the other? I encourage you and affirm your resolute commitment to wellness, as you face the parts of you that still flare up at times and remind you of the hell that is other people. (2) Then you encourage me and applaud certain passages that I write. You take note of my hesitancy and respond with patience and curiosity, perhaps in a similar way to how you do with your own students. So we redefine the terms of engagement. We allow the spaces of therapy and writing to co-inform one another, as this most human of relationships draws on all of its strengths to bring out the best in each of us. As Yalom (3)  reminds us:
 

This encounter, the very heart of psychotherapy, is a caring, deeply human meeting between two people, one (generally, but not always, the patient) more troubled than the other. Therapists have a dual role: they must both observe and participate in the lives of their patients. As observer, one must be sufficiently objective to provide necessary rudimentary guidance to the patient. As participant, one enters into the life of the patient and is affected and sometimes changed by the encounter. In choosing to enter fully into each patient’s life, I, the therapist, not only am exposed to the same existential issues as are my patients, I must assume that knowing is better than not knowing, venturing than not venturing, and that magic and illusion, however rich, however alluring, ultimately weaken the human spirit.


________________________
(2) No Exit and Three Other Plays
(3) Love’s Executioner and Other Tales of Psychotherapy


Trish: In a recent supervision session with my supervisee James, who works at an in-patient setting, we were reflecting on how patients there form a trusting alliance with the staff. James happens to be blessed with a benevolent warmth, and his presence is therapeutic before he even opens his mouth. He shared his thoughts about the negative impact on patients if they experience the mental health professionals as taking a position that is “above” them—whether that be in the way they dress or speak, or in the attitude that they convey—“I could never be in your shoes.” For James, what is important is the recognition that we can all find ourselves pushed beyond our capacity to cope and experience being unwell. That we need to have a willingness to “also see myself in their story.” Anne, it got me thinking about what you wrote in our first article—that BPD is a disorder of separation. And I wonder how it is possible to trust anyone if you feel so distant from them? As we grapple with understanding how our writing together built trust, it dawned on me that this process has been highlighting the ways in which we are similar rather than different.

Psychiatrist to his nurse: “Just say we’re very busy. Don’t keep saying, ‘It’s a madhouse.’”


When psychotherapy has an interpersonal focus, it can be described as paying attention to the interactions between client and therapist, as well as providing an opportunity for practising a more satisfying relationship that then gets taken into the real world of the client. So what is going on in our writing process, including in the comments? We agree it’s an alternative form of “the real world,” organically appearing out of the mutuality of the co-creative work. Through the collaboration, Anne starts to see Trish as a “fuller human being” with her own wants, needs, ideas, resulting in more trust of Trish. Trish reports seeing Anne also as a fuller person, in their element, strength and power, a kind of agency. We both express how the increased interactions are not necessarily about more stories of our personal lives, but rather an experience of “a different me.” For us both, we have an increased sense of how the other is with other people.

Anne asks Trish questions like, “How does it feel to be a subject with a client? To take up space?”

We both ask, “How much is too much?”

Trish has been thinking a lot about this in the last couple of days, about self disclosure as the therapist, and bringing more of the “real self” into therapy. She says,
 

I thought about your saying that you saw me as a ‘fuller human being’ through the writing process and it made us wonder what that would look like, i.e. to have Trish the fuller human being in the therapy sessions. There is always a risk that something may not work out the way you want it to. Including this collaboration.


For Trish there is tension about whether Anne could still trust her to help them in the therapy space if they see her vulnerable and feeling out of her depth in the writing space. This feels risky but also highly challenging to how she sees herself as a therapist. Trish’s previous self-image as being authentic and honest is tempering with the recognition that there are parts still held back. This important self-examination leads Trish to grapple with the boundary of what becomes known, foregrounding always that whatever she offers of herself still needs to be of therapeutic value. The added role of “collaborator” has both personal and therapeutic benefits for Anne. A healthy intimate relationship means both can safely be vulnerable with the other and know it can be held and ultimately strengthen the relationship, not damage it. The therapeutic potential is that if this happens with Trish, it can strengthen with others in Anne’s life.


Anne: I find it challenging to trust people who remain “distant,” as a therapist may appear, because it feels like rejection and elicits feelings of vulnerability. Navigating these secondary co-creative roles is tricky but feels reassuring to me, and the trust between us seems to increase. In therapy sessions, I am the one with issues, difficult feelings, vulnerability, who looks for support and understanding. You are the one who listens and focuses on how best to meet the needs that I express. So how is it that despite us writing about the therapy, our roles still shift? I often take the lead in the co-authoring, which is not surprising given my professional expertise. I am able to share information with you, Trish, around the process of writing together and send you co-written autoethnographic articles as examples—a classic example of table-turning, you tell me, when we reflect on the times you have sent me articles of a psychological nature in relation to our therapeutic work.

Psychotherapy is often described in the person-centred school as a respectful, collaborative, teamwork-like approach. In this way, the client-therapist team builds their alliance and works together, but—and this is a major distinction—it is all in the service of the growth of the client. And fair enough, given there is a fee attached. But it would be a deception to suggest that the therapist does not grow as well, or, as Yalom says, is not changed or affected by the work, or doesn’t think about the client beyond the therapy hour. How much of this knowledge is—or should be—available to the client? Do they even want to know?

Trish: Anne, you made a comment about not realising how much was going on “behind the scenes” in our sessions. This was probably in response to my talking about a certain approach I might take with a certain goal in mind. Do you think it is helpful for a client to know that what their therapist is doing is reparenting them, or providing empathic attunement, or providing a secure base that was lacking in childhood? I just can’t imagine a client caring about the what, as long as it works, but when I think about talking with other therapists about this work and leaving my clients out of the conversation, it seems ridiculous! I find myself imagining a conversation with fellow therapists:

Me: “Hey therapist colleagues, let me tell you about this great intervention I did the other day in a session…”

Therapist colleagues: “Oh cool…but how do you know it was great? Did you ask the client?”

Me: “Well… no… but, it’s in this book I read.”

Therapist colleagues: ‘“Yeah but how do you know it actually helped the client?”

Me: “Um… well, they probably don’t know it helped them… but… oh, shut up.”


Anne: I wonder at the disjunct between therapists’ acknowledgement that clients need to feel that you are not “above” us, are not inherently different from us, versus how infrequently clients seem to feel this sense of equality, accessibility, or sameness. As in James’ commentary above, I recognise the commitment in you, Trish, and others, to convey a sense of solidarity with clients; I also recognise what you have suggested many times, that clients do need that sense of being held, that the therapist is “holding things together” so that we can be vulnerable. Where is the balance between feeling this as hierarchical, and feeling in it together?

Trish: Anne, you are right that the balance is hard to find, particularly if there isn’t a dialogue between client and therapist about what is actually happening in the space together. As Yalom and others have often noted, it can be hard to know what helps in therapy, and I think quite often a therapist will have a different idea to the client about what was helpful, useful, or powerful in any given session. Sometimes a client will say to me, “When you said that thing last week, I found that really helpful.” And often I think, “Well actually, I didn’t quite say it like that, and it’s not what I meant, but OK. But didn’t you like it when I said this bit? You don’t remember that? Damn, I thought that was the good part…”


Cracking Ourselves Up: Enhancing Trust with Humour

Question: How many psychotherapists does it take to change a light bulb?

Answer: Probably just one, as long as it takes responsibility for its own change. This could be called having “a light bulb moment.”


Laughter has always been part of our therapeutic relationship, and we wonder as we go along what doorway this has opened to increasing trust. Our joking in the document is more frequent, but also a bit different in nature: more feeding off of one another, whereas in the room it’s a bit more measured. We are curious about the many roles humour seems to play between us in our dual roles. We discuss how—in the room—humour can also be a mechanism for deflecting, or keeping things on a more superficial level, and in this way is not always welcome. Nevertheless, once we begin our online interaction, the spontaneous humour grows. Trish writes of a time when she took a holiday and arranged for another staff member at the agency where she worked to see her clients if needed. The audacity of counsellors leaving clients in order to have some leisure time doesn’t go unnoticed by Anne in our track comments in the first article:

[Anne: how dare you LOL]

[Trish: How very BPD of you :)]

[Anne: LOL GUFFAW I think we may have a stand up routine by the end of this.]

[Trish: I know right? The side comments are almost as interesting as the article!!]


In this exchange, our shared humour strikes at the heart of the very condition that has caused Anne such anguish, and yet creates a moment of freedom as the heaviness of the label is discarded, all the while noticing that humour and pathos are indeed good friends. We agree that one reason both our irreverent humour and the creative collaboration work well is because it has emerged out of our pre-existing therapeutic relationship of almost six years. The trust and foundations were there before we altered our relationship, and Anne notes that widespread perceptions of BPD make it likely that such humour about the disorder would be hard to share with a therapist in a less established relationship.

One wall we have mutually hit together is a feeling of “too much”ness after the first essay, when we decided to continue writing together as well as still maintaining therapy sessions. The dual roles and time commitments of both soon felt too demanding, and we were able to talk about that openly and put some boundaries around it.


Trish: Anne, I recall that experience of “too much”ness was precipitated by your writing into our shared document about a dream you had had about me. I commented on how much was in the dream to be examined, but it seemed to be therapeutically, not creatively, relevant. Back then I wondered whether the writing together was blurring the therapeutic line in a confusing way. But now I think we see the line and we choose to walk along it courageously. I see an image of a tightrope walker, holding a long pole for balance. I wonder what the pole is representative of in our work together?

This experience caused us to recognise that we needed careful negotiation around how much and when we enact both roles: for example, do we collaborate while Anne is still a client? Do we have writing sessions and therapy sessions in the same week/month? After a time, we started to realise that they were folding back into one another in an iterative process that was becoming productive for both the writing and therapy, but we continue to monitor the efficacy of maintaining both roles simultaneously.


“Being Seen” through Creative Collaboration

Through humour especially, we both express a powerful feeling of being seen by the other, in deeper if not new ways. The feeling of “being seen” is, of course, a major part of the value of psychotherapy to a client, and was a strong part of Anne’s experience of therapy with Trish before the co-writing started. We decide to explore bringing some of this “whole person” or more interactive dynamic back into our therapy sessions, admitting that neither of us are quite sure what this will look like. We discuss how we might chip away at the “one-wayness,” the illusion of the therapist having no needs, feelings, investment. We consider questions like:

Is Trish always therapist Trish, even when we are co-writing?

What in that therapy space is different or the same?


It is confusing for us both at times, often in different ways.

Trish: I wonder, “Well what IS bringing more into the room?” I believe that my emotional responses are already an act of bringing myself. It is my standard practice to share things like “I’m aware that I’m feeling quite sad as you tell me this.”

We wonder together: what if we were writing a novel instead, or painting a picture? We are writing about our therapy, not something else, so it reinforces the therapeutic relationship. We reflect on the fact that Trish is also a teacher and practice supervisor, and in those roles she encourages her students to be prepared to walk the talk, to consider the ethics of asking clients to go further than they’ll go themselves. We begin to acknowledge our investment in each other.

