Category: Therapeutic Issue

The Performing Art of Therapy: Acting Insights and Techniques for Clinicians

Posted on by Psychotherapy.net Team

“Where does the actor acquire the understanding that for the doctor takes years of study?"
-Theater Director, Peter Brook

Act I: Therapists as Performers

Therapist, you are a performing artist, whether you realize it or not!

The moment a client enters your office, you are on stage, face-to-face with an audience, a scene partner, and a variety of characters you do not yet know how to play (after all, our clients both become and cast us in all of these roles faster than we can say, “How can I help you?”). And every move you make—or don’t make—influences the treatment, the play, the story you tell together.

“Like actors, as therapists our appearance, aura, voice, and relational responsiveness often leave stronger impressions on clients than the words we say or the techniques we use”. This is not to say that our clinical training is of no use; of course it is. But effective technique is less about what we do—less about reading a script by rote—and more about how we do it, how we use ourselves, how we perform our interventions.

When you watch actors performing in movies or plays, do you think about their techniques?—whether they used Strasberg, Adler, or Meisner? Probably not. You are more likely moved by the performers themselves—their ineffable presence, their use of self. Likewise, our clients are more affected by us than by our schools of thought—whether we studied psychoanalysis, CBT, or family systems.

No matter what kind of therapist you are, if you approach your work like an actor—or better yet, like a performing artist in your own right—I promise you will become more awake, alive, and engaged with your clients, while also having a greater capacity to care for yourself. I offer this promise as a psychotherapist who has used my experience as a trained, professional actor every day.

The skeptical reader may think that the words “perform” and “act” don’t belong in the therapy office. When I tell people that I use my training and experience as an actor more than any other resource as a therapist, they often take me to mean either that I’m “fake” with my clients, or that I deploy literal dramatic exercises in session. I’m not (or at least I try not to be) fake with my clients, and I rarely, if ever, use theatrical interventions in session, unless I believe they might be useful for a specific client in a specific moment. However, when I simply think about my clients the way actors think about their characters and scene partners, I enhance my capacity to dive into the deep end of their stories, beyond the words they speak—their “scripts”—even when I do nothing more than listen to them compassionately.

I may not end up doing anything radically different in session from what any other clinician might do instinctively. But by thinking of myself as a performing artist, as opposed to just a clinician, I find creative ways to join my clients in their emotional subjectivity, relate to them like a character who can help them grow, and allow myself to expand personally in the process.

Again, to be clear: “Acting” does not mean being fake, it means finding truth within a given set of circumstances. So, in that sense, “as therapists we are all actors: we use our selves (our primary instrument) to help bring other people’s authentic selves to life”.

Below is a pair of vignettes, each including a significant learning moment for me as an actor, and a corresponding revelation as a therapist. These dramatic/therapeutic narratives, illustrate how my use of self helped me to pursue the three main objectives that apply to the creative process of both artforms:

  1. To create a treatment frame in which our scene partners feel safe, oriented to the nature and purpose of our work, and free to participate in it.
  2. To join our clients in their emotional subjectivity, like actors embody their characters.
  3. To relate to our scene partners as a character who can help them to heal and to grow.

Act II: Using My Self as an Actor

I was 20 when I was cast as the gun-obsessed Quigley in Hyperactive, an edgy play about teen angst by Olga Humphrey. Quigley was described as a “masculine, hard-edged” adolescent, whose favorite magazine was Soldier of Fortune. I was an effeminate, soft-natured man, whose favorite magazine was Entertainment Weekly—in other words, nothing like Quigley. But I was also an actor, and as an actor’s my job is to find diverse characters within myself, even if they seem very different from me on the surface.

Other than having a teenager’s build, the only quality I seemed to share with Quigley was the determination to prove my worth. In my case, proving myself not only meant getting hired, which I did, but also finding some genuine version of this unlikely role within me. My greatest challenge was to make an empathic connection with Quigley’s bullish personality, his gratuitous language, and (most difficult of all) his obsessive, violent fantasies. All these qualities—or symptoms, if you will—made me extremely uncomfortable and seemed to alienate me from him, rather than to invite me into his emotional world.

My first task was to create a framework for my rehearsal process, within which I would have room to discover and explore who this person was, through trial and error—ideally without judging him. Rather than begin with preconceived acting choices for Quigley—much like therapists are often tempted to impose treatment interventions onto new clients—I needed to find a way to let him speak to me on his own terms. And since my head could not make sense of this boy, I had to find a way to access him viscerally—using my body, voice, and imagination.

As I began reading his crude and aggressive lines aloud at our first rehearsal, I imagined I was one of the bullies from my own high school past. I widened my legs, puffed out my chest, and spoke with an affected tough-guy bellow, straining to produce the intimidating, nasty persona adopted by so many males from my youth.

The result was what the kids call a “fail!” “My performance was cartoonish and over the top”; I’d created a caricature, not a human being. “Um, that’s a bit much,” my director said, with a penetrating squint of disdain in her eyes. Humiliation flooded my body and shut down my spirit. My effortful impersonation seemed to expose my limitations as both an actor and a man. I wouldn’t need to try so hard if I was actually talented or masculine enough, I thought to myself, further shamed by my inner critic.

But in the same moment, a window opened for me into Quigley’s inner, subjective life. I had unwittingly, but effectively, joined him in his debilitating self-consciousness, vulnerability, fear, loneliness—and self-hatred. His core intention wasn’t to intimidate and destroy other people, I realized. Those behaviors were secondary to his primary objective: to protect himself, validate himself, survive.

With those visceral motivations living in my body and mind, I could commit to Quigley’s macho expressions while maintaining an underlying sense of vulnerable truth. And as I played with this duality—grounded in my own fear of failure, and my instinct to overcompensate for it—I increasingly understood how he/I was motivated by a desperate need to be validated by other people. I could now bring a genuine version of him (and me) into the rehearsal studio with my scene partners, supported by the technical breathing and vocal exercises, as well as mind/body practices I had developed in drama school. (Again: the creative use of oneself is not a replacement for technique, but rather it informs the performer of what specific moves we need to make at any given moment in our scene work.)

By the time the production was on its feet, I was able to embody Quigley without extraneous effort: from his brusque introduction to his cathartic end, in which his mother and best friend hold him in their arms and thwart him from carrying out a violent attack on his classmates. Actors often try to force emotion and tears in high-stakes moments like this—not unlike therapists when we impose heavy-handed clinical interventions onto challenging clients we want to “fix.” As my actor friends say, we often try to “play the end of the scene” too hastily, rather than allow ourselves to be present in every step of the journey.

But I didn’t have to strain myself to find Quigley’s deep-rooted pain for this scene. All I had to do was surrender my feelings to my scene partners, with whom I’d cultivated a great deal of safety and trust throughout our creative collaboration. As we performed the climax of the play, Quigley’s taut energy thawed from my jaw, neck, and shoulders—where it had been deployed as a shield—and it dispersed throughout my body, accessing a range of other emotions. In fact, at one point I awakened to the insight that all along Quigley had been defending against, and overcompensating for, the absence of his father. It’s an abstract clinical exercise to analyze a data point like this about a person’s life, either in a script or a psychological evaluation. “But when we make efforts to join that person in all their subjective bodily, emotional, and intrapsychic complexity, we expand our capacities for empathy”, mutual recognition and creative transformative action, both on and offstage, in and out of therapy. Best of all, we learn to relate to that other person (character or client), no longer through the trailing edge of their transference, as the recipient of their resentment, frustration and fear, but through the leading edge of their transference—as the embodiment of their generative desire, longing, and hope.

Act III: Using My Self as a Therapist

Harry burst into my office each week like he was in a race against time; he wanted answers, and he wanted them fast. A straight, white, corporate millennial, he was used to instant gratification, and he expected no less from his therapy. He emphasized that he already understood himself “extremely well,” and that all he needed from me were “professional tips” to reduce stress in his highly successful life.

I was flattered; I’d been cast in the role of commercial guru, the kind who might dominate the American market with bestselling, confidence-inspiring catchphrases. Except I felt too slow, discursive, and insecure to play this part for Harry, more the man behind the curtain than the great and powerful Wizard of Oz. Each week, I expected him to look at me incredulously—much as I’d feared audiences would respond to me portraying a butch, gun-wielding teen—and see that my training and degrees were all a sham. I anticipated the day he’d tear back the curtain and expose me as the talentless hack I felt myself to be in his presence.

On the plus side, Harry showed up for our weekly “rehearsals” consistently, which spoke to the frame I had provided, which apparently made him feel safe enough to “play” with me. But each scene between us had a palpable yet indiscernible tension. First, he’d summarize his week, speedily and with the energetic poise of a cocky movie star—shoulders back, chest protruding forward, eyes sparkly with intense self-assurance. Then he’d present a dilemma—“I need to make more time for relaxation and balance,” for example. At this point, he’d look to me as if to indicate it was my turn to perform, and to prove I was a worthy scene partner.

I would then try to seize the spotlight, so to speak, masking my self-conscious insecurity with a commanding delivery of a line like, “I recommend yoga, three times a week. Put it in your calendar.” I was desperately trying to personify the omnipotent coach I imagined he wanted me to be. And though my “acting choice” arguably answered Harry by his own method, it felt as though I was trying way too hard to impress him—much as I had overcompensated in my bullish portrayal of Quigley, as I stumbled through my first few rehearsals of Hyperactive.

Eventually, I’d look back on these moments and realize how all these unnerving sensations could help tune me in to Harry’s complex internal world, and to join him there. But in the meantime, I felt blocked, like a superficial actor who failed to connect with his character on a deep personal level.

Over time, it became abundantly clear that Harry couldn’t be bothered with my attempted interventions. He’d wince disapprovingly at my suggestions and say things like, “Yoga never works for me. I just end up obsessing about the more productive things I could be doing with my time.” At the end of our sessions, “he’d stride out of my office with a proud posture, leaving me behind to reel in a slouch of inadequacy”. I couldn’t seem to reach him, no matter how hard I tried. I felt like the FBI agent Tom Hanks played in the movie Catch Me If You Can, endlessly chasing Leonardo DiCaprio’s slick and wily character, a master of escape.

This frustrating dynamic manifested in a number of ways between us, including our weekly schedule. Harry would frequently ask to alter our meeting times due to his ever-changing obligations, and I’d accommodate him more than I wanted. I did this because I was afraid to disappoint him. Not only did I sense he’d fire me if I didn’t manage to keep up with his demands, but more significantly, I had an inexplicable sense of dread that he’d erase me from his mind entirely if I let him down. Unwittingly, I was tuning in to Harry’s inner life. I could feel his deep ambivalence about trusting and depending on people vibrating within my own body. And as it turned out, my fears were not unfounded.

One day, after two years of working together, Harry raised the emotional stakes of our scene work. I was running behind (by about a minute), between notes and phone calls, and he had no intention of waiting; it was his time, and he’d enter my office if he wanted to. I was completely shaken off-center as he blasted through my door. Within the flicker of a second, my face flushed with a combination of shock and shame, but also disapproval and a smidge of anger.

As we made eye contact, Harry stopped in his tracks—and his reaction to me was startlingly evocative. While his body asserted its typical conviction, his eyes betrayed a doubt, fear, and deference that I’d never consciously sensed from him before. Since I was too caught off-guard to address this novel improvisation between us in the moment, Harry made a beeline for the couch and shared his latest dilemma as if nothing had happened.

The latest dilemma, it turned out, was that his long-term girlfriend, of whom he’d always spoken glowingly, had proposed to him. “It came out of nowhere!” he exclaimed wide-eyed. “I was totally thrown off my game. Shaken.” Hmm, like what just happened to me now? I thought to myself. “We’ve talked about getting engaged for a while,” he continued, “but I just thought when it happened, it’d be…different.”

“You mean you thought you would be the one who proposed?” I asked.

“Well, yeah,” he replied. “I mean, not because of gender roles and tradition and all that. It’s just…I would’ve made sure it was perfect.”

“What would you have done differently?” I asked.

His eyes squinted as he struggled for an answer. “I guess I just wish she…” he paused for a while, “seemed surer of herself?” As we talked, he realized that this proposal had surfaced an implicit contract in their relationship: that he was in charge of their major decisions as a couple. His girlfriend had gone out on a limb and broken that contract—and now Harry was struggling to understand why he didn’t feel safe following her lead.

Uncharacteristically, his body sank back into the couch as he stared blankly in silence for a while. Finally, he spoke again: “Maybe she’s not the right partner for me.” There it was, the confirmation of my underlying fear; if his long-term girlfriend was expendable, so was I.

