Can You See Me? Arab Immigrants’ Quests for Identity and Belonging

The multifaceted and emotional aspects of working with Arab immigrants—a community to which I belong—is something I have learned to navigate more effectively through writing. This medium allows me to articulate the ineffable and share my thoughts more sincerely and deeply.

In the coming few paragraphs, I will describe my work with American adolescents of Arab origin, some of which can be found here; my own experience of immigration and mourning; and my experience with an analyst, where the consulting room became a microcosm of world affairs. We both were lost in our own traumas, and our work could not progress. Finally, I will share my present experience in my psychoanalytic treatment in the hopes that these stories can help you better understand Arab clients.  

Between Homelands: Arab Identity and Resilience in the Face of Stereotyping and Discrimination

Although American families of Arab origin come from 22 countries with diverse cultures and backgrounds, it’s important to note that not every Arab is Muslim, and not every Muslim is Arab. Despite these differences, many face common challenges such as acculturation stress, stereotyping, and discrimination. These difficulties have been magnified by the aftermath of September 11, ongoing wars on terror, Islamophobia, pervasive anti-Arab and anti-Palestinian rhetoric, and of the war on Gaza, which has been described by the International Court of Justice as a plausible case of genocide.

The insights I share here are based on anecdotal evidence and are not everyone’s experience. While not every Arab immigrant might relate to my narrative, immigrants from other ethnicities might find similarities.

For first-generation Arab immigrants, acknowledging the profound loss of their homeland and the deep mourning that follows is essential. Furthermore, when we come as refugees, our grief is intensified by the pain, and injustice of being forcibly displaced. Additionally, issues of racism and othering often become more pronounced in their new country.

In addition to mourning and grief, Arab immigrants must balance their love for their adopted land with the awareness that they are often rejected, misjudged, and even disdained. Employing Frantz Fanon’s concept, among the White majority, we become the “phobogenic subject”—a target of racial hatred and anxiety. Imagine, as you hold your children, looking into their eyes filled with dreams and innocence, knowing that in some places, they are not seen for who they truly are but are feared and misunderstood because of these labels. In your heart, they are cherished beyond measure, yet to others, they might only represent fear and prejudice.

In our adopted societies, and even on global and international stages, we Arabs often represent Carol Adams’ “absent referent.” This term, coined by Adams—a vegetarian feminist—illustrates how subjects of oppression are discussed as if they are not present. For animals, it means the pig becomes pork, the cow becomes beef, and the chicken becomes poultry, making our meat consumption more palatable. Similarly, the identity of the Arab is reduced to labels like Muslim, backward, and potential terrorist, as a result the killing of men, women and children, and the leveling of cities becomes acceptable. Arabs are frequently this absent referent, discussed and debated without their actual representation, their narrative or voice, rendering their perspectives and humanity invisible.

It would be wholly insufficient to explore the Arab immigrant experience without delving into Palestine and the relentless war on Gaza. I realize this is a topic that often creates anger and polarization, but it cannot be avoided in this context. Since 1948, Gaza and Palestine have been etched deeply into the Arab psyche, the significance of this tragedy has intensified since October 2023. In my practice, the impact of the war on Gaza is palpable and is a replicated experience of many, if not all, clients who are against the slaughter in Gaza.

For many, if not most of us Arabs, Palestinians and racialized people of color, Gaza looms persistently in our thoughts. The plight of the children, women, and men of the Gaza strip has shattered any remaining veneers of hope, belief, and promises for Arabs and non-Arabs alike: we have come to recognize that racialized colonization is the norm. The so-called universal values of justice and human rights have conspicuously failed us.

For many of us Arabs and other people of color, the situation in Gaza, which has been described by the Israeli historian, Raz Segal, as a textbook case of genocide, has deepened our intolerance for mediocrity and double standards. One cannot advocate for the conservation of sea turtles while remaining silent about genocide, nor can one campaign against global warming without addressing the killing of tens of thousands of civilians. In my practice I increasingly see how Gaza is compelling many of us to reevaluate our actions, career choices, and investments critically: Are they promoting justice and equality for oppressed nations worldwide or merely bolstering oppressors and enriching the affluent?

I vividly recall the dismay when the U.S. persistently ignored calls for a ceasefire and blocked international attempts at halting the carnage. We were not asking for statehood or the start of negotiations—it was a desperate call for the cessation of the killing of children who could be our children, mothers, fathers, brothers, and sisters, who could be us. It was about the basic human plea to halt the slaughter. That such calls did not spur those in power to take decisive action against the atrocities—children maimed, orphaned, and slain in the most brutal manners—was beyond comprehension.

This epiphany has deepened my insight, revealing a painful truth: despite being a mother, a psychoanalyst, a well-established middle-class member of society, and a devoted New Yorker who has served this country for decades, I am perceived differently. Standing beside my White and non-Arab friends and colleagues, a stark realization dawns: “I am not like you.” It is profoundly disconcerting to suddenly see oneself through this lens, to grasp that in the eyes of others, you are not entirely human.

Against this backdrop, immigrant Arab children and families try to adapt. Children and adolescents from American families of Arab descent, especially newly arrived immigrants, tend to excel academically. However, because of this success, they often remain overlooked by research and policy. These young individuals face the challenge of defining their identity in a society that may not fully recognize or understand their history, religion, or customs.

Moreover, adolescence is typically a period marked by separation-individuation—a second phase where the youth begin to distance themselves from their parents, as described by the psychoanalyst Peter Blos. This process can be particularly tumultuous for immigrants, as it may be compounded by their cultural displacement. Such disruptions can cause difficulties in managing emotions and lead to identity confusion, issues that could be alleviated through peer support and opportunities for identity exploration.

Studies have shown that adolescent immigrants often undergo what is termed in the literature as “double mourning,” defined as grieving not only their passage from childhood but also the loss of their homeland and cultural values. This dual loss raises complex questions about loyalty in their new cultural contexts. Additionally, the literature points to significant emotional stress among immigrant adolescents stemming from discrimination, microaggressions, and acculturative stress. These factors adversely affect their social and psychological well-being. Studies focusing on Latino adolescents in North America have highlighted family conflicts and perceived discrimination as major sources of depression and acculturative stress. The role of school environments, including their ethnic makeup and the sense of belonging they foster, is crucial for the mental health of adolescents.   

Literature suggests that immigrant adolescents are prone to emotional stress, exacerbated by discrimination, microaggressions, and stereotyping. Studies highlight that these experiences can lead to a decline in social functioning and an increase psychological distress. Further studies in the United States identify parent-adolescent conflict and perceived discrimination as key cultural risk factors for stress and depression among Latino adolescents. The educational environment, particularly the racial and ethnic composition of schools and students’ perceptions of belonging, also significantly impacts emotional and behavioral issues, indicating potential areas for targeted interventions.

In addition to these challenges, Arab American adolescents face unique pressures such as Islamophobia and negative media portrayals, which can intensify feelings of alienation and cultural dissonance. A study of Arab high school students demonstrated a strong link between perceived discrimination and mental health issues, suggesting a heightened vulnerability among this group.

The Shadow of the Phobogenic Self: Interpellation of An Arab Immigrant

In my work with middle-school-aged boys and girls who, like me, are Arab immigrants, I encountered a reflection of my own “phobogenic” self—an aspect of my identity that, due to its roots in history and heritage, attracts phobic hatred and anxiety. This was not just my experience but also that of my young clients. This recognition brought to light the process of interpellation, a term revived by French Marxist philosopher, Louis Althusser, through which I became identified as the “Arab Immigrant.”

In this role of Arab Immigrant, my subjectivity was shaped not just by personal experience but also significantly by the state and security apparatuses in the United States. These external forces crafted a version of myself that diverged sharply from the person I had been before immigrating to New York. This realization highlighted the profound impact of socio-political contexts on personal identity, particularly for immigrants like myself and my clients, whose selves are constructed at the intersection of past heritage and present circumstances. To understand what I am trying to convey here, consider the image that will come up for you right after I say, “an Arab Immigrant woman.” Other than her image, how do see her life and how she conducts herself in the world?

A Vignette with the Boys: I Am You
For a three-year period, I worked with a group of middle-school-aged Arab immigrant boys. The goal of the group was to help the students adjust to life in the United States. It was the first time I had worked with my own people in a clinical setting and the first time I had worked in my mother tongue. I thought that having lived for so long in the West, I could help the boys in their transition. Instead, they helped me see a part of me I wasn’t aware of.

Early in the treatment, I dreaded the advent of each session. God forbid one of the boys should want to enter the room before the beginning of our meeting, I would eat him with my eyes. I brushed my feelings off as a reaction to the anxiety in the room. I thought the sessions were so difficult that it was understandable that I wouldn’t look forward to meeting the boys. 

The boys, although they came to the sessions willingly, could barely sit still. They fought with each other and with whoever poked his head into the room. It felt impossible to contain them and alleviate their anxiety and mine. For me, they were interpellated Arab immigrant boys in the post-September 11 era. I could only see them through a political lens. My goals for the treatment felt superficial and inauthentic. The anxiety was palpable.

Even to this day, I vividly remember how much it weighed on my chest. I was at a loss. I wished for a manual with clear steps for conducting the treatment. Or perhaps a curriculum of sorts to contain me and the group. Have you ever had a dream where you went to the exam unprepared or perhaps to class in your pajamas? Well, this is how I felt during each session: vulnerable, unprepared, and exposed. For them, I was the White teacher: Although I ran the sessions in Arabic, a language they used among themselves, they spoke to me only in English. In addition, they took liberties that I am certain they wouldn’t have taken with an Arab woman. I conducted the treatment through artwork. If they were not drawing the flag of their country of origin, they would build clay structures that resembled erect penises with testicles or would throw food at each other and make sexually tinged jokes.

My feelings towards the boys and the treatment didn’t change until I presented my work at a case conference, where I was the only Arab and the only immigrant and where I began to experience what W.E.B. De Bois called a “double consciousness” feeling: this sense of always looking at myself through the eyes of others. The audience had only positive statements to offer. Nonetheless, I couldn’t escape my feeling of being an Other.

I couldn’t overlook the fact that we spoke a different language, literally and figuratively. I realized that I did not fool my audience with my Western-looking appearance. I am different. This early feeling of disconnection and alienation came back in full force. I felt as if I had just gotten off the boat. I appreciated that it would be hard for my audience to see through the social, cultural, and political layers between us. But I felt as if the boys and I were specimens for study. We couldn’t be understood intuitively. We needed to be dissected and examined. Something felt so sterile, disconnected, and uncomfortably clean.   

Following the case conference, my feelings for and experience of the boys shifted. I could no longer hide behind the fact that I could pass for a non-Arab. I could no longer project on the boys’ disavowed aspects of my identity. I realized that I had dreaded the sessions because they were making my interpellated self intelligible to me. I had to concede that escaping this self was as impossible as escaping my own skin. The alien feeling I had at the case conference reminded me of how things were when I first landed in New York: scared, alone, and vulnerable. This memory helped me hold the boys in mind (1). I could feel their sense of alienation, experience the lack of warmth they might have felt; taste the dread of living in a land as alien as Mars, and feel heartbroken by seemingly endless losses.

My work with the group was no longer only about the participants’ transition and integration but also about my second chance to connect with my origins. It allowed me to create something of value. From then on, I felt a connection to the boys that could only bring warmth, understanding, and patience to the room. I wish I could tell you that with a magic spell I was able to contain their anxiety and work with them. But no such luck. Our work together had to take its course. I accepted my interpellated self and accepted their stigma and mine.  

A Vignette with Girls: Colonization of the Unconscious Mind
A few years ago, I worked with a group of Arab girls. Most of them wore the hijab, which is a headscarf that covers the hair and exposes the face. Some women who wear the hijab also wear a neutrally colored, loosely fitting long coat, while others only cover their hair and neck and wear Western modest attire.

I showed videos of pertinent issues to engage the students in a dialogue. One such video was a documentary of interviews with five teenagers who immigrated to the United States from various parts of the world. Two of the five interviewees were girls, one wearing the hijab. One of the girls in the group I was working with, whom I will call Houda, shared her reaction to the video. Houda, who wore the hijab, had immigrated to the United States just a year earlier. She was helpful, engaged, and engaging. A group leader’s gift. Houda was clearly upset and deeply touched by the experience of the girl in the video with the head scarf. She told us how the kids in her class often teased her. She said that once, and without warning someone pulled her scarf off. The other girls in the group gasped and looked frozen.  

When she gathered herself again, Houda continued. One day a fellow student asked why she dressed the way she did. Houda explained that she was Muslim, and that Muslims believed that God wanted them to dress like that. The student who had asked her retorted dismissively: “What kind of God is this God that would force you to dress like this?!” Houda related the story with gut-wrenching distress. She was choking, half crying and half laughing, swaying side to side, as if not knowing what to do with the pain. In Arabic, she said, “I wished I could have told her that our God is better than yours. You are idol worshipers.”

I realized then how blinded I had been by the prevailing culture’s values. I thought all along that the hijab was a liability. Following the session, I decided to do an experiment. I wanted to wear the hijab to know how I would feel to carry something so dear, something that sets me apart from most around me. By the way, I want to stress that I come from a secular Christian family. I never wore the hijab growing up, nor was I expected to do so.

That summer was the first time I tried the hijab on. I was taken aback to see myself looking like a conservative Muslim woman. I had a dream after I saw myself in the hijab. To present the dream in context, I need to share a feature of Jordanian society where I grew up: pockets of culture and tradition made of the same substance that, paradoxically, do not seem to link. Although Christians and conservative Muslims live, work together, and have warm a respectful relationship, in Jordan, they don’t always cross paths socially. In fact, it is quite unlikely for my Jordanian family to have close or intimate relations with a conservative Muslim family: in a sense, they just do not speak the same language.  

I was taken aback, therefore, when I had the following dream. I dreamt that I was back in Jordan. It was winter and the weather was rainy and dreary. Streets flooded, mud everywhere. The kind of day that makes you not want to leave the house except in emergency.

The apartment was boisterous and alive with the sounds of children, blasting radio and the cling-clang of some culinary project in the kitchen. Freshly washed laundry was spread out on every open piece of furniture. The humidity and the aroma of home-cooked food sapped every bit of fresh air. The place felt uncomfortable and tedious. Nothing was going on except chores. No playdates to relieve you from the screeches of your quarreling children, or the hope of a lighthearted adult conversation.  

The bell rang. A middle-aged woman was at the door. She was wearing a conservative Muslim dress, head scarf, and long neutral-colored coat. She was softly walking towards me. She brought with her the hope of a pleasant chat and her three children, who would entertain mine and give me peace and quiet. My sister and brother were there. They greeted her as if they knew her. I felt I should have known who she was. I felt I was expected to greet her warmly. After all, she made the extra effort on a bad day and dragged her children along to greet me and welcome me back to Jordan.

When I woke up, I realized that this woman was no one else but me. She is my interpellated Arab immigrant self. I might believe that I am an Arab Christian or think that this made any difference in my social encounters. Christian, Muslim, white, brown, or green, my internalized sense of myself is that of a Muslim woman with a headscarf, and long neutral-colored coat. I am that woman in the mirror, shackled with tradition, fighting for recognition, gasping to rise above the stigma of her heritage. I felt sad and ashamed. Ashamed that I had dismissed and rebuffed her. I denied her existence. On which peg in my New York life does she fit? Among my American welcoming friends, she could be terribly misunderstood. I thought that no matter how hard I might have tried to explain her, tried to bring her into focus, her image will always be blurred and unclear.  

