A Unique Mental Health Conference That Supports People With DID

Stationed safely behind my exhibit table at the annual Healing Together conference in Orlando, I observed the attendees milling about the hall. Their dress ran the gamut from business attire to resort wear, to outfits that seemed like Halloween costumes. Some were dressed as children, with ribbons, sparkles, young-style dresses, and fanciful headgear. Others looked like animals of one sort or another. A few pushed carts filled with stuffies or were with emotional service dogs. The weekend-long meeting, then in its 12th year, had just begun, and people were congregating at the snack and non-alcoholic beverage bar. Watching them greet one another enthusiastically, I surmised most were returnees. It was 2022, my first year at the conference, and I knew no one. The outfits disconcerted me most. I understood that they were an expression of dissociative identity disorder (DID), formerly called multiple personality disorder—the focus of the meeting—but I had never seen such an unabashed display, even in support groups.

Inside the DID Support Network

The conference is sponsored by An Infinite Mind, a nonprofit that aims to increase awareness of and education about DID for three constituencies: people who have DID, their supporters (family and friends), and professionals (clinicians and researchers). The hope is that greater understanding of the condition will counter myths and stigma, enable people living with DID to navigate their lives and treatment more effectively, and broaden clinicians’ skills and knowledge. Most medical conferences that offer Continuing Education Units (CEUs) invite presentations from professionals only. The board of An Infinite Mind invites them from all three cohorts, believing each can learn from the others. As someone living with DID—now 82, I was misdiagnosed as schizophrenic in my 20s and didn’t learn I had DID until my 40s—I was there to give a talk about my experiences and to promote my memoir, Losing the Atmosphere.   

Having spent decades trying to hide my neurodivergence—necessary for my dual careers as a librarian and an I.T. systems analyst—I was uncomfortable the entire weekend, though I went through all the proper motions: I spoke with people who stopped at my table, sold books, and gave my talk. In the weeks following the meeting, I tried to make sense of my reaction. In a way, I was like a dog acclimated to living with humans suddenly finding itself in a field of dogs. But where an actual dog would have joyously connected with its fellow creatures, I didn’t dare mingle. Like the legendary sailors who tied themselves to the mast so they wouldn’t succumb to Lorelai’s song, I remained tethered to my exhibit table. Yet something about the meeting drew me back the following year. I was a little more relaxed then, but it wasn’t until my third year, 2024, that I felt completely at ease, able to fully absorb the power of the conference. I would later learn that my timeframe was not uncommon.

A few hours before the 2024 doors officially opened, I entered the exhibit hall with my cart of books and handouts and began looking around for a table with my name on it.  

 “Hi, Vivian! Welcome!”

I turned. “Hi, Jaime!” I said to the founder of An Infinite Mind and the mastermind behind the Healing Together conference.

“Can I give you a hug?” she asked. My hesitation must have been obvious. “An elbow bump?”

We bumped.

She inquired about my train trip from New York, then said, “I know you don’t like crowds, so I put you at the end, near the crafts corner.”

“Thanks.”

She remembered. I was pleased. My first two years were during the Covid pandemic, and I worried about getting sick.  

A pre-school special education teacher, Jaime Pollack received several misdiagnoses, including schizophrenia, before she learned, in 2005, that she had DID. Her search for information about it led her to meet other people with the condition, and, in 2007, to start a peer-led support group. She soon realized they shared similar challenges, chief among them the lack of accurate information. There was an abundance of books and journal articles for clinicians and scientists but little for people who had DID—about what it felt like, how to manage day-to-day situations, how to find appropriate treatment. Believing she could be of more help filling this void, Jaime changed focus and started An Infinite Mind. 

“This is our biggest conference ever,” she said now, pride in her voice. “Would you believe we’re 400 in person and 300 online? From 26 countries! There’s even a group here from Australia!”

“Wow!”

“And people say DID is rare!”   

As I made my way to my table, I felt an inner calm, despite being nervous about my talk the next day. I had come home.

My exhibit set up, I walked around to see what else was on display and to greet people I knew from previous years. There were a few other memoirs, various therapy practices from around the country, a short educational film about DID, workbooks to help you get in touch with your internal parts, DID-themed crafts, a DID writing program, artwork and jewelry created by people with DID, and more.

When the doors opened, the familiar Disney-like parade filled the hall, but now I saw it as a glorious celebration. At Healing Together, you didn’t have to keep your inside selves hidden if you didn’t want to. If your body was 60 but you felt 8, here you could be 8. If a part of you was nonhuman, perhaps an animal, here you could be that animal. And if you were conservatively dressed, as I was, that was OK, too.  

Yet this was a serious conference. My presentation would be one of more than 40 that weekend, a mixture of those based on lived experience and those based on science. A sampling:

  • What One Therapist Wishes She Had Known Seven Years Ago about Treating Clients Who Live with DID
  • One Body, Multiple Eating Disorders
  • Healing from Toxic Shame
  • So, You’re in a Relationship with Someone Who Dissociates. What now?
  • PTSD and DID: Physiological Adaptation in Response to Trauma.
  • When Your Therapist Is Your Whole World (This was my talk, about becoming dependent on my therapist as a step toward healing, then eventually moving on, with my therapist still important but no longer my whole world.)  

All three cohorts were welcome to attend any of the presentations. The only cohort-specific events were the optional lunchtime chat-and-chews. There were four groups:

  • People living with dissociation and dissociative identities
  • Supporters of people living with dissociation and dissociative identities
  • Therapists with dissociation and dissociative identities
  • Therapists who treat dissociation and dissociative identities   

These get-togethers took place simultaneously, so if you identified as belonging to more than one group—there are professionals and supporters who dissociate—you had to choose.

When the first Healing Together conference, held in 2011, was in its planning stages, clinicians discouraged Jaime from going through with it. Bringing together many people with DID could create an unstable situation, they said. Jaime and the board of An Infinite Mind board didn’t agree. Largely plurals themselves, they understood the issues and knew how to address them.

DID is usually caused by ongoing childhood trauma at the hands of someone the child knows well. The trauma can be physical, sexual, emotional, or spiritual. It can be neglect or unpredictable behavior on the part of a caregiver. (For me, it was a combination of physical and emotional trauma and my parents’ unpredictable behavior.)  

Some traumatized children wall off knowledge of the trauma and the feelings associated with it. The resulting lack of awareness allows them to live seemingly normal lives. The splitting is not intentional. It kicks in automatically, a kind of psychic immune system, shielding the child from emotions like pain, anger, terror, shame, and feeling betrayed that would otherwise overwhelm. The child’s internal system may have multiple splits, with each walled-off part, or alter, playing a different role in protecting her. The parts may be of varying ages and sexes; some may be aware of the others, some may not.

This dissociation serves a purpose while the trauma is still ongoing. It becomes problematic when the child grows up, moves away, and is no longer being traumatized. Dividedness is not necessary for the adult’s survival, but her alters, stuck in the past, don’t know that. They are much like the Japanese holdout soldiers who hid in the jungle, ready to fight, long after World War II ended.

The board of An Infinite Mind understood the dynamics of dissociation and switching, particularly the effect of triggers, which can “wake up” alters holding disturbing memories. This is similar to veterans with PTSD who hear a car backfire and react as if they are on the battlefield. The alter who surfaces in response to a trigger may not know what year it is or where they are. What the person with DID most needs when this happens is to become grounded. This means knowing that they are in the safe present, not the unsafe past.

Some ways to facilitate grounding are walking a labyrinth, doing crafts, journaling, and activating the five senses: taste, sight, touch, smell, and sound. The following notice appears on the first page of the 2024 Healing Together agenda:  


Throughout the conference, you can visit our calming and grounding area when you need a break. There are art activities, a quiet space, sensory items, and a walking labyrinth.

Creating a Safe Space

The conference is made into a safe space in other ways, too. The exhibit hall, presentation rooms, and grounding areas are accessible only to those who have registered. No random guest in the hotel complex can wander in. Each presenter is instructed to begin their talk by announcing that it’s OK for attendees to walk out. Confidentiality is stressed. Most presentations are recorded; a few are not, because the presenters asked that they not be. The recordings are available for several weeks after the conference ends, so people can listen to sessions they did not get to attend or re-listen to others. Attendees are on their honor not to share the recordings with anyone who was not at the conference.

One effect of the safe-space bubble is that people with DID, whether dressed conservatively or conspicuously, get a taste of what it feels like to be neurotypical. We can converse in our native language. “We flew in yesterday” is DID-speak for “I flew in yesterday.” We can mention “littles,” and it is understood we are referring to the child parts inside us. We can talk about a particular alter having “body-time,” and everyone knows it means that alter was “out,” or “fronting,” i.e., that was the alter interacting with the world at that moment.

Like Brigadoon, the mythical Scottish village that comes to life one day every 100 years, Healing Together is a place where, for one weekend a year, people with DID get to be mainstream. It’s the attendees who don’t have DID who feel “other.” More than a few people who stopped at my table felt the need to justify their presence by saying, “I don’t have DID, but my daughter does…,” or “I don’t have DID, but I’m a therapist…,” or “I don’t have DID, but I’m buying the book for…”

People living with DID have many hurdles to navigate. One is the diagnosis itself. A fair number of clinicians, believing the condition is rarer than it is, don’t recognize it when they see it—outside of this meeting, people with DID do not generally “dress up.” Someone with DID spends an average of seven years in the mental health system before receiving the correct diagnosis. (For me, it was 30 years.) In fact, DID affects between 1-1.5% of the population. For comparison, schizophrenia affects 0.25-0.64%, and autism 2.8%.   

Another hurdle is finding a therapist. DID is about creating internal silos. Therapy involves breaking down the silo walls so information and feelings, however painful, can be shared among alters. Not many therapists are experienced in doing this difficult and lengthy work. (The search for a therapist with DID expertise took me six years, bringing me into my 50s.)

Still another hurdle is stigma, in large part generated by sensational media portrayals of DID. Among many examples are the 2003 mystery/thriller Identity and the 2016 horror/thriller Split. A physician I once consulted for digestive problems changed from cordial to fearful when he found out I had DID. First, he asked me to wait outside while he made a phone call. Then his receptionist said I could go home, and the doctor would mail me his recommendations. I subsequently sent him an article about DID I had written for New York Magazine, along with a note explaining that people with DID were no more apt to commit violent crimes than anyone in the general population. He apologized by mail, saying my article taught him a lot, but I chose not to see him again.

At Healing Together, people with DID, regardless of how we are dressed, have ordinary conversations, attend meetings, and participate in Q&A sessions as if we are just regular people, which we are. By the end of the weekend, it struck me that I hardly noticed the outfits anymore. And if I closed my eyes when I was talking to someone, I wouldn’t have known whether they were a person with DID, a supporter, or a professional, unless they chose to tell me, or unless they used plural pronouns while referring to themselves.

Though I could have used the grounding area during my first two years, I was too overwhelmed by the conference to seek it out. But in 2024, when my pre-talk nervousness escalated, I made my way to the crafts table. I didn’t know what I was going to draw until I saw a flower appear on the paper that was the hallmark of six-year-old Emily, one of my alters. Feeling calmer, I made another and posted both above my table.

I wasn’t happy with my talk. My pacing was off, and I had to skip the middle and jump to the end to stay within the time frame. Ordinarily, I would have found it hard to hold my head up afterward, yet I continued to be buoyed by the conference and enjoy interacting with the attendees. It wasn’t until the train ride back to New York, with 24 hours of rolling landscape as a buffer between Healing Together and the “real” world, that I understood why.   

***

I consider myself mostly healed—I have reached the stage of “functional multiplicity,” where my DID does not interfere with my having a full and satisfying life in the non-multiple world—but I had never before experienced an environment where I didn’t feel at all different from other people. It was also an environment where, despite my talk, I felt I mattered. Several times during the weekend, people told me they heard me speak in prior years, or had read my book, or had given a copy to their therapist. A feeling common in people with DID is that we are inherently less than, or not as worthy as, “regular” people. In me, that feeling is often buried so deep I am not aware of it. But for the entire weekend, I felt easy in my body in a way I hadn’t known was possible, as if a burden I didn’t know I was carrying had been lifted. Gazing at the trees whizzing by my window, I realized the burden was shame.  

Healing Together is a space where those of us with DID can think of ourselves as having dissociative identities. Full stop. The word “disorder” has no place in the description, being inappropriate for the remarkably creative way our psyches shielded us from the effects of trauma. It is a serious meeting with a generous sprinkling of light moments. My favorite from 2024: When introducing the keynote speaker, Jaime asked attendees to raise their hands if they had dissociative identities. Many hands went up. “So, there’s actually a lot more people in this room than are in this room,” she said to laughter and applause.

I look forward to hearing her introduce the 2025 keynote. 

***



My table in the exhibit hall of the Healing Together conference




The two flowers I drew at the crafts table.  

Editor’s Note: An excerpt from Vivian Conan’s Losing the Atmosphere can be found on Psychotherapy.net. 

Spilling Over Modernity’s Borders and Boundaries: A Decolonial Story About Alzheimer’s, Family, and Migration

“¿De dónde eres?” My friend’s 9-year-old niece asked me shortly after we were introduced to each other during Christmas. This was in Bogotá last year at my high school friend’s place. She sat next to me, leaning slightly toward me. Her question seemed fueled by a kind of curiosity that two strangers at times share when wanting to rush through the unfamiliar and quickly find a common place from where to discuss matters of much greater importance, like her Christmas presents. It must have been around 15 years since my high school friend and I last knew about each other’s lives. Various life circumstances might have contributed to vanishing from each other’s lives—including living in two different countries—until whenever the day was going to come for us to meet again and pick up our friendship right from where we left off to catch up on whatever many years in between.

My eyes shot open and met her curiosity, sensing all over my body the shock of her question. Did she unwittingly render me foreign to and within my homeland? I wondered.

“Pues de aquí. De Bogotá. Rola 100%!” I said to her, stating what for me was the obvious.

“Es que hablas diferente.” She further explained.

“¿Y tu?” Le pregunté,” pretending to ignore the state of my body, and attempting to reciprocate an interest in our origins.

“De acá.” Me respondió, while organizing her Christmas presents for their exhibit.

My friend overheard our conversation. On the way to the kitchen, she provided some context to resolve her niece’s confusion and to create mine.

“Ella es de aca pero hace mucho que no vive aquí por eso habla así.” my friend explained with the tone of certainty of an irrefutable conclusion.

“Así cómo ???” I yelled in horror; but she had now gotten lost far back in the kitchen as the Christmas host.

Like many, I became well acquainted with the origin question as an immigrant, hence actual foreigner to the sociopolitical and material history of my host country, the United States (U.S.); as well as with the experiences of those who although were born in the United States are inadvertently or intentionally rendered foreign in their homeland by others. This is, when informed by discriminatory singular and monolingual principles about nationals and foreigners from a land. Having left Colombia as an adult, in the U.S. the socio, geo, and body-political history of Latin America/Abya Yala I carry, materializes not only in my accent but in my interactional manners, phenotype, epidermis, and knowledges, which intertwined with local racializing practices, continuously mark the well or ill intended curiosities of the inquirers, nationals or immigrants alike, about their assumptions about my foreign origins. Regardless of their intent, in foreign soil, I share my origins with my chest filled with air, trying out a new sense of pride in the diaspora evoked by its nostalgia, not quite reaching patriotism but maybe darn close to it, if I were to speculate on what incarnated patriotism would be like:

“From Colombia.” I usually respond to that question and sometimes I point at my wrist when I wear its colors.

