Category: Therapeutic Issue

Preserving Connection in the Age of Polarization and Commodification

Posted on by Psychotherapy.net Team

As a psychotherapist and social worker, I was often uncomfortable while watching The Social Dilemma, a new Netflix documentary (2020).

The film focuses on the challenge and threat of social media to individual mental health, family stability, and to the worldwide social fabric. Featuring interviews with technical experts, innovators, and ethicists from Facebook, Google, Instagram, and Twitter, the film takes a deep dive into the impact and repercussions of contemporary technology. These former employees speak directly to how the industry, which is perceived as serving users, is instead turning them (us) into product, and how the financial success of social media is built around manipulating us into feelings, thoughts, and actions that can be predicted and monetized.

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These Silicon Valley industries originally framed their work around missions of helping people to connect—with each other and the world. Many of their innovators were motivated by desires to increase positive interaction and to encourage networking, facilitate personal expression, and empower underserved and disenfranchised communities. All of which utilizes language virtually identical to the terminology I absorbed as a social work student 25 years ago.

The documentary’s interviews (sporadically interrupted with less effective dramatizations) congeal over the 93-minute running time into a message that reviewers have called “genuinely scary,” “bleak,” “dire,” and “essential.” It speaks to the relationship we have all developed with technology and pointedly distinguishes the current breed of technical innovations from prior technical tools; namely, it emphasizes that a tool is a passive object with which we may choose to engage or not. The current technologies pursue our attention, draw us in, and are motivated to manipulate our usage. The constant pursuit of increasing the user’s online time not only feeds the monetary needs of the industry, but it inevitably reshapes our responses, as patterns of usage evolve into habits, and habits become addictive patterns. They may even be reshaping our world view.

Unfortunately, these arguments are consistent with what we in the mental health field accept as fact, from Skinner’s behavioral principles all the way to contemporary understanding of neuroplasticity and mirror neurons. Our expertise offers no escape hatch, it only reinforces the concerns and leaves us with our own professional dilemma: how then, within our mental health practice, are we to respond?

It’s not my job to give advice. But it is my job to help clients access information and resources that have the potential to empower them in their own pursuits.

I can raise awareness about the power of phone notifications and how they are used to shape responses.

I can repeatedly encourage folks to reach beyond what their internet stream provides them as news, facts, and history, noting that these industries have a bias toward polarization and that the feed you are getting is designed to make you more extremely biased in whatever direction you are leaning.

I can inform parents that middle school suicides have increased over 100% since the availability of cell phones and internet service.

I can affirm my client’s need for connection and a sense of community. I can affirm the ways that Facebook or other social media might serve some of those ends, and I can balance that by raising concerns about how it falls short and has been shown to increase fear of missing out (FOMO), which can create fertile ground for depression to take root.

I can work to demonstrate what human connection looks like. Yes, even on telehealth!

For over six months I had been providing counseling to a couple, both of whom struggled with issues of trust and security stemming from difficult childhood experiences, triggering each other regularly at home and in most of their shared sessions. Progress, however, was being made, and it was evident in a decrease in the severity and duration of conflicts at home. In sessions, they were increasingly capable of tolerating vulnerability with one another, and each had begun to embrace the belief that their partner’s upset was a defensive response rather than an attempt to hurt or control. Each had begun to see the other in a new way: outside of the polarized, good vs. evil worldview generated by injury, betrayal, and rejection. They were learning to accept and consider the ambiguity.

I asked the couple to turn their chairs to face one another and, once I could see they had settled, I asked them both to close their eyes and to focus attention on breath. After guiding them through a simple grounding technique, I directed their attention to their love for each other and, with eyes still closed, encouraged them to feel this love both truly and intensely and to channel it all through their eyes to their partner. I then asked them to open their eyes, to pour their love into the eyes of the other and, simultaneously, to absorb the love being gifted to them as well. After thirty seconds they both laughed, as young children might when delighted. I encouraged them to stay with it, and with broad smiles they beamed at one another. After another thirty seconds I encouraged them to conclude with a hug. The embrace was a long, sustained, fully embodied and clearly emotional connection.

With individuals I have recently begun incorporating Diane Poole-Heller’s Kind-Eyes Exercise, in which the therapist asks a client to close their eyes and imagine the eyes of someone greeting them with warmth and kindness, indicating they are happy to see them and extending enthusiastic welcome. The client is encouraged to hold that gaze and to notice the changes in sensations in their body, including effects on their breathing and heart rate, and then to introduce and try to hold the notion that they are, in fact, deserving of the warmth and kindness seen in those eyes.

Learning to embrace the other or to allow one’s self to feel treasured is learning to accept the premise that love, connection, and joy are found in the ambiguity and nuance of this imperfect moment.

In contrast, The Social Dilemma is, in part, a portrait of the hostile environment in which we all live and work. This environment constantly objectifies us. The exercises I describe here and the way I provide therapy are my attempts to hold true to what we know to be the path to human connection, wellness, and possibility. To adequately offer these services, I need to hold an awareness that the very basics of what therapy has to offer are fundamentally antithetical to many cultural norms.

And if this film has it right—that polarity is intensifying. The type of connection I facilitated and witnessed with this couple may just be an interpersonal means to resist dystopian ends.
 

2020, The Summer of No

Posted on by Psychotherapy.net Team

The calendar has turned to September, and leaves have begun to change color, but before completely turning my attention to fall, I want to reflect on how strange a summer it’s been. Due to COVID-19, I have had to grapple with more unwanted changes in my psychotherapy practice than ever before. It is best summarized as the summer of “No.” In an attempt to capture the breadth and depth of my experience, I’ve created a list of the Nos that have been hardest for me.

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No break. As a psychotherapist, summer is typically the time of a reduced schedule for me. Between my own vacation plans and those of my patients, I usually have more openings in my schedule. Typically, the warmer weather also decreases the number of new patient inquiries. For those like me who practice in parts of the country where summer sun invites us to be outside, there is less demand for psychotherapy. In contrast, during the summer of 2020, the demand for psychotherapy increased as people tried to cope with the impact of the pandemic. It was hard to say no to those seeking help when the need was so great.

No office. I, like many other therapists, became a front-line responder even as I moved out of my office and online. The scramble to learn Zoom, fashion a home office offering some semblance of professionalism, and establish new protocols with patients I’ve never met in person was a steep learning curve. Questions about HIPPA and collecting co-pays electronically became a common thread on listservs. As I lost the separation between my private and professional domains, my life became limited by lock-downs. The line between working and not-working was blurred. The dreaded commute looked less awful from the rearview mirror of nowhere to go. Six months out, my beloved office has become a very expensive post office box where I go and collect my mail on a weekly basis. Each time I open the door, I feel a bit like Miss Havisham in Great Expectations—the calendar says March, and the magazines are out of date. The water in the cooler is no longer cool or potable, most likely.

No variety. One of the deep satisfactions of my work is the individuality of my patients. The variability of the human experience set against the sameness of my physical space has kept me engaged in my work. But this summer, each session was characterized by universal angst about the pandemic. The particulars were different—the patient who was stuck in an unhappy relationship versus the mother surrounded by bored children—but the plea for reassurance was similar. Even more striking was the lack of separation between my own worries and those of my patients. I suffered from pandemic dreams and changed my routines to avoid falling ill.

No reset button. Every therapist I know complained of feeling burnt out, with little prospect of finding a way back to equilibrium. With gyms closed, travel out of the question, and social activities greatly curtailed, I found it increasingly challenging to practice self-care. As I lost track of the date and the day of the week, it was difficult to determine how to take care of myself. With no museums, movies, or plays, finding ways to let my mind rest and reset took unusual effort.

No way to meet new people. People struggled with the isolation of living alone. Figuring out how to date during the pandemic made dating apps feel even scarier than usual. Women worried about the window of fertility closing without an opportunity either to find a partner or feel safe to get or be pregnant during the pandemic. All of these fears were real, and trying to sort out how to encourage growth for my patients while respecting the reality of living through a pandemic was painful.

No joy. There was so much loss—deaths unattended, weddings canceled, and newborns not held by grandparents. There were no graduations, no proms, and no parties. Summer holidays were scaled back or nonexistent. It was hard work to find the joy in activities that now required masks and social distancing. Four of my patients, however, did get married this summer. After scaling back their plans, in the end, each celebration was a testament to flexibility and changed priorities.

No faith in our leaders. People searched for answers they could trust. Mask or no mask? Six feet apart or ten? Was flying safe or not? The discouragement and at times outrage about the failure of our leaders to lead kept our sessions focused on current news cycles with an abundance of hopelessness.

No more only pretending that Black Lives Matter. Pretending no longer passed as good enough, and although this was a positive change, the challenge was great. The reckoning of how to understand our country’s long, sordid history of racism was dissected within the safety of the therapy relationship. For many of us, especially those of us who are white, the painful and raw experiences of racist feelings and behavior were relatively new to include in our conversations.

No jobs. As patients were furloughed or laid off, economic worries became paramount. Some careers all but disappeared, such as event planners who found themselves not only without a job, but also without a career future. Recent graduates’ dreams of starting a new life were dashed. Older patients felt the sting of ageism in the workforce. For some people, it became a matter of choosing between their jobs and risking their health.