“It’s normal to feel a range of emotions at a pivotal time like this,” I said in an effort to validate him. “I appreciate your confusion and doubt, and since your girlfriend seems willing to give you some time to reflect, I suggest we continue talking before you make any big decisions.” He seemed momentarily held by this, but as I watched him take a minute to shield himself with his typical smug poise before leaving the office, I understood deep inside that this sense of security was tenuous, for both of us.

“Harry colonized my mind for the rest of that day, much like a challenging character might consume me as an actor”. At home, I looked in the mirror and tried to emulate his self-possessed posture. As my shoulders dropped back and down, my chest expanded, and my eyes and mouth affected Harry’s cool-guy charm, I began to recall the unpleasant sensations I’d get when trying to play the part of his expert guru. The external posturing I would affect at those times didn’t feel grounded in confidence, but instead seemed to serve as a shield to my internal self-doubt and fear of rejection.

Suddenly, I understood that the same was true for him. The look on his face when he’d barged into my office earlier that day, and the months and months of tension between us, began to make more sense. And as I joined his mind/body experience of self, I realized that what he really wanted was not for me to catch up to him or project the same overcompensating confidence that he did, but to get ahead of him. He longed for me to become someone who could set boundaries with him, disagree with him, and ultimately, care for him—without getting caught up in the same debilitating self-criticism that plagued him. But how could I successfully embody these qualities in the therapy room, and become the character with whom Harry longed to relate?

I thought about the end of Catch Me If You Can, when Tom Hanks learns to approach Leonardo DiCaprio no longer as an elusive fugitive, but as a boy abandoned by his father. I thought also of Harry’s father, who’d died suddenly of a heart attack when Harry was a child. Gazing in the mirror and focusing on the sensations within, I rediscovered what I had first learned with Quigley: biographical details about clients and characters alike resonate within us much more richly when we embody them, rather than simply study or analyze them. I then shifted roles and explored ways that I could present myself to Harry that might make him feel safely held.

I drew inspiration from men, in my life and onscreen, who were both palpably strong and nurturing, including Tom Hanks, Robin Williams, and Barack Obama. I considered their physical groundedness, the clarity of their thoughts, as evidenced by the easy poise of their heads, but also, most significantly, their emotional openness, illustrated by the lack of tension and flow of energy in their chest region.

As I played with where I felt these qualities in my own body, I didn’t try to impersonate the men superficially, but to connect with the experiences in my life—like caring for my younger brothers when I was growing up and being a camp counsellor—that brought out the warmth and confidence Harry needed from me now.

“When Harry next raced into my office, I was prepared to get ahead of him, and relate to him with focus, calm, and an embodied sense of security”. As we revisited the previous session, I validated his anxieties about depending on his girlfriend (or any intimate “scene partner” in his life) and invited him to talk about the pressure he puts on himself to “be ahead” of other people, including me.

Throughout this session, there was more ease, vulnerability, and play between us than ever before. But it wasn’t what I said, so much as how I’d learned to be in the room with him, that made the difference. I was even able to recommend self-care activities like yoga, which he’d rejected in the past, in a way that he now responded to with complete openness—in theater terms, same script, better performance.

As Harry exited that day, he turned around in the doorway, took a moment, and then said through the shimmer of a tear, “Thank you.” I simply smiled in return, maintaining the combination of groundedness, strength, warmth, and vulnerability that we’d discovered together in our session.

Finale

While I waited for my next client, alone in my office, I reflected on the connection Harry and I had found, and I recalled an interview with Meryl Streep, in which she explained that in her view, her success as a performer was only as good as it was “the last time.” Thinking of our sessions ahead, I knew we could expect more tension, insecurity, fear, and doubt to manifest between us. But at the same time, I knew my acting training could help me perform on this different kind of stage, where we’d continue to explore various versions of ourselves together.

I initially felt I needed to be someone else in order to access both Quigley and Harry. Like so many actors and therapists, I am driven by the desire to please my collaborators, to be the “expert,” and to “get it right” on the first line reading. But at the same time, in order to connect with our clients, characters, and scene partners as performing artists, we must practice our craft with humility, patience, and the belief that we are enough. We must trust that if we show up to each “rehearsal” with the willingness to be fully present—along with our vulnerabilities, naivete, and deep self-reflection—we will give our creative partners what they need to be present with us as well. Especially if we engage each other in a process of imaginative, empathic play.

Through our respective play sessions, Quigley and Harry both showed me that their apparent toughness, butchness, and self-containment were part of me as well—keys existing somewhere within my instrument, even if I don’t embody them every day. But an even greater revelation for me in both cases, was that the idiosyncratic “soft” qualities that makeup my everyday self—and that I originally believed were obstacles to bringing both young men into the spotlight—turned out to be exactly what they needed to find hidden keys within their own instruments. By playing these untapped versions of ourselves—even, and perhaps especially, when we felt inadequate—each of us found a way to breathe, to integrate, and to become more fully alive.

Note: This article has been adapted from Mark O’Connell’s new book, The Performing Art of Therapy: Acting Insights and Techniques for Clinicians, and his article “Character Work: What Therapists Can Learn from Actors,” in the Psychotherapy Networker, March/April 2019 issue. 

Premature Endings: When Clients Leave Therapists

Posted on by Psychotherapy.net Team

Premature Endings in Therapy

In this blog post, I consider the impact of premature endings of therapy on psychotherapists in general, and on myself in particular. I am focusing here on situations where a client leaves and breaks off therapy without giving the psychotherapist any preparation for the ending.

In my clinical experience, few scenarios have been as challenging as premature client termination, especially when I have not been prepared for that ending, and/or it was not foreseeable at the time. Certainly, many clients do not return after the first or a few visits, but others break off the relationship after considerable work has been done.

This may be years-long, ongoing treatment which involves complicated work around critical and aggressive transferences, and client concerns around trust. In such a case, a client may use attacking defenses to provoke reactions from the therapist, reactions that will serve to prove that the therapist cannot be trusted.

If we think of Freud’s 1912 Remembering, Repeating and Working Through, we have to work with our clients knowing that the therapeutic relationship may be part of a broken repetition of a previous relationship, rather than a more complete and healing experience that culminates in successfully working through the client’s issues.

When there is a premature ending, the therapist is often left with the sense that the client has used the work and the premature ending to remain fixed within their problems, rather than be able to work towards a better solution.

Because the premature ending of treatment is always an ongoing occupational risk, it is helpful for the psychotherapist to have come to terms with the way in which his or her own early environmental and attachment failures and problems exist as real and deeply felt experiences that may not have been healed but had to be painfully and quietly endured. There may be cases where we have become deeply invested in long-term therapy, where we may have worked, alert as possible, to projections and different transferences.

When the work breaks off suddenly, it can wound us deeply and leave us with grief and loss, along with a profound sense of failure, disappointment and rejection. Sometimes this occurs with a client who may have been overly critical and anxious about trusting the therapist throughout the work. This can be particularly so in treatment which has gone on for several years and in which the clinician worked hard on the client’s behalf.

The Pain of Premature Client Termination

Such a difficult client-initiated termination happened to me last year and I found the suddenness of the ending extremely hard to deal with. I felt myself overtaken by painful grief. I went over and over the final sessions questioning myself as to what I might have done differently.

What strikes me about these kinds of situations is the way in which, after the ending, the client remains in one’s mind, the way the transference remains alive. For example, on coming into my consulting room after a break, I tidied the place up a bit, and could vividly recall the way my client would often criticize my room.

In the end, and upon reflection, I don’t think there was anything I could have done. In one way, it could be said that my client broke off with me the way her father had broken off with her. This was a client who had particularly strong and unresolved attachment issues in her very early years, had gone through the breakup of her parents’ marriage at age four, and had then lived with her mother and brother. Her mother then remarried a very abusive man and the client witnessed as well as personally experienced violent abuse.

During our work, her capacity to trust me was the paramount cause of her recurring anxiety. Progress might have been made, but the question of trust would always hang over us, and in the end, the breaking off of the work, I think, had very much to do with the question of her not being able to trust me.

It is a difficult burden for us to carry when we are left suddenly in situations like these, when we are very invested in the work. In fact, we may not realize how much we are invested until the work has suddenly broken off and we are left dealing with the ending alone and/or in our supervision.

I am aware of my enduring sense of attachment to my client, and that for a long time I still thought of the 6 p.m. Monday time slot as “her” session. When I gave it to somebody new, I had the sense that they only had it on loan from her. The pain of the difficult ending remained in my mind, thoughts, and psyche. I wondered if it remained in hers, or if by ending with me, she found the freedom to be creative in another area of her life.

Therapist Growth Through Client Transference

I say this because I was recently teaching a seminar on Freud’s 1905 case of Dora. One of the key events of that case was that Dora broke off her treatment. It may be that the energy Freud was left with in the abrupt termination was part of what fueled him to write the case up. This in turn makes me think of the acrimonious split between Freud and Jung, and the creative energy that was released in each of them following the breakup of their work together.

One interesting thing about the ending of Dora’s case is what she did after leaving Freud. Because she returned to see Freud, we know that she confronted Herr K about his advances towards her and received an apology from him. For Dora, breaking off the work with Freud can be read as part of her way of escaping the abusive paternal transference. For Dora, the right to break off the treatment was crucial.

Could something similar have been provoked in my client? Could it be that in ending with me she was starting something that would lead to healthy creative expression? I like to think so. This abrupt ending may have felt premature from my side of the couch, but it might have been right for her. Nonetheless, I am still left working on the painful sense of loss, and perhaps abandonment, that her premature separation evoked in me.

Questions for Thought and Discussion

How did the author’s reflections on his case resonate with you?

How have you dealt with clients who have terminated without explanation or warning?

How would you like to use the information in this essay in your own clinical work?

How to Master the Art of Developing Your Therapeutic Voice

Posted on by Psychotherapy.net Team

Becoming an Artist

Surrounded by a sea of attendees at Psychotherapy Networker’s annual conference, I waited to ask my hero the question that had been burning inside. One man, with an uncanny resemblance to Sigmund Freud, entranced us yet again with a story of the work we’d all been celebrating and emulating in our own offices for so many years. Our master clinician and storyteller, group therapy guru, and most importantly, the single most generous and open discloser of his clinical process, Irvin Yalom was reflecting on his lifetime contributions.

It was now our turn to ask him questions. “Dr. Yalom, you’ve shown us how to embrace the process, and as the poet Rilke advised, to: ‘be patient toward all that is unsolved in your heart and try to love the questions themselves.’” Was I even talking into the microphone? The notes on my phone bounced out of focus, but I pressed on.

“Like jazz musicians, you’ve reminded us to enjoy the dissonances and savor the surprises we find within them. Can you talk about that, the role and importance of being an artist in our field?” I was grateful when he acknowledged that yes, he had thought of calling his book Letters to a Young Therapist after Rilke’s famous missives. “Even though I idolized so many, no, no, I never thought of myself as an artist. Even though I had wanted to be one, it wasn’t me!” It was like I had framed the wrong man. With him ready to quickly move on, I was stunned, stung, crestfallen. If Yalom couldn’t recognize being an artist, how could any of us?

Luckily for me — and us — Sue Johnson, the puckish British couples therapist and our evening’s interviewer, held him up a minute to take stock of his knee-jerk demurral. Wasn’t his work — its graceful storytelling and open embrace of the therapeutic process a testament to the power of our art to heal and enlarge? Was this any less artistic than the poet, musician, or actor’s craft?

Yalom’s initial objection ripened into delight on stage, and after the conference, in a private email, he thanked me, stating simply, “I’ll remember your comment for a very, very long time.” That’s what this essay is about: the artistry of our work and how we develop a therapeutic voice to help us get there. This is vital not only for ourselves and our supervisees, but even more so for our clients, who cultivate their own voice in the interplay with ours. Happily, there is ample scientific and empirical support for this artistic venture and cultivation of the voice, and I will use it to contextualize and illuminate our journey along the way.

Finding Our Voice

All artists — whether writers, musicians, or actors — must develop a voice, that hard-to-define yet distinctive style which runs like an invisible thread through their work, opening a space of creative possibility between their art and audience. As a supervisor of beginning therapists, I view this as essential, and liken it to the process we see on television each week on the show “The Voice.”

Just as Kelly Clarkson, Blake Shelton, and Adam Levine compassionately and thoughtfully mold, mentor, and inspire young talent, so too must we as supervisors help our beginning clinicians. Each has their own music and style they come in playing, and supervisors help them draw out their raw talent, experiment with new genres, and ultimately learn about how to make music that is, as Duke Ellington said, “beyond category.” This is therapy that transcends theoretical orientations, becoming a unique blend of the clinician’s theoretical and empirical knowledge, their personality, and emerging therapeutic repertoire.