Re-entering: From Here and From There Migration Experience

During the last couple of years, I have been spending more and more time in Bogotá than I ever have since the early 2000’s when I left. My mother’s health and increasing loss of memory called for it. Although no doctor would diagnose her with Alzheimer’s in her late 80s, that was the family’s narrative about that part of my mom’s life and our relationship with her still to this day. Her four daughters were no longer living in Colombia. My three sisters and I migrated to the U.S. at different times during our adult lives, for different reasons that required no explanation. Mom and dad raised us during the Colombian armed conflict, intensified by the international drug war and the U.S. intervention.

In a country living and enduring the ongoing wounds of war, poverty, and state neglect, as it is the case for many countries living through long-standing conflicts around the world, as I recalled, for many Colombians across various socio-political circumstances, since birth, the idea of leaving Colombia becomes part of what it means to live in Colombia, aspiring for refuge elsewhere. Violence humiliates the homeland and elevates the non-realizable promises of foreign land. Those of us who realized the idea of leaving Colombia represent the 6% of the population who currently live outside of the country—primarily in the U.S., Spain, and Venezuela. According to the Migration Policy Institute, Colombians are the largest group of South American immigrants in the U.S., representing 2% of U.S. immigrants. Colombian migration to the U.S. has increased three times as fast, from 144,000 Colombians in 1980 to 855,000 in 2022.

During our lives in the U.S., mom would come to visit for various periods of time, visiting with each one of us across states. My dad traveled once, which was more than enough contact with U.S. soil for him, given his politics. We would stay in contact through daily emails or texts, otherwise. Also, from time to time, I would travel to Bogotá for a long weekend or so for a visit. Before migrating, and all throughout the Covid pandemic, my oldest sister lived with and cared for mom in Bogotá until the impending heart-wrenching decision finally came knocking at the door to meet the four of us face to face.

The emotional intensity, and dedicated care my sister and her children had been providing mom with for the last few years had proven to be no longer sustainable for either of them. Con cabeza fría, we had to make the overdue decision, even against mom’s wishes that she no longer remembered. Mom needed to be relocated to a specialized nursing home for her proper care. She had outlived friends and close relatives. My father died back in 2008, and we heard that mom’s last living sibling, the oldest, Alberto, was still alive but bedridden in deteriorating health conditions. He died not too long after mom moved to the nursing facility.

My relatively advantageous immigrant conditions afforded me alternatives that only so many immigrants in the U.S. have in similar circumstances, with aging parents still living back in our home-countries. I began traveling to Bogotá regularly during the last year before mom died, spending months at a time with her while working remotely. My sisters would visit when able. Daily, morning and afternoon, raining or not, I would walk back and forth to visit mom at the nursing place in the north area of Bogotá from the small place nearby I rented during my stays. I would pick up on my way some kind of dessert for my mom’s sweet tooth that memory loss had forgotten to forget. I became very well acquainted with mom’s co-living folks and their visiting families; and also the nurses, aids, physical therapists, and cooking and cleaning staff, majority women, to the extent that exceptions for their visiting hours became the new visiting hours. It was through their lives—the only people I had close contact with at that point in Bogotá—that I re-entered a sense of living a life in Bogotá, although still having more than one foot in my immigrant life in the U.S., to which I remained virtually connected through a laptop.

Through life at the nursing home, I reintegrated myself to the familiar tensions of the Colombia Nation-State’ s sociopolitical heartbeat, revealing along the signs of the 24 years that have passed and have transformed both the country and my politics in the diaspora. The tensions were palpable. On the one hand, the advantageous circumstances of the families who could afford their relatives to live there were visible. And, on the other, so were the injurious sociopolitical conditions and longstanding neglect by the Nation-State toward the lives of the people working there. Although responsible for the care of the facility’s residents, they had to do so while undergoing living conditions that seemed to cry out in state neglect. This was one of the other jobs they needed for their survival and the survival of their family.

Some of their children were being educated under precarious conditions in public schools. Evictions from their home were more tangible month after month. The impeccable makeup of some of the women working in the kitchen kept hidden the marks of patriarchy’s hands from the night before, some of which was documented in futile police reports as well as in her self-defense fingernails imprinted on his skin. Their clothes served as curtains behind which their bruised bodies were concealed, while their bones would heal from their forceful impact against the wall, or the push down the stairs. Their children were their witnesses. According to the Colombian newspaper, El Pais, between May of 2023 and 2024, 149.017 family violence incidents and 630 femicides were reported in the country. Limping, the women would arrive on time at the nursing home after a 3-hours-long commute from the south of Bogotá to care for my mom with the best of dispositions possible. Story after story, the nostalgic Nation-State Colombia of the diaspora that I was so proudly holding tight to, wearing it on my wrist, and expanding my chest, started to melt throughout my body, transpiring through my skin, forming a polluted stream of outrage that took off running through la Avenida 19, running all the red lights, turning toward la Autopista Norte, eventually merging with Bogotá River, considered one of the most contaminated rivers in the world, according to WSP.

My relationship with mom that year was not exempt from a sort of re-entering experience. It was similar to how my re-entering to a life in Bogotá was. On occasion, mom would seem as if she could see in my face sort of a familial resemblance but not quite family. I was beginning to feel that way about everyday life in Bogotá although not linked to a matter of memory but migration. I recognized aspects of what I remembered was my homeland out of the unrecognizable features of the obvious changes since I left. I was able to discern some things but not others with my renewed borderland eyes as a Colombiana inmigrante en the U.S.

My life from when I lived in Colombia during the late 1900s met with my life as an immigrant living in the U.S. since the beginning of the 2000s only to discover they had already met over two decades ago and have become inseparable since. My memories from Colombia were never left behind. On the contrary, they carried me through the making of a new life in a new land. After all, we can’t separate ourselves from the history that makes us. I have been living both lives simultaneously, through a multiplicity unfolding either in Colombia or the U.S.

A sense of foreignness within the familiar, and a sense of familiarity within the foreign helped me discern the experience of dwelling in the borderlands, which my friend and her niece also brought out in the open during Christmas, when I reconnected with them months after mom died on March 29, 2023. The borderlands became a point for reflection on what it was bringing forth—difference—to ultimately transcend modernity’s definition of difference as fracturing borders or boundaries since the conquest of the Americas—the colonial difference. Walter Mignolo has written extensively on this topic.

The colonial difference refers to a hierarchy of separation (for control purposes) through the development of borders or boundaries that create races, cultures, Nation-States, identities, languages, genders, etc. Modernity’s colonial difference fractures the bones of the communal into hierarchical separate pieces whereby those lower in the hierarchy can be thrown down the stairs or against the walls of separation that it created. Thus, my friend nieces’ question about my origins, became a recognition of difference stemming from my 24 years in the diaspora crawling up my Colombian accent to renew it within a sense of plurality. My renewed accent marks a difference that does not have to be of borders, exclusion, fracture, or separation, but of relationality and connection out of what it means to live relationally, or in more than one world simultaneously.

I have heard many stories, mostly from Mexican, Chicanxs, Mexican-American, or Texanes, about their experiences when returning to their homelands in the Nation-State of México. They shared being made to feel that they do not belong on either side of the border: “not from here, not from there,” “ni de aquí, ni de allá [neither from here nor there].” I understand this to be a symptom of modernity’s logic of criminalization by difference and punishment when crossing the border. Anything that does not represent nationalism on either side of the border, thus promotes monolinguality, monoculturality, or singularity, is destitute and criminalized. On the contrary, from the borderlands of my experience, I am thinking about immigration interrogating the borders while being interrogated; thus, opening at the same time possibilities to rethink the fracturing premise of separation modernity promotes into being “from here AND from there, simultaneously, thus relationally.” This revised premise eases my body when facing the origin question by Colombians in Colombia.

Rendering the Familiar Unfamiliar: Radical Listening

More often than not, mom did not know exactly who I was, or when and where we may have met at some point in our lives. Only a couple of times, she recognized me as her youngest daughter, “marce,” as she used to call me. Although she never forgot her name, Gloria, she did not know where she was nor recognized her own image in the mirror. Sometimes I was her youngest sister, and other times, she would address me as her nurse or aid. When I would rub her hands, the touch would call her to reposition her hands and to start giving me instructions on how she wanted her nails done that day. When I would pass my fingers through her hair, sometimes she would address me as her hairdresser, or quite firmly in a tone I did not recognize, she would push my hand away demanding that I do not touch and mess her hair.

As much as mom did not remember that I was her daughter, I did not always fully recognize mom in the body and interactions of the 89-year-old woman living in the nursing home—except during her brief inconfundibles momentos [unmistakable moments] of humor here and there. This was not surprising to me, having learned about similar yet different stories from folks from various backgrounds with parents living with Alzheimer’s or dementia, not only in my therapy work. My family was now living through those stories but creating our own. Our story is also likely to be my story about possibly inheriting from mom a life with Alzheimer’s yet to manifest, at least as far as my memory can tell thus far.

Although not surprising, witnessing mom’s increasing experiences of discomfort, suffering, and loss of conversational abilities was at times hard. Yet, unexpectedly, under such unfortunate circumstances, not being remembered by mom at times opened alternative relational possibilities. But it required radical listening to recognize these as possibilities and through the rather overwhelming presence of Alzheimer’s. I have learned radical listening from various perspectives that I carried with me every day to the nursing home during my visits. These include perspectives on borders, memory, history, and aesthetics shaped by my lived experiences as a bilingual immigrant, my understanding of Narrative Therapy in English as a family therapist, and mostly by my engagement with the decolonial project from Abya Yala y el Caribe in Spanish and Spanglish as a member of the civil political society. These are perspectives that have shaped not only my family therapy work but my life as I write here.

Cognitively speaking, Alzheimer’s configured mom and I as strangers, no longer family. We became foreigners to one another. Most interestingly, however, it rendered us foreigners to modernity’s concept of the family. As an immigrant, working and living in community with immigrants in the U.S., questioning, revising, expanding, or delinking from the westernized idea of family has not been uncommon. Migration is a context for the necessary renegotiation of our ties and kinships within the context of voluntary or involuntary separation, and deportation. For example, during the current administration in the Nation-State of the U.S., during the last four years, nearly 4.4 million people have been deported to more than 170 countries according to the Migration Policy Institute.

Mom and I became foreigners to the western idea of the family settled and promoted in Colombia, and many other parts of the world, through Catholicism, heteronormativity, patriarchy, capitalism, and their institutionalization of relationships. As one of mom’s four non-adopted or non-in vitro children, our half a century-long enfleshed relationship was governed in great part by humanized fracturing assumptions of reproduction, motherhood, productivity, and gendered relationships founded on who gave birth and who was birthed to constitute a family. Thus, oddly, Alzheimer’s liberated us, not from accountability for all the headaches I caused mom over the years, rather, from thinking ourselves, and listening to each other, through the institutionalization of boundary-based relationships, its imposed social expectations, and Nation-State’s laws whereby the western family has been instituted as some sort of a social mandate. If I were to take a guess, these sort of institutionalized human laws and western concept of the family might be the sort of conundrums that would make la Pachamama, Madre Tierra, shake the earth. Mom’s forgotten aspirations for my life and my sisters’, which included growing up to become Colombian mothers, with good husbands, and decent, healthy, economically independent (from men), and hard-working women, were no longer shaping our relationship.

Deinstitutionalized by the unfortunate circumstances of Alzheimer’s, thus no longer being a Colombian mother and a Colombian daughter in the modern sense, we learned each other and cared for each other otherwise, sometimes minute by minute. The fracturing logic of the family boundaries planted by modernity was removed. Thus, I understood care to be instead about honoring the relationship with the person I owed my existence to in so many ways in addition to giving birth to me. As a family therapist, I am attentive to what the global and western concept of family imposes on relationships in an exploration of what sort of relationships are possible otherwise or in addition to.

My relationship with mom was unpredictable and in constant movement. It was to be discovered by dwelling in the moment of its expression. We had to discover who we were, a cada momento (every moment), according to the memories invoked and received as they came, no matter what. Was I the hairdresser, the woman who does her nails, her sister, one of my sisters, her nurse, or any other character out of my mom’s history? I could not arrive at the nursing home with certainty of who I was, but with clarity of where my existence—and my sisters’— came from. I became someone only through the act of being with mom and our memories, some of which we invoked together.

We connected through the ever-changing moment of the circumstances that brought to life some of the memories of what we were made of. The circumstances I am referring to were for the most part sensorial. The senses evoked sparkles of memories, interconnected with other memories, both hers and mine. The taste of the daily desserts, my touch, the temperature of my hand over hers, the boleros we listened to, the noise from the novelas on the TV we stared at, pictures of her younger life, the colors and textures of my clothes, my gray hairs, the co-living folks’ speech or appearance, the birds’ colors and their singing having Bogotá’s traffic as their symphony far in the background, as well as the colors of the flowers around us when we sat outside in the garden evoked memories intertwined. Those memories that have shaped, among other things, our half a century relationship, not only formed our lives but who we were to become moment by moment. I realized I was mom’s sister, por ejemplo, only in the brief moment that she saw me as her sister. Undoubtedly, we were radical historical and relational beings.

I can’t help to think about how social relationships, including relationships within the context of westernized therapy look like when we are to arrive at the encounter with someone else not with certainty (or doubt of) of who we are as therapists but with clarity about where we come from—as historical beings. This shifts away from the mainstream conceptualization of the therapist as an empty (no history) interventionist, solely performing according to the regulations of the institution and professional Eurocentric theories to be good or effective therapists. As historical therapists, instead, we become available to engage and receive the encounter with another, attending carefully to our histories, intentionalities and how we are shaped by the experience of the encounter. Thus, similar to who I became when visiting mom, who is the therapist is not independent from the encounter with who consults. The therapist becomes a therapist in the encounter with the person who is consulting. This shift requires an initiative to des-institutionalize the therapist, and to foreignize westernized therapy perspectives that situate an ahistorical therapist.

The Sensorial Grammar and Temporality of Memories

As mom’s cognitive abilities continued to deteriorate, it seemed as if for those of us around her, her presence in this world began to disintegrate into oblivion. She was talked about, no longer engaged with, her body moved from one place to the other, and words were put in her mouth, at times necessarily. Her existence was for the most part reduced only to her possibilities, or lack thereof in her present, in the here and now. Although her body was present, the growing absence of thought, reason, and the ability to access frameworks of intelligibility to express ideas in the present moment seemed to cast doubt on her very existence. Hence, if we were to recognize mom’s existence and vivid presence in this world, it required us—decolonially speaking —to overcome modernity’s spatial (here), temporal (now), universal assumptions. It also meant to cast doubt on the overemphasis on cognitive function, (capitalist) productivity, modern storytelling (or framework of intelligibility), and conversational skills as the only ways of being or existing. Then, it became more possible for me to continue to relate to mom, to learn from her, and to be transformed with her.

I came to understand that the sensorial had become the grammar of our communication, through memories. Mom’s life was unfolding through her bits of memories that situated us in their respective temporalities. Although evoked in the present, mom’s slivers of memories were transgressing modernity’s contemporary framework, its universalized linearity—past, present, and its spatial metaphysics that places the present as the monopoly for the principles of what is real and represented as real. She brought me into her life to take part in events that were happening before I was even born. When some of the aides or co-living folks would overhear our conversations at the nursing home, however, it was not uncommon that they would mistakenly “correct” mom’s temporality when instructing her about their (modern) sense of time—the time most of us operate under. They would persist in telling mom what year, place, and person she was, alluding to the calendar present even though it did not match the temporality of her memories. I could see in mom’s face deep concern and confusion by their efforts. She was in complete disbelief and shocked by how wrong and confused they were.

“What are they saying?” She would ask me.