No end in sight. There was no timeframe I could offer for when things would be better. Future plans remained uncertain, and even now there is still no end in sight. Exploring topics of mortality and challenging our very American notions of invincibility and superiority evoked existential crises about the meaning of life. Patients pleaded with me for assurance that things would be all right. Holding out hope, but not false promises, for the future required striking a tenuous balance.

As I and others steel ourselves for the one-two punch of the pandemic and the election this fall, it is worth pausing and acknowledging the toll COVID-19 has taken on our own well-being, not just that of our patients. It has been exhausting. I am committed to find a way to greet the crisp, cooler autumn air and fulfill my professional responsibilities. For despite all the “Nos,” one thing I do know is that human connections are what make life worth living, especially during challenging times like these.

When a Client Resists, I Persist

Posted on by Psychotherapy.net Team

When it comes to client resistance, I should know better than to blame the client. The burden is on me, the clinician, to adjust my approach, search for my hidden personal biases, repair a therapeutic breach, and empathize more effectively with the client. It is my job to remedy clinical stuckness, to take that responsibility head on, and for good reason. I am the service provider. I am in the position to help. It is not the client’s job to transform my deficiency or blind spot into effective help. I get this on an intuitive level. So why do I get stuck personalizing resistance and harboring secret negative judgements of my clients? Psychiatrist David Burns, author of Feeling Good, suggests that counselors struggle with client resistance because their egos get in the way. He says we are too fragile, therefore strive to protect our pride and identity, forcing us to match the client’s resistance with our own. Thus, to help the client and enhance the clinical work by taking their critical feedback, we must, according to Burns, “put our egos to death.” What he means by this is that I, as a clinician, need to drop my defensiveness so I can truly hear what the client is trying to communicate. Once I am no longer defensive, I am then free to see the client’s resistance for what it really is—information, rather than a personal attack, although it may feel like one. And I can use that information to adjust my approach and hopefully enhance the overall clinical work. In my experience, ego doesn’t go down without a fight; it doesn’t even like surrendering. When I have felt slighted or diminished by a client, my first impulse is to prove them wrong; I want to show them I’m right or that I’m superior, or smarter. This is the dark side of my clinical self. I find it far more clinically useful to expose this darkness to the light. This is no easy task, but the pain of putting my ego to death is worth it. A dead ego means I can engage with the client’s criticism and defensiveness without taking it personally, without being threatened, without having to argue back. The client can no longer offend or wound me. I can harness their criticism and use it as information that changes the therapeutic work. That’s empowering! But this is easier said than done, so below I provide 5 suggestions from my own clinical experience on how to do this: Reframe the client’s criticism/resistance: It is my work to reframe the client’s resistance and criticism as information. They aren’t resisting me; they are, in fact, communicating with me. And what they are saying is valuable information uttered in the hopes of making the relationship better. I try never to ignore this useful information because of my ego. The stakes are too high. Take responsibility: I am the service provider. If the client is resisting, the responsibility falls on me, not them, to remedy the situation. I will not become a defeatist or a helpless blamer of the client. I can make things better. I can directly change the situation. I am not powerless. In order to serve the client, I will own the situation and take concrete steps to address the client’s resistance. The client is a person: The client is in a vulnerable position. They aren’t trained mental health professionals with high-powered degrees, certifications, and letters after their names. How are they supposed to tell me that counseling isn’t working? Their main vehicle for feedback is resistance. Therefore, I strive for compassion for my client and for their need to resist. The client could be teaching me something: It is possible that resistance is the result of venturing into an area of my weakness or ignorance, which is not the client’s fault. I am not all-knowing and comprehensively skilled—becoming a competent clinician is a life-long endeavor. I learn just as much from my clients as they learn from me. Counseling offers me the potential to expose my ignorance. And the possibility of that shouldn’t threaten me; rather, it should excite me. Exposure of ignorance can be gentle; it can also be harsh; but within are lessons that can be used for my growth and the client’s benefit. Modeling: I can demonstrate health to my clients by receiving their resistance in a respectful manner. My goal is leading my clients and modeling healthy give-and-take. The client’s resistance can be a teaching moment where I show them how to offer feedback in a more kind and respectful manner. I recall working with a young man who taught me how to see the benefit of resistance. I remember that anytime we tried to discuss the content of his assigned workbook exercises, he would do everything in his power to change the subject, to mock the content of the workbook, to say it was boring or that it didn’t matter. He would say the exercises were “stupid.” And when he did complete the assigned work, he would write down one-word answers. This always came as a surprise to me, because our conversations at the beginning of sessions were usually engaging and positive. At the beginning of our relationship, we could spend an entire session hour talking about why he didn’t do the homework. I grew tired of the run-around and finally asked if he thought the homework was helpful. He answered honestly. He said doing the homework felt like school. And when it came time to discuss it in session, it ended our positive conversation. He added that I was the only positive male figure in his life. When he was young, his father had abandoned his family, and his mother dated a series of angry and controlling men. All of his teachers at school saw him as the “problem kid.” So it was a huge relief and comfort to be with a man whom he liked and with whom he could have fun, lighthearted conversations. In that moment, I realized that working through the content of a workbook was secondary, and what this young man really needed was a caring relationship from a man with whom he felt safe. I thanked him for his honesty and feedback and adjusted my approach. I focused more on relationship building and made the workbook exercises completely optional. I would only discuss them if he brought it up. From then on, the young man’s resistance was gone, and he voluntarily put more effort into the workbook. Understanding my client’s resistance helped me understand him at a deeper level and, in turn, improved our therapeutic relationship and its outcome. His resistance offered us both the opportunity to grow in our respective roles.

Dangerous Intimacies: Racism, Risk, and Recovery

Posted on by Psychotherapy.net Team

I Have These Fantasies

“I have these fantasies,” Ivan told me, his voice low and cold as stone, his eyes sliding away from mine and fixing on the wall behind me. “I wait for one of those women outside the building. I get her alone, and then I strangle her with my bare hands.” As he said this, his hands tensed and grasped, as if wrapped around someone?s throat. “I can almost feel it,” he said.

An African-American man in his early 60s, Ivan (a pseudonym) was in therapy with me for PTSD when he made these statements. I was surprised he expressed these feelings to me. Not because of the intensity or violence of Ivan?s words, but rather by the mere fact that he actually allowed himself to utter them out loud. We had been working together for over two years at that point, and this was the first direct expression of anger he had ever shown in session. Ivan had talked often about feeling angry—stating it in a vague and matter-of-fact way—but he had refused to do more than that. When I would encourage him to elaborate, he would just shake his head, press his lips tightly closed, and wring his hands. As I later learned, this was not resistance in the classic psychotherapeutic sense—it was something altogether different. By the time Ivan finally spoke his anger, I had come to appreciate what was at stake for him in doing so.

Resentment: A feeling of indignant displeasure or persistent ill will at something regarded as a wrong, insult, or injury (Merriam Webster)

Three years before this encounter, Ivan—a thirty-year seasoned social worker and substance abuse counselor who had received numerous commendations—found himself in an unexpected situation. During a session, a client told him she had herpes and was planning to go out to spread it to as many men as she could. Alarmed, Ivan told her that was unacceptable, and that she absolutely could not do such a thing. The client became angry and stormed out. On her way past the front desk, she told the receptionist that Ivan had grabbed her and sexually assaulted her. Rather than come to Ivan and ask him what happened, or asking anyone else if they saw anything untoward during Ivan?s session (he always left the door part way open during sessions with female clients), the site manager broke protocol and went directly to the police. Ivan, unaware of the accusation, went about his day.

The following day, the police came for Ivan, hauled him down to the police station, and harshly interrogated him for four long hours. They pressured him. They threatened him with violence. They yelled in his face. They laughed as they told him they could plant drugs on him and throw him in jail anytime they wanted to, so he might as well just confess to what he had done. This kind of scenario would be a harrowing event for anyone, but for Ivan—a black man who grew up in the inner city—interrogation by the St. Louis police was especially fraught. “I really didn?t know what they would do,” he told me. “”When you grow up in the city like I did, you stay away from the cops at all costs”. I was completely at their mercy. I honestly didn?t know what would happen to me in that room.”

Ivan was eventually released and, following a thorough investigation by both the police and the Department of Mental Health, was completely exonerated of any wrongdoing. Meanwhile, the client in question had recanted, admitting that she made up the allegation because she was angry. But it was too late—Ivan?s life was in tatters. Word had gotten out among both the professional social work community and the neighborhood that Ivan was a “sexual deviant” of some sort, though in typical gossip fashion, the details became contorted. He came home to see “child molester” spray painted on his garage. He had rocks thrown through his windows. Neighbors crossed the street to avoid him, and he was asked to leave neighborhood gatherings. His girlfriend of two years left him because of the rumors.

But worse than all of this were the symptoms of PTSD Ivan developed in the wake of his interrogation at the police station. He had nightmares and flashbacks. He would spontaneously start shaking uncontrollably and pouring sweat. He paced incessantly. He became completely unable to function, let alone work. And most intense and troubling for Ivan was his absolute terror of women. “I can?t be anywhere near women,” he told me. “I?m terrified of what they?ll do, if they might accuse me of something, of what would happen then. I can?t go back to that police station. So, I stay as far away as I can from females.” This might strike you as ironic, as I am a woman, and Ivan was telling all of this to me. In fact, we talked about this often, and I will return to it in a moment.