Of course, our creative collaboration presents challenges as well as benefits. What if it dissolves, runs out of steam, or there is a creative rupture? We discuss the value of this changed way of working, despite the risks. We discuss whether writing about this will be of benefit to other client/therapist teams, and, if this multi-directionality in our sessions doesn’t work for all clients, whether it is still a worthy experiment to share publicly.

Anne: One reason why I have this trust of you is because you have hung in there, not rejecting me, through so many difficult times. And why wasn’t my treatment of you as challenging as so many others in my life? My hard behaviour, I think, is triggered by feeling rejected or judged. But rejection and judging is part of life. So how does unconditional acceptance (“unconditional positive regard”) by you help me handle rejection in the real world? One of the ways I’m suggesting is to regard you with care as a whole person, not just a “therapist.” That is, not just “there for me.” In thinking about this over the last little while, I believe the improvement in much of my behaviour comes from my starting to regard others as whole human beings with their own needs and validity, whether they reject me or not, meet my needs or not. How can I increase my ability to put myself aside and regard others in a less transactional way? If I were to do this with you in our sessions, what does that look like? Certainly not your therapy, or therapy about you. But maybe it’s more like, “How does it feel to you when I just talk the whole session?” or “Do I hurt your feelings?” or “Am I boring you right now?” Maybe attending to you (and others) is holding the dialectic of “My feelings are hurt right now, but I can also attend to your hurt feelings at the same time, or even first.” Part of improving my interpersonal relationships, I think, is being able to perceive my impact on people.

Trish: The process of writing the article with you has provoked me to re-examine the firmly boundaried position of this understood one-way process. No person-centred therapist wants to be a blank screen, and I have always believed I bring my genuine self to the therapy process with clients. Being willing to be more explicit about my internal responses to things you might say to me, rather than hold some therapeutic high ground as I bracket them off, seems like an important way forward.

We agree that it should be as intentional as setting some ground rules for the experiment. Trish suggests regular check-ins, like asking “How is this going right now?” Anne wonders how productive setting ground rules or negotiating terms of relationships might have been in other relationships or friendships, too; maybe with such agreements those relationships would have gone better. Trish suggests to Anne, “See? You are now connecting what we are doing in therapy to your life in the real world, i.e. negotiating with people around the types of interactions you have—what works for both. So here is therapy on the page.”


Mutually Revealing

One day after a co-writing session, Trish scribbles some notes, including:

Explore in what ways (even without Anne knowing) the relationship between us has been therapeutic:

  • Corrective emotional experience
  • Being there
  • Not abandoning
  • Staying with

…and that these things build trust.

Trish: I believe that so much of what a therapist does with clients is to provide a corrective emotional experience. When there is abuse or neglect or misattunement early in life, the therapy of care and unconditional positive regard gives the client the feeling of what it is like to be held. So for you, Anne, maybe some of that was to not have to listen to someone else and validate them (in the way you did for your adoptive mother) in order to feel worthy. That you get to have the experience of this for yourself. In some ways, it is not so important that it isn’t the “real world” but the world of the therapy room. The emotions are real. That I attend to you is real. And you don’t have to be “good” (thanks, Mary Oliver) in order to feel this. And feeling this with me might then motivate you to know that it is possible, and that maybe you can also feel it in your “real” life.


I have been thinking about this quite a bit over the last few days, and I have formed the belief that we needed to do this work (i.e. corrective emotional experience) before we could move into a space of being more overtly interpersonal. Trust is needed for that. I have often wanted to challenge some of my other clients with Borderline features to have a look at certain aspects of themselves and their behaviour that might impact other people, or even me, negatively, but I have found that there is a risk of their fragmenting. If someone already has a fragile sense of self, a suggestion that they could do something differently can be experienced as “I am a bad person.” So it is interesting that we are contemplating this experiment of giving the space between us more attention. Perhaps you feel secure enough in our relationship now to let me challenge you. If I let you see that I have reactions to what you do or say, that it actually affects me, I believe that you can hold this information and stay intact.

Anne: I have been thinking a lot for the past five days about my saying to you to “get over it.” One thing I’ve noticed with myself (is it the BPD?) is that sometimes I don’t intend to, but I am still quite harsh. I have always laughed this off as my New Yorker brusqueness. But is that an excuse for rudeness and not wanting to change? I’m sorry, Trish, that I spoke to you in that way. This is my being accountable interpersonally, even in a therapy session. I meant to encourage you. And I do think you are fearless in going to these places that are not the norm in the Australian context, and I love that and was trying to encourage you, but it came out in a rude and insulting way.

Trish: Twice now you have thought you might have offended me or been rude to me, and twice I have not felt offended or hurt. I wonder what you saw to think that you hurt me? An expression on my face, perhaps? Something in my response? Actually, I feel that on both occasions you were suggesting that maybe I could be more—an invitation to think big. And yet you think you were being dismissive or hurtful. I remember your saying recently that sometimes you find it hard to tell whether some communication between you and others is rude/aggressive or not. And then you might have to backtrack and check it out. I promise if you are nasty to me, I will tell you at the time and we can work out whether you meant it or not. You were witnessing my own discomfort with ambition. You didn’t cause it, you’re not the bad guy in this scenario. I am noticing and appreciating how you are thinking about the impact your words may have had on me.

Anne: I think it’s important to me that both of us acknowledge that there is fear perhaps around my BPD, because it is not only a disorder of separation, it is also a disorder of dysregulated emotions and behaviours. Through our work together and the safety of that, I am becoming more able to acknowledge the harms I have done to others and myself, harms that I can now feel regret and sadness about. That includes times I have hurt you in our work together, too, Trish. This doesn’t mean I won’t lash out (again). And as safe as I feel with you, we both know I have lashed out most often against those who are closest to me. So I recognise the courage it takes for you to continue to show up when you have witnessed so many of my hurtful behaviours to others, and sometimes experienced them yourself. That is brave, and I recognise the risk to you.

It is good and important to work together to improve my ability to calibrate my impact on others—to perceive it more clearly, perhaps—but also to model to other therapists that someone with BPD may be frightening or erratic, yes, but we can also be deeply reflective, resilient, empathic, courageous, and hungry to change. And we can care about you, even when we are mired in our own pain. And that this care for you can provide an important window to re-engaging with a world that is sometimes overwhelming for us.

Trish: You talk about acknowledging our fear around your BPD, and I wonder if it is the same for us both? You fear that you will still injure others, including me, despite how far you have come. I also fear that you could hurt me, too, might lash out at me despite the safety of our relationship. And as our therapeutic connection deepens, I take my place as someone at risk of being hurt by you. So how do we hold this fear in a way that makes sense? It brings to mind the dialectic of the work. Where there is fear, there is also bravery; where there is safety, there is also risk. And of course, as always, there is the knowing and the not knowing. It is inevitable that we hurt or disappoint the people who mean the most to us. We will do wrong, it is the nature of the imperfect relationships in which we all engage. And that brings us back to trust. With trust we are able to stay in touch with the resilience and perseverance that we see in one another, which makes repair and recovery possible. So when you care for me, and for others in their turn, know that what you are doing is an ongoing process of recreating a secure base that is at the very heart of what we all yearn for when we love and feel loved in return.


Epilogue: Returning to Embodiment—March 2021

Anne: I’m glad I came to your office today. It has been a long time since we have shared space, and so much has happened in the interim, with COVID and multiple lockdowns. I was aware of you again as a changing human person, and the affective intensity of proximity. I think one reason I felt moved today was not just about the content we were discussing, but about the relationship and the exchange. It is, as Tara Brach would say, sacred ground, where people feel seen and heard. It’s so powerful. That room is a powerful sacred space for me.

Do I have anxiety about going backward, now that my DBT has finished? Disappointing you? Being disappointed by you? Of course! That’s every relationship, surely. Today I just felt moved by the proximity, the laughing—so much laughter!—the attending, the eye contact, the ambient noises, the longevity, the commitment, and the hope, even when I can’t find exactly who I am. And also the power of the room itself. That familiar room—the white blinds, your desk, cup, computer. The little table by the couch, the bin. Pepper had died during lockdown, and I felt his absence so strongly in the room. The environment matters, and I can see it now as another expression of you, of another way of your “bringing yourself” to your clients.

Trish: Yes, it was pretty powerful being together in person today. There was a certain energy which may well have been about how long it has been since we took up the chair and the couch, or perhaps about the added layer of the creative space that we are sharing as we write, knowing that our words on screen find calibration with the ones we speak to one another. Were you more aware of me than you have been in the past? You have said you wanted to be able to hold space for others while you navigate your own emotional space. I think I noticed a subtle shift—while you certainly wanted some thoughts from me about what was going on for you, there was something different, more of an ease in you and a space created for me. And somehow I felt that even though I didn’t really have a clear answer for you, I was still offering you something, and you saw that (and subsequently wrote about it). This work together is making me examine myself in the most profound way, and if I want you to do it, then I will, too. Maybe I am also trying to find out exactly who I am when I am in a therapeutic encounter with you. I know one thing, I will trust the journey.

Anne: I was more aware of wondering what techniques you may have been using, and why. That relational aspect that I had never really thought much about before our co-authoring. I assumed the therapist just showed up and it was a one-way thing. I’m enjoying this change in my awareness: not only in terms of acknowledging what you are bringing, but also for me, thinking relationally about you. You exist. You are thinking and feeling things, not just absorbing. I also think we had a lot more eye contact yesterday than usual, that was something I was aware of. And also the laughing… Why do you think we laughed more yesterday than usual? My perspective is that it was just a bit of happiness to see you again, and also I felt you laughed more than usual and that felt like a kind of openness from you.
 

***
 

As recently as 2015, at the end of Creatures of a Day, Yalom  (4) reminds us that even in the United States, these kinds of relational accounts are all too rare and
 

not generally available in contemporary curricula. Most training programs today (often under pressure by accreditation boards or insurance companies) offer instruction only in brief, “empirically validated” therapies that consist of highly specific techniques addressing discrete diagnostic categories… I worry that this current focus in education will ultimately result in losing sight of the whole person and that the humanistic, holistic approach I used with these ten patients may soon become extinct. Though research on effective psychotherapy continually shows that the most important factor determining outcome is the therapeutic relationship, the texture, the creation, and the evolution of this relationship are rarely a focus of training in graduate programs.


For Trish and Anne, this focus on our creative collaboration allows a deepening of trust and strengthening of our relational dynamics. Trish (and sometimes both of us now) uses many of the suggestions Yalom offers for calling attention to the bond between patient and therapist including: doing process checks, inquiring about the state of the encounter during the session, Trish’s asking if Anne has questions for her. Through creative collaboration, trusting in the here and now becomes multi-modal and multi-directional in ways that can offer new forms of corrective emotional experience. It has also firmly established a secure base, the core purpose of strong and trusting client-therapist relationships, never more important (and challenging) than with clients with Borderline Personality Disorder.
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(4) Creatures of a Day and Other Tales of Psychotherapy

Long Term Psychotherapy and BPD, Part 1: A Dialogue on Hope

Posted on by Psychotherapy.net Team


Question: What do you call a homeless horse with a Borderline Personality Disorder?

Answer: Unstable.
 