Thus, even as an unborn person, unquestionably I was mom’s companion through the pieces of her history from a time that for folks in the nursing home and in the majority of the Eurocentrically educated world, was not chronologically feasible. Both of us experienced those brief moments often to resolve whatever concerns she may have had, at times involving her parents and siblings—my grandparents, aunts and uncles, all biologically dead—and her childhood home in La Candelaria, in Bogotá’s historic downtown. She worried if we had locked the house after we left, or if we had brought the keys with us, if we had enough time to eat dessert and get home in time before her younger sister, Estella, would get there, or Alberto, her oldest sibling, would pick us up. It seemed as though the sensorial grammar of our communication implicated mom’s entanglement with what decolonial theorist Rolando Vázquez calls a relational idea of time and space that doesn’t have either a geometrical, chronological, linear, or circular understanding of time like modernity marks reality.

I got a sense of the temporality of mom’s memories not by asking mom her age, since she no longer had reference to that kind of time-thinking. Modernity’s temporality—defined by calendar date, clock time, age, or generations—were not determinants for tracking her stories or a reference to time. Instead, it was the people who featured in that memory and its setting that gave me a reference to the time of the events, making them feasible. Her experience in the present was happening through her history—that is, through her memories from a time when her parents were alive, she was living in la casa de La Candelaria with her siblings, and I had not been born. Hence, there were no westernized life span or human developmental theories that would serve as frameworks to interpret her experiences.

Instead, the vegan cheesecake de maracuyá of La Despensa, the bakery around the corner of my rental, would bring to the surface memories that contained mom’s lived experiences with their own temporalities in no specific order. Events would unfold through particular relationships and their settings. Her memories jumped from one moment to the other according to what the cheesecake called for, and I jumped along. Following her memories was more helpful than listening to them from assumed theories of time, stories, and development. I would say, decolonially speaking, that relational time re-dignified mom’s existence that modernity’s capabilities of erasure through its overinflation of cognition, the contemporary idea of time, and the metaphysics of presence had rendered it suspicious. For modernity, Alzheimer’s had placed mom in an evacuated present time—with no history. She was seen as living in an empty time like Walter Benjamin’s because all that counted as a measurable reality was no longer mom’s reality. Thus, on the contrary, from de-modernity, I would say that by radical listening to the plurality of mom’s lived experiences in their own terms that modernity destitutes through erasure, the senses restituted.

Sensorial Invocation

One of the settings or temporal references that would come up quite a bit in mom’s memories was the colonial casa de La Candelaria of my grandparents. It was the house where mom and her siblings were born and raised until she married dad. This was also the house that kept many explanations of the scars still visible in my body—head, knees, and face by roller skating throughout the house from one patio to the other, running up and down, and playing with my sisters on the swing set by the large fig tree in the back patio still standing. Every weekend mom would take us to visit our grandparents. The house was finally sold to an Italian man much later after my grandparents died. He renovated it into a hotel, maintaining its colonial architecture.

Late afternoon on Sundays when Bogotá’s traffic would be more bearable, I would drive mom from the nursing home to la casa de La Candelaria. The first time we got there I was dying of anticipation for the memories and experiences we were about to live together and for what I was going to learn about mom’s history once she would see the house and the colonial neighborhood. I was hoping that seeing the material presence of the house we have visited several times, through her memories, imaginatively, from the nursing home, would call upon a flood of pieces of memories here and there, unleashed from Alzheimer’s and running loose through La Candelaria’s narrow streets, passing through la Catedral Primada were she married dad, right across from the presidential residence, el Palacio de Nariño.

Overjoyed, I would yell out calling and pointing out various landmarks of our shared history through the neighborhood. I had not been there in years! It was extraordinary to be back. To my surprise and quite a bit of disappointment, my persistence in calling upon mom’s memories was futile. The house we had been at through the memories evoked and configured from the sensorial grammar of our relationship was not the material house of la casa de la Calle 11 con 2nda in the year 2023, nor its representation. It existed in a different temporality.

Over a year after mom died, cousins on my dad’s side, my sisters, and I were finally able to arrange a time to meet in Bogotá and drive to my dad’s family farm in Sasaima, one hour away with no traffic, to bury mom’s ashes. She is buried next to my dad’s, my paternal aunt’s, and paternal cousin’s ashes. They are overlooking the mesmerizing landscape of the Andes mountains, surrounded by the farm’s variety of lush vegetation that my dad had a deep connection to. The scars on my body that la Casa de la Candelaria could not explain, the farm in Sasaima could from rolling down the hills, swimming, and barbecuing with my sisters and cousins during the various trips with dad’s family growing up. Unlike the scars of the women working at the nursing home, these were privileged scars of a life from the minority in Colombia also living in the midst of Colombia’s armed conflict. Privileged and all, even so, neither la casa de La Candelaria nor the farm in Sasaima were exempt from becoming sites for violence where kidnappings took place of an aunt and cousins on both sides of the family while I was still living in Colombia.

During our day or weekend trips to the farm growing up, at lunchtime the family would get together and sit around the large dining table to eat what the land offered–herbs, vegetables, and fruits among other foods. We were always served delicious vegetable soup with cilantro. In the diaspora, I have experienced being at that table and sipping soup with cilantro millions of times. Cilantro calls on that memory. In a split of a second, cilantro opens the door for me to enter into that moment although I am on U.S. soil. It brings me to the sensing of the taste of food, the light coming from the wood windows, the touch on my skin of Sasaima’s humidity in the mid 70’s, and the crackling sound of the straw woven mats. I can’t recreate that experience otherwise. I’ve tried. I can see static images but can’t experience the sensation of being there that cilantro brings to life.

Returning to the farm in 2024, I was amazed by being at the same table, eating the food of the land, and soup with cilantro. I couldn’t believe it. It did not take me too long to realize though that it was a different “coming back,” it did not feel the same as the experience of the memory from the diaspora. It was as if the memory linked to cilantro existed in a life with a different temporality, in a parallel reality, yet intimately connected to the material farm. Just like mom’s experience of driving by la casa de La Candelaria in 2023, the vividly sensed farm within my connection to cilantro also belongs to a reality that was embedded in a different temporality, and therefore a different relationality. It is a place I can no longer drive to on my own—no matter the traffic or the day —but I can taste my way to it.

In connection to a decolonial premise, I would say that la casa and the farm exist in memories that do not subscribe to an understanding of modernity’s contemporary, its linear temporality, and notion of reality as presence. Although I would say that our memories surfaced in the present as expressions from a relational time, relationally, not always on our own volition, but under certain circumstances, such as sensorial. According to Vázquez, these memories, like all our memories, live in a plurality that is always moving. Hence, memories are not chained to a particular date or someone’s age in a dead or static past, for example. In that sense, these memories are not representations of the material in the present—mom lived certain moments of her day at La Casa de la Candelaria while being at the nursing home, but could not recognize the material house on Sundays when we drove by.

Our lived experiences live in our memories and grow their own heartbeats, giving us life. We are made of memories, collective memories, with their own lives, sensings, and times. Our existence comes from those memories. Thus, it might be more suitable to say that memories are beside us. They are not deep in history but wide in history, next to us or in front of us, accompanying us, guiding us, and constituting our lives, even though they do not always show up in the present, unless relationally and sensorially called upon.

Like my memories, mom’s seemed to be interacting with other memories, perhaps being that the reason why it was possible for me to join her in a moment in her life when although I had not been born, memories of my aunt, uncles, grandparents and the house better helped me to be there for her and with her. Therefore, although mom’s ability to recall events that took place in the nursing home that morning, an hour ago, or last week kept dwindling, her memories interconnected to mine and our senses kept alive aspects of what she had lived, shaping how she lived, and continue to live through us, her four daughters’ memories and the memories of all she had contact with, perhaps even before she was born.

Her existence spilled over modernity’s placed boundaries of her skin to re-exist via her relational memories in a relational time that has kept her alive after her biological death. Mom got to re-exist, inadvertently putting doubt to and rendering suspicious for me modernity’s persuasive cognitive driven and over inflated perspectives that previously rendered mom’s life doubtful and suspicious, when her life was reduced to be only cognitively spoken about.

Re-existence: Restitution by De-institutionalization

After getting over my disappointment from my mom’s unexpected response to La Candelaria, I chuckled a bit and rolled my eyes while driving back to the nursing home before it got dark. “Really?” I thought. Although I had been experiencing and learning from the ongoing and uncertain movement of my relationship with mom, and attentive to what the unpredictability that each bit of memory would offer to us, my over-a-decade of experiences as a therapist, academic, and researcher—Eurocentrically trained—couldn’t help it but to show up.

I realized that I had begun to identify a pattern of response from mom to “study it” and identify its conditions or context. I tried to generalize it by manufacturing similar conditions for the sustainability of the pattern of response. I wanted to replicate it. In doing so, I was attempting to manipulate mom’s response at my will by driving her to la casa. Ugh! I was guided by my own assumption and best intentions to create a “happy” moment for mom. I am fairly confident in saying that this is somewhat similar to modernity’s logic of knowledge production in therapy.

Based on the therapeutic model’s theory of change—or what the therapist believes (based on research) makes people “happy” (well, stable, healthy, or problem free etc.), interventions are identified with expected outcomes (via research or clinical case examples) to be replicated (mostly to a homogenous population). Such interventions are technified or manualized for easier distribution, consumption, and implementation for others to use with the persuasive generalized promise of delivering an outcome of change to help a-historical people. I am afraid that by doing so, I was imposing a boundary between the subject (investigator) and object (mom) to arrogantly identify sensorial tools for change, to technify and manualize our relationship based on modernity’s arrogance to self-define what is good for others.

Very gladly so, unintentionally perhaps, mom sort of delivered a candid middle finger—not the first nor the second in her life—at my attempts at technifying our relationship. I received her delivery happily. I had re-institutionalized our relationship, losing sight of the possibilities that come from the borderlands, memories and their sensorial grammar, relational time, and defamiliarization from modernity’s logic of erasure.

Mom’s implicit middle finger reconnected me to our lived experiences to sense more clearly what institutional practices do and fracture, like the institutionalization of the land, bodies, relationships, healing, and histories. Thus better discerning deep connections—being from here AND from there—to my home-land, in various relational times, my languages, and relationships with the people I owe my existence to, the food the land offers, the Andes where my parents ashes are spread, la casa and the farm along with their explaining histories, the Bogotá altitude, the strangers in the street, the acquaintances of the bakery around the corner, and the long-time friends and the people they owe their existence to. These are the sort of experiences that contribute to de-institutionalizing my work as a therapist and training therapists, to begin conceptualizing our work first and foremost from the histories that make us.

Author’s Note: I want to thank Jill Freedman & Gene Combs at the Evanston Family Therapy Center and their 2024 training cohort for listening to my reading of an earlier version of this story, which helped me revise it. 

Legendary Psychotherapists Share Their Secrets to Longevity

The Pioneers of Psychotherapy Lived Long, Productive Lives

Several years ago, I authored three books and a string of articles featuring contributions and interviews with some of the greatest therapists in the world. At the time, I searched for commonalities that might be relevant. Recently, I revisited those commonalities and noticed one factor, seemingly unrelated to the psychotherapeutic process, that stood out: advanced longevity. This subject seems to be of increasing interest today.

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By examining the experts featured in my books and articles, and adding a few more world-class therapists to the mix, I reached a striking conclusion. Simply put, many of these professionals enjoyed or continue to enjoy extremely long and productive lives. Here are some examples:

  • Albert Ellis lived to be 93 and completed his interview with me at age 89.
  • The father of CBT, Aaron T. Beck, made it to 100.
  • Muriel James, who penned the transactional analysis and gestalt classic Born to Win, lived to 101. For context, only 0.027% of Americans reach 100. Muriel was 86 at the time of our interview.
  • Ray Corsini, editor of Current Psychotherapies and one of the top psychologists of the last 150 years, was 94 when he passed away.
  • Suicide and thanatology expert Ed Schneidman lived to 91. Did you know Edwin Shneidman coined the term “suicidology”?
  • Career counseling guru Richard Nelson Bolles, author of What Color is Your Parachute? the best-selling career choice book of all time, lived to 90.
  • William Glasser, the father of reality therapy with choice theory, died at 89.
  • Viktor Frankl, the creator of logotherapy and a Holocaust survivor, lived to 92.
  • Robert Firestone, the father of voice therapy, was 94 and still active as I wrote this blog, but sadly passed away prior to its publication.
  • Irvin Yalom, an expert in group therapy, humanistic therapy, and death and dying, is 93.  

The Masters Share their Secrets to Longevity

If this phenomenon is the norm, what is responsible? Just what constitutes the magic bullet? Is helping others beneficial for the helper? Is listening and empathy advantageous to human physiology? Is it frequent sitting? (Certainly not according to any expert I have ever heard!) Is it getting up from the therapy chair, simulating an air-squat repetition performed at the beginning and end of each 50-minute hour fountain of youth? Have therapists stumbled onto their own brand of interval training? Could the benefits come from the intellectual stimulation from thinking and analyzing client behaviors?

When I asked Ellis about his secret to remarkable longevity, I jokingly asked if he had the water at his institute spiked with vitamin E or something. I inquired if he was into herbs or cranking out crunches while his clients shared their tales of woe. Was it the REBT thinking that kept him youthful?

Ellis shared that he had good heredity. His mother and her whole family lived into their nineties. His dad lived until age 80 and was one of the earliest to die in his family. Ellis insisted he didn’t use anything special, just worked on his emotional problems and avoided upsetting himself about things. He added that learning new things, helping people, and engaging with music kept him going.

But could the secret lie outside the therapy sessions? Or to put it a different way, could the answer be found in what therapists do when they are not actively engaged in the practice of psychotherapy or after the point in their career where they are no longer seeing clients?

Consider my exchange with Muriel James a while after our interview; when I inquired about whether she was still doing individual and group therapy, she told me she had branched out.

“What do you mean, branched out?” I asked.

She explained that she would get up early surrounded by a cup of java and about 50 history books. (Did she say 50 books? Yes, Howard, she said 50!)

She had discovered, at least at the time, that female history authors were discriminated against and therefore she was writing the texts using a male pseudonym. Talk about practicing what you preach. In my mind Muriel was using Born to Win self-therapy 2.0.

Yes, some luminaries in our field left us too soon, and for the 1000th time, correlation is not causation, but this phenomenon is certainly something to ponder. Just ask any therapist!

Questions for Reflection and Discussion

What are your impressions of the author’s connection between success and longevity?

How do you stay focused and sharp as you age in your clinical career?

Which one of these elder statespeople do you admire and why?  

Michelle Jurkiewicz on Gender-Affirming Psychotherapy with Children, Teens and Families

Lawrence Rubin: Thanks so much for joining me today, Michelle. You are a psychotherapist in private practice in Berkeley, where, among other things, you specialize in gender-affirming mental healthcare for children, teens, and their families. Did I get that right? 
Michelle Jurkiewicz: Yes, you did.
LR:
we have the gender affirmative model, and then we have gender-affirming care
What exactly is your gender-affirming model as applied to clinical work with kids and teenagers? What does that mean?
MJ: We have the gender affirmative model, and then we have gender-affirming care. The gender affirmative model is a way of thinking about and understanding gender diversity, which applies to everyone. It’s based on the premise that gender diversity is a normal and healthy human variation, that people have the right to live in the gender that feels most true to them, without criticism and discrimination. And it’s also based on the idea that there’s not a preferred outcome in terms of a young person’s gender, whether that’s transgender or cisgender. There’s not one that’s preferred.

Gender-affirming Mental Health Care with Children and Teens

LR: And you said that’s different than gender-affirming care.
MJ: Gender-affirming care is informed by the gender affirmative model. When we talk about gender-affirming care, especially when you hear about it in the media, it’s often referring to medical care. But gender-affirming care often takes place amongst an interdisciplinary team.

So, if you’re talking about puberty blockers and gender-affirming hormone treatment, then that is something that even as a psychotherapist, you would be working in conjunction with an endocrinologist or pediatrician, likely a social worker. There are various members of the team.