Ivan, understandably, harbored a great deal of resentment about everything that had happened to him. Notably, however, he was not upset with the client who accused him: “The client is, well, a client. You don?t expect them to act rationally,” he said. Nor was he upset with the police who interrogated him: “The police were doing their jobs. I was just some guy they thought had done this thing.” Rather, his resentment became directed at the coworkers—all of them women—who called in the police rather than following company protocol. “That?s what I don?t understand,” he said. “My coworkers, those women—they knew me. I had worked there for six years. That?s what really gets me.” In other words, Ivan?s resentment derived from the intimacy and vulnerability he had cultivated with the people—women—who then turned on him and put him in danger. The fact that some of these women were Black women particularly upset him. “They know exactly what calling the cops on a Black man can mean,” he stressed. “They put me directly in harm?s way. I can?t believe they did that.”
Re-Sentiment:
To feel something again, to experience the past in the present.

The Burden of Being Black

In contemporary American psychotherapeutic practice, therapy is supposed to be a safe space where clients can connect with and express their deepest and most vulnerable thoughts and feelings. The reigning ideology is that many of the troubles that people experience can be ameliorated by talking through what is bothering them, expressing unexpressed emotions, giving voice to submerged or disavowed feelings. Feeling again—or maybe for the first time—sentiments that have been foreclosed for any number of reasons. This is often a frightening prospect for clients, but for Ivan it took on additional significance.

When we first began meeting, about six months after the incident in question, Ivan insisted we keep the door open—not just a crack, but wide open. He was afraid to be alone with me behind closed doors. As he explained it, “What if you felt uncomfortable or just decided to interpret something some way and accused me of something? The police told me I could get twenty years for sexual assault. Twenty years! I?m 62—that?s a lifetime. If there was another accusation, they would put me away for the rest of my life.”
Given Ivan?s fear of women and his refusal or inability to become angry in session, it quickly became clear to me that the standard therapeutic interventions for PTSD were not going to be helpful. Not because Ivan didn?t have PTSD or that they wouldn?t have helped to relieve the internal push of some of his most troubling feelings, but because these interventions assume that a person is situated in a particular way in the social and relational world… or, rather, NOT situated in a particular way. As a Black man, some of the many harmful stereotypes Ivan had to contend with were that of being construed as scary or threatening, prone to violence or loss of control, hyper-sexed. Not only is it likely that such stereotypes prompted his coworkers to call the police, it affected Ivan?s relationship with his own emotionality, especially his anger.

One day, as he sat in my office trembling and sweating and talking about how his life had become a shambles, I tried to get him to express his anger about what had happened to him. After a few minutes of this, he looked up at me, incredulous. “I?m sitting here in this room with a White woman and you?re telling me to get ANGRY? You?ve got to be kidding me. I can?t do that.” I assured him that it was ok, that this was part of his process of healing, and he just scoffed. “Doc, I know you mean well but seriously, you don?t understand. I just can?t do that. I?m a Black man. You?re a White woman. I can?t get angry around you. I?ve learned my whole life that that?s a dangerous thing to do. I just can?t do it.” Despite my assurances that it really was ok to do so, Ivan was adamant. It was, he said, for my own protection. “Not that he would ever actually hurt me, but, rather, that I might become afraid of him”. And that, he felt, would be its own kind of violence. It could also put him in danger. “What if you get scared? What if you call the cops? I?d be right back down there looking at twenty years.” Anger, in other words, was not a discrete, personal emotion or feeling for Ivan, at least not in the context of his relationship with me and others who look like me. It was part of an interpersonal anger/fear dynamic with deep social and cultural roots steeped in race, gender, and sexual bias that shaped not only how Ivan expressed his anger (or didn?t) but also how he experienced himself as a person and how others experienced him—as a potentially threatening, scary force, regardless of his actions or intentions.
Ressentiment:
The persistent indignation of the historically oppressed
(Nietzsche)

“In Ivan?s case, it was obvious to me that race likely played a role in his coworkers? assuming he was sexually dangerous and calling the police”, and that it also likely played a role in how he was treated at the police station. But Ivan himself did not bring up these issues. I waited for many months for him to do so, but he didn?t. So after about a year, as he became somewhat more stabilized, I did.

One day, as Ivan sat on my couch jiggling his leg and wringing his hands, I said, “I wonder how your being a Black man might have figured into what happened to you. Do you have any thoughts about that?” He immediately stopped jiggling his leg and looked up at me, intently. I worried that perhaps I had offended him. “Doc,” he said. “It has everything to do with it. But I didn?t know if it was ok to talk about that in here.” I assured him that it was, and this opened up a whole new line of exploration in our work together. It was only in the wake of this that he was able to tell me why he was afraid to get angry in session, and for us to work toward making that a safe thing for him to do.

Ivan doesn?t blame racism for everything, though. “I keep thinking I must have done something to bring this down on me,” he said. “I must have. Otherwise, why me?” Though at the same time he is adamant: “If I had to do it all over again, I wouldn?t do anything differently. Not one single thing. You cannot go out and spread herpes to a bunch of people. No! You cannot do that! So, I would tell the client the same thing. I wouldn?t do anything different. That gives me comfort.”

Resentment, Race, and Recognition

We have, then, three facets of the feeling of “resentment” with and within which Ivan is operating (resentment, re-sentiment, and ressentiment), each having to do with his positionality as a Black man in 21st century St. Louis, MO, and each significantly impacted by the relational context of being in therapy with me, a White woman. This reminds us that affects such as anger, fear, and resentment don?t just function in one certain way for all people, at all times—or even the same person at different times. Affects and emotions are not stable, whole, inviolable states that we either have or don?t have, like the flu. They have texture, context, and dynamism. Importantly, how we experience and express affects and emotions is deeply culturally and historically shaped. Therapies that isolate and target them as abstract phenomena (“anxiety,” or “depression,” or “fear”) dislodge these feelings from their lived realities and can, as in Ivan?s case, compound a client?s sense of alienation and disconnect rather than foster recognition and healing.

As I write this now, Ivan is doing well. We are down to one session every three weeks. He still gets triggered and has moments of intense rage or panic, but now he can go to the grocery store and complete a shopping trip without having to leave if a woman walks too close to him, and he can ride the bus without having to sit way in the back to make sure no women are behind him. He?s even considering dating again. “I never would have believed it,” he told me. “When we first met, I thought ?Oh Lordy, how is this White girl going to help me?? I thought, ?God has a pretty sick sense of humor.? But you know what, Doc? I?ve learned a lot; you?ve taught me a lot.”

Perhaps. But Ivan taught me a great deal as well. Among other things, he taught me that, even as we care for our clients, they care for us, too, and often in ways that remain invisible. But more than this, Ivan?s caring for me by “protecting” me from potential fear (and, by extension, protecting himself from the possible consequences of that fear) led me to reflect on the fact that all emotional expression is not created equal, and not everyone has the freedom or the luxury to “get in touch with their feelings” or “use their words to say how they feel.” Affect and emotion are highly racialized in the United States, and for some people, the honest expression of those feelings can be literally—even fatally—dangerous. This understandably can evoke deeply ingrained cultural scripts about who is allowed to feel what feelings and in the presence of whom, which can affect the process and course of therapy in ways that are both subtle and profound. Clients of color, and especially Black clients, carry with them not only their personal histories but also centuries of oppression, racism, and accommodations to White privilege. It?s not enough for a therapist to be informed or to feel they are open-minded and treat all clients equally. Because the world is not an equal place. “Equal” is not what clients of color have grown up with and live on a daily basis. It?s not the world they walk into when they leave the therapy room.

So what to do? Does this mean that clients of color should only see therapists of color, and white therapists should only see white clients? No. But it does mean those of us who are White clinicians are ethically obliged to educate ourselves about racial dynamics and injustices and be prepared to discuss them from a place of respect and openness with clients of color. We need to be willing to take an honest and hard look at our own privilege and how it shapes our beliefs about health and healing. And we must recognize that the theories and interventions we have learned as “best practices” are based on White norms and do not take into account the legacies of bias and oppression that shape Black clients? emotional experiences and expression. This does not make these tools useless or ineffective. But it does make them partial and in need of active interrogation and adjustment (for a collection of excellent resources on where to begin, see Race and Racism: Resources for your Practice).

I am incredibly fortunate that Ivan took a chance on me. He was traumatized and vulnerable and he took an enormous risk working with a woman, and a White woman at that. He says I taught him a lot, but what he has taught me is infinitely more valuable: he taught me to recognize how much I don?t yet know.

References

Merriam-Webster. (n.d.). Resentment. In Merriam-Webster.com dictionary. Retrieved July 7, 2020, from https://www.merriam-webster.com/dictionary/resentment.