Introduction: What We Did

In this, the second of a two-part essay, we (Anne, the client, and Trish, the therapist) seek to share multiple perspectives of our co-writing collaboration, a process that we developed to inform our long-term therapeutic relationship’s new focus on Anne’s diagnosis of borderline personality disorder (BPD). Following on from Part 1, in which we detail the ways in which long-term therapy with Trish has had a powerfully positive impact on Anne’s (treatment for) BPD, this second part—begun 5-6 months after the first—moves into the “how” of our co-authoring experience. Through collaborating, Anne is able to practice better interpersonal relationships, which we identified in Part 1 of this essay as crucial to “building a life worth living.” The epistolary dialogue format (as in Part 1) models the importance of trust in the therapist/client relationship, especially for those with BPD, which for us has been built in a range of ways through creative collaboration. In Part 2, we explore the risks and benefits of this dialogic trust-building collaboration, and recognise the investments of all parties involved in the treatment of those with BPD.

In mid-2020, in the midst of Australia’s COVID lockdown, Anne was asked by a friend who edits a psychotherapy journal to contribute an article on their recent diagnosis of Borderline Personality Disorder (BPD). That process is detailed in Part 1 of this essay. In Part 2, we unpack how collaborative writing is impacting our therapeutic relationship, and how humour has played a powerful role in building trust. Our creative collaboration has also raised a number of questions and negotiations, including: What risks were identified? How were these processed and resolved? How has maintaining our dual roles improved our therapeutic relationship?

We explore not only what has changed in our therapeutic relationship due to our creative collaboration, but also what has happened underneath the changes and how co-authoring (or other creative collaboration) might be useful to both therapist and client. We consider why we came to write together, the power of attuning and attending, and shifts in the therapeutic atmosphere that can result in increased trust—most powerfully, a more expansive view of each other that seems to enhance our work “in the room.” For us, humour is a “way in,” a way for us to extend the safe space of the therapeutic exchange into different kinds of relating, a movement that leads to increased trust.

We share memes and jokes about therapy, BPD, and any other topics that need to be decompressed, which establishes a common irreverent sense of humour that solidifies the trust built over time. Common factors theory suggests that the most important influence on therapeutic change is the strength of the alliance between therapist and client. Looking beyond technique and intervention, how does what happens in the room affect our co-authoring, and how does our co-authoring affect what happens for both of us in the room? As before, we use a dialogic approach to give voice to both perspectives.

Trish (she/her): I remember several months back, you had had a bad couple of days, and you were feeling particularly isolated. I wanted to reach out in some way, so I sent you a video clip showing Pepper (my therapy dog, who has been a part of our work together) magically being able to speak through a phone app, asking how you were feeling. I hesitated several times before I sent it but did it in the end. Ultimately I think it achieved what I hoped—a moment of connection through humour, extended by you, when you sent me a video of your dog replying. This happened before the idea of writing of our first article was even on the table, but there we were, extending our therapeutic alliance beyond the counselling room and into a creative/visual space.

Anne (they/them): Our psychotherapeutic relationship is predominantly a one-way listener relationship, framed by your professional training and the terms of our engagement. Is the incessant talking of the therapy client and the never-ending listening of the therapist a false centring of the client in a way the world doesn’t uphold? Like you said the other day, the few times your own selfness comes out in sessions, the client often overlooks it and is like, “Yeah, so anyway, back to me”—which, sadly, I can totally see myself doing! What if you were to say to me, in a session where I might do that, “Hey Anne! I just said something about myself, and you totally ignored it.” It might be hard for me to hear, but that is exactly what happens in real life. And what would that mean for you as a “therapist-ever-becoming” who considers what might be possible when a client is so caught up in their own woes that they miss the you-ness? A you-ness that might be able to push them further toward better interpersonal relationships?

Trish: You came in with your American swagger, already a devotee to New York style of psychotherapy, where not everyone there might have their very own barista (it’s a Melbourne thing), but they certainly have a therapist. You seemed to be willing to take a chance on me, despite some differences that might have gotten in the way. We seemed to click, conversation flowed and continued to flow in subsequent sessions. We discovered things that connected us in shared experiences in our lives apart from the mutual age bracket we found ourselves inhabiting, both having been high school teachers, both loving dogs in the same devotional kind of way. But maybe it was mostly that I really liked you as a person—your inquiring mind, your desire to make sense of things, your wry humour, your ability to narrate your life from the couch in such a way that I was drawn into the story and cared deeply about the author. Your paid work took you away on a regular basis, often for weeks or months at a time, but you would appear again at my office and we would resume. Before I knew it, we had been doing this for a couple of years and entering the realm of long-term therapy—not new to you, but not guaranteed for me, for two reasons: Australians are not so familiar with this way of receiving (long-term) psychological support, and for me as a therapist sitting outside of the Medicare system, there were no financial structures in place to subsidize the work, at times a disincentive for prospective clients. But it has always been my preferred way of working, as one who has found a fit with the relational emphasis of therapeutic work.

When therapists get together and wax lyrical about unconditional positive regard, they rarely see this as a reciprocal idea. It is considered as something bestowed on the client, flowing from a compassionate therapist. But when it is present in the therapeutic space in its fullest capacity, it emerges out of a mutual desire for the therapist and client to see each other as the best that they can be. I want to help you and I want to be seen as someone capable of that. You want help from me and need to believe that I will not let you down. I keep getting to show up again; I can say I won’t give up on you, and you give me the chance to do that through your own acceptance and trust of me. So is this shared unconditional positive regard?

Anne: I was not surprised to find out that you were a teacher—you remind me of the best teachers I knew during my 11 years teaching in high schools. I can see why the kids would be drawn to you: your sense of humor and down-to-earth vibe instantly put me at ease. Yet one thing I’m seeing in myself through the BPD diagnosis and range of treatments is how transactional I can be: i.e., you are my therapist, and because I pay you, you should be like x. Today when we were talking about you, it occurred to me that if we are talking about mutuality, it has to include a kind of benevolence in me for you, too. It doesn’t mean you have to disclose personal details as I do, but I think the interpersonal, relational mode I was talking about does mean our therapy sessions could be a space where I try out caring more about the other.

You are not just my therapist because you were there and I said yes. You also said yes. I have not just stayed—you have stayed. You have said that you feel you can help people and maybe there’s a question in there that goes beyond me just “feeling better.” I don’t literally affirm to you that you DO help me. You do. And I don’t think I affirm you or acknowledge that in the way that you do for me. What does that mean or look like coming from client to therapist? I think I would like to try some kind of “attending to” you in our next session, as a kind of practice of my learning better how to attend to others, in a non-transactional way. It feels freeing to think of improving my interpersonal skills through getting out of my own needs and trying to live more in others’ experiences or needs. I’m not sure exactly what that looks like in our therapy sessions, but I do think this is evolving in a direction in which I can practice caring for someone without it being based on my own needs, even in therapy. Which is still part of my growth in response to my BPD diagnosis.

But why did we keep writing together, and how has it increased each person’s feeling of “being seen” in a more fulsome manner? Initially, it made sense for Anne to ask Trish to co-write the article for the psychotherapy journal, given she is Anne’s therapist and had played such a profound role in Anne’s diagnostic journey. But what we found was something more than a narration of how long-term psychotherapy might help those with BPD.

Trish and Anne started co-writing online while maintaining fortnightly therapy sessions, as face-to-face sessions had been prohibited by home isolation. During this time Anne was also completing their Dialectical Behaviour Therapy (DBT) program remotely, which had life-changing effects. We also acknowledge that we are producing writing that is going to have a public audience, and that now that shapes our creative collaboration in important ways.

We have tried writing separately and then sharing what we had written at a later point, as Irvin Yalom and his client “Ginny” did in Every Day Gets a Little Closer (1), but ultimately returned to co-authoring in a shared Google doc that has a satisfying interactivity and vibrancy. One aspect of the collaboration that emerged from the beginning is the humorous banter that we both enjoy. It is present in our therapy sessions, too, but not to the extent that it has bloomed in our tracked comments while writing together. So alive was that back-and-forth that we tried to include the tracked comments in the final draft of that first article, but it didn’t feel right; the spontaneity was lost once the time stamps and overlaps in the marginalia were formalised into the body of the essay.

The fluidity of being able to write into the same document, and comment on each others’ and our own writing, seemed to form a big part of the energy of the shared work. Trish identified “rooftop moments” and other important insights that emerged in the writing. We both flagged passages that brought tears.

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(1) Every Day Gets a Little Closer

Trish: Anne, you pose such interesting questions about this creative process and why it works. It takes me back to our earlier discussions as we explored the issue of the power dynamic in the client-therapist relationship. It is a strange beast because it seems like it is both needed and rebelled against simultaneously. Sometimes, as a client, you want me to firmly take the reins and show you the way, and at other times you are aware that as you bare your life to me, I keep mine under wraps. You step into a vulnerable space and I have a boundary that keeps me safe. And I want to offer support and guidance but reject labels like “expert” and get cosy with terms like Yalom’s “fellow travellers.” “Do you think our writing together altered an established power dynamic?” For in that space I saw you as the authority and looked to you to have the answers on how the work would come together. I completely trusted that you would take us to where we needed to be with our first article. How does it feel for us to exchange leadership roles as we move from one space to the other? I encourage you and affirm your resolute commitment to wellness, as you face the parts of you that still flare up at times and remind you of the hell that is other people. (2) Then you encourage me and applaud certain passages that I write. You take note of my hesitancy and respond with patience and curiosity, perhaps in a similar way to how you do with your own students. So we redefine the terms of engagement. We allow the spaces of therapy and writing to co-inform one another, as this most human of relationships draws on all of its strengths to bring out the best in each of us. As Yalom (3)  reminds us:
 

This encounter, the very heart of psychotherapy, is a caring, deeply human meeting between two people, one (generally, but not always, the patient) more troubled than the other. Therapists have a dual role: they must both observe and participate in the lives of their patients. As observer, one must be sufficiently objective to provide necessary rudimentary guidance to the patient. As participant, one enters into the life of the patient and is affected and sometimes changed by the encounter. In choosing to enter fully into each patient’s life, I, the therapist, not only am exposed to the same existential issues as are my patients, I must assume that knowing is better than not knowing, venturing than not venturing, and that magic and illusion, however rich, however alluring, ultimately weaken the human spirit.


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(2) No Exit and Three Other Plays
(3) Love’s Executioner and Other Tales of Psychotherapy


Trish: In a recent supervision session with my supervisee James, who works at an in-patient setting, we were reflecting on how patients there form a trusting alliance with the staff. James happens to be blessed with a benevolent warmth, and his presence is therapeutic before he even opens his mouth. He shared his thoughts about the negative impact on patients if they experience the mental health professionals as taking a position that is “above” them—whether that be in the way they dress or speak, or in the attitude that they convey—“I could never be in your shoes.” For James, what is important is the recognition that we can all find ourselves pushed beyond our capacity to cope and experience being unwell. That we need to have a willingness to “also see myself in their story.” Anne, it got me thinking about what you wrote in our first article—that BPD is a disorder of separation. And I wonder how it is possible to trust anyone if you feel so distant from them? As we grapple with understanding how our writing together built trust, it dawned on me that this process has been highlighting the ways in which we are similar rather than different.

