Category: Therapeutic Issue

What the APA Apology Means for Black Psychiatry

Posted on by Psychotherapy.net Team

On January 18, 2021, the world of psychiatry experienced something historic when the American Psychiatric Association acknowledged and issued an apology for their part in a history of racism¹. There is no doubt it was time for this monumental moment, which markedly took place on this year’s celebration of Martin Luther King, Jr. Day.

This apology doesn’t erase all of the history that is behind it, and it doesn’t solve everything that may come. Yet after the history that has led to the APA’s need for an apologetic statement, this is an important step forward. This is a milestone for Black psychiatry and for all of us, really, in the African American community. I believe it may even deserve its own place in the history books.

For Black American, the history of our country has been paved with injustices, many of which have had a lasting effect on every facet of mental health, from assessment to treatment. The trauma of the African American community goes back many generations to slavery. The history behind the need for the APA’s apology goes deep into our past and can still be seen in the current practice of psychiatry². Going back all the way to the very beginning, the necessity of this apology is painfully clear.

The roots of racism in the psychiatric field go back a very long time. Diagnoses of mental illness were used to justify the view of Black slaves as inferior human beings. A supposed mental illness invented by Samuel Cartwright called “dysaethesia aethiopica” was used to explain a slave’s “laziness” and disinterest in their forced lifestyle³. In those days, the work of mental health professionals was only used to harm Black Amercians, not help, as it is meant to do.

The APA was meant to be an institution that kept racism from being fully actualized. The organization should have been there for the mental health support of all Amercians. Instead it was founded on principles that allowed Black patients and White patients to receive separate and vastly different levels of quality in care. It should be clear who was given real support, and who was left to suffer.

Time and time again, injustices were suffered by the Black community, and APA was among those who remained silent. Again and again, the mental health of Black Americans was both damaged and neglected while society stayed silent. Racism remained an issue within American psychiatry and someone should have spoken up, but APA didn’t.

APA repeatedly did not support civil rights legislation meant to improve psychological conditions for Black people. They neglected at the most crucial of times to do anything more than offer mere consolation to the people who were really hurting. Regardless of how widespread race-related inequality was at the time, the APA has missed many opportunities to speak up before this recent apology.

This history has piled onto the state of mental health for Black patients today, and it is about time that we hear the APA take accountability for its actions and inaction. Racist beliefs were integral to the damage that has been caused in the long history of Black psychiatry in this country. African Americans were declared biologically inferior, and that bias never fully went away. From Cartwright’s categorization of an entire race of people as simple and lacking emotional complexity, to the still very recent disproportionate diagnosis of schizophrenia in the BIPOC (Black, Indigenous, and People of Color) community?, systematic racism runs through the field of mental health and has done so for a very long time.

The APA’s apology is a small step in the right direction. The damage done has been far too great, but this is not insignificant. Truly, it represents something incredible. Mental health treatment is so important for people, especially for those in the Black community. This is the work that helps people heal from trauma and address the disorders and mental struggles that make everyday life difficult. With the apology we have received from APA, we can gladly find ourselves so much closer to reaching what the mental health system in this country should be.

What this represents is hope. We have made it a great deal forward, and now we can continue to find hope for better in our future. On the day that I saw this apology, I celebrated, not just for the moment itself, but for what this means for what may come. While I’m glad for the APA’s apology, I’m excited to see more medical organizations stepping up to do the same. I have hope that this is only the beginning, and that this apology truly represents a positive move towards improved mental wellness in our community.

References
American Psychiatric Association. (2021, January 18). APA apologizes for its support of racism in psychiatry. American Psychiatric Association. https://www.psychiatry.org/newsroom/news-releases/apa-apologizes-for-its-support-of-racism-in-psychiatry.

American Psychiatric Association. (2021, January 18). Historical addendum to APA's Apology to Black, Indigenous and People of Color for Its Support of Structural Racism in Psychiatry. American Psychiatric Association.
https://www.psychiatry.org/newsroom/historical-addendum-to-apa-apology.

In 1851 a scientist “discovered” a disease that caused slaves to run away, this was the prescribed cure… (n.d.). Watch the Yard. Retrieved 16 March, 2021, from https://www.watchtheyard.com/history/drapetomania-dysaesthesia-aethiopica/.

Schwartz, R. C., & Blankenship, D. M. (2014). Racial disparities in psychotic disorder diagnosis: A review of empirical literature. World Journal of Psychiatry, 4(4), 133–140. https://doi.org/10.5498/wjp.v4.i4.133

Understanding the Pandemic’s Impact Through a Developmental Lens

Posted on by Psychotherapy.net Team

Rounding the Corner?

As we round the corner on the first year of living with COVID-19, it behooves us to ask the following questions: where is the intersection between developmental theory and the pandemic, and how can therapists use this information in their clinical work? Despite similarities in our clients’ experiences, there are significant differences, due solely to age, in how the pandemic has affected their lives. Although the pandemic has been discussed from a multitude of perspectives, such as race and socioeconomic status, most commonly it is referenced as a singular event, i.e., the pandemic. In fact, our clients’ age at the time of the pandemic is bound to influence their life both now and in the future. For many, the pandemic has had a devastating impact on their health, food security, learning, and living environment, but even for the more fortunate, living through a pandemic has had an impact on their long-term development as well.

The landmark study by Wallerstein and Kelly, Surviving the Breakup: How Parents and Children Cope with Divorce (2008), changed the conversation about the consequences of divorce on children as a function of their age at the time the marriage ended. As I reflected on that study, I thought a similar examination of the significance of the pandemic across ages would be valuable. Since we have yet to experience the true end of the pandemic, these are preliminary musings meant to be formative rather than summative; I offer them with the hope that as therapists our voices will contribute to writing the history of the consequences of living through a pandemic. 

The fields of psychology and psychotherapy are often bifurcated along normal/abnormal lines on the individual level, but what does it mean developmentally when entire populations have been thrust into the abnormal state that has resulted from COVID? We are living through abnormal times, and our clients are expressing their desire for normalcy. And the various ways they are expressing their yearning for normalcy are not merely a reflection of their pre-COVID lives, they are a function of the developmental tasks that were thwarted by the pandemic. 

Across the Lifespan

Infants and very young children have a multitude of developmental milestones to meet. The tasks of language development and early socialization were severely challenged by mask wearing and lockdown restrictions. Children as young as preschoolers have been taught to stay away from others and not to share their toys. We can only imagine how hard parents and teachers will have to work in an attempt to reverse the message that the world is a dangerous place when these children return to in-person early education programs. Maintaining six feet of separation and wearing a mask is a challenge for most adults, let alone three-year-olds. Starting life from the vantage point of mistrust has far-reaching implications. Healthy autonomy rests on a foundation of trust in the adult caregivers in a young child’s life. For those young children who fear venturing into the world, critical developmental tasks will be harder to achieve.