Nietzsche, Friedrich. (1989). On The Genealogy of Morals. (W. Kauffman & R. J. Hollingdale, Trans.). Vintage Books. (Original work published 1887)

The Double Standard

Posted on by Psychotherapy.net Team

“Of course, I wouldn’t say that to a friend!” My patient, Alice, has come to me for help with depression and procrastination, and we’ve identified her long-standing habit of calling herself “a lazy fuckup” when she gets stuck on an assignment. We’ve been using David Burns’ version of the “Double Standard” method of challenging this harsh negative self-talk. In this role-play method, I play an imaginary best friend who is a clone of her – with her same genetics, childhood background and adult circumstances – who has turned to her for help with her negative thoughts. She’s given me the name “Gina.”

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 “Alice,” I say as Gina, “I’ve been feeling so stuck on this work project and feeling down on myself about it. I’ve been telling myself that I’m a lazy fuckup. Isn’t it true, that I’m a lazy fuckup?”

 “Of course, that isn’t true!” Alice rises out of her slumped position and leans forward, almost as if she were going to lay a hand on ‘Gina’s’ knee. “You aren’t a lazy fuckup. That is such an unkind thing to say.”

“So, it’s not true? Are you just being nice to me because I’m your friend?”

Absorbed in the role play, Alice shakes her head without flinching. “Of course, it’s not true.”

I had a feeling this method would be helpful to Alice, as she has demonstrated plenty of compassion for the others in her life, reserving her harshness for herself, and she had already made progress identifying the distortions in her thoughts. But despite seeing that her thoughts were distorted, she wasn’t quite connecting with her positive, encouraging thoughts. Roleplay methods are often a powerful way to bring home a change at the gut level. I continue with the role play, encouraging her to get specific.
“But Alice, I’m so stuck on this project. What makes you think I’m not a lazy fuckup?”

This takes her a bit more time, and I can see her brain shifting gears, as she starts to engage the work of compassion, work that involves seeing what is there rather than reaching for a label.

“Well, it’s true that you haven’t gotten as far in on the email copy as you would like. And you spent most of the morning doing the New York Times crossword puzzle. It sounds like you are feeling pretty stuck,”

I nod along in character, encouraging her.

“But you did finally sit down to work on it. You haven’t given up,” she continues, “and that is important.”

We both smile.

Why are we kinder to our friends than we are to ourselves? Why do we poke at ourselves with hurtful labels and lash ourselves with should statements, those whips of the mind that create anxiety, guilt and shame? In TEAM therapy, “A” stands for “Agenda Setting,” or “Analysis of Resistance.” In this step, we walk with a patient to see what is positive about negative self-talk and the painful feelings it generates. Alice has come to see that the anxiety, guilt and shame that rise up when she starts to criticize herself for procrastinating, stem from deep-seated values to be productive, to move forward on projects she cares about, to engage instead of to withdraw. Telling herself she is a lazy fuckup is a way to keep herself from enjoying her procrastination too much, a kind of guard rail that protects her from the consequences of not getting her work done.

So, knowing that there are good reasons for her to stay stern with herself, I test her again, giving another one of her harsh thoughts, in my role as Gina. “But Alice, shouldn’t I just get over myself?”

“No, no,” Alice’s eyes are warm. “You want to move past this, I can see that. But name-calling and pressuring yourself won’t be helpful. You can get past this place where you are stuck. It’s going to be hard, and scary, and you might be tempted to believe you can’t do it. But I believe in you, and you can always call me for encouragement.”

“Wow,” I say, wanting to linger as ‘Gina,’ and bask in her kind encouragement, “that feels incredibly good hearing you say that. I feel so seen and supported and encouraged.” Reluctantly, I add, “can we hit the pause button?” She nods and sits back. She is calmer, sadder, tears in her eyes. She seems fuller.

“Wow, indeed,” she says. “I know where you are going with this. Can I talk to myself that way?” She considers this. “It should be a no-brainer. I mean, right now at this moment I feel so connected to you as Gina – it seems easy to want to stay present with her and encourage her. But somehow, when it comes to me, I feel hesitant.”

“Yeah, go on. There is something important in your hesitation. Why would you be hesitant to stay encouraging instead of punitive with yourself.”

“I really, really love to procrastinate. If I’m kind to myself the way I am with Gina, I will feel better, and then how do I know that I won't just get soothed and feel better and jump on the couch with another crossword puzzle? Being strict with myself is the only way I can stay on task.”

“So, your worry is that if you let up on yourself, that you’ll become self-indulgent?”

“Yes, exactly,” she nods.

“And what would your self-indulgent voice be telling you. What are the thoughts that tempt you to the couch?”

“Oh, I’d tell myself that I can totally do this tomorrow and that I deserve a break.”

“Can we go back into the role play?” She nods, and I resume again as Gina, “Alice, thanks so much for those kind words about my project. I feel so much better that I’m going to grab that crossword and go sit on the couch. I deserve this break.”

Alice starts to crack up.

“Oh no, you don’t my friend! I love you too much to let you do that. This project is really important to you! You won’t have time later, now is the time to do it! You can do that crossword after you finish this email copy and after you confirm your plans with Diana.” She breaks from the role play, “I get it now, kindness and accountability are all wrapped up together.” She sees me open my mouth, and beats me to it, “Now that’s something I would say that to a dear friend, and to myself.” 

The I-Thou Relationship in the Age of Telehealth

Posted on by Psychotherapy.net Team

Clinicians have long understood the therapeutic relationship to be the most powerful meta-intervention supporting client change and transformation. As Carl Rogers observed, the prerequisite for therapeutic change is that the client and therapist be in psychological contact. But when a computer mediates between counselor and client, how much does that impair this contact and obstruct the potential for therapeutic movement? In a world increasingly reliant upon telehealth services, we are challenged to preserve the authenticity of meeting if we hope to effectively combat the challenges to real connection inherent in technology-mediated relationships. Luckily for us, philosopher Martin Buber dedicated his entire life to uncovering the invisible potential embedded in relationships, and much of what he discovered can help us to remedy some of these relational complications in the age of telehealth.

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Martin Buber believed that we have the capacity to relate to each other in two distinct ways. When we actively and authentically engage each other in the here and now, Buber believed that we open up to ourselves and orient towards another as a “Thou,” which he characterized by mutuality, directness, presentness, intensity, and ineffability. He saw the I-Thou relationship as a bold leap into the experience of the other, while simultaneously being transparent, present and accessible to one’s own experience. I-Thou encounters in therapy occur when we are able to truly “show up” for our clients, which then affords them the possibility of embodying themselves. Martin Buber designated this meeting between I and Thou as the most important aspect of human experience. He viewed our capacity to confirm and be confirmed in our uniqueness by others as the source of growth and transformation that structures the foundation of our shared humanity.

However, to confirm another as a Thou is no simple task. We must be willing to embody the fullness of our own experience and release ourselves to the ambiguity of the moment if we are to open up the space for an I-Thou relationship. Instead, we tend to slip into seeing the person as an “It.” When we do this, the other person is experienced as an object to be influenced or used, or a means to an end. The world of I-It can be coherent and ordered, even efficient, but inevitably lacks the essential elements of human connection and wholeness that characterize the I-Thou encounter. When an extreme I-It attitude becomes embedded in cultural patterns and human interactions, the result is greater objectification of others, exploitation of persons and resources, and forms of prejudice that obscure the common humanity that unites us.

Buber emphasized the importance of holding a balance between these two necessary poles of existence. However, in the current age of telehealth, the computer itself fundamentally alters the medium through which an I-Thou meeting can emerge and tips the scale towards an I-It interaction. As technology pulls interactions toward I-It orientations, we increase the risk that our clients will miss the authentic growth and transformation that blossoms out of a real meeting between client and therapist. The process of trusting another person with one’s vulnerabilities and sharing a lived-in experience held and expressed through one’s body is much more dimensional than two talking heads communicating through a screen with words and ideas only. We must resist the danger inherent in telehealth, so the therapeutic encounter does not become abstracted, experience-distant, and limited to language spoken from the neck up.

I feel the gravitational pull towards I-It orientations when I find myself leaning into the comfort of familiar habits while facing a client on my computer screen. The presence of the technology tends to pull me into thinking about all the relevant interventions I could implement with my client in order to help them remove their suffering. This orientation is useful at times; however, it also encourages a lack of presence in the teletherapy session that bends attention away from the invisible elements of therapy that foster human connection and growth. Instead, therapy becomes centered on the visible elements of practicality that can distract client and therapist from the deeper therapeutic aim. However, I’ve noticed that I can counter this natural bending of attention by remaining centered in my body and trusting my intuition to guide me. Technology inherently obstructs the therapeutic relationship, but it does not destroy its potential. There still exists an invisible bond that can survive the medium of pixels, a power that can be actualized if we can trust our intuition to guide us towards opening up spaces for its potency. To do this, our presence must remain oriented towards the possibility of an I-Thou encounter.

However, I find that this new technology-centered therapeutic process can be much more draining than in-person therapy because of the extra effort needed to attend to elements that would otherwise be naturally apparent and expressed. The lack of ease in reciprocity in engagement is also dually draining for the therapist, as the usual “beats” of body-to-body communication are absent. I must remember to replenish myself with moments of deep connection and meaningful engagement outside of the therapy room if I am to sustain spaces for I-Thou encounters during the age of telehealth. Though the demand for therapists to pull clients into real participation requires us to hold an age-old responsibility in a new and complicated way, the taking up of that responsibility has the power to foster a type of healing that extends far beyond the therapy room. As Martin Buber once said, “In spite of all similarities, every living situation has, like a newborn child, a new face that has never been before and will never come again. It demands of you a reaction that cannot be prepared beforehand. It demands nothing of what is past. It demands presence, responsibility; it demands you.”

