Category: Therapeutic Issue

Navigating Client Loneliness in the Digital Age with Therapy

Posted on by Psychotherapy.net Team

I’ve noticed a striking paradox in today’s digitally connected world: loneliness persists despite the abundance of online connections. Many of my clients grapple with profound feelings of isolation, shedding light on the intricate relationship between technology and loneliness. As digital interactions increasingly shape our social landscape, it has become important for me to delve into the possible underlying connection between loneliness and digital habits of my clients. By examining this paradox, I have been better able to support them in navigating the challenges of modern connectivity while fostering their interpersonal connections and well-being.

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Nurturing Non-Digital Relationships through Therapy

Social media and messaging platforms often create a superficial sense of connectivity, where likes and comments substitute for meaningful face-to-face interactions. Moreover, the pressure to maintain a curated online presence can amplify feelings of inadequacy and isolation. Excessive screen time and reliance on digital communication can hinder the development of deep, authentic relationships, ultimately contributing to a sense of loneliness and isolation. Understanding these detrimental effects of hyper-connectivity on social well-being has been crucial for me as a clinician working with clients who have been impacted in this way.

I’ve come to realize that while virtual communities offer a semblance of connection and support, they often pale in comparison to the richness of genuine, in-person relationships. Online interactions lack the depth and intimacy of face-to-face encounters, leading to a sense of emotional emptiness. Additionally, the curated nature of online personas can create a distorted perception of others, fostering feelings of inadequacy and isolation. Excessive reliance on virtual interactions can thus contribute to anxiety and depression.

In my clinical work, I’ve witnessed the pervasive influence of the fear of missing out (FOMO). This hyperconnected lifestyle often leads to a sense of emptiness and disconnection from the world around them. However, amidst the frenzy of digital connectivity, the concept of the joy of missing out (JOMO) offers a refreshing perspective. By consciously choosing to disconnect from digital distractions, my clients can potentially create spaces for meaningful real-life and interpersonal experiences. I have strived to promote awareness of these concepts and to empower my clients to prioritize meaningful off-screen/offline connections.

Case Applications

I recall working with Sarah, a 32-year-old marketing executive, who presented with profound loneliness despite her extensive online network. Spending hours each day immersed in social media and messaging apps, Sarah sought validation through digital interactions. However, despite the illusion of constant connection, she felt increasingly isolated from genuine human interaction. Through therapy, I remember supporting Sarah as she acknowledged the detrimental effects of hyper-connectivity on her social well-being.

Sarah’s treatment plan focused on dismantling her curated online presence, moderating her excessive screen time, and reducing her reliance on digital communication. Together, we explored alternative ways for her to nurture meaningful relationships offline. I emphasized the importance of face-to-face encounters and encouraged Sarah to connect with a limited group of friends in real-life settings.

In a similar manner, I supported Michael, a 28-year-old Latino construction worker, who experienced feelings of emptiness and isolation despite his active participation in online communities. Raised in a tight-knit community, Michael valued deep, meaningful relationships rooted in face-to-face interactions. However, his demanding work schedule limited his social opportunities, leading him to seek connection through virtual means. In therapy, I recall reflecting on Michael’s cultural values and exploring strategies for fostering authentic relationships offline.

Recognizing the importance of developing culturally relevant social skills to navigate interpersonal interactions, I suggested incorporating extended family members into Michael’s treatment plan. We discussed the idea of using role-playing exercises with his relatives to simulate real-life scenarios and practice social interactions within a familiar cultural context. By engaging with his extended family in these role-playing sessions, Michael gained confidence in initiating conversations and building rapport with others while staying true to his cultural heritage. These sessions provided Michael with valuable opportunities to develop his social skills in culturally relevant contexts, ultimately empowering him to forge deeper connections within his community.  

***

Technology presents a double-edged sword in the fight against loneliness. While it offers innovative solutions for connection, it also poses challenges, contributing to the erosion of traditional social structures. By promoting digital interventions that prioritize authentic connection and well-being, I hope fellow clinicians can empower their clients to navigate the complexities of loneliness in this complex digital age.

Questions for Reflection and Discussion

What is your opinion on the author’s view of technology and loneliness?

What has your clinical experience been with clients who have chosen digital over live connection?

In what ways does the author’s position resonate with you personally?  

Facing the Fear of Flying Together: Reconsidering Exposure Therapy

Posted on by Psychotherapy.net Team

Beyond Resistance to Exposure Therapy

Exposure therapy for anxiety and related problems gets a bad rap. It is often seen as mechanistic, simplistic, unimaginative, and even cruel. The suggestions that “coaches” or AI could do as good if not a better job with exposure treatment, compared to well-trained therapists, only reinforce these beliefs. This contrasts with the treatment outcome research studies that show it as one of the most effective approaches in psychotherapy.

During my early years of practicing in a CBT-focused clinical psychology program, we were taught and expected to use exposure therapy. Soon, I found that I was not looking forward to the sessions that included exposure, and I abstained from volunteering to take on new clients whose presenting problems indicated that they could benefit from exposure therapy. I viscerally understood why studies have also shown that a majority of therapists, even those who identify as cognitive behavioral, shy away from exposure therapy.

My supervisor was certain that my and my classmates’ feelings were related to what he believed was at the core of the exposure underutilization: Therapists are, by and large, very empathetic people and thus we hate “making” our clients suffer. If we only realized that a compassionate approach sometimes requires short-term pain toward long-term gain, it would lead to an exposure therapy renaissance — or so he believed.

His contention resonated with me. I certainly was concerned when witnessing my teen client’s face turn pale and eyes water while touching the floor, doorknob, and trash can in our clinic bathroom while engaging in exposures for contamination fears. And I deeply felt the anguish of a middle-aged mother trembling as she held a knife and recounted the obsessive fears of hurting her daughter. But very few worthwhile things come easily, without pain attached to them. With my supervisor’s help, I started paying attention to the uncomfortable emotions and physical sensations that were coming up for me during exposures and worked on accepting them in the service of helping my clients.

It was a long journey, but I slowly improved, vowing that the avoidance of my distress was not going to be the reason for the avoidance of exposure therapy. This was my way of bucking the trend — much more pronounced these days — in which therapists lean into validating, complimenting, and colluding with clients’ defenses at the expense of challenging, probing, and having difficult conversations with them. A majority of therapists I know have become very good at accepting clients and being liked by them, but not great at actually helping them change in meaningful ways. But exposure therapy is far from the only approach that can be challenging to do and can lead to heightened distress in the short-term. I would argue these conditions are true for any good therapy.

Another observation my supervisor made was that many therapists were afraid of “pushing clients too far,” potentially leading to crying, hyperventilating, or even decompensating. “First,” he stated impatiently, with a hint of agitation, “no client will decompensate because of heightened anxiety — this fear only mirrors unfounded fears that clients often have, and it needs to be dispelled through psychoeducation.” He then assured us that we would become better at knowing how quickly to go up the exposure hierarchy (constructed at the beginning of treatment to guide exposures) with experience. Over time, he insisted, good therapists get a sense what the optimal dose of exposures is. Like Goldilocks, we learn that it needs to be strong enough to cause significant anxiety, but not too overwhelming to paralyze the client. That was, in his view, the art of exposure therapy.

Over the years, I did become proficient in the practice of exposure therapy, even penning a Washington Post article extolling its virtues. I have witnessed the transformation of people’s lives with the help of imaginal, in-vivo, virtual reality, and interoceptive exposures. And, yet, I have felt that by focusing on doing the exposures, we are missing crucial elements that could help more clients decide to take the leap and keep them engaged until they improve.  

Most people are deeply ambivalent about change, especially the change that requires hard work and invites distress. When some realize that anxiety is contracting or even ruining their life, but they are not sure how to muster the courage to do something about it, internal (and sometimes external) conflicts ensue. Leveraging the therapeutic relationship to work with clients on these conflicts and on finding a way to integrate the parts of themselves pulling them in different directions is at the heart of what I do. In this process, my clients and I have come face-to-face with what it means to be human — to struggle with uncertainty, isolation, death, and the search for meaning. As Irvin Yalom suggested, all our fears emanate from trying to deal with these givens of the human condition.

Flying with Rick: A Case Study

“I don’t think I can get on that plane, I’m sorry,” said my client as we lined up to embark on a flight to Charlotte. He exited the queue and started walking away from the gate. When I saw him slowing down and stopping about 100 feet away, still facing away from me, I gave him a few minutes and then approached.

His face was contorted with fear and apprehension. I was concerned that he felt he needed to fly to be a “good client,” despite multiple discussions we had about him taking the pilot seat in his exposure therapy journey.

“I’m not going to ask you to get on the plane,” I said. “This is your choice.”  

Rick had contacted me a few months before and said he was in his late 20s, suffering from flying phobia. In our initial meeting, I explained how I practice Cognitive Behavior Therapy (CBT) with an existential slant. We discussed what our work might look like, including the exposure therapy part, in which one gradually confronts one’s fears. “So, you’ll fly with me?” asked Rick, with a nervous half-smile. “If need be?”

I hesitated uncharacteristically. Being a nervous flyer myself had never stopped me from visiting my family overseas, traveling, or doing exposure therapy with previous clients. But abstaining from flying during the pandemic had increased my apprehension. Still, how could I expect my clients to face their fears if I was not prepared to do the same? “Of course!” I said, before I could change my mind. I wanted to model the courage that is one of my strongest-held values.

We first explored Rick’s history. He’d been uncomfortable in planes for as long as he could remember. His mother was a very nervous flyer, so Rick’s family rarely flew. When they did, his mom looked petrified and once even dug her nails into his skin during turbulence. So, he came to his flying anxiety by both nature and nurture. As an adult, Rick continued to avoid flying, and the less he did it, the more afraid he became. He still felt tremendous guilt about bailing the night before the flight that was supposed to take him to his best friend’s wedding. 

Then, just before the pandemic, Rick was offered a dream job. Although it required frequent air travel, he decided it was too good a career opportunity to pass up. “I figured this would be exactly the kind of push I needed to get over my fear of flying,” he said. But the pandemic curtailed his new team’s travel, and Rick got few opportunities to fly. Later, when the U.S. reopened, he needed to be ready to fly anytime. He endured a business flight to Colorado with the help of Xanax but felt so miserable before the trip and after the medicine wore off, that he realized he needed to seek therapy.

We started by watching videos depicting a wide variety of flights, including turbulent ones, followed by vividly visualizing flying scenarios. I guided him to engage his imagination, focusing on all aspects of the experience, as if he were in a movie. When the imaginary exposures raised Rick’s anxiety, we practiced “sitting with” the anxious thoughts, feelings, and physical sensations. For example, I asked him to mindfully scan his body to notice where the uncomfortable sensations were showing up. Rick described his throat drying up and chest constricting, and he learned to allow them to be as they are, without judgment or suppression.  

We also practiced observing the stream of anxious thoughts and imagining “placing” them on, for example, leaves in a stream or clouds in the sky — thus letting them continuously come and go. We discussed how this acceptance approach works best in the long run. We also practiced several breathing and muscle-relaxation techniques to be used only occasionally when anxiety becomes paralyzing. I warned Rick against using these “quick fix” techniques habitually, as they could become another kind of counterproductive avoidance. After a few months, Rick said he wanted to try “the real thing.”

At the airport, Rick blurted out, “I really, really want to do this, but I think I’m getting a panic attack!”

“Let’s breathe together like we’ve practiced,” I said. “Inhale for four, hold for four, exhale for eight though the nose…And repeat.”

Soon, Rick appeared more resolute and started heading back toward the gate. As I walked beside him, I felt my own anxiety bubbling up, but I kept a calm demeanor. Just before joining the line of boarding passengers, Rick stopped again. “It’s like I want to go, but some invisible hand is not letting me,” he said.

It seemed like he still was not accepting his ambivalence. How much easier it is for all of us to externalize what we don’t like about ourselves!

“Perhaps the hand is also a part of you,” I said. “There seem to be two parts of you.”  