In addition to falling behind academically, latency-age children lost many opportunities for extracurricular activities and the friendships they foster. Rather than having the typical, slow movement toward freedom, their options for exploration were limited. Adolescents were deprived of the chance to stretch their wings and assert their independence. One father in my practice said, “I hate seeing my kid on the couch hour after hour. He has nowhere to go, but I’ve got to wonder, what is he really learning about life?” Will our younger clients’ sense of the world and themselves be forever diminished by learning how quickly everything can be upended?

As college students returned home, frustrated at having their longed-for college years reduced to online classes in their childhood bedrooms, the rise in reports of depression were significant but not unexpected (Anderson, 2020). Young adults couldn’t find jobs and “failed to launch.” Some of my young adult patients adapted easily to working remotely and created pods with a select group of friends. This was true for some older adults as well, and many families came to appreciate the opportunity to spend more time together. Those who did date tended to commit quickly to each other to feel COVID-safe. In many cases, their friends and family never got to meet their partners, and couples had few opportunities to explore activities together as a way to assess compatibility. Depending on how many of these relationships stand the test of time when the world reopens, we may see a delay in marital age for this generation.

Other adult patients put significant life markers, such as having children, on hold due to the restrictions of lockdowns and the fear of spreading or contracting the virus. It is too soon to know how these delayed rites of passage will impact their futures. One mother in my practice, who has a toddler, is rethinking her desire to have more children as she waits for the data on the safety of the vaccines and pregnancy to be made public. Parenting as a rule presents inherent challenges, but as the toll of the pandemic has worn on, many of the parents in my practice voiced concern about their ability to juggle the responsibilities of work and home. Those parents with children enrolled in remote learning were at great risk both emotionally and practically. Some quit jobs or cut back their hours, while others relaxed their previous sanctions against “screen time” and abdicated specific parental responsibilities out of desperation. Mothers, in particular, were burdened with trying to fill in the gaps created by changes to routines and schedules. As their own needs went unmet, reports of depression and substance abuse increased.

Some adult clients also felt angry that the rug had been pulled out from under them just as they were about to advance in their jobs. The loss of economic stability is bound to have far-reaching consequences for their own futures as well as those of their dependents. As opportunities grew limited, those who had the ability to pivot and embrace a different career or lifestyle fared much better than those for whom the losses are permanent. The long-term implications of either outcome on self-esteem needs to be addressed.

For many of my middle-age and older adults, this time has been one of intense grieving. Many of them experienced their own version of “failure to launch.” Travel plans were canceled, downsizing was put on hold as adult children returned home, and retirement was delayed or accelerated due to economic changes. A patient in her sixties said, “I’d planned to work until 70, but it’s clear with cost-cutting measures (at her company), I’m being forced out. I’m just not ready. And with nowhere to go, what am I going to do with all my time?” She became quite depressed and worried about the quality of her “last chapter.” Others lamented the inability to hug their elderly parents or their grandchildren. The geographical separation from family and friends was heartbreaking and it led to revising priorities. Another patient, a wealthy man in his late fifties, decided to take an early retirement. His response to COVID-19 was to devote himself to his family. After some initial missteps, his family adjusted to this new arrangement. His increased presence in his children’s lives is bound to influence their development as well as his own.

The elderly, who are most at risk of dying from the virus (Centers for Disease Control, 2021), have the least opportunity to make up for lost time. News reports were filled with harrowing photos from nursing homes and hospitals. The lack of stimulation accelerated cognitive decline. Due to the lockdowns, many of the elderly suffered from increased isolation and loneliness. What was lost for this generation may be the hardest to calculate, but their deaths will reverberate in the lives they left behind for years to come. We can only hope that the horrific images of people dying alone in hospitals may inspire a change in how we view the needs of the elderly and end-of-life concerns in this country.

Several of my patients lost parents or grandparents to COVID-19 and other illnesses. Unable to have funerals or attend services, their grief has been much more complicated. Some are living with the pain of knowing their loved one died alone. It has made them rethink their own plans for growing old. Aging in place seems much more attractive to many at this point. As a society, how we manage the grief and devastation of the pandemic will shape the values and aspirations of generations to come.

Hopeful Signs

Across age groups, there have been hopeful signs that some consequences of the pandemic may have changed the culture in ways that might promote successful development. This is by no means to imply that the loss of life and cost to our economy were worth a pandemic, but it is helpful to consider what positive learnings we can take for ourselves and for our clients into a post-pandemic world. Awareness of climate change and the Black Lives Matter movement took on heightened significance around the globe. These attentions will hopefully have long-reaching consequences for improving the lives of younger generations and those with whom we work. Also, out of the necessity of scaling back our lifestyle during lockdowns, many people deepened relationships with a few key people in their lives, improving their feelings of being connected in the world. Time and again, what I heard from clients was an appreciation for the slower pace of life necessitated by pandemic protocols. The opportunity to work remotely enhanced job happiness for many. The absence of commuting and the limited availability of extracurricular activities was a game changer in terms of time management. As one client said, “I never had time to think before, I just did. Now I’m asking myself, what do I really want in my life?” Reconfiguring work/home boundaries is likely to be one of the most significant by-products of the pandemic.

Some found comfort through a heightened relationship with nature, which deepened their life satisfaction. Seeking time outside was a positive outlet. One client, who is a runner, appreciated the decrease in traffic and went on longer runs since he no longer commuted to work. “As I watched the seasons change and heard the birds like never before, I found renewed energy,” he said. In general, there was an appreciation for the preciousness of life and a sense of urgency to not waste time.

Personal Reflections

As I reflect on my own experience during the pandemic, I am reminded of the influence another historical event had on my life, albeit indirectly. My parents were both children of the Great Depression, which had a devastating impact on their formative years. They did not have to maintain social distance or wear masks, but each of their families suffered significant economic loss. Worries about money and food scarcity were constant themes in my house as I was growing up, even though by then my parents were leading a solid 1960s middle-class life. Both their scars and their ability to survive were underpinnings in how they made choices as adults and parents, and what they wished for their own children’s futures.

It is still too early to comprehend the full impact of the pandemic, but we already know that the longevity of American citizens dropped by a full year due to COVID (Andrasfay and Goldman, 2021). Nonetheless, it is not just the loss of a single year that will define the lasting impact of the pandemic. As I listen to my patients grappling with life during and, hopefully, post-pandemic, I applaud their resilience while acknowledging to them what they have lost during the pandemic. As the fear of the virus abates and we move out of abnormal times, our challenge will be to understand what normal development will look like in a post-pandemic world and to support each person’s quest to become their best self.

Reference:

Anderson, G. (2020, September 11). Mental Health Needs Rise With Pandemic. Inside Higher Ed. https://www.insidehighered.com/news/2020/09/11/students-great-need-mental-health-support-during-pandemic

Andrasfay, L. and Goldman, N. (2021). Reductions in 2020 US life expectancy due to COVID-19 and the disproportionate impact on the Black and Latino populations. Proceedings of the National Academy of Sciences Feb 2021, 118 (5) e2014746118; DOI: 10.1073/pnas.2014746118

Centers for Disease Control. (2021, February 26). Older Adults. https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/older-adults.html
Wallerstein, J. S., & Kelly, J. B. (2008). Surviving the breakup: How parents and children cope with divorce. Basic Books.