***
 

Part 2 will continue the conversation on how Martin Buber’s philosophy can help to remedy some of the relational complications in the age of telehealth, while expanding his concepts to include challenges from a client’s perspective, personal examples of my struggle to remain faithful to the I-Thou relationship, and the broader sociocultural implications of technology-mediated relationships.

Imagine If We Could All Love This Way: Connection, Healing and Love in the Therapeutic Relationship

Posted on by Psychotherapy.net Team

People Fascinate Me

Stories fascinate me. The mind, spirit, and the richness of the human condition have always captivated me. I came into this field at a unique time in my life — I was older, with a different life behind me of working in advertising and media for 10 years, a marriage and three children. My childhood was that of an immigrant with extraordinarily devoted parents who gave me a lot of love and nurturance, a good education, and a zest for helping others. Yet the loneliness that accompanied me as an only child often felt overwhelming. I created a vast, imaginary world from my yearning to understand, love, and connect with other humans. I had a deep, intrinsic ache in my soul that made me want to look at the horrors of the world and not turn away, but instead to try to “love it away.” There was, and is, so much love in my heart that it hurt. I wanted to give it to as many people as I possibly could — almost in desperation — constantly questioning if this was some unmet need longing to be filled. I still question this sometimes.

If we really think about it, we will never truly know the internal climate of any other human being. “I often wonder, does anyone get to witness or know the innermost thoughts or feelings of another?” Can we know what somebody is thinking as they drift off to sleep? Can we step into their deepest longings and most genuine desires? Do we get to witness their silent tears and harrowing, aching pain? Can we understand how they look at a sunset and appreciate the beauty of its rays? Can we feel the love they experience when their cup is so full that their heart is about to burst? What are they afraid of? What do they search for? What do they experience? The work of therapy is the closest I have come to truly understanding another’s heart. It is the closest thing that I have come to finding a pure, soul-to-soul connection. When this happens, it’s magical. I can feel the energy shift and, for that moment, come to understand why we are all here: to connect and be seen — truly seen.

Human beings are born into this world to connect. The autonomic nervous system is a relational system tuned in and to experience others. Throughout the course of our lifetimes, we rely on connections with others to find meaning in our lives (Dana, 2018). In his work on attachment theory, John Bowlby masterfully explains that human beings have an innate need and instinct to attach and form bonds and relationships with those closest to us. These bonds become a mirror for all the interactions we have later on in life. And what happens when this innate need and biological longing are unmet and there are various forms of mis-attunement? If the very people who are supposed to love and nurture you are seen as a source of terror and neglect, the impact is profoundly shattering. Hence, we cannot look at the darkest and deepest pain outside of human relationships and the wounds they cause in human connection. At its very core, trauma involves incredibly painful relational loss (Perry, 2006).

A Very Personal Journey

This was the reason why I changed my life and decided to become a psychotherapist. I went through my schooling eating up all the knowledge and information I could gather, breathing into my internships, feeling anger, frustration, pain, and sorrow for the system, my clients, the calamities of the world, and sometimes my utter helplessness to stop it all. But above all else, I felt an immense love — a love for the people I treated, who were brave enough to share their stories and trust me to walk beside them through their journey. I moved through my clinical hours at hospitals, private practices, intense higher level of care at an IOP/PHP, and finally owning my own group practice. I met amazing and wonderful people in the field who are dedicated and loving and want to help the ones they so diligently serve. But more often than not, I felt outside of it all — an ode to my childhood feelings of “aloneness.” I felt my ideals and ideas were out of the box; my perception of healing was not always in line with what the majority was prescribing as adequate care. I questioned, scratched my head, and felt confused by the notion of the us vs. them attitude that so many in the field still seemingly live by. In essence, the very core of the social work profession is equality — so how could we possibly think we know more about people’s lives, experiences, and what they need to heal than they do? Evidence-based practice, boundaries, protocols, treatment plans, and so on. I came into the field having been drilled with these teachings — entering treatment spaces robotically, feeling that if I followed this script of CBT, or that script of DBT, or any other three or four letter abbreviation for a theory, that I would somehow magically be able to do my job and change people’s brain chemistry. But how does that constitute the essence and core of what we are actually supposed to do?

Thankfully, I discovered wonderful theories and “giants” I felt aligned with — the work of Irvin Yalom, Diana Fosha and her AEDP model, Daniel Siegel, Daniel Gottlieb, Relational-Culture Theory, to name just a few — which gave me the platform to understand my own deep instincts around what helps people heal. I went to work at an IOP/PHP, treating individuals with substance abuse and mental health concerns. Working there often felt like a free fall. Running multiple groups per day with a variety of individuals who often didn’t even fit in with one another, intakes, evaluations, family sessions, and crisis, crisis, crisis. Every day, my fellow colleagues and I had to follow the check-in script during group sessions — “What is your mood? Do you have any suicidal thoughts? Homicidal thoughts? What was the time of your last use?” Intake evaluations asked questions like “Have you ever been sexually, physically, or emotionally abused?” This, after meeting the person 10 minutes ago. I had to get as many people in and out as I could — individualized care was looked down upon, and if I spent too much time with a client, I was somehow “over-involved.” I felt confused and bewildered practicing something I felt innately in my heart was wrong to do. My heart told me to sit and listen to these people’s stories, to move my chair closer to them, look into their eyes, hold their hands, and listen — sometimes not asking any questions at all, but just holding space when tears fell, anger erupted, or laughter ensued. “The Zulu term Ubuntu perfectly describes the importance of relationships in helping us thrive. Ubuntu means that a person becomes a person only because of other people”. I am human because I belong. As a result of decades of studies, we know that being separated from social connection and isolated from other people is a lifelong risk factor affecting both physical and emotional health. We live in a culture that encourages autonomy and independence, and yet we need to remember that we are wired to live in connection (Fosha, 2000). I felt guilty that I wanted to sit with these people and hear their stories, to pay a little closer attention to them, to tell them I cared, to show them love, compassion — to go the extra mile. After all, we aren’t supposed to do that. It shows poor boundaries and can cross ethical lines. Our administrators instructed us to limit the amount of time spent with our people and abide by clinically sound evaluations. I once snuck a tea kettle and put it in my office. What would one simple gesture of asking somebody if they wanted some tea mean to another human soul? It meant that “somebody actually cares about me.”

There was a thread that ran through almost every story that I heard — unimaginable trauma. To this day, I am still shocked and surprised to witness and hear about the triumphs of the human spirit and what people can live through. Don’t get me wrong, there were some people (and still are) who completely infuriated me. It seemed like it was the same problems over and over again, the same excuses, consistent behaviors that had no end in sight. I fought hard to fix them because I thought fixing it for people was what would make it better. I thought fixing it was the right thing — but it was the very thing that actually went against what I intuitively knew was the cornerstone of healing: connection. Why did I fight against this so? Why was I so afraid that my love for my clients was wrong? That being tenderhearted was a weakness and not an asset? I examined my own psyche and self, judging myself for feeling deeply and knowing all too well that I was doing something that I told my clients not to do: harshly judging myself.

Not Afraid to Love

Once, a client I had been working with for a long time and was going through a particularly difficult moment became extraordinarily physically sick in my office, in front of me. It was at night, when the only other staff members were the receptionist and another clinician running group. My client was evidently not well. She had recently been through a series of incredibly difficult traumatic incidents in the span of several days, was temporarily homeless, and was now vomiting profusely into any and every garbage can I could find, incoherent, barely able to stay awake. I did not know what was going on, but I knew I needed to get her to the hospital. I called an ambulance, and they arrived through the back door to take her to the nearest emergency room. After the ambulance took her, I noticed one of her bags left sitting in my office. I grabbed it and, without thinking, got in my car to take it to the hospital. As I was walking out the door, I told my fellow counselor where I was going — she looked at me and nodded — I still think of that and thank her in my heart for not questioning my intentions. I got to the hospital and sat with my client while she lay on a gurney until one of her family members arrived. I sat with her mostly while she slept, but I still sat with her. As Bonnie Badenoch so eloquently stated in The Heart of Trauma, “the essence of trauma isn’t the events but our aloneness with them.” I am not afraid to say I loved her, and I did not want her to be alone.

It is during these types of “ethical dilemmas” not taught in school that we must decide how we are to proceed when we enter the real world of the client. When I told a couple of my friends in the field about the incident, I got a few raised eyebrows and snide remarks, which of course made me question my own judgment. Boundary crossing. Went too far. But when I go back to that incident, I know that the only place it came from was from a place of love, from a place of humanity — that in that moment, the boundary separating client and therapist had no meaning. It was purely two people being human. Always, human first.

