Category: Parenting

Insight into the Clinical Challenges of Adoption

Posted on by Psychotherapy.net Team

What does it mean to truly embrace the journey of families made by adoption? This question has both intense personal and professional significance for me. I am both an adoptive parent of BIPOC children and a play therapist who has taken the journey with many adoptive families as my practice has moved into the worlds of complex trauma and attachment issues. Adoption has long been seen as a solution—the miracle, that solves the problem of child abuse, neglect, and abandonment. During the era in which my husband and I were building a family, it was our solution to pregnancy loss and challenges to fertility. The miracle version of the story has inspirational, even profoundly spiritual overtones in many families. The idea of bringing together caring adults who want to be parents with children who have lost the care of their first parents through some version of tragedy and harm is an inspirational narrative. To the degree that it replaced the secrecy and shame of earlier decades’ approach to child placement and adoption, or overtaxed, harmful group institutional care, it represents a significant step forward in the lives of children and families.

Beyond Happily Ever After

Despite being a child mental health professional, I was not well prepared as a parent for the “what’s next” part of the adoption journey. However, neither was I alone. Many of the families that I have come to work with over the years have struggled to balance their own “miracle” language with the realities of the trauma and attachment loss for the child, even when placement and adoption occur early in life, before the so-called “age of memory.”

Thanks to Bessel van der Kolk and others, we are increasingly aware of the importance of somatic memories built implicitly in the earliest months of life, even in utero. When the preverbal or early in life trauma experiences compound with attachment loss and disruption, it make the realities of emotional and behavioral regulation deeply challenging. Parents, like myself, struggle to respond adequately to a day-to-day reality quite different from “the happily ever” after version of the adoption miracle story.

In this space, a trauma and attachment-focused play therapist who enters the family system can have such a profound impact. We have to be ready to challenge the miracle narrative and, in its place, use the best clinical tools we have to help the child feel supported in the unfolding of their own true and three-dimensional story. This story includes a recognition of the emotional, and often cultural, dislocation and disruption that is at the core of this adopted child’s life journey.

It also must address an understanding of the messages from the most fragmented parts of the self that are communicated through the body. Attempts to deny, dress up, or over-soothe these losses and disruptions can land badly. When loss and adversity are left unprocessed and unresolved, this can lead to the intense emotional dysregulation some children display, and for others, can lead to a ticking time bomb for a crisis of worthiness, belonging, and the capacity to form deeply satisfying attachments over the life span.

For children with multiple disruptions as they moved through the foster care system, the complicated wounds to their attachment exact a painful and complex cost, as there are so many missed opportunities for adults to keep their part of the attachment bargain—that every little human born into the world deserves to have their basic needs met, to be enjoyed and nurtured. By the time the adoption happens, these forever caregivers may have a lot to prove and the negative energy they get from the child is the cumulative effect of others’ failures.

Many of my clients’ parents with whom I’ve worked have despaired that their efforts to connect with, and shape, the behavior of their dysregulated and insecurely attached adoptive child(ren) are met with rage and rejection, instead of responsiveness. Often, I have felt those impulses as well, during struggles to make the child’s response make sense in a cause-and-effect, logical consequence version of the parent-child relationship. For a child who missed out on the basic building blocks of the serve and return part of secure attachment, consequences are perceived as threats, and may work to grow the most defensive and rageful parts of the child’ personality.

A Layer Cake Metaphor for Adoption-Based Therapy

One of the attachment concepts I find so useful in these moments is based on the notion of mentalization, and the ability of caregivers to create and sustain an attuned mental map of what is going on inside the child. Peter Fonagy and others have been writing for many years about mentalization and the impact on reflective functioning in the attachment between parents and children. In my own experiences, I have come to realize that clinging to the “miracle” narrative can sabotage mentalization.

Why does this happen? So often the impulse to spare children the hard parts of their own story or soothe away uncomfortable information leads to a real phobia of their own child’s distress and the resulting failure of mentalization. The answer to this challenge is for therapist—and the adoptive parent—to help the child make sense of their story, including the hard parts; expand the family system’s capacity to hold the distress without minimizing it, and do this work with the parent as an active participant, with support from the therapist.

In attempting to teach a group of clinicians about weaving together of all the things that seem important in therapy with families, I came up with the metaphor of the layer cake. Play therapy, trauma/attachment work, dissociation theory/parts work and family therapy are all a part of this multi-layered work, even as we try to help our clients eat the “whole thing,” bite by bite.

I think of my work with a child who was adopted from an orphanage in the developing world as a preschooler, and the complicated, but beautiful layers of how the therapy unfolded for him a few years after his adoption in the US.

Play Therapy Layers

Like many children, offering open and child-centered play in the playroom, led to the emergence of post traumatic play narratives, giving clues or hints to the preverbal experiences. One example was many narratives around characters fighting over scarce resources, as well as abandonment stories played out with dinosaurs, video game characters, and superheroes.

Dissociation/Parts-Work Layer

Dissociation is the infant/child’s solution to the unbearable threat of betrayal by the original caregiver whether through overt abuse, neglect, sexual exploitation, or attachment loss. To fragment and isolate that chain of painful associations and emotional/somatic stress is a very adaptive way to cope. By the time this child entered therapy, these dissociative patterns had resulted in some fragmentation, including rageful episodes and “baby” parts who were almost incapable of receiving soothing from the parent. The parent admitted to a lot of dysregulation herself in the early months after placement and compounded the effect with threats, yelling, spanking. It was clear that we needed to playfully befriend these dissociated parts through some expressive work. Using a lot of drawing and flexible sand tray creations, we involved the parent experientially in play scenarios apologizing to the hurt parts of the child that she had frightened.