“Yes, it does feel like that.”

“What is each one saying?”

“One says, ‘You can do this, you’re strong, you’re not going to let the fear boss you around.’ And the other says, ‘You’ll faint or have a stroke if you get on that plane. If the plane doesn’t crash first. This is too much for you to handle!’” he said.

I waited, curious to see what he’d do with these two parts.

Rick asked for reassurance: “But it’s not going to crash, right?”

“Neither of us has a crystal ball,” I said with a slight smile, because Rick had been emphatic about his disdain for anything superstitious or new-agey.

He smiled back before his face turned solemn.

“I see more emotions coming up for you,” I said.

“A lot of irritation. Frustration with myself that I can’t be the person I want to be, that I am torn between these parts.”

“Is either part helping you expand or contract? Makes you larger or shrinks your world?”

“The first one makes me larger, but how do I make that one win?”

“It’s not about winning or losing. Only you know which one you’ll choose to listen to,” I said softly.

“I’m choosing to listen to the brave Rick, but the other part is still there…” his voice trailed off.

“That anxious Rick might always be a part of you. Can we just take him along for the ride?”  

The gate attendant announced the last call for passengers heading to Charlotte. My stomach began to ache. We might never get on this flight, I thought with mixed feelings. A part of me felt disappointed with my ineffectiveness as a therapist. And another part was relieved that I might be spared flying today. It was then that I decided that self-disclosure might be helpful to get us past this impasse — after all, we were in this together.

“The truth is, I’m not a fan of flying either, especially after a long hiatus. I haven’t flown since the pandemic began, and my hands are sweating.” I turned my palms around for him to see. “But I don’t want to look back on my life with regret for not taking a chance, the regret that I so often hear from my elderly clients.”

Encouraged by the look of grateful surprise that flashed across Rick’s face, I continued. “Imagine sitting with your grandkids on your 80th birthday. What would you like to tell them about how you approached this short and precious life?”

Rick’s eyes brimmed with tears. He rushed toward the attendant, but quickly turned around. “You’re coming?” he asked.

I followed him swiftly, letting my legs carry me and my anxiety. I was thankful he led us to the plane.

Once in the air, Rick was surprised that he was not as anxious as he thought he’d be. “Anticipatory anxiety is always the worst,” I said. When the plane started to shake and both of us noticed our anxiety rising, we practiced the acceptance strategies. The majority of the flight was smooth, and each of us enjoyed a soda and flipped through a magazine. On our descent, the plane shook slightly and moved from side to side as we went through a thick layer of stormy clouds. Rick’s face turned pale and he murmured, “What now?”

“You know what to do,” I said.   

Rick led us though some breathing exercises, and as his body relaxed a bit, he joked pointing out the window: “I am working hard to put my catastrophic thoughts onto these dark clouds!”

When we touched down, Rick turned toward me and mouthed, “Thank you.”

Now it was my turn to tear up. “Thank you. It was my honor to join you on this journey,” I said. 

***

I was grateful that we were able to find strength in vulnerability and face the fear together. When we own all parts of ourselves, we can come to terms with the existential givens in unison. Approaching each therapeutic encounter as an opportunity to delve into the fundamental challenges of human existence, we enable our clients to grow stronger in the face of life’s uncertainties. Rather than offering them absolute solutions aimed at minimizing their anxiety, we can join them in embracing the existential realities, along with the unease these bring. And confronting the core realities of our existence is essential for leading rich and purposeful lives.  

Exposure therapy is not about conquering anxiety but about finding a way to live authentically despite it. Instead of being technocratic cheerleaders, therapists using exposure have an opportunity to accompany clients on some of the scariest and most profound literal or figurative quests of their lives and witness the transformation that happens when we stop avoiding what matters.

“Have you decided how you’re coming back to D.C.?” I asked Rick as we exited the plane.

“I’m going to fly by myself!” he said with a smile. “And bring nervous Rick along.”  

Questions for thought and discussion

What were your impressions about this therapist’s approach to exposure therapy?

In what way or ways do you think the client benefited from her intervention?

In what ways have you found exposure therapy to be useful in your practice? Not useful?  

Creating a Safe Therapeutic Space for All Feelings

Posted on by Psychotherapy.net Team

Yesterday, after a long silence, my client suddenly asked me, “did I offend you?”

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Where did that come from, I thought to myself. She had historically been so agreeable — almost too agreeable. I often wished she would occasionally say something offensive. I let these thoughts percolate as I considered how to proceed. I am trained to think twice before answering a question directly. Questions are fodder for the therapeutic process. I decided to delve deeper by responding with a few questions of my own. “How would you know if you did? What would it mean to you if I felt hurt? Have other people suggested that you’ve been offensive to them?”

A Therapist’s Secret Wish

I don’t let her know about my secret wish that she offer something offensive about me. Afterall, this was her process and I want to be careful not to project my feelings onto her, lest she become disagreeable to fulfill my aspirations for her instead of her own. That would defeat the entire purpose. Despite my success at navigating the conversation, my desire to be the recipient of a nasty comment did not abate. Perhaps I sound like a masochist who enjoys reveling in the psychological pain of being insulted. You might be thinking, is this a repetition compulsion? She should’ve gone to therapy to face her traumas not become a therapist to reenact them. Or maybe others would call me a martyr who sacrifices her own need for respect to keep her clients happy with her. She sounds Codependent. Is she in this for the right reasons? You might wonder.

I definitely do not have a penchant for pain. When someone insults me, I do not like the way it feels. Despite my best efforts to hold them back, my eyes often fill with tears in response to even a minor slight. Like most humans, I protect myself valiantly when I feel judged or criticized. Were I, in actuality, to be a martyr for the sake of keeping my clients happy, it would actually be pretty devastating to hear negative feedback. It would mean they weren’t happy with me. Wouldn’t that defeat the entire purpose of the sacrifice?

Here’s the thing; I’m no masochist and I’m definitely not a martyr. However, I am invested in my clients. I believe that for my clients to heal, they need a space where they are free to say and be whatever and whoever they want — including offensive. I might be a sensitive person, however, when I’m in my therapist role, my feelings are only welcome if they are in service of the client. If they aren’t, I set them aside to work through later.

In my experience, clients don’t come to therapy to be rude or offensive, especially toward the therapist. They certainly don’t want to be perceived as an ingrate by someone whose job definition is to help them. They are often ashamed of their selfishness and deny it, not only in the therapy room, but in their lives. But here’s a little secret; if they leave part of themselves outside, then part of them won’t heal. For therapy to work, they need to give voice to all their thoughts and feelings, especially their most shameful ones.

As a therapist, it is my responsibility to make space for the repressed voices of my clients. Good therapy grants permission to express what, outside of therapy, might be labeled socially inappropriate. Lack of this permission can reinforce ineffective patterns of repressing feelings and increasing shame.

The therapeutic challenge comes when, in instances such as this one, my own feelings are at stake. It’s relatively simple to support a client when their complaints are about “other things.” However, when their pain might be related to me, even if I had no intention to hurt them and despite the feeling that they are nitpicking, I feel obligated to face the Herculean task of supporting them just the same. Indeed, this selfless endeavor may be the most important and impactful act of therapy. If I can respond to an insult with curiosity, receive negative feedback without defensiveness, and authentically validate the valid, then I am giving my clients full permission to shamelessly express themselves. I cannot think of a better way to convey unconditional acceptance. But don’t get me wrong, I’m not giving permission for people to act how they please. Actions need boundaries. However, in therapy, I believe that words don’t and that words shouldn’t, even if and when those words are offensive.

***

So, as I think again about yesterday, I hope I can find a way to convey this message, “no, dear client, you didn’t offend me, but I hope that one day you feel strong enough to take that risk. And when you do, I will not abandon or reject you. Instead, I will be honored that this vulnerable and precious part is finally brave enough to join us in session.”  

Questions for Reflection and Discussion

In what ways is the therapist’s attitude in this essay similar or dissimilar from your own?

How do you address situations where your client offends you?

In what clinical circumstances might you NOT address a client’s offensive behavior?  

Reflections on Clinical Techniques for Working with Loss

Posted on by Psychotherapy.net Team

In the “helping profession,” it is easy to talk about how we handled our successes, but seldom do we openly speak about the failures, the ones who got away. The people who leave treatment and don’t come back, or the ones who take their own life. How do you reconcile this?

Losing Clients in Therapy

I remember sitting in a training group run by one of my mentors — the topic was treatment failures. He said clients come and go, and that few therapists get through their career without experiencing the death of a client.
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The Ones Who Come and Go or Don’t Come Back

Over time, I have reframed my perspective from “What did I do or say wrong?” to the social work principle of client self-determination and come to accept it. I have done what I can do. I view therapy as a process and a series of stair steps on the client’s journey. Some clients may take the steps rapidly while others pause to practice along the way and return to a new and different therapist later to move forward. It is amazing how this concept, when presented to someone considered “chronic, repeater, or a therapist shopper,” helps them feel better.

On the Death of a Coworker

At the time of that training, I had only experienced the death of a coworker who shot himself — a young man, a recent college graduate who had volunteered and completed an internship in the mental health clinic. He fit the 1980’s Emergency Service Image of the day: suit, white shirt and tie for the guys; heels and hose and three-piece suit dress for the women. This nothing-out-of-place look was advanced by the department manager which, if you ask me, was designed to make the population we serve uncomfortable. He was working in rehab and pulling shifts in emergency services after hours. I was temporarily acting as program supervisor while the regular supervisor was on maternity leave, so his supervision was my responsibility.

Nothing is more unnerving to a new clinician than to be on the telephone in the wee hours of the morning talking to a military veteran in possession of a gun telling you they are going to kill themself, or who is seeing the enemy coming through the window to kill them. His speech was broken. His lips trembled. His body trembled as he spoke. It was clear to me that this novice clinician was not ready to clinically deal with the after-hours crisis. I went to my superiors and the department manager and asked them to remove him from after-hours work, but they ignored me.

Then one day, our executive director called us to an all-staff emergency meeting. He said this young man had shot himself in his home and was dead. I was shocked, sad for the young man and his family. and angry that management had not respected me clinically and listened, but I never felt responsible. Documentation supported me. I had done what I could do.

On the Death of Clients

True to prediction during my career, two mothers with young children have died while in treatment with me. While I was on vacation, the mother of an eight-year-old put a note on the door for the neighbor to care for her son, took his teddy bear, and used carbon monoxide poisoning. When I came into work on that Monday following my vacation, my supervisor called me into the office and said, “While you were gone…” I felt no accountability. A QA chart review did not find any clinical culpability. It revealed hundreds of times when I had asked her to enter inpatient treatment for substance abuse or depression and she declined. I was sad for the child and the family. I wrote what I called “The Alphabet” for the service and gave a copy to the guardian for the day that the child asked, “What was my mother like?” The Alphabet was a commemorative of his mother, with one of her positive qualities attached to each letter of the alphabet.

The aunt raised that little child and gave him everything his mother wanted him to have — life in a small town, school, freedom from the stigma of his parents’ substance abuse and repetitive domestic violence, sports, scouts, activities, friends, a college education, and a good job. His aunt and I have corresponded over the years. He got married last September.

In the second case, the mother of an eleven-year-old experienced a heart attack from the abuse of multiple prescription medications from multiple doctors in conjunction with illegal drugs. I was sad. I felt no guilt or responsibility because the clinical record was in order. I had done what I could do. I helped the family clean out the apartment with the blessings of my supervisor.

The family were like dispassionate machines which angered me. With their permission, I took a cookbook and kitchen knives that symbolized the child’s mother for the day that she asked, “What was my mother like?” I attended the service and took one of her friends.

I wrote “The Rose,” and shared it with the family at the luncheon following the service. One of the family members said to me, “If we had known, we would have had you read it at the service!” Instead, they had a priest offering words of comfort about someone he didn’t know. “The Rose,” like “The Alphabet,” was a tribute to the child’s mother (whose name was Rose) using metaphors of the flower to describe her.   