Psychiatrist to his nurse: “Just say we’re very busy. Don’t keep saying, ‘It’s a madhouse.’”


When psychotherapy has an interpersonal focus, it can be described as paying attention to the interactions between client and therapist, as well as providing an opportunity for practising a more satisfying relationship that then gets taken into the real world of the client. So what is going on in our writing process, including in the comments? We agree it’s an alternative form of “the real world,” organically appearing out of the mutuality of the co-creative work. Through the collaboration, Anne starts to see Trish as a “fuller human being” with her own wants, needs, ideas, resulting in more trust of Trish. Trish reports seeing Anne also as a fuller person, in their element, strength and power, a kind of agency. We both express how the increased interactions are not necessarily about more stories of our personal lives, but rather an experience of “a different me.” For us both, we have an increased sense of how the other is with other people.

Anne asks Trish questions like, “How does it feel to be a subject with a client? To take up space?”

We both ask, “How much is too much?”

Trish has been thinking a lot about this in the last couple of days, about self disclosure as the therapist, and bringing more of the “real self” into therapy. She says,
 

I thought about your saying that you saw me as a ‘fuller human being’ through the writing process and it made us wonder what that would look like, i.e. to have Trish the fuller human being in the therapy sessions. There is always a risk that something may not work out the way you want it to. Including this collaboration.


For Trish there is tension about whether Anne could still trust her to help them in the therapy space if they see her vulnerable and feeling out of her depth in the writing space. This feels risky but also highly challenging to how she sees herself as a therapist. Trish’s previous self-image as being authentic and honest is tempering with the recognition that there are parts still held back. This important self-examination leads Trish to grapple with the boundary of what becomes known, foregrounding always that whatever she offers of herself still needs to be of therapeutic value. The added role of “collaborator” has both personal and therapeutic benefits for Anne. A healthy intimate relationship means both can safely be vulnerable with the other and know it can be held and ultimately strengthen the relationship, not damage it. The therapeutic potential is that if this happens with Trish, it can strengthen with others in Anne’s life.


Anne: I find it challenging to trust people who remain “distant,” as a therapist may appear, because it feels like rejection and elicits feelings of vulnerability. Navigating these secondary co-creative roles is tricky but feels reassuring to me, and the trust between us seems to increase. In therapy sessions, I am the one with issues, difficult feelings, vulnerability, who looks for support and understanding. You are the one who listens and focuses on how best to meet the needs that I express. So how is it that despite us writing about the therapy, our roles still shift? I often take the lead in the co-authoring, which is not surprising given my professional expertise. I am able to share information with you, Trish, around the process of writing together and send you co-written autoethnographic articles as examples—a classic example of table-turning, you tell me, when we reflect on the times you have sent me articles of a psychological nature in relation to our therapeutic work.

Psychotherapy is often described in the person-centred school as a respectful, collaborative, teamwork-like approach. In this way, the client-therapist team builds their alliance and works together, but—and this is a major distinction—it is all in the service of the growth of the client. And fair enough, given there is a fee attached. But it would be a deception to suggest that the therapist does not grow as well, or, as Yalom says, is not changed or affected by the work, or doesn’t think about the client beyond the therapy hour. How much of this knowledge is—or should be—available to the client? Do they even want to know?

Trish: Anne, you made a comment about not realising how much was going on “behind the scenes” in our sessions. This was probably in response to my talking about a certain approach I might take with a certain goal in mind. Do you think it is helpful for a client to know that what their therapist is doing is reparenting them, or providing empathic attunement, or providing a secure base that was lacking in childhood? I just can’t imagine a client caring about the what, as long as it works, but when I think about talking with other therapists about this work and leaving my clients out of the conversation, it seems ridiculous! I find myself imagining a conversation with fellow therapists:

Me: “Hey therapist colleagues, let me tell you about this great intervention I did the other day in a session…”

Therapist colleagues: “Oh cool…but how do you know it was great? Did you ask the client?”

Me: “Well… no… but, it’s in this book I read.”

Therapist colleagues: ‘“Yeah but how do you know it actually helped the client?”

Me: “Um… well, they probably don’t know it helped them… but… oh, shut up.”


Anne: I wonder at the disjunct between therapists’ acknowledgement that clients need to feel that you are not “above” us, are not inherently different from us, versus how infrequently clients seem to feel this sense of equality, accessibility, or sameness. As in James’ commentary above, I recognise the commitment in you, Trish, and others, to convey a sense of solidarity with clients; I also recognise what you have suggested many times, that clients do need that sense of being held, that the therapist is “holding things together” so that we can be vulnerable. Where is the balance between feeling this as hierarchical, and feeling in it together?

Trish: Anne, you are right that the balance is hard to find, particularly if there isn’t a dialogue between client and therapist about what is actually happening in the space together. As Yalom and others have often noted, it can be hard to know what helps in therapy, and I think quite often a therapist will have a different idea to the client about what was helpful, useful, or powerful in any given session. Sometimes a client will say to me, “When you said that thing last week, I found that really helpful.” And often I think, “Well actually, I didn’t quite say it like that, and it’s not what I meant, but OK. But didn’t you like it when I said this bit? You don’t remember that? Damn, I thought that was the good part…”


Cracking Ourselves Up: Enhancing Trust with Humour

Question: How many psychotherapists does it take to change a light bulb?

Answer: Probably just one, as long as it takes responsibility for its own change. This could be called having “a light bulb moment.”


Laughter has always been part of our therapeutic relationship, and we wonder as we go along what doorway this has opened to increasing trust. Our joking in the document is more frequent, but also a bit different in nature: more feeding off of one another, whereas in the room it’s a bit more measured. We are curious about the many roles humour seems to play between us in our dual roles. We discuss how—in the room—humour can also be a mechanism for deflecting, or keeping things on a more superficial level, and in this way is not always welcome. Nevertheless, once we begin our online interaction, the spontaneous humour grows. Trish writes of a time when she took a holiday and arranged for another staff member at the agency where she worked to see her clients if needed. The audacity of counsellors leaving clients in order to have some leisure time doesn’t go unnoticed by Anne in our track comments in the first article:

[Anne: how dare you LOL]

[Trish: How very BPD of you :)]

[Anne: LOL GUFFAW I think we may have a stand up routine by the end of this.]

[Trish: I know right? The side comments are almost as interesting as the article!!]


In this exchange, our shared humour strikes at the heart of the very condition that has caused Anne such anguish, and yet creates a moment of freedom as the heaviness of the label is discarded, all the while noticing that humour and pathos are indeed good friends. We agree that one reason both our irreverent humour and the creative collaboration work well is because it has emerged out of our pre-existing therapeutic relationship of almost six years. The trust and foundations were there before we altered our relationship, and Anne notes that widespread perceptions of BPD make it likely that such humour about the disorder would be hard to share with a therapist in a less established relationship.

One wall we have mutually hit together is a feeling of “too much”ness after the first essay, when we decided to continue writing together as well as still maintaining therapy sessions. The dual roles and time commitments of both soon felt too demanding, and we were able to talk about that openly and put some boundaries around it.


Trish: Anne, I recall that experience of “too much”ness was precipitated by your writing into our shared document about a dream you had had about me. I commented on how much was in the dream to be examined, but it seemed to be therapeutically, not creatively, relevant. Back then I wondered whether the writing together was blurring the therapeutic line in a confusing way. But now I think we see the line and we choose to walk along it courageously. I see an image of a tightrope walker, holding a long pole for balance. I wonder what the pole is representative of in our work together?

This experience caused us to recognise that we needed careful negotiation around how much and when we enact both roles: for example, do we collaborate while Anne is still a client? Do we have writing sessions and therapy sessions in the same week/month? After a time, we started to realise that they were folding back into one another in an iterative process that was becoming productive for both the writing and therapy, but we continue to monitor the efficacy of maintaining both roles simultaneously.


“Being Seen” through Creative Collaboration

Through humour especially, we both express a powerful feeling of being seen by the other, in deeper if not new ways. The feeling of “being seen” is, of course, a major part of the value of psychotherapy to a client, and was a strong part of Anne’s experience of therapy with Trish before the co-writing started. We decide to explore bringing some of this “whole person” or more interactive dynamic back into our therapy sessions, admitting that neither of us are quite sure what this will look like. We discuss how we might chip away at the “one-wayness,” the illusion of the therapist having no needs, feelings, investment. We consider questions like:

Is Trish always therapist Trish, even when we are co-writing?

What in that therapy space is different or the same?


It is confusing for us both at times, often in different ways.

Trish: I wonder, “Well what IS bringing more into the room?” I believe that my emotional responses are already an act of bringing myself. It is my standard practice to share things like “I’m aware that I’m feeling quite sad as you tell me this.”

We wonder together: what if we were writing a novel instead, or painting a picture? We are writing about our therapy, not something else, so it reinforces the therapeutic relationship. We reflect on the fact that Trish is also a teacher and practice supervisor, and in those roles she encourages her students to be prepared to walk the talk, to consider the ethics of asking clients to go further than they’ll go themselves. We begin to acknowledge our investment in each other.

Of course, our creative collaboration presents challenges as well as benefits. What if it dissolves, runs out of steam, or there is a creative rupture? We discuss the value of this changed way of working, despite the risks. We discuss whether writing about this will be of benefit to other client/therapist teams, and, if this multi-directionality in our sessions doesn’t work for all clients, whether it is still a worthy experiment to share publicly.

Anne: One reason why I have this trust of you is because you have hung in there, not rejecting me, through so many difficult times. And why wasn’t my treatment of you as challenging as so many others in my life? My hard behaviour, I think, is triggered by feeling rejected or judged. But rejection and judging is part of life. So how does unconditional acceptance (“unconditional positive regard”) by you help me handle rejection in the real world? One of the ways I’m suggesting is to regard you with care as a whole person, not just a “therapist.” That is, not just “there for me.” In thinking about this over the last little while, I believe the improvement in much of my behaviour comes from my starting to regard others as whole human beings with their own needs and validity, whether they reject me or not, meet my needs or not. How can I increase my ability to put myself aside and regard others in a less transactional way? If I were to do this with you in our sessions, what does that look like? Certainly not your therapy, or therapy about you. But maybe it’s more like, “How does it feel to you when I just talk the whole session?” or “Do I hurt your feelings?” or “Am I boring you right now?” Maybe attending to you (and others) is holding the dialectic of “My feelings are hurt right now, but I can also attend to your hurt feelings at the same time, or even first.” Part of improving my interpersonal relationships, I think, is being able to perceive my impact on people.

Trish: The process of writing the article with you has provoked me to re-examine the firmly boundaried position of this understood one-way process. No person-centred therapist wants to be a blank screen, and I have always believed I bring my genuine self to the therapy process with clients. Being willing to be more explicit about my internal responses to things you might say to me, rather than hold some therapeutic high ground as I bracket them off, seems like an important way forward.

We agree that it should be as intentional as setting some ground rules for the experiment. Trish suggests regular check-ins, like asking “How is this going right now?” Anne wonders how productive setting ground rules or negotiating terms of relationships might have been in other relationships or friendships, too; maybe with such agreements those relationships would have gone better. Trish suggests to Anne, “See? You are now connecting what we are doing in therapy to your life in the real world, i.e. negotiating with people around the types of interactions you have—what works for both. So here is therapy on the page.”