The EMDR/Trauma Protocols Layers
Bridging from trauma content held implicitly in play into first person narrative work, while staying grounded in the present is a tricky business. I used a flexible and playful approach to adding EMDR processing in the playroom for short periods, especially when the adoptive parent was able to support and bear witness to that work. This often served an additional purpose of shifting angry and embittered caregivers into empowered and compassionate ones.

As they come to see their child’s story through their eyes, it increased their reflective capacity and attunement. This parent struggled at times with her own impulse to soothe—she and I talked of her desire to “put a bow on it” and keep the child from feeling the intensity of his losses and rejection as he grew older, and became more aware by following my lead in the playful EMDR sessions.

Anti-Racist, Anti-Bias Icing on the Cake

This is an area of great challenge for adoptive parents who may have limited experience with the day-to-day realities of being Black or Brown, especially in the White majority spaces where many adoptive kids are growing up. In this case, the parent had really minimized the impact of cultural dislocation for her child, but as I insisted on broaching the subject directly, we discovered a lot of distress for him around looking different from her, navigating racial/cultural groups of peers, and as we began to work through the hard parts of his own story, anger at the birth country for “throwing away children” arose.

Permission to feel big feelings was needed throughout that work, and collateral work with the parent on her own biases and perceived need to soothe and minimize these experiences of microaggressions was crucial. Given the polarization and negative narratives in the wider culture, this work will likely be ongoing throughout his development, but the work so far has helped them both to have a framework in which to stick together, and build the parent’s capacity to move past the “miracle” of coming together into the power of growing together through adversity.

***

As my own children have moved from adolescence into young adulthood, I continue to marvel at how unfolding layers and the expanding capacity hold the hardest parts of their stories. I never cease to be humbled by my own invitation to that process, in my own family, as well as in my psychotherapy work, and even the potential to act in a wider culture that needs that capacity now more than ever.

Love is Not All You Need: A Revolutionary Approach to Parental Abuse

Posted on by Psychotherapy.net Team

The Referral Letter

The referral from Dr. Adams, the psychiatrist, read:

13-year-old young woman took an overdose of paracetamol 3 weeks ago. Called mother who took her to Accident & Emergency. Seen and followed up over last 2 weeks. No suicide ideation. Discharged to GP. Family issues. Please can you meet with this family this week?

Session One, Part One: Overdose and Desperation

A few days later as I (Kay) walked into the waiting room at the family medical practice where I worked, I saw Becca hunched over her cell phone, radiating animosity. Her mother Jane sat on one side of her, eyes on the latest New Zealand Woman’s Weekly story, but without the eye movement of a reader. Her father, Al, resigned, stared out the window at the dripping rain. Susie, Becca’s 15-year-old sister, picked absent-mindedly at her nail polish.

My step faltered as I sensed that the meeting ahead of me might be testing but I strode in, hand outstretched: “Hi! You must be Becca. I’m Kay.”

Temporarily startled, a reluctant smile escaped her as she awoke from cyber-land. “Hi, you must be Jane. Hi, Al. Hi, you must be Susie. Would you like to come up?” I gestured toward the stairs that led to my office stairs. As I reached the first landing, I noticed Becca glancing at herself with uncertainty in the floor-to-ceiling mirror that filled the stairwell. The family awkwardly found their way to their seats. I began my usual introductory patter but didn’t get far before Al expostulated, “Look, we need to sort this out! We can’t handle it any longer.” His eyes shot towards the brooding Becca. “She hit her mother in the face the night before last and then she locked herself in the bathroom for hours. We tried to get her to come out and talk but she just shouted abuse at us.”

Jane glanced towards me as she found some words.

“Becca went very quiet, and I got really scared. We thought we had taken all the medicines out of the cabinet after the overdoses, but we couldn’t help worrying after what happened the other week. We took turns sitting outside the bathroom door just listening in. Eventually, she came out and went up to her room. It all started when Al tried to tell her she couldn’t carry on talking to me like she was.”

“Becca,” I ventured, “did you realize that your parents are feeling so scared and don’t know what to do?” My question was met by a “no” that ricocheted around the room like a bullet. “Becca, would you be willing to help me understand what has been going on in your family?”

Becca’s reply began with a fake whine which escalated to foul-mouthed accusations. “She’s always saying, ‘Honey, what’s wrong?’ What’s wrong? What’s wrong? What’s wrong? What’s wrong? What’s wrong? What’s wrong? What’s wrong is that she’s annoying me. My mum is a stupid bitch with no life. That’s what’s wrong.”

I said, “Becca, is this way of talking the kind of talking that is causing trouble in your family?”

Becca said, “This is so fucking dumb.” Susie let out a protracted sigh.

“Becca, stop talking like that. It’s not fair. Mum and Dad have had enough and what have they done to you?”

The door slammed loudly as Becca made her exit. Jane leapt out of her seat, but Al caught her by the arm.

“Let her go. You always go after her. It’s no good. You can’t keep running after her like this.”

Concerned to sidestep the impasse between them, I spoke up.

“Okay, how about I go downstairs and find out what’s happening, and we can take it from there?” Al and Jane nodded, defeated. Susie was pale.

It turned out that Becca had found the back door to the building. I caught a glimpse of her crouched down with her back against her parent’s car, head between her knees. She looked up, saw me and went to sit on the other side of the car, out of view. I asked Emma, the receptionist, to keep a discreet eye on her. When I went back to the room, Jane and Al agreed to sit it out.