There is a yin and yang here that, when in proper balance and harmony, lead to a fully developed artistic voice. This voice not only serves the therapist but promotes the opening and expansion of the patient’s own voice, becoming the driving force of creative therapeutic work. This also forms the basis for a lifetime of creating art. Yes, all of us therapists (veterans too!) do this daily, in the poetic and musical lines we shape in what others easily pass over as ordinary prose. Freud had it right from the beginning when he suggested, “When we can share that is poetry in the prose of life.”

Wouldn’t it be inspiring if all of us — beginning and veteran clinicians alike, supervisors and supervisees — could embrace the artistry of our everyday work? Wouldn’t it be illuminating if we had a working model of how to cultivate and deepen this?

Building a Voice

The model that I’ve arrived at is both simple yet expansive. A therapeutic voice is the combination and interplay of therapeutic presence and therapeutic authority, the complementary and seemingly contradictory elements that like yin and yang, enable us to create a three-dimensional picture of our patients and ourselves. Think of it like how our two eyes, each with their independent perspectives, magically create depth perception.

An ambitious supervisee recently confessed to me, “I have to anticipate everything before our session, and know exactly where I am taking my clients. I feel like a white-water rafting guide who’s one turn away from taking the whole crew down with me!”

This supervisee, like so many others, is proficient at being directive, setting goals, and moving quickly towards intervention. Unfortunately, they don’t offer enough room for the patient to openly explore and steep in their feelings or draw on the relational process to entertain new possibilities, which is why they so often feel up a creek without a paddle.

Therapeutic Presence

What they need more of is the yin of therapeutic voice, therapeutic presence — the capacity to be receptive, mindfully attentive, emotionally available, nonjudgmental and resonant with the client’s unfolding experience (1). Freud originated this concept in his earliest recommendation for practicing therapists in 1912, underscoring the vital importance of “evenly hovering attention.” Like a koan, the therapist should “simply listen and not bother about whether he is keeping anything in mind.”

Considered the foundation for tuning in to the patient’s unconscious, it provided a potent tool for opening one’s mind and heart to new possibilities for understanding and engaging the patient’s psyche. Like the Zen Buddhist notion of “beginner’s mind,” or mindfulness itself, therapeutic presence comes from the framework of “not knowing” in the service of creativity. To paraphrase the Nobel prize-winning poet Wislawa Szymborska, the point — like the poet’s main task — is to say I don’t know and keep on going. It’s to wonder aloud!

Therapeutically present therapists are understanding, open-minded, and comfortable with a range of different feelings and perspectives.These therapists have internalized Robert Frost’s prescient quip, “No surprise for the writer. No surprise for the reader!” Patients feel a sense of safety, trust, and warmth in their company. The space seems to open with them. This disarming quality makes it easy for patients to explore new subplots and turns in their stories. They find themselves surprised at how much they are saying and learning in just the telling itself.

Therapists who practice this kind of presence don’t have to know immediately and aren’t bothered by the ambiguity or complexity of what they are hearing; they “dwell in possibility,” as Emily Dickinson said, a “fairer house than prose.” They allow patients to be in the driver’s seat so that they can show them the territory first, and in so doing, instruct their therapist how to best be of service. This openness allows patients to take more risks in therapy, to deepen the exploration of their thoughts and feelings, and to get to genuinely enjoy the deeper waters of the psyche, even providing modeling for them to be more open to the various and contradictory sides of themselves! In short, to paraphrase Whitman, they are reminded that, “We are large. We contain multitudes!”

Owning A Voice

Plopping down in my office chair, and letting out a formidable sigh, another supervisee recently lamented: “Sometimes I feel like I’m taking it all in but then can’t get a word in edgewise, and I’m not even sure if what I’m thinking even makes sense. Am I really helping them at all, or are my own mixed-up feelings just getting in the way of making any headway?”

I know many fantastic supervisees who excel at being empathic, reflective, and thoughtful with their patients, but lack the confidence to make discriminating interpretations that take into account their valuable instincts and intuition regarding new creative possibilities.

These supervisees, understandably, worry that if they use too much of their authority, they will overwhelm or possibly hurt their clients.

They need more of the yang of the voice of therapeutic authority — which I define as the command of theory and technique and a discriminating awareness of how to put these into practice. It is the confidence to properly select, apply, time, and adjust one’s interventions in a multicultural and relationally sensitive manner (by relying on the yin of therapeutic presence, of course!).

The clinician with therapeutic authority is happy to show patients how to blaze a new trail and empower them to sort through the various aspects of their experience to find bigger patterns and new possibilities. Like an artist mentoring a new student, they can see the bigger and smaller picture and can help with the difficult passages encountered in putting new skills and pieces together. Most importantly, the therapist with a balanced dose of therapeutic authority knows how to do this with proper timing, tact and empathy. They are not going to break patients down like a military drill sergeant, but instead are going to be thoughtfully discriminating and penetrate deeper into problems and their implied solutions.

Supervisory Support

It is vital for supervisors to support beginning clinicians in developing their clinical intuition and instincts, the confident application of their theoretical and empirical knowledge, and a sense for having the “authority” to make therapeutic moves. Just as a singer needs to take risks with trying out new ways to expand their interpretation of a song, so too does the beginning clinician, and as supervisors, we are right behind them to encourage it!

Supervisors also need to model how to both be comfortable with and to chase the kind of not-knowing that makes creative therapeutic work possible. Like Yoda to Luke Skywalker, we help emerging clinicians to learn how to use “The Force,” showing them that, paradoxically, it is only by surrendering and letting go that we truly open the space for something new to emerge.

Just like our young poet needed Rilke to learn how to become an artist (and Rilke in turn was mentored by the great sculptor Auguste Rodin), so too do our beginning clinicians need us to illustrate how they can be balanced and integrated in their own unique therapeutic voice by uniting these two crucial faculties. And it turns out that all of us, no matter what level we are at, need to remember that we are always cultivating and expressing this artistry!

Empirically Supported Artistry

Art never needs more than its own justification, but as a scientist practitioner, you might need to be reminded of the scientific support for viewing therapy as an artistic enterprise. Look no further than Neuroscientist Antonio Damasio’s recent book, The Strange Order of Things, which eloquently showcases the way in which our “right-brained” feeling comes first, inspiring and motivating our greatest cultural innovations and products, and that joined together with the logic and language of our left-brains, becomes something truly extraordinary. Daniel Pink in In a Whole New Mind illustrates the 21st century’s cultural sea change from a left-brained leaning computer age, to a right-brained leaning conceptual age that integrates right and left to make the best of both worlds.

In my model, therapeutic presence is the right-brain dominant aspect of our therapeutic artistry, and therapeutic authority is the left-brain pilot, so to speak. Therapeutic presence is at once dreamlike and free-associative, holistic and big-picture, image and metaphor centered, and largely implicit and nonverbal. It undergirds the profound empathic connection between us and our patients, especially to those sides of our clients that have experienced trauma and yet still long for—even in secret — a more redemptive narrative.

Therapeutic authority flows from the language and logic-based sides of our brain with its highly developed executive functioning. More largely conscious and deliberate, this side enables us to zero in and edit the many clinical possibilities before us so that we can work with true specificity and discernment, tailoring our treatment for the unique person sitting across from us, and getting to the heart of the matter.

A 19th century poem by Frances Cornford sums up this lovely process best. Entitled “The Guitarist Tunes Up”, we learn that this musician leans into their instrument with ‘attentive courtesy’:

Not as a lordly conqueror who could

Command both wire and wood,

But as a man with a loved woman might,

Inquiring with delight

What slight essential things she had to say

Before they started, he and she, to play.

For a visual of this interplay, we can look to none other than that famous Renaissance man — Da Vinci and his iconic drawing of his Vitruvian Man. It is only by integrating the square of our logic with the circle of our feeling do we become something truly divine — artists in our own right.

Learning & Teaching from Art

If we are to find and develop a therapeutic voice, we must first look at how therapy itself connects to the arts and how, as supervisors and supervisees, we can attend to these important dimensions. We’ll look specifically to poetry and music as starting points.

Poetry Lessons

A poem, such as a sonnet, compresses a question or problem, its exploration, and a final statement of some revelation or new understanding into 14 lines. In Shakespeare’s famous sonnet, “Shall I compare thee to a summer’s day?” the speaker wrestles back and forth with how his love is and is not like summer. Initially, it seems very fitting to compare her to the beauty and splendor of the season, but upon further inspection, new ideas emerge. Among other things, she is much more constant, evenly tempered, reliable, and more lovely than the summer months.

Much like Shakespeare’s speaker, we wrestle with our initial diagnostic impressions of our patients: Shall I compare thee to a borderline personality, a depressive, or an adjustment disorder? It is not immediately clear, and so many of our first sessions entail testing out various hypotheses to determine who the patient is and is not.

As Shakespeare’s poem continues, surprises and new discoveries emerge and toward the final turn of the poem, the poet concludes that his love will be eternal as a result of the poetic act itself: “So long as men can breathe or eyes can see/so long lives this, and this gives life to thee.” This is the aim of a transformative therapeutic process. Much like a sonnet, by the end of the therapeutic experience, a patient will be able to make a few “turns” and come to a way of internalizing the therapeutic process so that it too will become eternal.

Music Lessons

Beethoven’s fifth symphony provides an immediately recognizable compressed musical idea. In only four notes, a focal theme is established that is explored, varied, and reharmonized much in the same way that occurs in therapy. The capacity of the therapist to articulate that melody — the dominant trend or relational pattern that pulls the various strands of a patient’s story together —goes very far in clarifying what has been troubling patients while it points them in the direction of how they can move forward. Much of the time, patients are playing the notes of their issues but are not aware of the melody and cannot synthesize it into a focal theme. They bring us their own invisible scores and hope we will give them feedback to recognize their own music.

About seven and a half minutes into the third movement of Rachmaninov’s Symphony in E minor, we hear the main theme played by the French horn, in the manner that a patient initially expresses when it is recognized by the counselor: “You hear me! This is the song I didn’t know I was singing.” Shortly after, the theme gets played by the violin with a melancholy poignancy: “I have been waiting a long time suffering with this alone.” This is the sense of sadness and mourning that the patient feels for having had to sequester this aspect of self in the service of protection and adaptation.

As the theme gets worked upon and elaborated, new instruments, such as the oboe and flute, come in to take on the line, with hope gathering. Calmer and with greater poise, a certain pride and expressiveness opens now that this very significant idea can be incorporated into the larger musical narrative of the patient’s story.

Let’s see how this artistry translates to a representative case and get a preview of putting all the pieces together.

A Case of You

I’ve named this “A Case of You” as a nod to Joni Mitchell’s heartbreakingly beautiful song because this patient seemed at first blush like she was too much to handle. Pretty quickly into our first session, I realized that, like for so many of our cases, the following lyrics truly applied:

“You’re in my blood, you’re my holy wine, you’re so bitter and so sweet, oh I could drink a case of you, and I’d still be on my feet!”

A student came to her intake appointment complaining that her friends did not understand her, that she couldn’t fathom why they were so turned off by the razor blade that she kept on her desk as a reminder that she could cut herself, and that she had been told to come to counseling many times, but it had never been helpful in the past. She asked, why should she bother now?

Previous counselors told her that she needed a higher level of care than they could provide, and those appointments left the student feeling misunderstood and blamed for troubles she could not fathom. She also felt a sense of hopelessness at not being able to make true contact, just as she had not with family and friends. Aiming right for the jugular, she also scoffed at me: “Counselors are incompetent and don’t really understand me. You probably won’t either!”

In addition to feeling interpersonally rejected on several fronts, as a first-generation college student, she experienced the pressure of well-meaning parents who hoped to see the family’s metaphorical stock rise with her success. At the same time, her family expected her to be at the ready when they called her to take care of her younger siblings. She was a painter who loved the darkest colors of her palette, with her works centering on Hopperesque misfits wandering in the night.

Initially, her cutting was a regular strategy to express and modulate her emotions, combined with a preoccupation with death, and the ways in which friends and other therapists had been repelled by her behavior made me wonder whether this student had borderline personality disorder. Like in Shakespeare’s poem, though, I was not sure whether this comparison truly fit.

Here we see the internal wrestling of therapeutic authority and presence. The first stab at therapeutic authority can have us all too quickly categorize or even pathologize what we are seeing before we get the full story. At the same time, this discriminating faculty provides crucial information that we really need to follow. Like a samurai warrior, psychologically speaking we need to forge the sword and learn how to use it appropriately. Toggling back and forth between this function and therapeutic presence — the open and receptive Buddha nature — allows us to see the big picture clearly while also focusing keenly on the supporting details that we need to assess and intervene incisively.