3. https://health.clevelandclinic.org/pandemic-isolation-can-be-especially-hard-on-older-adults/

Termination: A Process by Any Other Name

Posted on by Psychotherapy.net Team

My client, a psychologist by training and fellow traveler through COVID’s unforgiving landscape, had initially visited with me because of anxiety and his growing difficulty managing it. Accustomed to a take-charge style that centered around scanning his environment for potential threats to his family, he had grown tired, not just of the challenges COVID presented, but from the sheer effort and energy it took to manage his anxiety. The details of our work can be found in a recent blog I wrote, so I will fast forward to the later portion of our time together when we began reviewing the path forward for him (and us)—life after therapy.

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As we reviewed his progress, it became clear to both of us that he had made significant gains in managing anxiety, breathing a bit more into his life and enjoying moments with his wife and children. All of this without the pressure that came from constantly scanning his inner and outer worlds for threats and subjugating himself to a harsh inner list-maker. His goals were being addressed and he was making significant changes and progress. The time for planning an ending to our work was approaching, so I broached the subject.

The conversation quickly pivoted to the word “termination,” and although I had used it numerous times with past clients and in my teaching and writing, it suddenly felt quite leaden rather than a natural part of the therapeutic process. Perhaps because I was particularly fond of this client, termination felt like a loss and triggered my own attachment issues and deeper existential concerns around loss.

I considered each of these and sought the wisdom of those who had come before me in order to move more comfortably into this uncomfortable space with my client (and myself). From a developmental perspective, termination suggested a separation/individuation process that, while inevitable and painful for some clients, was a harbinger of growth. From a traditional analytic perspective, termination followed resolution of the transference, awareness of defenses, strengthening of the ego, and a lifting of repression, while more contemporary analytic theory favored a more natural progression in the relationship between therapist and client. Jung believed that termination reflected the client’s awareness of a new philosophy for living—an awakening—and as such carried a more growth-oriented valence. Anchored in a more positivistic appreciation of the role of therapy, humanistic theory suggested that the final phase of treatment focused around movement towards growth and accomplishment. Finally, from a more pragmatic and behaviorally-oriented perspective, termination is the logical and planned conclusion to a predictable, scientifically-grounded, ends-oriented intervention.

And then I came across an interesting article (Maples & Walker, 2014) that reviewed and critiqued the label “termination.” I liked what these authors had to say because they, like I, had considered that termination and its historical associations and connotations were weighted down by historical attempts to find just the right name for the final episode of the therapeutic relationship, and that most of these attempts had resulted in a negativistic perception of termination, mostly around loss. In response, they proposed the concept of “consolidation,” which suggested a normative process centered around the stabilization, strengthening, and reinforcement of therapeutic gains—a preparation for the client’s journey ahead without the therapist.

All of these concepts, particularly the latter, made sense but left me wanting more. I sought something a bit more post-modern: a collaboratively derived and meaningful frame for this particular moment in the therapeutic portion of my client’s journey with me in therapy.

***

So, in our most recent session, I asked my client, “what would you like to call this phase of our work together?” And he simply said, “I’d like to call it the comfort zone!”

Seemed simple enough, but I sought clarification. What did this actually mean? His response was “I’ve gotten to a place where I am comfortable with myself.” There it was! My client was not deeply immersed in labelling this latter phase of our work, nor was he reflecting on our separation. He had done what he came for. The simplicity of his “comfort” was comforting to me because our work, and I, had helped him find his way there.

What’s in a name? Everything, as long as it is of the client’s making.

References

(1) Maples, J. L., & Walker, R. L. (2014). Consolidation rather than termination: Rethinking how psychologists label and conceptualize the final phase of psychological treatment. Professional Psychology: Research and Practice, 45(2), 104-110.

The Thought Process Underlying Perfectionism and How Therapists Can Help

Posted on by Psychotherapy.net Team

As I listen to my clients describe their “maladaptive” ways of functioning, I usually discern adaptive elements in the patterns they perceive as dysfunctional. This surprised me at first but doesn’t anymore.

It is as if their symptoms have a point, and the problem is that they have taken this point too far. If so, the solution is not to reverse the problematic way of functioning but to dial it down into a more moderate range—a smaller and more readily attainable goal.

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But not necessarily an easy one. Research indicates that black-and-white thinking lies at the root of many mental health problems. Thinking in simple binaries makes it impossible to dial behaviors down because, if it’s not black, it must be white—there is nothing in between. There are many examples of this pattern, and perfectionism is one.

Perfectionism is a schema that recognizes just two categories of performance: perfect and unsatisfactory. There is nothing in between.

Perfectionism doesn’t work. Research indicates that it is associated with low self-esteem, depression, eating disorders, and, ironically, poor productivity. Nonetheless, perfectionism has a valid purpose: it can be rewarding to strive for high levels of performance.

Kirsten was a middle-level manager who looked successful from the outside but suffered from anxiety that was mostly related to her job. She worked long hours but said she was always behind. She had nothing but critical things to say about her performance, although she acknowledged that her evaluations were more than satisfactory. I also noticed that Kirsten frequently disparaged her performance as a therapy client: I found what she said quite clear, but she often interrupted herself with comments like “That didn’t make sense” and “I’m all over the place in the way I’m telling you this.”

Replacing Binaries with Spectrums

The alternative to black-and-white cognition is to think of psychological phenomena in terms of spectra. The spectrum relevant to perfectionism concerns personal standards for performance. The question is: what is good enough? Here is the continuum of possible answers:

1———-2———-3———-4———-5———-6———-7———-8———-9———-10
Horrible      Bad      Mediocre      Okay      Good      Excellent      Perfect

Clients with whom I have worked vary in how they answer this question. Almost none think that performances in the 1-3 range are good enough, but then variability kicks in. Some are content with performances that are below average but halfway decent, and standards range from there all the way up to perfectionism, with lots of gradations in between. I ask clients to mark the point on the scale that represents their answer to this question. Fractions and decimal points are often given by perfectionistic clients, who like to be precise, and Kirsten’s answer was 9.3

In black-and-white thinking generally, spectra are chopped into dichotomies. The two halves might be very unequal in size, because the dividing line might not be anywhere near the midpoint. We can understand clients’ thinking at a deep level by asking ourselves the question, “at what point does the client dichotomize the continuum?”

In black-and-white thinking about performance quality, perfectionists divide the continuum with a cut-point so close to its end that almost all of the spectrum is viewed as representing failure, with just a thin slice for success. On the above spectrum, the cut-point would be between 9 and 10. This lop-sided dichotomy results in constant failure experiences; it helped to explain why years of positive performance evaluations and promotions had not ameliorated Kirsten’s feeling that she was barely keeping her head above water as a professional.

To provide a visual illustration, I draw an arc over each side of the binary, label the large one “failure,” and label the small one “success.” This diagram illustrates the onerous nature of the standards by which perfectionists evaluate themselves.

The Goldilocks Zone

I generally try to help perfectionistic clients moderate their standards, but at first the idea of doing so makes many of them anxious. Their fear of lazy laxity may be so strong that it propels them to the opposite end of the spectrum: perfectionism.