The child was raised by her father. I used to see them when he would come by to pick her up for her visitation. It was clear he found it difficult to deal with her mother, but he adored his daughter as she did him. Her life has been a little harder. I found some of her mother’s old friends. They told me she was a mother, but the grandparents were raising the children. As a child, she tested “gifted.” Currently, she is using her artistic ability as tattoo artist. She still lives in the area, but our paths have not crossed. The cookbook, the knives, and “The Rose” await the day our paths cross again. I have done what I can do.

I still use what I call “The Alphabet” and “The Metaphor” technique in my professional life as one of my techniques to help clients with grief issues bring closure. In my personal life I have used it many times for family and friends and seen it in a time of sadness bring a smile, laughter and, “Oh, I remember” that warms the heart of a grieving face!

Questions for Reflection and Discussion

How have you dealt personally and professionally with losing clients?

How might you have avoided a particular client’s unexpected departure from therapy?  

What are your thoughts about attending a client’s or their family member’s funeral? 

How In-Person Sessions Create Space for Clients Unspeakable Truths

Posted on by Psychotherapy.net Team

Many of us have not gone back to in-person sessions even though the Covid epidemic has passed. Before March 2020 I was firmly convinced that telephone sessions were better than skipping sessions, but not as valuable as in-person sessions. I only agreed to telephone sessions when patients went on long business trips or had some other compelling reason that made them unable to come in person. But beginning in March 2020 my practice transformed — all phone (or in a few cases video) sessions. After two years of living in my “weekend” house, I sold my office in New York and accepted the fact that my practice was going to be entirely by telephone. I use video calls for new patients (for a determined period) and for couples, but telephone sessions for everyone else.

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Since my “conversion,” I have thought a lot about the pros and cons of telephone vs. in-person treatment. In the newest volume of The Psychoanalytic Review, Carl Jacobs writes, “…telephony is so much more preferable to video. Since the time of its origin, psychoanalysis has been based predominantly on listening: The use of the couch is more easily replicated by telephone.” (March, 2024). I agree that for some patients, speaking on the phone makes it easier to talk about difficult subjects and may feel more intimate than video or even in-person treatment. However, phone sessions and video sessions make it impossible for the analyst to recognize non-verbal enactments.

John slams the door each time he enters my office; Hal has body odor; Janet brings coffee to her session and spills it in the waiting room; Barbara puts her feet up when she sits on my couch without taking off her shoes. In all these cases, analysis of the meaning of the behavior led to fruitful discussions of their unconscious meaning. This was particularly true with Sharon, who physically enacted what she could not tell me or maybe even admit to herself.

A Revealing Therapeutic Interchange

[Therapist’s thoughts]: I am aware that Sharon’s crotch is in full view. She does this often when she is wearing a skirt. I am trying not to look at her crotch while she is talking to me, but I have the impression that she is not wearing underpants. I think to myself that perhaps she is just wearing dark underpants. I start to question myself. Am I really seeing her genitals? Yes, I am. How should I handle it? If I ignore her exposing herself to me, I will be doing what her mother did — acting as if she is not a female with genitals. On the other hand, I know that however I say it to her, she will be mortified and furious at me. In the past, I felt the mortification would be too much for her, but this time I feel this is much more directly sexual than her sitting this way in the past.  

“Are you aware of how you're sitting?” I asked.

Sharon immediately put her knees together.

“What are you talking about? What are you saying? I’m sorry. You hate me. You think I’m bad. What are you saying? You want me to leave?”

“I don’t hate you,” I said. “I don’t want you to leave. You were sitting with your crotch exposed to me and I think that has some meaning. Don’t you?”

“I'm sorry. I like you and I respect you. I don’t know what you’re saying,” she cried. “You think I’m bad. I’m sorry. You want me to leave.”

“I know you like me and respect me, and I don’t want you to leave,” I said. I leaned forward in my chair. “I don’t think you are bad. You don’t need to apologize. I just think that sitting like that means you have some feelings about yourself and about me that we need to understand.”

“I’m sorry. Sitting like that doesn’t mean anything. I just don’t think it matters how I sit.”

“You mean it doesn’t matter if your crotch is exposed or not?” I asked.

“I just don’t feel like a sexual person. I don’t feel like a woman. Look how I dress. Look how I take care of myself. I just don’t feel like a sexual person that’s why it doesn’t matter how I sit.”

“You mean you feel like there’s nothing between your legs?”

“That’s right. What’s between my legs is dirty and smelly and bad and disgusting. You don’t want to see it.”

“So, you think that I am pointing out how you’re sitting,” I said, “because I feel your vagina is bad and smelly and disgusting.”

“I offended you. I’m sorry. I won’t do it again. Don’t worry about it.”

“You didn’t offend me. But I think exposing yourself is a way of telling me something.”

“You know you’re inappropriate sometimes? I can’t believe you said that to me. Who would say such a thing? I don't know anyone who would say such a thing.”

“You mean you would rather I act like your mother and make believe that there’s nothing between your legs or that it’s too disgusting to talk about?”

“Maybe it’s like my leg. I don't want you to see that I have a disfigured leg. I want you to say you can’t tell I have it. But I also don’t think I have anything. I am completely out of touch with my body (crying). I don’t feel connected to it. I can’t touch myself still. I don't feel like a woman. I don’t really have breasts. Sometimes I don’t even bother to wear a bra.”

“What about underpants?”

“What do you think is wrong with me? Do you think I don’t wear underpants? Of course, I wear underpants.”

“If you don’t feel you need to wear a bra because you don’t feel you have breasts, I wondered if you wear underpants because you feel you don’t have a vagina or clitoris.”

“Of course, I wear underpants. What do you think is wrong with me? How could you say that? I can’t believe it. You must think I’m disgusting.”

[She got up and walked out of the office. My heart was pounding. I had at first doubted what I was seeing and went back and forth in my mind about whether I was seeing her genitals. I told myself it could not be true. It was not possible. I had never experienced such an explicitly sexual enactment with a patient. But finally, I knew what I was seeing and felt that if I ignored it, I would be sending her the message that she wasn’t a woman, that there was nothing between her legs. On the other hand, if I said something, I risked overwhelming her and pushing her out of the treatment. I decided I had to say something to her; I had to say the unspeakable, but I wasn’t sure if she would come back.]

[When Sharon did come back for the next session, she was angry for the first few minutes. But then she told me that after the session, she remembered her mother sitting in the living room on the couch with her legs spread and touching herself.]  

“You mean your mother was masturbating in front of you,” I said.

“Yes. She did it in front of my brother too. I wasn’t sure what she was doing. I asked her to stop, but she said she wasn’t doing anything.”

[Her mother overstimulated Sharon and then denied it. Sharon was forced to develop ways of coping with her mother’s abuse — being confused about reality was a defense against unbearable anxiety.]

*** 

Sharon’s traumatic childhood experience would not have been unearthed if I was talking to her on the telephone or video (which is face-to-face). On the phone or on video, she would not have been able to engender in me the same confusion, self-doubt, anxiety, and denial that she experienced as a child; she would not have been able to communicate the unspeakable truth. Telephone sessions may be useful for many patients, but for those who enact rather than verbalize their early experiences, it is not optimal.

Questions for Thought and Discussion

What are your impressions about this author’s clinical approach with this client?

Might you have done or said something different under these circumstances?

How do you address uncomfortable situations like these in your practice?  

Existential-Spiritual Techniques for Fostering a Healthy Perspective on Aging

Posted on by Psychotherapy.net Team

Introduction: The Existential-Spiritual Model

The case vignette that I will share presents the application of an Existential-Spiritual model of coping when working with patients experiencing the natural inevitability of aging and the “normal” responses associated with it. The integrated model includes six intervention practices: self-compassion and mindfulness, discovering meaning in life, prayer, creativity, expressing gratitude, and being open to a sense of awe. Existentialism poses universal questions and concerns, while spirituality provides space to process grief and loss and create meaning in life (1). The aims of spirituality include having compassion for others’ pain and suffering, advocating for social justice, and gaining awareness of and learning from the tragic dimensions of existence, thereby enhancing an appreciation for and valuing of life. This case of Jonathan highlights how dreams can be a valuable resource in gaining a deeper understanding of an individual’s attempts to deal with their existential and spiritual challenges, as well as finding passion and purpose in life (2).

Initial Phase: Processing Unprocessed Grief and Loss

Jonathan is a 68-year-old male who entered individual psychotherapy for the first time. He reported that he has been married for 40 years and has a married adult daughter and two grandchildren, ages 8 and 12, who live nearby. He had retired just one year prior to the pandemic. Jonathan, who majored in English literature, pursued a law degree for financial stability and a personal value of and commitment to social justice. After law school, he worked in his father’s medical supply business to support his father’s declining health due to numerous medical problems and an early death from diabetes at age 56.

Jonathan expressed concerns of feeling “empty inside” and experienced lack of direction, meaning, and purpose in life since his mother died approximately five years ago, just six months after his retirement. He reported feeling numb and indifferent over the wars in Ukraine and Gaza/Israel, and the intensified polarization of political discourse he observed during his extensive time watching cable news. Given his commitment to social justice, these feelings were different for him. In addition, a close friend had died early on in the pandemic, but he was unable to visit him in the hospital or attend his funeral due to COVID-19 safety restrictions.

Jonathan wanted to work with a psychotherapist experienced in Existential-Humanistic approaches based on his longstanding interest in the existential writings of Tolstoy, Sartre, and Camus. During his initial psychotherapy session, Jonathan reported a disturbing dream from the night before. He was in a building with a male colleague and his own daughter trying to find a pool. His colleague pointed to some skin lesions on Jonathan’s body; one had rows of 20 elevated dots that looked like shingles. There was another area that had been festering for some time. He was preoccupied by his skin condition in the dream and when he looked up, his colleague and daughter were no longer there.

Jonathan frantically searched the building asking for help in finding his colleague, daughter, and the pool. He recalled walking into an office with an elderly woman who was volunteering in the building. She was unable to provide any guidance as to his colleague’s or daughter’s whereabouts. Jonathan felt anxious about missing out on seeing them and the opportunity to swim. He woke up feeling worried and not knowing what to do.

I used several existential approaches, including Jonathan telling the dream in the present tense to develop a sense of presence and agency. I asked him what he thought the dream meant and inquired about his main feelings in the dream. Jonathan responded that he felt that something was missing in his life and “life was passing me by.” Jonathan associated the dream skin lesions with his mother’s fatal skin melanoma. He also described the colleague in the dream as confident and adventuresome, much like his recently deceased friend. I wondered if the dream reflected Jonathan’s hope that his therapy would help reduce his anxiety, but also his fear of what his treatment would uncover.

When asked to elaborate on the circumstances of his mother’s death, Jonathan expressed that she had been living in an assistive living facility in Florida for three years with a full-time aide. He then expressed guilt that he only visited her a few times a year due to his busy work schedule. He said he felt emotionally overwhelmed being with her as she did not recognize him during his last few visits, and she needed everything repeated numerous times. Jonathan said he was actually relieved when she passed away but felt ashamed for having these feelings and did not share them with anyone.

To further his sense of agency, I asked Jonathan, “What is the existential message that can be taken from the dream?” He responded, “I need to stop avoiding making a medical appointment with my dermatologist because I am scared of what it could be” and that he might be paying a price for not processing his numerous losses. I then asked Jonathan, “If you could continue the dream, how would you want it to end?” After struggling with an answer, he said he missed seeing his colleague at work, swimming, and spending time with his daughter and grandchildren.

The initial phase of psychotherapy focused on his unprocessed grief and loss over his mother’s and close friend’s deaths, reflecting on the impact of the COVID-19 pandemic, and clarifying his values. He expressed resentment that he and his wife, who were eagerly looking forward to his retirement, were unable to fulfill longstanding travel plans to Asia, South America, and Alaska during the pandemic. Jonathan felt it unfair that he had sacrificed being a lawyer to help run his father’s medical supply business, and that he historically had placed others’ needs above his own.