Mutually Revealing

One day after a co-writing session, Trish scribbles some notes, including:

Explore in what ways (even without Anne knowing) the relationship between us has been therapeutic:

  • Corrective emotional experience
  • Being there
  • Not abandoning
  • Staying with

…and that these things build trust.

Trish: I believe that so much of what a therapist does with clients is to provide a corrective emotional experience. When there is abuse or neglect or misattunement early in life, the therapy of care and unconditional positive regard gives the client the feeling of what it is like to be held. So for you, Anne, maybe some of that was to not have to listen to someone else and validate them (in the way you did for your adoptive mother) in order to feel worthy. That you get to have the experience of this for yourself. In some ways, it is not so important that it isn’t the “real world” but the world of the therapy room. The emotions are real. That I attend to you is real. And you don’t have to be “good” (thanks, Mary Oliver) in order to feel this. And feeling this with me might then motivate you to know that it is possible, and that maybe you can also feel it in your “real” life.


I have been thinking about this quite a bit over the last few days, and I have formed the belief that we needed to do this work (i.e. corrective emotional experience) before we could move into a space of being more overtly interpersonal. Trust is needed for that. I have often wanted to challenge some of my other clients with Borderline features to have a look at certain aspects of themselves and their behaviour that might impact other people, or even me, negatively, but I have found that there is a risk of their fragmenting. If someone already has a fragile sense of self, a suggestion that they could do something differently can be experienced as “I am a bad person.” So it is interesting that we are contemplating this experiment of giving the space between us more attention. Perhaps you feel secure enough in our relationship now to let me challenge you. If I let you see that I have reactions to what you do or say, that it actually affects me, I believe that you can hold this information and stay intact.

Anne: I have been thinking a lot for the past five days about my saying to you to “get over it.” One thing I’ve noticed with myself (is it the BPD?) is that sometimes I don’t intend to, but I am still quite harsh. I have always laughed this off as my New Yorker brusqueness. But is that an excuse for rudeness and not wanting to change? I’m sorry, Trish, that I spoke to you in that way. This is my being accountable interpersonally, even in a therapy session. I meant to encourage you. And I do think you are fearless in going to these places that are not the norm in the Australian context, and I love that and was trying to encourage you, but it came out in a rude and insulting way.

Trish: Twice now you have thought you might have offended me or been rude to me, and twice I have not felt offended or hurt. I wonder what you saw to think that you hurt me? An expression on my face, perhaps? Something in my response? Actually, I feel that on both occasions you were suggesting that maybe I could be more—an invitation to think big. And yet you think you were being dismissive or hurtful. I remember your saying recently that sometimes you find it hard to tell whether some communication between you and others is rude/aggressive or not. And then you might have to backtrack and check it out. I promise if you are nasty to me, I will tell you at the time and we can work out whether you meant it or not. You were witnessing my own discomfort with ambition. You didn’t cause it, you’re not the bad guy in this scenario. I am noticing and appreciating how you are thinking about the impact your words may have had on me.

Anne: I think it’s important to me that both of us acknowledge that there is fear perhaps around my BPD, because it is not only a disorder of separation, it is also a disorder of dysregulated emotions and behaviours. Through our work together and the safety of that, I am becoming more able to acknowledge the harms I have done to others and myself, harms that I can now feel regret and sadness about. That includes times I have hurt you in our work together, too, Trish. This doesn’t mean I won’t lash out (again). And as safe as I feel with you, we both know I have lashed out most often against those who are closest to me. So I recognise the courage it takes for you to continue to show up when you have witnessed so many of my hurtful behaviours to others, and sometimes experienced them yourself. That is brave, and I recognise the risk to you.

It is good and important to work together to improve my ability to calibrate my impact on others—to perceive it more clearly, perhaps—but also to model to other therapists that someone with BPD may be frightening or erratic, yes, but we can also be deeply reflective, resilient, empathic, courageous, and hungry to change. And we can care about you, even when we are mired in our own pain. And that this care for you can provide an important window to re-engaging with a world that is sometimes overwhelming for us.

Trish: You talk about acknowledging our fear around your BPD, and I wonder if it is the same for us both? You fear that you will still injure others, including me, despite how far you have come. I also fear that you could hurt me, too, might lash out at me despite the safety of our relationship. And as our therapeutic connection deepens, I take my place as someone at risk of being hurt by you. So how do we hold this fear in a way that makes sense? It brings to mind the dialectic of the work. Where there is fear, there is also bravery; where there is safety, there is also risk. And of course, as always, there is the knowing and the not knowing. It is inevitable that we hurt or disappoint the people who mean the most to us. We will do wrong, it is the nature of the imperfect relationships in which we all engage. And that brings us back to trust. With trust we are able to stay in touch with the resilience and perseverance that we see in one another, which makes repair and recovery possible. So when you care for me, and for others in their turn, know that what you are doing is an ongoing process of recreating a secure base that is at the very heart of what we all yearn for when we love and feel loved in return.


Epilogue: Returning to Embodiment—March 2021

Anne: I’m glad I came to your office today. It has been a long time since we have shared space, and so much has happened in the interim, with COVID and multiple lockdowns. I was aware of you again as a changing human person, and the affective intensity of proximity. I think one reason I felt moved today was not just about the content we were discussing, but about the relationship and the exchange. It is, as Tara Brach would say, sacred ground, where people feel seen and heard. It’s so powerful. That room is a powerful sacred space for me.

Do I have anxiety about going backward, now that my DBT has finished? Disappointing you? Being disappointed by you? Of course! That’s every relationship, surely. Today I just felt moved by the proximity, the laughing—so much laughter!—the attending, the eye contact, the ambient noises, the longevity, the commitment, and the hope, even when I can’t find exactly who I am. And also the power of the room itself. That familiar room—the white blinds, your desk, cup, computer. The little table by the couch, the bin. Pepper had died during lockdown, and I felt his absence so strongly in the room. The environment matters, and I can see it now as another expression of you, of another way of your “bringing yourself” to your clients.

Trish: Yes, it was pretty powerful being together in person today. There was a certain energy which may well have been about how long it has been since we took up the chair and the couch, or perhaps about the added layer of the creative space that we are sharing as we write, knowing that our words on screen find calibration with the ones we speak to one another. Were you more aware of me than you have been in the past? You have said you wanted to be able to hold space for others while you navigate your own emotional space. I think I noticed a subtle shift—while you certainly wanted some thoughts from me about what was going on for you, there was something different, more of an ease in you and a space created for me. And somehow I felt that even though I didn’t really have a clear answer for you, I was still offering you something, and you saw that (and subsequently wrote about it). This work together is making me examine myself in the most profound way, and if I want you to do it, then I will, too. Maybe I am also trying to find out exactly who I am when I am in a therapeutic encounter with you. I know one thing, I will trust the journey.

Anne: I was more aware of wondering what techniques you may have been using, and why. That relational aspect that I had never really thought much about before our co-authoring. I assumed the therapist just showed up and it was a one-way thing. I’m enjoying this change in my awareness: not only in terms of acknowledging what you are bringing, but also for me, thinking relationally about you. You exist. You are thinking and feeling things, not just absorbing. I also think we had a lot more eye contact yesterday than usual, that was something I was aware of. And also the laughing… Why do you think we laughed more yesterday than usual? My perspective is that it was just a bit of happiness to see you again, and also I felt you laughed more than usual and that felt like a kind of openness from you.
 

***
 

As recently as 2015, at the end of Creatures of a Day, Yalom  (4) reminds us that even in the United States, these kinds of relational accounts are all too rare and
 

not generally available in contemporary curricula. Most training programs today (often under pressure by accreditation boards or insurance companies) offer instruction only in brief, “empirically validated” therapies that consist of highly specific techniques addressing discrete diagnostic categories… I worry that this current focus in education will ultimately result in losing sight of the whole person and that the humanistic, holistic approach I used with these ten patients may soon become extinct. Though research on effective psychotherapy continually shows that the most important factor determining outcome is the therapeutic relationship, the texture, the creation, and the evolution of this relationship are rarely a focus of training in graduate programs.


For Trish and Anne, this focus on our creative collaboration allows a deepening of trust and strengthening of our relational dynamics. Trish (and sometimes both of us now) uses many of the suggestions Yalom offers for calling attention to the bond between patient and therapist including: doing process checks, inquiring about the state of the encounter during the session, Trish’s asking if Anne has questions for her. Through creative collaboration, trusting in the here and now becomes multi-modal and multi-directional in ways that can offer new forms of corrective emotional experience. It has also firmly established a secure base, the core purpose of strong and trusting client-therapist relationships, never more important (and challenging) than with clients with Borderline Personality Disorder.
________________________
(4) Creatures of a Day and Other Tales of Psychotherapy

Jessica Stone on Play Therapy in the Digital Age

Posted on by rezendevknowfully.com

Crossing the Digital Divide

Lawrence Rubin: Hi, Jessica. Thanks for joining me today. How did you become interested in digital play therapy, which really is cutting-edge and somewhat controversial with children?
Jessica Stone: I kind of straddle a few worlds here. I am a licensed psychologist with a specialty in play therapy. Within it, digital play therapy has become one of those areas of interest over the last 20 years, stemming from experiences with my own kids, who had this whole portion of their world that I didn't really understand, know about, or enter into. It struck me as a little bit ironic and maybe even hypocritical that here I spend my time at work and my energy learning and doing play therapy with children and entering their world, while my own kids have this whole portion of theirs that I was putting no effort into understanding. And so, I kind of had to smack myself upside the head and say, all right, I need to learn more about this. Why is this important to them? Why are they interested in it?