From that moment onward, I began to see how my thinking was colonized. In my article Through the Trump Looking Glass into Alice’s Wander Land: on meeting the House Palestinian I use Malcolm X’s analogy of the House vs. Field Negro to describe how I was the House Palestinian I noticed how often in my work with my people, my thinking and ways of functioning come from a colonized mind. I delivered a keynote address at the National Institute for Psychotherapies annual conference. In a 16-page essay, I repeat the word Christian seven times. I repeat it as if it were an important part of my life when I rarely, if ever, visit a church, and my connection to Christianity is mostly through Christmas gifts and Easter eggs. But on some unconscious level, I felt I needed to claim this religion, perhaps to identify with my aggressor, to tell them that “I am like you,” or, tragically, to disidentify from my own people: to the hijab, a liability is in itself colonial thinking.  

At this point in my life, I refuse to refer to myself other than a Palestinian or an Arab. I believe religion began to be used to fragment our societies because bonding together and our collective power can be formidable.

Immigrant’s Mourning: Peter Pan’s Neverland

I have wanted for a long time to claim that Arab immigrants and refugees have a unique position in terms of our struggle to adapt to life in the United States, especially regarding the history of Arab-West relations and the political issues I outlined above. I yearned to claim that the Arabs had it worse than anyone else, that our pain was more chronic, our longing more tender, our losses irretrievable, and our weeping inconsolable. But I couldn’t. Alas, the DSM-5-TR does not come with a diagnosis a la carte; there is no such thing as Arab Generalized Anxiety Disorder, Russian Paranoid Schizophrenia, or Character Disorder Français. The symptoms are the same, but the causes are different. To paraphrase Tolstoy, every happy immigrant is the same, but every unhappy immigrant is unhappy in their own way. Nonetheless, we are a particularly racialized and demonized minority. We are indeed the phobogenic subject.

Arabs might arrive in the United States as refugees escaping a war-torn homeland or an oppressive regime oppression, such as Palestine, Syria, Yemen, Sudan, and Iraq. Usually, their trip to the US is difficult: in addition to having to uproot themselves and abruptly and without permission, leave family and loved ones behind, they have to find a safe passage to their adopted homeland. When they arrive, they have to adjust to a strange land, language, smells, and faces. In addition, often they have to contend with below-the-poverty-line lives: someone who might have been a well-established office manager in his home country, because of language restrictions, would end up washing dishes for three dollars an hour, barely making ends meet.

In addition to the anguish, sadness, and hardship, they must be in a society that judges them, sees them in one light, and often disrespects them and their heritage. Considering that most of us Arabs are of the Muslim faith, Islamophobia and misrepresentation of the Islamic teachings tarnish a treasure Muslim immigrants hold dearly. A faith built on surrender and respect is misperceived and manipulated and misrepresented by politicians and mainstream media. Consequently, something you hold dearly, a book that is your blueprint for good and patient living, wrongly becomes deformed and ugly. The Arab Muslim immigrant is left heartbroken and dissociated from a logic that does not make sense.

The experience of immigrants, in general, tends to include periods of mourning. I once felt that immigration was like a never-ending funeral—an infinite procession of losses—relationships interrupted, events not attended, words left unsaid, memories that cannot be recaptured… A world and life are gone forever, but they are undying in my mind. I likened this experience to Peter Pan and his Neverland (2). Peter was an immigrant; he left his home in Kensington Gardens in search of a better life.

He told Wendy that one night, when he was still in the crib, “father and mother [were] talking about what [he] was to be when [he] became a man. …” He rejected their plans and left the crib and ran to Kensington Gardens, where he lived for a “long, long time among the fairies.” But, one day, Peter Pan dreamt that his mother was crying, and he knew exactly what she was missing—a hug from her “splendid Peter would quickly make her smile.” He felt sure of it, and so eager was he to be “nestling in her arms that this time he flew straight to the window, which was always open for him.” But the window was closed, and “there were iron bars.” He had to fly back, sobbing, to the Gardens, and “he never saw his dear mother again” (3).

Peter lives on the Island of Neverland, which is make-believe, and everything that happens there is also make-believe—time moves in circles, no one ages, and most of the events are pretend. He comes across as a superhero, an invincible boy who does not want to grow up. Peter likes to portray himself as independent and self-sufficient. He claims he “had not the slightest desire” to have a mother, because he thought mothers “over-rated.” The lost boys were only allowed to talk about mothers in his absence, because the subject had been forbidden by Peter as silly. When he is away, the boys express their love—and longing—for their mothers: “[All] I remember about my mother,” Nibs, one of the lost boys, said, “is that she often said to father, ‘Oh, how I wish I had a chequebook of my own!’ I don’t know what a ‘chequebook’ is, but I should just love to give my mother one.”

Despite his claims of self-sufficiency, however, Peter longed for a mother. Every night, he snuck into Wendy’s house to listen to her mother’s bedtime stories, which he would relay to the lost boys in Neverland.

Part of the immigrant’s psyche, like Peter Pan, lives in a “Neverland,” a make-believe imaginary space. There, relatives do not age, his mother still expects him for Sunday lunch, the dog waits for him at the door, and his friends look for him on the weekends. It is where he is understood without explanations, where he does not need to spell out his name or pronounce it, where his actions and reactions are just the way they should be, where everyone looks familiar, and where he safely blends into the background. Like Peter, the immigrant does not want to grow out of his Neverland, nor accept that his country, as he knew it, is no longer there. He does not want to mourn, for doing so means losing home forever.   

The immigrant is unaware that the interpersonal scene back in his home country is not the same. Time did not stand still: his friends aged, and their roles changed; parents, siblings, and cousins moved on, and the space that he once occupied is now filled with someone or something else (there is already “another little boy sleeping in [the] bed,” to use Peter’s metaphor). The immigrant is left suspended, never landing—a spectator to the events behind barred windows and painfully aware that even if he wanted to go back, he could not.

For the immigrant, visits to his home of origin become a harsh reminder of his mortality and insignificance in the schema of life. The memories he has of himself back then, of the person he developed into—the one who “came from nothing, progressed from a primitive and physical state of being to a symbolic one” (4)—do not exist and there is no proof that he ever existed. He left no traces behind. The memories and emotional experiences he holds are nowhere to be found.

In my experience, the immigrant’s trajectory entails an effort to assuage the pain of leaving “no traces … behind” by creating something that can be productive in the new land and applauded in the old one. It has to be successful enough to make an impact back home, so he won’t be forgotten, valuable enough to mend the rupture (real or perceived) created by his departure, and desired by others enough to give him a sense of still being needed.

Just as Nibs wanted to get his mother a “chequebook,” the immigrant wants to bring back proof that the losses were worthwhile and his love for his homeland is unrelenting. Thus, to view the pain and longing as pathological and to attempt to heal it before the immigrant is ready feels to him like murder—as if separation will kill the person he once was. It is to deny that he ever belonged to a group. To move quickly past the wound robs the immigrant of the energy that propels him to harvest the fruits of severing his ties.

Just as Peter and the lost boys left their mothers behind, the immigrant leaves his mother figure—their motherland and all its symbols—behind. In the New World, they struggle with the loss of psychological existence as a member of the larger group with whom they share a permanent sense of continuity in terms of the past, the present, and the future. Accepted ways of self-expression and old adaptation mechanisms must be shed: they are, at worst, dangerous and threatening; at best, they are unique or exotic.

Freud wrote that one mourns his lost object by separating from it, “bit by bit.” At times, the immigrant’s “bit by bit” mourning of his homeland is seemingly perpetual. For all intents and purposes, his love object is not dead: the country is still there, his parents call regularly, his friends stay in touch, and he can reach his siblings anytime. But he mourns the loss of his country on every significant occasion that takes place there. He might rejoice in a sibling’s wedding, but he will not know the little stories and many encounters that kindled the couple’s love; he might be sad that an uncle died, but he cannot and will not miss the uncle the same way others will. His presence at the funeral or his letter of condolence is that of an outsider; he is the undesignated mourner, unable to soothe or be soothed.

When the immigrant arrives in the new world, he spends much of his psychic energy adjusting and adapting. Unconsciously, he survives on the mistaken belief that his “secure base” is stable, and he can “refuel” anytime.

Speaking of my personal experience, my emotional connection to my country was like Peter Pan’s Neverland—a make-believe space where people never age, and time goes round in circles. My house is just as I left it the day, I moved out more than 40 years ago—as if my teenage siblings are still waving goodbye, as if my friends look for me every weekend, my mother waits for me for Sunday coffee, and my father is no older than I am now. But my sister and brother are parents now, my father passed away, and my friends are busy with new commitments. I am only a spectator behind the barred windows to events that move me, but I can’t touch. To use Peter’s metaphor, there is another baby in my bed.

For many, especially Palestinians, returning home can be a jarring experience, a stark revelation in black and white of all that has been lost, how life has irrevocably changed through no fault of their own. Your home is occupied by someone else, the streets you walked on as a child are barred for you, your neighborhood and your streets have been renamed, and the shop down the corner is now a supermarket that has been built on top of the ruins of most of your neighborhood. “I’m trying to understand why the sight of my son standing near the gate of the house, on a bench stretching to catch a closer glimpse of the garden, shattered my heart”

Recently, my son and I visited Palestine. One winter morning, we went to see my mother’s home in West Jerusalem—the home she lost in 1948. I arrived to find everything as she had described: the big stone construction, the arched balcony, the two staircases, and the lemon tree. It was all there. I longed to nestle under the tree, climb the stairs, or perhaps stand on the balcony. Of course, I could not; this was no longer my home. To this day, I’m trying to understand why the sight of my son standing near the gate of the house, on a bench stretching to catch a closer glimpse of the garden, shattered my heart. Perhaps it felt like he, too, was mourning, dreaming, and wondering what could have been. Or perhaps it was the sense of powerlessness to protect my son’s rights, his dreams, and his wishes.

Radioactive Identifications and the Psychoanalytic Frame

The psychoanalyst Wilfred Bion recommended that we approach treatment without “memory, understanding, desire, or expectation” (5). Is that possible when the intersubjective space is flooded with trauma, hurt, grief, and rage—when it is drenched with sociopolitical forces beyond the control of the clinical couple? Can we hold the psychoanalytic situation when the power differential is not only between expert and client, but also between colonizer and colonized, terrorist and terrorized?

In such circumstances, any communication between the clinical dyad, even silence, Bion argued, is liable to create “an emotional storm.” To sail safely through this storm, the analyst needs to maintain clear thinking. But if the situation becomes too unpleasant, the clinician might opt for other forms of escape, such as sleeping or becoming unconscious. I would argue, based on the personal experience I describe in an article I wrote a few years ago, entitled “Where the Holocaust and Al-Nakba Met: Radioactive Identifications and the Psychoanalytic Frame,” that under circumstances such as those above, it is nearly impossible to do anything more than make “the best of a bad job,” as Bion noted.

In my article mentioned above, I delved into the intersection of historical trauma, psychoanalytic treatment, and sociopolitical influences through my personal experience. As someone of Palestinian heritage, I engaged in therapy with a Jewish analyst, the descendant of Holocaust survivors. Our interactions became deeply influenced by the respective historical traumas associated with our backgrounds—mine with the Palestinian displacement known as Al-Nakba and his with the Holocaust.

The concept of “radioactive identifications,” first introduced by Yolanda Gampel, is central to understanding the dynamics within our therapeutic sessions. These identifications refer to psychic remnants from memories of extreme social violence that remain potent and disruptive. In our therapy, these identifications manifested through various interactions, complicating the therapeutic process.

I worked for a little over two years with an analyst whom, in a paper published, I call Dr. Shamone. I chose Dr. Shamone, a queer Jewish analyst opposed to the American Psychological Association’s complicity in torture, hoping he would understand the experience of being an Other. I was unaware of his anti-Palestinian beliefs at the time. Our early sessions were promising; I felt comforted and believed he was genuinely interested in my well-being.

However, a few months into our sessions, Dr. Shamone accused me of vandalizing his air-conditioner with graffiti. He believed the scribble, which looked like a combination of our names, was my doing, likening it to the act of “teenage lovers.” I could not believe what I was hearing. I sat in utter shock and dismay. I felt my heart shatter into a million pieces. I could not speak. My eyes were welling up. I felt overwhelmed with sadness, disbelief, and powerlessness. Who am I to this man? I wondered. How does he see me? Which part of me comes across as an irresponsible, immature woman who acts like an adolescent? Which part of me seems like a potential vandal and someone who would break the law so nonchalantly?

I spent the time between this session and the next researching the graffiti. Could it be an artist who scribbled on people’s air-conditioners? What could this word be? At the next session, I told him I thought the word on the air-conditioner could have been “Lakshmana,” which is part of the name of an organization called LifeChange. Dr. Shamone acknowledged that a week before the session, someone researching this organization visited him while writing a critical piece on the organization, accusing it of harming those who join it. It didn’t occur to me to ask him why it was that he accused me instead of wondering whether the researcher or someone belonging to that organization was responsible.

I am a Palestinian, but not a Terrorist

I entered psychoanalytic treatment with Dr. Shamone about 13 years after the September 11 tragedy. At the time, I thought the difficulties I faced had more to do with being an Arab from the Muslim world in an environment that demonized and feared people like me. On a conscious level, I was, of course, aware of my heritage but did not realize the extent to which radioactive identifications with intergenerational trauma and global events could affect the treatment. In the consulting room of Dr. Shamone, such identifications seeped between us — formless, odorless, and deadly.

Dr. Shamone began to struggle to keep himself awake during the sessions. Halfway into our meetings, he would become drowsy, his eyes would close, and his head would hang over his chest. At first, I felt as if I needed to protect him. I did not want to embarrass him. When I saw him dozing off, I would look away, pretending I had not noticed. One day, I came in with a bunch of chocolate bars. He wondered if I had a crush on him; perhaps chocolate was a sign of love. I said, ‘‘No, it is just that chocolate contains caffeine.’’ He responded, “You know, you are right, I gave up coffee a while ago.” I smiled and thanked him for accepting my gift. I thought then that his sleepiness was perhaps nothing personal, but caffeine withdrawal symptoms.

During this period, persisting to the end of our treatment, our relationship seemed to oscillate between a waltz, a judo fight, and an extended Amy Goodman interview. Dr. Shamone was only able to remain engaged and present when the discussion centered around Middle East politics. But when issues of everyday life took the place of politics, and topics such as my boyfriend, children, or work took center stage, he would feel drowsy and doze off. It was as if this monster between us was too much to bear if it wasn’t being continuously addressed. The monster had to be front and center; when it was hidden, the atmosphere became heavy and pregnant with unuttered statements. This dynamic continued for over a year.

Finally, I began to take his sleepiness personally. I felt this way because it was then that I began sharing my childhood trauma. I told him that I would feel hurt when he fell asleep and did not know what to do with that. Other times I would tease him; as soon as I entered his office, I would ask, “Are you going to doze off today?” This question usually worked, and he would stay awake.

Dr. Shamone felt certain that I was bringing something to the room that was making it hard for him to stay awake. He said at times what I was saying felt confusing, which made him lose concentration. But his conclusion shed no light on anything useful. Now I wonder if his sleepiness was a way to evade the reality of our dynamic, a flight from his feelings about me, or a way to escape from a traumatic memory that was being triggered by me.

Perhaps it was I who held unbearable trauma that he sensed and could not handle. Maybe he could not bear feeling responsible, at least in some way, for the trauma that led to my damaged mother. Or, perhaps, this was a parallel process to what Palestinians experience their predicament unrecognizable, their lives ungrievable, and seemingly on the road to annihilation. At the same time, the world dozes off on the sidelines.