He felt that it was unfair that these losses happened to him now, just as he was on the verge of finally pursuing his own dreams. He also felt that his mother’s and friend’s deaths, as well as the social isolation during COVID-19, were disruptions of the life “he was supposed to have,” rather than inevitable parts of anyone’s life. He wondered if he was being punished for not being compassionate and supportive of his mother at the end of her life. I suggested using self-compassion statements to soften some of the self-critical attitudes, such as how he should have grieved his mother’s passing.

Jonathan and I explored how his sense of guilt, regret, and shame over his mother’s death had drained his coping skills and flexibility to deal with his mourning process. We discussed how some of his basic assumptions of the world — such as “The world is fair,” “bad things should not happen to good people,” and “there is a reason for everything that happens,” — were shattered and left him “drifting at sea without a paddle,” not knowing what to do. We explored how these feelings were similar to how he felt at the end of his initial dream and how these factors may have impacted — and could continue to impact — his ability to mourn and grieve. Jonathan gradually was able to acknowledge, but not accept, that the world is unfair and unpredictable, and that random events can happen to good people.

I asked Jonathan to describe in more detail his last visit with his mother. He recalled her sitting up in bed requiring her full-time aide to feed her pureed food. She was staring out the window as if she was already in a different place. Jonathan said she was there physically, but in some ways she had died psychologically. I suggested that he was experiencing an ambiguous loss, making it challenging to start grieving her passing because she was still there physically. He tried to imagine what she might have been experiencing looking out of the window, and he wondered if she was scared of dying and being forgotten by others.

The next session included recalling positive memories of his mother — what kind of person she was before her Alzheimer disease diagnosis, and what values she lived by. He brought in photographs including her wedding picture and one where she was holding his daughter when she was an infant. His mother’s eyes in the second picture conveyed a warm, loving glow, which was comforting to Jonathan. He also recalled how she went back to school to become an elementary school teacher when Jonathan and his younger sister were in high school, and how much he enjoyed hearing stories about her work. He realized that his mother was more than his memory of what she was like at the end of her life.

Jonathan also discussed how his best friend, Michael, passed away three months into the pandemic. They had become best friends in 8th grade, and even though his friend moved out West after college, they maintained regular contact, including yearly visits. Michael was adventurous, loved hiking and fishing in the Pacific Northwest, and enjoyed talking to strangers. I suggested to Jonathan that the colleague from his initial dream might symbolize this friend, perhaps indicating a desire to emulate his confidence and adventurous spirit.  

Jonathan fondly recalled that the conversations he had with his friend always had the quality of picking up right where they left off. His beloved friend Michael, a social worker, always provided a listening ear and would ask challenging, but supportive questions. He was non-judgmental and helped Jonathan with various struggles. When asked what he missed most about his friend, he replied, “I could talk about anything without feeling judged, and he treated everyone with respect, always seeing the best in others.” When asked what Michael would say to him now in terms of how he should handle all his losses, he replied, “Just savor the preciousness of each moment, don’t take anything for granted, and take some risks.”

On top of these two significant losses, Jonathan felt that the pandemic was a very isolating and frustrating experience. His retirement dreams were put on hold, leading him into several unhealthy patterns, such as excessively, or perhaps obsessively watching cable news, growing more irritable with others, and being intolerant of conversations with friends and family members with opposing political viewpoints. His main pleasures during the pandemic were his weekly Zoom meeting with his daughter’s family, reading, and taking daily walks.  

I asked open-ended questions at this time, including: “What sustained you during the pandemic?” “What did you learn about yourself?” and, “Where did you find the strength?” Jonathan felt that his longstanding interest in Buddhism and the Jewish value of healing the world (tikkun olam) provided a sense of stability. Specifically, Buddhism stressed the importance of not getting too attached to things, the importance of just “being” and accepting things as they are. Although these beliefs provided some degree of intellectual comfort, they did not have a major impact on his actions or his self-confidence.

In order to provide Jonathan with a deeper foundation and sense of direction, I asked Jonathan to describe his core values, which he identified as supporting his family, treating others equally and with respect, and pursuing excellence in whatever he did. Since his retirement, he felt that part of his identity had been lost even though his career was never in line with his values of social justice and being a lawyer, leaving him lacking passion and direction. He was encouraged to explore if these values were still effective and whether he needed to reconsider refining them in some way. Jonathan was gradually able to realize that although he did not need to financially support his daughter and grandchildren, he could model for them how to handle adversity and aging in a graceful way, as well as find other ways to channel his need to treat others equally and with respect. I stressed that values are not fixed in nature but can be created. At this point in therapy, he was also encouraged to practice mindfulness exercises and self-compassion to increase his level of self-reflectiveness, to be less judgmental of his struggles, and to recognize that his feelings are transient.

Middle Phase: Establishing a New Sense of Self Through Existential Approaches

Four months into treatment, Jonathan reported a vivid dream where he was walking in New York City trying to get to a meeting in his office on the East Side. He was waiting with a group of people in a building near Central Park. Some of the people were taking too long so he decided to leave to make it to the 3:00 meeting. He was trying to find a cab, but they were all full. He walked down an area in midtown that was sectioned off with small houses that one would typically see in the suburbs. One of the buildings had a large window where he saw a group of people relaxing and socializing.

Jonathan realized he had to get to the office, so he finally got into a cab and saw he only had a $10 bill to pay for the short trip to the office. The traffic was slow, so he decided to get out of the cab to walk the remaining distance. There were long, winding, hilly sidewalks that are not typical of the city, and he realized that he was on the opposite side of Manhattan from his office. He sensed he would miss his meeting as he saw trains passing by near the Hudson River. He then found himself walking down a long, beautifully constructed road with tall, shady trees leaving the city through a tunnel. He woke up feeling that he wanted to stay in the city and that going through the tunnel was potentially dangerous.

Jonathan felt the dream meant that he was struggling to find a new path in life, that he had lost a core part of his identity in his retirement, and that he lacked a sense of community. Like in the Robert Frost poem, The Road Not Taken, he feared making the wrong choice, reminiscent of his decision not to pursue his dream of becoming a lawyer. He was asked to visualize what it would be like going through the tunnel. Jonathan imagined it would be dark, claustrophobic, and scary to walk on the narrow sidewalk with a guardrail with all the cars driving by fast. He felt that he would eventually be able to get to the other side, but it would take a great deal of effort and time. He was asked to imagine what it would be like if he went further into the tunnel to the other side.   

Jonathan struggled but was eventually able to say that he wished his parents and best friend were on the other side to greet him, saying how proud they were of him and the sacrifices he made for his family. He cried and realized that he had taken them for granted when they were alive. I acknowledged Jonathan’s determination, courage, and perseverance despite his anxiety and that the dream reflected his progress in therapy. At the end of the session, I asked him to think about if he was currently taking anything else for granted in his life. The following session, he mentioned that he felt gratitude that his family was healthy, that he had a few close friends, and that he could still give to others and pass on his knowledge and insights to his grandchildren. I then suggested that at the end of each day he write down what he was grateful for.

Consolidation Phase: Integrating Spirituality and Creativity and Reevaluating Values

In the subsequent sessions, I asked a number of open-ended questions to further work through Jonathan’s grief and mourning including, “Are there any ways you can honor your parents and friend by living out the values and causes they believed in?” Jonathan felt that his parents were generous in giving to those less fortunate, and that his mother had volunteered in a pediatric clinic at a local hospital after her retirement. Jonathan was also determined to honor his friend’s life for the years he did not get to experience by being more adventurous and taking more chances, including planning a trip with his entire family out west to a national park. He felt that identifying these values and living them out would be a way of honoring their memory and remaining close to them even after they passed.

Jonathan returned to the next session visibly shaken by an encounter at a supermarket the day before. He noticed a homeless man desperately wanting some food. The people in line were rude and impatient with him, avoiding eye contact as if they felt disgust at his condition and shame for looking away. Jonathan quickly went to the cashier and offered to pay. Jonathan’s and the man’s eyes met, and Jonathan felt that this was something his parents would have done without any recognition for it. He felt that this small moment of compassion was a way of honoring his parents’ values. He eventually decided that he wanted to volunteer in a nearby soup kitchen one day a week and to tutor local elementary school children in reading and writing.

The final stage of psychotherapy included a number of significant events and choices. Jonathan took a trip with his entire family to Yosemite National Park. While looking at the Sequoia trees with his family, he felt a deep sense of connection to his friend, Michael, and a feeling of awe in being in a place so vast and mysterious. He subsequently began to pray more consistently, to be more courageous and adventurous like his friend, gradually releasing his fears of the unknown and uncontrollable. Jonathan appreciated that although someone dies, the relationship does not end and can continue to evolve (3).

Upon return from his trip, Jonathan reported a dream where he was walking a tall winding staircase at a water amusement park. He recalled looking down and realized that he could seriously hurt himself if he fell. Despite his anxiety, he kept on walking up and was securely placed in a luge headfirst while lying on his back. He felt scared and excited about what it would feel like going fast down the waterslide. Jonathan woke up feeling energized and proud of his courage like he did on his recent trip with his family.

Jonathan began to read and write poetry, which he shared with his grandchildren. The poems reflected themes of savoring the moment, particularly in nature and while listening to music, avoiding getting lost in trivial complaints, and expressing gratitude for what one has. Jonathan felt that his creative writing was the beginning seeds of his own legacy.

As the psychotherapy concluded, Jonathan acknowledged how his parents’ and friend’s values and personal qualities had a significant impact on his life and that he shared these values of promoting the growth and well-being of the next generation. Generativity became a new core value that provided a sense of purpose and meaning in his life (Buechler, 2019).

Concluding Thoughts: What is Psychological Health When Working with Older Adults?

The case vignette highlights the benefits of integrating existential and spiritual interventions when working with older patients. Jonathan needed to gradually process his unresolved guilt, regret, and shame regarding his mother’s and friend’s deaths before he could fully experience joy, vitality, and meaning in life once again. His mourning process was further consolidated by honoring his parents’ and friend’s values, the causes they believed in and how their good qualities had changed him for the better (4). He recognized that he shared these same values, which was fulfilling for him in maintaining a deep connection to them even when they were no longer physically present. Jonathan was able to acknowledge the legacy he received from his parents and began to integrate the value of generativity in his life.

The theme of giving to others less fortunate become a unifying thread in his life narrative. While he could not prevent or slow down the inevitable tragedies in life and the regrets over past choices, the thread provided a meaningful foundation and compass in navigating new, turbulent challenges in life. When reflecting on his treatment, Jonathan recalled that his brief interaction with the stranger in the supermarket may have impacted the person’s life, and Jonathan experienced a sense of their shared humanity.

From a meaning-centered psychotherapy lens, Jonathan not only acknowledged the historical meaning of continuing his parents’ values and legacy, but also started creating and experiencing other sources of meaning in life (e.g., experiencing connection and awe in Yosemite (experiential) and deciding to embark on more adventures and being courageous in creating new experience himself (creative source of meaning)). Jonathan’s experience of awe enabled him to deepen his awareness of life’s fragility, resiliency, and sense of wonder (5). His involvement in reading and writing poetry facilitated a change in his attitude and perspective on life. His daily practice of mindfulness provided a safe space to observe his thoughts and feelings in a nonjudgmental and self-compassionate manner, while practicing gratitude increased his appreciation for the gifts of life and the legacy of those who passed before him. Prayer facilitated his ability to let go of his need to control life and provided a sense of safety in letting go of his fear of the unknown (6).

Jonathan’s journey highlights that psychotherapy with an older adult can bring “a heightened existential awareness…a new appreciation of the preciousness of life… (and the ability) to trivialize the trivialities” (7). At this development stage, there is a degree of comfort, meaning, and purpose that one’s actions, deeds, and values can have a known or unknown rippling effect on one’s family and others (8).

Questions for Thought and Discussion

What are your impressions about an existential-spiritual approach to therapy?