As I got to know more about the patient’s relational backdrop and leaned into my therapeutic presence, things looked a bit different. I learned about her parents’ difficulty tolerating fear, anger, and sadness, and their own struggles with managing chronically high levels of stress. I also learned about my client’s repeated experiences of the family being unable to acknowledge or stay with her emotional experience.

Just as the subject of the Shakespearian poem was no longer so much like the summer, it seemed more and more that she was no longer like a patient with a borderline organization and instead more like one with a neurotic organization or a possible adjustment disorder. She appeared to be in a conflict that could not be acknowledged squarely as she was in the midst of an important developmental transition, both issues coloring each other and placing her in an ever-tightening Gordian knot.

By trusting my therapeutic authority, a focal theme emerged. When this patient expressed negative emotions, people could not tolerate them and emotionally and physically abandoned her. This pattern was consistent with her emerging friendships — others were not interested in hanging out with her despite her charm and intelligence — and extended to her early family experience, in which her parents subjected her to the silent treatment for days whenever her emotions ran too hot. Taken together, the patient internalized a message that her emotions were problematic and disruptive and that they must be put aside and suppressed. In other words, they became “not-me” and funneled into the dissociative symptom of cutting.

Until I was able to home in on a focal theme, I, like the therapists before me, was part of the problem, imagining in my countertransference that it was the patient who had the major issue. Internally, I underestimated how much my feelings were part of an enactment, containing only a small piece of the story. Initially, I was bracing myself for difficult work, assuming that the student had a great deal of pathology and would make little movement. In a way, I was reenacting the dynamic of the student’s relational backdrop, finding her issues disruptive to my sense of authority just like her parents and her prior therapists had — “it is not me, it is her.” By maintaining a therapeutically present stance, I was able to observe this crucial dynamic and incorporate it into a new understanding and relationship with the client.

Therapeutic authority led me to a focal theme that helped me see that it was totally understandable for her to shy away from sharing her intense feelings and need to hide and express them in her not-so-secret ritual of cutting. She was protecting both myself and herself from “not-me” and letting the world know, with what seemed to be twisted pride, that cutting was her right and a very valuable part of her emotional life. Looking back on that detail now, it was very prescient in the way it encapsulated her attempt to express and independently resolve her bind.

Reading and Tracking Changes

Guided by a mindful application of therapeutic presence and a discriminating use of therapeutic authority, the student went through the kind of musical sequence referenced above. Initially, having a therapist who was able to respect and receive the fullness of her experience without mistreating or abandoning her by becoming critical or explosive or falling apart was a tremendous step toward a new relational experience. The recognition that her focal theme was understandable and heard enabled her to begin to speak of it without the kind of shame and dissociation that often accompanies a “not-me” experience. It also enabled her to begin to trust and hope again.

She became inwardly and outwardly relaxed so that she could begin to examine the many facets of her current and past experience and thus begin the riffing that is essential to the jazz improvisation that is therapy. In short, she began to find and develop her own voice as a patient!

The patient could view her behaviors as more comprehensible and expressive of the hidden conflicts she had been harboring and that had been left unformulated and disconnected. This expanding sense of self-compassion became an important antidote to her cutting behavior and provided an alternative avenue for exploring and containing her emotional experience. Interpersonally, she became less defensive and fearful of others abandoning her, having had a transformative set of experiences in which she felt the consistent presence of a reliable other. She began to show her pain not only in her words but in the artwork, she did as a painter.

When a poetic turn or musical theme has been established, shifts can immediately be seen in the patient and felt in the relationship. These can occur simply in the change of posture (often, a straightening of the back and sitting up in one’s chair), a richer tone of voice, a feeling of newfound connection and space in the therapeutic relationship, or in the spontaneity and flow of narrative or images that emerge in the therapeutic interplay

In the first session, trust was developed as the student began to see me as a figure who could understand and appreciate the depth of her pain and recognize the myriad ways in which she had been misjudged and pigeonholed by her family, friends and, most notably, other therapists. We also developed a focal theme centering on how this rejection led her to suppress and negate her important and precious feelings. Taken together, I believe that these turns led to decreased scores in hostility and emotional distress, each indicative of the fact that she was feeling more trusting, less defensive, and relieved at being able to begin to experience her emotions more directly.

These scores continued to remain significantly lower than baseline for the next few sessions, whereupon we worked on developing ways of shifting patterns in her relationships with friends and family. At around session five, the student’s depression scores started to decrease as she began to feel greater self-efficacy and agency in being able to affect change in her life inside and outside of the therapy space. Simultaneously, her levels of anxiety followed suit as they made a statistically significant drop from baseline in our final session of the semester. Our work together concretized the notion of making a more poetic and musical line in our therapeutic work, and the importance of drawing on artistic metaphors to inform treatment and expand both the therapist’s and the patient’s voice in that process.

A New Slant on Working Dynamically

We are very accustomed as clinicians to thinking vertically, troubling ourselves over quick diagnoses and assessments, especially given the limited time we often have. At some points, this may take away from focusing horizontally on the musical line and the movement of the intervention. In music, in order to play or sing a melody successfully, one needs to be as attentive to the horizontal motion of the notes carrying a melodic line forward as to the vertical axis of hitting the note itself.

In clinical practice, one can analogize the horizontal forward motion to the momentum of an intervention, the movement toward a new relational experience. The vertical playing of the note is the clinical equivalent of ensuring you understand the patient’s experience correctly and getting a proper diagnostic read. This horizontal motion is informed by therapeutic presence just as, conversely, the vertical movement is guided by therapeutic authority. Both are essential, and they need to be worked in concert to turn notes into music.

This musical way of approaching relational work helps us to be more efficient, fluid, and creative, focusing simultaneously on how to skillfully assess and intervene in our fast-paced culture. Moreover, it enables us to carry the themes of the patient’s past into new orchestrations and harmonizations in the present, providing a model for continued transformative possibilities in the future. Through this process, patients internalize working creatively with their own themes and then take us into new melodic and harmonic territory, stimulating further treatment progress and development. Taken together, this fosters a positive feedback loop in the creative matrix between patient and therapist, and from this synergy, transformative changes quickly follow. This is precisely what a well-tuned therapeutic voice does for the clinician and their client.

References

Cornfeld, F. D. (1965). Collected poems. Cresset Press.

Questions for Thought and Discussion

Who inspired you to find your voice?

What are some of the unique attributes of your therapeutic voice?

Which of your clients helped you to find your therapeutic voice?

In what ways do you compare psychotherapy to an art?

Psychotherapy and Autism

Posted on by Psychotherapy.net Team

I just finished writing a book for psychotherapists on helping teenagers and young adults with autism. This topic does not get much coverage in the clinical literature on autism, as treatment books focus most often on children. This blog post will share some major points from the book. Autism is a neurobehavioral condition impacting social comprehension. It is often described as impacting “social skills,” but that is much too limiting. Autism impacts how an individual perceives the social world and interacts with that social world. Individuals with autism literally have a different way of perceiving social relationships, and they use skills they find appropriate given those perceptions. Autism makes up “who the person is” and not just “what the person does.” Having Autism makes up a major part of the answer to the all-encompassing question teenagers and young adults ask: “Who am I?” Therapists can help older clients take on this challenging question by helping them answer more specific questions like: “What does being a person with Autism mean?” “How do I want to live my life as a person with Autism”? “How important is it to have friends and what sort of friends do I want to have?” “How much am I capable of doing on my own?” “How much independence can I hope for?” “Where do I agree and disagree with my parents and teachers in terms of what they expect from me?” “How much do I care (and why do I care) about how people respond to my Autism symptoms?” Applied Behavior Analysis (ABA), the primary treatment approach used for autism, emphasizes learning skills to replace behaviors that are causing problems. ABA still plays a major role in treatment for Autism for teenagers and young adults. Using the questions listed above is an effective way of determining what skills the teenager or young adult needs to learn. So, for example, once your client has worked with you on what sort of relationships he or she wants, you can use ABA approaches to help them learn skills needed for obtaining those types of relationships. But what you are making clear is that you are not taking a “one-size-fits-all” approach to what skills to learn. You are not telling your client “You need to have friends” or “You need to do more with other people.” You are helping your clients decide what they want, even if it is different from what their parents, teachers or healthcare providers think they should want. Addressing disagreements between what young clients and their parents want from therapy can be a real barrier to progress. Everyone wanting to have the final say in what gets addressed can be more challenging with this type of therapy than any others. You have parents who are used to guiding their child’s treatment, and then the child (now a teenager or young adult) who is tired of being told what they should want or what goals they should have. This is even more of an issue with autism because childhood autism treatment requires heavy parental involvement. Backing off on this involvement, so that their child can have more say over what gets addressed, can be difficult for parents. I remember one client, a teenage girl with autism just starting the 11th grade, whose main issue was disagreements with her parents. Her goal was to interact with her peers more at school, but she was not particularly interested in more social activities outside of school. But her parents wanted her to do much more socially. They had another daughter who they described as a “social butterfly” who was often at parties and out with her friends. When they saw that their other daughter (my client) did not have much interest in parties, they determined that something was “wrong” with her and that her autism symptoms, which she dealt with all her life and had been under control for years, were causing her problems that she did not see. My client had considerable disagreements with her parents about this issue and was really starting to resent them for it. She was comfortable with her limited social activities and did not want to do much socially outside of school (but did want to do more socially in school). Her parents disagreed and we had to address this issue before deciding what direction treatment would take. This sort of disagreement is not uncommon for families of a teenager or young adult with autism. Given how intense autism in childhood can be and how involved parents often are, they may come to expect their child will not fully understand what they need from treatment. Having family sessions, where everyone is given their say but the therapist makes clear that the young client must be listened to, can help parents recognize the validity of their child’s views. It can also give the therapist the opportunity to talk with the parents about how there are different perspectives on what makes social relationships meaningful and what to expect from friendships. When I had the chance to discuss these issues with my client’s parents over two family sessions, they were more receptive to considering what their child wanted socially. They were actually initially quite angry at me for “giving in” to their child and treating her too much like an adult. It was only after we discussed these issues in depth, and everyone had the opportunity to express their views without interruption or criticism, that the parents were receptive to allowing their daughter to set the goals for therapy. Therapy for autism in the teenage and young adult years is more individualized than therapy for autism during childhood. One example of how this works out is that “social scripts” are used as opposed to “social stories.” Social scripts are based on discussions during the therapy sessions specifically addressing what the person wants in terms of social relationships and what situations they find most difficult in reaching social goals. Social stories, on the other hand, emphasize more general rules that are used across a variety of social situations. Many types of therapy approaches used effectively for treating different conditions for teenagers and young adults can also help individuals with autism. Mindfulness, cognitive-behavior therapy and relaxation therapy all have been found effective for treating anxiety, depression and anger comorbid with Autism. T client can learn how to use these skills to reach the social goals they set for themselves. Perseveration and self-stimulatory behaviors are common problems in autism that need addressed. They typically get addressed as clients identify the negative responses they get from other people because of these behaviors. Using the “Red Card/Green Card” exercise is one effective approach for this problem. Essentially it involves helping the person practice suppressing their repetitive behaviors by allowing them periods of time to talk about whatever they want (including perseverative topics) without interrupting them when the “Green Card” is up, in exchange for focusing on specific topics the therapist brings up when the “Red Card” is up. I have also found reviewing material related to the “neurodiversity movement” to be invaluable for helping determine effective ways of helping teenagers and young adults with autism. This is not a therapy orientation per se, but is a philosophical movement emphasizing that autism, along with other neurobehavioral conditions, is best thought of as a “difference” and not a “disorder”. Reading material related to this movement can give you a different perspective on helping make therapy for someone with autism as beneficial and individualized as possible. Reference: Marston, D. (2019) Autism & Independence: Assessments & Treatments to Prepare Teenagers for Adult Life. PESI Publishing & Media: Wisconsin.

My First Private Patient

Posted on by Psychotherapy.net Team

The following is an excerpt taken from The Fear of Doing Nothing: Notes of a Young Therapist by Valery Hazanov, published by Sphinx, an imprint of Aeon Books © 2019 and reprinted with permission of the publisher.

My First Private Patient

Climbing up the stairs from the subway stop on 13th Street, I reached for my phone and saw a text from a former classmate. It was August 2015; I had just received my license.

“Val, it’s been ages!” she wrote. “How are you? Did you start your practice already? Someone asked me for a referral: a professor from Moscow who’s looking for a Russian-speaking therapist in the city. I don’t know him, but his son works with Daniel and sounds really nice … Would you be interested? Let me know and we need to get drinks!”

“The man, I learned from his son, was a microbiology researcher in his seventies who came to New York for an experimental treatment of cancer”, with which he had been diagnosed a few months earlier.