During that period, I began to censor myself with Dr. Shamone. The analysis stopped being about my internal process and growth, but about how to keep Dr. Shamone engaged, about what material to bring in so he would remain present.

As I considered ending our work together, Dr. Shamone suggested, “Make sure your next analyst is not Jewish.” When I expressed my hurt, he added that I might harbor murderous intentions and come to the session with a weapon. This statement was a final blow, making me feel utterly alienated and unsafe.

In one of our last sessions, I told him about the fictitious traits I endowed him with when I approached him for treatment. I said, “I thought you would not be supportive of the Israeli government. I imagined that you were pro-Palestine.”

“Of course, I would be supportive of Israel! If things get tough for me here, I could always move there and be accepted.” I responded with a heavy heart. “Will you be living in my grandmother’s house?”

With a confused look on his face, he was quiet for a moment. Then he said in a thoughtful tone, “Sometimes we hurt each other.”

Back to the Present: My Journey with My Current Jewish Analyst

About two years ago, I began working with a supervisor to enhance my skills as a couple’s counselor. The supervisor was incredibly thoughtful, kind, and down-to-earth, with no pretenses, just analytic love and acceptance. Our connection transcended a mere supervisory relationship, embodying profound care and hope for my well-being on this life’s journey. Consequently, I decided to engage in personal analysis instead. While we sometimes focus on supervision, our interactions are primarily a therapeutic dyad.

Having previously worked with Dr. Shamone and had this painful experience, with my present analyst, I immediately brought up Palestine after expressing my desire to become his analysand. He reflected, “If you had asked me 20 years ago, my response would have been different. Now, I understand the situation on a much deeper level.” I have been with my current analyst for over two years now, experiencing significant personal growth and feeling deeply grateful for his attentiveness and presence. When the war on Gaza began, he would check in on me regularly, even outside our sessions, to ensure nothing was overlooked and to express his concern during those difficult times.

Contrary to Dr. Shamone’s advice, my current Jewish analyst has become one of the most important and healing people in my life. I continue to work with him because he is an honest and caring witness to my life and genuinely cares about me. Each session enriches my understanding of how to live authentically and trust myself as a therapist. Like my analyst, I strive to be authentic, helpful, and deeply caring with my clients.

Reflecting on my experience now, several years following the termination of treatment with Dr. Shamone and having this analytic experience with my present analyst, I find it insufficient and too generous to attribute my ex-analyst’s action solely to radioactive identifications. I have come to believe that my ex-analyst’s behavior was not just professionally unethical but overtly racist. His demeanor and actions towards me perpetuated a narrative that cast me in the role of a terrorist, devoid of an unconscious—my words came with subtitles I did not write.

Can You See Me?

Remember the experiment I mentioned earlier about wearing the hijab myself? On several occasions, I would wear the hijab and go about New York streets, watching for reactions. On my first trip, I discovered that there was a social network hidden in plain sight. Women wearing the hijab and men who seemed to be Middle Eastern or South Asian acknowledged my existence. They greeted me with a look, a gentle nod or some gesture, as if to say: I am here for you. I see you. I am like you. I realized how much I had been missing. That I have brothers, sisters, and a family I never tapped into. On other occasions, and for no apparent reason, my projections left me anxious and feeling in danger. I was worried someone would intentionally push me or pretend to be tripping and bump into me, or that I might be lynched in plain sight.

One summer, I had foot surgery and had to use crutches. During those times, when I traveled around New York in Western dress, I felt taken care of by many. For example, I never lacked a seat on the subway. Riders would rush to give me theirs. Dressed like a Muslim woman, I felt as if they looked right through me. As if I didn’t exist. Crutches or no crutches, they didn’t know what to do with me. I did not feel discriminated against per se, I just felt invisible.

A feeling of sadness and loneliness took me over. My Palestinian or Arab self is a charged topic. I, therefore, often enter my social encounters edging to be seen, but opting to hide.

I realized that there is a point that my dear psychoanalyst cannot enter;

I wish I could let him in. Perhaps I can hum a tune of a song he’d remember.

I wish he could smell the air of my land, see the beauty in desert roads, rundown houses, and joyfully running barefoot children with smudged clothes.

I wish he could taste the food I miss and know my teenage friends who are grandparents.

I wish I could mention the name of a neighborhood and he’d tell me about the streetlamp that stood there.

I wish he could laugh at my Arabic jokes, know a poem or two, or remember a public holiday.
But I don’t want to share my misunderstood traditions—I don’t want to find out how peculiar they seem to him.

I don’t want to introduce him to my beloved Palestine, I am afraid I might find out that he can’t understand the endless heartbreak I experience daily.

I don’t want to share my wish to remain in Neverland, where time goes round in circles, where no one ages, and where my siblings are still waving goodbye. I don’t want him to tell me that no such land exists.

I don’t want to uncover my inner world and end up being a specimen—dissected by his skilled psychoanalytic blade and disjointedly reassembled.

I really don’t want him to see me, all of me. I just want him to sit with me, hold my pain, blow on my wounds, and just answer “yes” when I ask him:

Can you see me!?

References

(1) Allen, J. G., Fonagy, P., & Bateman, A. W. (2008). Mentalizing in clinical practice. American Psychiatric Publishing, Inc.

(2) Barrie, J. (1911). Peter Pan. Barnes & Noble Classics.

(3) Kelley-Laine, K. (2004). The metaphors we live by. In J. Szekacs-Weisz & I. Ward (Eds.), Lost Childhood and the Language of Exile (pp. 89-103). Karnac Books.

(4) Becker, E. (1973). The Denial of Death. Free Press.

(5) Bion, W. (1970) Attention and Interpretation. Tavistock.

 

©2024, Psychotherapy.net

Standing With Clients in the Twilight of Life

Chris had advanced cancer, and only a short time left to live.

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Connecting at the End of Life

Chris was in his 70s, and he felt full of regret as he approached the end of his life; he felt afraid of dying, and disappointed in himself. He believed he’d damaged and lost all the key relationships in his life — who would want to be near to him now, he wondered?

In the course of our weekly therapy conversations, Chris came to realize ways his selfishness had hurt his personal relationships, and he came to recognize that his supposed preference for a solitary lifestyle had become an excuse or rationalization for his estrangement. He thought, though, that he was now paying too dear a price for his errors: dying alone in a nursing home.

Chris lacked a formal religious faith, yet he had spoken of his vague sense of a life beyond this one, and he expected to again see the loved ones who had already passed away. One morning when I came to his room, Chris was sitting on the edge of his bed crying.

He looked up and said, “Talk to me, Tom, I’m scared.”

I pulled a chair up close and looked at him and spoke quietly.

“Chris, when you first came here, you told me you thought you had wasted your life and burned all your bridges. You thought that you’d made all the wrong choices, and had neglected relationships, and that you would die alone.

“But you have been surprised by so many things that have happened during the past few months. Your son came from the west coast to see you and decided to stay here with you till the end; and you thought you had lost him. You hadn’t spoken with your sister for years, yet she and her husband have become regular visitors to you here.

“Many friends you had long lost touch with have reappeared, and you didn’t know how they found you or learned you were ill. Look around the room, Chris, and see all the gifts and cards and flowers you have received from people you thought would not know or care that you were ill. So many unexpected hands have reached out to you, Chris, to help comfort you as you prepare to move on from this world; you never expected such tenderness and reassurance.

“You have spoken lovingly of your parents and grandparents and aunts and uncles, and how you look forward to seeing them again on the other side. So, here you are Chris, poised between this world and the next. You have been loved by many over the past few months, even when you had believed yourself to be unloved. Many hands have been extended to you in this world to help you on your journey, and you anticipate many hands to greet you when you arrive in the next world.”

His quiet sobbing subsided, and he gave a big sigh and said, “Okay, okay, thanks, I feel better.”

A few days later Chris quietly passed.

Nursing homes, typically less formal than outpatient settings, have been special places for me as a psychotherapist, especially when I encounter people with major or terminal illnesses. I commonly engage in exquisitely poignant therapy conversations about life and coping, and about dying and grieving. Clients facing the end of their lives often feel a need to speak openly about their fears, hopes, doubts, and beliefs. Meeting their needs often involves bold entry into topics sometimes avoided or not considered as part of treatment. But it can be profoundly touching and rewarding to meet clients directly in the midst of their most vulnerable moments.

Questions for Reflection and Discussion

What are your reflections on the type of clinical work this author describes?

In what ways do you embrace or avoid working with the elderly or dying client?

What are some clinical challenges that might accompany working with this population?  

When Symptoms Overshadow a Diagnosis: Psychotherapy as Archeology

When a prospective client makes an appointment to “work on my anger,” I can never be sure what other, deeper issues might lie beneath that common presenting concern. In my clinical experience, anger rarely exists in a vacuum, leaving me to wonder if it is driven, for instance, by personality pathology, trauma reactivity, or rooted in a specific mood disorder that will also need addressing. The person might hyperbolize or downplay their anger problem details during the phone screening. I have also come to wonder if their anger could fuel hair-trigger sensitivity and reactivity, which might add an element of danger to the therapeutic relationship.

Early in my career, I worked in a jail where I intervened with many acutely angry individuals. I knew my way around potentially dangerous people. While their anger required more immediate address, often with solution-oriented methods, what had always interested me more deeply was discovering the person beneath the anger. However, given the nature of corrections, inmates frequently moved for programmatic and security reasons, so my time with them was short, and my interventions were symptom- and situation-focused.

An existentialist at heart, I always wondered about peoples’ internalized experiences. What kind of meaning do they assign to phenomena? What defenses are at play? How does that all affect the clinical picture and what kind of material is in there to work with for better gains? Thus, what I later came to appreciate about working in private practice rather than institutional settings was spending more time with people and really getting to know them. I was better able to contextualize and understand symptom functions and help clients learn about themselves and to relate more effectively with others — especially when anger entered the clinical frame.

Robbie Needs Anger Management

When Robbie’s mother, Jane, called for an appointment for him, I was expecting him to be a child, perhaps even a teen as opposed to being in his early 20s. “He lives with me and is doing OK, but he’s been diagnosed with ADHD for years and can get rageful. He’s got to clean this up and stop living in the fast lane if he hopes to hold a job,” she shared.

I learned that at one time Robbie was on ADHD medication, but discontinued it after he completed high school, and had no interest in restarting it. Jane shared that it was questionable whether the stimulant medication had much of an effect, anyway. She was hoping that meeting with a male therapist, someone he might relate to, who encouraged exploring his emotions and aspirations, would prove more effective.

For his first appointment, Robbie arrived with Jane. They sat next to each on the couch across from me and seemed to interact amicably, something that didn’t always happen when family members arrived together. Robbie nodded along to Jane’s historical details about his development and family matters. He sometimes reminded her of a detail or filled in a blank with his personalized recollection. While Robbie was fidgety at times, he did not exude a hyperkinetic or inattentive vibe. Throughout, he maintained a bit of brightness, as if there were some contained excitement, but it was too early to explore deeply.

At first glance, I considered the possibility of ADHD. Clients I’ve worked with who have been diagnosed with ADHD have low frustration tolerance that often led to angry outbursts. Further, like the prototypical class clown who has that ever-present grin, Robbie had an ongoing light smile of sorts, and he could be a little interruptive and fidgety. “Perhaps, if he indeed has ADHD, he’s just learned to manage well,” I thought as the interview went on.

Therapy with Robbie Begins

On the day of our first therapy appointment, I heard a motorcycle pull up out front, and a second later, in walked Robbie with his helmet. “What a day for riding,” he beamed, taking off his jacket and making himself comfortable on the couch. “What do you enjoy most about being on your motorcycle?” I asked.

“It’s the thrill,” replied Robbie. “King of the road! Just taking off and maneuvering. It’s harder for a cop to get you, too!” he laughed.

Settling into the session, I said, “I wanted to ask, how was it for you last week when we met for the first time with your mom here?” “It’s all good,” said Robbie. “We have a great relationship. She told you everything.”

“She gave me a lot of information, for sure. Given it’s your time to meet with me, I was hoping to hear more of your thoughts about what you’d like to get out of coming here.” Robbie admitted he wasn’t sure.

He explained he knew he was directionless, watching friends finish college or settle into long-term relationships and jobs. Nonetheless, he said he felt free and like he was having a good time and that it would all work out. “Maybe I’m a ‘live fast, die young’ kind of guy. My mother always tells me I can’t last if I don’t get some direction,” he finished, rolling his eyes.

Clasping his hands behind his head and looking about the room, Robbie circled back to my question. He wondered out loud what one does in therapy. “I mean, I do get frustrated easily, and bored quickly. Those medications I took way back didn’t do much. Maybe I focused a little more in school, which was cool, but, you know, this is me. Why do people get frustrated with me if I get frustrated or want to do something? That’s ADHD, right?” he grumbled.

“What can you tell me about people getting frustrated with you for getting frustrated?” I asked.

“People can get under my skin. It’s not just my mom about ‘getting direction.’ She just wants me to be successful. I’m not too irritated with her. I get it. But other people, it’s like they can’t keep up with me or something. I’ve had girlfriends say it, and when I get people together for ski trips or rock climbing, they can’t keep up. If I want to have fun, it seems it’s got to be on my own. I get pissed off. I don’t want to, but people come with me, know I go all out, then complain I’m wearing them out when we’re skiing at first light until dusk. I don’t want to waste time, you know? Make use of time on that vacation!”

“What exactly happens?” I asked.

“Err, I got really pissed one time last year and smashed my GoPro camera as I let my friend know what I thought about his whining,” Robbie said, irritably. “I mean, c’mon, you come on a ski trip and don’t want to ski? Then I’m like, ‘f*&k it, I’m still gonna have a good time,’ and skied off.”

Robbie quickly lit back into a bright expression.

“Are you still friends?” I continued.

“Yeah, he knows it’s just me. He’s seen it before. I guess I’m an acquired taste,” laughed Robbie.

Throughout, Robbie could veer off course, getting distracted by a topic that seemingly popped into his head. It never seemed he had much attachment to the discussion.

Over time, I learned more about other relationships, such as when Robbie told me that dating was tough. It wasn’t because of aggression, but rather he felt he burned out girlfriends. “I’ll find a girl who I really vibe with, and we’re climbing and stuff, and hanging out a lot at the start. A lot of energy, you know? But then, like this one girl, she wanted to do more chill stuff like typical dates to movies and dinner and family events. I really tried to accommodate. I liked her a lot. I tried to have my cake and eat it too by getting together during the week for after work cycling or going to the climbing gym. She told me she just couldn’t handle that activity load. We’re still friends though.” Robbie’s brightness flattened.

I replied, “I can’t help but notice your expression changed, Robbie.”

“Hell, I do get lonely,” he admitted. “I want someone to do stuff with! I like sex and all, but I can get that on demand with girls I’ve known over the years. Chicks dig me, haha! But those girls don’t have to deal with me like a relationship girl would, I guess.”

“What more can you tell me about this loneliness?” I followed.

Robbie explained that he never quite felt “full.” On one occasion when he seemed dull compared to his usual energized self, I acknowledged that I noticed he did not seem the usual Robbie. He said it was one of the “not full periods.” Robbie was able to liken it to a silo that gets filled with grain but has a leak, emptying it again, then hearing an echo within. After some exploration, it seemed that Robbie’s activity level was the grain, keeping him feeling full, but even that had its limits when he couldn’t keep up with it.

“What happens on the occasions you encounter the echoing silo? What’s it like? How long might it stay empty?” I inquired.