Al began, “It’s good you have seen her like this. We are falling apart. We can’t do this on our own.” There was a moment’s silence. Al looked to Jane. Jane’s shoulders began to rock as if she were holding back sobs. Al continued, “Becca doesn’t treat her mother like a parent. I mean she says things to me that I would never, ever have thought of saying to my parents. You just want to slap her face, but you can’t you know?”

Jane, her body stiff, said with a look of desperation, “The other night, Becca was screaming at me that the dinner was ‘crap’ and ‘shit.’ Adam, our 4-year-old, hid under the table. It broke my heart to see him so scared of her because he loves Becca. I feel like we are losing Susie too because she can’t stand it. She is staying ‘round at her friend’s house all the time.”

Al looked towards Susie, raising his eyebrows.

“You’re no angel either, Susie, but at the moment you come a long second to Becca.”

The story unfolded. It appeared that this was a long-standing pattern which had recently escalated from initial bad-tempered-ness to dramatic, life-threatening actions. I discovered that Al and Jane considered that they were being held hostage by Becca’s threats to harm herself, both subtle and explicit. Such threats followed any insistence that she carry out some duty that she didn’t wish to fulfill such as tidying her bedroom or if Jane said “no” to her persistent demands for money or to stay out late.

Jane had begun to fear returning home from work, anticipating that she would be met with yet more demands from Becca, and find herself caught once again between holding out against them or risking further threats of self-harm. Al was also finding home life unbearable. He longed to be able to “fix things” for his family but, in the face of Becca’s threats, had no idea what to do and couldn’t find words for the mixture of frustration, fear, and anger that preyed upon him. Al had started going around to his friend Mike’s house each night for a drink until what had started as occasional visits had become habitual. He felt guilty that he was not at Jane’s side but told himself and Jane, “I no longer have a place in this family. I am sick of being abused in my own home.”

Jane and Al had no idea what to do. Becca had been “seen” by Mental Health Service several times and, after the usual assessments (in which “mental illness,” abuse, and other possible sources of distress were excluded as a cause of Becca’s behaviour), the service had come to the conclusion that the overdose and threats of self-harm could best be explained by what was referred to as “family dynamics” and suggested that Jane and Al seek family therapy. That is how they arrived at my door.

How many parents, confounded by a family life that has become dominated by teenage tantrums, threats, violence, and the dread that their daughter might respond to any challenge to their demands with an overdose or violence, would be willing to talk about how they fear living in their own homes? How many would tell family and friends? Wouldn’t it be more usual for parents in this predicament to remain silent in their humiliation that their own child is abusing them? Of those family members and friends who had some knowledge of the situation, how many of them would be too respectful to speak up about this family’s predicament without being invited to do so?

Could these tantrum overdoses and the tyrannical threat of them instigate a servicing of young people’s every want? What might these young people be led to think about themselves if their each and every whim was serviced? Where would this lead? How might this have them lead their lives? How might this affect their family life? All these questions went through my mind as we reflected on this family and their tribulations; all these questions guided us in our considerations. This is the story of a family worn down by tantrums and abuse. This is also the story of a mother who decides to revolt.

Session One, Part Two: When Loving and Giving is a One-Way Street

“You know, Kay, we’ve always said, ‘love is all you need.’ It’s been our motto. I’m beginning to think we’ve made some big mistakes because I can’t understand why Becca is behaving like this. We have given them all so much love. We have always bent over backward to make sure that they are okay. It’s just so unfair. I try to listen and understand but she doesn’t want to talk to me anymore, and then she starts with her threats. I know I shouldn’t give in to them, so I try and hold my ground, but I feel like I have overreacted. Then I feel bad and give in. I know I shouldn’t. I just feel like I am stuffed!”

Jane’s voice faded into despair. As tears began to form in her eyes, she wiped them away hurriedly with the sleeve of her hoodie. Al chipped in, his voice weary with resignation.

“I just don’t know where we’ve gone wrong.”

I addressed the despairing Jane and displaced Al.

“Do you think it’s possible that all your loving and giving has become a one-way street, and that somewhere along the way your children’s wants have become confused with their needs?”

Jane swallowed hard.

“We’ve always tried to give them what they wanted. I always thought that if we respected them, they would respect us, but they don’t seem to. I just find it so hard to know what to do.”

I asked, “What do you think Al?”

Al shifted uneasily in his seat.

“What’s going to happen to them in the hard world out there?” he said wearily. I wondered if servicing their children’s needs had, contrary to their good intentions, been depriving their children of invaluable life lessons.

“Al,” I asked, “are you concerned in any way that unfairness has crept into the care of your children in that, by giving so much, your children may not have had enough opportunities to learn what they need to learn to live in the hard world out there?” Al had no trouble replying:

“Yep. I don’t think they have any respect for other people, and they don’t know how to be responsible.”

“Susie, what do you think of the idea that your parents have been unfair to you by not helping you to be ready for the hard world out there? Do you think that maybe, out of their love for you all, they need to find ways of mothering and fathering that might seem unfair to you now but may prove to be fairer to you in the long run?”

Susie stared at me, her eyes fixed in surprise, then she recovered herself. “I don’t think they’ve been unfair, but I suppose we have had it pretty easy. I don’t know, it’s getting me down too.”

“Susie, have you been worried about Becca?” Susie’s lip began to tremble. “Susie, how would it be if I carried on speaking with your mum and dad to see if we can find a way to help things be better for Becca and for you all? Would it be alright if I spoke with them without you present? I think your mum and dad need to find the way forwards on their own as your parents.”