“We would like you to work with him on themes of positive thinking and optimism,” the son told me over the phone. “We understand that it might be crucial for the success of his treatment.”

I did not have a practice, but quickly (Israeli style) arranged something for the following Friday: John, the leader of the men’s group, lent me his place near Central Park. It was a good-looking room with many ancient artefacts, an enormous sofa, and a window that looked onto a leafy courtyard with two benches.

I came thirty minutes early and as I was waiting for Mikhail Alekseyevich to arrive, I photographed the room with my phone camera and sent it to my mom and a few friends in Israel.

“Look at you, Doctor!”

“Beautiful, Valery …”

“Can we come for a session?”

I was standing by the window, trying to imagine who I would meet, reflecting on the irony of my first private patient being from Moscow, thinking about the type of Russian he might be – in what sociological box from my past would he fit …

A buzz at the door. We begin.

***

“Here?” an older woman asked nervously as she was wheeling in Mikhail, who seemed disinterested, slumped in his wheelchair, looking very thin, turning his gaze to the window – away from me.

“Hi, I’m Valera. Nice to meet you.” I shook their hands.

They introduced themselves.

“Welcome to New York, Mikhail Alekseyevich,” I said after his wife had left the room.

“Puzzling city …” he replied in a pensive voice.

“How so?”

“I don’t know. Who are you? I didn’t quite comprehend from my son. He keeps taking me to all these appointments. Are you a doctor?”

“I’m a psychologist.”

“A psychologist? He didn't mention…I’m surprised he brought me here, I never understood what psychologists do.”

“Me neither.”

““You tell people that everything will be alright?””

I laughed. “Something like that.”

“How old are you?”

“Thirty-three.”

“Young, young … And where are your parents? In Moscow? Here?”

“My mom lives in Colorado and my dad is in Israel, where I grew up.”

“My God. You have no one here. How do you manage?”

“I run a lot.”

“I see. That’s good. So tell me, psychology, is it even scientific?”

“I don’t think it’s scientific.”

“You see, Valery, my cousin’s daughter in Moscow is a psychologist,” he said with a grimace. “She tried to explain many times … She’s a singer, she does yoga, she lights candles that smell nice. She told me that there are three ways to be happy, but I can’t remember them … What’s a psychologist then? What exactly do you do?”

“Have you read The Grapes of Wrath?”

“Yes. Many years ago.”

“Remember the guilt-ridden uncle who’s dying to talk to someone and ends up drinking instead?”

“Vaguely.”

“The family needs to keep moving, if you remember. There’s no time for what he needs. He keeps bugging them, wants to tell somebody, anybody, what happened to his wife and how it was all his fault. He’s breaking down, he’s feeling ashamed. He’s lonely and misunderstood. I talk to people like him.”

“And?”

“Sometimes it helps. Sometimes it doesn’t do anything.”

“What will it do to me?”

“I’m not sure yet.”

““How will you ‘cure’ me? Tell me to forget that I have cancer and look at the positive things in life?””

Checkmate against the psychologist by the Russian researcher, by generations of people who did it all by themselves, who withstood Stalin and the World War and the Gulag and never complained and kept on going. No need for therapists, thank you very much, we’ll manage by ourselves. But tell me, psychologist, what is your plan? Will you tell me that everything will be fine and I’ll whine a little and feel sorry for myself?

“I don’t think I’ll do that. It sounds like a terrible idea,” I said.

“What then?”

“You tell me: maybe you want to fight, maybe you want to let go.”

“Oh, I don’t know. Honestly, I don’t even know what I’m doing here. ‘It’s a new treatment,’ they said to lure me. ‘You don’t have it in Russia!’ Big deal. All I wanted was to die in Moscow and that’s not going to happen. But I don’t want to talk about that…I don’t want to talk about myself. I’m gone, I’m not interesting anymore. In a moment I’ll be back to dust: a forgotten man in a forgotten place. You, on the other hand! You’re young, so young … You have a future, you have something to look forward to, something to hope for, something to wake up to in the morning that is not a CT scan or a blood transfusion or a ‘lab analysis’ or a ‘Mr. Barsky, have you given a urine sample this morning? Was it too yellow, Mr. Barsky? We’re a little worried, Mr. Barsky.’ ‘Oh, are you?! A little worried?’ I don’t want to talk about that nonsense. I want to talk about you.”

“I understand. What would you like to know?”

“For example, where do you live?”

“I live in Brooklyn, by a park that’s called Fort Greene.”

“A big park?”

“Not too big, I see it from my living room window.”

“Nice. Who do you live with? You’re married?”

“I used to be … I live with my best friend.”

“Well, that’s not the worst.”

“It’s not.”

“Do you like New York?”

“Not particularly.”

“Why not?”

“Because it’s a place that’s good at separating people; not so good at bringing them together.”

“Interesting. What’s your favourite city then?”

“I like Jerusalem.”

“Why?”

“It’s chaos, it’s the Middle East, everyone’s in your face. That’s more to my liking.”

“You’re an interesting type, Valery…I wonder what’s behind the mask, though!” he said, smiling.

I laughed. “”Behind the mask of a psychologist there’s another psychologist, and then there’s another one – until there’s a person.””

He laughed too. “Another question: what did you have for breakfast?”

“I had coffee and toast with strawberry jam.”

“I can’t have that, you know? Dietary restrictions,” Mikhail said, sighing.

“Mikhail Alekseyevich,” I said after a pause. “Your son told me that your cancer is at the fourth stage.”

“That’s right.”

“How has it been?”

The ping-pongy nature of our conversation never stopped. Mikhail didn’t want to tell me how it had been, but he also didn’t want to leave. He lingered in the office even after I had told him that our time was up. He wanted to talk about music, about places in New York that I liked, about where I grew up in Moscow.

John’s cozy room, the garden outside, my life’s story – it was all a respite from his painful reality: torn from his home, dying from cancer, treated by people whose language he did not understand.

Was it a psychotherapy session if I told him more about my life than he told me about his?

As we said our goodbyes, I wasn’t sure if he wanted to return or not. “Let’s be in touch,” he said as his wife was wheeling him out.

“I left the session feeling that I had met Nabokov’s Pnin” – a Russian intellectual in exile, never fitting into his surroundings, not quite sure what to do in America, how to be. Clearly not a person who would voluntarily stumble into a psychotherapist’s office asking for help. Smart, witty, playful: I really hoped I would see him again. I hoped that I had placed enough hooks, dismantled the psychologist stereotype he had had in his mind – it was the only way in, I felt. One word of jargon, one “It must be so hard for you,” one “I feel that you are experiencing some ambivalence about seeking help, Mikhail Alekseyevich,” one “There is something scary about opening up and talking about ourselves,” and he would have walked away, never coming back. “Americans,” he would have thought, “psychologists,” he would have told himself, “why can’t they talk in a normal way?”

A few days after the session, I called him.

“Yes, dear,” Mikhail answered in a soft voice. “I’m listening.”

“Your son told me that you haven’t been feeling too well.”

“Oh, you know, it’s to be expected with my diagnosis. But how are you? Did you have a nice weekend? Did you spend it in the city?”

“It was alright.”

“What did you do?”

“Went for a run, wrote in the library, met up with a friend.”

“Nice, very nice. Good for you.”

“Will I see you again, Mikhail Alekseyevich?”

“Sure, why not? But there is a small problem: I can’t leave the place I’m at anymore because of my condition. That’s what they told me, I’m stuck here.”

“I’ll come over.”

Three days later I appeared at the treatment facility in which Mikhail had been hospitalized. It was one of those modern places that are part hospital, part living apartments. There were inspirational quotes on the walls and names of donors. The rooms were given names like “Mist” and “Four Winds”. It looked like a getaway hotel by the hot springs, except that all the residents had cancer.

Mikhail was sitting in a wheelchair when I came, his tiny body covered with an enormous woolen blanket, pointing to the table next to his bed with medical equipment: “Needles, stupid needles …”

“Only a week had passed since our first meeting, but he looked much weaker and sicker”.

“First things first,” he said. “Are you hungry? Would you like to eat something?”

“No, I’m fine, thank you.”

“Well, at least allow me to pour you some tea.”

Drinking tea together, we eased into a conversation about Russia. Mikhail was dismayed by what was going on, telling me about how politics had ruined science, how people didn’t feel free anymore, how it all looked familiarly scary.

“Why does it feel like a damn cycle?” he wondered. “A predetermined fall to the abyss.”

“It does feel like a tragedy … We know how it will end but can’t do anything about it.”

“Exactly,” he nodded.

“When I think of Russia,” I said, “I only think about the very distant past, and about Moscow, which I absolutely love. It’s not the ‘right’ approach for immigrants, we’re supposed to hate it, to bemoan the glitzy, materialistic behemoth that Moscow has become. ‘Oh, how terrible! They only have Gucci boutiques all over, what happened to our Moscow?’ But beneath it, beside it, apart from it…You have the little squares, the theatres, and they renovated nicely, and I just love the feeling of walking there. It’s a funny thing to go back. You know they have this train from the airport that goes to the centre? Then you can take the metro, two stops to Kiyevskaya, around where I grew up. Last time I was there I got out of the train and was amazed: it’s like it hasn’t been twenty-five years, it’s like I never left. Strange feeling.”

“You’re a nostalgic person, my friend.”

“That’s true. But…there is this idea of a Country, of what it stands for, its values, etc. Living here, I’ve been thinking a lot about the bubbles, the niches in which we live; the Tuesday mornings and the Sunday afternoons. And sometimes they have nothing to do with the Idea, with Putin, with the ‘political situation’. It’s either good or bad. It’s a texture of living that either works or doesn’t.”

“I know what you mean.”

“I talk a lot for a psychologist.”

“I wouldn’t know.”

“Tell me something.”

“I was thinking about my family when you were talking. How we all spread around, like birds who flew to find warmer climates and never came back. My two sons are here: one in New York, as you know, the other one in Boston. They did well, I think, I hope.”

“How often do you see them?”

“Once a year, maybe twice. Tatyana and I visit occasionally, stay for the summer, spend some time with the grandchildren. Sometimes they would come visit us in Moscow. But it’s a peculiar feeling: after all this time, all this flying around, I am sitting in Four Winds ready to die and be buried, and where? Where do they bury people here?”

“I think in Queens, maybe in the Bronx.”

“Okay, ‘Queens’. What the hell is Queens? What does it have to do with me, with what I have done in my life?”

“It has something to do with your children and their children.”

“True. But it’s still odd, this whole thing. What is a place? What does it mean to be from somewhere, to live somewhere? I don’t know anymore.”

“Me neither …”

We never met at John’s place again. “Every week, at varying times, based on Mikhail’s medical procedures and condition, I would come to sit with him by his bed”, or take him to the porch outside Four Winds.

We did many things together. We watched YouTube (a scene from Tarkovsky’s Sacrifice with Bach’s St Matthew Passion superimposed was his favourite), we talked about his research and what he thought needed to happen to it, about the papers he wanted to finish but felt he would never be able to. We talked about Russian literature, about immigration, about Israel. We ate fruit and snacks. I brought him a ginger ale once (he had a sudden craving), and a chocolate bar another time – I don’t remember if he was allowed to eat that …

“Thank you for coming,” Mikhail would always say when he saw me. “What’s the news?”

He liked when I described, in detail, a certain place in New York, like a park, or a building.

His face would light up. “What do you see when you enter it? How big is it? What is its exact circumference?”

I never knew, of course, but I would google it in his presence and we would talk about that and I would learn things like the area of Riverside Park (266.791 acres) or the year the Avery Library at Columbia was founded (1890).

With time, and only after starting with the perimeters and context of his life, we were able to go deeper – dreams, regrets; soul stuff.

“What do you miss the most?”

“I miss my sofa in Moscow! I’m serious! We just bought it, it felt like a big achievement …”

“Funny.”

“I miss being needed.”

“Yeah …”

“No one needs me now. Who am I? An old man who’s waiting…waiting to end this.”

“What exactly do you mean by needed though?”

“Someone calls: ‘Prof Barsky, what do you think we should do with this experiment, this paper?’ etc.”

“What about your family, how do they need you?”

“I don’t know. Now, I don't know. I feel like I’m just a bit of a nuisance.”

“Judging by their relentless attempt to keep you alive, it doesn’t feel that way.”

“True. Maybe they got attached.”

“What do you mean, ‘maybe’?”

“Well, yeah, definitely.”

“It’s just that the work was at the centre of your life…Now that it’s been taken away you probably wonder what’s left.”

“You’re right. Not much. And let me be completely honest: I don’t know how to face this, Valery. I really don’t. Can modern psychology help us here?”

