Nothing Left to Give: A Psychologist’s Path Back from Burnout

Journal 1: Warning Signs-15 January 2021

I have nothing left to give anymore. I thought the break over Christmas may have helped, but it hasn’t. I am still exhausted, more than ever, and I can’t believe I am saying this, but I feel like I am just going through the motions of caring, that I am “pretending to care,” which is so horrific to say. I do care for my clients; I’m just finding it hard to do this work.

It gets worse. I had a session today with a client. A client with multiple current crises and past traumas still left unprocessed, a presentation making up most of my caseload. This session has floored me.

I am ashamed to admit that my mind was almost completely disconnected from the client throughout the session. My mind was all over the place:

I don’t know if I can help this client anymore.

I wish this client would do what will help instead of just talking about it all the time.

I feel so out of my depth.

I don’t know if I can keep doing this kind of work.

I can’t leave; so many people depend on me.

I feel so trapped.

I need to focus on my client right now. It’s not okay that I’m caught up in my shit.

It is one crisis to the next for this client.

It will never end.

I don’t have anything more to give to this person.

I feel like I’m on autopilot. I’m here, but I’m not here.

It’s hard to know that this client will be safe.

This client deserves a psychologist that can help.

I want this session to end.

I have never been that detached before, and I know I have let her down. A thought popped into my head soon after her session with me ended – you are this client!

I was immediately taken aback as, on paper; we are nothing alike, and we don’t share similar pasts, current life situations, personalities, traumas, or even approaches to life. Despite my immediate disagreement with this thought, it repeated itself. . . you are this client!  

Right here, right now, while reflecting on this session, I still find myself rejecting this thought, this knowing. I’m not this client. My mind is saying:

This client’s experiences, past and present, are a lot more complex than mine.

This client has experienced multiple traumas, depression, and work-life stressors.

I don’t even have half of that…but maybe the similarities lie in how the suffering presents, not the causal events.

Now, this has made me stand up and listen. Despite our notable differences, our suffering does have similarities. We are both going around in circles, staying stuck in situations that are not healthy for us. We both have lost pleasure in our lives in what we do. We withdraw, keep busy or turn to substances (food for me) to cope. We both continue to push ourselves to do better and be better both professionally and personally. We both find it hard to talk about our problems to others. We keep it hidden. We are constantly irritable and exhausted. We both have very high standards and expectations of ourselves. Our worth is caught up in what we do for a living or who we are for other people. We are profoundly insecure and, at the same time, desire safe and supportive connections. We both feel disconnected from who we are. We both suffer from bouts of depression and anxiety. We both dream of escaping, breaking free from our suffering. And we are both beyond burnt out and have no more fucks to give. We are both feeling trapped in our lives.

Shit! We are alike.

Well, what do I do with that now?

I know what I have advised the client to do, and if our sufferings are similar, I need to either step back from my career as a clinical psychologist or make some significant changes to how I’m doing things right now. I need to prioritise care for myself.

But am I that bad?

Maybe this is all just in my head.

It’s just too much even to fathom right now.

Too many people need my help; I need to keep pushing through.

I need to focus on doing what is best for the clients.

Wellness Practice

Don’t shove down any insights you may be experiencing. Don’t question it. Sit with it. Pay attention. You can do so with a daily check-in.

Daily Check-in

Answer the following questions to help you check in with yourself: What is happening for me right now? What am I feeling? What is on my mind? How is my body feeling? Do this regularly to help you gain self-awareness and be in a better position to respond to any difficulties. You can even start a journal to capture these daily check-in insights.

Journal

Start a journal to record your wellness practices throughout this book. The writing process in and of itself can offer therapeutic qualities, and it helps us slow down, pay attention, look in, engage with ourselves, and process our experiences.

Journal 3: Severely Burnt Out-3 March 2021

Since my last journal entry, I have left my job and career behind. I feel deeply ashamed and guilty for leaving my job as I did. It happened so suddenly, so quickly; no one saw it coming. In some ways, even I didn’t, although I had thought about it quite a bit. A week ago, on February 25, 2021, my mind and body spoke for me—“I can’t do it anymore.”

You are not well enough to take care of others right now. Leave this for those who can. Your job is to take care of yourself, and leaving your work is caring for yourself and others.

On that day, I showed up to work at the psychology practice where I had been working for almost five years, Zest Infusion. Like many preceding days, I felt completely and utterly exhausted, emotionally, mentally, and physically. Along with this feeling, I felt a sense of dread, hopelessness, fear, anxiety, self-doubt, and a lack of care to give to anyone.

I had set up a meeting to talk to the practice director, Dr Ilze Grobler regarding the need to change my schedule to support my well-being. I was still struggling with what I wanted to do. Reducing my client load or leaving meant that clients would suffer, but if I kept working the way I was, I would suffer. Both decisions involved suffering; no one would win. I remember feeling very anxious to talk with Ilze about it all, not because of what she’d say (she’d always been compassionate) but my fears of what this meant for everyone—for clients, me, and Ilze’s business.

My heart was heavy, and my mind was too. I knew I wasn’t okay, and something needed to change, but I was battling my need to care for others and myself. I didn’t realise how bad my health was until I was in front of Ilze, letting her know what was going on. Ilze’s compassion made me feel safe enough to connect with the depths of my suffering and listen to what I needed. She mentioned that she knew of a psychologist in a similar position who needed to take time away from the profession to care for herself. At that moment, I admitted I couldn’t do it anymore. I couldn’t push. I couldn’t be present for my clients. I couldn’t adequately put my pain aside and be present; worse, doing so would create more suffering for everyone. I had to stop, and I had to stop then. Ilze’s compassion helped me to find what I needed at that moment and to express it.