Susie’s face softened with relief. Jane and Al agreed that the next time we met we would continue to explore how this habit of unfairness had taken root in the mothering and fathering of their children. I warned them that the road ahead might well be a rocky one and that other parents facing similar challenges are often met with intensified threats from their daughters or sons when they re-establish their parental authority. Jane and Al left our meeting, sobered by the realisation that they could go no further along the road that they had been travelling but relieved to be no longer standing paralysed at this crossroads.

Session Two: The Dif?culty of Knowing What’s Fair and What’s Unfair, What’s Unreasonable and What’s Reasonable?

Jane announced that there had been something of a turning of the tables. The day after our session she had decided that it was time the girls learned to do something for themselves. Instead of doing their clothes washing for them as she had always done, she had left their washing lying on their bedroom floors where they left it and stayed in bed herself for an extra hour. When later that day Susie asked where her clean washing was, Jane simply said, “Oh, I’ve given up doing your washing now.” Much to her surprise, Susie asked her to show her how to use the washing machine. Not surprisingly, Becca had left her dirty washing in a heap in her room.

Al, who was running late, joined us. I put him in the picture.

“We were talking about wants and needs and I was asking Jane about whether or not your parenting in the past has been about 'loving and giving?’”

“Well Susie has been getting too much until now,” Al responded. “My sister set her up with an interview as a summer lifeguard and she didn’t even bother to go. Lynette was really annoyed about it and had a real go at me. She said, ‘You two have to toughen up with those girls.’ I’ve realised she’s right.”

“What do you think you have been serving? Have you been serving her wants or her needs?”

“Her wants!”

“What do you think her needs are?”

“Her needs are to take some responsibility for herself. She hasn’t lifted a finger all holidays. She’s just sat at home emptying our fridge.”

“At what point do you think mothers and fathers should let their children know that if they as parents continue to take responsibility for them, they will be depriving them of taking responsibility for themselves?”

“Well, we do but we don’t stick to it,” Jane said.

“Yes. We lay down the law and then we give in,” Al replied.

“Looking ahead to when Susie is 40 years old, do you have any idea what she might wish you had done or said to her right now, aged 15?” I asked.

“She’d say ‘take responsibility for yourself’ wouldn’t she?” Al suggested.

“I suppose so, but we would have to make her do it and I would find that very difficult,” Jane responded.

“You said last time we met that you have a motto of ‘love is all your need.’”

“Yes, you know I have always thought that if we just loved our kids, it would all work out,” Jane said. “Last Sunday morning was a real low point. Becca started swearing at me when I got home from a late shift and was on my bed with all her friends drinking and eating. I found myself thinking ‘whatever happened to my lovely daughter?’”

“Do you think it’s possible that in the past, even though your intentions have been so very loving, love has been confused with giving in to what your children want?” I enquired.

“I guess so. I just thought they would love us if we loved them and that if we respected them, they would respect us,” she said.

“Are you coming to question how children learn love and respect for their parents and others?” I asked her.

“Yeah, I guess I haven’t made a point of them respecting me so maybe they haven’t learned it. I lose their respect for myself every time they say ‘no’ to me and I let it go,” she said.

“Al, what do you think about this? How do you think children learn to be loving and to practise respect?” I asked Al.

“Well, it’s been harder for Jane,” he said, adding, “I’ve always worked long hours and before we had Becca, we agreed that she would stay home and be a full-time Mum. We were really hanging in for Becca.”

“Yes,” Jane agreed. “You see Susie isn’t Al’s. I had Susie when I was 17 and I was a single parent until I met Al when Susie was 2. We had some problems and had IVF. Then she was preemie and we thought we were going to lose her. It was a terrible time.”

“Given you had to go through so much heartache to have her, did you ever think that Becca deserved special treatment in any way?” I suggested.

“We were just so thankful that she had survived,” Jane admitted. “Looking back now, I tried to give her the best of everything, and we doted on her.”

“Yeah, it was our one time away from her and she was all we could talk about,” Al said.

“Do you think that loving Becca so much has led you to be especially sensitive to her moods, wishes, and feelings?” I asked them.

“When I look back now, I think so,” Jane said.

“To be honest, she was very spoilt,” Al added after.

The Letter

The next day I wrote Jane and Al the following letter.

Dear Jane & Al,

It was good to meet you yesterday. As I mentioned, I often write to families after our sessions to ensure that I have adequately understood their situation and in addition to ask questions I wish I had asked during the session itself.

Sure, enough some questions came to mind whilst I was reflecting on your situation. I would be most interested to hear your answers or any thoughts you might have about these questions next time we meet. If you think that I have not described what we talked about fully or have misunderstood your situation in any way, could you also bring it to my attention next time?

Jane, before Al arrived you talked about some changes you had made. You said that a couple of days before we met, you had decided to have a ‘lie in’ and had resolved that you were no longer going to do the girls’ clothes washing. You also informed me that you felt you hadn’t had enough expectations of the children in the past and that you wished that you had started years ago. But you said that your lie-in was not as peaceful as you had hoped because you found yourself troubled, wondering whether or not your expectations of the girls were unreasonable or unfair.

Jane, do you suspect that your expectations may be having a late growth spurt but that perhaps, and very understandably, you are feeling a few growing pains? After all, have you ever noticed how overnight changes often feel as uncomfortable as a new pair of shoes to begin with?

Jane, do you have any ideas about why it was difficult for you to work out what expectations might be reasonable and fair? Do you think it may have been in part because your expectations of Becca at least, have been so shaped by the weight of your gratitude for her very existence?