Kirsten acknowledged that she strove for near-perfection in her approach to tasks, but her understanding of the problem was not that her standards were too high but that her performance level was too low. She said, “I need to strive for perfection to improve. If I start going easy on myself, I’ll become lazy and do even worse.”

This fear is the result of dichotomous thinking: if standards are not perfectionistic, they will be loose and sloppy. The solution is to replace this binary with another spectrum:

1———-2———-3———-4———-5———-6———-7———-8———-9———-10
Lazy slacker      Easy-going      Average      Conscientious      Perfectionistic

This diagram shows that perfectionism itself can be understood as an extreme on a spectrum of self-evaluative standards that vary in stringency. This spectrum maps onto the previous one—it is about how good a performance must be to be considered good enough. Again, I ask clients to mark their point on the scale. (Kirsten gave herself a 9.2.)

When I help clients move beyond black-and-white cognition to think in terms of spectra, possibilities open. Rather than making either/or choices, clients can learn to think in nuanced ways about the personal standards they would like to have—not too low and not too high.

Not a Point but a Range

This spectrum shows that perfectionism is not so much a bad thing as too much of a good thing. Perfectionists are not wrong to value high standards, but they take a good idea too far.

I have found that it is not necessary to reverse high standards, but only to adjust them toward moderation. Nor is it necessary to adopt the standards of the average person. The solution is to move into the Goldilocks Range, which is an area around the midpoint of 5.5, say between scale-points 4 and 7, or even 3 and 8.

Previously perfectionistic people usually feel most comfortable around scale-points 7 or 8, and Kirsten was no exception. We had some careful discussions about the difference between excellence and perfection and about how a person could be conscientious, exacting, and achievement-oriented without being perfectionistic. I validated the value of high standards and made it clear that I was not suggesting she become easy on herself and satisfied with mediocre work. The modest but important changes she made preserved her rigorous, hard-working style but moderated it enough to allow some flexibility and satisfaction. Her anxiety level decreased, and she began to enjoy her job for the first time.

This post focuses on perfectionism, but the spectrum strategy applies to a wide variety of mental health and relationship problems, as described in my book, Psychotherapeutic Diagrams. I have found that clients generally function best when they move from the extreme end of a spectrum into the part of the Goldilocks Range that is closest to their original style. For example, aggressive clients become assertive, anxious clients become cautious, and oppositional clients become independent.

A small- to medium-sized adjustment usually changes a maladaptive style into an adaptive version of itself and transforms a problem into a strength. My clients are glad to discover that resolving their difficulties does not require them to become a different kind of person. I ask clients to mark the point on the scale where they would like to be, and the distance from their current position is usually about 2 scale points; this makes the goals of therapy seem quite attainable.

There is a big practical problem with perfectionism: People have only limited amounts of time and energy, life has many aspects, and being perfectionistic about some aspects means short-changing the others, because there are only so many hours in a day. The goal of living a well-rounded life requires us to give up perfectionism.

***

Trying to reverse clients’ habitual ways of functioning can feel like swimming upstream, with opposing currents such as genetics and long-term histories—difficult factors to overcome. When clients realize that the changes they need are not dramatic or wrenching, and a 2-point adjustment on a 10-point scale could change them from an unhappy perfectionist to a hard-working, conscientious person, they feel more relaxed and optimistic, and so do I. Thinking in terms of spectra has brought my therapeutic efforts into accord with my clients’ natural styles and made our work together more harmonious.

References

Shapiro, J. P. (2015). Child and adolescent therapy: Science and art (2nd ed.). Wiley.

Shapiro, J. (2020). Finding Goldilocks: A guide for creating balance in personal change, relationships, and politics. Amazon.com Services.
 

Tokophobia: Recognizing the Multifaceted Fear of Pregnancy and Childbirth

Posted on by Psychotherapy.net Team

“The pregnancy test was negative,” Gretchen recounted through tears. Her tears were not a straightforward reflection of disappointment and longing, as one might assume. They accounted for a complex stew of relief, guilt, and shame about the relief and fear of this ongoing cycle that was proving to be torturous and emotionally exhausting due to Gretchen’s unmanageable anxiety.

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Gretchen and her partner had been trying to get pregnant for several months. Having a biological child was something they both very much wanted. Each month, in the weeks leading up to a possible positive pregnancy test, Gretchen would be excited about the prospect in theory, but utterly terrified about the reality. She often had panic attacks, was inundated with worries about the ways pregnancy and childbirth can go wrong, and was physically repulsed by the idea of a human life growing inside her. The idea of pregnancy made her feel trapped—the state being inescapable and the thought of that, unbearable.

Even before trying to get pregnant, Gretchen had struggled for years with tokophobia, an intense fear of pregnancy. Her extreme difficulty with managing even the process of trying to conceive reinforced Gretchen’s belief that she certainly couldn’t handle an actual pregnancy.

Another client, Octavia, had also been struggling with tokophobia, although hers looked quite different. In our most recent session, she was also in tears. After hooking up with a man she’d gone on a few dates with, Octavia had “spiraled” for days after. “I just couldn’t stop thinking that I’d somehow gotten pregnant,” the notion of this outcome intolerable to her. She was consumed with fear, despite the fact that they hadn’t had sex, let alone gotten fully undressed in their encounter.

Octavia recounted to me the hours she’d spent researching obscure ways of getting pregnant and the repeated phone calls to friends and family seeking reassurance. She knew logically, somewhere in her brain, that it was impossible and felt embarrassed, but Octavia couldn't shake the fear. In the end, she cut things off with the guy.

***

Pregnancy understandably creates a certain amount of anxiety (with a whole extra layer heaped on top given current pandemic circumstances), but for some, the concept itself prompts excessive fear, strong physical responses of anxiety and repulsion, and behavioral avoidance that is debilitating and outside the norm.

Tokophobia wrecks a person’s ability to move forward with their life goals or get close to people—or allows them to do so only under extreme and unrelenting distress. Both Gretchen and Octavia exist in a state tinged with deep pain and impairment—a life not quite lived.

Unfortunately, although this phenomenon is widely experienced, it is not thoroughly researched. There are some, but not enough, comprehensive studies and little in the way of specific treatment guidelines. People are suffering and likely not getting much help—or even realizing that what they are experiencing has a name.

In the literature, tokophobia is broken down into two main types: primary (fear of pregnancy/childbirth without having direct experience) and secondary (fear following a traumatic pregnancy or childbirth experience). In doing more reading and reflecting on my clinical observations of clients like Gretchen and Octavia, I came up with the following distinctions, or subtypes, with the idea that each requires a tailored therapeutic approach, and therefore it’s important to make the distinction.

  • Reluctant: A person with tokophobia who wants to get pregnant
  • Avoidant: A person with tokophobia who avidly does not want to get pregnant and experiences obsessive and extreme worry as well as significant OCD-like avoidance and compulsions.
  • Ambivalent: A person with tokophobia who is uncertain about whether to pursue pregnancy.

