Category: Therapeutic Issue

Gift Giver: The Impact of Giving Clients Gifts

Posted on by Psychotherapy.net Team

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

The Value and Challenges of Therapist Gift Giving

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

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

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

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

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

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

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

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

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

Questions for Thought and Discussion

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

Looking Beyond Trauma: A Neurodivergent Therapist Shifts Her Clinical Focus

Posted on by Psychotherapy.net Team

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

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Missing the Autism Tree for the Forest of Trauma

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

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

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

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

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

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

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

Postscript

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

Questions for Reflection and Discussion

How might you have worked with this client?

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

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

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

Posted on by Psychotherapy.net Team

The Legacy of OCD

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

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

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

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

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

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

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

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

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

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

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

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

Sound and Fury

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

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

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

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

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

Meaning Matters

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

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

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

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

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

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


***

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

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

Questions for Thought and Discussion

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

How have you used metaphors in the treatment of OCD?

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

The Healing Power of Therapeutic Presence

Posted on by Psychotherapy.net Team

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

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

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

The Power of a Therapist’s Self Awareness

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

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

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

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

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

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

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

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

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

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

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

Meaning Making in the Shadow of Death

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

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

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

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

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

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

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

Narrative Therapy: Discourses Around Death and Dying

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Building Meaning at the Threshold of Death

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

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

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

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

Posted in Approach, Death and Dying, Families, Family Therapy, Narrative Therapy, Population, 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?