The main way the gender affirmative model works with children and teens is the way that the therapists themselves are holding the space for a child to be able to explore who they are and be who they are, as well as increase what we call gender literacy. In the most basic sense, gender literacy is increasing an understanding of the sociocultural norms of gender roles and stereotypes, and what potential consequences there are if you step outside of those boxes.

We want children to be able to be themselves and explore who they are while also—in age-appropriate ways—making sure that they understand the world that they live in and that not everyone necessarily understands gender diversity.   

LR:
the main way the gender affirmative model works with children and teens is the way that the therapists themselves are holding the space for a child to be able to explore who they are
What is your particular role in that network of professionals that converge in working with a kid or a family around gender and gender transition?
MJ: There’s not as much need to be in contact with young children before puberty unless there’s something else going on. Then, of course, like any child, we would be in touch with pediatricians and other relevant professionals.

But when a child enters puberty, and there is the question or desire for puberty blockers or later for gender-affirming hormone treatment, the gender centers require an assessment from a mental health provider, which they take into consideration. It’s one piece of the whole picture of whether this is the right thing for the child. The psychotherapist’s job in those instances is to share your thoughts about whether, in your professional opinion, that is the best next step for this child and family.   

LR: So, they will take your input, based on your observation and your work with the child and family, into consideration before the team decides, although I imagine it’s ultimately—hierarchically—it is the physician who makes the decision.
MJ: Well, the parents ultimately, but yes.
LR: Is this evaluative process with pre-pubertal clients what you refer to as your holistic evaluation?
MJ: We typically think of the holistic evaluation even prior to that. But in terms of specifically with pubertal kids who are seeking gender-affirming medical care, we’re referring to taking everything that we possibly can into consideration. And that means that we work very closely with parents as well.

So, we’re looking at all aspects of their history. We’re looking at how parents feel about it because it’s important that if this goes forward, we have the parents’ full support.   

LR: While we’ll chat about the family a bit later, I would imagine at this juncture that dealing with parental ambivalence would be an important part of that holistic evaluation.
MJ: I think oftentimes, parental ambivalence is addressed and worked with even prior to this evaluation. 
LR:
the gender affirmative model does not advocate for specific psychological testing
I would hope so. For those psychometrically driven clinicians out there, are there specific inventories or questionnaires, psychological tests, so to speak, that would be part of an evaluation?
MJ: The gender affirmative model does not advocate for specific psychological testing. Prior to the gender affirmative model, the child had to undergo a whole battery of psychological tests. We don’t do that anymore.

There are various screeners and batteries, and things like that that some clinicians use to help them get a child’s gender into focus. I personally am not using those so much because I feel like I’m well-trained and I have a lot of experience, and that, through my conversations with children and their families, I get a very good picture and don't need those batteries.

I will say, though, that I am an advocate for more research in that area. I think there are some people that are working on a more standardized evaluation process, of course. But I have not found that useful in my own work.   

LR: I guess when you’re talking about gender-affirming care, you are already outside of standardized notions. You’re already considering not just the psychological makeup of the child, but the whole ecosystem. To then try to empower some instruments to carry the burden of decision making almost seems antithetical. 
MJ: I agree. I think the tension is around insurance companies.
LR: And then there’s the issue of liability. If the clinician is going to be called into court, psychometrics may be desired, or even demanded. In the course of your typical evaluation, what are you looking for historically, developmentally, in a teenager? In other words, what are some of the markers you are looking for that give you a sense that this child has always been on this path?
MJ: That’s a good question because I think what we’re seeing is shifting, and it used to be that the kids that we were working with came out when they were very tiny, and they maintained that identity until puberty, and then they accessed gender-affirming medical care.

I think now we’re seeing more and more kids come out later, in which case, when we’re looking at their history, we’re not necessarily looking for stereotypes, such as they played with stereotypical toys of the other gender, or they wore clothes of the other gender—although we do gather that information, but it’s not a required piece of their history.

If we’re going to introduce gender-affirming medical care, we’re looking for some sort of sense that this has been a consistent and persistent identity, especially once we’re talking about gender-affirming hormones. Because puberty blockers have not been shown to have long term adverse effects once they’re stopped, that could happen potentially more quickly if a child is in a lot of distress and puberty is right then and there. But that doesn’t mean then that that child would necessarily go on to gender-affirming hormones.

We are looking for some sort of consistency in their identities. We’re developing this pathway in conjunction with medical providers, which requires that the child is, at the same time, learning about the risks and benefits in a developmentally appropriate way. In some ways this is asking them to take on something we don’t typically ask of cisgender kids in terms of their medical care, but it does mean that a lot of times these kids know a lot.   

LR:
if we’re going to introduce gender-affirming medical care, we’re looking for some sort of sense that this has been a consistent and persistent identity, especially once we’re talking about gender-affirming hormones
They’re informed.
MJ: They’re very informed, and that’s a necessary piece of the process.
LR: Why does WPATH (World Professional Association for Transgender Health) recommend that while evaluating these kids, you look for, if not rule out, autism spectrum disorder? What's the link that they think must be examined there?
MJ: If a child is on the spectrum, it does not disqualify them from gender-affirming care. However, what WPATH is addressing, and what I’ve seen in my own practice, is that there is a huge correlation between gender diversity and being on the autism spectrum. The most recent statistic I’ve heard is that about 10 to 12% of gender diverse children are also on the spectrum. That’s huge compared to the regular population of kids.
LR: As a clinician, and perhaps intuitively, what do you think the connection is?
MJ: I don’t know, but my best guess, and the way I think about it as of this moment, is that a necessary piece of being diagnosed on the spectrum has to do with social differences, the way that one reads cues, the way that one responds to others and interacts with others. And so, I wonder if children who are on the spectrum feel less inhibited by social norms around gender, so they have naturally more freed up space to take it up. 
LR: Do you have to sort of screen for, if not rule it out before proceeding with transitioning?
MJ: We don’t inhibit a child from proceeding because they’re on the spectrum. But what we do need to be screening for is the hyper-focusing and rigidity that often accompanies spectrum-related behavior. We need to make sure that that’s not what’s going on with gender.
LR:
here is a huge correlation between gender diversity and being on the autism spectrum
Are there any myths you’ve come across about these gender diverse kids who are searching—and is ‘searching” a good enough word? 
MJ: Gender exploring! I think that there are many myths, and one of the ones that comes to my mind immediately is the idea that kids can’t know their gender if they’re gender diverse. They’re likely to change their minds later, so we should not really be listening too much to what they’re saying. We have to wait a while. I think that’s a big myth.

I think another myth, which is part of our bigger culture, and we all hold it and have to work on it, is that being transgender or gender diverse in some way is less ideal than being cisgender. And that’s a big shift in thinking. That’s something that I am monitoring within myself. Oh, and then there’s the myths of the gender affirmative model, that it’s just a fad or a kid might say they’re transgender because they're trying to fit in with peers, or that being a gender-affirming therapist means that if a kid says they’re transgender, the therapist is going to immediately write a letter and say yes, puberty blockers. Yes, hormones. In reality, these are decisions that are very carefully sorted through and that take time.   

LR:
another myth, which is part of our bigger culture, and we all hold it and have to work on it, is that being transgender or gender diverse in some way is less ideal than being cisgender
Is that second myth related to what you refer to as quieting the gender noise in the clinician’s head?
MJ: We all have a gender. We all grew up with expectations. We all hold biases about gender. And that’s what we think of as gender noise. Gender noise, the myth that I was talking about, was the myth that somehow being cisgender was preferred or more ideal, and that’s just been stated as fact, basically, for as long as we’ve known in Western culture. That’s a more difficult one for some people to really shift around. And even when we shift around it, I think if we’re really not paying attention, it can be easy to slip out of that. This is especially so if I’m not monitoring my countertransference, monitoring my own biases about gender.
LR: Makes me think that gender noise is on one end of the spectrum of therapists’ presence with these kids, and severe unchecked countertransference is all the way at the other end, and there are so many points in between where that noise can impact the therapeutic relationship.
MJ: I want to make one more point about gender noise based on something I’ve noticed in my practice with cisgender people. I’ve had several cisgender male clients who have expressed a lot of stress and even angst around masculinity with questions like, “Am I measuring up?” or “Am I too masculine?” Does that mean they’re aggressive? Just trying to sort out for themselves what it means to be a man and what is okay and not okay. And I would say even that is gender noise.
LR: What is that male bashing concept typically attributed to the dangerousness of hypermasculinity? 
MJ: Oh, toxic masculinity?
LR: Is that what you refer to when you say a cisgender male might come in worrying that they’re just a little too beefed up emotionally? 
MJ: Some of them worry if they’re even doing masculinity correctly. Like, are they masculine enough? There’s such mixed messages out there right now and I don’t know that historically, I have had so many male clients talking about these issues as I have in the last couple of years.
LR:
we all have a gender. We all grew up with expectations. We all hold biases about gender. And that’s what we think of as gender noise
I wonder if the males who come in worrying about their masculinity is more of a function of their education level, their intelligence, their sensitivity, and if they are sensitive to ‘am I being too masculine,’ then that sort of answers its own question.
MJ: Exactly, exactly. And I think the Me Too Movement, along with toxic masculinity, has brought these topics to the forefront.
LR: Not to mention the politicization, but we’ll save that for another conversation. How does gender stress differ from gender dysphoria? 
MJ: It’s a good question. When I think about gender dysphoria, in the most basic sense, it’s the distress that someone feels when their gender identity does not match the gender designated to them at birth. And gender dysphoria, often, but not always, can show up around their body, like, not wanting certain body parts they have, or wishing they had body parts they don’t have. Feeling like their face, or their bone structure, or body shape, or genitals are wrong. The distress is very internal.

You don’t have to be gender dysphoric to experience gender stress. You could feel very comfortable with your gender identity and your body and all of that, but on a regular basis, encounter situations based on your gender that cause stress. For example, if you’re a trans girl, and have to choose between men’s or women’s bathroom, the very process of going to the bathroom can become stressful. That would be gender stress even if you’re okay with who you are, and your body, and everything.  

LR:
when I think about gender dysphoria, in the most basic sense, it’s the distress that someone feels when their gender identity does not match the gender designated to them at birth
How have the gender issues that have been presented in your practice changed over the last 20 years?
MJ: They’ve changed quite a bit! Early on, most of the children that were brought to me around gender were assigned, or designated male at birth and were wanting long hair and to wear dresses and play with dolls, and they were saying that they were girls. Their parents wouldn’t really know what to do at that time. They would have questions like, “Is it bad to let my little boy wear a dress or play with dolls?” or “Do we affirm that and say it’s fine,” or “Do we change pronouns or a name?”

These were little kids that usually ranged in age from 3 to 6. But sometimes they were older, but almost always they were quite young. Early on in this work, I didn’t really ever have a parent bring a child who was designated female at birth when they were little. The way I understood this was that the girl box, so to speak, is a lot bigger than the boy box. It was, and maybe still is okay for little girls to cut their hair short and play with the boys and be good at sports. But it was not seen as okay for a little boy to wear a dress.

Over time, this has shifted. And as I touched on a little bit earlier, while we still see those young kids, they’re not coming to our offices as frequently. I think because parents have more awareness out there and perhaps parents aren’t as worried when the kids are little and they’re going to kind of see what happens and support their kid in the meantime. Parents might only bring their kids into therapy when that kid is nearing puberty and they’re starting to sense stress in the child about a changing body.

The other difference that we’re seeing is that kids come out later. I have many families that bring a teenager to me who has come out as transgender, post puberty. We never used to see that, and now we’re seeing it more and more. I see that pretty equally among “designated male” at birth or “designated female” at birth. But when we start to talk about who is showing up for medical treatment, there is a greater number of designated female teens showing up for hormones than there are designated male teens.    

LR:
parents might only bring their kids into therapy when that kid is nearing puberty and they’re starting to sense stress in the child about a changing body
Before we shift gears, is there anything else I should ask about the kids?
MJ: Not so much specific questions, but I guess what I would say about the kids themselves is that some of these kids absolutely know who they are. Regardless of how certain or sure they are of their identity, what we know these kids need is family acceptance, and family acceptance does not necessarily mean, “oh, my kid’s trans, so let’s go get hormones.” They need to know that families have their back, and ideally that communities, teachers, churches, have their back and love them no matter who they are.
LR: In your book, you said that if depression and anxiety develop, it’s likely due to negative social responses, so treatment should be aimed at helping and healing the surrounding environment. Are you saying that effective intervention for the child or teen means that the clinician must work with the family?
MJ: We do help the child, too, but I feel like the root of it is not necessarily about their child’s gender as much as it is about the parents’ response to their child’s gender expression. If we think about just anxiety and take away the gender piece when we’re working with an anxious child, we often find that we have to work with the parents as well. You know, there’s something going on at home, or there’s ways the parents can do things differently to help work with us, to help treat the anxiety. We were not just treating that in isolation.

So, in that way, it’s not that big of a leap to think about it as you’re starting with the family. And somebody doesn’t have to be out there being super politically active if that’s not what they want to do. But the way that they are holding gender in mind and interacting in the community, in their own communities, for example, and raising awareness, I think is huge.   

LR: Do you go to the school in the course of working with a particular child and family? Do you go to churches? Do you go to community centers? What is the extent is your work outside of the therapy office?
MJ: I think gender-affirming care is a team effort. We’re lucky here because we have people at UCSF’s Child and Adolescent Gender Center, where there’s an educational specialist. And if the family wants, that person will go with the family to the school and advocate on the child’s behalf.

If the family doesn't want to bring in an educational specialist, I know about creating a gender and educational gender plan. I can offer information to the family if they feel like they can address the school themselves.

That’s basically about having a discussion with administrators about whether there is a safe person for this child to go to if something were to happen. What bathroom is this child going to use? Do they have access to one that feels safe and comfortable to them? Whether teachers are informed or not, whether the kid is out to peers or not, those sorts of things are talked about amongst the adults to create a plan to support the child at school, for example.   

LR:
I  think gender-affirming care is a team effort
So basically, extending the office to include all possible support members to extend the safety of the office into the world that they actually have to live in.
MJ: Exactly.
LR: What about the kids who express gender stress, even gender dysphoria, but don’t want to, or aren’t committed to chemical intervention? 
MJ: We’re seeing this a lot. I think this is one of those myths out there that transgender and gender diverse children and teens necessarily are seeking out medical intervention. Because that’s not true. It’s a subset that wants medical intervention, and even within that subset it has to be determined to be the right next thing for them.

There are many, many young people who identify as gender queer, non-binary, or even as a trans girl or a trans boy who have no desire for medical intervention. They love their bodies the way that they are. And so, there’s that piece, and then in terms of the journey piece like we talked about in the book, is that gender journeys are something we’re all on throughout our life, right!?

Even as a cisgender woman—and being a woman has been an important identity of mine—but how I experienced being a woman, and thought about being a woman, and expressed my femininity or lack thereof at 20 years old is very different than how I do it now in my 40s. So, there can be shifts in how we express gender, experience it, and then there can also be shifts in identities.

That happens over time, and so we don’t think of there ever necessarily being an end point in terms of a gender journey, although there may of course be an end point in therapy when kids are doing well, and they’re not needing that level of support.   

Gender-affirming Work with Families and Beyond

LR: What are some of the clinical challenges that the parents have brought to you, or the families? Because it’s not just parents, it’s also siblings, maybe even the extended family.
MJ: There are so many if we got into specifics! But I’ll start general first. When a child comes out as transgender or gender diverse in some way, it impacts the entire family, especially the family unit living together. And siblings have a range of experiences. Sometimes it’s not an issue, and everything’s fine, but other times, the sibling may go to the same school. This sibling may either feel they are a target, or they may actually experience being a target, like being teased for who their sibling is, or they may fear that that is going to happen, even if perhaps it doesn’t. Siblings might not understand and might need support in even understanding what this means.