Don’t get me wrong — I don’t approach any situation with my clients lightly. I theorize, ponder, contemplate, go to supervision, examine and think about some things before and after they happen. I can utilize the most up-to-date techniques and skills, the most provocative questions, and evidence-based treatment that is “proven” effective for the specific issues the person is facing. Do they have results? Absolutely. But do they resonate? It is attunement that is the real language of love. Having another person deeply feel that they are not just understood, but that the other feels with them, and can internalize them, as Diana Fosha explains “existing in the mind and heart of the other.” I have found that the great difference for our people is knowing that somewhere out there is another soul that sees them and is ok with it. This person (therapist) cares deeply, is brave enough to talk about anything, can call you out but not make you feel small, and can sit with the darkest demons and still stick around. It’s this feeling that resonates — that feeling of being gotten and understood. Those are truly the moments that envelop the therapy relationship with healing.

“And yet there are some of our people whose wounds run so deep that even our best efforts can’t seem to penetrate”. Day after day, year after year, the magnitude of the experience, the heaviness of the ghosts don’t go away. At this moment, I often break down and sob for my own limitations in helping others move out of grief — for thinking I had some omnipotent cure that will rescue them. It’s ok to have those moments. Having them means I’ve been human. Having them means I have love in my heart. I think when we start to push them away and resist the feeling — even towards our client — is when we deny the very essence of the complexity of every human relationship. I hate to admit that I often still want to find a way to “fix it,” thinking that if I do then everything will be ok. But I have found that this is not what my people need. Instead, even after months or years have passed and I feel like I am stuck and question my own competence, they communicate growth, resilience, and gratitude for my simple act of being a witness to their stories and not turning away in fear, not giving up, and not looking away.

As I look at my clients and myself in the context of relationships, I realize the process of both our spirits, not just theirs. Therapy is as much my own journey as it is that of my clients. I would be foolish to say that my clients do not deeply impact me, change me, make me grow, and play a profoundly important part of my life. As a clinician, I must be expertly aware of my emotions, body sensations, and reactions to and from the people I sit with day in and day out. I don’t always hit the mark — I often mis-read, mis-attune, and just don’t get it. My hope is when I realize these things, that I have the courage to share them with my people. After all, where else than within this relationship do we get to talk about it, all of it, and still go on? The great dance of rupture and repair is some of the most impactful work I do in therapy. The social construct of the relationship between therapist and client is that of power. I set the limits of what I want to share and when, what I am willing to give or not. Does that not defeat the entire purpose of healing? If I am mad and frustrated with my clients, am I to hold back or to be open with the feelings and sensations that are evoked, to notice how we each conduct a dance, how we both have to shift to come to connection? How both of our vulnerabilities often get in the way of moving forward in the work we are entrusted to do. Furthermore, I worry over getting stuck in “cookie cutter therapy” — one glove fits all approaches, evidence-based practice, staying within the lines of “normal practice.” This may work for some, but in recognizing the truly complex nature of every individual that walks through my door, I see that the needs and wants of what will facilitate their healing may be different for all of them. To practice “in the box therapy” is unethical — there, I said it.

And what about love? I love my people, I truly do. Do I say this to all of them? No, I don’t. Have I said it to some of them? Yes, I certainly have. Why wouldn’t I? If we are free to express anger, frustration, concern, and all the other things within the therapeutic relationship, why not love, the most powerful force on this planet? And yet, as I write these words, I fear the judgement and criticisms of so many who are probably reading this — my own insecurity I guess, I’m working on that. I’m working on knowing it’s ok to feel and give love to somebody purely for being human, especially in this work.

One of the most amazing and painful realizations I’ve had while doing this work is that “I get to see people as they really are — in their rawest, purest form, in anger, in tears, in laughter, and in pain”. I see them like most people in their lives do not. I so long for others to see these humans as I do. To me, the unfairness of this situation and the mourning I have learned needs to happen when entering this relationship is the fact that this type of connection can only exist in this sort of vacuum. This place where the storms and influences of the outside world don’t have as much influence to touch the sacred resonance that is often created. This makes me incredibly sad for the world we live in — that some of the most authentic relationships we can have with another human being have to be sealed in this cup and tucked away far from anyone else to actually know about. That these powerful moments of painful magic and deep connection only live in the safe confines of this relationship. I sometimes long to scream from the rooftops, “Look at all these amazing people I know!!! They are breathtaking! Look at the courage they have to take me into the depth of their souls and trust me to hold their stories!” I only get to scream this inside my own heart. Perhaps these moments only have the capacity to survive within this type of safety — but, just like John Lennon, I’m a dreamer, imagining a world where everyone gets to be seen and to connect on that level. How would things be different?

References

Badenoch, B. (2018). The Heart of Trauma: Healing the Embodied Brain in the Context of Relationships. Norton & Company, Inc.

Dana, D. (2018). The Polyvagal Theory in therapy: Engaging the rhythm of regulation. Norton & Company, Inc.

Fosha, D. (2000). The Transforming Power of Affect: A Model for Accelerated Change work. Basic Books.

Perry, B. (2006). The boy who was raised as a dog. Basic Books Hachette – Book Group.

Center of the World

Posted on by Psychotherapy.net Team

“She tells me I’m completely self-absorbed, that I’m acting like I’m the center of the world. I’ve spent our last three years trying to figure HER out and how to connect with her! How on Earth is that self-absorbed?”

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David Burns, creator of TEAM-CBT (which stands for Testing, Empathy, Agenda Setting, Methods), teaches us that a key moment in diffusing a conflict comes when we use the Disarming Technique. Instead of defending ourselves, we lay down our shields and find something to agree with in what the other person has said. But however much we may tell ourselves we want a good relationship, many of us find this step challenging. How can we agree with something that feels so wrong and unfair? And what happens when we see the kernel of truth in an accusation?

“It wouldn’t be honest for me to agree with her that I’m completely self-absorbed.”

“I have to agree with you,” I tell my patient, and we both smile as he recognizes me using the disarming technique with him. “You aren’t completely self-absorbed, or you wouldn’t be trying to improve the relationship.”

He sits back in his chair, tilts his head and motions for me to keep talking.

“So, is there anything you could find to agree with in what she said. I mean, really whole-heartedly agree with?”

“Well, I can agree that she seems to think I’m self-absorbed!”

He’s making a common mistake in the disarming technique—we call this a ‘faux disarm.’ “How would you feel hearing that from someone?” I ask him. “Suppose I said to you, ‘Dave, I can see that you really seem to think I’m self-absorbed.’ Would you feel heard and validated?”

“Um, no,” he said with a touch of sulkiness. “I just don’t feel like I’m being self-absorbed! I’ve been working so hard to figure out how to connect with her. When she throws that at me, I feel so taken for granted.” The muscles in his jaw tightened. I see I may have pushed him too far. In TEAM-CBT, the correction for this is to ‘fall back’ to empathy and what is called ‘paradoxical agenda setting’ in which we support someone’s good reasons not to change.

“You have been working really hard on this,” I agree. “You said you feel taken for granted. I can imagine you must have felt pretty hurt and angry when she said that to you. And maybe you are also feeling hurt and even a little annoyed with me right now. Am I reading you right?”
He nods, silent, his face shifting from anger to sadness; his jaw relaxes. “I was a little annoyed at you, but I get it, you are trying to help me. It’s okay, let’s keep going.”

I’m hearing that he’s trusting me, so I move forward, but rather than continuing to push him directly as I did before, I shift to using paradox to support his resistance, and give voice to what I think is holding him back. “Maybe at a moment when you are feeling that hurt and angry, it’s understandable that you aren’t wanting to get close to her or see where she is coming from. Your priority is to protect yourself.”

This seems to have landed. He nods ruefully. “That’s right.” He puts his hands over his eyes for a moment, turns inward. “When she hurts me like that, I do want to defend myself.”

I stick with supporting his resistance. “Ouch. That makes sense to protect yourself from that pain.”

He doesn’t respond right away. I let the pause linger, sensing that something is shifting. “But I care about her, and I do want to understand where she is coming from, not just protect myself.”

He’s starting to convince me that he is ready to lay down his defensiveness, but I stay paradoxical to see if he’s really committed to working in that direction. “But is that wise? You said she hurts you.”

“It does hurt, but I don’t think she really wants to hurt me.”

“Where does the hurt come from?”

He makes a face. “Oh, you’d probably say it’s because I’m stuck on the idea that I should never be self-absorbed.”

I shrug an acknowledgment, “Yup, I probably would say that a belief like that would cause pain.”

He gives me a small smile. “Thanks, as it happens, I agree with you. And I get it. Of course, she’ll experience me as self-absorbed if all I’m doing is defending myself. But I don’t always do that. Isn’t she giving me one of those distortions you talk about, all-or-nothing thinking? I still don’t want to agree that I am completely self-absorbed.” He chews on this for another moment. “Maybe I don’t have to agree that I’m completely self-absorbed, just that I’m being self-absorbed at that moment?”

“I like where you are going with this—it sounds like you have found a kernel of truth in what she said. What would that sound like if you told her that?”

“Well, how about ‘Samantha, you are right, I’m being self-absorbed right now.’”

“Nice,” I respond. “How does it feel to imagine saying that to her?”