I recognise that my awakening to the depths of the pain and suffering I am experiencing has happened because of two compassionate women in my life, Dr Ilze Grobler and Dr Hayley D. Quinn. Without these women, I wouldn’t have been able to take the steps I have made so far. It was Hayley and Ilze who told me…

You are not well enough to take care of others right now. Leave this for those who can. Your job is to take care of yourself, and leaving your work is caring for yourself and others. 

Maybe I can believe, in time, that it is okay to take care of me.

Wellness Practice

Surround yourself with empathic, non-judgmental, warm, kind and empowering people. If you haven’t got them, find them. You will know you’ve found one when you can be yourself around them. If there is not someone in your immediate environment (friends or family), seek out a professional. A mental health professional (e.g., psychologist, counsellor) is trained to provide a safe, secure and supportive environment, so you can be free to be yourself, to share your pain and suffering.

It will depend where you are in the world with how you go about this and what professional to see. In Australia, it can be helpful to see your doctor first, a doctor who specialises in mental health, who can do an assessment and assist with referrals to appropriately trained professionals. You can also visit the following link https://www.healthdirect.gov.au/mental-health-where-to-get-help. This page will help guide Australian readers on the next steps to link with a professional.

If you find this whole process daunting, that’s okay, it is. Bring a friend, someone you trust, so they can support you through the process. They don’t need to know what to do; you can find out together. This way, you don’t have to be alone.

Journal 4: Letting People Down-10 March 2021

I see my burning out and inability to work as being pushed off the side of a cliff, free-falling into the space below with microscopic moments of being lifted, flying to somewhere unknown, feeling scared and free simultaneously.

The past couple of weeks have been extremely challenging. I have spiraled in and out of feeling relief, quickly followed by crippling fear, guilt, and shame. I constantly think that I have let others down (Ryan, colleagues, and former clients) and that I’m selfish for prioritising my care over others. The fear, guilt, and shame are currently overtaking any feelings of relief.

The feelings of fear, guilt, and shame were most substantial when people I care about started to find out I was sick and no longer working. The day the email to my clients and colleagues went out to let them know I had left was particularly gut-wrenching. At first, I couldn’t look at the emails from clients and colleagues. The shame and fear I felt then wouldn’t allow me to read them. I feared they would hate me. I feared harm would come to them; I believed I failed them.

Further, I felt guilty for the position I put them in—not having regular, familiar, and reliable psychological care. I feared they would be angry with me, hurt, and that they’d believe I abandoned them. Or I felt like I had abandoned them. I can’t shake these feelings and thoughts; they are constant companions.

Despite how I feel or think, I must confront this fallout in a way that supports both myself and those affected. I don’t want to hide. I’ve done that before. In my late teens and early 20s, I was experiencing what I later came to recognise as clinical depression. During this time, I worked at a local restaurant fulfilling both waitressing and administrative roles. One day, I upped and left and never returned. I didn’t speak to anyone from work, friends, or family. Those close to me at the time knew something was up, but I didn’t talk; I didn’t know how back then. I felt deeply ashamed for being sick; I believed I had no reason to be. The shame kept me silent. I’ve learnt a lot since then. I’ve learnt to speak up, front up, and recognise that anyone can become mentally unwell and that there is no shame in being mentally ill. I’m thankful for the experience of clinical depression for this learning experience.

This time I want to be the person who fronts up to the fallout, speaks up, and honours the responses from colleagues and clients for my abrupt departure, doing what I couldn’t do all those years before. With this intent, I told Ryan and my family that I was sick and started reading emails from clients and colleagues.

Reading my former clients’ email responses has been particularly tough. I have felt many emotions—grief, loss, gratitude, support, compassion, kindness, and despair. Most of the responses were compassionate, demonstrating concern for me, sadness for not receiving psychological care from me anymore, and non-judgmental support; very few clients responded with what I feared (i.e., feeling abandoned, angry, and let down by me). I wasn’t mad at those who felt this way; I was glad they could express their feelings. It was a difficult time for all.

Despite the overwhelmingly compassionate responses from everyone, right at this moment, I still feel weighed down by it all. I still believe I have let my former clients down; I should be capable enough to support them and hold up my end of the relationship. I want it all to be over. I want to crawl into bed and not deal with it. I still worry about the potential harm that may come to my former clients due to not having a psychologist until they secure a new one. I worry about the workload now on the Zest Infusion team, and I feel bad for no longer financially providing for my family. I feel overwhelmingly responsible for everyone’s pain and suffering at the hands of my actions. I feel like I’m drowning. It’s like it will never end.

What keeps my head above water is the continual support from those who genuinely love and care for me—Ryan, Jayd, Hayley, and Ilze. I love when a message pops up from Hayley or Ilze to check in to see how I am going and knowing I can speak with Ryan and Jayd when I am having a bad moment. I am fortunate to have their support. It gives me the strength to continue putting my needs first, back away from being the carer for others, and allow others to care for me. It helps me to acknowledge that I’m sick and not in a position to care for anyone right now, and it would be wrong for me to do so. They are helping me focus on my choice to care for myself while also doing what is needed to finalise work. For example, setting and sticking to a workable schedule for doing the background work necessary to assist clients in being seen by another psychologist (i.e., writing reports to their doctors, handovers to new psychologists, and answering client emails) and scheduling an appointment for myself as soon as possible with a psychologist. I’m focusing on what is necessary to finalise the care for others whilst also taking care of myself.