However, I think parents struggle more than siblings do, partly because we’re finding that young people just tend to have more flexible minds around gender than us adults. One particularly difficult thing is that every parent has dreams for their children and ideas about who their child is, who their child is going to become. When they realize that there’s an aspect of their child where their gender is something different than they’ve imagined, there has to be a reworking of those dreams and expectations. Oftentimes, there has to be a lot of grieving and mourning for what they thought that they would experience with their child, or what their child would experience in life.

There’s often anxiety for parents about how the world is going to accept their child. They may ask, “Is my child going to be hurt in this world because of who they are?” Then there’s the stress of extended family. I’ve worked with families where things are going really well within the nuclear family, but the thought of telling grandparents feels really dicey out of fear that the grandparents aren’t going to understand.

Or I’ve worked with families who are religious, and their particular church or synagogue is not supportive of gender diversity. This is a community that the family loves and relies on, and they’re having to face the harsh reality that they may need to move out of or disconnect from this community in order to support their children. Or they wonder if there is a way for them to bring education to those communities and to help them to grow and expand to accept their children for who they are. So, it's a lot of pieces that parents are holding.   

LR:
here are many, many young people who identify as gender queer, non-binary, or even as a trans girl or a trans boy who have no desire for medical intervention
What family factors have you experienced that might undermine successful intervention with the child, or do those families simply not come to therapy?
MJ: Rejection is the biggest thing. If parents are absolutely like, “this is not true, it’s not real, I’m not even going to discuss this with you,” that is the worst-case scenario, and we see those children do very poorly. That’s where we’re seeing the highest rates of suicide. The highest rates of runaways. And once these children run away, they’re at greater risk of victimization than their cisgender homeless peers. So, we know that the biggest protective factor is family acceptance.
LR: Are the transgender kids accepted in the broader LGBTQ community, or do you find it depends on the community? 
MJ: It’s actually kind of complicated. In my experience, some older adults or adults in general‚ not young adults, but middle age and older in the LGBT community can be quite non-accepting and surprisingly dismissive that these identities are real, coupled with the belief that it’s sexual orientation and not gender identity.

I would say that we see less of this within the younger members of the LGBT community, like adolescents and young adults. I think there’s still some cases

Embracing Technology in Counseling: Innovative Tools for Enhanced Client Support

In recent years, technology has become more pervasive, entering many fields, including, for our purposes, counseling. And for better or worse, it has provided innovative tools that enhance therapeutic experience and offer new, convenient, and accessible avenues for clients to access a variety of mental health supports. From telehealth sessions to digital resources and AI-driven interventions, the possibilities are vast and increasingly accessible.

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The Importance of Technology in Counseling

In the wake of the COVID-19 pandemic, telehealth has emerged as a key instrument for the delivery of mental health services. It offers clients flexibility and accessibility, removing barriers such as geographic distance, transportation issues, or scheduling conflicts. Telehealth platforms allow for face-to-face interaction through video calls, creating a space for meaningful therapeutic engagement. This approach has been particularly beneficial for clients who feel more comfortable in their own homes or who may struggle with anxiety related to in-person meetings.

Email and secure messaging platforms provide an invaluable extension of the counseling relationship. Clients can now send a secure message through a client portal. These tools allow clients to reach out between sessions for support, clarification, or to share progress in a timely and secure manner. This continuous line of communication can help maintain therapeutic momentum and provide timely interventions when needed. However, it's crucial to establish clear boundaries and guidelines around digital communication to ensure both client and counselor well-being.

But the real big one, the humdinger, is artificial intelligence (AI). It is emerging as an asset in the therapeutic process. AI-driven tools can assist in creating personalized therapy homework assignments, offering clients tailored exercises that align with their treatment goals. For instance, AI can suggest cognitive-behavioral strategies, mindfulness exercises, or journaling prompts, providing clients with structured ways to work on their issues outside of sessions.

Moreover, AI can serve as a practice partner for clients working on interpersonal skills. For example, a client preparing to engage in conflict resolution with a spouse might use an AI-powered chatbot to role-play scenarios. This practice can help them build confidence and refine their communication strategies before addressing real-life conflicts. While AI cannot replicate the nuances of human interaction, it offers a safe and controlled environment for clients to experiment and learn.

So, yes, the possibilities might just be endless, but I would like to give you one, real-life, actual example of a client using technology for their benefit.

Technology as a Lifeline for Bipolar Disorder

One case involves a client of mine diagnosed with Bipolar 1 disorder, who used technology to build a support network. Recognizing the importance of communication and preparedness, she created a detailed Google Drive document outlining her mental illness. The document included descriptions of her symptoms, warning signs of a potential episode, and specific suggestions on how her friends and family could support her during difficult times. Additionally, she listed emergency contacts and step-by-step instructions for what to do in a crisis.

This proactive approach has had a hugely positive impact on her life. By sharing the document with her close friends, she empowered them to better understand her condition and respond effectively when needed. This not only provided her with a sense of security but also strengthened her relationships with her support network. The ease of access and the ability to update the document as her needs evolved demonstrated the power of technology in fostering a supportive and informed community around her.

I found this use of technology by my client helpful for a number of reasons. There’s a level of sober self-awareness that a person needs to have if they struggle with Bipolar 1. The nature of the disorder comes with manic highs where sometimes the trigger of an upswing can be identified or even anticipated. But this is not the case for everyone. Sometimes the upswing comes without warning and takes over someone’s life with destructive consequences. If that is the case for one of your clients, planning and brutal honesty is critical.

I am in the habit of saying to clients, “forewarned is forearmed” (I stole this from one of my graduate school professors). Meaning, I want clients to be honest with themselves about how powerful their symptoms can be, and how they are not always in full possession of their mental faculties during the onset of an episode. Therefore, it is imperative they plan for those times. And to primarily focus on preemptively equipping their support network with information and resources on how to support them when they struggle to care for themselves. This wisdom applies itself broadly to clients struggling with a variety of mental health disorders, not just Bipolar 1.

***

There is wisdom in knowing your limitations and preparing for difficult moments. For clients who struggle with chronic, persistent, and severe mental health disorders, they absolutely need a strong support network. I strongly encourage my clients to think about the strength of their support network as a measure of their recovery, maintenance, or long-term wellness plan. And, thanks to technology, fostering and empowering that support network is easier than ever.

Questions for Reflection and Discussion

What challenges have you experienced bringing this level of technology into your practice?

What reservations do you have integrating AI into your clinical practice?

What techniques and methods would you like to learn moving forward?  

Managing Post-Election Despair in Therapy: A Clinician’s Conundrum

Managing Therapist Post-Election Despair in Session

I consider myself a liberal Democrat, living in a blue pocket of a red state. As a licensed MFT (Marriage and Family Therapist), I also identify as female, white, middle class, and heterosexual. Like many Americans, I stayed up all night to watch the presidential election result come in. My grief and devastation, along with my fears and anxieties about the future, made sleep elusive. After a mere two hours, it was time to get up, resume my role as therapist, and try to figure out how to work with clients on their concerns about this. I had spent weeks working with clients on election anxiety. But this day was different: it is unusual to be experiencing something so distressing that your clients may also be simultaneously experiencing.

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Typically, I manage my self-of-the-therapist by practicing self-care and working on it outside of a clinical setting. But, on this day, I was going to have to find a way to work with clients on concerns I had barely begun to process myself. Should I even go see clients when feeling such sadness and despair? What could I possibly say to alleviate anxieties they might have about deportation, eliminating the education system, reproductive rights, etc.? How would I respond to real concerns that they could lose their healthcare or Medicare under this new administration, thereby losing access to their therapy services? How could I reframe people’s concerns, when I could not think of anything positive about the future? I had rarely felt less like going into work.

9:00 AM. Couple therapy session, mid 30s, White heterosexual couple, liberal Democrats. Both expressed their anger, frustration, and powerlessness about the results. They described their frantic research to determine if they should move their family to another country. I began the session listening, validating, and empathizing. However, our discussion soon shifted to all the ways that the election discussion between them paralleled other dynamics we have been addressing in therapy.  

How did his high anxiety and spiraling thought process relate to her role of staying strong, presenting the calm facts to the children, and managing his anxiety? What messages do they want to give to their children about their election response? What would need to happen for them to take his idea of moving internationally and make that a reality? What is their biggest fear? We ended the session with the couple pondering how they might take their powerlessness and turn it into activism by volunteering to help turn the electorate around in two years.

10:00 AM. Couple therapy session, mid 40s, heterosexual Latino couple, she identifies as Democrat, he identifies as Republican. They began the session with their intense argument about the results. She described him as smug and being a “sore winner;” he described her as bitter and naïve for thinking the outcome would be anything else. Using Gottman’s ideas of the 4 horsemen of the apocalypse, we explored how their interactions with each other reflected these problematic patterns. How did these character attributions relate to their negative affect? How did they display defensiveness, contempt, and criticism? How was their interaction about the election different than their other interactions? How could we shift this discussion on value differences to a more respectful one? How do they manage their perceived differences in values?

11:00 AM. Individual therapy session, male, White, Jewish, mid 60s, presenting problem of anxiety. He entered therapy agitated and began to pace the floor. Due to the nice weather, I suggested that maybe we do something different today and take a walk in the park. He agreed. We walked and explored his anxiety: What would happen with Israel? What if he loses his Medicare and senior benefits? How would he cope with this level of uncertainty? What if his young daughter had an unwanted pregnancy? He ended the session with his own suggestion of avoiding any more election coverage and how taking a break from social media would probably help him the most right now.   

12:00 PM. Individual therapy session, African American female, early 50s, presenting problem of grief. She focused on her anger towards voters and her fear that the results were a result of racism and sexism. She expressed concern for her transgender son and what changes might affect him. What would her deceased mother have said to help ease her fears? What other losses do these results bring up for her? What personal experiences has she had with racism and sexism that this is evoking for her?  

1:00 PM. Individual therapy session, early 20s, White man, unsure party affiliation, presenting problem of depression. This was the only session of the day where the election was not discussed, and we had a session much like previous ones. It could have occurred on any other day.

2:00 PM. Couple therapy session, early 50s, White, Jewish, Republican. They began the session talking about how happy they were about the election results and their shared optimism for what the future holds. They described how they bonded over their relief that Israel policy would likely be beneficial. Using Solution Focused Therapy, I focused on these moments of exceptions: what was different about their shared experience last night? How could we expand upon what was working between them last night? When else have they been able to connect like that?

3:00 PM. Individual session, African American female, late 20s, Independent, presenting problem of co-parenting challenges with her ex-husband. She shared how disappointed she was in the results and was struggling to make sense of them. For the first time today, a client asked me directly, “What was your response to these results? Make it make sense for me!” What do I self-disclose and how much? What could I say that is genuine, brief, and helpful to our relationship? I paused and said, “Yes, I was very disappointed also. The way that I make sense of it is that I think that most people want similar basic things: to be financially stable/not stressed about money and want the best for the people they love.

“People in this election took different paths to what and who they think will give them and their family the best outcome on these measures. It is easy to look at this and see all the ways that the path they chose might not actually do that for them. We can’t control what happens from here, so my personal challenge is to figure out how to cope with it and manage my own fears around what could happen.” She was satisfied with my response, and the session moved on.

***


4:00 PM. I am exhausted. I complete my notes and head home. Today was a difficult day, but I am proud that I was able to self-disclose appropriately, take election talk that could be viewed as “venting” and weave it into therapeutic work, and find a way to work effectively with a topic that I am still processing. I am confident that this will not be the last time I face such a challenge.   

Questions for Thought and Discussion

In what ways do you resonate with the author?

How have you addressed election/political/emotionally laden issues like politics with clients?

To what extent would you have self-disclosed as did the author? Differently or at all?  

How Do You Maintain Compassion and Respect for Your Clients?

Compassion is the basis of morality.
—Arthur Schopenhauer, The Basis of Morality  

Should you have to treat people who have assaulted or murdered others? What about working with clients who hold hateful beliefs or taboo fantasies or act in ways that directly contradict your moral standards? What if they’re blatantly sexist, racist, homophobic, or transphobic? How do you know what your role is when you feel disgusted or angry or upset by how a client lives their life?

All humans are unquestionably shaped by their values. No matter how much you try to embrace your open mind, some implicit biases are inescapable. Everyone has preconceived criteria for which behaviors feel acceptable or unacceptable.

Therapists often work with people the rest of society often belittles, misunderstands, and ostracizes. When a client sees only the bad in themselves, you reach in and find all the good. You hold a light in a place that can feel so dark.

But what if you don’t like the client? What if you not only disagree with their values but find their personality annoying or obnoxious? What if some or all of their mannerisms irritate or upset you? What if you find yourself feeling agitated during your work together?

Let’s slow down here. We invite you to spend a moment thinking about a value you hate. Hate is a heavy word; we chose it because it triggers strong emotions. For example, maybe you hate self-centeredness or people acting like they know everything. Now imagine you have been assigned to work with a client who holds or embodies these specific traits. They show no interest in changing, but they’re in a state of distress, they need help, and you have the expertise to help them.

Could you do the work? Could you genuinely support this client, find their goodness, and be on their team? In everything you do with them, could you commit to caring about their well-being?

Feelings of dislike exist on a large spectrum. Unfortunately, you may not be prepared to manage it when it happens. Negative countertransference arises when we experience conscious or unconscious negative reactions toward a client. Despite the word negative, these feelings are not good, bad, right, or wrong. But we must be mindful of how they can affect treatment. Acting out as a result of negative countertransference can include:

  • Rejecting your client
  • Offering unsolicited advice
  • Avoiding certain topics because they make you feel uncomfortable or unsafe
  • Openly disapproving of your client’s choices
  • Withdrawing from emotional connection
  • Being defensive or dismissive of your client’s feedback
  • Demonstrating inconsistent boundaries throughout treatment
  • Trying to overcompensate for your dislike by being overly agreeable or passive
  • Prematurely abandoning a client due to your own frustration or hostility

Negative countertransference sometimes happens when a client inadvertently knocks at unresolved parts of your own life. Maybe their anger reminds you of your father’s anger, and you have a contentious relationship with him. Maybe their passivity speaks to your own difficulty asserting yourself, and you resent having to be the strong communicator in the relationship. Perhaps you’re an unpaid intern and aren’t sure if you can make rent this month and your wealthy client is lamenting about their next real estate venture. Because you are a human and not a robot, it would make sense if you felt agitated by these circumstances.

There are no bad clients. But some clients may feel bad for you. In addition to unpacking personal reactions in therapy and supervision, here are some guidelines for managing your emotions and offering helpful and ethical care to your clients. We explore them in more depth in the subsequent sections.

Managing Your Emotions in Therapy

Leaning deeply into unconditional respect: Deliberately choosing to respect your clients for who they are, where they are, and what they bring to you

Deliberately searching for the good: Intentionally finding and holding on to your clients’ strengths and virtues

Embracing empathy as a nonnegotiable: Prioritizing a warm, empathic approach with your clients regardless of your similarities or differences

People are just as wonderful as sunsets if you let them be. When I look at a sunset, I don’t find myself saying, “Soften the orange a bit on the right-hand corner.” I don’t try to control a sunset. I watch with awe as it unfolds. Carl Rogers, A Way of Being 

Respecting clients means fully accepting them for who they are and where they came from. It entails honoring where they stand in their current journeys.

Respect moves into valuing autonomy. Clients have the right to live their own lives and make their own choices. You can have your opinion, but you do not live in your client’s body, reside in their home or community, or manage their relationships. Respect is the prerequisite for unconditional love. And love can be such a rich part of therapy, even if you don’t identify with loving your clients in the specific sense of that word. Respect is also a catalyst for helping you release rigid expectations about how a client should think or behave. This opens deep space for curiosity and connection.