“It’s humbling,” he replies, and I see a mix of feelings on his face. “I feel sad realizing how many times I’ve been too busy defending myself to hear what she’s saying. No wonder she feels like I’m always being self-absorbed. And at the same time, I’m noticing that I’m actually starting to feel curious about what is going on with her. And that feels much better than defending myself.” His face opens as he looks at me. “Have you ever heard that expression, ‘I’m the piece of crap at the center of the world?’” I give a laugh, and he continues, “It’s a relief not to be the center of the world!” 

Family Therapy in the Age of Zoom: What a Long Strange Trip It Has Been

Posted on by Psychotherapy.net Team

If there is no plan, nothing can go wrong
Kim Ki -Taek — Parasite

It’s not the strongest of the species that survive, nor the most intelligent, but the one most responsive to change.
Charles Darwin

It’s recycling day, can’t we just put the kids outside on the curb?
Parent — Pandemic, week five

Dude!…You’re Glitching!
Fourteen year old girl on Zoom session

Long Strange Trip

The pandemic has changed the larger world forever and will forever change the world of therapy. Our therapeutic ecology — how we practice our craft, where and with whom — will never be the same. It’s as if we’ve clicked into a science fiction show and can’t change the channel because we’re in it — clients and therapists have become talking heads, connecting as best we can and collectively feeling the fatigue attrition that accompanies the absence of being in person. The Grateful Dead were right: it’s been a long strange trip, especially for the empaths.

Michael is a single man in his thirties. He’s suffered a lifetime of painful shyness and being overweight. His job requires computer skills, so he spends most of his time in his cubicle, with little socialization on the phone or with co-workers. He’s described breaks and lunch as “torture.” Prior to lunch, he would get revved up with good intentions and then, he said, “I’m like Wile E. Coyote chasing the Roadrunner — I hit the wall.” One time, he got the gumption to attend a meet-up group for shy people, and no one showed. Yet, despite these challenges, he’s determined to be more social. Then, something happened. At our last Zoom therapy meeting, he was more confident and relaxed, like he’d just put on old slippers — smiling and even cracking jokes. For me, it was a kind of optimistic disorientation. At first, I thought that it was the combination of medication, his Wile E. Coyote resolve and hopefully some of the therapy that, like the British Baking Show, had produced a slice of Magic Pie. It wasn’t — it was the pandemic.

Because of “social distancing,” Michael paradoxically experienced being together with people while he was apart. Everyone now shared his life — now he could enter conversations with the knowledge that others also shared the taut, jangled wiring of his interior. It was as if he became an Italian apartment-dweller sheltering in place with his neighbors and singing together with them off their shared community of balconies, everyone listening with hearts joined in the absence of judgement and the voices of hope. Better still, because of the imposed distancing, Michael could now be safely social.

The Zoom Era

And what about therapists — what is this doing to us? Many are working from home. Those of us with children, pets or partners and who don’t have a home office have to find a “quiet space.” Ha! Good luck with that basement, people! Or, if we’re lucky and the landlord isn’t banning entry, we can go into our off-site office space — but that, too, has its own set of Zoomy consequences, not the least of which is “Zoom Fatigue.” By day’s end, sessions can feel like you’re in the front row at a lecture on sofa cushions where the speaker can see you. Just as you start to blissfully nod off, your head suddenly jerks back, and you snort loudly and say something weakly therapeutic like, “really..?” and then wipe the drool onto your sleeve — très embarrassing.

Zooming our client’s home space is not without merit. Back in the day when I was a probation officer in Cabin Creek, West Virginia, and then a social worker doing school evals, and then a research therapist on a project with heroin addicts and their families, I was blessed with being both witness and participant in the amazing diversity of the human condition. You learned to go with the flow and, you swam in the deep end of the family pool — dogs, cats, kids, babies, ferrets, frogs, multiple TV’s, radios blaring, grandparents, people who just showed up whom you didn’t know, dinner on the stove, or a silence that also spoke to you — all this before the age of the Internet. It was so powerful that when I first started my private practice, I would ask families to invite me to dinner and a family session at their home. “Now, we have Zoom — welcome to the shallow end. But we can all still learn to swim.”

You can observe a lot by watching.
Yogi Berra
Peter Lopez, a family therapist on the board of The Minuchin Center for the Family, is a home-based family therapist. On one of his Zoom visits, he wanted to speak to both parents and have an enactment with them that would increase the parent’s executive capacity and demonstrate to themselves and their kids that Mom and Dad were on the same page. In a moment of inspiration spurred by there not being enough headphones for everyone, he asked the parents to “move closer together so you can share…”

Another family therapist, a young woman who works with a diverse population of low-income families and mandated, substance-abusing high-risk teenagers, finds that being “in & not in” someone’s house can diminish her connection and, in some cases, embolden teens to challenge her — like the fifteen year old teenager who greeted her on FaceTime lying in his bed with his shirt off. “Would you do that in my office?!,” she asked, incredulous. “Uh, no, but I’m not in your office….” “Well, when we meet on Facetime, you are in my office!” And then, softer — “So when you put your shirt on we can start, and you can tell me how you’re doing.”

She still delineates the boundaries — for the kids she sees, her office is their safe space. To compensate for the in-person absence, she’s upped the amount of between-session “homework” that she and her clients then share at the next session. Trauma and disconnect are prevalent. A young girl being raised by her grandmother whose mother is absent provided a path in between sessions. Together they came up with an assignment to come to sessions with a weekly playlist of songs that emotionally spoke to the client. The girl picked “How Could You Leave Us?” by NF, which should come with a warning label and tissues — it’s remarkable.
We have to be inter-connected with everyone and everything.
Thich Nhat Hanh

You cannot solve a problem from the same level of consciousness that created it.
Albert Einstein

An informal survey asking therapists to describe their experience of practicing Zoom therapy in the pandemic seems to break into two distinct groups: one, maintaining a kind of Buddhist perspective of acceptance –— that life is suffering and impermanence in which every day is an opportunity to practice mindfully — to another, a bit less accepting — “I fucking hate it!”

A Third Way?

Which begs the question — is there a third way? The short answer is “Yes.” And it’s not without precedent. Einstein’s quote is like learning a brilliant escape trick from a gifted magician. The magic is not what is seen or said but in what he doesn’t say. What he omits is the specificity of consciousness — it does not have to be higher or lower, just different. And we therapists are all about being different. To be effective, we access different aspects of ourselves that then activate different and more adaptive aspects of our clients. It’s what Minuchin described as the “differential use of self.” If we want others to be different, then we have to be different. For systems thinking and for family therapy, in particular, those differences in thinking were already in the works well before the pandemic.

Lynn Hoffman pointed out in Foundations of Family Therapy (1981) that “the advent of the one-way screen, which clinicians and researchers have used since the 1950s to observe live family interviews, was analogous to the discovery of the telescope. Seeing differently made it possible to think differently.” And by circular extension, thinking differently also comes from acting differently.

Up until now, we’ve relied on our in-session felt experience, one-way mirrors and videotaping to guide ourselves as instruments of change. One recursive emotional and visual distinction between the now and the then of the one-way mirror’s transformative introduction, is that families could not see the people behind the glass, nor could the people behind the glass see themselves being seen. Videotaping sessions, however, offered a “third” answer, giving therapists the capacity of “seeing” themselves and the family’s patterns in context. It shined a light on how to experiment with adapting interventions systemically and collaboratively. While inventing Structural Family Therapy, for example, Minuchin, Jay Haley and Braulio Montalvo invited family members behind the mirror. They recognized cultural and class differences between themselves and the “natural healers” from the minority community that they were training to be therapists. Minuchin realized that “in order to join, we needed to change.”

“With Zoom however, there is a binding irony that holds therapists and clients in its’ grasp. It is as if we share front row seats watching a mystery play”. The opening scene’s roiling dense fog and dim lights mask the fullness of detail, so we squint, holding our breath hoping to see what’s really there. We’re doing our parasympathetic best to figure out the plot. It’s the work of it that fatigues us and leaves us wondering if this is as good as it gets.

Therapy is therapy as therapy does, but how we use ourselves in this new environment re-boots an age-old clinical question; what exactly is both necessary and sufficient to produce change? Montalvo called the position from which we work “The possibilistic premise.” Meaning that regardless of the location of the family’s pain, we are still faced with respectfully challenging the system’s homeostatic “stuckness.” We know that we can effect those changes in person. When Zooming, however, it can sometimes feel as if we’re “Major Tom,” floating in space, attempting to weld the hull as we circle the earth.

So, as Bowlby, Susan Johnson, the Gottmans and our own families have shown us, the quality and kind of our earthly and relational attachments are important. While we may feel even more like Russian Dolls, breathlessly stacked within each other’s context and the context of the world writ large, it’s not a question of “if” we adapt and attach in different ways, it’s more a matter of “How?” Perhaps as Theodore Reik suggested, we should listen with greater clarity, not just with a “Third Ear,” but now with ear buds. We are finding ways to compensate for what’s lost with diminished sight and the absence of physical presence. Our adaptive make-up is yielding results. However because we are inherently empaths, we feel the absence of presence. But we shouldn’t feel bad entirely. Rumi’s poem, “Love Dogs,” reminds that “the howling necessity” implores us to “cry out in your weakness,” such that “the grief you cry out from, draws you toward union.”
It’s the end of the world as we know it, and I feel fine.
R.E.M.