I’m in awe of the overwhelming support from former clients for my health and well-being. Many of them have said in their messages to me something to the effect of “if there is anything you have taught me, Shannon, it is the need to prioritise care for self.” I’m so happy they have learned this from me; it helps me to know that they have learned a valuable healthcare strategy, care for themselves. More than this, everyone’s responses (including the clients) showed me that even when what you have to do affects them, it doesn’t mean they will hate you. They may express their hurt but also offer care and kindness. I’m grateful to have been surrounded by such wonderful human beings. The free-falling stopped in these moments, and I felt lifted and supported in this place of the great unknown.

Wellness Practice

You can’t change what has happened. Your illness will impact others. This doesn’t mean you are a “bad” person; it means you are human.

Acknowledge and show compassion for any undue impact on others. For example, “I’m sorry for the impact leaving work has had on you.” Don’t sacrifice your needs to take care of others right now. You will only do further harm to yourself and to the very people you don’t want to hurt.

Turn your attention to your recovery. Do the work so that this doesn’t happen again. What is one small step you can take today in service of your recovery? For example, make an appointment with your doctor to discuss a referral to see a mental health professional, prioritise rest, make time to catch up with a trusted friend, or spend time in nature.

Journal 5: Uncertainty-16 March 2021

At some point recently, I lost that lift and started to free fall again, and this time I was aware I had no place to land. I was fucking freaked out. I was staring into the abyss, and there was nothing. I have never jumped off a cliff; I always have a destination. I’m a planner; I always have a plan.

The free-falling recommenced when I was wrapping up the last bit of administrative work I had to do for my former job. This work has taken a few weeks, working full-time hours to complete, and it has filled my days and kept me from seeing the naked abyss of my life, a protector in some ways.

So, of course, I started to look for work frantically. Honestly, I have been looking for work on and off before then. If you were a fly on the wall for the past few weeks, you would have seen me sitting at my desk, editing my resume, signing up to major job sites, and applying for jobs after finishing a full day of client report writing. You would have heard a few thoughts about what I should do inside my mind. One of them was to do something within my expertise. Another was to do something entirely different with little to no responsibilities. I even thought about not working. My favourite idea was to take off in a van around Australia. At some point, I recognised that my mind and body were busy finding a place to land (i.e., a plan).

I talked about this with Ryan just the other day. I promised to talk more with him, especially when I get caught up in my head about something and take actions that are not helpful to me. Talking with him helps. I know he cares for me and has no qualms about being honest with me if what I do is not in service of that. I wouldn’t share with him or anyone in the past, and I would end up with a messy yarn of irrational thoughts, beliefs, and behaviours that only made me sicker. Talking it out with him helps untangle some of that yarn and keeps me from losing my shit. This time was no different.

On one of our daily walks with our puppy Hana, I shared with him what was happening in my mind and that I had been frantically looking for work, feeling the pressure to earn a living and pull my weight. Just voicing what was going on in my head helped. His words of encouragement, love, and support to do whatever helps me be healthy and happy have helped untangle some of this story and guided me to the firm decision to take 12 months off from working in the mental health field, stepping away from a caring role. I’m very thankful I decided to talk with him about my current messy thoughts; it has led to a critical decision.

This decision felt so good. A weight was lifted from my shoulders. My gap year began. A gap year with a stark difference; one focused on getting better and doing what is necessary to heal.

Gap Year Rule

To engage in activities that meet my needs. Care for self without engaging in work involving providing mental health care to others for at least 12 months.

While this decision and Ryan’s support have helped significantly, I realised I still didn’t have any place to land; I didn’t have a plan. I was still free falling into the unknown, uncertain where I might land. The view was cloudy, messy, unclear, scary, and foreign.

At some point (not sure when), the clouds cleared. I don’t know why; maybe a combination of journaling, talking with Ryan, and time. Whatever the reason, it became clear that I was pushing myself to find land (i.e., a work plan) because I believed doing so would help me feel safe, secure, and in control. I was looking for certainty. However, pushing myself to find a work plan only created more suffering. I needed to stop pushing myself to have a plan and instead let go, be present in the sky, this place of uncertainty, the great unknown. If I remain still, present in this place, I believe the answers will come at some point, and the plan will unfold. A plan that will likely be healthier and much wiser than the one made from pushing.

So, the plan is to be still and ignore the urge to push; to focus on caring for myself— meditating, spending time in nature, hanging with loved ones, stand-up paddle boarding, hiking, and stretching, whatever supports me at that moment.

Wellness Practice

When everything stops, it can be unnerving. Sending you into a tailspin of complicated feelings, thoughts and body sensations, often unexpectedly, especially if you are a high achiever.

Uncertainty is a tough place to be in, and reaching certainty in a moment isn’t always possible.

Instead of dealing with this all alone, talk about it with trusted friends, family or a professional. Speak it out loud. When we voice what is going on, it supports processing our experiences.

Have you ever talked something out with someone, and they haven’t said anything particular back to you, just sat there and listened, and afterwards, you have felt better, maybe even knew what to do next?

Talk with someone. If you don’t have someone, talk it out with a therapist, or write it in your journal.