In what ways was this author effective in working with Jonathan?

Might you have worked differently with this particular client?

References
(1,6) Gordon, R. M., Groth, T., Choi, E., Galley, J., Marcantuono, J., & Kulzer, R (2023b). An Existential-Spiritual model for coping during and after COVID-19. Spirituality and Clinical Practice. Published online: December 11, 2023.

(2) Gordon, R. M. & Groth, T. D. (2023a). Relational and existential supervision and therapy for adolescents with life-threatening illness. Journal of Infant, Child, and Adolescent Psychotherapy, 22(4), 311-322.

(3) Buechler, S. (2019). Psychoanalytic approaches to problems in living. Routledge.

(4) Kessler, D. (2019). Finding meaning: The sixth stage of grief. Scribner.

(5) Schneider, K. J. (2004). Rediscovery of awe: Splendor, mystery, and the fluid center of life. Paragon House.

(7) Yalom, I. D. (1996). Lying on the couch. Basic Books.

(8) Yalom, I. D. (2008). Staring at the Sun: Overcoming the terror of death. Jossey-Bass.   

Psychodynamic Therapies: How Did We Get Here & Where Are We Going?

Posted on by Psychotherapy.net Team

I just finished reading Our Time Is Up, a wonderful combination of novel and memoir authored by the talented psychoanalyst and writer, Roberta Satow. Dr. Satow has created the most vivid description I’ve ever read of what real psychotherapy actually feels like — from the very different perspectives of the patient, the therapist, the supervisor, and the trainee. Most books on psychotherapy either miss its elusive magic or overplay its drama — this one has perfect pitch and puts you right there in the room.

Throughout my career, doing psychodynamic psychotherapy was always the part of my week I most enjoyed. Satow’s book both recalled many fond memories and inspired me to pull together what will likely be my final thoughts on what is wonderful about dynamic psychotherapy, and what are its limitations.

Psychodynamic Therapy’s Checkered Past

I’ll start with the checkered past — especially paying tribute to Sandor Ferenczi, the master clinician who was the underappreciated father of psychodynamic therapies. Next, I’ll evaluate the much reduced, but still crucial, role of dynamic techniques among the current chaotic and bewildering array of therapies. Finally, I’ll try to predict the future — what is the best-case final fate of psychodynamic therapies?

[Full disclosure] I graduated from Columbia University’s Psychoanalytic Center and taught its Freud course for 10 years. But I never was much of a fan of 4/5 times a week, on the couch, traditional, regressive psychoanalysis — regarding it as unnecessary and impractical for almost all patients and wasteful of resources better allocated to once a week, sitting up, long- or short-term dynamic therapies. While best at psychodynamic therapy, I also learned and integrated cognitive, behavioral, interpersonal, and family approaches. I think Freud was greatly overvalued in his own time and is greatly undervalued in ours — and I equally oppose blind Freud worshipers and blind Freud haters.

Freud: Great Model Builder, Lousy Clinician

Having invented psychoanalysis (in collaboration with his mentor, Joseph Breuer, and their shared patient, Berthe Pappenheim), Freud divided it into three separate endeavors: 1) research tool; 2) model of the mind; 3) clinical treatment.

Psychoanalysis as a research tool was at the outset enormously exciting — uncovering basic aspects of human nature that informed not only psychology, but also the study of myth, anthropology, sociology, art, and literature. But most new insights into the unconscious were made early on, and nothing really novel has emerged from the couch since Freud’s death.

Much more enduring has been the psychoanalytic model of the mind. Here Freud sat on Darwin’s shoulders — applying Darwin’s revolutionary, but generalized, discoveries in evolutionary psychology to the specifics of human behavior and symptom generation.

Freud borrowed from Darwin three crucial insights: 1) human mental functioning is just as derivative from our primate ancestors as is our bodily morphology; 2) much of our behavior derives from inborn motivations that reside outside our conscious awareness; and 3) these have been shaped by natural and sexual selection.

Freud filled in Darwin’s general outline with exquisitely detailed and specific analyses of the form and content of the unconscious and how one’s past experiences powerfully influence current hehavior. Freud’s model of the mind contained some bad (but then plausible) guesses which are the source of current ridicule — but the main concepts hold up extremely well and remain important in understanding people and treating them.

Freud never claimed to be a great therapist, or even to having much interest in psychoanalysis as a clinical art. He saw himself much more as an adventurer using psychoanalysis as a research tool in the scientific exploration of how the human mind works — awake and in dreams. Descriptions by Freud’s patients describe him as highly intellectual and patriarchic in his approach, using the therapeutic encounter to formulate and test his theories of how the unconscious works.

Ferenczi: Master Clinician

Sandor Ferenczi, Freud’s student & analysand, was the great clinician of early psychoanalysis and by far the most powerful influence in how psychodynamic therapies have since evolved and are practiced today. He was responsible for defining its healing qualities, introducing many major innovations, and adapting esoteric psychoanalytic theory to real world practice.

Here’s a summary of Ferenczi’s clinical contributions:

Therapeutic Alliance: Ferenczi emphasized the importance of negotiating a strong collaborative relationship with the patient, established on more equal terms, characterized by shared goals, and with mutually agreed upon roles and division of labor.

Interpersonal/Relational Therapy: Ferenczi was much more alive than Freud to the power of the healing relationship and the importance of establishing a strong affective bond with the patient. As his student, Sandor Rado, put it, “Insight never cured anything but ignorance.” The relationship is more curative than specific interpretations, however brilliant or accurate they may be.

Empathy: Ferenczi regarded therapist empathy as an essential tool in promoting change. Sharing feelings and feeling understood facilitates change as much as does gaining specific insights.

Here-and-Now: Freud mainly used psychoanalysis as a research tool to determine how past experiences shaped the unconscious and influenced current behavior. Ferenczi did this too, but also brought more focus to the triggers of present problems and how best to solve them.

Therapist Activity: Freud aspired to (but never really achieved) being a passive “blank screen” upon which patients could project their fantasies. Ferenczi was much more active and real in the sessions.

Patient Activity: Patients don’t get better just through free association and the insights gained in the therapy sessions — they must also widen their experiences and get out of repeated behavioral ruts. What happens between sessions is at least as important as what happens within sessions.

Corrective Emotional Experience: This was best stated by Ferenczi’s student, Franz Alexander, who said, “The patient, to be helped, must undergo a corrective emotional experience suitable to repair the traumatic influence of previous experiences. It is of secondary importance whether this corrective experience takes place during treatment in the transference relationship, or parallel with the treatment in the daily life of the patient.”

Psychodynamic Therapy: Regressive psychoanalysis was originally a great research tool but has never been a practical treatment — it is way too resource wasteful, suitable only for pretty healthy patients, and risks creating excessive dependence and hiding in the treatment. Ferenczi’s innovations allowed psychodynamic theory and technique to be flexibly applied in less intensive, but very effective, sitting-up psychodynamic therapies occurring usually once a week.

Time-limited Focused Therapy: Ferenczi and Rank realized that long-term therapies were too intense and inefficient to treat the many people who needed help. They developed a remarkably useful brief dynamic therapy (currently much underutilized) that focuses only on understanding and changing the most pressing presenting conflict.

Self- Disclosure: Ferenczi was not shy about revealing information about himself if this would further the relationship or provide a useful model for the patient.

Role of Childhood Traumas: Freud’s first theory of neurosis attributed it exclusively to early childhood sexual traumas. But he abruptly and completely abandoned this causal theory in the early 1890s because such childhood sexual experiences were so commonly reported by his patients. Freud then assumed the reported experiences existed only in fantasy, rather than having actually occurred in reality. Ferenczi had the more balanced view that real childhood traumas do sometimes play a contributory, but not exclusive, role in producing adult symptoms and that they are not exclusively sexual.

Treating More Difficult Patients: Many classic psychoanalysts were often so picky about selecting patients that only the people who didn’t really need treatment would qualify for it. Ferenczi adapted psychodynamic understanding and techniques so that they could be usefully applied to the more severely ill.

In summary, Ferenczi, not Freud, was the clinical father of psychodynamic psychotherapy and his innovations shaped how it is still practiced today.

Psychodynamic Therapy’s Current Status

My previous essay; Psychotherapy Status Report offered a report card on the current status of psychotherapy. It nicely provided context for the more specific question of where psychodynamic therapies fit in. The short answer is that all psychotherapy practice is fragmented and chaotic — and that psychodynamic training and practice add to the confusion.

There is little integration among the more than 50 different named forms of psychotherapy. These are often seen as competing; most trainees receive instruction in just one narrowly focused method and many practicing clinicians identify with just one form of therapy. “CBT” is the most popular brand name, followed by “psychodynamic,” and “trauma-informed” which is becoming increasingly popular. There is also an age and gender disparity. Older therapists are more likely to identify with psychodynamic; younger with CBT; women with trauma-informed.

Training in psychodynamic psychotherapy is also chaotic. There are hundreds of different programs varying greatly in theoretical model, prerequisites, intensity, techniques, and accreditation. At one extreme are the traditional psychoanalytic institutes which are more selective, require many years of intense didactic and clinical training, often still use of the couch, and require personal analysis. At the other extreme, there are now psychodynamic training programs that are open to all and, remarkably enough, completely online.

There is very little research on psychodynamic psychotherapy because it does not conform easily to standardized clinical trial research designs and only a handful of its practitioners are research trained. The few scattered research studies suggest that psychodynamic therapies are equal in efficacy to better studied psychotherapies.

Dynamic therapy is gradually declining in influence. Most psychiatric residency programs now provide little or no training in psychodynamic therapies — even though such training is still often desired and sought after by some residents. Young therapists in other disciplines are less and less likely to be trained in dynamic techniques. And insurance companies are less likely to fund dynamic as opposed to other techniques that are less intense and better studied. The average age of dynamic therapists is rising, and its cultural relevance is diminishing. The future does not seem bright.

Future Directions

Will Psychodynamic Therapy Continue as a Separate Profession?

I hope not. Psychodynamic therapy was always my favorite technique, but only if combined with cognitive behavioral, interpersonal, and family techniques. Similarly, the training programs I created were based on the integration of psychotherapies, not their separation into separate silos.

I have long felt that psychoanalysis is too important to be left to the psychoanalysts. They have maintained an unfortunate rigidity in technique and teaching; have been resistant to innovation; and missed opportunities to expand their purview and influence. Their biggest mistake was rejecting Aaron Beck’s CBT. Beck was a trained analyst who originally conceptualized his innovations as an expansion of psychodynamic techniques, not a replacement. Had the psychoanalysts been wise, they would have embraced CBT as an extension, rather than rejecting it as a competitor. I don’t think that psychodynamic therapies should be taught in institutes that specialize in it. Similarly, I don’t think that “CBT” or “DBT” or any of the other 50 alphabet denoted therapies should be taught or practiced as a separate discipline distinct from other psychotherapies.

Instead, I think psychotherapy should be considered a unified therapy which includes within it a wide variety of techniques. And training programs should no longer brand themselves narrowly. Narrowly trained therapists become hammers looking for nails, rather than flexibly responding to patient need. Psychodynamic techniques should be highly valued because they are very valuable- but they should be valued as a component of psychotherapy, not as a separate specialty.

Will Psychodynamic Therapists Be Replaced by Computers?

I’ve written an entire blog on the history of computers delivering psychotherapy: their current role and their future potential. Bottom Line — there is nothing humans do that computers won’t eventually do better.

One small consolation is that computers will have more trouble and take longer replacing psychodynamic therapists than almost any other type of professional. More than most human endeavors, uncovering someone’s unconscious motivations and facilitating corrective emotional experiences are intuitive and inferential processes that don’t easily lend themselves to the number-crunching powers of machine learning. But given enough data and enough time, even these most human of skills may be mastered by artificial intelligence.