Long story short, I ended up entering into an online game called Runescape that my oldest two (of four children) were both playing at the time. I am no digital native by any means, and I was not very good at these games, but the point was that I was taking interest. I was listening to them. I was asking them questions. We were having conversations about what happened in the game, what quest they were working on; things that were important to them that prior to my entering their world, I couldn't participate in or even understand. I began to see that because this co-play was so impactful with my own children, I needed to incorporate it into my work, which really opened the door to what I have been doing for all these years.
LR: So, you recognized that technology was so important and present in your kids’ life that you would be almost doing a disservice to your young clients if you didn't cross that bridge into their digital world. Tell me, what exactly is digital play therapy?
JS:
I am no digital native by any means, and I was not very good at these games, but the point was that I was taking interest
Digital play therapy is a modality that is based in speaking the client’s language through what I call the four C’s, which are competency, culture, comfort, and capability. These are basic elements of therapy in general, but digital play therapy in particular is couched within the broader context of prescriptive play therapy, which taps into what Charles Schaefer calls the therapeutic powers of play. So the point is that there is a foundation for it. It's not just, oh, let’s just jump on this bandwagon and start throwing these digital things into what we’re doing. We as clinicians need to have a very firm and solid foundation in what it is we’re doing and why we’re doing it regardless of our theoretical foundation, therapeutic modality, and interventions, or whether the platform is virtual or face-to-face. And as in all therapies, we must ground our interventions in solid case conceptualization and treatment planning.
LR: I know that Charles Schaefer co-founded the Association for Play Therapy and has written extensively on play therapy, but can you tell our readers what he means by the “therapeutic powers of play?”
JS:
it's not just, oh, let’s just jump on this bandwagon and start throwing these digital things into what we’re doing
If you can close your eyes for a minute, imagine a graph with four quadrants that represent what he calls the core agents of change. These are facilitating communication, fostering emotional wellness, increasing personal strength, and enhancing social relationships. In turn, each of those quadrants consists of the 20 therapeutic powers of the play. For instance, in the quadrant of “facilitating communication”, we have self-expression, access to the unconscious, direct and indirect teaching. In the quadrant of “enhancing social relationships,” we have the therapeutic relationship, attachment, social competence and empathy, and so on. I think what Dr. Schaefer has done is given us a really amazing foundation from which to then tailor and customize it as fit for whatever our modality and our theoretical foundation would be.
LR: So when working with children, it's important to consider their communication skills, their emotional development, their strengths, and their social connectivity, and then if you choose to work digitally with them using an app, a video game, or even a virtual reality platform, you are doing so from a solid theoretical foundation and justification for that intervention.
JS: Right, and one of the things that I wanted to add was
there are three levels of digital play therapy: at the first level, you are simply open to it, including it in the conversation, and trying to understand why it's important for that client
that there are three levels of digital play therapy. At the first level, you are simply open to it, including it in the conversation, and trying to understand why it's important for that client. The second level would be when someone brings in, for example, a YouTuber that they are interested in, or a game, and they want to show you a video of it, or together you're looking up information about it. So you're using a digital tool, but it's to learn more about it and to share in some aspects of your client’s life. The third level would be all of the above and would also include actually meeting with your client within a game (whether you are with them in the room or virtually) or using an app together. And so, in order to have digital play therapy, you don’t have to be in the Roblox game with them. You could be at level one or level two, talking about it, asking questions about it, or having your client show it to you, or taking a tour of it.

If Not for the Legend of Zelda

LR: And that becomes part of the treatment plan as well. And you may not even know which level you're going to be entering into until you know the child a little better. Can you give an example off the top of your head of a level three experience that you had with a client?
JS: Absolutely, but I’ll sanitize all over the place for obvious reasons. I had a little elementary school age guy who came in to me because he was selectively mute. He didn't speak to any adults, including his teachers. He spoke to his parents, but he didn't speak to any adults outside of his home.

We had this amazingly intricate way of playing the physical game Guess Who, not the digital version. We came up with this whole worksheet with all the different options that he could point to and we were really proud of ourselves for having gotten to that point. But then he wanted to move on and saw that I had a Nintendo Switch sitting on my shelf. He pointed to it, and I said, “Oh, yeah. You know, I have this Switch, and really the main game I have on there is Legends of Zelda.” I listed the other games I had, but the main one that the kids really wanted to play at the time was Zelda: Breath of the Wild, and so he wanted to play it. By the way, I have the “regular” Nintendo Switch, the one with the two removable handset controllers and central viewing screen that both players can see.

We each had a controller, and I said, “But what we have to do now is to figure out how we’re going to communicate, because one of the handsets controls where the person is looking, and the other one controls where the person is walking. So if we’re not communicating, we’re going to go off a cliff, or we’re going to run into an enemy, or, you know, something is going to happen because we’re not explaining to each other what our agendas are, or what our desires are.”

it was a breakthrough that I really don’t know that we would have had it were it not for Legend of Zelda
He also had a tablet that he could type on to communicate so he indicated that he would point because he was the walker, and I would be the looker. As we were playing, we came to this dangerous thing and it became this frenzied moment because we were going to be attacked. All of the sudden, he screams out at me, “Look over there!” While I had never heard his voice before, I didn’t want to make too big of a deal of it.

I was like, okay, play it cool, but inside I was so excited. Out of the corner of my eye, I see his hand fly up over his mouth, like, oh, my gosh, I can’t believe I just did that, right? And I said, “Oh, I’m so glad you said that,” and I looked where he told me, averted the danger and we went on. I said, “You really saved us. I’m so happy that you talked to me to tell me that because we would have totally been attacked.” After that pivotal moment, he would chitchat, and there weren’t any communication lapses. It was kind of like, well, the cat is out of the bag, and I didn't make it an unsafe environment for him to do so, and it was a breakthrough that I really don’t know that we would have had it were it not for Legend of Zelda, the two controllers, and the need to communicate with each other. It's amazing.

The 4 C’s of Digital Play Therapy

LR: That was a breathtaking moment. How does it capture those 4 C’s of digital play therapy you referred to earlier on?
JS: The first three—competency, culture, and comfort really culminate with the fourth, which is capability.

Competency is those core skills that derive from our theoretical beliefs, experience, and continued education, regardless of our discipline of practice. It is within the professional. It is what we bring into the therapeutic space.

Culture is very interesting to me and something that we’ve talked about for decades as being important to incorporate into our clinical work. It has blossomed and expanded from religion, race, and place of origin to include other facets of peoples’ experience, like music, food, and interests, and of course their digital involvement.

A while back, I was invited to speak at a PAX convention, which is like Comic Con but for people who enjoy gaming. There were literally thousands of people there, all of whom shared this common experience and who have historically been characterized as “other,” with all the stereotypes that go along with gamers, like spending days in their mother’s basement playing video games.
LR: They don't fit in.
JS: They don’t fit in. And while I don’t want to perpetuate any of those damaging and non-appropriate stereotypes, there I was with thousands and thousands of people and I was the “other.” I’d never felt like the other in my life, but in that moment, it really struck me that it is such a disservice to think of people who have digital interests as “others.”

First of all, it is quite hypocritical, because at any given moment, most of us have a device near us. We have a phone we don’t leave our house without. We have our computer, and millions of people play very casual games like Bejeweled or Candy Crush on their device. So, it's quite hypocritical for us to say, “Oh, those people are others,” when really, there are simply different levels of gaming. So, the culture piece is really important to me, and we can’t simply reject portions of our clients’ lives—in this case their digital interests.
LR: If technology is so significant a part of our culture, why is there still a seeming reluctance on the part of some clinicians to incorporate it into therapy, and in this case play therapy with children?
JS: That actually brings us into the next C, which is comfort, the importance of which is that we be genuine and congruent within ourselves, and that's something that I think that a lot of therapists don’t have about technology. I talk to people, and they're like, “I don't know how to get my photos off my phone. I don't know where to find them.” So first, I think it's just basic knowledge and comfort. We know that at the beginning of the pandemic, people were freaking out. They didn't know how to use a platform like Zoom or, you know, whatever it is that they're using. Where do I get the link? How do I get into the app? How do I talk to people? What if they can’t hear me? As therapists, regardless of whether we are working with adults or children, we have a lot of things to think about when we’re in session, including, how does this fit into our case conceptualization and align with our treatment goals?
LR: How do I validate it?
JS: So
when a new anything is added into that therapeutic mix, like technology, it throws everything else off kilter a little bit so that we don’t feel secure, we don’t feel congruent
when a new anything is added into that therapeutic mix, like technology, it throws everything else off kilter a little bit so that we don’t feel secure, we don’t feel congruent, and now we are not only worrying about the logistics, but also whether I am doing the right thing for my client. And so when you package all that together, it's like, oh, I don’t even want to touch that because it’s too risky. It's too scary. In my book, Digital Play Therapy, I refer to this as techno-panic. We can point to so many different points throughout history, such as Socrates saying that the written word was going to destroy the oral word. Radios are going to destroy… TV is going to destroy… Video is going to destroy…
LR: So techno-panic results in people, and perhaps in our case therapists, keeping their distance from technology because of anxiety, worry, and insecurity.
JS: Yes, I’m going to keep my distance, because that has enough in it to scare me but not enough to inform me.

And by the way, the fourth “C” is capability—something to bring the other 3 C’s together. Capability means continually striving and reaching forward throughout one's career to embrace, or at least consider new modalities, concepts, and techniques to discover, explore, and practice.

The Virtual Sandtray: Origins

LR: This conversation reminds me of an experience I had a few years back when I encouraged a fellow play therapist, Deidre Skigen, who had been using the SIMS program as a virtual sandtray, to write an article for Play Therapy magazine. Soon after it was published, a veteran sandtray therapist (and purist) sent in a 32-page paper lambasting the idea of using a simulated sand tray. According to your 4 C’s model, this veteran clinician could probably not check off any of the C’s. With that said, please tell us about your groundbreaking app, the Virtual Sandtray.
JS: Sandtray is amazing and has been around for just about 100 years.
Dr. Margaret Lowenfeld started with the World Technique in the 1920s while working with kids after the war
Dr. Margaret Lowenfeld started with the World Technique in the 1920s while working with kids after the war. She really wanted to understand more about their experience and, in particular, their resilience. She understood that the sand tray is a creative, projective way of working with people either nonverbally or verbally. Traditionally, it's a tray with a blue bottom, and depending on the clinician’s theoretical orientation, can be made in different sizes. It can be populated with various objects and figures, which when placed in the sand create a symbolic representation of the child’s external world, their unconscious conflicts, fantasies, and projections.

It can be freeform, and then it becomes the clinician’s job to understand what that client is expressing. Sometimes people will tell a story and narrate it. Sometimes they won’t. There’re so many things that will depend on where someone’s theoretical foundation is coming from with regard to sand therapies. This is the foundation and fundamental aspect of doing sandtray therapy—your client is creating a world, a microcosm right there with you.
LR: And your Virtual Sandtray app?
JS: In 2011, following a devastating tsunami in Japan, my very good friend and colleague, Dr. Akiko Ohnogi, co-founder of the Japanese Association for Play Therapy put out a plea, “Please send us materials. We have all these people.” She and her therapist-colleagues needed materials to work with people impacted by the tsunami.
no matter what you do, sand is bulky and heavy and will escape whatever you put it in, no matter what, so an alternative was needed


I got together a bunch of stuff, and I sent it over feeling quite proud of myself for contributing to all of this but then thought to myself, how are they going to do sandtray without a sand tray? While sand trays are very popular in the United States and come in many varieties, portable kits are clumsy at best, and how were we going to get all the necessary miniatures to them? No matter what you do, sand is bulky and heavy and will escape whatever you put it in, no matter what, so an alternative was needed.

As it happened, I had received an iPad for Mother’s Day that was pretty cool to have, but it wasn’t getting much use until I thought, “It should be on an iPad.” And then I started thinking about how it could be used by clinicians and interns in hospitals and schools, in crisis situations as well as in traditional therapy spaces, whether in-person or online. A virtual sand tray could be used with immunocompromised people and clients who were traumatized and would be triggered by the sensory contact with the sand. Interestingly, my husband had taught himself to program when he was a teenager. He said enthusiastically, “You know, I’m going to start that project for you.” Being married, I had of course heard that line before, but he proudly proclaimed, “Oh, that sand tray project.” It just bloomed from there.

the Virtual Sandtray started out as a touchscreen app so that you could have the kinesthetic experience of the creation of the tray
Dr. Schaefer invited me to his annual retreat/think tank, so I was able to share my thoughts and receive excellent feedback from my play therapy colleagues. And Drs. Linda Homeyer and Daniel Sweeney, who wrote the definitive book Sand Tray Therapy, offered to beta test it and provide additional feedback. So, I was very fortunate to have such amazingly educated and experienced people giving us information, knowledge, and feedback on our app.