For an avoidant tokophobic like Octavia, it wouldn’t make sense to delve into the meaning and source of each of her thoughts or try to dispute each specific worry, when an approach like Exposure and Response Prevention (ERP)—the most effective treatment for OCD—is more likely to ultimately bring some relief. And while it is tempting to treat Gretchen’s reluctance as ambivalence, helping her explore alternative options for growing her family, she is clear in her conviction, but unequipped to manage her physical and psychological anxiety.

Most importantly, I think our job as therapists when working with a client with tokophobia is to 1) take it seriously and 2) conceptualize and treat it appropriately.

My sense is that those struggling with phobic fear of pregnancy and/or childbirth typically feel dismissed, confused, and ashamed (related either to the fact that they feel such fear and aversion to something they expect “should” come naturally to them or to their avoidance and rituals that they recognize as embarrassing/extreme/out of touch with reality).

So when I encounter a client with tokophobia, I often say something like, “Yes, this is a real thing, you are not alone, and furthermore, we can take steps to reduce the shame and nudge you towards the life you want.”

I can offer legitimacy to their experience and compassion to their suffering, while paying attention to the distinct ways tokophobia can manifest person to person. Clients like Gretchen and Octavia don’t have to feel so isolated or hopeless.

The Queen’s Gambit and Me: The Surprising Similarity Between Therapy and Chess

Posted on by Psychotherapy.net Team

I was mesmerized from the first frame of The Queen’s Gambit, a Netflix mini-series about a Kentucky orphan girl in the 1960s and her passion for chess. Thoughts of the show colonized my thinking for the three days it took me to get through its seven episodes. I loved it, it intrigued me, and I cared deeply about the characters. It was a perfect jewel. But little did I know how those seven hours would change my life.

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I don’t remember how it happened, but a week or so after the final credits rolled, I started to research chess. I’d never played before and didn’t even know how the pieces moved, so I typed “chess for beginners” into YouTube and curiously, like Alice, fell down the rabbit hole.

I find that I’m dreaming about chess these days and have started to see chess tactics and strategy in everything. I’ve been a psychotherapist for thirty-five years and it's become clear to me since I started playing how a course of therapy conforms, in many ways, to a chess game, with its well-defined opening, middlegame, and endgame.

The first few therapy sessions, when you’re learning about your new client, are like the opening. You start slowly and respectfully, using moves that you’ve used many times before to get a feel for the person sitting across from you. You’re getting situated, knowing that you’re at the very beginning of an important relationship.

For example, I start the first session with my new client, Isabelle, with the opening move I’ve used so many times before—a variation of the question “What brings you here today?” Everything is possible at this point, and I have no idea where this exchange will take us.

During this opening phase, I’m getting a sense of the pacing. Will she jump right in with a cascade of emotion (making dizzyingly fast moves) or sit quietly waiting for me to ask questions (establishing a pensive introspective pace to the “game”)? In this case, holding back and very reserved (not making risky moves), 28-year-old Isabelle explains that she wants to improve her relationships. She’s on pause with her boyfriend, who has not treated her well, and is wracked with indecision about whether to go back to him. She doesn’t trust herself. But when asked her biggest goal in life, she says she wants to meet the love of her life.

A session later, in a latter part of the opening, Isabelle tells me about the struggles she faced in childhood. I learn that her much-loved mother, whom she describes as an angel on earth, suffered mental health problems that were so severe that when she was eight and her parents divorced, she was sent to live with her father’s parents. They were very strict remote old-fashioned immigrants who did not speak English, and she did not speak Italian. She rarely saw her mother and felt alone and abandoned.

More complexity is introduced in a later session as Isabelle reveals that no matter what has happened in her childhood, she’s determined to build a wonderful future and has enrolled in a course to become a life coach. With this goal in mind, at the turn of new year, she’s started to eat more healthily, is trying to exercise, and has incorporated a meditation practice into her day.

In this part of the therapy, the middlegame, I’m searching for patterns. It’s both a science and an art. Isabelle relaxes, and story after story comes spilling out. I’m receiving reams of information and have to make continuous decisions about which pieces are vital to attend to and which not to “take.” I could focus on a tantalizing piece of information that Isabelle shares (capture a knight that’s available to take but which won’t advance my position), but I have to make sure not to make a move unless it contributes value. There’s no doubt that I could chase the pieces all over the board, but I need to develop a plan that will guide my choices.

Over time, the essential issues are brought into focus and, in the endgame, many of the peripheral bits have been eliminated so that only the primary core issues remain. There are fewer pieces on the board, but every one is vitally important. We’re narrowing our focus on the need for Isabelle to forgive herself for having left her mother, who later died of cancer, and working on helping her develop a deep well of self-compassion. The search for the love of her life will have to wait until she’s very comfortable with the love of herself.

Isabelle is not, of course, my opponent, and a course of therapy is certainly not a process of win or lose, but I like to think of strategizing how to help my client in her struggle (our chess game) as the mutual challenge for both of us. The pleasure of checkmate comes from feeling that we’ve shared a profound experience together resolving something important, and that now Isabelle and I can celebrate that positive change has happened in her life.

I've found that there have been many surprisingly meaningful aspects about life during the pandemic, and discovering chess is certainly high up on my list. I smile when I think about it and look forward with anticipation to the next game. Where it’s going to fit into my uber busy life, I’m not sure. But for the moment, hey, set up the board and let’s play!

How an Anti-Tech Group Therapist Became a True Believer

Posted on by Psychotherapy.net Team

Therapists’ offices have always intrigued me. Much like the artwork on the jackets of old vinyl records, they secure my memories with pleasing visual touchpoints. Pre-and post-session rituals marked my weekly appointments: stopping off at the same deli for a coffee, sitting on a park bench, browsing the poetry section in the corner bookstore; such places served as footholds for the different phases of my psychological awakening.

First Wave

After twenty-three years in my own cozy therapy office, it was time to say goodbye. The downtown institute that housed my practice went bust, and the landlord heaved dozens of veteran therapists out onto the cold winter streets of Manhattan.

As I packed up my books, rolled up my oriental rug and wall tapestry, and wrapped my Buddhist knick-knacks in newspaper, everything in my office took on meaning; the spider-cracks in the plaster ceiling that I had planned to paint, the well-worn grooves in the carpet from my trusty Aeron chair, the slight sag in the center of the couch that held so many stories.

I considered my attachment to my cozy therapy office as I closed the door behind me for the last time. Walking home that night, I realized that all my personal therapists and their offices were gone too. Soon after, the pandemic hit.

Second Wave

When New York City shut down, I thought that I had no choice but to shut down, too. As a group therapist, I couldn’t see how my groups could survive. Individual patients would have phone sessions—but therapy groups? Over the years, I had amassed ten weekly, ninety-minute groups, consisting of over 100 individuals. What would happen to them?

So I phoned a fellow group therapist and asked if she planned to shut down. She guffawed:

“Why on earth would I do that?”

“But how will your groups meet?”

“I moved them to Zoom.”

I paused and asked in all earnestness: “What’s a ‘Zoom?’”