“I’m not sure.”

“Have you ever worked with dying patients?”

“No, I haven't.”

“So, what do you think, how should I do it?”

“Big question…Words like ‘meaning’ or ‘acceptance’ – you know them, you don’t need me to repeat them. But then how else can we talk about it? I’m not sure…Maybe reduction of bitterness? Making it a project of extreme gratitude to what’s around, to who’s around? I mean, it’s true for me as well – can’t hurt.”

““Coming to terms, coming to terms,” he said with a smile. “I’ve never done it!””

“We all suck at this. But tell me stories, it helps.”

Often when we sat on the porch he would put his hand on mine and we would be silent for a few minutes. Then, he would remember something recent or very distant, associatively it seemed, and tell me about it.

“There was this type, what was his name…Ah! Igor Bogdanov, yes, yes. Anyway, it must have been in the Seventies. We were just starting out, he was at my department then and we had a trip together to Nizhny Novgorod, to give a talk or something at the local university. We took the train from Moscow, seven or eight hours, I don’t remember, and delved into a conversation about the department, its politics – the usual stuff. And then he turns to me, I still remember it, and says: ‘Misha, you know what? You’re too gentle for science.’ That’s what he said: ‘too gentle’.”

“Are you?”

“I don’t know. Sometimes I think I was. Science, you see, you need to fight there, you need to push, forget about everything, about everyone. I am not sure I was able to do that. I have regrets, Valery. I live with certain regrets; I think I could have done more. Publish more, teach more, forgive me for the pathos: discover more.”

“Yeah…”

“I can’t shake these feelings off. I understand in my head: ‘You’ve done a lot, stop!’ But it doesn’t feel like that, it doesn’t feel enough.”

“How will we get you there?”

“I thought you were the expert!”

“I thought we had agreed it’s not scientific!”

He smiled and shook his head.

“There is this question in psychotherapy that I frequently think about: whether it is a process that’s supposed to make us feel better about who we are or to change who we are.”

“And what do you think?”

“I think, ultimately, it’s about acceptance.”

“Okay. But it bothers me, it does. It’s such a childish thing to be bothered with. I mean, how infantile: I am sitting here thousands of kilometres away, forty-five years later, ready to die, still thinking about that comment.”

“But what bothers us always feels childish. That’s inherent in ‘bother’.”

“How so?”

“‘How un-Stoic of me, why can’t I regulate myself, how am I swayed by stupid emotions…’ That’s what we think when we are ‘bothered’ by something, no? But what’s an emotion? It’s the basics, it’s us as a kid, it is childish.”

“Okay.”

“I have a friend in Israel who told me a story once. During his reserve service in the army he was stuck for weeks in a remote base somewhere. One of his friends came to him there in the camp, I think he was doing the dishes or something, and his friend goes: ‘Yona, you know what I realised? You’re a lone wolf.’ My friend told me that he could never forget that comment. It’s nothing, right? Completely innocuous. But that’s the thing: it’s always simple. A word, a sentence that hits something real. And then we obsess over it and feel foolish, or, if we’re lucky, relieved – in psychotherapy…”

“Was he a lone wolf?”

“Probably.”

“And if he were your patient would you have tried to change that?”

“I would have told him: when you hunt, hunt together sometimes, brother.”

Mikhail laughed, but then stopped. “And what would you tell me?” he asked, closing his eyes halfway. “Do you think I was too gentle?”

“I don’t know,” I said. “But if I had to guess, I would guess that your gentleness was a gift from God that made you the scientist that you are.”

***

The treatment facility in which Mikhail had been hospitalized was in a constant state of buzz. There were doctors and nurses and relatives and other patients in perpetual movement. There were many TVs and they were always on and for some reason it was CNN and the news, most of the time. There were people with different-sounding professions that would come, every couple of minutes, it seemed, to the room and talk about physiotherapy that needed to be done, “management of care” that had to be managed, financial decisions that needed to be made, Mikhail’s diet, furniture that could be brought in or out according to Mikhail’s wishes, books that they were able to order for him in Russian and he should explore this opportunity because not in every place was it possible but it was possible there and if he would only ask…

Is the mobile phone working okay? Is the Wi-Fi signal strong enough? Would he prefer a vegetarian option for dinner? Does he need more channels in his cable? There are now options in Russian.

Mikhail, weary, deaf to this all, was motionless in reaction to this spinning around him. “Why can’t they leave me alone for a moment?” I imagined him thinking. “Why all these questions?”

“I don’t know if it’s true, but I felt that his life had been about protecting his sanity”, his focus, from the intrusion of this energy of mundane concerns. I don’t think that just because he had cancer that was slowly killing him, he became a person who could not stand any of that, who could not bring himself to care about that non-important nonsense. And I sympathized with him, obviously, and felt that it was appropriate that we were meeting at that frantic facility and not in a secluded office, because suddenly it emphasized an essential part of psychotherapy: its fending off of corrosive distraction – standing firm in the face of the never-ending attacks on the things that matter. Sorry for the clichés, but it did feel like we were creating an island, and we tried to protect that island together. And he was not just a patient, but rather a collaborator in that process, which was as much mine as his, I believe.

Whatever was going on in my life in the months of August and September of 2015, wherever I was – Mikhail was with me, transcending the confinements of the “consulting room”. Like a good friend who becomes a part of your daily existence, to whom you say that you feel tired, or that you like your tea with no sugar but with lemon, or that your back has been bothering you recently and it’s annoying. Somehow, he became that person. “He liked to call me on the phone, between our sessions, to tell me a story, or a joke, or ask for my “opinion” about something”. “Valera, milenkiy,” [my dear, in Russian] he would frequently conclude the conversation, “I miss you.”

Gradually, it became difficult for Mikhail to talk. He would take long breaks between sentences, holding his head as he tried to say something. “Valera,” he would say, “do you think we can fully be known by another person?”

“I think there are parts of ourselves that remain forever only ours.”

“Yes, yes. It’s true … And that’s what remains?”

“What do you mean?”

“That’s what we take with us?”

“I think we take more.”

“Maybe. It’s just that sometimes I think, what was it all for …?”

“You’re in a bad mood today.”

He laughed, weakly. “You’re right. It’s just … I don’t know how I can accept this. I had visualized something different.”

“What?”

“First of all, yes, and forgive me if it sounds infantile, but this was supposed to be happening in Moscow, in my apartment. I mean for heaven’s sake, I spent forty years there.”

“What else?”

“I didn’t achieve enough. I just didn’t. I was okay, I was a good researcher, but I could have done more. Much more. And it bothers me. Why didn’t we meet twenty years ago, Valery? This isn’t relevant anymore…What can you tell me now that will change that? Nothing!”

“Twenty years ago I was thirteen.”

“You know what I mean.”

“You mean that I was a top therapist at thirteen. I think you’re right.”

“Be serious.”

“There’s nothing to be serious about. It’s a bunch of thoughts in your head. It’s a fantasy that you created because you had thought that life is measured by some yardsticks that kept evading you, that kept getting higher and becoming unreachable. We make ourselves miserable believing in this nonsense, myself included, but it’s all about letting it go. And it’s never too late and you know it. You know it’s not too late because you can still think and you can still feel and you can look around and say, ‘Thank you very much world, God, universe, fate, me…’ – whatever you believe in – ‘for giving me my wife who has cared for me all my life, my two great sons, and their children who will be coming to my grave because that’s how they were raised. And thank God for at least one article or paper or invention that actually mattered for something and wasn’t just a bunch of words.’ You can do it right now.”

“Valera…”

***

A few more weeks had passed when I came to his room and saw that he couldn’t get out of bed anymore. He would lie, eyes closed, hand on his forehead, in pain, mumbling something to himself. He would try to get up on his elbows when I came, sometimes succeeding, sometimes not.

“Well, that’s what it’s come to,” he said in a shaking voice. “What should we talk about?”

“How is your pain?”

“Oy…” he sighed. “Look at my hands,” he said. They were all pink and swollen. He was dying.

And “I remember looking at him, understanding how ridiculous my thought was, but also that I couldn’t help but think – “Why? Why is he going? In what way is that fair?””

“Did you get some sleep tonight?”

“I did, I think.”

“Can you eat at all?”

“A little bit …”

“Can I bring you something?”

“No, no, I am okay.”

“Do you want me to read you something?”

“Yes, please.”

“Okay. Believe it or not, I’m reading you this from my mobile phone.”

“Wonderful.”

“‘And there in the middle, high above Prechistensky Boulevard, amidst a scattering of stars on every side but catching the eye through its closeness to the earth, its pure white light, and the long uplift of its tail, shone the comet, the huge, brilliant comet of 1812, that popular harbinger of untold horrors and the end of the world. But this bright comet with its long, shiny tail held no fears for Pierre. Quite the reverse: Pierre’s eyes glittered with tears of rapture as he gazed up at this radiant star, which must have traced its parabola through infinite space at speeds unimaginable and now suddenly seemed to have picked its spot in th

The Murder of Hope

Posted on by Psychotherapy.net Team

Hope

During my short time as a mental health therapist, I have become aware that when a client enters my office for the first time, they are not alone. I am no longer surprised to find that they bring with them a crowd. Sometimes the client is young, as April was, not quite a teenager but perhaps not quite a child anymore either. She brought with her a myriad of people—family members, friends, classmates, crushes, and her abuser. I saw some of them immediately as our eyes first met, and I instantly recognized the power that they held over her, in her consciousness, daydreams and nightmares. They sat down with her and I could feel their grip, I could feel the fear in my own chest over what they had done.

There was another being that I had only recently become acquainted with. Her presence was not quite as potent but was steady from the start. She entered the room as soon as April did and invited me into a dance of both creativity and pain.

“It was not until this presence was murdered that I came to know her as Hope”. In the weeks that passed after April chose to end her life, I got to know the heavy stone of grief that had settled in my stomach. I spent hours resting my hand on chest, on my belly, breathing in this pain that felt more complex than just the loss of April. I turned it over in my hand, wondered what was there, in my grief with her. In the weeks that followed, I realized that this rock was not just holding April, but another being: Hope.

When I look back on my time with April, I can distinctly remember the first time that Hope made herself known. April had come into my office as if it was her own and flung my blanket onto the ground, spreading it flat with the tips of her fingers. She pressed her cheek onto it and traced the shapes below her. “We can lay on it as long as we don’t put our feet on it,” she told me. I laid next to her and she spoke of her dreams. So easily, she named her abuser as he was and told me about her body. As she did, I could feel the terrified child in me reach toward the terrified child in her, and then she was there. Hope made her entrance in this easy connection, breathing into me what could be. I began to feel, in this tangled mess of articulate children, the beginnings of an older woman.

Even before Hope was murdered, I spoke to her. It began in my car, after we met. I left each session and imagined what Hope was like—a bold, creative, quirky teenager who loved her friends ferociously and spoke to her pain with tenderness when it arose. She dressed in ways that made her feel empowered and felt safe to express her creativity, her passion, her fears. I imagined an adult woman who lived her days with gentle passion, unafraid of her desires and longings. A woman who wrapped others in her own sense of embodiment, who believed that healing was possible, who advocated for herself as fiercely as she did for others. It was easy to see the ways that this energetic, playful, imaginative child could become a wildly creative and embodied woman.

I must admit that in many ways Hope was not only made of the girl. She was made of the girl that I once was, who was much more withdrawn and fearful. She was made of some of my creativity, my passion, my wildness. She was made of some of the woman I am and some of the woman that I also long to become. Hope was free and tender in ways that I sometimes am not, and she was made of the sort of reckless dreams that I held around this beautifully courageous child.

Pain

Therapy with children is a wonderfully playful mess composed of hours of Jenga, making houses out of shoeboxes, outbursts, laughter, and moments of stunning articulation. Some children enter therapy tentatively, but for April it was not the case. With April, every activity involved a story, involved imagination and intricate webs spun between characters, both fictional and real. Amidst these stories, she’d tell me her own: about the abuse, and the terror that gripped her at night, and the maddening ways that one tries to make sense of such harm. She wondered about her fear, her desire, and how these things become intertwined. She asked questions that my child-self would have been far too scared to ask: “Am I still loved?” “Do I still belong?” “Is there something wrong with me?” In these questions there was no escaping my own fear, my own history with assault, my own terror that something is wrong with me. Questions I’d asked and supposedly answered as an adult, and yet.