The Virtual Sandtray started out as a touchscreen app so that you could have the kinesthetic experience of the creation of the tray. I also did a lot of research and reading into Dr. Cathy Malchiodi’s art therapy work about the inclusion of digital-art representation and symbolism and I am so proud to say that we have recently partnered with the Lowenfeld Trust, who endorsed our product and the way it has stayed faithful to the basic tenets of her original work with the sandtray.

The Virtual Sandtray: Applications

LR: So what exactly can you do with the Virtual Sandtray app, and what clients is it best suited for?
JS: So, I'll say this as a nutshell and then put it to the side. There are a lot of administrative features that we’ve built in for the therapist which are separate from the actual clinical uses. It is also important to note that the app is atheoretical, as is use of a physical sand tray. The Virtual Sandtray app is like all other materials in the playroom, a tool that is adaptable to the clinician and the client, regardless of presenting issues. It is also useful for any age, as is a physical sand tray.

You can dig in the sand. You can build up the sand. You can paint it, add grass, or water, or cobblestone, or you can have it be sand color. You can place 3D models in it, rotate the tray, and navigate at any angle. Like a physical sand tray, it is three-dimensional in every regard.

a happy-go-lucky scene of rainbows, butterflies, and unicorns can be created against a dark and foreboding background


You can make the models bigger or smaller, turn them around, move them, and knock them over. You can blow them up. You can change the background. A happy-go-lucky scene of rainbows, butterflies, and unicorns can be created against a dark and foreboding background. Congruence between the main scene and the background is relative. You can dig down in the sand, paint the inside of the tray blue so that the bottom of the tray is like water.

 

11 Year-Old: Safety and Security with Unicorns and Fence, but Danger (Dragons) Lurking
 

 

Adult: Castle as Calm Space/Sanctuary

 


You can create a multidimensionality in the sand so that, for instance, two layers would just be sand, but the third layer is liquid. So, in the happy-go-lucky scene I mentioned above, you can change the liquid layer to lava. So now we have a multilevel, multidimensional depiction of this world for this client. We also have camera filters, so you can make it look like it's snowing, or raining, or you can invert the colors. You can do night vision, like it’s seen by aliens or something like that.


9 Year-Old: Red Dragon Scene- Danger, Missing Scary, Unsafe, Trauma


Therapist Process Tray: Sadness Over Missing out On 4th of July Due To COVID

LR: Jeez.
JS: One of my current favorites is this one called “broken,” and there’s a couple different broken varieties, but if you can imagine a scene where the person has created a scene depicting their family and then they use the camera filter so it appears shattered. This might reflect how that client feels about their family.

By the way, you can save trays and load previously saved trays to work on again. The clinician can review and compare/contrast the in-person with the online sessions. In the secure, encrypted remote mode with a free client version, no personal health information is collected, and there are multiple language and accessibility features and well over 7,000 3D models available.

Sandtray with a VR Twist

LR: In your book, you talk about the virtual reality version of your sandtray app.
JS:
In VR with the Virtual Sandtray, you can be either up in what's called God mode, where you're up above the tray, looking down, or you can come down to the level of the sand tray and interact with your creation
In 2016, I started learning more and more about VR. I remember thinking, "Mental health is going to explode with virtual reality." So my husband created a version of the app for virtual reality. In VR with the Virtual Sandtray, you can be either up in what’s called God mode, where you're up above the tray, looking down, or you can come down to the level of the sand tray and interact with your creation. So imagine a child is depicting a theme in which they have been bullied at school, or an adult client is interacting with their spouse and that interaction has been traumatic. Unlike with the Virtual Sandtray app, the client can go right down to the level of the depicted scene to walk and interact within it. It is an entirely different level of immersion. You can certainly crouch down in a traditional tray and become more physically engaged—grab the items and narrate, and move them around and all of that. But in VR, you're staring them in the face. The thing is right there. It's a really powerful, amazing, immersive experience to use the virtual reality version of it, and I’m really proud of that.
 


Animated Bullies Looking Down on Child Who is Much Smaller/Crying



Bullied Child As He Would Like It To Be—He Is Now Bigger and Talking To Them
 


VR Version of Sandtray of 11 Year-Old’s Sandtray Scene From Above

LR: Readers may be familiar with the use of virtual reality in cognitive behavioral therapy, in exposure and response prevention. And this isn’t necessarily used for exposure in an anxiety or trauma reduction sense, but it's adding another level of immersion into the play.
JS:
VR could be used in an exposure play therapy format by putting a big spider in the tray or scene
VR could be used in an exposure play therapy format by putting a big spider in the tray or scene. I can make that thing enormous, and then it becomes a challenge to the client, who has to ask themselves, “How do I manage that? How do I keep myself safe? How do I titrate toward, or away, or whatever it is?” I use VR in my clinical practice for a variety of reasons. I’ve used it with adult women for empowering them. I’ve used it with all ages for identifying safe places and spaces.

I even have a job simulator. I have a kid whose life is very regimented, and she comes in, and she just destroys the whole office. She chooses the job of being an office worker, and she goes in and dumps the coffee, and throws things, and just makes this huge mess, and it's so cathartic for her to do this with no real-world consequences.

Synchronicities

LR: What’s the difference, Jessica, between synchronous and asynchronous telemental health play therapy?
JS: This conversation that we’re having right now is synchronous. We’re both here at the same time, speaking to each other, even though we’re in different locations. If you have synchronous learning, it's the educator and the student in the same place at the same time. Asynchronous is when we were emailing back and forth. Or it may be an online platform where the educator and the student are not in the same realm at the same time. In therapy, it would be the therapist and the client were not in the engagement at the same time. So when we give a client homework, or when they're going to draw something or create something, or make a list, or whatever it is, that would be asynchronous.
LR: In face-to-face (live) play therapy, the clinician has all the goodies right there in the room—the drawing materials, blocks, sand tray, clay, papier mâché, and dollhouse, to name a few. How is this done online in a synchronous format?
JS: There are just so many different things that people are doing, and it's just wonderful. The resilience of human beings is amazing. A lot of clinicians have either identified what the client has on their end and what the therapist has on their own end, and then they can each use their materials when they see each other; for example, they could play Uno. And we’re talking about, like, traditional play materials. If we’re talking about digital, there’s a way to do so many things digitally.

Other clinicians have created play therapy kits that the client can pick up or that get delivered, so both have similar materials in their respective spaces. In a sense, it’s parallel play. I’ve had a couple of clients just say, “Okay, let’s draw a whatever-it-is,” and then on my end, I do it, and on their end, they do it, and then I hold it up and they hold theirs up and we show each other. If you’re doing it digitally, you can screen share. What it boils down to is using the tools and materials that have clinical significance and relevance and that meet the needs of the client and their treatment, and that ties into your therapeutic modality of choice.

And this brings us way back to that fourth “C,” capability, because if we really understand what we’re doing and why we’re doing it, then we are able to identify those components and find alternate ways to employ them, but if we don’t have them identified, what the hell are we doing?
LR: What you're describing seems parallel to your experience at the PAX conference where there was this alternate mainstream, and you were the “other.” I imagine that there are some therapists out there who fall into this “other” category, as well as those who are curious and in need of training and exposure, and a third group that has already embraced digital play therapy.

As we come to an end, Jessica, can you name five apps that you have found most useful therapeutically with children?
JS:
I will say that the Nintendo Switch has been an amazing resource for me in therapy, whether through telehealth or in person, and the same goes for my use of virtual reality platforms
Like you said, the Virtual Sandtray would be my tippy top. I have found a lot of therapeutic value in VR programs, and that, again, can open up a whole ‘nother conversation. I will say that the Nintendo Switch has been an amazing resource for me in therapy, whether through telehealth or in person, and the same goes for my use of virtual reality platforms. Underneath that, Roblox. While I know a lot of people who let out a collective groan about Roblox for a number of reasons, I would ask techno-curious readers to watch YouTube videos. Learn more about it. Play some things yourself. It's not as scary and awful as a lot of people think it is. You have to be savvy and have some digital citizenship.
LR: Digital citizenship.
JS: There’s hundreds and hundreds of options to choose from, different varieties and genres that you can then tailor to your client’s needs and interests. It's like Disneyland, you know, for options. Then we have Uno Freak. I mean, that's really basic. We’re just going to play Uno. Like, you put a card. I put a card. You put a card. I put a card. Draw cards. You know, just really basic, fundamental. I actually like the Uno Freak version of Uno better than the card version.

There’s Board Game Arena, and there’s a couple other board game types, as well, traditional games like chess, checkers, Othello. Battleship is a good one, but there are hundreds of other games that you may never even have heard of that you can explore, and they each have little tutorials to walk you through it. So I would say those are really fundamentals that people could start with. Certainly, if people want to know more about some of the other arenas, then I’m happy to do that. Skribbl is there if you want to play something like Pictionary. You both join. You draw. You guess. You laugh. You engage. You learn a lot about people’s frustration tolerance and their coping skills and styles, as well as their interpersonal skills and styles.
LR: Maybe the greatest takeaway from this conversation, Jessica, is that, while this may be scary and new and even evoke techno-panic in those who are probably prone to techno-panic anyway, it really is worth becoming more aware of, because there’s probably not as much of a divide between digital play therapy and nondigital play therapy as people fear or think. Anyway, the real healing comes in the relationship between the therapist and the client and how we use whatever we have or whatever they bring to help them to get where they're going.
JS: I really would like people to think of it as an "and", not an "or". And that we can take all those fundamentals and use them in really powerful ways, whatever the medium is.


LR: And I think, on that note, we’ll stop. Thanks so much, Jessica, for pointing us to the bridge between the digital and non-digital world of therapy and, in particular, play therapy.

Pandemic Lessons for Introverts (and their Therapists)

Posted on by Psychotherapy.net Team

Melissa* is a professional in her early thirties. She is married and has two dogs and a cat. She is also a self-described introvert. “What that means,” she said when we first started working together “is that I like people, but I don’t like socializing. I’m happiest when I’m at home with my husband and my pets. I prefer working in my garden to being around other people.”

Melissa is one of many self-described introverts for whom the COVID-19 pandemic has provided a surprising and often welcome respite from the difficult demands of everyday interactions with others. The concept of “introversion,” popularized by Carl Jung, is often described as a reserved or shy person who enjoys spending time alone. As with most descriptions of personality, introversion and extroversion exist on a continuum, with most of us experiencing a mix of these characteristics, and many people who consider themselves more on the introverted side of the extrovert-introvert continuum have still had difficulties during the pandemic. But, as a recent New York Times article suggested, forced separation from their hectic lives has given some people the opportunity to see just how hectic those pre-pandemic lives were (1). After reading the article, Melissa resonated with the example of Josh Bernoff, a public speaker and author who lives in Arlington, Massachusetts, who acknowledged how stressed he had been prior to the pandemic as he was constantly traveling, planning his next on-the-go meal, and forced into socially awkward conversation with veritable strangers.