Now that you have decided that your children can learn to serve themselves rather than being served, what kind of response do you think you might anticipate from them as time goes by? Do you think that they will take kindly to your new expectations which express your love for them in a way that serves their needs rather than their wants? Or do you think they might protest the changes in some way or other?

Jane and Al, towards the end of the session we talked about how separating your children’s wants from their needs had been especially hard with Becca.

Isn’t it understandable that if you have waited so long for a child and then when she is born and you are in fear for her life, you might want to treat her with especial care? Is it any wonder that your love and concern might leave you blinkered to some of her needs and sensitive to her wants?

Jane, do you think your ‘special care’ of Becca might have had a bearing on ‘giving in or setting boundaries and sticking to them?’ Thinking about it now, do you suspect that weak boundaries might be even more painful for you than for her in the long run?

You both told me that you don’t want to make your children unhappy, but then you talked about some realities that life holds. You said there was a difference between real unhappiness and tantrumming. If you always say ‘yes.’ if you’re always ‘manipulated.’ Where do your children hear ‘no’ from? What kind of lives will they lead if they never hear ‘no?’

Al and Jane, at what point do you think a mother or father should say to a young person: ‘I will not allow you to have such power over our family anymore; we are in charge, not you?’ Truth be told, what do you guess Becca would most like her parents to do right now?

I cannot believe that departing from the ways in which you have mothered and fathered your children in the past is going to be easy. In fact, would you consider that it might be one of the most difficult things you might ever take up in the course of your lives?

I look forward to meeting with you again on the 4th of March. Best wishes,

Kay Ingamells

Session Three: ‘Self Sensitivity’ 90%, Sensitivity to Others 10%

Jane came on her own to the next session. Although Al told her he was busy at work, she suspected that he had been overcome by his feelings of powerlessness and resignation. We began the session with my reading the letter aloud to Jane. Jane reported that the letter made her “realise I thought being a loving mother meant taking care of them in every way 100% of the time and this has made it difficult for them to respect me as well as for me to respect them.”

Once again, she reported some novel developments. Jane had “put her foot down” when Becca had decided at the last moment that she didn’t want to attend her surf rescue training.

“I said, ‘we are going in the car now,” Jane said. “And when we got there, she said, ‘Don’t make me go. You’re so mean, I hate you.’ I found it really difficult, but I insisted she stay. I went away feeling really upset but when I came to pick her up, she said she had enjoyed it.”

“Did you take a stand for what you knew in your mother’s heart was right only afterwards to be undermined by guilt for not responding to her wants?” I replied.

“Ummm I did.”

“How come you put your foot down even though the guilt was putting such pressure upon you to give in?”

“Well, I thought it was the best thing for her.”

“Does putting what was ‘best for her’ first rather than giving in to her wants say something about your wisdom as a mother?”

“Yes! That I know what’s right for her and it’s okay to say it and insist that she does what she says she will do.”

“Do you think guilt would have got in the way of your motherly wisdom in the past?”

“I think it would have. I wouldn’t have wanted the children to plead and cry. I wouldn’t have wanted them to be unhappy. I would have brought her home again.”

“What has enabled you to act on your motherly wisdom and use your motherly voice lately rather than be sidetracked by their pleading and crying?”

“I don’t know.”

“You’ve given me one example after another of how you have used that motherly voice very powerfully and afterwards.”

“And yet I don’t feel in control. I don’t feel in control at all.”

“Do you also think it is possible that using your motherly voice is uncomfortable because you are not that used to speaking with it yet?”

“I said to Susie when she butted in, I said, ‘I’m the mother. I’ll decide what Becca will do and what she won’t do. I don’t need input from you.’”

“Do you think that it’s possible that your children have developed over-sensitivity to themselves and to their own feelings and insensitivity to you and to your feelings?”

“Yes!”

“If you were to put that in percentages, what percentage of the time do you think they are sensitive to their feelings and what percentage of the time do you think they are sensitive to your feelings and the feelings of others?”

“They consider their own feelings 90% of the time. Al is really kind and generous and caring, but certainly he would put what he wants to do above anything or anyone else, especially me.”

“What happens to your feelings and to your needs?”

“They get forgotten.”

We talked about the effects this imbalance of sensitivity, e.g., self-sensitivity, versus other sensitivity was having in her relationships with her children and their relationships with her. Some of the questions I posed were:

“Would you be interested in restoring the balance between Becca’s over-developed sensitivity to herself and her under-developed sensitivity to others and in particular to you as her mother?”

“What kind of struggle would you expect if you were to pit your mother’s wisdom against the widespread mother guilt?”

“Overdoses as tantrums” and a big night out.

A month later, I had a call from a worker from the after hours Mental Health Crisis Team to report that Becca had taken another overdose. The overdose had followed an argument with her mother about tidying up her room in which Becca struck her mother in the face breaking her glasses. Jane had to go immediately to her optometrist as she was due to start work an hour later and could not work without them. Becca tried to stop her mother leaving the house, but Jane had no choice but to do so. Becca took the overdose as soon as Jane left. This overdose posed a greater risk than the earlier ones and it looked like she was, in a manner of speaking, “upping the ante.” Jane became concerned that Becca would take her own life and so arranged a safe haven for her at Becca’s aunt’s home for a few weeks.

Becca was seen for an urgent psychiatric review. The psychiatrist concurred that Becca’s overdoses appeared to be an extreme reaction to her parents attempting to set appropriate boundaries. A safety plan was put in place with the parents, and I met Jane and Al a couple of days later. To my surprise Al and Jane were not as shaken by the overdose as I had expected. Instead, they concluded that Becca’s extreme behaviour was her way of “testing us.”