***

As the sole rights holder and author of Nothing Left to Give: A Psychologist’s Path Back from Burnout, I Shannon Swales hereby grant permission to Psychotherapy.net to reprint the journal entries dated 1/15/21, 3/3/21, 3/10/21, and 3/16/21.   

The Transformative Power of Empathy in Therapy

Therapy as a Place of Safety and Respite

Each person’s therapeutic process will be unique, as will their stories, experiences, and needs. With that in mind, the approach I take with each of my clients varies. I offer a bespoke approach, tailored to the individual needs of each client, built around their personality and presentation. But regardless of their differences and needs, I will always use, and deeply value softness.

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I have come to realise the immense importance of being gentle with my clients. Life, with all its challenges and hardships, can often leave individuals feeling battered, tired, and worn. Many of them seek therapy in a state of heightened vulnerability. It is during these moments that therapy becomes a sanctuary, one that offers them a soft place to land.

As a therapist, I believe deeply that it is my duty to create an environment of warmth, understanding, and compassion. I recognise that my clients may be carrying heavy burdens, and that it is my role to offer them temporary solace and respite from the outside world. I strive to be a gentle presence, providing a safe space where they can lower their defences and be truly seen and heard.

In this gentle space, I encourage my clients to explore their emotions at their own pace. I do not rush or push them to confront their pain before they are ready. Instead, I hold space for their vulnerability, allowing them to express themselves without judgment or criticism. I offer a listening ear, a compassionate heart, and a genuine desire to understand their experiences.

In moments of distress, I remind my clients that it is okay, and perhaps even necessary, to be gentle with themselves. I encourage self-compassion and self-care as essential tools for navigating life’s challenges. Together, we explore gentle practices such as mindfulness, relaxation techniques, and self-soothing strategies that can provide comfort and support during difficult times.

Being gentle in therapy also means recognising and respecting each client’s unique journey. I understand that what works for one person may not work for another. I adapt my therapeutic approach to meet the needs and preferences of my clients, honouring their autonomy and empowering them in their healing process.

Through gentle guidance and unconditional support, I aim to instil hope in my clients. Life may be hard, but therapy can be a refuge amidst the storm. It is a place where they can find solace, gain clarity, and develop the strength to face their challenges with resilience and grace.

In the gentle space of therapy, I strive to be a source of comfort and empowerment for my clients. I believe in their inherent worth and their capacity for growth and healing. By offering them a soft place to land, I hope to help them navigate life’s complexities with kindness, understanding, and a renewed sense of hope.

As a therapist, I am privileged to witness the incredible resilience and strength of the human spirit. Every day, I can guide individuals on their unique journey towards healing and self-discovery. One such client who stands out in my mind is a past client, Emily.

The Use of Compassion and Kindness in Therapy

When Emily first entered my office, I could sense the weight she carried on her shoulders. Her eyes held a mixture of pain, fear, longing for relief, and a need to understand and be understood. It was clear that she had been through significant hardships and was in desperate need of support.

With empathy as my compass, I created a safe and nonjudgmental space for Emily to explore her emotions and share her story. I listened intently, acknowledging the depth of her pain and validated her experiences. I understood that healing begins with feeling seen and heard, and I made it my priority to provide those for Emily. Emily’s hardships had clearly and profoundly taken their tolls—she was tired, mentally, emotionally, physically, and spiritually.

Through our sessions, I encouraged Emily to delve into her emotions and confront the underlying traumas that had shaped her life. It was not an easy process, as she had built walls of self-protection to shield herself from further pain. However, with gentle guidance, she was gradually willing and increasingly able to navigate through the layers of her past and unravel the patterns that held her back.

As our therapeutic relationship grew, Emily began to trust me and felt safe enough to peel back the layers of her vulnerability. She shared her deepest fears, insecurities, and darkest moments with me. In those moments, I realized the immense responsibility I held as her therapist, and I vowed to hold space for her pain and support her in her journey towards healing. There were moments when Emily faced overwhelming emotions that threatened to consume her. She felt lost, as if she would never find her way out of the darkness. In those moments, I provided a steady presence, a beacon of hope, reminding her that healing takes time and that she was not alone in her struggles.

Together, we explored various therapeutic techniques and coping strategies that would help Emily regain control over her life. We worked on building her resilience, nurturing self-compassion, and cultivating healthier ways of relating to herself and others. It was a collaborative process, and I marvelled at Emily’s courage and determination to confront her pain and grow from it. Over time, her wounds began to heal, and I witnessed her transformation into a resilient and empowered individual. She reclaimed her sense of self-worth and discovered her true potential.

***

Emily’s story serves as a reminder to me of the transformative power of therapy. It reaffirms my belief that every individual has the capacity to heal and grow, given the right support and guidance. As a therapist, I am honoured to walk alongside my clients, witnessing their strength and resilience as they navigate their path towards self-discovery and emotional well-being.

Questions for Thought and Discussion

In what ways is the author's orientation to therapy similar to your own?

How do you assure that therapy will be a place of safety for your clients?

How do you address situations where clients enter therapy feeling very unsafe?  

Balancing Between Creative and the Clinician: Reflections on Self-Integration

I was only 100 hours away from finishing my registrar program to be endorsed as a clinical psychologist when I confessed to my clinical supervisor:

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“I don’t think I can do this anymore. I want to quit being a psychologist.” The pressure of clinical work was all too much. But let’s start at the beginning, a few years before that confession. Now, burnout is an experience all too familiar to psychologists, particularly early career psychologists. The insurmountable weight of emotional involvement, the pressure to provide “effective” therapy, and the complexity of cases can lead to a sense of fatigue and sometimes even disillusionment. I was no stranger to this experience. Just a few months into my clinical registrar program, working in a group private practice, I found myself teetering on the crispy edge of burnout. With what felt like the weight of the profession on my shoulders, I began to question my career choice. The disconnection from the passion that once drove me was almost too much to bear. In a bid to relieve some of the pressure, I went into solo private practice. At least then, I could practice in a way that worked for me.