“That’s exactly how I felt,” she told me. “I hadn’t thought about how hard I work all the time to do social stuff that other people find so simple.”

Years ago, individuals who were quiet and reserved were often admired, but today, at least in the United States, according to Susan Cain, author of Quiet: The Power of Introverts in a World That Can't Stop Talking, introversion and its often-associated characteristics of sensitivity and shyness has become synonymous with some type of personality flaw (2).

Melissa, who had grown up in a world that admires the outgoing extrovert, spent much of her life feeling ashamed of herself for preferring solitude to social interaction. “I’ve always thought there was something wrong with me,” she told me early in our work together. “So, I’ve worked hard to be more outgoing, even though it’s never been comfortable.”

The reality for Melissa, as for many self-proclaimed introverts, was not quite as black and white as it might have appeared at first. During the pandemic, even as she was enjoying her time alone, she found herself thinking that it might be nice to spend a little time with one friend or another. But as the world has begun to open, Melissa is taking stock of some of the lessons she has learned about herself during the pandemic.

“I don’t want to get caught back up in that crazy social schedule I had before,” she said. “I want to be able to find time for myself, to read, listen to music, go for long solitary walks. But I also want some time with people I care about.”

I asked her to talk to me about what appealed to her about spending time with those people. “That’s a really interesting question,” she said. “I don’t think I’ve ever taken the time to think about what I like about being with them, because I’m always so busy either forcing myself to spend time with someone when I don’t want to or pushing people away because they want to spend time with me when I want—need—to be alone.”

I asked her to tell me about what she liked about being with friends and family she cared about, and as she tried to explain it to me, she realized that she actually enjoyed her time with other people when it was her choice to be with them.

I said, “You need more quiet time than some of your friends and family, and more time alone. But it’s not that you don’t like being with people at all.”

“You’re right,” she said. “I just realized that one of the things I’ve really liked about the pandemic—and I hate that so many people are suffering from it, and I kind of feel guilty about the fact that I’m enjoying anything about it—but one of the things I do enjoy is that when I talk to a friend or my sister or my mother or a colleague on Zoom, it’s for a limited time. Most of us just can’t stay on Zoom forever, so it has a natural limit that’s probably much more like my own personal limit.”

We were both silent for a minute, digesting this idea. I was wondering if there was a way to carry this new information about herself into the world as it opened up and had just started to ask her that question when she said, “I’m trying to figure out if there’s a way I can use that knowledge about myself moving forward. I have to go back to work, and I have to start seeing my friends and my family again. But can I set some kind of limits with them? Or will I just fall into the same habits as before, going along with what seems right to them and then fighting to find my time and space?”

As the apparent slowing down of the pandemic leads businesses to re-open and social life to ramp up, Melissa, like other clients who have enjoyed the time on their own, faces an interesting dilemma. She put it this way in one of our discussions: “I’ve learned a lot about myself during this time,” she said to me. “Now I want to see if I can incorporate my sense of peace about myself as a less outgoing person with my desire to be connected—but on my own terms.”

Many clients who do not consider themselves introverted at all have also told me that they learned to appreciate time on their own more than ever before. As another client put it, “It seems like some of the activity in my life was doing stuff because I was afraid of feeling left out. It felt really good to slow down, to be on my own, and to do things that I wanted to be doing, not because I was driven to be part of the crowd.”

The gradual ending of the isolation resulting from the pandemic has brought on some concerns, including what Melissa and several other clients call “fear of re-entry,” that is, fears about returning situations in which interpersonal interactions stir up discomfort and anxiety. But one important takeaway for therapists and clients has been to pay attention to and respect what they have learned about themselves during this time. We therapists can help clients recognize and respect their own needs and shift away from always pushing themselves to engage in social activities. Recognizing the “power of introverts” can lead to acknowledgement that it can be useful to respect their own qualities, even if they do not meet the demands of an extroverted culture. And many clients might also discover for themselves what Melissa recently told me: “As I allow myself to take the time alone when I need it, I find that I’m able to engage in the social interactions that I want to engage in much more easily.”

*Names and identifying information changed to protect privacy

References

(1) Richtel, M. (2021) The U.S. is opening up. For the anxious, that comes with a cost. Retrieved from https://www.nytimes.com/2021/03/17/health/US-reopening-anxiety-ocd.html?action=click&module=RelatedLinks&pgtype=Article.

(2) Cain, S. (2013) Quiet: The power of introverts in a world that can't stop talking. Crown.

Additional Writings on Introversion

Buelow, B. and the Introvert Entrepreneur. (2012) Insight: reflections on the gift of being an introvert. Introvert Entrepreneur.

Dembling, S. (2012). An introvert's way: Living a quiet life in a noisy world. Penguin Books.

Helgoe, L. (2012) Introvert power: Why your inner life is your hidden strength. Sourcebooks. 

Imagining the Way to Self-Compassion Using the Ideal Parent Figure Protocol

Posted on by Psychotherapy.net Team

“I know I’m supposed to be self-compassionate, but I don’t know how to do that, and that makes me feel even more like crap!”

My patient Sally has struggled with years of chronic depression. Through hard work in therapy, she understands that her rough childhood has set her up with a tendency to be harsh with herself. She understands that energy wasted on self-criticism and negative emotion leaves her less free to take initiative and connect with others. But when she wakes up in her apartment alone, all that wisdom seems to fly out of her head, and she feels crushed by a load of self-loathing.

Much the way we learn language, we learn patterns of relating to ourselves early in life. John Bowlby and researchers who followed him described this process as the formation of secure or insecure attachments to a caregiver. People lucky enough to have warm and sensitive parents can develop a secure attachment, which leads to the development of kind and encouraging ways of being with oneself. This inner soothing and encouragement support brave engagement with the world that helps reinforce a sense of the self as capable, and of the world as responsive to one’s needs. A smoothly functioning emotional system allows wise choices in response to the present situation in accord with one’s values.

For those who did not internalize a relationship with a sensitive and encouraging caregiver, life is harder. They can become overwhelmed with feelings of shame, helplessness, anger, and fear, or they may feel depressed, deadened, or cut off from experience. Unregulated or silenced emotions inhibit healthy exploration, which reinforces negative images of the self, generating further negative emotion and inner harshness. Self-compassion can seem like a strange and distant land.

Enter the Ideal Parent Figure visualization protocol, developed by Daniel P. Brown, PhD. as a method for healing attachment disturbances in adults (1). His method relies on the fact that the unconscious mind does not distinguish between images that derive from memory and those that come from the imagination (in fact, most images that we think of as memories are imaginary reconstructions of events). With deliberate visualization practice, we can come to “know” something we did not directly experience. In this method of treatment, I ask Sally to visualize herself as a young child and to imagine ideal parent figures that are perfectly suited to her and responsive to her needs. From there, I ask her to imagine herself playing and exploring with the ideal parent figures offering perfect support and encouragement. Once that imagery has been established, we will have her use these Ideal Parents to respond to her in moments of distress, giving her a visceral sense of an attuned, soothing, and encouraging relationship, and a vivid sense of how she can treat herself.

Sally was dubious. “That sounds kind of cheesy,” she told me. “Also, I can’t really imagine what ideal parents would be like.”

That’s exactly the point. Kids who grow up with parents who were unable to provide good-enough care will stop hoping for something that never comes. We protect ourselves by not thinking about what we can’t have, which reduces the pain but, if practiced repeatedly, can create a deliberate (though unconscious) failure of imagination. The Ideal Parent Figure visualization protocol seeks to reverse that. It turns out that no matter how terrible and abusive one’s childhood was, each of us knows what we needed to thrive. I find this to be a wondrous and hopeful thing.

Ideal Parent Figure visualization uses the process of exploration to discover the kind of support that fosters further exploratory behavior. This method provides a solution to Sally’s frustration of “not knowing how” to be self-compassionate: she will explore until she comes upon the experience. As the therapist, I will provide her with support and light guidance as she navigates this uncharted territory. I’ll be prompting her to imagine Ideal Parent Figures who have five key features: 1) The Ideal Parent Figures are reliable and consistently present—they provide a deep sense of safety and refuge that creates a secure base from which to explore. 2) The Ideal Parent Figures are perfectly attuned; they see us and accept us exactly as we are, which sets us free to be completely and authentically ourselves. 3) The Ideal Parent Figures know exactly how to soothe us, so if we get distressed or over-excited in our exploration, they help us settle down, so we can return to pursuing what is interesting and meaningful to us. 4) The Ideal Parent Figures are delighted by us. We can see their faces light up when they connect with us—not because we have achieved or accomplished anything, but because of our being ourselves. 5) Finally, the Ideal Parent Figures understand we are growing and developing, and they encourage us to become our best selves.

Importantly, the specific imagery comes from the patient herself; she is tapping into the wisdom of her own imaginal experience to create parent figures ideally suited to her. And because these figures are ideal, they will provide a source of support and resiliency more effective and powerful than anything a fallible, human parent or therapist can provide.

Insights during Ideal Parent Figure work often have the feel of a lightbulb turning on. The insights my patients have experienced have included the following:

“My parent figures would NEVER hurt me. They are strong enough to protect me.”

“When I feel safe, I naturally get curious and want to explore.”

“My ideal mother figure understands my mistrust, and she doesn’t pressure me to come close before I am ready.”

“My parent figures don't turn away while I am angry. They stay interested and want to know why I am upset. It’s okay to be angry.”

“My ideal mother figure is delighted by me, even when I am being bad and she is setting limits—I can see it in her eyes.”

In our first few sessions, Sally quickly became frustrated. “Nothing is coming up, I can’t imagine anything.” This frustration is normal and is a sign that she has come to the “edge of her imagination.” Exploration requires trying things, running into blind alleys, trial and error, persistence. “That’s good, keep going,” I encouraged her. “Imagine that your ideal parent figures are with you, sensing exactly what is wrong and responding in exactly the right way. They love being here with you as you explore. They know you can figure this out, and they will stay with you as long as you need, for hours, days, weeks, or even years. Imagine what that would be like.”

In our fourth session, Sally’s imagination “popped.” “They know I can get this!” she said with a smile, “that’s how they can be so patient. They’ll stand by me as I figure this out.” Her expression changed, and what followed was an eruption of grief she had missed out on when she was little. She broke into deep sobs while imagining being held, forever if she wanted, by her ideal mother. The moment was anything but cheesy. Afterward, she felt an unusual sense of peace and hopefulness.

After that point, when that feeling of frustration or sadness emerged during visualization practice, she could reliably call up the image of her ideal mother to soothe herself. Becoming more confident, she started to have fun and looked forward to visualization sessions. Meanwhile, she reported that her mood improved, it had become easier to get things done, and she was reaching out more in relationships. “Well,” she told me with a smile, “I think I’ve figured out how to be self-compassionate.”

References

(1) Brown, D. P., & Elliot, D. (2016). Attachment disturbances in adults: Treatment for comprehensive repair. W. W. Norton and Co.

Many thanks to George Haas of mettagroup.org for his exploration of the language of encouragement.