We discussed how they had dealt with tantrums when their children were toddlers. On seeing the similarities between toddler tantrumming and Becca’s extreme form of teenage tantrumming, Jane and Al became inspired with a renewed courage and confidence. It now appeared that perhaps this was a problem that they recognised and not only had some experience in handling but could rightfully assume they might overcome. The next morning, I had a phone call from Jane. She had discovered from the mother of one of Becca’s friends that Becca was planning a big night out to a nightclub in the city with a group of teenage friends. The nightclub called Krave was in the heart of the city, an hour by bus from the suburb that Becca lived in. Jane and Al told Becca that she couldn’t go as she was underage. Becca was outraged and insisted that she would go regardless. Jane later discovered that $100 was missing out of her purse and challenged Becca who, as usual, denied taking it.

Jane and Al enlisted the help of Becca’s aunt, uncle, and elder brothers to come around that evening. Despite this, Becca made her escape out of her bedroom window.

The team hot-footed after her, combed the local mall and found her waiting at a bus stop with two friends. Al took hold of her arm and asked her to get in the car. Becca began to scream “blue murder,” shouting “you are not my parents. I don’t know you. Help someone! Help! Help!" The passers-by that had assembled called the police who arrived very quickly at the scene. The police believed Jane and Al’s version of events rather than Becca’s street theatre. Becca’s protest resulted in her being handcuffed, read her legal rights and taken down to the cells.

I asked Jane how she felt about the evening’s events.

“It’s good to be in charge at last. I have never seen Becca so demure. The police wouldn’t release her until she had promised not to harm herself.” Guilt had not had its way with Jane this time.

Session Four: Instigating the Revolution

While Jane and Al had begun to turn the tables on the habits of parenting which had flourished on their sensitivity to their children’s feelings and servicing of their wants versus their needs, I was concerned about the extreme nature of Becca’s actions and that Al and Jane’s newfound determination could be compromised in the face of them. Consulting with David in supervision, we decided that a community approach was needed to match the gravity of the situation and to provide sufficient reinforcement for Jane and Al’s fledgling initiatives. While no approach was without its risks, any alternative

Healing the Authoritarian Wound Through Writing: 8 Writing Exercises to Share with Clients

Posted on by Psychotherapy.net Team

A Therapeutic Place for Writing

Therapists endeavor to help clients handle life’s problems and their particular difficulties, including those that have come about because of the way they were treated as children, adolescents, and adults. We deal with people, and we need tools that actually help people grow, heal, and change. One great tool at our disposal is inviting clients to write.

One of the areas that interests me is the consequences of authoritarian wounding, those wounds created by prolonged contact with a family bully, like a father, mother, or sibling, with a bullying mate, authoritarian mentor, teacher, clergyman, boss, or co-worker, or with any other authoritarian who is operating in one’s sphere. I’ve written extensively on this in Helping Survivors of Authoritarian Parents, Siblings and Partners (Maisel, 2018) and in scores of blog posts for Psychology Today and The Good Men Project.

A second area that interests me is the value of writing as a useful tool that therapists and coaches can use with their clients and offer to their clients. I’ve advocated for the wisdom of inviting clients to write, most recently in Transformational Journaling for Coaches, Therapists, and Clients (Maisel, in press). In this piece, I’d like to share with you eight writing exercises that I use in my work with survivors of authoritarian wounding.

I think you’ll see how these exercises can also be used with all clients, either as is or with some tweaking. I hope that your main takeaway from this piece will be that clients can make tremendous strides in self-awareness and in healing when they write in a focused way about what matters to them. These aren’t the “describe a tree” or “describe a sunset” writing exercises that you might encounter in a writing workshop. These are therapeutic exercises that invite clients to face their experiences, learn from their experiences, and move past their experiences.

Maybe you don’t currently invite clients to write between sessions or assign any homework. You might want to rethink that a bit. Many psychotherapy clients are smart, articulate, sensitive folks who may well already keep a journal or engage in some other reflective writing or who, even if they aren’t journal-keepers, are likely to be receptive to the idea of doing some writing. If you do decide that providing writing exercises might prove a valuable therapeutic tool, here are a few points to consider:

  • I let clients know that if a given exercise doesn’t speak to them, they can write on a prompt of their own choosing or, of course, not write at all. It’s wise to give clients who’ve been wounded by an authoritarian this sort of instruction and permission, since they will have had a long, difficult history with rules and especially with the consequences of violating or ignoring rules.

  • I explain to clients that perfect knowing isn’t the goal. If they increase their awareness a little bit or heal a little bit, that is a victory and a blessing. We all have the wishful hope that we can get from a muddy understanding of something to a crystal-clear understanding of it, but perfect understanding is more than elusive, it is unattainable. I remind clients that if they get even just a little something of benefit from the exercise, that is a welcome outcome.

  • I warn clients that the exercises may well prove provocative and emotionally difficult, and I give them real permission to stop if the going gets too hard or painful. You can tie this instruction to several of the tips in the tip box provided below, for instance to the ideas of creating a support system and staying alert for triggers. Clients should be helped to understand that this work is not easy and that stopping should be viewed as a self-care strategy and not a defeat.

Before I describe exercises I have found useful with clients who have been impacted by authoritarian relationships, I would first like to describe some of the long- and short-term impacts of authoritarianism on the individual. These include (but are certainly not limited to) lifelong relationship difficulties (including serially choosing authoritarian mates); existential despair rooted in feelings of worthlessness; a pessimistic, critical attitude that makes it hard to give life a thumbs up or people the benefit of the doubt; an anxious nature that plays itself out as indecision, confusion, and an inability to make clear or strong choices; a felt lack of safety, including in the therapy session; obsessive worrying and powerful feelings of overwhelm; and a pull toward addictive behaviors.
 