“Dang,” began Robbie, looking away. “I lose my excitement vibe, you know?” He continued that he force feeds himself activity to try and get back the momentum and fill the silo, but it’s a trudge. He might have days of feeling apathetic and stuck in his head, thinking too much. He described how he can get to belittling himself for probably being a disappointment to his mom, who had it tough and had dreams for him. “It’s all kind of exhausting,” he finished. With half of his usual energy, he grinned and said, “But I’ve learned to accept myself.”

It sounded to me that Robbie was prone to crashes into depression and that he had a polarized self-concept.

Between sessions, I found myself realizing Robbie’s restlessness and impulsivity weren’t so ADHD-like afterall. When I combined this with how Jane denied any clear early history of typical ADHD symptoms in Robbie, and that she denied having any perinatal ADHD risk factors, I began drawing a different conclusion.

A Hypomanic Personality Dynamic

Robbie was clearly a depressed young man, and it seemed he had a sort of “keep active” or “moving target defense.” He was living a duality—a depressed inner world that he kept suppressed with a hypomanic defense. Perhaps the ultimate denial!

I didn’t realize it at the time, but Robbie was exhibiting what some have called a hypomanic personality, sometimes referred to as a hyperthymic temperament. While not included in the DSM or ICD, the hypomanic or hyperthymic personality are nothing new, and, in fact, have remained of interest to various personality experts (see references).

Millon provided descriptions of this personality style from historical giants. Kraepalin, for instance, said that these are patients who, “…throughout their entire lives display a ‘hypomanic personality’ pattern without severe pathogenic developments [i.e., crashes into full affective disorder episodes].” Schneider wrote, “hyperthymic personalities are cheerful, kindly-disposed, active, equable, and great optimists. Often, however, they are shallow, uncritical, happy-go-lucky, cocksure, hasty in the decision, and not very dependable.” McWilliams, perhaps the modern authority on this personality 100 years later, provides similar descriptions.

A movie character fitting a hypomanic personality that readers may be familiar with is Paul Mclean, played by Brad Pitt, in A River Runs Through It. Also, the portrayal of Scott Scurlock, an infamous 1990s bank robber, featured in the recent Netflix show called How to Rob a Bank, exemplifies a more intense case in that Scurlock’s personality also entailed sociopathic characteristics.

In time, I learned that those with what could be considered a hypomanic/exuberant personality may feel more alive chasing rainbows than the idea of long-term success, for this would require a type of settling, and thus, stagnation in their eyes. This is dangerous because they depend on being a moving target, lest their depressive ghosts catch up with them. Unfortunately, while an immediate salve, this perpetual motion encourages the cycle, for lack of success engenders a sense of failure, feeding depression, which the hyperthymic activity defends against.

Their solution to troubling emotions is the problem. As described by McWilliams, living this energized, unstable existence can become exhausting. Thus, the defense becomes weakened enough that the suppressed internal depressive experience crashes the gate until the energized state reconstitutes and corrals the depressive escapee back to the sidelines where it can only shout insults, which the guard ignores via enthusiastic distraction once again.

The Therapeutic Work with Robbie Deepens

After spending numerous sessions learning about Robbie and encouraging him to engage in sharing/self-revelation, we began more pointed work.

“Robbie,” I began, “from what you shared, correct me if I’m wrong, but it seems like that ‘being active’ protects you from having to deal with that hollow feeling?”

He agreed that it’s the pattern. “It seems like, if you really look at it, life has become a defensive act against feeling that hollowness,” I continued.

“I’m curious,” I began again, “have you ever thought about what life would look like when it’s really going your way?”

“Yeah, not having this moody stuff. Finishing things.”

I asked, “When can you recall that you weren’t moody?”

“I’m not sure. Maybe when I was pretty little. I remember playing and being happy with my dad and brother, the whole family.” Robbie had shared that his father eventually cheated on his mother and left, and she had to work, so wasn’t around as much. Eventually she got a divorce settlement and was able to stay at home more.

It became clear that Robbie harbored a lot of feelings of rejection and subsequent sadness; he was living two sides of the same coin with the ever-present sadness being defended against by an exuberant denial.

In order to stop this rollercoaster, since the hypomanic defense was a product of his bleak internal world, therapy would need to resolve his feelings of rejection that encourage the sadness.

“Like I said, I want a steady girlfriend,” explained Robbie.

“You’d like a meaningful relationship, some real intimacy?”

“Of course.”

“Strictly romantically, or?”

“I don’t want to have arguments with people like what happened with my friend, either.”

As if Jokey Smurf entered the room, Robbie laughed about breaking the Go-Pro camera and the horrified look on his friend’s face. “It’s crazy! I’m like some f**ked up movie character sometimes. But that’s being human, right?”

“Humans can act f**cked up sometimes, for sure, but I recall you saying you really didn’t want it to keep happening for you. I’m curious about what’s behind the laugh about it,” I inquired.

“Man, you therapists find stuff under every rock, don’t you?” asked Robbie, trying to evade my question.

“Hey, you told me you want to learn to make some changes, so it’s my job to notice things that might get in the way. To me, if someone has a contradictory response, it tells me they could be struggling to be real with themselves. Make sense?”

“So, what, I can’t laugh at myself?” he followed.

"Not taking oneself too seriously can ease the pain, can’t it?” I continued.

“It’s the best medicine!” Robbie added.

“Robbie, what are you medicating?”

With that, Robbie said he can’t escape some frustrations so laughs about them. Upon examination, his frustrations were rooted in painful ruminations, coupled with the exhaustion inherent in not being able to stop running if he is to “deal” with them. Distraction was corroding him, but admitting he had little steam left made Robbie feel vulnerable. He would often run on fumes, only to discover some psychological alchemy that provided fuel for the escape rides, which, over time, we saw were getting shorter, almost episodic. Whether this was the result of something therapeutic, such as feeling there was someone to help him manage what lay beneath, incrementally lowering his defenses, or a natural dip in childish energy that occurs as one eases into adulthood, it is hard to say. Regardless, Robbie’s more frequent low points were taken advantage of, where he would become more revealing of his years-long festering conflicts.

Effecting Deeper Therapeutic Changes

In months that followed, Robbie continued with an almost cyclothymic presentation. But the nature of the moods changed. There were peeks at more vulnerable parts of him. He kept up an energetic cheerfulness, but it wasn’t so charged. There were often peeks at actual lamentation and sadness that accented what was left of the hypomanic demeanor. At times, it was more of a reactive, temperamental mood. This seemed corollary to being more in touch with the depressive foundation; making contact with painful memories can be anger-provoking, and great therapy material.

There was still restlessness at times, but not in the old hypomanic sense. It was rather a more nebulous anxiety as Robbie edged into being more self-revealing and exposing his internal landscape. We seemed to be contacting bedrock issues, which, like in geology, would seem like stable turf, but if there are nearby fault lines, that could all change.

But Robbie learned more about the language of emotions and being real with himself. He realized that under it all, he hoped someday to discover it all never happened, but eventually accepted the idea he can’t somehow have a better best. With the disintegration of the denial, the smoke screen of exuberance he made for himself continued to lift. Relationships improved. When he felt more in them, he related better, leading to people being able to have more constructive, stable relationships with him and his fear of rejection no longer had a leg to stand on.

Over this two-year span of meeting with Robbie, I was never sure of how tenuous progress was. Would his psychological fault lines quake? He was invested, rarely missing an appointment, and had made strides in reducing the initial concerns and being more real. It often felt like skiing in avalanche country where anything could upset the delicate structure of snowfall and off it goes, taking everything established in its path with it.

As we wrestled with his long-simmering conflicts and learning to better understand himself and relate to others, Robbie began taking non-matriculated college classes to see what school was like. This was good grist for the therapy mill. Productive, real-world structure. In the meantime, Robbie still enjoyed his interests. Along came a part time job, then a girlfriend. Then the end of our sessions. Sometime after, Robbie left a voicemail asking for a letter about his having been in therapy and if he was ever a danger to anyone. Apparently, he was moving in with his girlfriend, who had a child whose father was contentious and heard Robbie had been in mental health care for being explosive in the past.

Postscript

I can’t help but feel that Robbie wouldn’t have reached this stage if his encounter with mental health care continued to see him as having ADHD, or as having problems with anger control. Some people say diagnoses don’t matter, that “we treat symptoms and not diagnoses,” which has the implication that symptoms can always be treated similarly. This can be a specious and dangerous outlook. Symptoms may occur across diagnoses, but that doesn’t mean they’re treated similarly. This diagnostic consideration of hypomanic personality, despite the debates about its legitimacy, allowed me to contextualize the nature of Robbie’s symptoms, which guided my approach to intervening with him. If merely addressing symptoms was sufficient, it wouldn’t have mattered if Robbie’s presentation was chalked up to ADHD or a hypomanic personality. The ADHD medications in theory would’ve fixed him.

We generally never know how our patients fare in the long term. Robbie’s hypomanic presentation was deconstructed, and an honesty about his life settled in. Consistent structure followed, highlighted with the activities he’d escape through, but now in more moderation. A semblance of a well-balanced interaction with himself and the world took form. Chances are, spot-reducing symptoms wouldn’t have allowed such a rich experience. Symptom reduction is great, but how does the person now live with their newfound experience? Does it have stability?

Personality is important, whether it’s pointedly treating personality disorders or helping someone integrate updated parts of existence into their being and work that into the world around them. Hopefully, Robbie is a reminder about the intricacies of therapy. It certainly was to me! It’s more than what’s observable, and what’s observable isn’t always what it seems.

References

Akiskal, H., Placidi, G., Maremmani, I., Signoretta, S., Liguori, A., Gervasi, R., Mallya, G., &Puzantian V.R. (1998). TEMPS-I: Delineating the most discriminating traits of the cyclothymic, depressive, hyperthymic and irritable temperaments in a nonpatient population. Journal of Affective Disorders (51),1, 7-19.

Jamison, K. (2005). Exuberance: The passion for life. Vintage.

McWilliams, N. (2011). Psychoanalytic diagnosis: Understanding personality structure in the clinical process. Guilford Press.

Millon, T. (2011). Disorders of personality (3rd ed). Wiley.

Oser, D. (2019) Hyperthymic temperament. Psychiatric Times, 36(9). https://www.psychiatrictimes.com/view/hyperthymic-temperament  

The Secret to Forming Powerful Relationships that Spark Change

The very best paper on how psychotherapy works was also one of the earliest (written in 1936) – Saul Rosenzweig’s “Some Implicit Common Factors in Diverse Methods of Psychotherapy.” It made the bold prediction that the psychotherapy relationship is much more powerful than specific psychotherapy techniques in promoting change. Hundreds of studies comparing different forms of psychotherapy (mostly done during the last forty years) confirm Rosenzweig’s brilliant intuition. Although a given specific technique may occasionally score a small win over another specific technique, the overwhelming number of randomized clinical comparisons result in tie scores. It’s remarkable how little this robust finding from psychotherapy research has impacted on psychotherapy training and practice. Most training programs focus on teaching just one narrow- gauge technique and their graduate practitioners tend to identify themselves for life by the school of therapy in which they trained. Paradoxically, then, most psychotherapy training pays least attention to what matters most in clinic practice — forming a powerful healing relationship with the patient. And psychotherapy training also often ignores the most important practical issues that help determine the nature of that relationship. If and when should a therapist give advice? What if any is the place of humor in therapy? Is it OK ever to self-disclose? What kind of contact makes sense outside of sessions and after treatment ends? We will briefly touch on these issues.

Forming A Relationship

The first session with any new patient is by far the most important — if it doesn’t get off to a good start toward a strong relationship, there may not even be a second session. And first impressions do have a very strong impact on the later ones. The patient will always regard the first meeting with a therapist as an important life event and it is important that the therapist never treat it as routine. I loved first meetings — the chance to be helpful; getting to see the world through another person’s eyes; the excitement of a new relationship; the challenge to my empathic and relating skills. Getting information is, of course, an important goal of every first visit, but getting the patient’s attention and confidence is even more important. The patient must leave the session feeling understood, that you care, and that you know what you are doing; Diagnosis and psychoeducation are part of establishing an empathic relationship. It is a great relief for patients to learn that their previously puzzling symptoms fall into a well-recognized pattern, with a fairly predictable course and well recognized, effective treatments. They are not uniquely damned; not hopeless, not alone. Treatment plans are negotiated between patient and therapist — never delivered from on high. Options are offered with an explanation of the pros and cons of each- and the patients get to choose what best fits their goals, needs, and resources. Decisions made early can always be revised as more is learned and the relationship deepens. The patient should leave the first session much more hopeful than before they arrived. This must be based on realistic hope encouraged by the developing new relationship and a sense that presenting problems have been understood and are manageable. But note; there is no room at all for phony reassurance or underestimating the work that must be done. I would often end a first session saying something like: “if you really put your heart into this, and I put my experience, I think that together we can accomplish a lot.”

Is It Ever OK Ever to Give Advice?

Many training programs, and their graduates, teach and preach against ever giving patients advice. This is based on the theory that advice always reduces patients’ autonomy and ability to figure things out on their own. In support of this view is the ancient Chinese proverb, “If you give a man a fish, you feed him for a day. If you teach a man how to fish, you feed him for a lifetime.” This is sometimes good advice, especially for very healthy patients — but never say never. For contrast, my commonsense rule of thumb is to titrate advice — the more advice the patient needs, the more advice you should give. This applies especially to patients with more severe psychological problems who sometimes lack the judgment to make good decisions on their own and often don’t have other people to turn to for help. Trainers and therapists who preach most vociferously against offering advice must treat only the healthiest of patients.

When Is Self-Disclosure OK?

Many training programs also preach against therapists ever telling patients anything about their feelings, lives, or experiences. This is partly based on the notion that therapists should be a “blank screen”, partly on the fear that therapist self-disclosure may be self-servingly exploitive and impede patient progress. I agree up to a point, but less dogmatically and categorically. Therapist self-disclosure is indeed rarely necessary, carries risks, and should be reserved for special situations and specific purposes. But again, this is another case of “never say never.” With grieving patients, I’ve often revealed what my own feelings were on the loss of a loved one — as an expression of empathy and indication that exquisitely painful loss is an inevitable and normal part of our shared human condition. I have also on occasion shared work, child rearing, and marital experiences as a way of role modeling methods of dealing with life situations that have worked for me and might work for the.patient. Self-disclosure must be rare and to the point lest it lose impact and risk being done more for the therapist’s benefit than for the patient’s. I have occasional seen self-disclosure become a boundary violation in itself and on three occasions it evolved into therapists committing even worse Boundary violations. So, handle with care!

Can Therapists and Patients Share a Laugh?

Some, apparently humorless therapists claim that humor has no role in therapy — that, in one way or another, the joke is always at the patient’s expense or a distraction from real therapy. This attitude strikes me as being sad for the therapists who hold it and harmful to the patients who are subjected to their prim austerity. Charlie Chaplin said it best: “Life is a tragedy when seen in close-up, but a comedy in long-shot.” Seeing life in a longer shot is an essential part of any good therapy — and shared humor is an essential part of gradually gaining greater perspective. Rarely will shared humor take the form of telling a predigested joke; almost always the wisdom of humor comes from seeing the comedic in everyday situations. This is not to ignore that the patient is also suffering, but rather to achieve respite, distraction, and distance. A piece of advice I give to almost every patient is to find more good minutes into every day — and recapturing the ability to smile or laugh is a great step toward more good minutes and better days. Psychotherapy, like life, is a very serious thing, but both can be much brighter if leavened with a tincture of humor and the benefit of comic distance. Evolution surely built in the universal human capacity for fun because it has tremendous survival value. All work and no play makes therapy very dull for both patient and therapist.

What’s Appropriate on Social Media?