Should this pessimistic prediction discourage people from entering the field? I think not at all. First off, psychodynamic psychotherapy is a better hedge against computer replacement than almost any other career choice. But more important, doing psychodynamic psychotherapy is one of the most rewarding ways of spending one’s time on earth. You have the immense satisfaction of understanding and helping others, with the valuable added bonus of learning from your patients how to become a better person.

***

Which brings us back to where we started. Roberta Satow’s book is a great introduction for new psychotherapists and a great refresher for experienced ones. No manual of psychotherapy, and no textbook, can ever capture the special healing ambiance of the therapist/patient relationship. Only the lived experience of someone who has been a patient, been a therapist, been a supervisor, been a trainee — and can write really well — can bring therapy alive in a way that inspires and educates.

Questions for Thought and Discussion

In what ways do you concur or disagree with the author’s assessment of dynamic psychotherapy?

Would you consider training in psychodynamic therapy?

What kind of client would you refer to an analytic therapist and why?

Ink Therapy: Harnessing the Power of Vintage Self-Help Books

Posted on by Psychotherapy.net Team

My dad was an avid reader, visiting the library weekly as well as purchasing new and used books. As a teenager, I spied a vintage copy of a 1957 work titled How to Live with a Neurotic: At Home and Work and snuck it into my tiny bedroom.

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A Very Brief History of Self-Help Literature

I couldn’t attain complete privacy in my room, shared with my brother, due to the 6-foot barbell we stored under the bed preventing the door from closing fully. But seriously, for the most part who needs privacy when you have weightlifting to focus on?

I discovered the book was written by Albert Ellis, a New York clinical psychologist, and I thought his ideas were monumental. I made up my mind right then and there that one day I would write my own book and interview Ellis. Indeed, many years later, when Ellis was 89 years young, I did, and the interview was much more intriguing than I ever could have imagined. But I digress. 

As a graduate student, I came across his name again, only this time he had teamed up with another clinical psychologist, Robert A. Harper, to pen a 1975 edition of A New Guide to Rational Living. The word “new” was added to the title since the original version was released in 1961. The book outlined how to use Albert Ellis’ Rational Emotive Therapy or RET (now Rational Emotive Behavior Therapy or REBT) to enhance happiness in everyday life. 

Simply put, I thought it was hands-down the best self-help work I had ever read. It turned out I was not alone in my opinion. The head of the publishing company, Melvin Powers, a lay hypnotist and self-made millionaire, whose picture graced the book cover along with his wife, agreed. Powers, one of the premier publishers of paperback self-help literature, said in the foreword, “it may well prove the best psychotherapy book for layman ever written.” Powers ended the foreword with, “You have my best wishes in reading a book that I think will remain the standard for years to come.” (Don’t you love it when others concur with your opinion?)

If the book had an Achilles heel, it was that the text might have been a little too complex for the average person to understand. But an answer was right around the corner.

Enter Wayne Dyer, a counselor educator at St. John’s University, who, after studying Ellis, created an easier-to-comprehend and much more popular book titled, Your Erroneous Zones in 1976. According to some estimates, 100 million copies have been sold! Behind the scenes, a controversy brewed with Ellis claiming Dyer stole his ideas and gave him no credit in Erroneous Zones. Dyer became one of the most popular lecturers and a guest on thousands of television and radio talk shows worldwide.  

The bottom line is that these classic 60s and 70s bibliotherapeutic works are still a goldmine for clients in 2024 and beyond. As I often quip, “Good counseling and self-help never goes out of style.” I have often heard therapists assert that the 1960s and 1970s were the golden age of self-help.

Self-Help Guidance for the Next Generation of Therapists

A few other gems from the era you could suggest as bibliotherapy to assist your current clients could include:

The blockbuster and often provocative 1964 transactional analysis (TA) text Games People Play by the founder of the theory, former psychoanalyst Eric Berne. Or another TA flagship work, I’m OK – You’re Okay, by psychiatrist Thomas A. Harris in 1971.

Taking this theme a bit further, Muriel James and Dorothy Jongeward wrote Born to Win: Transactional Analysis and Gestalt Experiments in 1971, integrating the work of Fritz Perls into the equation. TA made psychotherapy and self-help fun using words like Parent, Adult, and Child, in place of analogous and confusing Freudian terms such as Super-ego, Ego, and Id.

As a final example, clients who wish to blend psychology with spirituality could benefit from M. Scott Peck’s 1978 The Road Less Traveled.  

One unique feature of the books from the era is seemingly that they crossed the invisible line between textbooks/professional literature, and self-help or so-called pop psychology. To put it another way, these works, and many others like them, were as at home in a graduate counseling, psychology, or social work class as they were in the hands of people outside of the mental health field struggling with marital issues, addiction, depression, anxiety over public speaking, or many other challenges of everyday life.

In embracing the timeless wisdom of vintage literature, our current clients can unlock a treasure chest of insight from the past. It’s not just about self-help, it’s about tapping into a reservoir of wisdom that transcends time, offering guidance and solace to all who seek it.

Questions for Reflection and Discussion

How have you used self-help books with your own clients?

Which of the author's favorites have you used either personally or professionally?

What other newer self-help books have you found useful in your practice  

Losing the Atmosphere, A Memoir: A Baffling Disorder, a Search for Help, and the Therapist Who Understood

Posted on by Psychotherapy.net Team

[Editor’s Note: The following article begins with an excerpt from the author’s book, Losing the Atmosphere, A Memoir: A Baffling Disorder, a Search for Help, and the Therapist Who Understood, followed by a portion of the Afterword by her therapist, Jeffery Smith.]

The Saddest Present

“Do you got anything to tell me?” Wendy asked, her custom at the start of a session. It was late October, 1998. I looked at Jeffery trustingly, expecting his usual No.

“Yes,” he said softly, reluctantly.

“What is it?” Not Wendy’s confident voice, but someone’s who felt she was about to be dropped.

“I’m going to be away from December sixteenth to January fifth.”

Three weeks. A long moment of silence. Then Wendy again. “You know dose doll-babies I cut up with scissors a few years ago? I need to see them.”  

Jeffery lifted the couch seat and rummaged through the storage chest beneath. That was where he kept my blanket and pillow, crayons, and drawing pad, what made his office my special place for four hours — two double sessions — each week. I looked away, not wanting to see what else he stored there.

Hearing the lid close, I faced him. He handed me a small paper bag. I turned it upside down and tiny plastic body parts fell to the floor.

AlmostVivian had bought the dolls several years before, when I was still seeing both Sarah and Jeffery. It was during the time the babies on the bottom level were coming out often in sessions, alternately moaning and screaming. I listened and was amazed because I didn’t feel any torment. Sometimes, I tried to stop the sounds by choking the babies in me, putting my hands around my neck and squeezing so tightly I coughed. Jeffery would pry my hands off so I could breathe, telling me to let the sounds happen, that even though I didn’t know what they were about, someone in me did, and eventually I would, too.

But outside of session, I felt their neediness coursing through my veins, a hunger and yearning that could never be satisfied. I was sure that monster neediness would repel Sarah and Jeffery and I would lose them forever. I hated the babies and wanted to bash them out of me. I needed Sarah and Jeffery to know about the hate. It was too big for me to handle alone. On the walk home from work one evening, AlmostVivian got the idea of using dolls instead. She stopped at a toy store and bought their entire stock of miniature plastic babies, 12 of them. Each was about four inches tall, sealed in its own cellophane package, with dimples and blue eyes.

In my next session, which was with Sarah, I took the dolls and a pair of sharp scissors from my backpack. Laughing diabolically, I held the closed blades like a dagger and plunged them into a doll’s stomach. “I’m going to kill you!” I said, as I began cutting through the waist. It was a voice like that of TheOneWhoCursesCars but raging at the Inside babies instead of Outside people. The plastic was hard, and the scissor loops dug into my fingers. I kept cutting. When the doll’s body was severed, I pulled on her head. It came off with a popping sound. I tossed the three pieces aside and attacked the next doll.

At the same time that one part of me was gleefully plunging scissors into the guts of the dolls, another part was aware of Sarah, sitting silently on the floor with me. As if I were in her head, I knew she was uncomfortable. I also knew it troubled her to be uncomfortable, because she felt that as a therapist, she should understand and accept what I was doing. I didn’t want her to be uncomfortable. I needed her to talk in her gentle Mommy voice and look at me with the soft eyes that were ordinarily filled with love for me. I needed her to understand the desperation behind my lunatic laughter. But the more I butchered the dolls, the more uncomfortable she seemed.

Suddenly I felt dirty. Unacceptable. Sarah was good and pure. She believed in God and went to church. I stopped cutting, threw everything back into the paper bag — the three dolls I had mutilated, the nine still sealed in cellophane, the scissors — and stuffed the bag into my backpack. For a minute I looked at Sarah, not saying anything, trying to win her back with my eyes. She regarded me dubiously.

I felt my face get soft and my body relax. Then I heard Emily’s whisper. Young, trusting, shy. “Sarah?”

Sarah cocked her head and looked at me from a different angle.

“Sarah?” I whispered again.

The warmth came back into her eyes. “Emily?”

I slid my hand toward her along the floor. She took it in hers, and we locked eyes. “Hi, Sarah,” I said.

“Hi, Emily.” She smiled kindly at me. All was well again.

The next day, in my session with Jeffery, I continued the massacre.

“Somebody’s really angry at the babies,” he said.

Once I saw I didn’t repulse him, I let go, stabbing and cutting. “Now you’re going to die!" I growled.

Theoretically, I knew this killing spree wouldn’t free me from the babies. I also knew I was supposed to embrace and care for them, because they were part of me and needed to heal. But I didn’t want them to be part of me. Shrieking and giggling, I dismembered all but one, then stopped. If I destroyed the whole lot, how would I get them back when I was ready for them to heal? I tossed the last cellophane-wrapped doll to safety on the other side of the room, then snatched one of the severed heads off the floor and cut it into tiny slivers.

Several years had passed since then. The bottom level was less dominant, and I less needy. I had forgotten about the dolls until now, with Jeffery’s three-week absence looming. Looking at the body parts on the floor, I knew I had to fix the most broken baby — the one with her head in slivers — before he left, so I could take her home and care for her myself while he was away.

“Do you got any glue?” Wendy asked.

So began our routine for the next few weeks. At the beginning, middle, and end of each session, I glued one sliver of the baby’s face in place, allowing time for it to set, all the while joking about my pediatric trauma unit. It was painstaking work. I wouldn’t let Jeffery help but was glad he was there, watching each piece make the baby more whole.

I also asked questions.

“Are you going to be in another time zone?”

“Yes.”

“What airline are you taking?”

“I think it’s Tower.”

I had been expecting something like United or American. Those flew to many places in the United States. Tower went mostly across the Atlantic Ocean. Best not to ask where. “Make sure you’re careful.”

“I’ll be very careful.”

Things could happen even if he was careful. Dr. Welch died while he was on vacation in Europe. “Are you going to come back?”

“Yes.”

In our last session, before Jeffery left, I worried that I wouldn’t be able to hold onto the reality of his existence for three weeks. He said some of us knew he existed when I couldn’t see him. Others didn’t. “You need to set up a bucket brigade, so the ones of you who do know can pass the information to the ones who don’t.”

I liked that idea and sprawled on my stomach, crayons in hand, to draw 21 tiny buckets. I cut them out, wrote one date on each, and heaped them, like a pile of multicolored confetti, on top of the mended baby. She had scars on her face that would never go away, but she was whole.

Jeffery drew me a coupon: two stick figures, big and little, him and me, holding hands. There was a dotted line connecting their hearts, and a border around the whole picture.

“Is dat border because you and me are in the same world together, even if you can’t see me and I can’t see you?”

“That’s exactly right.”

“And even if you’re in a different place, you’re still the same person?”

“That’s exactly right. I’m me, and I never change on the inside even if I wear different clothes, or my voice sounds different, or I’m in a different place.”

When it was time to leave, I put everything into my backpack: mended baby, paper buckets, coupon. As I stood in the doorway, I realized Jeffery’s office would be empty for three weeks. That was scary. I hoped he wouldn’t die.