And so, in these ways she began to ask me into her pain and demanded that I also acknowledge my own. As my own therapist put it so clearly, “there are some clients who invite you into more of your own healing.” I felt Hope here, too. As we stood in the lobby and said goodbye, April easily rested her hand in mine. I could feel two children speaking to each other, holding their own pain, holding each other’s pain. I could feel my own, adult hand, and I could feel Hope. I could feel the beginning of an exhale I longed so much for April to have. A type of exhale that is kind and purposeful and full of her own hopes and dreams—what a feeling it would be to witness. I knew, and Hope knew, it would not be easy to get to this exhale. And yet we believed that she was capable of it—perhaps not of entire days or weeks or years of settling into her own breath, but moments. Moments where joy and freedom were allowed.

And perhaps this is where the ache of death was felt the strongest. That when April decided she could not live any longer, she took with her two beings that I had grown to love fiercely. I have spent so much time thinking of the girl who sat in my office, the girl who played and laughed and bellowed at the top of her lungs in the lobby, completely unashamed. I have thought about the girl who spoke with astonishing clarity about those who harmed her, who bravely revealed her fears and her pain without looking away from me. I have thought about her hand in mine and her loudness and her lovely oddities. And I have missed these things fiercely.

As I have sat with my grief, as I’ve held the ache and numbness, I have been angry. I’ve been angry that when she killed herself she also murdered Hope, a being who I needed for April, but who I also needed for myself. As I’ve continued since April’s death, I’ve often wondered about Hope. I’ve wondered if she matters, now that she’s dead. I feel angry that I did not get a say in her departure—perhaps this is unwell of me, to have tangled myself up in April’s Hope so much that now it feels as if a part of me has died, too.

I’m furious because this is not what I signed up for. I signed up for pain, and for a long, difficult battle towards some sort of wellness, but I did not sign up for this. I did not sign up for creating this beautiful being with another person who gets to decide if they want to die and take Hope with them. The tangle of grief becomes nearly unbearable as I think of Hope. The girl and I, “we made her together, we crafted her from laughter and tears and imagination”. She was formed from a goodness I can still feel sitting at the base of my throat, a goodness that I have yet to let go of. As I live and know that she is dead, I want to cling to Hope and ask her to stay somehow, without half of her being. Without the girl, Hope is dead. And with her, the goodness.

It’s been nearly impossible for me to grasp that perhaps the heartbreaking truth is that Hope, for her, is dead. As much as I have taken this rock of grief in my stomach and wanted to smash it into the ground and say, “No! You cannot take Hope with you, too!” it must be true that Hope has also been killed, and there is so much grief in that. Letting go of April and her Hope will perhaps forever be molded into the being of my own Hope; the woman who I am and who I hope to become. Letting go of the girl means that Hope lives in me as an ache. She continues to grieve and rage and long for the goodness that once was. She sits and cries with those who also grieve the loss of the girl, and she keeps going, still holding the ache. In some ways it feels easier to stay in the anger, to argue with the girl, with Hope, to hold them here with my grief. Settling into the despair is harder, is a continuous reminder that yes, she is gone. They are gone.

Risk

Shortly after April’s death, I read these words in a blog by Jerusha Dressel: “Hope is a choice to stay.” The months after her death marked a death for me—in my personal life, and in my work as a therapist. I struggled to believe that I would ever feel connected to another client again. I sat in this feeling of death and wondered, where is Hope? Months after she would begin to make an appearance, for just a moment. I would see her after a productive session, and I would hiss at her: “get out of here.” Connection with my current clients brought a newfound sense of risk and dread: if I care about them, if I love them, they could die. And if they do, a part of me will die again. I wanted to do everything in my power to keep this from happening again. Perhaps if I don’t allow myself to love, to feel deeply connected and hopeful, then therapy will not hurt so much. I will not risk losing a piece of my soul again.

In the same breath that I hated Hope, that I wished I would never see her again, I also longed for her to return. I longed to feel connected again but feared so much the consequence that most of my being would not allow it. When I could not find her in myself I thought back to those words: “Hope is a choice to stay.” In this way therapy feels like a constant entering into the terror of Hope: afraid of the death and the grief that connection might bring, and yet. Hope is a choice. To keep listening, to keep feeling, to keep holding the trauma of our lives and each other’s lives. There is an excruciating beauty in the invitation to enter these spaces of pain and betrayal, and I began to center myself again in that truth. We are wired for connection. Amidst tremendous suffering, we are not required to see the ending—to see Hope of recovery or health or happiness. Somehow, in the despair, we can choose again just to stay. To behold each other’s stories. To feel the pain deeply and fully and remain with each other in it.

Hope and I will continue to be on hiatus. As I grieve and rage, I do not want to see her. And yet I know that every day as I choose to re-enter all that is therapy, she is around. A part of her has died. A part of me has died. And still, we stay.
 

How to Maintain Your Therapeutic Dignity with Blood Dripping Down Your Chin

Posted on by Psychotherapy.net Team

When we moved from Dallas, Texas to Fayetteville, Arkansas back in 1993, I quickly realized that any therapeutic anonymity I'd experienced in Texas was a big “not happenin,” that is unless I wanted to hole up in my house and never partake of food, fun or the festivities that went on in my lovely new hometown. The place was too small and just Southern enough where your business wasn’t just yours.

Now, after practicing 26 years in Arkansas, I'm far from reclusive so I regularly run into people I’ve seen as patients. I’ve been aware of how running into one another in public might impact their relationship with me and any work we did together, but often it was the result of simply living.

Like what you are reading? For more stimulating stories, thought-provoking articles and new video announcements, sign up for our monthly newsletter.

I'd been in Arkansas for about four years when I auditioned and earned the role of radical feminist and socialist Emma Goldman in the vaudeville musical TinTypes. I came on stage at one point in roller skates, singing raucously and playing violin…badly. I worried a bit, “Does anyone really want to see their therapist doing that?” When I played the passionate Desiree in Little Night Music, a patient told me they had to quit seeing me, “Because you kissed another man.” I explained about how kissing on stage is not really kissing, and we looked into her feelings. My son had a horrific tantrum at a toddler birthday party that violently came to a halt when his very hard head bounced off my lip, causing blood to spurt all over me and him. And of course, the story in my head became, “Hmmm…are those moms I’ve seen questioning my competence?”

It's like trying to live your real life while also retaining some amount of therapeutic professional respect and dignity—in roller skates and with blood dripping down your chin.

Since that fateful afternoon, I've taken even more risks—and hope that the ethical disclosure gods don't chew me up and spit me out. For several years, I've had a blog and a podcast and I'm quite open there as well. I respect that this isn't everyone's cup of tea. And might not, depending on your theoretical orientation, sound like good, responsible practice. But I've come to believe that we as therapists may be unintentionally enabling the silence of mental illness stigma by not being more up front about our own struggles.

Don't get me wrong. I use discretion. I go many a day without saying a word about myself. My job is to listen, to hold, to contain, to suggest, to educate, and to guide. However, I've revealed that I went through a divorce when I think it will be helpful. Actually, two divorces. But that's not the point. I've also disclosed that I have performance anxiety, panic attacks, and a history of anorexia, again, when I think it's helpful for the patient. And I reveal that I've been on both sides of the couch—as patient and psychologist.

The criteria? If it's truly helpful to the patient and not about some need I have to “share.” What I've experienced is that my openness is respected. My vulnerability and risk—helpful. People now tell me, “Your openness about your own vulnerabilities gives me more permission to do the same.”

This all came dramatically to the fore two years ago, when I presented in a local This Is My Brave show. If you don't know this organization, it was begun by Jennifer Marshall, who'd been blogging anonymously about her bipolar disorder for years. It was only when she came forward—as herself—that her blog's audience skyrocketed. And she realized that her vulnerability mattered. The organization now hosts programs both nationally and internationally, featuring people with mental illness telling their stories to a live audience.

When I agreed to do it, I thought it wouldn't be anything. I'd already been writing about my anxiety. So, what could be difficult about it? Once again, my own running narrative was ill-conceived. It was quite emotional. And hard. Yet I'm so glad I did it. I've revealed my own vulnerability, my own passions, and my own struggles. Bloody chin and all. 

How Self-Disclosure of Learning Differences Guides My Clinical Relationships

Posted on by Psychotherapy.net Team

Origins of Empathy

As a child, I remember the frustration of not being able to tie my shoes, ride a bike or grip a pencil. The fact that I needed extended time on tests and note takers throughout high school and college was no less discouraging. However, one of my greatest challenges was adapting to adult employment and social demands; a process during which few people seemed to care about my specific struggles. I still remember fearing the supervisor who would criticize my handwriting and the sting of rejection after a first date. Although my therapists were empathetic, I was often curious about whether they had similar personal experiences, and whether disclosing them would have strengthened the alliance between us. Now, as a therapist who specializes in working with young adults with learning differences, I have made self-disclosure not only a basic component of treatment, but also part of how I present myself to the outside world, as my personal story is published on my website as well. This dynamic has led to a transference and countertransference between my clients and myself that starts from our first session and strengthens our relationship in many ways, while also providing an opportunity for us to reflect on our differences.

Part of my initial interest in becoming a psychotherapist and coach stems from my personal experiences struggling with learning differences. I am interested in using some aspects of my life to help other young adults with similar diagnoses navigate their challenges. It is reported that 75 to 85 percent of young adults on the spectrum are unemployed, and although the exact statistics on unemployment among adults with other learning differences are not known, it is widely thought that they also face a variety of barriers.1 The clients that come to my practice often say that they are struggling to manage their workload, navigate interpersonal situations with colleagues and bosses, and establish friendships and romantic relationships. “Preserving the uniqueness of their challenges while drawing on my own experiences is a tricky balance as a psychotherapist”, but I have developed a few strategies for doing so.

Fellow Travelers

My clients frequently find me through my writings for the NVLD (Nonverbal Learning Disorder) project, a non-profit that disseminates research and builds awareness regarding this unique visual-spatial disorder. One of the first things I tell them is that everyone’s experience is unique, and that my job is to help them to navigate their lives while also drawing on some of my own personal experiences related to common issues such as self-disclosure in the workplace, creating organizational systems and finding mentorship. The key is to listen fully to their stories and experiences, helping them to brainstorm and find their own solutions, while also offering, when appropriate, some personal anecdotes that might be helpful for their specific situations. An example could be a client who states that he or she is not sure how to best self-disclose their learning difference to their employer. We may explore ideas about different times and places to self-disclose, and I can talk about what I have learned from my own experience. I have found that many clients often appreciate this approach, stating that when I speak from a personal viewpoint it helps them to trust me more and feel as if I can relate better to their experiences.  

If transference in psychotherapy normally consists of unresolved feelings and expectations that are placed onto the therapist–oftentimes in an unconscious attempt to recreate or approximate a past relationship, and countertransference is the therapist’s resulting conscious and/or unconscious feelings that are projected onto the client, “the therapeutic relationship between two young people with learning differences is ripe for the enactment of these feelings/experiences”. I often find that the clients I work with report a feeling of safety and security, perhaps seeing me as an older sibling or parental figure, especially when they describe feeling understood or supported by my being in a unique position to empathize with their learning differences.

Transference & Countertransference

One client, whom we will call Joyce, frequently contacted me after our therapy had ended in order to ask questions that usually began with “since you have and know about NVLD…” Because our work together had ended, I redirected her to another therapist who practiced in my office, but she did state that she had felt a sense of security and safety with me that she may have felt earlier with her mother, whom she used to call to help guide her with difficult situations. In some ways, she may have unconsciously seen me as a parental figure helping her to navigate difficult questions related to her job and personal life. 

While working with male clients, I have often found that the transference/countertransference relationship may take on a different form. This is due to the fact that there is an element of both bonding and competition; many of the young men I have worked with may have a complicated history with women, especially regarding rejection and feelings of emasculation, a topic about which they may look to me for understanding. While I do not usually disclose my romantic status or experiences, by validating the unique challenges of dating with a learning difference and providing some practical steps for managing these feelings, I establish a bond with these clients, who describe previous male friendships in which they discussed these issues. A dynamic of male companionship can often form between my clients and me. However, some of my male clients have also seen me as a source of competition, and have reacted strongly, stating “you don’t know anything” or “how can you understand me?” Admittedly, it may be uncomfortable for some of my clients who see me as a “success story,” especially when they are struggling to find work or build interpersonal relationships. This is also a dynamic that I try to work through with them, making space for it to be discussed in the therapy room.

I attempt to use my countertransference as an indicator of not only how I should respond to the client in the room, but also of when, if and how I should self-disclose. A dynamic of male connection may lead me to respond to a client’s disclosure regarding rejection in the dating world with a few suggestions for improving one’s strategies, perhaps with the caveat that I have learned from my personal experiences. Depending on my relationship with the client, I may also use my countertransference as an indicator of my familiarity with certain aspects of the client’s professional experiences. For example, I remember identifying with a client I will call Michael, when he described challenges figuring out certain aspects of his job, as I have had similar experiences. However, if a client expresses competition or hostility towards me, I may also notice a feeling of defensiveness that arises in me, which will cause me to be more cautious regarding self-disclosure. Again, “countertransference can be an indicator of when and how to self-disclose”.