Here I am very strict; perhaps hypocritically so. I don’t think therapists should display their personal lives on any form of social media. Unlike occasional and specific self-disclosure during sessions that is directed to the patient’s specific needs at that moment, social media self-disclosure is generic; self-not-patient centered; and has many risks with no benefit. My hypocrisy: I do often express my fear and loathing of Trump on Twitter and even wrote a book about it. Here I felt my responsibility as a citizen trumped my role as a therapist. Others may disagree with this choice — I don’t apologize for it but can’t argue against their view.

When Is It OK to Have Contact Outside Sessions?

Some severely ill and/or suicidal patients definitely need out of session contact — either by phone or (I think preferably) by text. Behavior therapists routinely do sessions out of sessions- accompanying phobic patients when they are beginning to enter previously forbidden territory or situations. And I had a psychoanalyst friend who combined his usual quite traditional practice with doing runs with more seriously ill and demoralized patients who needed behavioral activation. All in all, though, I strongly discourage out of session contact except in special circumstances like these or to help patients experiencing emergencies.

Is Contact OK After Treatment Ends?

I think any close nonprofessional contact after therapy ends is a bad idea and should always be off the table no matter how much therapist and patient like each other. It is just too subject to exploitation and the possibility it could ever happen is too likely to influence the therapy before it ends. In contrast, I do recommend having occasional email or text follow up exchanges with patients after therapy ends. My longest such contact has extended for 56 years since the end of our treatment — it consists of brief but mutually satisfying emails exchanged every few months. Follow-ups help me learn what works, and what doesn’t in therapy and are encouraging because most people do much better than I expected.

***

As in all useful human relationships, therapy is a two-way street. We usually help our patients. They almost always help us become better people and expand our knowledge of human nature; ourselves; and how the world works. I loved the wonderful opportunity to do psychotherapy and am forever grateful to the patients who shared their lives with me. Questions for Thought and Discussion Which of the author’s points resonate most with you? Which of the author’s points are very different from your own, and why? What would be the top of your list of key elements of therapy?

How to Avoid Burnout and Find Joy in Corporatized Care Settings

As a clinical supervisor and marriage and family therapist, I’ve encountered, as most in our profession have, a challenging paradox entrenched within today’s corporate landscapes: while our mission revolves around healing others, we often find ourselves navigating environments that overlook our own well-being. This striking contradiction serves as a wake-up call, signaling a pressing need for a radical overhaul in how we perceive and implement mental health care within corporate structures. It’s a reality I’ve witnessed firsthand as I guide my supervisees through overwhelming caseloads, intricate cases, and resource constraints; where chronic stress, pervasive burnout, compassion fatigue, and moral distress become all too familiar companions on our journey.

This reality underscores the urgency for change. Creating sustainable healing environments demands a fundamental shift in our approach — one that goes beyond individual self-care and embraces a paradigm of structural support rooted within organizations. In this article, I will explore the intricate dynamics of healing within corporate entities, aiming to shed light on the myriad factors influencing mental health care practices. Furthermore, I will confront the complicity of corporate structures in perpetuating the challenges faced by mental health professionals. This exploration serves as my call to action, as I advocate for a more compassionate and empowering approach that not only supports the resilience of mental health professionals but also enhances employee retention and overall well-being within organizations.

The Toll of Healing

Pressures in Practice

One of the most glaring issues facing mental health professionals in corporate settings is the overwhelming caseload they tackle daily. According to research, these professionals often find themselves swamped with numerous cases, leaving little time for rest or reflection (1). Moreover, the complexity of these cases adds another layer of challenge to their already demanding workload. The intricate nature of cases handled by mental health practitioners highlights the considerable cognitive and emotional resources required for effective navigation (2).

In conversations with my supervisees, a recurring concern emerged: many felt they had no time during their workday to engage in essential tasks like case conceptualizations. This left them grappling with their clients’ issues even after leaving the office, encroaching on their personal time meant for family and relaxation. Several of my supervisees expressed frustration over this predicament. They found themselves unable to fully switch off from work, constantly mulling over client cases while at home. This not only affected their ability to unwind but also strained their relationships with family and loved ones. In essence, the boundary between work and personal life blurred for these mental health professionals, highlighting the need for more support and resources within corporate structures to enable them to effectively manage their workload and maintain a healthy work-life balance.  

Adding to these challenges is the pervasive issue of resource deficits within corporate mental health settings. Roth (3) shed light on the scarcity of resources such as time, funding, and institutional support, acting as persistent barriers to effective mental health care delivery. This limited access not only hampers practitioners’ ability to provide comprehensive care, but also exacerbates feelings of frustration and helplessness.

Consequences

The cumulative impact of navigating overwhelming caseloads, intricate cases, and resource deficits reverberates throughout mental health care, resulting in many adverse consequences for practitioners. Chronic stress, a prevalent outcome of prolonged exposure to high-stress environments exacts a significant toll on mental health professionals’ physical and emotional well-being (4). The incessant pressure to meet the demands of their caseloads while contending with limited resources contributes to a sense of perpetual strain and unease.

Burnout, another pervasive consequence of the relentless demands placed on mental health professionals, manifests through emotional exhaustion, depersonalization, and a diminished sense of personal accomplishment (5, 6) underscores the toll of burnout on practitioners’ professional efficacy and personal satisfaction, highlighting its detrimental effects on both individual well-being and organizational effectiveness. Moreover, the phenomenon of compassion fatigue emerges as a significant concern within the field, as mental health professionals become emotionally drained and desensitized to the suffering of their clients. The empathic engagement required to provide effective care can exact a heavy emotional toll, leading to feelings of emotional exhaustion and detachment.

Furthermore, moral distress, defined as the psychological anguish experienced when individuals feel unable to act in accordance with their moral beliefs, further compounds the challenges faced by mental health professionals (6). The ethical dilemmas inherent in navigating complex cases within resource-constrained environments can evoke profound feelings of moral distress, contributing to a sense of moral injury and moral erosion among practitioners (7).

One of my supervisees faced a challenging case involving a client experiencing severe trauma that required Eye Movement Desensitization and Reprocessing (EMDR) therapy instead of traditional talk therapy. However, institutional policies limited the client’s access to EMDR sessions to only one per week. Despite our recognition of the urgent need for more frequent sessions to address the client’s trauma effectively, they felt constrained by these policies and unable to provide the recommended level of care.

As the supervisee continued to engage with the client’s case, they began to experience symptoms of compassion fatigue. The emotional toll of witnessing the client’s distressing experiences day after day left them feeling emotionally drained and desensitized. They struggled to support the same level of empathy and engagement that they once had, leading to a sense of detachment from their work.

As the demands of their caseload persisted and the constraints of institutional policies became more apparent, the supervisee eventually found themselves experiencing burnout. The emotional exhaustion, depersonalization, and diminished sense of personal accomplishment became overwhelming. Despite their dedication to their clients, the supervisee felt increasingly disillusioned and disconnected from their work, questioning whether they could continue in their role as a mental health professional.

In summary, the toll of healing within corporate mental health settings is multifaceted and profound, encompassing a range of challenges that imperil the well-being of practitioners and compromise the quality of care provided to clients. Addressing these issues requires a comprehensive understanding of the systemic factors contributing to practitioner distress and a concerted effort to implement structural interventions that prioritize practitioner well-being and enhance the resilience of the mental health workforce. It is imperative that organizations acknowledge and address these challenges head-on, fostering a supportive and nurturing environment that empowers mental health professionals to thrive in their roles and deliver optimal care to those in need.

The Irony of Healing

Contradiction in Practice  

I’ve witnessed firsthand the struggle mental health professionals face in prioritizing their own well-being while caring for others. This paradox is deeply ingrained in societal expectations that prioritize clients’ needs over practitioners’ self-care, perpetuating a harmful cycle of neglect and burnout. This cycle of neglect and burnout is deeply entrenched in societal expectations (8).

Despite my expertise in promoting mental wellness, I've observed many professionals, including myself, grappling with implementing self-care practices due to time constraints, stigma, and the normalization of overwork within the field (9). Moreover, the demanding nature of our work — dealing with trauma, emotional distress, and crises — often leads to emotional exhaustion and blurs the boundaries between professional and personal life, making it challenging to maintain a healthy work-life balance.

The contradiction inherent in the mental health profession, I purport, is exacerbated by systemic factors entrenched within corporate structures. I’ve witnessed the negative impact of hierarchical power dynamics, productivity pressures, and a pervasive culture of perfectionism as they dissuade mental health professionals from seeking support or acknowledging their vulnerabilities (10). Consequently, practitioners find themselves compelled to prioritize productivity over their own well-being, resulting in heightened stress, burnout, and diminished job satisfaction.

I have seen many pre-licensure practitioners facing significant challenges in accessing essential mental health support due to financial constraints, particularly with the burden of student debt. This lack of corporate prioritization and support directly contributes to the scarcity of resources, such as adequate time and financial assistance, leaving many practitioners struggling to afford essential mental health services. This systemic inadequacy further compounds the challenges faced by mental health professionals, exacerbating the toll on their well-being and hindering their ability to provide optimal care to their clients. 

Change to Address the Self-Care Deficit

In my assessment, addressing this irony demands a fundamental overhaul in how mental health care is perceived and administered within corporate frameworks. Instead of relegating self-care solely to individual responsibility, I recommend that organizations acknowledge it as a collective pursuit necessitating systemic backing and resources. Recognizing the intrinsic link between caregiver and client well-being, I suggest that corporations dismantle the obstacles upholding the cycle of neglect and cultivate environments that promote sustainable healing.

Self-Care Deficit Theory states that individuals possess an innate capacity to engage in self-care activities to uphold their health and well-being (11). However, when individuals face physical, psychological, or developmental limitations that impede their ability to meet these needs, a self-care deficit arises, leading to adverse health outcomes. Applying this theory to mental health professionals within corporate settings, it becomes evident that the prevailing emphasis on individual self-care imposes an unrealistic burden on practitioners, contributing to burnout and compromised care quality. To address this issue, I recommend that organizations acknowledge their responsibility in supporting and facilitating self-care practices among employees. 

One recommendation based on this theory is to implement self-care support programs within corporate structures. These programs could encompass educational workshops on stress management techniques, mindfulness practices, and boundary-setting strategies tailored to the unique needs of mental health professionals. Additionally, organizations could offer resources such as self-care toolkits, online forums for peer support, and access to counseling services to assist employees in addressing their self-care deficits and preventing burnout.

This transformative shift entails not only providing mental health professionals with the resources and support necessary to prioritize their own well-being but also cultivating a culture of care that values vulnerability, self-compassion, and work-life balance. This may involve implementing policies that promote flexible scheduling, providing access to affordable mental health care services, and offering ongoing training and supervision to help practitioners develop effective self-care strategies. Moreover, organizations must actively work to destigmatize help-seeking behaviors and create environments where individuals feel safe and supported in addressing their mental health needs. By recognizing and addressing the irony of healing within corporate structures, organizations can not only improve the well-being of their employees but also enhance the quality and efficacy of the mental health care services they provide. This requires a commitment to systemic change, one that prioritizes the holistic health and resilience of both healers and those they serve.

Unveiling Corporate Complicity

Corporate Culpability

Within corporate structures, I’ve observed how profit-driven motives often take precedence over employee well-being, creating a challenging environment for mental health professionals. The imperative to maximize productivity and minimize costs can lead to understaffing, excessive workloads, and limited resources, all of which contribute to increased stress and burnout among practitioners. As mental health services become increasingly commodified within corporate settings, the focus on profitability overshadows considerations of ethical practice and quality care. Consequently, mental health professionals like me and my supervisees may find ourselves pressured to prioritize financial goals over the well-being of our clients, leading to ethical dilemmas and moral distress.

Moreover, in my experience, the hierarchical nature of many organizations often creates power imbalances that inhibit open communication and transparency, making it difficult for employees, including mental health professionals, to advocate for their own needs. Decision-making processes are often centralized among upper management, leaving frontline workers feeling disempowered and undervalued. This lack of autonomy and involvement in organizational decision-making can contribute to feelings of alienation and disengagement among mental health professionals, further exacerbating issues of burnout and turnover.

In one poignant instance, a supervisee of mine, a compassionate mental health professional, opened up to me about their struggles within the organizational hierarchy. Despite their unwavering dedication to providing top-notch care, they often felt constrained by the rigid structure of the organization. Decision-making power remained tightly held by upper management, leaving them feeling voiceless and undervalued. They felt unable to advocate for their own needs, which left them feeling disconnected and disheartened. The toll of this environment weighed heavily on them, exacerbating feelings of burnout and having them considering abruptly quitting.

In my experience, the commodification of mental health care within corporate structures often prioritizes short-term financial gains over the long-term well-being of employees and clients alike. Cost-cutting measures, such as limiting access to therapy sessions or reducing staffing levels, can compromise the quality and effectiveness of care, ultimately undermining the mission of promoting mental wellness. Furthermore, the relentless emphasis on profitability may deter organizations from investing in preventive measures or comprehensive support systems for mental health professionals, perpetuating a cycle of crisis management rather than proactive care.

The Fallacy of Resilience

Despite the increasing awareness of mental health issues in the workplace, many organizations persist in prioritizing resilience as the primary solution to employee stress and burnout. This focus on individual coping skills fails to address the systemic factors within corporate structures that contribute to mental health challenges. It perpetuates the notion that employees should simply “tough it out” rather than tackling underlying organizational issues. While resilience training programs are well-intentioned, they often place the burden of responsibility solely on the individual, implying that better coping strategies alone can counteract the effects of toxic work environments or high-pressure job demands.

In my view, individual resilience, while valuable, cannot fully offset systemic deficiencies like excessive workloads, inadequate resources, or toxic organizational cultures. Additionally, I believe that the disproportionate emphasis on resilience may inadvertently stigmatize individuals who struggle to cope with workplace stress. It implies that their inability to “bounce back” is a personal failing rather than a reflection of broader systemic issues.  

Moreover, I assert that the expectation of unwavering professionalism can foster a culture of silence regarding mental health issues, causing employees to internalize their struggles and refrain from seeking help due to concerns about appearing incompetent or weak. This culture of stigma and shame can hinder individuals from accessing necessary support and perpetuate a cycle of secrecy and denial within organizations. In prioritizing the appearance of resilience over the actual well-being of employees, corporations are inadvertently fueling a culture of silence and denial surrounding mental health issues, thereby intensifying the challenges encountered by mental health professionals.

Ultimately, I believe the fallacy of resilience highlights the necessity for organizations to embrace a more comprehensive approach to employee well-being, one that acknowledges the significance of tackling systemic factors and fostering supportive work environments. Instead of expecting individuals to simply “tough it out,” organizations should take proactive measures to address the root causes of workplace stress and cultivate a culture characterized by openness, support, and compassion. It is only by addressing these underlying structural issues that corporations can establish environments genuinely conducive to the mental health and well-being of their employees.

Rethinking Corporate Dynamics

In my experience, I firmly advocate for a holistic approach to fostering employee wellness within corporate structures. This encompasses policy reform to incorporate provisions for mental health support, flexible work arrangements, and stress management initiatives. Adequate resource allocation is equally crucial, ensuring investment in mental health resources, training programs, and employee assistance programs. Moreover, fostering cultural shifts within organizations, promoting open communication, destigmatizing mental health issues, and prioritizing work-life balance, is essential for creating a supportive and thriving work environment.  