Atmosphere people never died. People in bodies did.

“Be very careful,” I whispered.

He nodded and waved.

We said goodbye three times and I backed out, holding him with my eyes until I closed the door.

For the first time since Jeffery started becoming more of a flesh-and-blood person than an Atmosphere person, all of us believed he existed, even though he was away. Every few days, we mailed a letter to his office, along with the cutout paper buckets for the days that had passed since the previous letter.

On the day he was scheduled to fly back — three days before my session — I visualized him in his body. He orders a drink when the flight attendant comes down the aisle. He rests it on his tray table while he reads a magazine. He gets in line for the bathroom. All day, I listened to the radio — for plane crashes. I worried that he wouldn’t be able to land because of the snow, even though most of it was in the Midwest.   

The phone rang late that evening.

“Hi, Vivian. It’s Jeffery. I’m back.” We had prearranged that he would call.

“Thank you for telling me,” I said, and we hung up.

I played his words over and over in my head. Was his voice different? Was he the same person?

Tuesday came at last. To avoid seeing the patient before me leave, I walked through the waiting room to hide in the kitchen, as had long been my custom. Soon I heard the first in the usual sequence of sounds. The door to his office. Next, the hall door. He or she was gone. Now the noise of the sliding-door closet in the waiting room. I peeked out. He was standing in front of the closet. In a body-shape; Jeffery, yet not Jeffery. He took off his shoes and put on another pair. So that’s where he hid the new ones that upset me. I knew I should step back, because he would pass the kitchen door on his way to the next sound: the bathroom. But I ran into the waiting room.

“I saw you!” I laughed, jumping up and down. “I saw you go into the closet and change your shoes.”

Jeffery looked momentarily surprised. Then he smiled, a wide smile that deepened the crinkles in the corners of his eyes “Hi, Vivian.”

“Are you really back?”

“Yup. It’s me.” His smile got bigger.

He’s obviously happy to see me. I’m glad he’s happy. I’m devastated he’s happy. His happiness is proof that he wasn’t with me in the atmosphere all along. I hate him. I love him. I hate him. I punched him in the arm.

Still, he smiled.

“So, how are you?” I said, a little girl trying out sophisticated talk. It sounded funny. I giggled and tried another phrase. “Nice to see you.” Oh my god. That’s what you say to someone who has been away. The scary words kept tumbling out of me. “How was your trip? It’s been a long time.” He smiled. I wanted to cry. I punched him again and giggled some more.  

I tried to frame him in a familiar context, but nothing fit. He wasn’t the Atmosphere Jeffery because he didn’t know everything I thought and felt and did while he was gone. Yet he connected eyes with me in the old way. But he was in a physical body and his body had probably been across an ocean. Could the Jeffery who smiled at me now be continuous with the Jeffery who had waved goodbye three weeks ago?

I spent the entire session trying to merge the before and after Jefferys; I looked for the mole he used to have on his forehead. It was still there. Most of all, I kept checking his voice and eyes. The old Jeffery was in both. Yet I couldn’t settle and never got to tell him all the things I had saved up. I left feeling empty and cheated.

When I got home, I wrote a letter that I mailed the following day.

You think you came back, but you didn’t. Your smile came back, but not your insides to our insides… You can’t expect to take up from where we left off….  

Over the next few months, as Jeffery’s presence in the Atmosphere continued to fade, the entire Atmosphere began to lose potency. Though Sarah and Marybeth were still in it, their essences were weak, not enough to sustain me. There were major upsets over minor events. Jeffery forgot to call when he said he would, or he remembered to call but his voice was ever-so-slightly hurried; either way, I was sure he hated me, and I had lost him forever. Jeffery wore a new sweater; this evidence that he went to a store or received a gift meant he was gone from the Atmosphere, and I had lost him forever. Jeffery changed my session from Fridays to Thursdays so his weekends could begin earlier; it was clear I was a burden to him and had lost him forever.

With each incident, I felt betrayed anew. “I HATE YOU!” the angry ones screamed. The hurt ones whined. “You said you would call, and you forgot. You shouldn’t say something if you can’t do it.” The abandoned ones became paralyzed and mute. Each time, Jeffery reassured me that I hadn’t lost him, and he hadn’t changed. Only my perception of him had changed. Each time, I would feel better. Until the next time.    

The more Jeffery became real as a flesh-and-blood person, the more self-conscious I was about the nonsense syllables and noises that had seemed natural and acceptable before. But I was unable to talk about Inside concerns in regular English words, so I filled long stretches of my sessions with prattle about Outside happenings: my boss was being fired; the traffic on the way to his office had been horrendous. All the while, Inside yearned for the kind of connection I used to have with the old Jeffery.

I brought a computer to a session and found I could type what I couldn’t say out loud. Jeffery answered either by typing back or talking, depending on what I indicated I wanted. This became our new method of communication. Often, I didn’t know what I was going to say until I saw the words appear on the screen. It was as if they flowed from my fingertips, bypassing my brain.

One day I wrote about what I considered Jeffery’s shortcomings as a skin-container person, and how much I missed his Atmosphere version. I finished typing and handed him the computer. When he lowered his eyes to the screen to read, I took the opportunity to scrutinize his body. Who was this person trying so hard to reach me? I looked for things that would make him real and found them in comforting imperfections: a small hole in his sock, one unruly gray hair sticking out of his thick black eyebrows, an ink spot on his shirt pocket. He typed something, then held out the computer to me.

I’m a skin person, but I’m a lot more like an atmosphere person than what you think of as a skin person. Because you think of a skin person as somebody who drops you. Somebody who breaks the connection with you. I’m not the kind of skin person who does that.   

I looked up to see a sincere face that matched the words. His eyes met mine and held them, and I felt a tiny bit of the connection I used to feel with the Atmosphere-like Jeffery. At the same time, I was aware that he was not in the Atmosphere. The eyebrow hair was still sticking out.

Only Wendy could report in out loud words about anything that mattered to Inside. Before I had this new conception of Jeffery, she used to appear just at the beginning of sessions, a scout checking for potentially dangerous skin-world manifestations in the otherwise Atmosphere-like Jeffery. But with Jeffery rarely in the Atmosphere anymore, Wendy now stayed out for most of the session, a lone soldier on the front line, and no one else got a chance to be with him. At first, because Wendy was perky and chatted freely, Jeffery thought I was adapting well to my new perception of him.

“Wanna hear a joke I heard on the radio?” Wendy asked one day in her saucy little-girl voice.

“Sure,” Jeffery said.

“What’s the difference between an HMO and the PLO?”

“I give up.”

“You can negotiate with the PLO.”

Wendy was delighted when Jeffery laughed.

“I know a joke, too,” he said.

Jeffery had never told us a joke before. Atmosphere people didn’t joke. “What is it?” she asked, trying to maintain a cheerful voice

“How can you recognize a happy motorcyclist?”

“I give up.”

“He’s the one with dead bugs on his teeth.”

Wendy managed the required giggle, but there was an earthquake Inside. Jeffery had violated a boundary, crossed further into skin territory than Wendy could protect us against. Her giggle stopped abruptly, and she punched him in the arm. “You’re not supposed to tell jokes,” she said angrily. “Only we’re allowed to tell jokes.”  

His face turned serious. “I’m sorry. I won’t do it again.”

“And don’t smile! Don’t act glad to see us when you first come in.” She punched him in the other arm. “That’s just to make it even,” she said in a more gentle voice, “so your arms will be balanced.”

We had had the conversation about smiles many times. Jeffery knew we saw his smile as proof that he was seeing us for the first time after a break. If he had been in the Atmosphere, there wouldn’t have been any breaks. “It’s good to remind me,” he said.

I did keep reminding him — about his smile, his tone of voice, his mannerisms — in an attempt to preserve what little remained of the Atmosphere. I still needed it for time-outs from the real world, though it wasn’t as soothing as it used to be.

Atmosphere people were no longer pure essences, so completely mingled with mine that I never felt self-conscious about anything I did. Now they were separate, looking down on me from someplace near the ceiling, where they hovered in invisible bodies. “Alone” in my apartment, I was embarrassed when I pulled my pants down to sit on the toilet, because they could see me. Once, when I was cooking fish, I opened the window to get rid of the smell — not for me, but for them. I felt foolish whenever I did things like that, yet I kept doing them.

The only times I felt satisfyingly connected to Jeffery were when we had toast, my ultimate comfort food. He let me keep supplies in his kitchen: a toaster on the counter, a loaf of artisanal white bread and a stick of butter in the refrigerator. We developed a ritual of having toast at the beginning and end of each session “Breaking bread together,” Wendy called it. She was usually the one who ate with him, chatting, using big words, playfully comparing the designs his bites and hers made in our slices. Jeffery and I may have been separate people, but we were having the same sensations of taste, smell, and crunch.

Four months after his Tower Air Christmas vacation, in the last week of April 1999, Jeffery and I were sitting on the floor in the kitchen at the start of a session.

“Do you got anything to tell me?” Wendy asked.

“Yes.”

I stiffened and waited.

“I won’t be here next Thursday.”

I felt a stab. “Did you forget it was my birthday Friday?” We had planned to celebrate during our Thursday session. The stab went so deep, I couldn’t even punch him. I inched backward until I felt the wall behind me, then slumped forward, head between my knees.

“I’m sorry,” Jeffery said.

He did sound sorry. I looked up to see him sitting cross-legged on the mat.

“I hate you!” screamed an angry voice. “You forgot my birthday,” whispered a devastated one. I punched his arm several times. He pressed his arms into his sides but didn’t flinch.

It suddenly struck me that all this was ridiculous. My body would be 57 next week and I was carrying on like a three-year-old having a tantrum. Jeffery wasn’t an Atmosphere that had deserted me. He was an ordinary human being, the kind you might see in the supermarket, but a very wonderful human being. It was rare that he missed a session. He must have something he really needed to do, and I was making it so difficult. Part of me was still upset. Another part felt a surge of love for him.

While one voice was whining, “It was gonna be my birthday,” another voice, grownup and calm, interrupted with, “Wait. I think it’s time to give you a present.”   

Jeffery looked at me quizzically. I reached for my computer and began typing.

…When you are a baby, you would never think of giving your mother a present, because your mother just IS. She is part of you, and you are part of her. But when you get a little bigger, you realize your mommy is a separate person, and she can get glad at you, and she can get mad at you. That is very scary. Now you have to do things to make her like you, or you will use her up. When you realize, you are supposed to buy your mother a present for Mother’s Day, you cross into a whole different dimension. You lost something you will never get back.

I passed the computer to Jeffery. He read. But before he could type an answer, I took it again and continued writing.

We never thought of you as someone we needed to give a present to. But last weekend, something made us know that now we did. We remembered when you used to say you needed to be seen. And we knew you would be seen if we gave you a present. So, we walked up and down the booths of the Columbus Avenue crafts fair, and then we saw a very special puzzle box with a secret compartment… When we were packing up the shopping bag to come here tonight, we put the box in, and we were very depressed about it. Then we forgot it was there — until we just got so upset when you asked us to change the session next week when it is our birthday. We realized we were right. It’s time to give you a present. It’s the saddest present we ever gave. But it’s also a very nice present.

I handed the computer to Jeffery. This time, when he finished reading, I reached inside the shopping bag and passed him a small package wrapped in white tissue paper. Jeffery held it in his hand and looked at me, as if he didn’t know what to do.

“Open it!” I commanded.

Rigid with anticipation, I watched him unwrap the layers of tissue. When at last he held the round box in his hand, he still didn’t say anything. He just turned it over slowly examining the top, the bottom, the side. But I saw that he was admiring the graceful streaks of dark brown grain running through the blonde wood, polished as smooth as satin.

“Take it apart,” I instructed. “The side piece first.”