In my clinical work, transference and countertransference are often sparked by the patient’s vulnerability in the therapeutic relationship, something that individuals with learning differences will sometimes go to great lengths to conceal. Sometimes, they will hide behind a veneer of competence, lest anyone discover their sometimes painfully embarrassing challenges. The transference and countertransference dynamics in a therapeutic relationship often emanate from these struggles becoming visible, causing relief, vulnerability and perhaps shame at the same time. An articulate and thoughtful client, whom we will call Jenny, recounted how she had transferred to a reputable private school to receive more academic support and was subsequently abandoned by her previous friends, who stated, “So you think that you are better than us?” Despite distancing herself from her new school’s perceived “preppy” culture, she was reticent to explain that she had enrolled there because the workload and lack of individual attention at her local public school had become too onerous to handle. Quite the opposite of feeling “better,” her true reasons for transferring were a source of embarrassment. Hence, she described feeling “invisible” to her former friends, as they had falsely assumed she must have chosen the school for its supposed prestige. Jenny’s story prompted me to reflect on how many of my peers had also judgmentally questioned my parents’ decision to send me to small private schools, with statements such as, “Wait! How many people go to your school!? That’s weird.” Not to mention, “Are your parents rich or something?” I stated to her, “It is so frustrating and somewhat ironic when people assume you attend a private school because your rich parents want to help you escape the chaotic real world of public education, instead of the reality that you would do anything to be able to thrive while attending a school with over thirty students per class, loud and confusing hallways, and overwhelmed teachers.” Jenny thanked me, and although I never disclosed my experience, the fact that I had made hers visible created a positive transference between us. In that moment, I may have seen her in a way she would have wanted to be seen by an empathetic friend.

“Group therapy sessions necessitate a different kind of self-disclosure” and create a different stage for the expression and integration of transference and countertransference into the therapeutic work. I led a small group on developing dating skills for young men on the spectrum. The participants asked me, “Do you have a girlfriend,” and “What dating experience do you have?” I did not answer the first question but did confirm that I had faced some the challenges in this area. I added that I had developed some strategies and techniques of my own for finding success. My self-disclosure sparked an ongoing discussion of the struggles of dating between the group members, a discussion in which I was a participant in but not the expert leader. In other words, my self-disclosure leveled the playing field, so to speak, which facilitated a deeper and more meaningful conversation in the gruop. Because the participants acknowledged that they did not feel comfortable speaking about these issues with anyone else, the transference that may have developed was that of a relationship between intimate friends. Regarding my countertransference, I also felt a sense of kinship with the other participants.

Self-disclosure regarding around my learning differences and a careful monitoring of the related transference and countertransference relationships with certain clients has enriched my clinical work. My clients have had both positive and negative reactions to my self-disclosure, which has provided an important opportunity for deepening the clinical relationship. While not all my clients react positively to knowing that I also have a learning difference, the majority have developed a trust and willingness to explore how my self-disclosure may help them in treatment. Although I will continue to make sure that sessions focus on clients and not on myself, I believe that, overall, my decision to self-disclose has been a positive experience for clients.

Resources

Carley, J. M. (2017, April 13). The Employment Shift: Rethinking Autism Employment Initiatives. Fallbrook, California , USA.

The Instant Replay: Reliving a Critical Moment

Posted on by Psychotherapy.net Team

In doing psychotherapy, I sometimes feel like I am wandering with my client through a dense forest of brush and brambles, trying to find a pathway out. Often there is no clear direction or clue, and the way ahead may be difficult. However, there are also times when I have found it particularly helpful to ask my client to return with me to a salient event in his or her life and look at it once again in considerably more detail. This might involve, for example, reexamining a triggering experience or an incident that brought the client into therapy. I call this process of reexamining an earlier event—exactly as the client remembers it happening, moment by moment—the “instant replay.”

Like what you are reading? For more stimulating stories, thought-provoking articles and new video announcements, sign up for our monthly newsletter.

You might do this when the client first brings up such an experience, but often it is best not to do so right away. The event may be too raw and painful when it first comes up in therapy; and additionally, you may not yet know enough about the client to grasp the full significance of this landmark in the larger terrain of his or her life. Consider the following case.

Beth, a fifteen-year-old, had been admitted to the hospital due to explosive outbursts, depression and suicidal ideation. Her anger toward her family seemed inexplicably intense, and her worst outbursts were directed toward her mother. For example, on the day she was admitted to the hospital, she had planned to run away, and when her mother found out and tried to stop her, Beth had threatened to “deck” her mother, had refused to return home and had threatened to jump out of the car when her mother tried to bring her back. When asked about her anger in family sessions with her mother—and sometimes in individual sessions as well—Beth would withdraw into a seemingly impervious and almost catatonic silence. When she did talk about her anger, Beth expressed feeling criticized, and stated a belief that everyone in her family blamed her for all the family’s problems, including the breakup of her mother’s marriage to her stepfather, and the fact that her biological father had stopped all contact with her. She was not convinced by attempts at reassurance that her mother and stepfather had had their own marital problems and that her biological father had stopped contact not only with her, but with other family members as well.

As time went on, another side of Beth began to emerge. Her mother revealed that at times, Beth had written letters expressing unbearable remorse about her behavior and a desperate wish to change. One letter, which was four-pages long, was entitled “The Unconditional You.” It described a story from a book Beth had read about a girl who was ungrateful and cruel toward her mother until she realized with shock that her mother still loved her unconditionally. The letter went on to express Beth’s belief that she and her mother were like the girl and mother in the story. Beth’s mother voiced exhausted confusion about letters like this and the fact that her daughter could still explode into rage toward her, even after writing them. Beth’s mother seemed to have difficulty accepting that her daughter could have such seemingly contradictory feelings.

At about this time, Beth opened up, first in group and then in individual therapy, about her history with her biological father. He and her mother had separated when Beth was very young, but he had continued to visit Beth, and had remained close with her until he moved to another state when she was 11. They had promised to write each other every week. They did so for a while, but a few months later he remarried and without explanation stopped responding to her letters. Beth’s behavior worsened after this.

The day after she told me about this, I found Beth crying in her room when I came to meet with her. She had spoken to her mother on the phone and was feeling hopeless about ever returning to her family. We talked about the phone call, and then I told her that her mother had showed me the letter about the story she had read. I said that I knew how badly she wanted unconditional love but that I believed that her mother couldn’t always give her this kind of love because her mother was dealing with her own problems.

At this point, the time seemed right to do an “instant replay” of the events that had brought Beth into the hospital. I reminded her of what had happened the day of her admission—how her mother had tried to stop her from leaving, how they had argued, and how she had exploded and eventually been taken to the hospital. I asked her to tell me what they had actually said to each other and we reviewed their argument, step-by-step and word-for-word. She described how her mother had attempted to talk her into returning home. Beth had refused, and after more attempts to persuade her, her mother had finally grown exasperated and said “You can just stay [away]! I’ve tried for seven years, and I give up!” That was the moment when Beth exploded and threatened her mother.

“It sounds like it really upset you when you mother said that. It really hurt you and made you angry.”

“Yes,” she said.

“It scares you when your mother says things like that.”

“Yeah.”

“Can you say why?”

“Because I’m afraid my mother is going to leave me like my dad did.”

This was the first time Beth had ever explicitly made a connection between her behavior toward her mother and her hurt about her father.

In the next few sessions, we clarified and extended this insight. Working individually with Beth, I pointed out that when she had felt hurt by some of her mother’s actions, the hurt had been supercharged by the past pain related to her biological father’s rejection. In parent work with Beth’s mother, I explained that Beth’s battle for distance was accompanied by a fear that she would lose her mother completely, leading her to do things that forced her mother to take greater parental control, while simultaneously pushing her mother away. And in family sessions, we explored together how Beth’s feelings about both of her parents had come to be focused on her mother. As Beth said to her mother in one of these sessions, “It’s easier to get mad at the parent who is there for you.”

Somewhere within us, painful memories are frozen in time. Unexpectedly, they may leap to life, opening old wounds. But under the right conditions, we can gain the upper hand over time—revisiting and re-running those painful experiences, freeze-framing the exact moments when we gave them power, and clearing a path to healing.
 

The Shape of Hopelessness

Posted on by Psychotherapy.net Team

Mr. C doesn’t say he is sad. He isn’t crying. But his face is like stone, draped in a small disconnected smile, and my own insides have turned to lead. Hopelessness clamps down like a vise. I am sitting at the foot of his hospital bed in the nursing facility where I provide psychiatric consultation. Mr. C rarely leaves his bed, around which he insists the thin pink privacy curtains remain closed to wall off the three other men who share his room. The social worker had asked me to see Mr. C because he’s due to be discharged, and she’s been worried about him. Even the air in the room feels heavy. It’s hard to move or even breathe without hope.

Mr. C is only in his early 40’s, but diabetes has taken a part of each foot, and he can no longer work as a chef or care for his mother, who has dementia. “Now I’ve got nobody. Even when I was taking care of my mother and had a job, I could barely leave the house because of my anxiety, and I let my feet rot,” he says. “I’m afraid I’m not going to do the basic things to take care of myself. There really isn’t any hope for me.”

Like what you are reading? For more stimulating stories, thought-provoking articles and new video announcements, sign up for our monthly newsletter.

My thoughts start to churn. There is no way I can help this man. His problems are not solvable. What I have to offer is too puny, and my own background too sheltered. I even notice a small spark of anger at him rising inside me. I want to leave, to retreat to the comfort of my office and sit with thoughts unmarred by unbeautiful things.

I’ve had the luck of meeting a master of empathy, a meditation teacher I met last spring on a day of silent retreat. Attempting to focus on my breath as I sat on my cushion, my mind had erupted with grief over a recent personal loss. The pain was disorienting, concentration all but impossible. My teacher’s advice was simple: let the feelings come, notice them. Her words were ordinary, but her compassion was not. She received my sadness without flinching, letting it vibrate within her as she held my gaze and smiled with warmth and calmness. I felt my connection with her creating another dimension that allowed my sadness to find the space to take its own shape; I did not have to carry the pain alone. It opened like a quilt held between us, and I could see it for what it was and only for what it was. My pain was no longer the sign of inevitable and unending suffering; it was just a feeling I was having in that moment.

Now, as I sit with Mr. C, I gently shake myself from the trance of hopelessness and the trap of my own ego that sustains it. I can’t solve this man’s problems, but that is not shameful. His problems are severe and overcoming them will require a lot of hard work from him. He may or may not be willing to do that work. I can offer him empathy, compassion, and guidance. Those things might not be enough, but then again, they just might be. As I bring myself back to this moment at the foot of his hospital bed, I recognize that within an experience that feels like a burden is a remarkable privilege: that of being close to another human being.

“You can’t see things getting any better. You don’t have your mother to take care of anymore. You won’t have your job, and you are worried that you’ll give up fighting the anxiety. You remember how hard it used to be, and it’s going to be even harder now. That must feel utterly overwhelming, and you are probably terrified and feeling intensely hopeless. Is that right?”

He nods somberly, holding my gaze, and tells me about the spells that come down on him in the afternoons when things quiet down here at the nursing home. The feeling of tunnel vision, of unreality, of feeling almost outside of his own body.

“I have such a sense of sadness as I hear you speak about this,” I tell him. “And at the same time, I am grateful that you are sharing this with me. I admire the strength it takes to be honest about what you are facing. And I can see how believing that things are hopeless might almost feel like a kind of relief. You can stop fighting so hard.”

He almost interrupts me, showing more life than I’ve seen him show to this point, “Yes! It’s so, so hard. I hate it here, but all I want to do is curl up in this bed and hide from everything!” And for the first time, he starts to cry. As his tears fall, he asks me earnestly, “What can I do? Can you help me?”

At this moment, something shifts. He isn’t falling back into hopelessness and helplessness. He is asking me for help. In fact, I have plenty to offer him. “There are powerful tools to address your anxiety,” I tell him. And gently, keeping tabs on his level of interest, I explain how avoidance locks anxiety in place, and how exposure therapy can retrain the mind to experience anxiety differently. “If you want,” I offer, “I could show you how to systematically challenge your fears. It’s very hard work, but it could open a lot of possibilities for you. Would you want to work in that direction?”

“Yes, I’d like that,” he replies.

Hopelessness is a horrible feeling; it is no wonder we flinch from it. When we welcome it between us, it becomes all of what it is, and only what it is, and there is room for something else that looks a lot like hope.