Respecting clients does not mean condoning problematic behavior. We’re not advocating clients harming others or themselves. We absolutely want to see people make optimal choices in their lives.

However, respect means seeking to connect with the context and motive driving someone’s behavior. As a species, each person’s way of being is influenced by so many factors, including their culture, geography, upbringing, family influence, neurobiology, trauma, and genetics. It is especially important to remember this when working with clients you find challenging.

Respect can get muddled if you struggle with believing your clients owe you something. For example, therapists sometimes believe that clients owe them:

  • Complete honesty
  • A desire to do deep work
  • The belief that therapy is a worthwhile investment
  • Motivation for growth
  • Insight into their current needs or problems
  • A full understanding of therapeutic boundaries
  • A willingness to integrate feedback
  • Socially acceptable behavior
  • Measurable progress

Having some parameters for treatment is reasonable. You are hired to support your clients to achieve specific mental health treatment goals. This work should adhere to certain protocols; deviating too far from the basic structure of therapy can create problems. However, treatment in the real world does not exist in a predictable cut-and-paste formula. Clients come to therapy with unique personalities, unmet needs, and distinct behavioral patterns. Many arrive in a state of crisis when other resources have proven to be unreliable or unavailable. If they are mandated to therapy, they might resent having to meet with you altogether. In almost all cases, clients are juggling numerous stressors, and they want relief from their distress.

Respect helps therapists mitigate the risk of inappropriately generalizing or stereotyping clients. For example, let’s say you conduct an intake with someone who discloses a horrible experience they had with another therapist in the past. They express their anger toward the healthcare system and tell you they have doubts that you can help them. Some therapists would flag this client for being “too difficult,” or even, “treatment resistant.”

Respect means you give the client the benefit of the doubt. You listen to what they have to say about those past experiences. You care about their pain, and you emphasize that you care about that pain because you value their wellness.

As a therapist, respect means you hold the CHAIR (consistency, hope, attunement, impact, and repair) model as much as possible. You strive to convey a positively consistent presence for your clients. You find and hold on to hope for change in every way you can. You seek to attune to their emotions and needs. You look for opportunities to impact them and help them experience their world differently. And if and when conflict occurs, you take the lead in repairing that discourse.

Respect also means truly owning what lies in your locus of control. This, too, is covered by CHAIR. Ultimately, you can control the knowledge you obtain, the therapeutic actions you take, and the presence you exude. You control the boundaries you set, how you advocate on behalf of your clients, the referrals you provide, and the way you acknowledge making a mistake. Depending on your specific workplace setting, you may also control many logistics, including your fees, documentation protocol, after-hours contact, intake paperwork, and the arrangement of furniture in your office.

In reality, however, you can do everything you’re clinically supposed to do, and you still can’t control your client’s reactions. You aren’t in charge of deciding whether you have rapport. You can’t fix whether a client’s partner loves them or whether their boss perceives them to be incompetent. You can never control what a client does or does not do within the context of therapy itself.

The good news is that the more you can respect your clients, the more meaningful this work feels. This is because when you have a foundation of respect, you can lean more deeply into the caring part of this work.

We believe it’s impossible to care too much about a client. To care is to be invested in someone’s well-being. When you care, your heart and soul come into this work. It is one of the most beautiful traits you can bring to clients. As for us, we care about our clients immensely and wholeheartedly. We also have no qualms about telling them we care. We want them to know they are worthy of being cherished because they are. Holding this privilege gives our work such vitality.

Caring is not the same as enabling, overextending, or breaking therapeutic boundaries, however. Those specific actions often come from a place of caring, but they might speak more to unchecked countertransference when therapists lose professional objectivity and presence.

Caring lends a hand to respect, allowing you to detach your compassion and tenderness from expectations. Within this state of respect, you genuinely want what feels best to your clients without defaulting to an assumption that you know what’s best for them. You can value rapport and connection without ever demanding it. Most of all, you can and should care without conditions.

From this lens of respect, therapists can trust how the process of therapy organically unfolds. The freedom lies in the flexibility. It is the balance of accepting clients for exactly who they are while holding on to the hope that change can always happen.

Therapy, from this framework, bursts with possibilities. Embracing radical curiosity sets the stage for holding unconditional positive regard for your clients.

You won’t agree with or like every client you work with, but respect means trying to understand that most everyone is doing the best they can in a given situation. People want to secure their survival. Clients seek to avoid pain, even when that means hurting themselves or others.

How You Cultivate Deep Respect for Clients

Prioritize curiosity at its utmost capacity: What past circumstances led this client to make the choices they made? How, in every moment, are they seeking to minimize pain? Which behaviors have become solutions to temporarily cope with distress? Who hurt them and created those unhealed wounds in the first place? How are they trying to do the best they can with what they have?

Check in with yourself when you think a client owes you something: Be mindful of the tendency to assume your client inherently owes you something. If you find yourself struggling with this, ask yourself, Why do I find this so important? If you’re struggling to let go of this expectation, practice saying to yourself, How can I meet this client exactly where they are? 

Focus more on what you owe your clients: You owe consistency, hope, attunement, impact, and repair. You can’t control how your clients respond to what you offer. Leaning into your locus of control may help release the demands you feel toward clients or the treatment itself.

Pay attention to your countertransference: Countertransference is not good, bad, right, or wrong. It exists and can’t be avoided. But you can be mindful of how you orient treatment when it arises. Remember that your client, even if they remind you of someone or something you dislike, is a whole person with a distinct personality. Remind yourself often of this aspect of therapy.

Commit to neutralizing your values within therapy: In your personal life, you are entitled to orient yourself in ways that honor your values. But your job as a therapist is to show up and support your clients with respect, compassion, and professionalism.

Allow yourself to care tremendously: You are allowed to care about your clients. You are allowed to have feelings of protectiveness, adoration, warmth, delight, and closeness with the people you work with. Deep care, of course, should not justify consistently breaking therapeutic boundaries.

Have a plan if you simply cannot set your negative reactions aside: Sometimes this happens. You may not be able to work with certain clients because their content is too triggering to you. This does not make you a bad therapist. However, it’s in your client’s best ethical interests to refer them to a provider who can competently treat them. If this isn’t possible, focus on getting quality supervision, consultation, and/or personal therapy to address your issues.

Deliberately Searching for the Good in Clients

As therapists, we are called to search for the good, even when the good feels buried or insignificant compared with other traits we see in our clients.

It is also imperative to remember that no value is unanimous. As the philosopher Friedrich Nietzsche said in his book Beyond Good and Evil, “There is no such thing as moral phenomena, but only a moral interpretation of phenomena.” Humans have decided on some parameters of good and evil, but a choice that feels boundlessly immoral to one person may be entirely warranted to someone else.

If you assume a stance of moral superiority, you risk operating from a “me-versus-you” mindset. This mindset can create competition, and competition erodes the fabric of the relationship you’re trying to build. If you aren’t on the same team, you unknowingly risk becoming opponents. You may feel irritated, offended, and riled by your client. Your client may feel judged, condescended to, or unsupported. You both are apt to move into defense stances—and this defensiveness may prevent the crucial scaffolding of emotional intimacy from developing.

Your work as a therapist means signing up to care about people who think and act differently than you do. Biases are inevitable, but you must be able to examine inward and dismantle feelings of superiority. You are not a savior. You are not the all-knowing expert. You have simply been invited into a sliver of your client’s life. You owe it to them to witness their pain and understand the gravity of their life story.

Searching for the good means assuming a stance of giving clients the benefit of the doubt. This becomes especially important when working with clients who feel challenging. When you can pause and drop into a client’s pain, when you can land into the rawest feelings and deepest wounds, you soften. There are many ways for therapists to soften, but it happens when the therapist can truly land and sit with someone else’s emotions, no matter how big, heavy, or confusing they are.

Softening is the catalyst for opening. Opening emotion, opening trust, and opening connection. Everyone needs a soft place to land, and you have the opportunity to create this place for your clients. Not all will take you up on it. But many will.

Your expertise isn’t what makes therapy meaningful. Your courage to move beyond societal constraints and listen to another person is part of your impact. It’s a deliberate choice. But in our judgmental world, you are privileged to make this choice every session.

It is tempting to find out what is wrong with your clients. The reward of this work comes from uncovering what is wholly good.

Embracing Empathy as a Nonnegotiable

Empathy refers to the capacity for relating and sharing feelings with another person. It means being able to sense what someone might be experiencing and hold space for that experience. When someone feels empathic, they feel warm, and people tend to be drawn to the energy of warm people.

What person comes to mind when you think of the word warmth? It may or may not be a therapist, but it’s certainly someone who feels highly approachable and friendly.

Those who exude warmth demonstrate how much they care about people, and this care is felt through their words and actions. They tend to be optimistic without being overly positive. They remember details and they understand pain. They know how to hold emotions without overreacting or underreacting. You want to be around them because they feel safe, and that safety feels good.

Some people mistake empathic therapists for naive therapists. This, however, is rarely the case. Truly holding empathy without constraints means understanding and making space for all the mistrust, skepticism, and shame that people who walk into therapy carry.

Instead of condemning or withdrawing from those barriers, empathic therapists simply make space without any pressure or judgment. They respect the client’s defenses for their necessary function. Empathy is patient, and empathy doesn’t have an agenda.

We encourage therapists to self-assess their empathy by ranking themselves on a scale from 1 to 5 for each of the statements listed below:

1 = almost never

2 = rarely

3 = sometimes

4 = often

5 = almost always

1. I seek to understand a client’s pain deeply.
2. I consider the context of why someone might think or act in a certain way.
3. I can imagine what life feels like in my client’s shoes.
4. I am told I am a great listener.
5. I am told I am warm or kind.
6. I consider myself to be exceptionally compassionate.
7.When I think about my most difficult clients, I would rank myself as having an extraordinary amount of empathy for them.
8. I do not expect people to change on my behalf.
9. I am patient with relapses, regressions, and setbacks.
10. I believe I can genuinely sit with another person’s emotions well.

You want to strive for a score of 40 or more. If it’s lower than that, consider deliberately practicing more empathy in your work or asking for help if you are struggling with a particularly challenging client. Like any muscle, our capacity for empathy needs to be worked out regularly to build strength. But the stronger it is, the more you will connect with your clients and respect them for exactly who they are.

Guidelines for Softening and Finding the Good

Imagine your client’s younger self: Your client’s present self is a product of millions of interactions and experiences. The “challenging” clients are often the ones who have experienced extreme hardship earlier in their lives. When you can drop into noticing their younger state, you will likely find it easier to hold empathy. For instance, instead of solely seeing a client as an angry, self-righteous man, you can also see the part of him who is a fearful and helpless little boy.

Look past diagnoses and symptoms: Diagnoses are theories that summarize a given set of presenting behaviors. Even if you accept a diagnosis, everything is subject to scrutiny and change as humanity evolves. It is imperative to push past limiting thoughts such as believing that someone with panic disorder or someone with schizophrenia automatically behaves a certain way. Diagnosing can be a helpful starting point, a tool, but it is never an end point. It does not paint the full picture of who someone is, what they struggle with, and what they need to move forward.

Practice more mindfulness: Slow down in session. Be more deliberate with how you listen and understand your client. If it’s helpful, consider entering a potentially challenging session with the intention, I will look for what’s wonderful in this person. When this notion is your compass, you seek to find strength and goodness.

Remember, everyone is trying to survive: This stance can’t be emphasized enough. Recognizing this truth is not the same as condoning any specific behavior. Rather, it offers an understanding of why people develop certain patterns, no matter how destructive.

Prioritize empathy: Although empathy is often taught as a preliminary skill in graduate school, it’s not a pervasive trait among all therapists. If you struggle with experiencing or manifesting empathy, focus on what might be in the way and, over time, prioritize implementing more empathy in your work.

Reflecting on Domestic Violence: How One Therapist Made a Difference

I loved my work in community mental health, but I hated office politics—the best way to avoid them was to spend as much time outside the building as possible. I accomplished this for over 10 years by providing in-home services.

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Making a Mental Health Impact in the Community

My very favorite program under the in-home umbrella was referred to as “Mother House.” It was a joint program between a Christian based church that wanted to make a difference in the community and the child & family team of the community mental health center (CMHC) where I worked.

The church owned and maintained a four plex, two-bedroom apartment building, the purpose of which was to provide safe shelter for women with children leaving domestic violence relationships. To qualify for the housing, they required the mother and a child to have a diagnosable mental illness and to be receiving treatment for that illness. They asked the CMHC and particularly the child/family services program to provide mental health treatment.

The CMHC where I worked was very traditional in their orientation to service programs; separating adult services from services for children. An adult parent needing mental health services was seen in the adult division, while the child was seen in children’s services. Never the two should meet. “It can’t be done” they said. “One therapist cannot work with both adult and child service programs at the same time.”

By that point in my career, I had worked in every type of mental health program you could imagine—inpatient, outpatient, day treatment, rehab, adult and child case management, and crisis intervention. By then I was the senior clinician in the agency. I was a perfect fit and said, “Watch how it can be done.”  

Making a Domestic Violence Shelter Work

Over the course of the project, I had anywhere from four mothers, and 8 to 11 children of all ages in treatment under one roof at any time. Mothers were occasionally asked to leave the program when they could not honor the rules. One parent and one child in treatment and no men were permitted to live in the building. I had the independence to do whatever I needed to do keep them functioning; grocery shopping, bill paying, doctor’s appointments, school meetings, and therapy.

I loved the constant challenge and the variety of individual, family, or group therapy. I loved the unplanned picnics, holidays, water balloon fights, family feuds, wars with the neighbors, and the continual challenges of keeping men from moving in on the women. I did not care for the police calls. When the police did come, they sent four squad cars and for hours they screwed up what I could have settled in 30 minutes. Things ran far more smoothly when I was in the building.

One of my first families was a mother with a severe mental illness who had lost or given up custody of her four children. The first to come home was her 13-year-old daughter, Wendy. She came home angry, defiant, and rebellious. She had a lot to be angry about and a right to be angry. She was not a bad child, just an angry one. I did not think therapy was successful for her, but she had her anger to keep her going.   

The mother had to leave the program after the fourth child came home because the apartment was not big enough. We lost touch clinically but through sources in the system, I continued to hear of what was happening in the mother’s life and those of her children.

Fast forward to 2021. The picture of a young woman came through my Facebook page, and although the last name was different than I remembered it when working with the mother and four children, I knew it was Wendy. That 13-year-old girl, now in her thirties, was married, a mother, and looking to connect. I responded to her, and she replied. While she had created that post over two years before, we decided to meet at a local restaurant—she, her mother, and me.

When I arrived, she greeted me as soon as I walked through the door, jumping up from the table to wrap me in a big warm hug before I could even sit down. She did not bring her mother because she wanted to let me know personally and privately that she was sorry for the horrible way she treated me while they were living in the apartment. “I was so angry.” I respond, “You were, but you had a lot to be angry about.”

Wendy shared her story, and what a story it was! She had experienced her share of struggles and challenges, several of which I had heard through my mental health grapevine. She was happily married to a good man and together they had a huge family of “his, mine, and ours.” She had turned out to be a wonderful mother, and a loving and caring daughter to her mother.

***

I subsequently reconnected with Wendy’s mother with whom I met occasionally for lunch. Surprisingly, she recalled that her time at Mother House with her four children, and when she later came home with them, was one of the best times of her life. She said, “We were all like family in that building and you were part of the Family!”

Questions for Reflection and Discussion

What are your impressions of the Mother House project?

What challenges might you experience working with this population?

How might you have worked differently with Wendy under similar circumstances?    