When Worlds Collide

Could therapy exist without walls? Would I be able to sense unspoken feelings from patients from a flat two-dimensional image? Could a screen transmit subjective and objective countertransference, induced feelings, subtle body movements, and the endless emotional tics and hiccups that appear in face-to-face sessions? I bristled at the thought of moving my practice online. But the pandemic forced me to face a stark reality: evolve or face extinction.

When I told my group members that we were moving online, their reaction was mixed. The older patients responded with cranky disapproval.

“How could you degrade the group in this way?” one asked me.

“I share your concerns, Alan. Let’s give it a try and see how it goes.”

I left out that I had two college tuitions to pay, a home mortgage, elderly in-laws to support, insurance premiums, and countless other monthly expenses that the pandemic wasn’t shutting down. To my great relief, the younger people accepted the proposal enthusiastically. “What’s your URL?” they asked.

“I’ll get it to you soon,” I replied. I immediately searched “URL” on the internet and discovered that it meant “uniform resource locator.” What the hell was that?

Boomer to Zoomer

With the help of my teen daughters and a nine-year-old MacBook crammed full of family vacation photos, I learned the basics of Zoom and patched together a weekly schedule.

Next, I had to consider the background for my sessions. Visually, my home presented a minefield of challenges. Every wall and bookcase overflows with family pictures, children’s artwork, and cardboard boxes containing my old office and my daughters’ dorm rooms. So, I dragged an old film projector screen out of storage, erected it behind me, and turned on my computer video camera.

It was my first visit to my cyberspace office—me floating in a wall-less white space.

The big day finally arrived. I sat in front of my computer, took a deep breath, and logged on to Zoom. My anxiety kicked in, and I found myself forgetting nearly everything my daughters taught me. Messages like “Samantha is in the waiting room” popped up, and I clicked. One by one, group patients began to appear in their square “Brady Bunch” boxes.

“It’s so good to see everyone.”

“I missed group!”

“I’m glad we can still meet.”

I immediately pleaded for patience with my computer skills; the group members delighted in my vulnerability. “Don’t worry, we’ll get you through this.” Soon everyone was chatting and catching up like old friends.

To my surprise, the group was flowing—disjointedly, yes, but flowing. I discovered that many members were scattered throughout the country, unable to travel back to the city. One woman was participating from the Czech Republic, which wasn’t allowing flights in and out of the country. I marveled that online sessions make it possible for members to attend from nearly anywhere.

“Hey, where’s Steven?” a younger group member asked. “He never misses group.”

Steven, a grey-bearded father figure with a sunny disposition, was the oldest and longest-running group member. Anxieties about his health were being expressed when a message popped up: “Steven is in the waiting room.” I clicked on it quickly. I was getting good at that.

When Steven’s gaunt face appeared, group members gasped; his eyes were sunken, and his usually bright outlook was dimmed beyond recognition. He had COVID.

“I’m so…happy…to see you all,” Steven wheezed. As he related his journey from a mild cough to high fevers and the ER, the group hung on his every word. “I’m so scared, Stephen said, “I don’t want to die. Not now.”

Soon tears were flowing, and cyber hugs were being dished out. By the end of the session, Steven managed to smile again. “You guys…are a…miracle, ” he said as he gulped air, “This is the first time I felt hope since…this nightmare…began. Thank you. Thank…you all.”

As we signed off, another miracle occurred: I had become a true believer.

New Standards

After a few weeks, I could feel the online groups start to lose vitality. Immediacy, the beating heart of group, was waning. Instead of an exhilarating experience that challenged ingrained characterological traits and inspired emotional intimacy, the online groups devolved into lackluster support sessions. Members stopped relating to one another and were monologuing about themselves. Energy dwindled, attendance ebbed, and newer members dropped out.

My office was gone, and my groups would be, too, if I didn’t take action. To succeed in cyberspace, I had to reinvigorate my leadership skills and set new standards. I needed more energy, focus, and clarity.

I launched an entirely new set of pre-group rituals. Thirty minutes before every session, I set aside time to review each group members’ development. I reviewed their histories, revisited their goals, and considered new ways of challenging them. I even incorporated group members into my daily Buddhist practice. Every morning, I reviewed my groups, targeted each group’s member’s emotional growth in my daily meditation, and considered new ways to engage them.

I became determined, from the moment I signed onto Zoom, to hit the deck running. I pushed members to take more risks and focus. I scanned their faces constantly for any emotional shifts and evidence of unexpressed feelings. I confronted any signs of repression.

“Samantha, what was that thought?”

“Steven, you seem distracted.”

“Alan, can you put that frustrated look into words?”

No sooner had my groups slowly jump started to life than I realized that they were suffering from another problem: a loss of boundaries. Group members became voyeurs. During sessions, members gave tours of their homes and showed off their living spaces, partners, pets, or children. Such distractions ran wild and fueled resistance to relating. During the first few weeks, members also signed into the group while snuggling in bed, eating meals, feeding their dogs, smoking cigarettes, baking bread, or casually sipping a tumbler of whiskey.

One young woman greeted her group from her bathroom, fresh from a shower. As she towel-dried her hair, her bathrobe fell open, revealing her bare shoulders and the tops of her breasts. “Oops! Sorry!” she crooned as group members ogled her.

It was time to reassert boundaries. I firmly reminded everyone that the group rules applied online: no eating, no walking around, no texting. Anything that distracted from relating to one another was banned. I also instructed members to pick a spot in their homes and sit for the entire group, no more multitasking.

And finally, I requested that every member prepare for group by revisiting their intentions and considering the following three questions.

  • Why did I join the group?
  • What are my feelings toward my therapist and fellow group members?
  • What emotions am I holding back?

To my surprise, group members expressed relief. The reassertion of boundaries lowered everyone’s anxiety and quickly brought the relationships in the group back into play.

A Cure Through Love

As of this writing, it has been ten months since my groups began meeting online, and I’m delighted to report that they are bustling with new members. Yes, my cyberspace therapy office isn’t cozy, but I have learned that therapy isn’t about places—it’s about relationships. As long as relationships remain the central focus, therapy can thrive nearly anywhere.

Freud suggested that in essence, psychoanalysis is a cure through love. The pandemic continues to test my mettle as a psychotherapist but doesn’t quell my love of the work, a love that I’ve learned can transmit through a computer screen. Not only is love limitless—it’s officeless, too.
 