I’ve witnessed firsthand the toll that excessive caseloads can take on our well-being. That’s why I advocate for implementing manageable caseloads within corporations. By ensuring mental health professions have a reasonable number of clients to attend to, quality of care standards can be maintained, and burnout and exhaustion can be reduced or possibly prevented. Moreover, I firmly believe in the power of comprehensive training programs tailored to the needs of mental health therapists. These programs should not only cover clinical techniques and interventions but also prioritize self-care strategies and stress management techniques. By equipping therapists with the necessary skills and knowledge to navigate the challenges of their profession, corporations empower them to thrive in their roles while prioritizing their own mental health.

In addition to manageable caseloads and comprehensive training, access to mental health support resources is essential for the well-being of therapists. This includes easy access to counseling services, peer support groups, and supervision sessions. Having a supportive network and resources readily available ensures that therapists can seek help when needed and receive the support they require to maintain their emotional resilience in the face of challenging cases and demanding work environments.

Our Mental Health Heroes

In closing, it’s important for me to recognize the immense challenges faced by our mental health heroes within corporate structures. Their tireless dedication to the well-being of others often comes at a significant cost to their own mental health and resilience. Despite the barriers they encounter, these professionals continue to show up day after day, driven by a genuine passion for helping others navigate life’s complexities. Their commitment is both admirable and deeply impactful, yet it’s essential for me to acknowledge the toll it takes on their well-being.

As I reflect on the experiences shared in this article and those throughout my career, it’s clear that our mental health heroes are not immune to the struggles they help their clients overcome. Hindered by corporate structures, they grapple with burnout, compassion fatigue, and the weight of ethical dilemmas, all while striving to provide the best possible care in often challenging circumstances. Their journey is one marked by resilience and dedication, but it’s also one that demands acknowledgment, support, and compassion from the corporations that employ them.

In extending empathy to our mental health heroes, I must also recognize the inherent humanity within each practitioner. They are not invincible superheroes but rather individuals with their own vulnerabilities, struggles, and needs. By fostering a culture of empathy and understanding within corporate structures, we can create environments where mental health professionals feel valued, supported, and empowered to prioritize their own well-being alongside that of their clients.

In essence, the empathy I extend to our mental health heroes mirrors the compassion they demonstrate in their daily work. Addressing the systemic challenges they face within corporate structures is crucial to paving the way for a future where both healers and those they serve can thrive in an environment of genuine care and support. This entails recognizing the toll of burnout, compassion fatigue, and ethical dilemmas, and actively working to alleviate these burdens through systemic change and support structures. I propose that high-quality client care is linked to the well-being of our mental health professionals, and this must be prioritized by corporations that employ them.

Questions for Thought and Discussion

What are your impressions of this author’s perspective on corporate mental health?

How might you work with a company or corporation to improve the mental health of its employees?

In what way have you been impacted by corporate mental health challenges and how did you address them?  

References
(1) Kim, J. J., Brookman-Frazee, L., Gellatly, R., Stadnick, N., Barnett, M. L., & Lau, A. S. (2018). Predictors of burnout among community therapists in the sustainment phase of a system-driven implementation of multiple evidence-based practices in children’s mental health. Professional Psychology: Research and Practice, 49(2), 132–141. 

(2) Maslach, C., Schaufeli, W. B., & Leiter, M. P. (2001). Job burnout. Annual Review of Psychology, 52(1), 397-422.

(3) Roth, C., Wensing, M., Kuzman, M. R., Bjedov, S., Medved, S., Istvanovic, A., … & Petrea, I. (2021). Experiences of healthcare staff providing community-based mental healthcare as a multidisciplinary community mental health team in Central and Eastern Europe findings from the RECOVER-E project: An observational intervention study. BMC Psychiatry, 21, 1-15.  

(4) Awa, W. L., Plaumann, M., & Walter, U. (2010). Burnout prevention: A review of intervention programs. Patient Education and Counseling, 78(2), 184-190.

(5) Bakker, A. B., Demerouti, E., & Schaufeli, W. B. (2004). Dual processes at work in a call centre: An application of the job demands-resources model. European Journal of Work and Organizational Psychology, 13(4), 393-417.  

(6) Jordan, K. B. (Ed.). (2015). Couple, marriage, and family therapy supervision. Springer.

(7) Canin, N. (2023). Exploring countertransference in psychoanalytic research: Reflecting on being a researcher, a psychotherapist, a mother and a human being in a neonatal high care unit. Psychoanalytic Practice, 31(1), 19-53.

(8) Adams, R. E., & Boscarino, J. A. (2005). Differences in mental health outcomes among Whites, African Americans, and Hispanics following a community disaster. Psychiatry, 68(3), 250-265.

(9) Greenberg, N., Docherty, M., Gnanapragasam, S., & Wessely, S. (2020). Managing mental health challenges faced by healthcare workers during covid-19 pandemic. BMJ, 368, m1211.

(10) Ocampo, A. C. G., Wang, L., Kiazad, K., Restubog, S. L. D., & Ashkanasy, N. M. (2020). The relentless pursuit of perfectionism: A review of perfectionism in the workplace and an agenda for future research. Journal of Organizational Behavior, 41(2), 144-168  

(11) Underwood, P. R. (1990). Orem’s self-care model: Principles and general applications. In D. Orem (Ed.). Psychiatric and Mental Health Nursing (pp. 175-187).   

Gift Giver: The Impact of Giving Clients Gifts

I don’t remember the first time I gave a client a gift. I don’t remember who it was or what I chose, but years ago, I established a tradition of giving gifts at particular milestones. If gift-giving was mentioned at all during my training as a psychologist, it was solely in the context of how to manage receiving gifts from clients. Therapists might lend something from their office as a transitional object during a long separation or a particularly difficult time, but to give a gift was viewed as a breach of boundaries. Forty years later, I take a different perspective.

The Value and Challenges of Therapist Gift Giving

Giving a gift is an opportunity to acknowledge the special relationship between therapist and client. It has the power to reinforce the depth of closeness, of being known, that often only happens in the setting of a therapeutic alliance. Transference and countertransference are part of the connection between therapist and client, but not the sum total of the relationship. Showing our humanity can be a true gift to a client.

Over the years, I have settled on a few select items to give at times of major transition. I give a copy of Gift from the Sea, by Anne Morrow Lindbergh, to clients getting married; Make Way for Ducklings when a baby is born; and a stone coffee coaster with the town seal of Brookline, where my office was located, when clients move or end therapy.

Additionally, I mail condolence cards when someone experiences a significant loss. Recently, one client who received a card from me on the occasion of his father’s death remarked that it felt so formal to get a card in the mail. In a sense, it seemed out of character to him for me to be that traditional. As generational and cultural norms shift, I may need to rethink my choices.

I don’t have a rule about who gets a gift or a card, and I don’t give them to everyone. I decide based on a gut feeling that this act will be well received, and that acknowledging our relationship as something that exists beyond the allotted sessions will be beneficial. There is a basic humanness that exists inside the professional alliance that I value expressing. It touches my sense of gratitude for the trust the client has placed in me. For certain clients, there also can be worth in modeling an act of kindness for them.

In preparing to write about this topic, I reached out to a dozen colleagues to inquire about their philosophy regarding gift-giving. I realized I had never talked with another clinician about my tradition, nor had I heard anyone else mention this subject. Although I was a bit nervous that I might be judged negatively for my behavior, I approached the conversations without bias about other clinicians’ practices. I am more curious about their thinking than the position they take.

I learned from these exploratory conversations that only one other colleague gives gifts regularly. She reported that the more trauma the client suffered, the greater the chance she would give them a gift to help with the healing. Others talked about calling clients or sending texts to acknowledge life events, which mirrors their behavior in their personal lives. Interestingly, one therapist talked about the significance of the gifts she had received from her therapist many years ago, mementos she still treasures, but she herself never adopted this practice because she struggled to find gifts that she deemed suitably meaningful.

Unanswered questions for me include whether the age of the patient population might impact giving gifts, whether the gender of the therapist and/or client influences the choice, and whether the type of training and years of experience are reflected in how one thinks about gift giving in therapy.

And finally, I am curious if doing remote versus in-person sessions will have any impact on this practice. With more therapists only doing remote therapy, I wonder if gift giving on either side of the equation might diminish. I know for myself that now having a fully remote practice, I receive fewer holiday gifts than when I was seeing clients in person. But, to date I have maintained my gift-giving practice even though it now requires more trips to the post office, and I miss the connection from handing the gift personally to a client.

Giving gifts has enriched my practice. Although I largely rely on my words to communicate in therapy, gift-giving is a tangible way to communicate that I value clients and care about them. It is a concrete representation of the very real relationship that is carved out of years of hard work together.

Questions for Thought and Discussion

  • What is your position on this practice of giving gifts to clients?
  • To what kinds of clients have you given gifts?
  • If you do give gifts, how do you choose them for specific clients?

Looking Beyond Trauma: A Neurodivergent Therapist Shifts Her Clinical Focus

As a therapist, I often find myself navigating the complex layers of my clients’ lives, working to untangle the web of trauma and its aftermath. In my years of practice, I have had the privilege of helping many individuals heal from deep traumatic wounds. I never planned on this, but my first job laid it in my lap, and I’ve loved every minute of it since. The hardships that I’ve seen people go through and be able to heal themselves are nothing short of impeccable. It’s almost indescribable. However, one particular case has profoundly impacted my perspective and approach: the story of an 18-year-old biracial male recently diagnosed with Autism, whom I initially treated for PTSD and trauma-related attachment symptoms. I referred him for an ADOS evaluation and looked at the report. I was glad that this assessment lent clarity but frustrated at myself that I didn’t see it sooner.

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Missing the Autism Tree for the Forest of Trauma

Alex came to me with a history marked by significant trauma; he witnessed domestic violence most of his childhood, was abused by a daycare worker, and did not have any relationship with his biological father. His experiences had left him struggling with severe PTSD, anger outbursts, and disengagement from school. He had relational problems with his mother and would not often communicate.

My initial sessions were focused on addressing these urgent, debilitating symptoms — the depression and the outbursts. My training and instincts as a trauma-focused therapist kicked in, and I dedicated myself to creating a safe space for him to process and heal. We did a lot of experiential work, along with play and gaming therapy. We worked on externalizing all that had been internalized — bringing it out and releasing the frustration of not having a relationship with his father, anger towards his mother, anger towards the men who abused her, and fear. We also spent some time deepening the relationships between the sibling and mother.

However, as weeks turned into months, something nagged at the back of my mind. There were aspects of Alex’s behavior that didn’t entirely fit within the framework of PTSD. After moving through the trauma work and no longer meeting criteria for PTSD, he still did not engage in effective two-way communication with me — his answers were often short, and he remained hyper focused on his hobbies.

My focus on his trauma had been so all-encompassing because of my own hyper focusing, that I missed the autism, which in retrospect, had been masked beneath the trauma only to surface afterwards. I saw this a lot in my practice and experienced it myself. And it’s not as if I could have “treated” the autism, but perhaps I could have been more helpful had I helped Alex to better understand himself, and not pathologize himself.

It wasn't until I embarked on my own journey of self-discovery, guided by insights from other autistic providers, that the pieces began to fall into place. I realized that my training and the field’s emphasis on trauma had not adequately prepared me to see neurodivergence, especially in individuals whose trauma symptoms were so pronounced. This is a common question I get from students, “why are we not prepared for neurodivergence?” I have a few theories, but this is just where we are. We need to listen to the autistic and other neurodivergent communities, their narratives, their stories, because our research and clinical training can’t keep up. This realization was both humbling and enlightening.

My work with Alex prompted me to seek further education and collaboration with autistic and neurodivergent colleagues. Their perspectives and experiences have been invaluable in reshaping my approach to therapy. I now understand that trauma can sometimes overshadow neurodivergent traits, making them harder to recognize. This has reinforced the importance of a nuanced, multifaceted approach to therapy. I have read that some do not agree with this concept, but I have seen this over and over in my practice. I’ve also witnessed narratives of where once their ADHD is managed the autism pops its head out, surprise!

In sharing Alex’s story and my journey, I hope to encourage other therapists to broaden their perspectives, as I have mine. I have come to value the necessity of being vigilant and open to the possibility that neurodivergence might be present even in the most trauma-affected clients. By doing so, I believe that I have been able to provide more comprehensive and compassionate care. I have also come to value the importance of ongoing learning and self-reflection — not just for me but for the entire field. Alex’s story is a testament to the importance of this mindset. As a neurodivergent therapist, I hope to continue in my commitment to being informed and adaptive, ensuring that I do not miss the vital aspects of my clients’ identities and experiences. Through this commitment, I can better help my clients to heal and thrive.

Postscript

Once Alex received the autism diagnosis, the mother and I met to review what this all means for her and her almost adult child. We’ve spent a lot of time talking about transitioning into adulthood and the challenges and strengths that Alex has. This diagnosis hopefully opened the door for more supportive services, and it opened up the pathway for the mother to start examining herself in a new light. As she and I talked, she started to look at herself through a neurodivergent lens and her experiences made more sense to her. We also talked about how not knowing has impacted her and Alex’s relationship negatively in the past but now they have a new perspective on things they can connect in a different manner. They have internalized ableism within her parental expectations, which often led to highly intense conflict. But now, they see themselves as a nervous system responding within the context of each other rather than blaming one another. This opened up space for compassion, understanding, and empathy.   

Questions for Reflection and Discussion

How might you have worked with this client?

What are some of the gifts a neurodivergent therapist might bring to therapy?

In what ways might a neurodivergent therapist struggle with particular clients?  

Breaking Down Obsessive-Compulsive Disorder: The Heart of the OCD

The Legacy of OCD

When I was in third grade, I was gripped by the fear that my mother would be killed if I didn’t follow orders. From whom and where these orders were coming wasn’t entirely clear, but I quickly learned to obey. Like the main character, John Nash, in the movie, A Beautiful Mind, I was being watched, and everything I thought was monitored for loyalty to the sinister totalitarian state of which I had now become a new citizen. There was no way out.

Every day at the religious school I attended, it whispered in my ear, “She’ll be dead when you arrive home if you think something bad.”

Living each day with a pure heart became a new curse it threw in my face, a way to trap and punish me in the most painful way imaginable. It would take away the person I loved and needed most in the world: the single mother who protected me and the flame of sensitivity within me which the world seemed all too eager to snuff out.  

When the neighborhood kids dared me to throw away my Winnie the Pooh bear all too soon, I foolishly gave in and was heartbroken. The next night, Paddington Bear in his blue duffle coat and red bucket hat appeared on my bed. When we returned from the movies, my mother asked about the hopes and fears of the characters because she could see it still percolating in me. Like a music conductor, she’d encourage me to allow every section of the orchestra of my mind and heart to play out just a little louder, strengthening a confidence in an invisible capacity I could not yet name.

I adored my mother and knew that without her, my sensitivity would be swept away. So, as Abraham did with God in the story of Sodom and Gomorrah, I negotiated with the amorphous all-powerful entity controlling my fate. If I read every word in the prayer book, it might be appeased. If I had an evil thought, I could cancel it out, and if done right, the entity might be mollified, but in the end, the charges kept returning. No sooner was I absolved of a crime I didn’t know I committed when a new trial restarted. The world was full of impossible binds. Death and doubt resurfaced at every turn.

It wasn’t surprising that I developed OCD. My mother had an identical fear of losing her mother at the same age and struggled with contamination OCD, opening doors with tissues and ever ready with rubbing alcohol. “It’s just my craziness,” she’d confess.

One day, a red futon tied to the roof of our car fell while driving along the highway. Pulling over to the side of the road, 10-year-old me peered into my mother’s eyes expecting to find terror there.  

“This stuff, Michael, the big stuff doesn’t scare me. It’s the little things that get me, remember?”

And with a smile, I helped reattach our precious cargo.