Exploring a Non-Clinical Business

Unfortunately, the relief from burnout was fleeting. In another desperate bid, I explored a non-clinical creative venture. This creative detour in writing allowed me to show up as my full self, not having to hold back aspects of my personality and mask as a “professional.” The creative work also rekindled my love for helping others in a different capacity. As I helped businesses find their writing voice, I started to find mine again. Just as I thought I had found the answer in creative work, a new challenge emerged.

How could I work as both a psychologist and a creative? At the heart of my issue was a paralysing fear of stepping out of my traditional clinical role as a psychologist. I feared potential repercussions, repercussions from my peers for doing work that was wildly different from what my university degrees were in. I also feared repercussions from the psychology institution. This internal conflict made me feel like a tug-of-war rope being pulled in too many directions. I was trying to balance both worlds without breaking apart.

The Importance of Supervision and Therapy

Thankfully, clinical supervision and my own psychotherapy were stabilising forces throughout this inner turmoil. Supervision provided an open space to explore my fears, rage, and uncertainties without being shut down. My supervisor’s questioning led me to realise it was possible to have the two roles without compromising my professional integrity.

Psychodynamic psychotherapy played an equally supportive role. It helped me explore the underlying causes of my anguish, and the deeper, unconscious conflicts that were contributing to my struggles. I discovered that my fear of being a regulated professional was actually a manifestation of an unconscious fear of authority.

Supervision and therapy helped me to see this internal conflict had latched onto my professional identity as a psychologist because it felt safer than confronting the real, underlying fear. As I faced that underlying fear, my inability to see a future in the profession lifted. With space to think outside of myself, I then wondered how many other professionals were in similar situations. Turns out, there are many health professionals with non-clinical or creative businesses. Many were also silent about their non-clinical ventures for similar reasons to me.

With grief in my heart, I wished I had known how many other professionals were doing non-clinical or creative stuff at the start of my journey. It would have made holding the two jobs and two professional identities that much easier.

***

Returning to psychotherapy, I felt like I had come home. But this time, home felt like a space where I could be open, confident, and creative. For the past few months, I’ve had my biggest caseload with the most complex patients, and I am nowhere near that crispy shell of a therapist I once was. I can now channel my angst into my creative work, and as a result, I have a newfound flexibility and creativity in my therapeutic practice.

Sitting back on my supervisor’s couch with only a few hours left in my program, I reflect on my initial confession of wanting to quit psychology. I now see that it wasn’t about the profession, but about finding a way to integrate all aspects of myself.   

Integrating Generative AI and Digital Play Therapy into Clinical Practice

The Chicken Lady

When my now almost 30-year-old son and his brother were in elementary school, I took on a new role—the Chicken Lady. I didn’t intend to achieve that title, but it is one I hope I always remember because it symbolizes a pivotal moment in my time as a mother and a therapist. May we all have our own Chicken Lady experiences.  

AI generated image of a chicken in armour
Image created by Photoleap

The Chicken Lady was born soon after I realized my children were speaking a language I didn’t understand in the backseat of the car on the way home from school. They were having a very in-depth conversation about a game they had recently started to play—RuneScape, which is classified as an MMORPG (Massively Multiplayer Online Role-Playing Game). It is essentially an expansive fantasy world where players can engage in interactions, quests, combat, and skill-building activities. 

RuneScape emphasizes problem-solving and social interaction within a richly detailed environment. Typically, we would all chat together on the way home from school, discussing things that had happened during the day, what we would be doing over the weekend, and other such family-type things. When I began noticing that the conversations had shifted and I no longer understood the content, I felt a bit of sadness. To be clear, I am quite aware that kids will have their own interests and conversations. Individuation is an important developmental process.

In that moment, I thought about whether or not I would just leave this to them as their brotherly bond. I asked them questions about the game and one of them said, “You should just play it, mom.” And so, I did. This was the birth of my exploration into discovering the therapeutic value within all things digital. I witnessed the connection, the interaction, the executive function engagement (and more) within the play for my children, and I knew there had to be value within my work as a therapist as well.

Artificial Intelligence: A Brief Overview

Artificial intelligence (AI) is a very broad field of computer science focused on creating systems capable of performing tasks that typically require human intelligence, such as learning, reasoning, organizing, problem-solving, and understanding language. The term is attributed to John McCarthy and the Dartmouth Summer Research Project in 1956. As an aside, many people disagree with the term “artificial intelligence,” as they feel it does not accurately describe what this tool and process is. It is unfortunate because the connotation of intelligence that can mimic human processes often diverts conversations in ways that can be distracting. Science fiction writer Ted Chiang offers Applied Statistics as a very viable alternative. I am inclined to agree with him and his proposal of the term. 

Generative AI

Generative AI refers to a type of artificial intelligence designed to create new content such as text, images, stories, and more—to generate content through programs such as ChatGPT. Unlike traditional AI systems that follow predetermined rules, generative AI uses complex algorithms, often based on neural networks, to learn patterns from large datasets. This allows it to generate original and unique outputs that can mimic creativity and problem-solving skills.