Standing Up to Microaggression: A Clinician’s Experience

Posted on by Psychotherapy.net Team

Microaggressions (noun)—Definition: Everyday verbal, nonverbal, and environmental slights, snubs, or insults, whether intentional or unintentional, which communicate hostile, derogatory, or negative messages to target persons based solely upon their marginalized group membership. (1) Looking back, a racial enactment between myself, a person/clinician of color, and my white therapist seemed inevitable. In our very first session, my therapist made some statements that revealed what I perceived to be her “White Savior” complex. I was taken aback by my therapist’s apparent lack of awareness of her own racism, as she had explicitly advertised herself as working through a critical post-colonial lens, and so I called her out on it. My therapist was quick to own her racist statements and take full responsibility. Despite the initial wounding and because of the subsequent repair, I continued to work with her because she did model a good relational and clinical holding style in following sessions, and I felt that she was helping me with the issues for which I was seeing her. Towards the end of our sixth session, I was sharing with my therapist how someone had explicitly sought me out for clinical supervision, mentioning familiarity with some of my work and writings, and how that had filled me with professional pride and confidence. My therapist’s exact reply is now hazy, but she said something along the lines of, “I think they chose you to be their supervisor because, as a white person, they can learn how it is for you—from your experiences as a person of color”. These words landed on me like a bolt out of the blue, and I instantly felt objectified. My therapist had unnecessarily racialized my experience, my whole identity reduced to that of “a person of color.” I had a vivid mental image of Black and Indigenous people literally being put in cages and zoos to be “observed,” and another of a laboratory rat being poked and probed—an object to be studied, “an other” whose experiences (painful or not) were being observed. A part of me still wanted to deny that it was I who was feeling the pain—to mask it as simply identifying or empathizing with those who have suffered racism. My heart began to beat fast, while my mind was trying to digest what I had just heard. Knowing very well that I have historically tended to minimize or deny micro-aggressions committed against me in the past, I resolved to be present to this current painful experience. Curiously, my heart wasn’t pounding but rather flapping—like a weak fledging trying desperately to fly away, but not having the strength or ability to do so. Instinctively, I put my hand to my heart to calm and hold the young, hurt thing, a part of me afraid that it was actually going to fly away. Anger has always been easier for me to own, so I told my white therapist with visible anger, “I am trying to calm myself before I speak.” My heart was ready to flee—and escape the pain—the pain of the blow which was multiplied in its effect, having come so hard and unexpectedly in a place that was supposed to be safe. The rest of my body, however, was ready for a fight—“I will not back down!” For the whole week, I allowed myself to fully stay and experience what had occurred in that painful therapy session. Paradoxically, this experience of staying with the pain of the micro-aggression pushed me into a spiral of transformative growth and healing, with the words of Rumi now resonating with me:

“If you desire healing, let yourself fall ill let yourself fall ill.”

It broke through my thick wall of defenses which had protected me from feeling or expressing my painful feelings in the past—especially those feelings when I had been “put down” or been the target of hate. Until then, I had vehemently denied and protested ever being cast in the role of a “victim.” Now I owned and allowed myself to feel them ALL—the feelings of indignity, humiliation, sadness, hurt, and fear—some of which were being held by very young parts of me. I became my own therapist, healing these young parts, unburdening them from the pain and hurt they had carried for years—simply waiting to finally feel acknowledged and validated, but more importantly, to be held and healed with self-compassion.

“We are healed of suffering only by experiencing it to the full.” Marcel Proust

In the next session, I clearly let my therapist know how her racist words and projections had negatively impacted me. To her credit, she took full responsibility for her racist remarks without trying to defend them in any way. This time we agreed that this was not a rupture that could be “worked through” or repaired to allow the therapeutic relationship to survive or grow stronger. Basic trust and safety had been violated by my therapist’s unexamined racist views and beliefs, and we agreed to terminate our relationship. However, having my therapist witness and listen to the impact of her words on me and take full responsibility for it was healing to me, and I did communicate that to her. In those moments, I recognized that as a therapist, irrespective of race, I have an ethical obligation not to perpetuate individual and systemic modes of oppression and racism, especially with my clients, and to pay attention to asymmetric power dynamics and intersecting identities to provide a safe relational context in therapy. I see how I have been guilty of protecting the status quo of white supremacy in my defensive denial of acts of aggression towards me (within and outside therapy settings) in the past. I have now vowed to directly challenge and dismantle oppressive thoughts and systems of power by speaking up against such micro-aggressions. Here is a list of defenses based on Internalized Racial Oppression from the People’s Institute for Survival and Beyond workshops shared with me by Nalini Kuruppu, LCSW, that I have found useful in my own self-reflections. My own defenses are highlighted. Defenses of Internalized Racial Superiority (for white-identifying people): White = Normal (unconscious understanding that white is the standard of humanity), White Denial, Intellectualizing, Individualism, White Distancing, Perfectionism, Entitlement, “Professionalism”, Expect Comfort, Rationalize, Minimize, Dominance, Demanding, Tokenism, White Saviorism, Self-Congratulations, Appropriation/Theft, Color Blindness, Addictive Behaviors, Defensive White Anger, Paternalism, White Tears, Dismissive, Arrogance/Expertism, Silence, Indifference, Need to be in control Defenses of Internalized Racial Inferiority (for Black-Indigenous-Persons-of-Culture BIPOC): Distancing (from race/ethnicity), Mimicking, Assimilation, Code Switching, Denial, Shame, Worthlessness, Fear/Hypervigilance, Guilt, Self-hate, Hopelessness, Ethnocentrism, Colorism, Protectionism (of whites), Tokenism, Invisibility, Exaggerated visibility, Addictions, Tolerance, Avoidance, Exceptionalism (the “model minority” myth). What about you? Do you directly speak to the asymmetry in power and the dynamics due to intersecting identities in sessions? Can you identify how you may be perpetuating oppression and racism? References: (1) Sue, D. W. (2010). Microaggressions in everyday life: Race, gender, and sexual orientation. John Wiley & Sons Inc.

Snatching Defeat from the Jaws of Victory

Posted on by Psychotherapy.net Team

After several tries, Jim, age twenty-five, was finally accepted into a prestigious bank management program. Once in the program, however, Jim found it difficult to make time to study. Assignments were handed in late, if even completed at all, and Jim developed severe headaches, all of which eventually led to his being the only trainee to leave the program, just days before he would have been forced to withdraw.

Alice, a first-year student in the Ph.D. program in psychology at a northern university had a similar experience. An otherwise unusually hard working and effective person, she found it easier to help others than to help herself. A cherished friend, colleague, and fellow student, Alice consistently failed to handle the demands of the graduate program, despite a well-demonstrated ability for academic work. While ably helping fellow students with their work, she neglected or mishandled her own papers, and her presentations were neglected to the point where her status in the program became jeopardized.

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Both Jim and Alice exhibit a pattern of self-defeating behaviors—clusters of thoughts, ideas and actions that sabotage success at work and in relationships. Self-defeating behaviors include a broad spectrum of self-imposed handicaps and other ploys and tactics that may suggest emotional trouble. Simply stated, a self-defeating behavior is any behavior that keeps someone from reaching their goals or sabotages their ability to be successful in ways that matter to them.

The obvious questions that arise in situations like these are “Why exactly do these people become their own worst enemies?” and “What would make bright, upwardly mobile, and ambitious individuals self-sabotage?”

Many explanations have been proposed for these behaviors. The most traditional analysis claims that people who repeatedly “shoot themselves in the foot” fear success, feel guilty about their behavior, or simply suffer from low self-esteem. Other explanations include the possibility that self-defeatists have inflated opinions of themselves, and that they use self-defeat to take control of a fear of failure. Perhaps Jim had serious doubts about his ability to successfully make it through the bank management program, so his being “too busy” to find the time to study, as well as his headaches, provided excuses that justified his exit without having to risk failing in the actual program.