He fingered the side, then slid it up. It came off in the shape of a crescent moon. He slid the top off sideways to reveal another cutout piece underneath. I watched his face and was thrilled to see his appreciation deepen as he lifted the last piece and discovered the hidden compartment, lined with dark brown felt. It was a truly magical box, small enough to fit in the palm of your hand, large enough to hold a secret.

“Thank you,” he said, looking up. “It’s a very beautiful box.”

I felt powerful — and grownup. I had given Jeffery a present that made him happy. I had let him know I saw him. But underneath, a deep sadness started to roll over me. Before it completely engulfed me, Wendy, always close to the surface, popped out. “I think it’s time to have some toast,” she said gaily.

“Good idea,” Jeffery agreed.

Retracing the Human Journey of Attachment

from the Afterword by Jeffery Smith, MD- Vivian's Therapist   

Losing the Atmosphere is more than an account of living with multiple personalities. In telling her story, Vivian opens a window into the drama of early attachment: how, during our first three years, we become connected to our caregivers and, through those connections, gain awareness of ourselves and begin to forge the capacity to cope with strong emotions.  

The best way I have of understanding Vivian’s Atmosphere is to think about the experience of birth. After existing in the insulated, warm, muffled environment of the womb, humans are suddenly ejected into a world with loud sounds, sharp sensations on the skin, and cold air. The shock must be enormous. Now imagine a protected childlike Vivian facing the emotional equivalent of birth. The Atmosphere was ever-present, existing in the form of molecules intermingled with hers, so there was total, immersive contact. This womblike protection kept her from ever experiencing aloneness. Any fear was met with a reassuring presence; emotional pain was instantly understood and thus barely felt. After years of being surrounded by this protective Atmosphere of benevolent beings with no needs of their own, constantly attuned to the feelings of one small girl, she is suddenly subjected to the harshness of raw emotions.

Losing the Atmosphere is about encountering, for the first time, fear, pain, and separateness. We have all gone through these very experiences but so long ago that they lie beyond the reach of memory. Because Vivian’s self was split into separate parts, and because some parts were shielded from these universal experiences until adulthood, she is able to give a firsthand account of a journey we all make on the way to becoming attached and emerging as social beings.   

This material is excerpted from Losing the Atmosphere, A Memoir: A Baffling Disorder, a Search for Help, and the Therapist Who Understood, by Vivian Conan, and re-printed here with explicit permission of the publisher, Greenpoint Press.  

Teaching Prisoners to Lead Grief Support Groups

Posted on by Psychotherapy.net Team

A Novel Prison Hospice Program

Most people are unaware that many prisons in the United States have hospice programs. What makes them unique is that they utilize select inmate volunteers to serve as caretakers for the dying. The prisoners go through extensive vetting with the hospice staff, current volunteers, and the prison wardens. Once chosen, they become a part of the care team along with the doctors, nurses, and clergy. Most recently, four psychiatry residents from Tulane Medical School were part of a new program that trained 31 caregiver-inmates at four different prisons in Louisiana to facilitate in-house grief groups.

Prior to the grief support project, I had not worked directly with the incarcerated population. Thus, my knowledge of this kind of working was abstract and superficial. It was mostly two extremes, the horrible gruesome details of the crimes that had been committed, or the stories of those who had been wrongfully committed and their civil rights stripped from them for years. I (HC) was intrigued when my therapy supervisor, Dr. Marilyn Mendoza, spoke with me about her experience with Angola’s hospice project and her visits to other facilities. I wasn’t sure what to expect when she connected me with Mr. Jamey Boudreaux, the director of Louisiana Mississippi Hospice and Palliative Care Organization, to talk about the project.

The goal of our grief support project was to teach a select group of incarcerated individuals to lead grief support groups for their peers. In the state of Louisiana, whenever an incarcerated individual meets with a mental health professional, a document is generated which goes into his or her file. These documents are available for the Department of Justice to review. As you can imagine, there is significant stigma that mental health notes will negatively impact the decisions of the Pardon and Parole Board. Thus, by having trained incarcerated individuals provide bereavement support to their community, the dreaded mental health documentation can be bypassed. In addition, having peers with shared experiences lead groups allows participants to feel more comfortable in sharing their stories.

The project involved six participants selected by the corrections facility as individuals that had qualities that made for a good peer support facilitator. Depending on the number of participants, there could be up to 15 weekly meetings. The first three weeks were focused on introductions, outline of the project, and didactics of grief and groups. Weeks four to nine was a six-week adult grief support group led by a facilitator (in our case, psychiatry residents). The weeks contained different topics of introducing their deceased loved ones, sharing a photograph, sharing an item, writing a letter, planning for a special day, and reflecting on the experience. Weeks 10 to 15 repeat the same format but with the participants assigned a week to facilitate.

A Clinician Embraces a New Challenge

Although the outline and the project seemed straightforward, I was worried. I had no prior experience in working with therapeutic groups. Was the setting going to be conducive to groups? Would I be able to establish rapport with the participants? Would I be able to relate to the participants? Would I feel safe where the groups were being conducted? Would the participants be comfortable sharing sensitive information with me?

As I prepared the didactic material, the day for the first visit came. I was grateful that Mr. Boudreaux, who was familiar with the corrections facilities, accompanied me to Elayn Hunt Correctional Center located in St. Gabriel, LA. On the drive, he shared the history and changes that have occurred in Louisiana’s corrections facility. The security process included confirming our identity, searching our vehicle, confirming our identity again, and a complete body scan.

As we walked down a long walkway between chain-link fences, I pondered on all the different possible crimes that people may have committed to bring them to this facility. I had the list of names of the participants that would be joining me. Through public records, I could easily look up the details of their charges, convictions, and sentences. I decided not to as it was unnecessary to know for our work together. In hindsight, I like to think it would not have changed my perspective of the men I worked with, though I will never know for certain. Mr. Boudreaux also mentioned on our drive that it was a faux pas to ask incarcerated individuals why they are behind bars and for how long.

As I prepared, I wondered if I would have difficulty in getting the men to discuss their feelings. I felt that perhaps being in a cold, rigid setting would have made it difficult for them to be vulnerable in sharing their emotions. Would I have any credibility as a “free person” who had no idea what life was like in prison? Being a soft-spoken Asian woman, would I be able to redirect the group if discussion derails into a heated conversation?

As we continued towards the Skilled Nursing building, a few casually dressed men greeted us and I was unsure if they were incarcerated individuals or staff members. The Skilled Nursing building provided the highest level of medical care for the sickest residents. I instantly felt at home as the inside looked, sounded, and even smelled like the regular hospital units I was accustomed to. The eight participants were waiting in a room surrounded by windows facing directly at the nursing station. The men politely shook our hands and introduced themselves.

Mr. Boudreaux had been working with them on improving the education and resources available for the men providing end of life care. As I listened to them reflect on their work, I was struck by how passionately they spoke of their work and their patient advocacy. When I gave them the general outline, multiple participants asked thoughtful questions and seemed very eager to learn. They shared that the experience providing hospice care has been very difficult yet rewarding. I learned that these men are given the option of learning a trade or receiving more education. Hospice was neither and it was completely voluntary. Despite being a thankless job, this core group of volunteers devoted their time to helping others as it gave them a sense of purpose.

The first three meetings were lectures based with PowerPoint slides printed on physical paper. Each person came prepared with writing utensils and jotted down notes as I talked. They were engaged and asked insightful questions. They were interested in topics from the neuroscience behind grief to the spiritual aspects of grief and loss. They even made a point of asking if I could bring the articles or books I listed on the reference page at the end of the packet. There was a genuine curiosity to learn as much as they could.

A Surprising Place for Compassion

Week four was our first official session using the peer-support model. Having never led groups prior to that time, I was a bit anxious. We started the session by discussing ground rules of respectful listening and confidentiality. They shared how important confidentiality was in a setting where at times what you say can be used against you. Each person shared how he slept at night (“like a baby” can mean two totally different things), how he felt, and introduced the person whom they were grieving. They were all immediate family members, some that had passed years ago and some only months ago. As the sessions progressed, I became more comfortable.

Something the men have told me multiple times was that the course gave them the opportunity to learn skills that were not only helpful in facilitating grief groups, but also supporting their own family in the free world. I was inspired by their motivation and passion for helping others and often found myself lost in thought on the long drive home. I reflected on what it was that made this experience something I looked forward to weekly. Working in outpatient psychiatry, I sometimes feel drained by patients coming to me for a quick solution. It was refreshing that these men were looking within themselves for the answer. I was grateful that they felt comfortable in being vulnerable. There were lots of laughs and some tears shed.

When the second half of the lessons started, where the participants were each assigned to facilitate group, it did not feel repetitive as the men created new topics to focus on. Though each participant had their own style in facilitating, they all possessed great leadership skills. Many of them were trusted mentors and already possessed counseling skills. They created a therapeutic environment for sharing. I felt that in comparison to the sessions that I led, which might have been separated by a sense of power differential, they were building onto the conversation.

They chose interesting topics such as reflecting on their favorite memories, sharing where they keep photos and why, and what items from their loved ones they would like to have. There were times when the men disagreed with each other and respectfully brought up their own perspectives. They also provided comfort for each other. We frequently discussed how their loved ones continue to live through them and how spirituality and their culture affects the way they grieve. At the end of every session, they expressed gratitude for having a space to share.

Although our primary focus was on grief, it was only natural that we also discussed other sensitive topics. There was a lot of discussion about trauma and “the hand you were delt.” They described past life decisions as choosing between a series of what consisted of only bad options. Psychosocial factors made it very easy to choose a life of crime and drug use. It also made it difficult to trust others. It was after incarceration that some were compelled to take the arduous, personal journey of searching for purpose. Religion and spirituality were often sources of comfort and guidance.

During our discussions about grief, I reflected on how although it was such a personal journey for everyone, the universal stages of grief were ever-present. Some men spoke of their loss in superficially lighthearted manner as to not disrupt the complex, darker emotions lying underneath the surface. Some shared their experiences of shifting between the various stages of grief. Some shared how they grew from the experience. In some ways, being isolated from the outside world made it easier to stay in denial for longer. It was difficult to have a sense of closure, there was limited opportunity in attending funerals or, especially during the pandemic, to share the grief in-person with another family member.

As hospice volunteers, they have all experienced grief from losing patients. They each took shifts keeping vigil at the bedside of their fellow dying inmate, ensuring that their last moments would not be alone. After a patient died, they felt that it was only appropriate to push the emotions to the side to attend to the many other duties. They described a sense of relief in then having a gathering dedicated to sharing complex emotions. We felt less alone. I say we because the men included me into their groups. This was a foreign experience to me as I have mostly limited self-disclosure in my practice. Each person was a successful facilitator, I felt heard and supported.

Our last session was bittersweet. I felt proud of all the work the participants did and was confident that they would be able to lead grief groups successfully. Echoing my initial concerns, some of the men wondered if others would be able to share their feelings and personal details of their lives. Throughout the weeks, I gave them supplemental material regarding compassion, reflective listening, exploring feelings, and managing strong emotions. I could see that they studied the additional resources, sometimes quoting them or utilizing specific skills. The last session, I gave them a handout on termination. They quickly read the title and declared that they didn’t like that word termination because it sounded too definite. I like to think that the things we have learned from each other will continue to positively impact our lives.

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The award ceremony was a bustling event with some unfamiliar faces of important people at the facility. I brought some snacks that were required to be repackaged in clear containers. One of the men made two different homemade cakes that tasted professionally done. Compared to our usual intimate group, it felt a bit foreign as I called each participant by his legal name to obtain his certificate. I have come to know them each by their nicknames, their unique personalities, and the stories they have shared with me. The car ride home felt a lot like being let out for summer break after graduation from college. There’s a sense of uncertainty about whether I will be able to reconnect with these wonderful, caring people I have met or if this was truly the last time I will see them.

This has been one of the most meaningful experiences that I have had in my career. During times I feel exhausted and drained from clinic, I think of my time at Elayn Hunt. The men reminded me of the fulfillment and joy that comes with being able to help others. Their passion for learning is truly infectious.