Julie Bindeman on Reproductive Mental Health Care, Dobbs, and Beyond

Lawrence Rubin: Hi, Julie. Thanks so much for joining me today. You describe yourself as a reproductive psychologist whose specialty centers around reproductive challenges related to fertility, pregnancy, and abortion. Did I get that right, and can you elaborate a bit on what this professional identity means?
Julie Bindeman: Reproductive Psychology is not the kind of specialty you’ll find in graduate school departments. In fact, I’m working with some colleagues to look at what is the curriculum around reproductive health in graduate programs these days. Thus far, it’s not as encouraging as I would hope it would be.
The reproductive time period actually can be anywhere from the time somebody begins to menstruate or begins the ability to produce sperm, all the way to—for men and cisgender men—more so end of life, and for cisgender women into the early 40s-ish (from perimenopause through menopause). So, it’s several decades of a person’s life.
For so many of those decades, cisgender women in particular, spend time trying to avoid pregnancy. It becomes very interesting when everything that we’ve been taught about preventing pregnancy gets turned on its head when we want to become pregnant. We have a lot of conversation in our schools about sex ed, but we don’t have any about fertility and what that means and what that looks like.
So it’s the whole gamut between the attempts at getting pregnant, even deciding, “Do I want to have a family,” and considering that; “Do I want to have a family now with this person, do we feel like we’re compatible;” all the way to, “We’re struggling to get pregnant and we need to seek out a reproductive endocrinologist for infertility,” which is a very specialized doctor.
So, I think, because there’s a specialty in the medical world, and because psychology is a little bit slower to catch up, historically speaking, the idea of a moniker of a reproductive psychologist provides some clarity about what I do, which is different than other psychologists, but also is a very particular niche that involves a lot of study.   
LR: This reminds me of a cartoon I once saw of two girls sitting on a park bench, reflecting on their lives ahead. One of them says, “Well, I think after my second divorce, I will…” It makes me think, Julie, that although the reproductive age physically starts around puberty, people’s ideas of reproduction and parenting and maybe even fertility—probably begin before they were born. Perhaps, a reproductive legacy.
JB: There’s a concept called the “reproductive narrative.” It encapsulates the idea that we all start having a reproductive story early in life, and that story changes, and it’s just as valid of a story if someone is not interested in parenting as it is if someone is very interested in parenting. And when we meet potential partners, we have to see how our reproductive stories mesh, and sometimes they mesh really well, and sometimes there needs to be some negotiation.

Reproductive Mental Healthcare in the Era of Dobbs

LR: If part of the reproductive narrative entails a chapter on the act of becoming pregnant either willingly or unwillingly, then I would think that part of that narrative, from the perspective of a reproductive psychologist, would include discussions around abortion.
JB: Here, let me assist you with it. One of the big concerns for some clients who come to me about deciding whether they should get pregnant or not, is, “Is it safe for me to carry a pregnancy in the state in which I live, and if it’s not, do we need to move?” They explore concerns like, “Do we need to move just for our pregnancy?” In certain states, people are really putting their lives on the line just to have a family.
LR: I’m not going to hide the fact that part of my intent for this interview was my interest, as I hope it will be the interest of many of our readers, in how the Dobbs ruling has impacted mental health clinicians working in the area of reproductive health. In that context, and first, how has Dobbs impacted Julie, the person of the therapist? We’ll get to Julie the therapist later.
JB: I wasn’t surprised. When the leak came in terms of what the ruling was going to be, there was already so much talk about. People were saying, “this can’t be it,” and “they’ll never do that,” and “we’re talking about established precedent for 50 years.” Unfortunately, I was sitting there saying, no, this is it, this is what the intention is. It’s only going to get worse from here.
I remember even having a conversation with my dad, who said, “No, that’s just like hysterical thinking.” Looking back to when the Dobbs decision was finally released, I wish I could say I was surprised. I was not! I had been seeing this coming since Trump was elected, quite honestly. That was the reason that I marched the day after the inauguration. I could see it coming. It was very clear to me that they were going to use whatever mechanisms of power that were available to restrict reproductive rights. So that was one part.
As a mom of someone who was born a cisgender female, I was and am also worried because my child has their whole life in front of them, and you know, I’m not sure if they’ll have a family or not. They might. They might not. That’s yet to be seen. So, I’m concerned for what their choices might look like and what is available.
I have two kids that were born cisgender male, and I worry about them and their potential partners. I knew this was going to impact IVF too. So, when the ruling in Alabama came down, people were like, “Oh my God,” and I was like, “Yeah, no, of course it’s going to IVF next, because the logical conclusion is personhood and personhood being conferred to an embryo.   
LR: The second part of my original question is, “How has Dobbs impacted the way that you are in the room with clients who are thinking about it or going through the abortion process, and what advice springs from that for other clinicians doing it or thinking of doing it?
JB: I happen to live in a state (Maryland) that is very protective of reproductive rights and, in fact, has a shield law. I submitted a letter to the committee that was reviewing it when it was a bill to say that in addition to physicians, let’s protect mental health professionals, because I think that’s an important inclusion that we have, in terms of what we might know.
When I think about worst-case scenarios, I think about people connecting the idea of personhood or person status to a fetus, and then connecting it to laws that already exist. So, if you don’t realize you’re pregnant and you have some wine, is that now endangering the welfare of a child or child abuse? Or if you have an abortion, is that considered child abuse, feticide? I think they will go after women. Even though right now they’re going after physicians, I think they will go after women eventually. It just makes logical sense to me. So that’s sort of my catastrophizing, but again, I don’t think it’s that far off.
As a therapist, I think there have been several weeks of my career that have been indelibly difficult, and nothing I learned in graduate school has been helpful. I was a grad student during September 11th in Washington, DC. That was tough because how do you process an experience with someone when you’re living it too?   
And I would say that for my clientele, the next time I had that experience was the 2016 election. I had clients, who, like me, were grieving, because we saw what the implications could look like.
And then I would say that the third time it happened in my career was the Dobbs decision. I had people calling who were panicked about it. “Are my embryos safe?” was a question I got asked a lot by clients, and I would be like, yeah, for now they are—you know, again, depending upon where you live.
Many of my clients were feeling helpless and angry, and of course, I shared that sense of anger and righteous indignation. I think it’s really challenging to be a clinician when you’re experiencing in real-time exactly what your clients are experiencing too, when you don’t necessarily have the perspective that often we are able to bring to our clients, when we’re not living what they’re living. When we do live what our clients are living, it’s so hard to have that sense of perspective, because our fear centers get activated, or at least mine does.
For clinicians who are either practicing or considering practicing in this domain, it’s important to know your state laws and how they apply to you. If you’re a clinician in Texas, for example, where they have that SB8—which is the bounty hunter laws that it’s so lovingly referred to as—clinicians are in danger under what that law is, and it is a civil penalty. So, anyone can rat you out for any reason, especially if they’re motivated by money. It’s a $10,000 fine. That’s not nothing! Most of us might not have that lying around to pay. So that becomes a very real risk.   
There are other states that are starting to look at that. There are other states that are looking at assisting minors in having abortion care. So as clinicians, I think for the time being, HIPAA protects us, but it’s really important that we are careful about what we say in our notes because notes can be subpoenaed. And so, if I’m talking to a client about an abortion they are planning or an abortion they had, I’m not going to come out and write, “… spoke about abortion.”
I might say something like, “spoke about family planning” and have it be really vague. I think those of us that are practicing in PSYPACT states also need to be aware of what are the other laws in the states where our clients might be sitting in that we don’t necessarily know because they’re not necessarily connected to the statutes that relate to psychology.   
LR: Would you say there is a dividing line/light switch moment between the way you walked into the room pre- and now post-Dobbs? On the morning after, pun fully intended, did you walk in more nervous, more fearful, and aware of having to be far more conservative or careful with your words?
JB: As a clinician who is very up to date on the laws of my state, which I know most others may not be, I’ve been an advocate for many years. I’ve helped to lobby to get some of those laws passed. And so, I wasn’t concerned, because I knew my state legislature—and in a lot of ways, I know many of them personally—that they were going to protect reproductive rights, and that is what they have done the last couple of years too. So, they did not disappoint.
Our state has done some really great things. As I said, they passed a shield law, they’ve expanded who can perform abortions. So instead of it having to be only a physician, it’s been expanded to physician assistants, nurse practitioners, and midwives, which is awesome. More care, we like it! Our Governor has gotten our own sort of storage of mifepristone and misoprostol— ‘mife’ and ‘miso,’ as it is.
So, I didn’t feel that light switch. One of my best friends who lives in Texas did feel that light switch. She had also been living under SB8 two years prior, so she was not surprised. She had had some time too, to be like, okay, now we’re really going to do this because we don’t have the Supreme Court protections. What’s happening in Texas is legal versus legally dubious.   
LR: It sounds like one doesn’t even have to identify as a reproductive psychologist or work in concert with physicians to experience these issues, because anyone who practices couples therapy or family therapy might find themselves thrown into this reproductive ring. As such, it’s just smart to know your state laws, to connect with advocacy resources, and to be very, very careful of what you’re saying and how you say it. And based on your writing, you don’t bring up abortion explicitly but talk in hypotheticals.
JB: One of the things I do as a reproductive psychologist is to conduct third-party evaluations for prospective gestational carriers. And as part of that conversation, we talk about abortion and because they are not pregnant, there’s no concern. I can talk about abortion till I’m blue in the face. They are not pregnant. Everything is a hypothetical.
But I may talk hypothetically, if they live in Texas and there is a problem with the pregnancy. I may say something like, “You are now eight weeks pregnant. You cannot get care in Texas. Let’s talk about where you can go to get care? You know that your doctor is not going to be able to save your life should your life be on the line unless it’s really dire and, you would have to ask yourself if this is something I want to risk?” It’s about looking at each client’s risk profile, which has changed since Dobbs.   

Abortion Counseling as Mental Health Care

LR: But, outside of these specific evaluations, you also do what you might call generic psychotherapy, where the issues may, but most likely will not come up. We are traditionally taught not to bring up religion or politics unless the client does, so is it the same when it comes to reproductive health and abortion if a client doesn’t broach the subject?
JB: Of course I bring it up. I bring it up because everyone thinks that once you get pregnant, it ends with a baby, and that’s just not the case. Not that I’m trying to freak my clients out that are newly pregnant and excited and whatnot, but we talk about, “Hey, have you had a conversation with your partner, should this pregnancy go in a way that you don’t expect? What might that look like? And, you know, it’s a hypothetical because it’s a very rare occurrence. And, I’d rather you have this conversation before it happens than have to have that conversation for the first time as it is happening because it’s just too much to unpack in that moment as you have to make a critical decision about the pregnancy.”
LR: You describe abortion as healthcare. Would you say that the kind of counseling that you do considers abortion as mental health care?
JB: Absolutely. I come at this from the side of the law of my state, which is specific in saying that mental health is a reason for someone to obtain abortion care past 24 weeks. I also come to it from a religious perspective, which may sound kind of odd, but in the religion that I grew up in and that I practice, which is Judaism, one of the tenets is that you save the existing person at all costs. My religion doesn’t see a developing fetus as an existing person. It sees it as a potential person. So, unless that fetus is basically sticking out of someone’s vagina—sorry to be so graphic—and has taken a breath, it is not a person.
LR: I just want to draw reader’s attention to a chapter in your new book that has a comprehensive table called, “Religious Points of View about Abortion.”
JB: When people think about this, and they’re like, “oh, but I don’t see people who are having babies because I work in geriatrics, or I work in pediatrics. This isn’t important to me. I don’t need to know this stuff.” And to that, I say, “actually you do, because how are you talking to your parents of the kids you work with about, what was the reproductive story that that child was born into? Were there losses before that child was born? After that child was born? Was it a long journey? Was it an uncomplicated journey? Was it fraught, and you weren’t sure this baby would ever get there? This is in addition to, was the baby in the NICU or anything like that, that you’re going to want to know about your patient.”
I also think it’s important because if we’re seeing young kids, their parents are often trying to expand the family, and sometimes it doesn’t work as easily as the first time. And so, how do you support a young child who knows there’s something happening with their parents but doesn’t know what it is and doesn’t have that understanding of what infertility might be or pregnancy losses might be? How do you help the parents talk to their child about it? How do you help, as a therapist, talk to the child about it, give them a place to have their own thoughts and expressions?   
For those that work with an older population, and I’ve had older clients who have been still traumatized by the Dobbs decision, because of the abortion they had in the 70s, either pre-Roe or post-Roe. Or even talking about how this is going to impact so many people and having that empathy for it. And that sadness of what I thought I knew, what I thought I could trust, that 50 years of precedent went down the drain.
So, it’s come out in lots of different age groups, and I think it’s really important. I’ve had male clients talk about it too, their concern about abortion and it not being an option—and not in that kind of cavalier, like, I don’t want to deal with that kind of way, which I think we often ascribe to men when we’re talking about abortion. That doesn’t seem to be the case, but somebody I care about might be very impacted by this.   
LR: What are some of the myths around abortion that clinicians—whether reproductive clinicians or not—need to consider when abortion enters the clinical frame?
JB: So let me first dispel a couple of myths that have existed about abortion. Abortion does not cause future infertility. Although I can’t tell you how many of my clients who had abortions when they were younger, and then as they wanted and were ready to have a family, struggled with infertility, how they made that causal. But I’m like, nope, there is nothing causal to that.
Abortions don’t cause cancer, so that’s really important to know. Also, there is no such thing as post-abortive syndrome. That is not a thing. I appreciate the American Psychological Association for a deep dive that they did in 2008. And one of their conclusions was, nope, there is no need to add something to the DSM about post-abortive syndrome. It is not a thing.
What I think is important for clinicians to think about is what research tells us, which is that most people with access to abortion feel relief. Now, there are some circumstances like terminating for medical reasons—I’m not lumping that into that. That’s a very different, specialized circumstance. But the majority of people who are seeking out mostly first-trimester abortions experience relief—95% of them!
In that 5% who might not, they might experience regret. And where this gets confabulated is the idea that regret becomes mental illness versus regret is a feeling just like lots of other feeling experiences a human can have. And it is a feeling that will come and go. And so, we don’t need to pathologize regret!   