Alice might have been handling her anxieties about the graduate program by developing a praiseworthy excuse for her own self-doubts and conflicts about her performance. If her sacrifices on behalf of her fellow students led to her inability to successfully complete the program, she could take comfort in the belief that she would have succeeded if only she would have finished. Her self-defeating handicap protected her from the risk of failure.

I have had success working with self-defeating individuals like Jim and Alice by helping them to learn to reflect rather than react and by identifying the negative self-beliefs that were partly responsible for their propensity to self-sabotage. With Alice, these beliefs caused low expectations for success and, hence, little motivation to try for better performance in future endeavors. This precipitated additional failure and helped to create a cycle of self-defeating behaviors for which she constructed defenses (e.g. rationalization) as her only means of coping. Therapy consisted of eliminating the irrational negative beliefs associated with self-defeat and replacing them with positive and rational alternative ones that she could gradually accept as valid. In addition, Alice was encouraged to consider alternative explanations for her failures. This was accomplished by considering hypothetical explanations for various events in which she was unable to succeed. With Jim, we were able to shift his attribution for failure from his claim that he lacked the ability to succeed to the realization that his failure in the bank management program had more to do with his insufficient effort. This enabled him to develop an expectation of possible success and helped him to imagine that he could, in fact, succeed if he was willing to try, and try differently, a second time.

A question that has had a great deal of traction with clients like Alice and Jim has been, “If you could do this over again, what would you do differently?” This helps them to begin a conversation that allows them to consider a different pathway, one that takes them to success rather than defeat.The satisfaction I was able to enjoy with both Jim and Alice had a great deal to do with their ability to tolerate the insights that illuminated their histories of self-defeat.

Gradually, they were able to relinquish the distorted beliefs and rationalizations that camouflaged and perpetuated their self-sabotage. Both of them were good examples of how insights become a blueprint for change in the course of a psychotherapeutic experience. Too often, the people I work with become "insight rich and change poor," which is why, for some, therapy feels moderately helpful, but not sufficiently productive and fulfilling. Good therapy has both therapist and client keeping a careful eye on the extent to which insights are implemented and identifiable and measurable change is able to occur.
 

Working Towards Therapeutic Solutions with Men

Posted on by Psychotherapy.net Team

In my experience, men typically and stereotypically really don’t like opening up about their feelings and prefer not to admit there’s a problem in the first place. So how to help get them into therapy becomes a compelling challenge.

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Many years ago, I read a report that found that one in three of the young men polled within it would rather smash things up than talk about their feelings. It was a tad extreme, I thought, but there you go. Thankfully, things have moved on a bit since then. However, men are still reticent. For instance, it turns out that they would rather talk to their barber about their problems than talk to their doctor, which is why the Lions Barber Collective exists. An international organisation that recognises the unique bond formed between a man and the bloke who clips his hair, it trains members up as mental health first aiders. Not only do they listen to the guys who sit in their chairs, but they can also spot the early warning signs of a developing mental health condition and then point them in the right direction for help. This usually means a psychotherapist. Which means we are back to talking about feelings. Which, as we know, men are not wont to do.

The problem is complex. But a big part of it is that talking about their feelings is still seen as a sign of weakness among many men. And despite the prevalence of metrosexual men in our media, the strong and silent male myth still pervades. Also, when men do talk, because of said stereotypes, what is more than likely depression can often be written off as a “bit of a low mood” instead.

Another problem, to my mind at least, is that when a man who doesn’t like talking about his feelings goes looking for a therapist, he goes looking online. And practically every single therapist’s opening statement will say something along the lines of “I offer a safe and non-judgemental space in which to explore your feelings.”

Egad!, as the exclamation goes. Are you trying to scare them away? Do you want men to come to see you for help? And, if you do, how do you reel them in? (Big hint: male-orientated metaphors help.) Enter then, any form of solution-oriented therapy.

I’m a rational emotive behaviour therapist (REBT) and have found that as a form of cognitive behaviour therapy (CBT), its philosophy and structure are easily explained and understood. As an active and directive approach, it offers me a way of being actively involved in the therapeutic process rather than sitting back and offering a safe space in which my client can talk whilst I sit passively by. As a form of solution-oriented therapy, I can even discuss SMART goals from the outset. And, before it starts exploring all the emotional consequences of a person’s dysfunctional beliefs, REBT can challenge them empirically, logically, and pragmatically.

I explain REBT to prospective clients in a very matter-of-fact way. My webpage is plain and straightforward. It attracts a large proportion of potential clients (including men) who want their therapy delivered in a similar style. This has been very helpful to anybody who is nervous about, or unable to, talk about their feelings.

Many years ago, a highly anxious man was brought to my clinic. In fact, he was so anxious that he was having a panic attack in the waiting room and was breathing deeply and slowly into a brown paper bag. It wasn’t having much effect, and it was clear his anxiety was not going to go away any time soon. I brought him into my clinic room anyway.

“Would it help if you just sat there breathing into the bag while I explain what this therapy is all about?” I asked.

He nodded. And so I discussed both REBT and the ABCDE model of psychological health, as well as the roles played by dysfunctional and functional belief systems. After a while, I simply asked him if he had noticed anything. He nodded slowly.

“What have you noticed?” I asked.

“I’ve stopped panicking,” he said.

I asked him why that was.

“Because I can see a way out,” he replied. “I’ve not been able to see one before.”

Fast forward a few years to a man who came to see me for psychosexual dysfunction, a tricky subject at the best of times. In my initial telephone consultation, before I engaged with him for therapy, this man described himself as a typical alpha male type who didn’t like all that touchy-feely stuff. He’d been living with his particular form of anxiety for over five years, hadn’t had any form of sexual contact with his wife for over three years, and was only speaking to me because his wife had delivered him an ultimatum. He’d had several courses of therapy already, including sessions with a sex specialist.

“I didn’t like it,” he said. “They were all sympathetic, but I wasn’t looking for sympathy. And they were all trying to get me to open up about my feelings, but I either couldn’t or didn’t want to.”

“So, what’s going to be different this time?” I asked.

“I really liked your website,” he said. “It was very direct. I know I will have to speak about how I feel at some point, but there’s a format there that appeals to me.”

Studies have shown that men aren’t averse to therapy per se, but they are averse to therapy that is loose, conversational, and exploratory. One study found that the best treatment styles for engaging the menfolk were, “collaborative, transparent, action-orientated, goal-focused” (Seidler, 2018).

When delivered in the correct way, I have been able to encourage men to talk about their feelings. I haven’t had to get all stoic and blokey myself, I just have to explain myself in a clear and concise way, preferably without mentioning either safe spaces or feelings. In my experience, if a man phones me up for therapy and I ask him what his goal is, he will usually commit to the process. And together, we venture forward on a journey of change

References

Seidler, Z. E., Rice, S. M., Ogrodniczuk, J. S., Oliffe, J. L., & Dhillon, H. M. (2018). Engaging Men in Psychological Treatment: A Scoping Review. American journal of men's health, 12(6), 1882–1900. https://doi.org/10.1177/1557988318792157