Eight Writing Exercises

Here are the eight writing exercises. Each comes with three prompts, as I find it useful to provide clients with choices.

Exercise 1. This really went on (you weren’t crazy)

We can almost believe that what happened to us didn’t happen to us, maybe because we did a lot of dissociating, because other people saw the authoritarian in a different light, because we wished so hard that it wasn’t true or that bad, or for some other reason. But it did happen. Please pick one of the following three prompts to write on (they are written from your point of view):
 

1. What exactly went on? Let me pick one experience that still deeply affects me and try to describe it as carefully as I can. I do want to know for certain that what I believe went on actually did go on!

2. I want to think a little bit about how it might be to remember some of those terrible experiences without having to re-experience them and without having to be flooded with bad feelings. Can I see a way to do that?

3. I have long thought that I must be a little crazy to believe that such awful things could possibly have gone on. But they did go on. So how can I completely let go of that feeling that I was “a little crazy” for believing what, it turns out, was completely appropriate to believe?

Exercise 2. You didn’t have a choice (you didn’t choose it)
 

If your experience of dealing with an authoritarian happened in childhood, it should be clear to you that you didn’t choose to experience that wounding. But as clear as that truth may be, it’s still easy to feel complicit or as if you deserved what happened to you, maybe because you weren’t “perfect.” Now is a good moment to get clear on the fact that you didn’t choose to be abused by that authoritarian. Please pick one of the following prompts to write on: 
 

1. Is there some part of me that still thinks that I did choose my situation? How can I still be thinking that? And what can I do to stop thinking that?

2. If I’m still dealing with an authoritarian today, do I have new choices to make? Different choices to make? After all, I’m not that child any longer!

3. Because I didn’t really have a choice in the matter, I think I may have gotten it into my head that I’m not entitled to make strong choices or maybe that I’m not equal to choosing. I think I’d like to do some reflecting on that possibility.

Exercise 3. You didn’t have allies (you had to go it alone)

It is hard to overestimate the extent to which you had to go it alone. Authoritarians can’t function if everyone around them says “No!” For the authoritarian to bully others, those others must be staying silent, not fighting back, tacitly accepting the situation, or even defending the authoritarian. Maybe you were lucky to have an ally in an aunt, a sibling, or someone else, but basically you had to go it alone—the proof is that no one ever successfully stopped the bully’s behavior. Please pick one of the following prompts to write on:


1. Did I or didn’t I have any real allies during those bad times? What was the exact nature of my situation with respect to allies and/or a lack of allies?

2. If I did have a real ally during those times and he or she is still living, do I want to reach out and say something to him or her? Or maybe say something to him or her even if he or she is deceased?

3. I wonder, what are the consequences of having had to go it alone? Did that make me independent or dependent? Did it make me love solitude or recoil from solitude? Let me do a little writing and tease out those consequences.

Exercise 4. You didn’t have power (you couldn’t fight back)

Grown-ups possess all the power. Children can dream about being powerful, fantasize about being powerful, and engage in small acts of strength, but they are essentially powerless in the face of adult abuse. This true powerlessness can produce lifelong feelings of powerlessness, even though you are now an adult with all the powers of an adult. Please pick one of the following prompts to write on:

1. I want to think clearly about the ways in which I was powerless in those terrible times, primarily for the sake of making absolutely certain that I do not blame myself for not taking actions that were just not available to me.

2. How would I describe the power I now possess? Surely, I do possess some adult powers! How would I describe them? And how do I use them?

3. What would it take to transform myself into a “real life superhero?” And what would I be able to accomplish then?

Exercise 5. You couldn’t possibly understand (how could you?)

You may blame yourself for not understanding what was going on, for being too innocent, for missing what was right in front of your nose. But how could you possibly have understood? Feeling that something was seriously wrong and fully understanding the complicated dynamics of the authoritarian personality are two different things. Really, how could you have understood? Please pick one of the following prompts to write on:

1. What do I understand now that I couldn’t possibly have understood back then?

2. What intuitions that I had back then about my situation and about what was going were actually accurate? Did I maybe have some understanding of the situation that I couldn’t quite access then?

3. What additional understanding is available to me now? Is there more for me to understand?


Exercise 6. You were genuinely afraid (of course you felt scared)

Authoritarians scare us. You may have spent much of your childhood terrified. Of course you were afraid. The question to grapple with now is, do you still have to be afraid today? Please pick one of the following three prompts to write on:
 

1. I want to remember what it was like to be frightened as a child, to validate that experience. I am going to go back in memory, remember what I felt, and honor that I had those terrible experiences. But I am going to go back very carefully.

2. I know that I’ve lived in a fearful way and that I’ve been scared a lot in life. What can I do to feel safer now?

3. I want to live differently. How can I live more bravely? What would such a life look like?


Exercise 7. You were truly harmed (there were real consequences)
 

To say that you were wounded isn’t to speak metaphorically. Something in you got seriously injured. Maybe it was your willingness or your ability to deal with conflict. Maybe it was your self-image, your self-esteem, or your self-trust. Maybe it was your ability to trust others or to deeply care about others. The list of possible injuries is long. Please pick one of the following three prompts to write on:
 

1. I want to calmly and patiently identify the consequences of that wounding. That’s the important writing I’m going to undertake.

2. I think it might pay off to describe some of the ways that those consequences played themselves out. This won’t be easy, but I think that drawing a direct line between the wounding and the things I’ve done in life might prove eye-opening—and maybe I can forgive myself a little in the process.