It can be used for numerous day-to-day administrative (letters, session notes, treatment plans) and training tasks (learning objectives, quiz questions, slide decks, presentations) to create personalized therapeutic content (images, storytelling) and a variety of interventions and exercises. By integrating generative AI into therapeutic practices, therapists can offer more tailored and personalized experiences for their clients. In this regard, I offer the following table.

Aspect Description Therapeutic Application
AI Learning Process AI learns from large datasets including therapy concepts, psychology texts, articles, and more  Reading and collating large volumes of data 
Text Generation AI creates written content for therapeutic use  Writing personalized stories about overcoming anxiety 
Image Creation  AI produces images based on descriptions  Visualizing a client’s experience 
Language Understanding  AI analyzes and interprets context in communication  Grasping underlying emotions in client responses 
Customization for Therapy  Adapting AI for specific mental health applications  Training on therapy techniques, adjusting vocabulary 
Prompt Creation  Therapists and clients learn to craft effective questions for AI  Components and iterations inform the client’s conceptualizations 
Continuous Improvement  AI refines outputs based on feedback over time  Learning over time provides improved responses 
Multimodal Integration  Advanced AI systems work with text, images, and audio  Combining written responses with generated images 
Ethical Considerations  Prioritizing client privacy and data protection  Ensuring the use incorporates confidentiality, secure data storage, and client protections 

Administrative Uses

AI provides a way to complete administrative tasks quickly in therapeutic practices, streamlining processes such as letter writing, case notes, treatment planning, and business analyses. For instance, AI-powered tools can draft and format professional letters, saving therapists valuable time while ensuring consistency and accuracy, or even help finding a synonym as I have done in this paper from time to time using ChatGPT. APA has even addressed how to cite the use of ChatGPT.

AI can transcribe session case notes, summarize key points, and organize information, allowing therapists to focus more on their clients and less on paperwork. This can also assist in treatment planning, creating templates and formatting documents as desired. Additionally, AI can assist in creating personalized, evidence-based, formatted plans by analyzing sanitized client aspects and suggesting potential interventions. 

For therapists who provide trainings, AI can assist in the creation of required proposal content. If the trainer inputs a description of the training, the slide deck, or any other details, AI can generate elements such as training descriptions of specific lengths, trainer bios, learning objectives, quiz questions, and more. By providing the desired format (APA, multiple choice, true/false), prompts can guide AI to provide the information in ways that will minimize necessary alterations. All material should be evaluated and edited for accuracy. This is an area where the therapist’s expertise is critical to alter, amend, and/or add information. AI is here to format and collate information for the user, not to replace the therapist’s experience, expertise, or knowledge.

The Many Uses of AI in Therapy

Generative AI is transforming therapeutic practices by enabling the creation of personalized and vivid representations of a client’s experiences, narratives, hopes, dreams, fears, and visions. Generative AI can turn descriptive narratives (prompts) into detailed creations, providing a tangible representation of a client’s inner world. These aids are incredibly beneficial in therapy, helping clients articulate and explore complex emotions and thoughts that might be difficult to express verbally. By depicting their personalized experiences, clients can gain new insights and perspectives, facilitating deeper self-understanding and emotional processing.

Images

Visual representations can both represent and communicate important components of a client’s life. AI image generation allows for the creation of personalized images based on descriptive prompts provided by the client or therapist. These images can depict complex emotions, significant life events, or abstract concepts that might be difficult to express verbally. For instance, a client might struggle to articulate feelings of isolation, but an AI-generated image can visually convey their personalized essence of this experience.

By providing a tangible representation of a client’s inner world, these images serve as powerful therapeutic tools. They facilitate deeper emotional exploration and understanding, enabling clients to gain new insights and perspectives. This visual aid not only enhances the therapeutic process but also empowers clients by giving them a new medium to express and process their emotions.

Stories  

AI can create powerful therapeutic stories; it can craft personalized narratives based on a client’s experiences, dreams, or visions, creating rich and immersive stories that resonate deeply. These AI-generated stories can serve as powerful therapeutic tools, allowing clients to see their personalized situations from different angles, have a more objective view of representation, identify patterns in their behavior, and/or explore alternative outcomes. Narrating their experiences through AI-generated stories helps clients externalize and reframe their thoughts, leading to potentially greater clarity and emotional relief. 

Interventions

Generative AI can be invaluable in discovering interventions tailored to individual clients. By analyzing a client’s unique experiences and responses, AI can suggest personalized therapeutic strategies and interventions. These AI-driven recommendations might include specific therapeutic exercises, coping mechanisms, or behavioral techniques that align with the client’s needs and preferences and the therapist’s theoretical foundation. This tailored approach ensures interventions are highly relevant, enhancing the overall therapeutic experience and outcome. Integrating generative AI into therapy not only personalizes the treatment process but also empowers clients by providing them with tools and insights uniquely suited to their personal journey. 

Prompt Creation with AI

Creating effective prompts is arguably the most crucial aspect of integrating generative AI into therapeutic practices, particularly when exploring a client’s experiences, emotions, self-concept, identification, and representation. In the context of generative AI, a prompt is a carefully crafted input or question that guides the AI to produce relevant and meaningful output/responses. These prompts serve as catalysts for AI to generate content that mirrors the client’s inner world, whether through prompt creation, image generation, or narratives.