A Reproductive Psychologist’s Personal Journey

LR: For those among our readers who have read some of your other work, can you give us—and I don’t mean to diminish it in any way—a little bit of the experience you had as Julie, the mom, along your own challenging reproductive journey?
JB: When people ask me how I found this work, I tell them I came to it honestly. My early grad school experiences centered on teens and kids. That’s what I was really interested in, and so I worked at a high school, where one of my seniors was pregnant. The way the school managed it was incredible. They threw her a baby shower, and when the baby was born, different people watched the baby so she could still go to class so she could graduate on time. What an incredible community to circle around her and help her. It was amazing.
As I continued, I worked at another school that was Catholic, and one of my seniors got pregnant. That was a very different experience. It was interesting in that conversation where we had to sit with the mom and tell her what was going on, and the mom was like, okay, cool, we’ll get an abortion. And the kid was like, nope, I don’t want that.
At the time, I didn’t make much of those experiences. I later had my own kid. When he was about 18 months old, my husband and I reflected on how great he was and decided we needed another one because the world needs another one just like him—since all children, of course, are carbon copies of one another, right?!
We did not have an issue conceiving the second time, although I had in my mind it would be a little harder because I anticipated it would take six months. In retrospect, I guess I was ambivalent, thinking I would have more time than one month. I wasn’t quite ready to have another kid, but there it was.
That pregnancy was over just as soon as it started, when at eight weeks, the ultrasound showed that I had had a miscarriage. It’s called a “missed miscarriage” because it was shown on ultrasound and I had no knowledge of it. I had a D&C. Interestingly, I had begun specializing in postpartum health after my son was born, so after the miscarriage, I wanted to learn the difficulties of the postpartum experience.
We don’t talk about postpartum and how hard it is. We really don’t talk about pregnancy losses which seem to be shrouded in secrecy. So, it wasn’t until my own miscarriage that I realized how insensitive I had been when my friends had had miscarriages. I didn’t know what to say, and so I went to the platitudes, that I think most people go to because we want to be helpful. Rarely are platitudes helpful!
My doctor was optimistic and encouraged us to try again, which we did. I became pregnant very quickly, and while everything seemed to be progressing in those early weeks, I was bleeding. Our anatomy scan at 20-weeks suggested that we have a second opinion. We were referred to a maternal fetal medicine specialist (MFM), where we learned that our baby had hydrocephalus, and ventriculomegaly, in which the brain ventricles were measuring much larger than they should have.
We were told that the best-case scenario was that our baby could live into his 40s with the developmental quality of life of a 2-month-old. That was not a best-case scenario for me! That was not the life I would want to bring into this world, and it was not what I would want to do to my son, not what I wanted to do to my marriage.
We called our clergy and talked about options, one of which was labor and delivery, and the other was that we could drive to New Jersey for a surgical abortion. I was confused because I knew abortion was legal in my state, so why did we have to go somewhere else for surgery? I later pieced together that six months before, a physician named George Tiller, who had performed an abortion in Kansas, was shot to death. His death created so much of a chilling effect that the doctors in my area stopped performing abortions. I ended up having to labor and deliver a little boy who died. It was awful, and both very different, and compounded by my miscarriage. We were later told that this was a lightning-strikes-once situation, a one in a million, and that we should try again when we were ready.
It took me about four months before my cycle came back and my story gets redundant in this way. We tried for one month and got pregnant. I was very nervous during that pregnancy, which we learned was with a girl. I was getting scanned all the time and found out at 18 weeks that the also had ventriculomegaly, hydrocephalus, and partial agenesis of the corpus callosum. Because I was 18 weeks, I was able to access a surgical abortion with one of the kindest doctors to whom I was, and am, very grateful.
We tried again quickly because I didn’t know if I would have the courage to keep trying. And we got pregnant immediately, and this was a pregnancy where I didn’t feel any symptoms, and I was disconnected from it.
At 18 weeks, the MRI showed that we were having a girl and that she was healthy. I was excited and terrified. I asked them to show us the pictures of the last baby we lost and the baby I was carrying, and the differences were so clear. The brain of the baby I was carrying had all sorts of contrasting grays and whites, compared to the blackness in the image of the baby we had lost, which represented fluid. It was a beautiful picture. I went through the rest of that pregnancy fairly terrified, and I think my MFM probably had some vicarious trauma because she had been with me from the beginning.
We went back for my checkup at 36 weeks, and she asked me, “how do you feel about having a baby this week?” I had four more weeks so I said, “I’m good.” She half-joked, “it wasn’t really a question. You’re going to have a baby this week. When would you like to have your baby?” She just didn’t want anything to happen to this child. So, my daughter was born weighing 5 lbs. even. She was fierce. We had a “normal” stay in the hospital, and then they let us go.
When she was about 14 months old, I said to my husband, “hey, so, you know we always talked about three.” He looked at me like, “are you effing crazy?” I said something like, “I must be, but I really want to try for three. If it works, great. If it doesn’t, that’s fine.” And, again, we got pregnant the first time we tried. When we got an MRI at 18 weeks—and this pregnancy just felt so different to me because I was in a place where whatever happened, happened— and my husband was really excited because it meant we could get a minivan. I remember saying something like, “I will not get a minivan unless we have the number of children we might need for a minivan.” He was like, “okay!”Our son was born healthy, and now I have an 11, 13, and an almost 17-year-old. We are very, very done.

LR: I certainly appreciate the depth of your sharing, Julie. when you first started talking about it, I thought, “She’s probably told this many, many times, and it’s going to be very matter of fact.” But you told the story as if it was so fresh, and it just suggests to me that this part of your narrative will always be alive for you, as it problably is an will be for others who have had challenging reproductive journeys.
JB: Can I read you something as you say this?
LR: Sure.
JB: In the acknowledgement section in my book, I write about my story and actually dedicate the book, to the two babies we lost. “…I am grateful for these two babies I said goodbye to before I could say hello to, as they awoke me to the passion for reproductive mental health, and, primarily, the intersection of abortion and mental health.”

Ethics, Competency, and Advocacy in Reproductive Mental Healthcare

LR: This begs the question, “Are there limits to self-disclosure in reproductive psychology, reproductive psychotherapy?”
JB: It’s a really interesting question that I look at from two different vantage points. So, one vantage point is if you’re a therapist with just sort of a normal population, whomever that normal population might be, and you become pregnant, the pregnancy itself is a disclosure, isn’t it? Like there’s a point in pregnancy where you just can’t hide it, and so it’s a disclosure, and I think it’s useful for patients to know so that they can plan, and they’re not surprised.
And then, you know, there can be a lot that might come out in the transference around maternity and nurturance, and things like that. So, I think it can actually lend itself to a lot of really useful therapeutic material. I think if you’re working with the population that I’m working with, I didn’t have a choice but to disclose because I wanted to give my clients an opportunity to change therapists if they needed to. I wanted to acknowledge, “Hey, seeing me pregnant could be really triggering, and I don’t want you to feel like you have to stay with me. Because I get it, and it can be really, really hard.”
It also came out in other ways, like with a client for whom it took months to disclose that, as a child, she had experienced terrible sexual trauma committed by a relative. She was with me through my losses, and she was with me through the birth of my daughter. After my daughter was born, she was able to say she felt like her “badness” and “evilness” contributed to my losses. She felt responsible for them.

LR: That’s very sad.

JB: Yeah! We did some good work around that. Without the disclosure, that work couldn’t have happened. I didn’t show up at my office Friday afternoon after that first ultrasound. So, you know, I had to have someone tell my clients something. And again, lots of interesting things came out from it.

LR: a lot of my resources is through an organization called the American Society for Reproductive Medicine, and within it, a professional group called the Mental Health Professional GroupDo the APA, ACA, and NASW have resources for clinicians who are finding themselves in this therapeutic arena, or who are considering or looking for guidance through live contact?

JB: Not so much within the larger professional bodies. Perhaps NASW. I couldn’t tell you specifically. Where I get a lot of my resources is through an organization called the American Society for Reproductive Medicine, and within it, a professional group called the Mental Health Professional Group. Thats where a lot of the research and work is being done. APA has had more since the Dobbs decision. Sorry to be pitching my book, that wasn’t my intent, but the reason I decided to edit this book was because there wasn’t anything for the mental health professional that had a client that was now experiencing or considering abortion.

You can’t refer someone out when we’re talking about days or weeks to decide to have an abortion. You have that ethical obligation not to abandon our clients, and we have an ethical obligation to not practice outside of our competency. And so, this book is to fill that gap in between competency and not abandoning clients.

LR: Could you recommend a couple of potential paths for advocacy for clinicians who want to get into it and make a difference that way?

JB: I think it depends on how much you want to do. There are lots of advocacy opportunities such as volunteering for a state delegate campaign in your district and talking directly to them, I found that useful and interesting. Or, talking about it at a City Council meeting where you can go on the record. You can talk about healthcare in that kind of way. These are sort of smaller things that people can do.

There’s organizations like the National Abortion Foundation. They not only have abortion funds through them, but also provide a warm line to people. I don’t think it’s a hotline. They train people so that they can help talk to people that are struggling. So that’s a great organization.

There are lots of local abortion funds. That’s a great way to get involved again, you know, depending upon how involved you want to be. So, for a birthday fundraiser one year, I’m going to pick out an abortion fund. This is where I want my contributions to go, like, contribute to this in my honor.

I have lobbied at the state level, even not in my state. I’m happy to talk to anybody. And my husband had the opportunity to go to the City Council meeting, which is where our delegates were going to talk about what happened in session. He said, “I was going to share our story, but do you want to do it? I can give the time to you.” And I said, “Oh honey, they have heard it from me. They need to hear it from you.” I was really, really proud of him.

LR: It sounds like part of what got you through your pregnancies was you and your husband moving together as a unit. I probably should have asked this question earlier on, but “Have you had the experience of working with any women or families who have been denied abortion?” I know this was addressed in the “Turnaway Study” and is very state-specific.

JB: In my state, that is not an issue for people because it’s so protected here. That being said, I’m part of PsyPact, and was working with someone in a restricted state who had gotten a poor prenatal diagnosis and who was trying to decide what to do. Part of our worked centered around getting more information. A lot of her wait-and-see was about getting further along to get more information about the pregnancy. And every piece of information she got was like adding crap to the pile. There was never good news that she was given. It was just bad, bad, bad, bad, bad.

They got to the point where they felt, “our baby is not going to survive, and this is awful, and I think we’re both ready to terminate the pregnancy.” But she lived in a state where accessing that kind of healthcare was really challenging. She had resources, she was smart, and she had people that she could connect to that could help her connect to other people.

So, initially, her abortion was denied by the hospital. They’re like, nope, we’re not going to do it. And then it was denied by insurance, they’re like, nope, we’re not going to cover it. And the hospital is like, well, if your insurance says we can’t do it, we can’t do it. So, it was sort of this merry-go-round.

She was finally able to get connected to the vice president of her insurance company and shared with him what she had gone through, and what was happening, and what she needed in terms of healthcare. He pulled the strings he needed to pull so that she could have an abortion. But otherwise, she would have had to travel.

And we do see that a lot. We’re seeing more and more people that have to carry to term because they don’t have the luxury of traveling. And while abortion funds are great, they can’t fund the entire expense of traveling and procedures, particularly later in pregnancy.

LR: On that note, I want to alert readers to the importance of the Guttmacher Map, which lists the levels of abortion restrictions by state. Julie, are there any questions I should have asked, or that you would have liked me to have asked?

JB: I don’t know if it’s a question per se, but just something to leave people with. My abortions defined what I do and defined how I work and gave me purpose in terms of the scope of practice. However, they don’t define who I am. They are just a part of who I am, but they are not the defining measure.

And I think when some people experience trauma related to their abortion or traumatic abortions, it doesn’t mean that all abortions were traumatic, are traumatic. But when people experience that kind of trauma, it’s so easy to have it define them, that they become defined by their trauma. We see them all the time in our patients, regardless of what kind of trauma it was. Or they’re trying to run from it so much that they—so they’re not defined by it. Through a lot of work that I’ve done, I feel like it’s a part of me. It’s one aspect of me. It is not the whole description of me, but there was a time where it was—like it was all I was doing.

LR: This ties into your earlier mention of the reproductive narrative and how we are born into reproductive narratives that sometimes define the entirety of our reproductive journey. I’m reminded of clients who bring with them the legacies and trauma of their ancestors, such as slavery, the holocaust, and other atrocities.

JB: Well, if you’re thinking about Norma, who was the original plaintiff in Roe versus Wade, she was the third generation of people who had unintended pregnancies but had no recourse, and she wanted a recourse. What ended up happening in that pregnancy—she had already had two other babies who had gone into foster care and then eventually were adopted—and so this third one, she adopted out because the courts were (are) are really slow.

There is a fantastic book called The Family Roe. The way it is written, and how it weaves it all, is just incredible. I think you asked earlier, too, about what resources are available for clinicians. There is an email that you can subscribe to. It’s a Substack you can subscribe to, and the journalist’s name is Jessica Valenti, and her Substack is called Abortion Every Day. She is really keeping tabs on what is happening on a granular state level, not just federal, but she’s been keeping tabs about like, what is the status of getting abortion on the ballot in different states, and what are the shenanigans that some representatives are trying to do to prevent it.

LR: Clearly, we’ve only scratched the surface, so I’ll simply end by saying thank you so much, Julie.

JB: Thank you, Larry.

©2024, Psychotherapy.net

The Importance of Being Heard: When Clients Need Us to Listen

“I feel completely useless to him. I feel like I could fall into a coma mid-session, and he wouldn’t even notice. He’d just keep jabbering away.”

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Navigating Challenging Therapeutic Waters

I spoke these words to my clinical supervisor, Ari. I had been a therapist for just a few months and had no idea how to help one of my clients. Tony, I told Ari, had arrived early to our first session, and before I could even ask, he began telling me his goal for therapy. “I need to learn how to cope with things, especially my girlfriend. When we get into a fight, all I can do is obsess over her. I can’t function at work; I can’t even get myself to do the laundry. I just sit there, looking at my phone, waiting for her to text me.”

I had initially found Tony’s volubility refreshing. Unlike those one-word-answer clients with whom I was struggling to connect, he would answer each question with enough detail to obviate my follow-up questions. Everything about him seemed expressive, even his thick, shape-shifting mop of black hair seeming to change each session as though reflecting his current mood.

Week after week, month after month, he shared his story, telling me about the father who had always seemed intent to one-up him and the mother who would drunkenly come into his room at night and, through tears, complain about her marriage. I started to see how he replicated these childhood conditions in his romantic pursuits, choosing self-involved and emotionally unavailable partners.

Some weeks, his hair spikier than normal, he would describe the wonderful weekend he’d had with his girlfriend—going rock-climbing, going to fancy restaurants—and wonder if she might be the one. Other weeks, his hair noticeably droopier, he would recount with tears in his eyes how she hadn’t once over the past week shown any interest in him. “It might seem like I’m playing a game, but I’m just trying to gather information. Every night last week, I asked about her day, and I’d listen and ask more questions as she went on and on about her horrible coworkers. All the while I’m waiting for something, for anything, for just one question, one piece of evidence that she’s interested in me.”   

When Tony would say that he was going to start looking at engagement rings, I would feel my muscles tense and tell myself to keep my opinion to myself. When he would describe yet another way she had mistreated him—“She gets jealous if I’m on the phone with my sister too long, but like every day she’s texting her old boyfriend”—I would ask what he wanted in this relationship and what he believed he deserved. I would sometimes try to explore the similarities between his girlfriend and his parents, but he never seemed interested in that inquiry.

I initially felt such a strong connection with him, I was now telling Ari, but then something seemed to change. It now felt like it didn’t matter if I was even there, like it wouldn’t make any difference if he spent the hour talking to my plant. He would just go on and on without even pausing. If I wanted to ask a question or share an observation, I would have to interrupt him.

Ari asked some questions and then fell silent. Ari does not have expressive hair, but I’ve noticed that sometimes his brow will reveal his emotional state, and just then his forehead lines deepened. “It sounds like you’re doing good work with him,” he finally said. But I wasn’t doing any work with him, I countered; that was the problem. “When I was starting out as a therapist,” he said, “I felt a lot of pressure to say the right thing and make the right interpretation, but that’s not always what our clients need.”

Ari said that there was probably a reason Tony kept coming to see me. I thought about this and realized that he never came to sessions late, and if he ever needed to cancel a session, he would always make sure to reschedule that same week.   

“You’re listening to him,” Ari continued, “you’re paying attention. It doesn’t sound like his parents ever really listened to him. It doesn’t sound like his girlfriend really listens to him.”

When Tony entered my office later that week, I felt, for the first time in several weeks, excited about our session. Moreover, my changed mindset caused me to see him differently. I still saw the energetic 30-something with ever-evolving hair — today’s style making him resemble Rob Lowe from The Outsiders—but as I looked into his eyes, I also saw the little boy he’d once been. I saw his excitement and fear, his longing to be heard and loved.   

The session itself felt different. I had wanted to help Tony all along, but it took Ari to help me see what type of help he really needed. I had wanted to make life-transforming interpretations, but I could now see that he was not yet at a place where he could receive such interpretations.

Tony first needed the corrective experience of being heard. He needed to know that I cared enough to give him my complete attention and move at his pace without forcing my own agenda upon him. There might be time later for interpretations, but that’s not what he needed now, and understanding that made all the difference, for him and for me.   

Questions for Thought and Discussion

In what ways are the author's experiences like those of your own?

What are some of the methods you found effective for working with Clients like Tony?

What have you found to be some of the more effective uses of supervision?