Postscript from the Bunker

After not seeing our granddaughters at our house for eleven weeks, my wife and I share a grandparental Folie à Deux — an ache like an old injury that we’d come to accept, now reawakened with every primitively crayoned coloring book that hung on our walls like an in-home Children’s Louvre. As grandparents of a certain age, now when my wife and I see all their stuffed animals in a pile, we silently share the Buddhist themes of impermanence and suffering. It feels like a Christmas Story staging of Toy Story — our precious time together is ghosted in front of us as a reminder to our mortal selves that “this is it.” This perfect time of their lives, full of wonder and imagination, is just another pandemic curtain closing on the “Duck Duck Goose” show. Now our own mortality is awaiting, as quiet mourners do when “joining” family and friends on a Zoom funeral.
Alone together.
Dave Mason

Then there’s this — amidst all the noise, people find themselves and others. I see a recovering alcoholic/substance abuser in his thirties. He’s been in recovery for seven years. He has a great sponsor and a solid home group. As the pandemic continued, he began to miss the in-person connection with his group and his sponsor. So last week, with the intent of doing “Step work,” he and his sponsor sat safely apart on his sponsor’s back porch. As night began to fall, he said that without any cues, they both simultaneously became silent and quietly surveyed the backyard as darkness fell. He said it was one of the best conversations that he’d ever had.

Like the scene from Little Miss Sunshine, when on their way to the “Little Miss Sunshine” contest, Dwayne flips out after finding out that his color blindness has just destroyed his dream of joining the Air Force, getting away from the “fucking losers” that constitute his family and having a life of his own. He’s profanely inconsolable. His mother says, “I don’t know what to do!” Then his stepfather says to Olive, “Olive, do you want to try talking to him?” Without a word or hesitation, Olive gingerly makes her way down the embankment, ignoring the dust scuffing up her red cowboy boots, and squats down next to her big brother. She puts her arm around Dwayne, leaning her head onto his shoulder. She doesn’t say a word. They both sit together as one in the silence. Quietly, as if whispering a confession, Dwayne says, “O.K., I’ll go.” He then helps Olive up the hill and says to his family, “I apologize for the things that I said, I didn’t mean them.” They load in the van and continue on.

“Off in the distance is a billboard, the message faded but visible, “United We Stand.” We can hope”.

Tools to Help My Patients

Posted on by Psychotherapy.net Team

Coping Strategies and the Paradox of Change

When patients come to me, they are already using various coping strategies to regulate their emotions, improve their mood and deal with challenges. Their strategies—such as drinking, withdrawing, gambling, eating, or hoarding, as maladaptive as they might be—are seemingly essential to their survival. And they are effective… until they aren’t, which is generally the point at which I meet many of my patients for the first time. In fact, their coping strategies can and often do become the major source of their adjustment problems.

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The paradox of change—“Doc. Please help me to change, but change is scary so I’m going to stay put. Accept me as I am.”—can be more readily seen when viewed in this context. It is vital for the therapeutic relationship to recognize that I am essentially asking my patients to strip away the very things that they have been clinging to for survival.

Among other goals for therapy, such as learning to manage emotions, making sense of their past, and assisting with the other changes they desire, therapy is also about “tool replacement”: I’m helping people replace harmful coping strategies with new, healthier ones.

However, if patients have experienced a great deal of trauma, I must sometimes collude with my patients’ denial to maintain their existing coping strategies before beginning to help dismantle them. To illustrate, I must first work with a patient who has experienced complex trauma to resolve some of the trauma while they continue to drink. Otherwise, a premature referral to AA could be a set-up for therapeutic failure.

Reducing the Layer of Judgment

Not only do my patients have various coping strategies, but they often judge themselves harshly for having to rely upon them. A way of explaining the layer of judgment is to use the metaphor of the panopticon, Jeremy Bentham’s 18th century semicircular prison design that allowed one guard to simultaneously watch all prisoners without their awareness of being watched. In the case of therapy, the all-seeing guard is also the patient. The layer of judgment that patients see as they look down on themselves from the guard tower includes:

“What’s wrong with me?”

“Why can’t I be like other people?”

“Why can’t I just get over it?”

There is a common emotional thread woven through these self-statements, and it is often shame. Therefore, I have to help them identify how they feel. Also, I try to help them understand what shame feels like and what it is. I tell patients that shame feels like “embarrassment times 10.” I also distinguish guilt from shame: “Guilt is feeling bad for what you do. Shame is feeling bad for who you are.”

These self-statements, along with embarrassment, remorse, and shame, create the layer of judgment that can make their difficult situations worse. This layer is like a lid on a pressure cooker: it keeps the entire mechanism in place.

To illustrate, I often use the example of obesity. Obese people generally know about the mechanics of weight loss better than people who have never struggled with weight gain. But if weight loss were about simple mechanics, no one would be obese. For that matter, no one would engage in any unhealthy activity.

But obese people often use food as a coping strategy to regulate their emotions. When they subsequently tell themselves how awful they are, it generates more emotions that they have to manage. And how do they best know to do it? By consuming more comfort. The next day they are filled with remorse and shame—which then needs managing. The result is a vicious cycle: the very coping strategy they feel ashamed of is prolonged.

So, for change to occur, this layer of judgment must be challenged with as much compassion I can offer and self-compassion they can muster. Change comes not from self-condemnation, but from greater acceptance and higher self-regard.

Achieving the “No Wonder” Goal

To achieve greater acceptance while reducing self-condemnation, my role is to help patients find healthier coping strategies both through the process and from the material. One way to ease the layer of judgment and reduce the concomitant shame is to propose working toward what I call the No Wonder Goal.

The aim of the No Wonder Goal is to have an emotional understanding of how and why their coping strategies picked them. Please note the specificity of the language. I often tell my patients, “You didn’t pick your coping strategies. They picked you.” In other words, no one starts out drinking to become an alcoholic or begins collecting to become a hoarder. Rather, the psyche says, “Aha—relief! I found what I need to calm down.” What starts out as a social activity, a hobby, or an adventurous undertaking can turn into a destructive addiction, compulsive activity, or manic behavior.

The purpose of working toward this emotional understanding is to thin the layer of judgment and to soften their self-condemnation. I recently had a patient who developed a driving phobia who was condemning herself for her irrationality. I said to her, “It makes no sense that you’re afraid to drive. It used to be no problem. However, these days, just going to the store can be scary! Your psyche is trying to protect you from harm, perhaps even trying to save your life from COVID. What a better way than to stop going places. Your home is where you are safe, so it’s no wonder that this particular coping strategy picked you.”

I also try to transform what has been concretized back into a metaphor. As an example, a porn actor with severe OCD went through an entire bottle of hand soap daily and washed his face at least 25 times per day. During one session, I said, “Could it be that you wash so much because you feel ‘dirty’ being a porn actor?” Through the No Wonder Goal process, he realized that he felt dirty inside, and no amount of washing would make him clean. He was then able to transform the concretized activity back into a metaphor, and as a result, became less judgmental about his OCD.

Of course, it takes months and possibly longer for this idea to sink in (to be an emotional understanding). But many patients have mentioned without solicitation that in the one session when I introduced the No Wonder Goal, they felt a sense of relief and a little less shame.

For greater acceptance, I can also ask, “Does this self-condemnation sound like someone from your past?” Most of the time, patients will tell us that it sounds like their mother or father. Let’s say the patient’s mother’s name is Katie. I will say something like, “OK, so this is your Katie-brain talking to you. Katie was trying to protect you, but in a misguided way.”

The other intervention is to call the self-condemner a committee member (with a caveat for dissociative patients). “What is this committee member saying to you? Can you let the committee member know that you appreciate the protection but that you don’t need it right now?”

Over time, patients realize that this part of their psyche serves a very important function, and its purpose is to protect them against a real or perceived threat. And how can they hate themselves for that?

Tool Replacement

I’m not going to elaborate on the actual tools, since they are generally known—avoiding withdrawal or being controlling, asserting themselves more, connecting with others, expressing emotions, just to name a few. However, it would not be therapeutic nor practical to try to dismantle patients’ coping strategies without helping them build healthier ones or build onto the ones they already have in place. Sometimes I provide them with new tools while their old coping mechanisms are still in place. At other times, as they use their new tools more, the older ones organically diminish.

One tool that I value is to ask patients to use their feelings. Frustration and anger can be transformed into determination, jealousy can produce striving, and sadness can be used to find acceptance. The example I like to give is MADD, Mothers Against Drunk Driving. They gathered their anger, pain, and despair to become the most effective group to educate others and strengthen drunk driving laws.

Recall that tool replacement exists in the process as well as in the material. The process of opening up about their shameful coping strategies, crying over them, and acknowledging missed opportunities and lost relationships is a form of grieving. Grief must happen for greater acceptance. This process, plus exposing their vulnerability as we accept them as they are, can lead them to feel better about themselves, have greater peace of mind, and enjoy more satisfying relationships.

Reducing harsh self-judgment, knowing how they got to the place where they were when they walked through my door for the first time, and managing their emotions with new coping strategies can truly be transformational.