A prompt can capture the essence of a client’s priorities, experiences, perceptions, thoughts, and feelings. Depending on the client and the therapeutic needs, the client or the therapist could create the initial prompt with iterations and changes guided by the client. Prompts act as powerful projective tools, revealing underlying therapeutic material. As the process unfolds, subsequent iterations allow for deeper understanding for the client and therapist. By refining the initial prompt to more accurately represent their internal landscape, clients engage in a valuable process of self-discovery and expression. 

The iterative nature of prompt creation significantly enhances its therapeutic value. Each refinement can unveil new facets of a client’s self-representation, offering a fluid, dynamic, and evolving view of their inner world. As clients fine-tune their prompts, they embark on a journey of self-reflection, identifying and articulating aspects of their experiences that may have previously been unconscious or difficult to express. This process not only helps clients gain clarity but also allows therapists to track changes in the client’s self-perception and emotional state over time. By engaging with the AI-generated output—accepting, modifying, or rejecting it—clients further refine their self-understanding, benefiting both themselves and the therapeutic process.

The therapist or client, or a combination of both, can lead the prompt generation process. For example, to help a client visualize a calming environment, a therapist may ask the client to “describe a place that feels safe.” This can include colors, items, people, animals, weather, and many other aspects. A client-driven image may include a request for something which depicts “a sad little boy with brown hair, brown skin, and brown eyes who is all alone in a storm.” Aspects which do not fit the criteria can then be changed through iterations, thereby revealing the client’s experience or desired depiction.

Prompt creation can serve as a projective exercise along with the desired creation. Each version of the creation, whether initial or refined, holds valuable insights. The evolving nature of prompts encourages ongoing dialogue between client and therapist, fostering a collaborative and exploratory therapeutic environment. When used skillfully and ethically, it can significantly enhance the therapeutic process, providing both clients and therapists with tools to advance the treatment plan forward.

The Ethics of Using AI in Therapy

The integration of generative AI in therapy presents significant ethical considerations, particularly regarding the protection of personal health information (PHI) and maintaining client confidentiality. Therapists must ensure that any data input into AI systems omits identifiable information as a safeguard of a clients’ privacy. This involves adhering to strict guidelines for data anonymization and being vigilant about the types of information shared with AI tools. Ensuring that all generated content complies with privacy regulations, such as HIPAA in the United States or GDPR in the United Kingdom, is essential to maintaining trust and ethical standards in therapeutic practice.

As mentioned earlier, of key importance is the therapist’s expertise, experience, and training. While AI can provide valuable insights and tools, the therapist must have the final say in what is included and presented to the AI tool, and the decision regarding what type of output is generated within the therapeutic interaction. Therapists need to explore programs in advance and critically evaluate AI-generating programs, ensuring they align with therapeutic goals. This requires an understanding of both the technology and the therapeutic context, emphasizing the importance of ongoing education and supervision regarding the use of AI applications within therapy.

Case Example

Emily is a 16-year-old transgender girl who presented for play therapy treatment during the transitional process of altering her gender identification and representation. She utilized generative AI to explore and articulate her experiences through image and story generation. Emily was assigned male at birth but discovered her identification as female. Among other approaches and interventions, her therapeutic process was enriched by the use of generative AI. She was able to visualize and narrate her journey of self-discovery, family acceptance, and social representation.

Emily began her therapeutic gen AI journey by creating representative therapeutic images. She crafted complex prompts and many iterations that helped her create images which depicted her true identity as a female. Despite being born with male anatomy, these images allowed Emily to see herself in a way that felt authentic and congruent with her internal sense of self. The visual representations were a powerful tool in helping her recognize and affirm her identity, providing a sense of validation and clarity.

“Gay Pride Event Many Happy Teenagers”
(Created with Photoleap, numerous prompt iterations -representations of Emily’s Work)

Therapeutic Outcomes

Through the use of image and story generation, Emily achieved several therapeutic outcomes: 

1. Self-Representation: She was able to see a visual representation of herself that was congruent and customized to her experience.

2. Narrative Creation: Emily created a narrative that represented her journey, helping her process and make sense of her experiences.

3. Sharing with Others: She produced content that could be shared with others, both known and unknown, fostering understanding and support.

4. Prompt Iteration: Emily learned to determine the important components of her experience and represent them accurately through prompt creation and iterations.  

A Beginner’s Guide to Generative Artificial Intelligence

Generative AI is a type of artificial intelligence that creates new content, like text and images, based on patterns it has learned from data. Unlike traditional AI, which follows set rules, generative AI uses complex methods to generate original outputs.

Key Concepts of Generative AI:

1. Neural Networks:

  • Think of neural networks as layers of connected “nodes” that process data, similar to how our brain works.
  • They help the AI learn patterns in data, enabling it to create new content. 

2. Training Process:

  • AI learns from large amounts of data, such as texts and images.
  • AI goes through the data multiple times, adjusting its internal settings to improve accuracy.  

3. Generative AI in Action:

  • Text Generation: AI models like GPT can write coherent text based on a given prompt. They are used in chatbots and content creation.
  • Image Generation: AI tools can create images from descriptions, helping visualize concepts.  

4. Applications in Therapy:

  • AI can create personalized narrative content, like personalized storytelling.
  • AI-generated images can help clients visualize their emotions and experiences.  

Important Considerations:

5. Data Quality: The AI’s performance depends on the quality of the data it learns from.

6. Privacy: It’s crucial to keep client information private and secure.

7. Understanding Limitations: While powerful, these AI models have limitations and can sometimes produce biased and incorrect results.  