My mother was familiar with living an existence as paper-thin as the tissues she carried with her everywhere to ward off germs. Her parents’ marriage fell apart shortly after their arrival in New York from the Middle East via Panama, when her mom — my grandmother — became the main breadwinner and caretaker of the family of four young children. Sensing her fragility, my mother stepped in to minister to her. A highly educated woman now working behind the counter at a department store to make ends meet, and my mother easily noticed the pain — the unspoken sadness, longing, and fear that others hardly detected. Even my mother’s siblings mistook their mother’s desire to have joyful holiday dinners as just another form of control, instead of what it really was: a cry for help. Please eat and show me, not only that you love me, but that somehow God hasn’t abandoned me like my husband. 

My mother stayed close to home, learning to fear rather than crave independence. Without the freedom to disagree or feel anger, her sensitivity became the emotional suture for a constantly bleeding family. In doing so, she lost much of the thread holding herself together. She doubted her own instincts and confidence, even though she had a sixth sense of empathy few recognized as her hidden superpower. English professors noticed it and called on her regularly for her insights in class, but in the real world, she felt unmoored.

OCD emerged as an expression of how precarious the world felt to her. It offered her a blameless way of seeking the boundaries and guidance she couldn’t ask for directly. When OCD dictates something — when it says, “please tell me everything is going to be okay, please wash your hands, please help me right now!” — it allows for an aggressive urgency that’s otherwise forbidden.  

Sound and Fury

As a psychologist, I’ve treated individuals struggling with OCD since my graduate school days. Then, you could find me on the streets of Manhattan touching tissues to doors and diluting them before doing exposure exercises with clients. You’d find me in the library turning over every stone in my dissertation research on what did and didn’t work for OCD.

These days, I get calls and emails from clients around the world who fail OCD treatment and say they’re not encouraged to talk — even with their own therapists — about the deep feeling and fire they experience within their OCD. To attribute any meaning to OCD, they’ve been taught, is to enable reassurance. To envision OCD as anything other than a bio-behavioral glitch is dangerous and foolish. “It takes seventeen years on average to arrive at appropriate OCD treatment, why would you jeopardize that,” say their therapists. But what if, instead, we listened to what burns so brightly inside OCD?

My perspective on OCD is likely to be dismissed as misguided and anachronistic, even taboo. In the OCD community, talk therapy is believed to be unhelpful at best and regressive at worst. A widely circulating meme in the recovery world echoes the mainstream view, inspired from a passage in Macbeth: OCD is “just sound and fury, signifying nothing.” But what if the meaning at the heart of OCD is there and we’re just not talking about it? What if these clients aren’t failing treatment but treatment is failing them?   

OCD is as much about feeling as it is about thought, as much about meaningful self-expression as distracting noise. Hardwired by nature and stoked by nurture, our brains repeatedly throw an unsolvable dilemma that’s trying to communicate something valuable. OCD is both friend and enemy, but we tend to view it only as an enemy because by the time people get help for it, it’s a five-alarm fire. If you look at it with the right eyes — ones attuned to the sparks of sensitivity within it — you see raw potential in it that’s inspiring, sensible, and bold.

I’ve long been one of the few therapists who espouses this unpopular view. When I questioned CBT orthodoxy in training and experimented with integrating meaning-centered approaches, I was asked to turn in my badge. When I suggested that OCD had an upside in a recent Christmas blog — and foolishly called it a superpower — I was as welcome as the Grinch. Recently, though, I’ve been heartened by two exciting developments: Internal Family Systems as a new OCD treatment and John Green’s book, Turtles All the Way Down, an OCD-inspired story recently made into a movie by the same name.   

Meaning Matters

Internal Family Systems is an evidence-based therapy that helps sufferers befriend their OCD protectors. These parts nurture the sides of the self that have been cut off due to trauma like my mother’s or the intergenerational trauma I inherited. The overactive OCD mind perpetually anticipates dangers and buffers feelings of rejection, hurt, sadness, and terror. If these managers don’t succeed, firefighters take over with compulsions. Running the gamut from checking, washing, counting, or reassurance, compulsions provide visceral instant gratification. They comfort with a cost; repetition is the only way to satisfy, though not for long. Any satisfaction you achieve doesn’t last, and it’s never enough.

My mother’s compulsions to wash her hands were frequently triggered after being recruited into carrying too much of other’s emotional mess. With no relationship to help verbalize her profound empathy and disgust for being placed in such an impossible role, her protectors took over. My own terrors were touched off by the adult world coming for my bear again, only this time it replaced the bear with my mother. I’ve worked with clients whose OCD took away their freedom to sing, to take the subway, or to trust their own goodness. Each of them found unexpected ways to link their OCD to a fuller, more coherent story.

In Green’s book, one of the characters questions a scientist who has given a detailed history of earth and life on it. She insists that the entire world is resting on the back of a giant turtle. When he challenges her about what that turtle is standing on, she replies “it’s on another.” Flummoxed about what that turtle is standing on, she replies, “Sir, you don’t understand. It’s turtles all the way down.” This image doesn’t just capture the repetitive and elusive nature of OCD, it speaks to a hopeful afterimage. What if everything you think of as the random chaos of OCD is held up in more creative ways than you ever imagined?

In recovery from OCD himself, Green crafted Turtles All the Way Down to showcase OCD’s characteristic thought spirals and the methodically masterful ways it wears down its main inhabitants and robs them of their agency. OCD is a nuisance to be rid of, not exalted. As an OCD advocate, Green wants us to feel that. And yet, his characters tell another story, centering OCD around its existential heart, a profound sensitivity hardly ever discussed. 

Teenage protagonist Aza Holmes is haunted by the sudden death of her father from a heart attack and OCD jumps in to protect her — IFS style — from overwhelming fears over the precariousness of life. Is Aza really just a fictional character without any volition of her own? Is the 50 percent of the bacterial microbiome that makes up the human body in true control of her? Aza constantly digs her thumbnail into her middle finger to see if she really exists. But no sooner than she is found, she is lost again, spiraling about the possible infection she’s now unleashed.

Aza’s OCD finds an ingenious way of expressing her existential dilemma. Her scab is a brilliant metaphor of the ever-present wound of her father’s death and all of our deaths. Like my own childhood terrors, the relentless question — to be or not be — constantly buzzes in the OCD sufferer’s ear, a fly always just out of reach. As for Hamlet, a broken heart — not a worried mind — is at the center of OCD. Or as Aza puts it: “When you lose someone, you realize you’ll lose everyone. And once you know, you can never forget it.” A broken heart — not a worried mind — is at the center of OCD.


***

It’s been more than 15 years since my worst nightmare came true and I lost my mother to cancer. And yet, in the aftermath, something shocked me in ways my early fears never prepared me for: instead of falling to pieces, I discovered something new in conversations with my mother in my dreams.

I finally get what you meant that day on the side of the highway. Like those turtles, you were carrying the world on your back. The big stuff. You saw that I could do it too and protected that power every step of the way. You knew how to celebrate it as a gift never to be taken or lost. I realized that gift was life itself, and it was the mysterious heart of OCD. It was holding me up better than any of those turtles ever could, and with it, I could carry everything.

Questions for Thought and Discussion

What methods have you found to be most effective in addressing OCD with your clients?

How have you used metaphors in the treatment of OCD?

What do you find to be the greatest challenge in working with OCD?  

The Healing Power of Therapeutic Presence

I was driving to my therapist’s office and listening to an audiobook when I started to cry. I wasn’t even sure why I was crying. Once in my twenties, I went several years without shedding a tear, but now, in middle age, two years since becoming a therapist, one year since starting psychoanalysis, I was doing this weekly.

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“What were you listening to?” Laura asked once I sat down in her office.

“It’s actually a children’s book. It’s this scene where nobody believes this girl, and she feels all alone. But then her brother,”—and now I felt the tears again welling up—“her brother tells her that he believes her. And she’s not alone anymore. It’s not even a sad scene,” I sniffled. “I don’t know why it gets to me.”

The Power of a Therapist’s Self Awareness

Earlier that week, I had been in my own office, sitting across from my own client. Rachel, a 10-year-old girl, who had started meeting with me to process her father’s alcoholism. She had been vivacious and funny during our first several sessions, causing me to wonder whether she even needed therapy. I kept listening, asking about her father’s drinking but not pushing too hard for her to talk. And then the previous day, seemingly out of the blue, she started recounting some painful memories of her father, one in which he called her mother some horrible names and blamed her for ruining his life.

Rachel had always had a manufactured exterior, a smile usually on her face, but as she shared these memories, I could see tears filling her big blue eyes. “When he blamed your mom for ruining his life,” I said, “I wonder if you thought he was maybe talking about you.” She slowly nodded and then bit her lower lip as though hoping this would stanch her tears.

I felt at that moment inadequate as her therapist. I didn’t know what to say. I wanted to tell her that everything would be okay, but I didn’t know if that was true and didn’t want to lie to her. I tried recalling some clinical vignettes I’d read in different psychotherapy textbooks, trying to remember the life-altering words that those master clinicians had spoken in similar situations. Nothing came to me.   

I realized that I was matching Rachel’s pained expression with one of my own. “It’s good that you’re talking about these things,” I finally said. “I wish that talking would make them better.” She kept looking at me. “But that’s not how it works.” I again tried to imagine what a master clinician would say. My mind again drew a blank.

I suddenly flashed to a time in my early thirties when my paternal grandmother had unexpectedly died. I immediately called my mother, and as soon as I began telling her what had happened, I started to cry. She drove over to my apartment and sat with me for several hours. I don’t remember her saying anything especially profound, but she made me feel less alone, and that was what I most needed.

Now sitting in Laura’s office, having told her about the audiobook, I started to talk about my session with Rachel and my flashback to that day with my mother. “Part of me felt I was giving Rachel what she needed, but another part kept thinking there was something I should be saying to her. I felt like such a failure.”   

I then told Laura that when I’d been listening to the audiobook, she herself had come to mind. “This probably doesn’t make sense, but as I think about it now, it’s like I suddenly realized that you’ve been here all along. It’s like I’ve in some sense, not recognized your full humanness and presence in these sessions. I’ve always respected your skills as a clinician, but I think I’ve seen you as this impersonal instrument or tool that I could use to learn how to gain personal insight.”

The tears were again coming. “But you’re not a tool. You’re a person who listens to me and cares about me. When I’m sad, you feel sad with me. When I’m happy, you’re excited for me. You’ve been here all along, and I think I’ve been afraid to truly acknowledge that.”

Laura and I talked some more, and I eventually thought back to Rachel. There would be times when the words I spoke to her would matter, when I would need to ask the right question or make the right interpretation, but I now saw that I had not failed her during that last session. I had been there with her, allowing her to share her pain and feeling her pain with her. I had given her what my mom had given me that day years earlier and what Laura was now giving me every week. I had given Rachel my full humanness and presence, and that had been what she most needed.   

Sasha McAllum Pilkington on Grace and Storytelling at the End of Life

Lawrence Rubin: (LR): Sasha, thanks so much for joining me today. I was drawn to the narrative stories you’ve shared through your hospice work in New Zealand and the incredible way you help the dying and their families. But before we begin, I know you had something you wanted to say about your work with these clients. 
Sasha McAllum Pilkington: (SP): Kia ora, Lawrence. Thank you very much for having me. Tēna koutou katoa. Hello, everybody. My name is Sasha, and I work as a counselor for Harbour Hospice. We provide specialist palliative care for people in the community and have an inpatient unit. I work mainly as a counselor in the community. I just wanted to say that sometimes when I’m talking about practice, I use stories to illustrate what I mean, and I wanted people reading this to know that I do that with the consent of the people that I’m speaking about and with respect to their confidentiality. So, thank you. 

Meaning Making in the Shadow of Death

LR: I'm glad that you started right there, Sasha, because my very first question is, what does your way of co-creating stories with dying clients say about what you believe works in therapy or consultation?
SM: I think being alongside people who are dying, and their loved ones, is very important. When I speak of being “alongside,” I am referring to supporting a person to reflect on their experience and what matters to them in ways where they experience themselves as worthy of respect and holding knowledge about their own life. I think recognizing our shared humanity is significant in working with people who are seriously ill and approaching death. We are all mortal beings with bodies that can become unwell, and we can all suffer. I am no different in this regard from the people whom I meet in my work and keeping that idea forefront in my mind allows me to see the person beyond the illness and whatever changes that imposes. Change is a shared endeavor and, in my view, takes place in the relational space. So, the stories I have co-created with the people I have met show, I hope, a spirit of collaboration and the importance of the therapeutic relationship in generating change. It can be very hard living with a life-ending illness so I hope the writing acknowledges that while showing what might be possible for both the person who is unwell and the therapist.

You might notice that I use some unusual language constructions as we talk. My use of language reflects some particular understandings that I think are important therapeutically. For example, I speak of “the person who is dying” rather than “the dying person” to acknowledge that people are more than the illness they live with. They are more than the problems they live with. As a narrative therapist, I think identity descriptions are important as they influence how we think of ourselves, what we think might be possible for us, and then how we might respond. The identity of “dying person” can limit how the person sees themselves and then influence how they might respond and act.   

LR:
I speak of “the person who is dying” rather than “the dying person” to acknowledge that people are more than the illness they live with
Some might say that hospice work, at the very end of someone's life, either by natural causes or an illness, is the end of a story. But I'm hearing you say something that suggests that the storytelling that you co-create is not simply about an end.
SM: Relationships endure beyond death, don't they? One of the opportunities I get is to talk to people about the kinds of stories that they might like to endure and to meet with families and ask them what kinds of stories they might tell about that person after they have died. This puts me in mind of a family meeting I was part of that took place on a rural property with a farming family. The men were sitting around in their gumboots — big blokes who probably had never spoken to a counselor in their life, let alone been anywhere near one. I was asking the person who was dying how they would like to be remembered, and then the family what stories they'd be telling about their loved one.

At first, the family were shy and hesitant to talk. But as they warmed up, they started to tell some really funny farming stories, which were brilliant. One was about how the man fell out of the tractor and just lay there because he couldn't stand up but had insisted that he go on working. And these men started to laugh as they were sharing these stories from their lives, and then one of them said to me, “Oh, I thought you counselors were meant to make us cry, not laugh.” It was quite delightful. Talking about such stories not only can nurture the relationship with someone after they have died, but they can also make it grow. The written stories we co-create therefore often reflect not just how a person has died but what might endure from the relationship family members have had with them. For example, the published story called “A Small Hope,” which illustrated how a therapeutic conversation brought forward some beautiful memories two young children had of their father, and then how they were developed into legacy stories they could carry with them throughout their lives.   

LR: And perhaps that flies in the face of what the uninitiated believe counseling in hospice to be, which is about sadness, crying, and lamenting. But it sounds like the storytelling that goes on in these last days, or weeks, or months of your clients' lives are not just about sadness and grieving and saying goodbye, but almost like living eulogies.
SM: I think the work really reflects the richness of life and what people have to lose. There are stories of both great sadness and also the savouring of life, and what has been most precious. There is a lot of crying, but there is also a lot of laughter. People walking past my room sometimes wonder what on earth’s going on when they hear all the laughing coming out, and it can change from moment to moment. So, yes, the conversation can reflect what and who has mattered most to a person, the real richness in their life, and ways of living, as well as losses they may be experiencing. 
LR:
I'm always listening for the beauty in people's lives, the stories, the nested stories within whatever we're talking about
Has this particular way of working with the dying and their families over the years changed the way that you ask questions?
SM: Yes, writing collaboratively has changed my questioning. I've been writing therapeutic letters and collaborative notes for decades now and writing stories that illustrate practice over the last 10 years. It has changed both my way of questioning and what I’m listening for, as well.

If I'm looking back on conversations, say, in a transcript, it gives me the chance to really look closely at my questions and to think, “How could I have asked them better? What work is that question doing? Has it been helpful?” That constant examination and thinking about questions has really allowed me to be a lot more intentional and be more skillful in my questioning. At the same time, I think my listening has changed. I'm always listening for the beauty in people's lives, the stories, the nested stories within whatever we're talking about. Just the other night, someone was talking to me about accompanying a family member who was dying and said, “You know, the job of the family is to deeply love,” and it just really struck me. I heard that clearly and in a way, perhaps, that I wouldn't have prior to doing all this writing.  

LR: So, the stories, the notes, that flow from these interviews are, in a sense, love stories, stories of love, and how that's permeated the lives of the dying and their families?
SM: Yes, sometimes. I’m very much listening for expressions of Aristotelian goodness such as love and kindness, compassion, courage, determination, and because I'm listening for it and inquiring into those spaces, it very much comes forth. I was just thinking of your use of love. I mean, it is a form of love, doing this work, I think, isn't it?
LR:
there is an idea that the work is all sad, and what I would say is that it can be both sad and uplifting and enormously meaningful
Well, it certainly is, in my mind, the ultimate act of giving. And if love is defined in part or in whole by giving, then when you are sitting with a dying client and their family, it is, I think, the deepest form of giving. So, yeah, I think it is about love the way you describe it. What have you learned from working with the dying and their families that may encourage others, perhaps those who are sheepish, to venture into this particular domain? 
SM: I really hope that the stories I’ve published will encourage those who are interested in this work, and support them in gaining some confidence and feeling prepared for what they might encounter. I think, as we were saying previously, there is an idea that the work is all sad, and what I would say is that it can be both sad and uplifting and enormously meaningful. This work does require me to be present for suffering and to be able to enter some of the taboo areas of life. But having said that, when people are approaching death, there are also stories of what's been important and what's been good about living, and they can be incredibly rich. For me, I think there's something also about working with problems that can't be solved, that can't be fixed, and being alongside a person and making sense of what's happening… Conversations that generate helpful meaning making, that are transformative perhaps, or reveal the extraordinary in the taken-for-granted. For me, anyway, that's enormously rewarding. 
LR: So, because their futures are so foreshortened and their death is so inevitable, it's not like looking forward to alleviating depression or looking forward to lessening anxiety. It's looking forward to an absolute end and helping them to prepare for that end with the greatest sense of meaning they can.
SM: Yes, indeed. Meaning making is a significant part of the conversation I have with people. Making sense with people about what is currently happening to them as they live with the illness and also reflecting back on their lives. Having a sense of living meaningfully is very important to most people at the end of their lives. Every person's life is different and people bring different things to their dying. However, while our conversations talk about dying and perhaps what they might be afraid of, or what dying means to them, we also talk about living. We may spend time speaking about how they might like to spend the last phase of their life and what is precious to them, for example. 

Narrative Therapy: Discourses Around Death and Dying

LR: Your clinical work is grounded in the Narrative Therapy tradition of Michael White and David Epston, so I’m wondering what are some of the dominant discourses around death and dying that may actually be unhelpful to clinicians working with the dying and their families?
SM: When I first started working in palliative care, I noticed that there were many cultural messages about a “right” way to die and a “right” way to live with an illness that were highly influential in shaping people’s experience of the end of their lives. I learnt that dominant cultural discourses could be helpful for some people whereas for others they positioned them as not getting it right in some way.

One cultural idea that springs to mind is the idea that death is a bad thing to be fought. If you have a curable illness or apply this idea to your experience in particular ways it can be very useful. However, for many people living with an incurable illness, the idea of a fight can start to become unhelpful. It might lead to them fighting the illness at any cost, for example, forgoing quality of life in pursuit of more and more treatments to avoid dying. Or it may position them as either winning or losing a battle, which can be a very unhelpful and limited description for someone who is dying.

Part of my role is to create a space for people to reflect on how they are going about living with the illness and approaching death so they can examine whether they are doing it in ways that fit with their values and what matters to them.

I've illustrated therapeutic conversation with people who have taken up a fighting stance against an illness with different consequences in some of my papers. For example, in the first story that I ever wrote, I met with a man who refused to acknowledge he was dying and was fighting by continuing to work rather than spending time with his family, and that didn't fit with his values. For him, the meaning of fighting his incurable cancer was not abandoning his wife, and he decided to have some enormous experimental surgeries. It was a really important thing for him to do. A fighting stance can work for someone. I can think of another person who had a really traumatic childhood, as did his wife. They had found each other at a young age, and it had been a very happy relationship. And for him, the meaning of fighting his incurable cancer by having some enormous experimental surgery was not abandoning her. It was a really important thing for him to do. The cultural idea of fighting can be both unhelpful and helpful. Dominant ideas aren’t usually good or bad in themselves. However, if they are guiding a person’s life, are unexamined, and don’t fit with their values, they can be problematic. It's more important how particular cultural ideas are applied, the way that they affect people’s relationships with themselves and their experiences, and the meaning they hold as a way of approaching death.   

Another dominant Western idea that can have unintended consequences is the message that we should be positive. In fact, Carla Willig describes the pressure to be positive as a cultural imperative in Western societies. At the end of life, the idea that we must be positive can shut down talk of our mortality and of suffering leaving people alone in their experience. Part of what I do is to listen and be present for stories that are often silenced. They may be experiences of suffering or fears about dying for example. There are few relationships where people can speak of such things. The idea we “must be positive” affects health professionals, family, and friends as well. It may have family members and visitors trying to cheer people up rather than acknowledging what a person is going through. So, at times, it can be a very persuasive and unhelpful idea.  

There are many cultural discourses that can cause people distress when they are approaching death. The idea that relationships end with death, and we have to “move on” rather than that relationships continue beyond death. And then there are some of the individualistic discourses; Western discourses such as “the reason that I've got cancer is because I didn't eat right, exercise enough,” and so on, right? People are often made to feel they are to blame and individually responsible for the bad things that have happened in their lives even when they are societal issues. Those are just a few examples. I find Narrative Therapy helpful in untangling ideas so that the people I meet with can examine them more closely.  

LR:
another dominant Western idea that can have unintended consequences is the message that we should be positive
What is it about Narrative Therapy that helps you to untangle some of those dominant but unhelpful discourses with the dying and their families?
SM: Narrative Therapy has encouraged me to be curious about another person’s world and to use questioning practices to inquire about ideas that a person raises in conversation. This allows the ideas to be brought forward so the person can examine them and reflect on their influence on their life. The dominance of certain discourses or ideas can mean they are taken for granted as “truth” and unexamined. Narrative Therapy has trained me to pull apart the threads of an idea in collaboration with the people I meet with and to look for how that idea impacts on different groups of people with the workings of power in mind.

Hope is an experience that I commonly examine with the people I meet with. Hope can mean many things to many different people, and I can't assume that I know the meaning of it in a particular person’s life. I might ask, “What does hope mean for you?” There’s an example of such a conversation about hope and the questioning I might use in the story “A Small Hope.”

I think Narrative Therapy really lends itself to assisting people at the end of life to reflect on the cultural ideas that are shaping their experience and then choose and think about how they want to go about the end of their lives.   

LR:
Narrative Therapy has encouraged me to be curious about another person’s world and to use questioning practices to inquire about ideas that a person raises in conversation
And that sort of brings us back full circle to our opening when we talked about storytelling, co-creating stories, co-creating notes. You've said in your writing that in working with the dying, you try to bring forward identities other than illness. What did you mean by that?
SM: We're more than the problems that we live with, aren't we? We're more than an illness that we have, but when we're unwell with a serious illness that's perhaps kept us from doing what we normally do over a period of time, the idea of being a sick person, the sick identity, if you will, can really take over. And identities matter. They don't just speak to our past and to who we think of ourselves being, they really influence our decision-making and what we think is possible for us. So, the idea of being a sick person, if it takes over, can be quite limiting in what a person thinks is possible for them, and it can lead to ideas such as a person thinking that they're a burden or that they've got no way of responding to what's going on with them.

I, for instance, can think of a person I saw who didn't feel that his life was worth living because he thought he was a burden to others. When I met him, one of the things I noticed was that despite this man being unused to living with other people and describing himself as a bit of a hermit, the carers kept coming into the room. I asked him about this and the relationships with the carers and discovered he actually learned all about their families and the countries that they'd come from.

I discovered that he was someone who was deeply respectful of others and who was able to get on and make the people around him feel really good about themselves. And through exploring this, we were able to expand his possibilities by bringing forth identities of him as a person whom others liked, as someone who cared about other people and so on. I guess we were able to bring forth a sense of living meaningfully for him. The identity we brought forward of him as someone who could give to others and make them feel valued was really helpful in starting to push the idea that he was a burden out the back door.   

LR: And you wouldn't have known that had you not been at his bedside to actually see the community in action.
SM: Exactly, it was very helpful. In fact, people would be knocking on the door when I'd be seeing him. It was really quite something, and he was very surprised. He hadn't actually noticed how many people liked and cared about him until I began to ask him about all the visitors and what might lead them to want to spend time with him. 
LR: And that's one of the essences of Narrative Therapy, which is looking to take what they call the thin story and add depth and richness. So, I can see how someone approaching the end of life can become overly focused on that singular event, which you, through your storytelling, expand and enrich.
SM: Yes. The idea of a person being just sick or dying is a thin story of who a person is. Bringing forth the depth and richness of who they are can be enormously therapeutic. As I get to know people, I am listening for who and what matters and has mattered to them in their life and how they have gone about their life. As they share these details, I particularly listen for Aristotelian virtues that are expressed in how they have lived. The themes of virtues give rise to the possibility of rich identity descriptions for the person — them being a compassionate or kind person for example. Such identity descriptions are very helpful for someone who is unwell, as it is possible to enact them with a sick body. If someone’s been a great sportsman, that’s not going to be such a useful identity going forward even if it is something pleasurable to remember. Let me share an example of how these rich descriptions of a person can give rise to sometimes transformative responses.

I was once asked to see a man who was living with a number of very serious conditions. He was refusing to speak about his dying even though he was in the last few weeks of his life, and was insisting on having resuscitation even though it would be hopeless and at the same time very traumatic for his family. He was self-medicating to the point where there was real concern that he might accidentally kill himself and wouldn’t discuss his future care needs. It had come to a critical point, especially for his family. When any of our staff tried to speak with them about any of these matters, he became angry. After an incident where he shouted at one of our doctors, I was asked to go out and see him.

I went out and met him and his wife, and as is common practice for me, I began by asking him about himself and his life aside from the illness. As we discussed who and what was important to him, I was listening for Aristotelian virtues that he had expressed in the way he went about his life. I learned that he dearly loved his family. They were incredibly important to him, and he was very concerned about their well-being. I learned that he was a really considerate employer who knew all about the families of his employees. He personally bought them Christmas presents. He was a very kind man. And I also learned, in his early life, that he was a courageous person. He was an adventurer. He had been involved as a bystander in a very violent and frightening incident and had behaved with incredible compassion and courage. So, these are identities that I sought to bring forward through inquiry as I hoped that they might be helpful to him.

After nearly an hour, he said to me suddenly, “Sasha, you've got it.” And I said, “Oh, may I ask what is it that you think I've got?” And he said, “You get why I want to live. You get why I don't want to die. You will be my death philosopher, and I will talk about dying with you.” We were then able to talk about his dying and how resuscitation would be hopeless and traumatic for his family to witness. Remember, family really mattered to him, and that value was very present in the conversation. We were able to talk about his hopes in taking the medication, that it was harmful, and also about what he might want for the end of his life. I don't think it was just that he felt seen and heard, which was so important, but also that he was able to access parts of himself that he needed to have those conversations. The conversation and the two we had following this one allowed us to plan for him to have a dignified peaceful death with his family nurtured as well.  

Building Meaning at the Threshold of Death

LR: Well, it sounds like you're giving these folks an opportunity to contribute to the narrative rather than being a passive recipient of the traditional story of the dying person and giving them a sense of agency, and utility, and value. This makes me wonder, based on something you said in one of your wonderful writings that working with the dying is sacred. What did you mean?
SM: I meant that I think it needs to be revered, that we need to give every respect to the people we're talking to, that I need to give every respect to the person I'm talking to. I'm entering the most tender areas of a person's life. They may not have been able to share their fears, their experience, with anyone prior to that moment, sometimes because they want to protect those they love most, sometimes because it is taboo to go into these territories, and no one has been able to ask or even wonder.

I might be talking with a person about what their fears are about dying. What part of dying are they most frightened of? Just recently, I was talking with someone about her deep shame at the thought of other people seeing her naked body. Another was frightened about incontinence, and how would she maintain her dignity? These people are worthy of my every respect, and when they're able to share some of those fears or losses, it's the gift, and it's a gift to be honored, I think.  

LR:
these people are worthy of my every respect, and when they're able to share some of those fears or losses, it's the gift, and it's a gift to be honored
So, you don't use the word “sacred” necessarily in a spiritual or religious context.
SM: No, I'm using it just in the sense of to be revered but perhaps a bit more than that. The hospice has a Māori name called karohirohi, which means where the light hits the water, the liminal space, the space between living and death, and perhaps there is something about that space that's sacred, something that’s out of the ordinary. It's something to take great care of.
LR: By virtue of it being a liminal space, it is out of the realm of day-to-day experience. It really pushes one to be somewhere they've never been before. And to have the courage to do that, whether we call it heroic or sacred, special, unique — there may simply not be a word — but I do love the word “sacred.” Sasha, can you give an example of having worked with a client who, in spite of your best efforts, was not able to embrace meaning, was not able or even willing to take you up on your invitation to write a story that their survivors could have?
SM: I think you raise an important point. I adjust what I do according to the person or family I am meeting with and what it is that they want and works for them. I don't write stories with everybody as it’s not right for everyone for lots of reasons. I think that there is almost always the possibility for assistance, and supporting people to have a sense of living meaningfully if they are willing to have a conversation. Some people have more to grapple with than others and I may not be the best person for them to talk to. Someone else might be a better fit. I think it is for me to adjust and try and discover what works for each family. People have different ways of approaching death and living with illness. Talking may not be their preferred option or what is best for them. I respect their knowledge of themselves and what they want.  
LR:
I think that there is almost always the possibility for assistance, and supporting people to have a sense of living meaningfully if they are willing to have a conversation
They're very lucky then. What lessons about death and dying have you learned from working with the Māori?
SM: Many. I read Michael White's paper, “Saying Hello,” and learned about the idea of relationships continuing beyond death, but Māori, who are the indigenous people of Aotearoa New Zealand, have held that idea for 1,000 years or more. Māori incorporate their tipuna, their ancestors, into daily rituals. The idea that those who have died are part of our lives is a taken-for-granted idea within their culture and is a powerful example for me.

When I was learning all of this in the ‘80s, family therapy, thinking systemically, wasn't necessarily the usual way of thinking. Whereas, again, for Māori, thinking systemically, meeting as a group and working things out, was, again, a practice that they had done for 1,000 years. And I think the other thing is that the way that they mourn is, in my mind, very enlightened. For example, a tangi or tangihanga, which is a funeral, takes place over days rather than in an hour, giving meaningful time for connecting and expressions of grief. Such a practice has influenced the time my family and many others give to mourning. And I believe that New Zealanders touch their dead more than any other culture in the world, and perhaps this is part of the legacy and influence of Māori. I feel I’ve benefited from the influence of Māori processes.