Concluding Thoughts

Integrating generative AI into Digital Play Therapy™ marks a significant evolution in the field of mental health care. Through blending advanced technology with psychotherapeutic expertise, therapists can enhance their practice in multiple ways—from creating personalized therapeutic content to streamlining administrative tasks and discovering tailored interventions that resonate with each client’s unique experiences.

Just as I embraced the world of Rune Scape to connect with my children, therapists today can embrace digital tools, including generative AI, to form deeper connections with their clients. This technology offers unparalleled opportunities for creating vivid visual representations, crafting personalized narratives, and developing customized therapeutic strategies that cater to individual needs.

However, the integration of AI into therapy must be approached with careful consideration of ethical responsibilities. Ensuring client confidentiality, maintaining rigorous training standards, and critically evaluating AI-generative programs are essential practices that uphold the integrity of therapeutic work. Therapists must balance innovation with ethical responsibility to protect clients' privacy.

Thoughtful and ethical use of AI can allow therapists to enhance their practices by offering clients more options for engaging, insightful, and effective therapeutic experiences. The future of therapy is bright with the possibilities that generative AI brings. As we continue to learn and adapt, we can utilize these technologies to transform the therapeutic process in profoundly positive ways.  

Honesty, Not Empathy, is the Greatest Gift a Clinician Can Offer

Despite spending years in my own therapy, attending graduate school, receiving excellent supervision, and working as a therapist for the past couple of years, I am still in the process of discovering what exactly people find so healing about therapy. Is it the experience of empathy and unconditional positive regard? Perhaps it’s the space to express repressed thoughts and emotions? Then again, some people say it’s the reparative attachment relationship. Others feel that it’s the wisdom and insight of the therapist that’s paramount.

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In my previous post, I shared my belief that clients heal most when they can express themselves fully without fear of judgment and retaliation. So, when a friend expressed that her most pivotal moment in therapy occurred when her therapist expressed helplessness and despair, I was intrigued. Didn’t she want her therapist to be strong and confident? How could my friend feel safe to be herself if her therapist was so reactive? To me, this sounded like an unethical experience of countertransference. I needed to understand more.

Countertransference or Therapeutic Transparency

Ella (not her real name) had been questioning her therapist’s care and commitment relentlessly. Despite many conversations and ongoing reassurance, Ella continued to doubt that her therapist had her best interest in mind. While she repeatedly challenged and tested her therapist, they would continue to show up unconditionally without judgment.

Her therapist helped Ella to check the facts, reflected on the possibility of transference, and continued to offer a reparative attachment relationship. Ella knew that her emotions were irrational. She would lash out and her therapist would not retaliate. What more proof did she need that her therapist was not going anywhere?

About a year and a half into their course of therapy, Ella’s therapist informed her that she would be taking two weeks off for a vacation. Ella expressed fear and worry and accused her therapist of abandoning her. Her therapist listened to her nondefensively, validated her experience, and helped her cope forward.

Ella worked through object constancy and knew intellectually that her intense emotions were a reenactment from her childhood. While her therapist was away, she used every strategy from self-compassion and acceptance skills to reframing her thoughts. She engaged in distress tolerance skills and tried to keep herself busy. She reminded herself repeatedly that a temporary break does not mean the relationship is over. But her emotions got the better of her and she texted her therapist with a suicide threat. Luckily, despite being on vacation, her therapist noticed the text. She contacted Ella’s emergency contact who was thankfully able to deescalate the situation.

Upon her therapist’s return, Ella and her therapist met for a session. As soon as Ella walked into the room, her therapist burst into sobs. Through her tears, she shared that she was overwhelmed and unsure if she could help Ella, who was expecting therapy to save her from herself. Although she had wished to help Ella, the burden was too much for the therapist to bear.   

After hearing this story, I was perplexed. How could Ella have found this experience to be so therapeutic? I thought the therapist had been way too honest about her feelings. She sounded judgmental, hurtful, and perhaps even a bit self-centered. What right did she have to hijack the session with her own fears? I would’ve been devastated if my therapist were to react this way.

Ella, however, was relieved. She had experienced the tears as a piercing jolt of reality that cut straight through her debilitating insecurities. She had been unable to synthesize her rational thoughts with her internal emotional experience. While she “knew” rationally that her therapist cared about her wellbeing, she had never been able to “feel” it. She could not get herself out of the insidious loop of doubting and testing. She had been heading towards a self-fulfilling prophecy and the reaction of her therapist stopped her in her tracks.  

After this incident, Ella’s behavior shifted dramatically. She and her therapist had a meaningful repair and they continued to work together for another couple of years. She shares that although she continued to struggle with doubts, both in and out of therapy, she learned to accept her intense emotions while also choosing more effective ways to navigate them.

***

I’ve learned a lot from Ella’s story. Sometimes the most powerful tool that we have as therapists is simply our own feelings. We can be the first person to be brave and honest enough to reflect on their impact. Others may have responded with anger and accusations towards them but that’s not the same as honesty. That’s defensive and retaliatory. I’m suggesting that sometimes, what a client needs is a chance to see themselves in a mirror. And when we are certain that we have built enough safety in our relationship with them, I think being vulnerable and honest enough to share our feelings may be the biggest gift we can give them.

Questions for Reflection and Discussion

Do you agree or disagree with the notion that honesty is more important in therapy than empathy?

What are your limits of expressing your feelings with a client?

How did you address a challenging situation in therapy around expressing your feelings?  

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
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