3. I want to write about my strengths, too. I think it might be a good idea to spend as much time writing about my strengths as my injuries.


Exercise 8. Healing is possible (in part, through writing)

You may have gotten into the habit of thinking that nothing can really change in life, including, and maybe especially, your own personality. But healing, change, and growth are possible. Use your reflective writing practice to help you make the changes you identify ought to be made. Please pick one of the following three prompts to write on:
 

1. I think I’d like to describe some daily practice that will serve me as I try to shed the psychological and emotional baggage of the past.

2. I want to create some firm-but-gentle action plans that support my intention to heal, grow, and live well.

3. I want to write about a better, brighter future, one where I feel less burdened by the past and more optimistic and passionate about the future. Let me write about that.


Eight Helping Strategies

In addition to inviting clients to write, you can also make the following suggestions and work with clients on the following issues:

1. Creating physical separation

Survivors of authoritarian wounding regularly report that only physical separation between them and the authoritarian in question allowed them to feel safe and provided them with the opportunity to heal. And the wider the separation, the better! You can have very productive conversations about the need for physical separation and the practical details of such separation.

2. Creating psychological separation

Survivors are likely to still love, or feel that they ought to love, their parents; be pressured by other family members to continue to deal, psychologically and emotionally, with their parents; and never quite be able to get their parents out of their head. You might try a guided visualization where your client is invited to escort the perpetrator out of her head once and for all.

3. Ventilating and eliminating feelings of guilt

Survivors typically experience guilt. Some feel guilty about not protecting their younger siblings from the family dictator. Some feel guilty about having failed themselves or not having lived up to their potential. Some feel guilty about physically or emotionally separating from their authoritarian parent. You can help your client ventilate these feelings and begin to think thoughts that serve them better, thoughts like, “This guilt isn’t serving me.”

4. Creating a support system

My client Maria explained, “I have to be able to handle things on my own because, growing up, I lost so much power and so much self-confidence that my goal for myself is to be powerful and self-confident. However, that doesn’t mean that I have to handle every single thing alone. So I’ve created a kind of informal support team. I don’t turn to them first thing—first, I want to trust my own resources. But I’m not stubborn, and I do turn to them just as soon as I understand that I could use some help!”

5. Staying alert for triggers

In the language of the 12-step recovery movement, a trigger is an internal or external cue that is likely to cause a person in recovery to relapse and resume the addictive behavior. A trigger might be the appearance of a certain feeling, like feeling overwhelmed, seeing someone in a film or a television show in a similar situation, relationship events that mimic family-of-origin events, or encountering a certain smell (like an aftershave lotion) or a certain sound (like a door slamming). You can help your clients identify their triggers and create a plan of action to deal with those triggers.

6. Communicating with and enlisting “healthy” family members

Survivors often express that maintaining contact with family members who saw the situation the same way that they did was their number one healing and survival strategy. A client and her sisters might support one another in validating their memories (“Yes, Anna, it was that bad!”) and standing together in mutual defense and in ongoing defiance of the authoritarian parent. You can help your client identify allies and begin the process of reaching out to allies.

7. Not accepting the vision of family members who do not see the situation as your client sees it

Other family members may have had a very different experience of Mom and Dad from your client’s experience. They may have entered the family later than your client did; maybe the authoritarian had mellowed by that time, and the younger sisters and brothers did not receive the same authoritarian wounding as your client did. Maybe her siblings were in fact just as abused and traumatized as she was, but they are currently in denial about their experiences or have followed in the authoritarian’s footsteps. You can help your client deal with her siblings’ demands that she be “nicer” to the authoritarian parent and with their accusations that your client is being disloyal or ungrateful.

8. Limiting contact

Your client may still be living with the family tyrant or may have returned to live with that parent, perhaps because the parent has become infirm. If complete physical separation is out of the question and complete psychological separation is unlikely, the questions you can pose to your client are “What’s the least amount of contact that you can have with your mom?” or “How can you stay out of your dad’s way most of the time?” You can help your client think through the practical details of limiting contact and the emotional consequences of remaining in contact.

Clinical Case Applications

Let me briefly describe two client situations where reflective writing helped my clients grow in awareness and make important life changes.

One client, John, a British professor of history, had never finished writing any of the many books that he’d begun. I invited him to get some thoughts down on paper about why this might have been the case. He shared the following journal entries with me:
 

I grew up with mean parents. After years of therapy, I think I’ve come to identify a kind of demon who comes into my consciousness and does not want me to be productive or successful. That demon was born in childhood. It somehow has to do with safety. It did not feel safe living with my parents, plus they told us that the world wasn’t a safe place. They filled our lives with continual anxiety and catastrophizing.

Here’s how that all plays out now. My creativity starts to flow and then anxiety floods in. I tear up the work, I tear myself down, and I abandon the project as no good. I’m also flooded with feelings of intense dread all the time, especially at night; and during the day, I’m always finding ways of avoiding entering my writing space. And my writing space is easy enough to avoid, as I have classes to teach, committee meetings, a bit of a commute, and all the rest. It’s supremely easy to avoid my study. And my study is so lovely. I wanted to write, ‘lovely and inviting,’ but it never does invite me.


In another session, he shared the following journal entries:
 

Those demons. The demons have made it harder for me to keep meaning afloat in my life, they’ve made it harder for me to keep despair at bay, they’ve made it harder for me to live my life purposes, and they’ve contributed to my anxiety and depression diagnoses. It’s all a piece. I’ve come a certain distance in all this and I can function, but I’m still searching for answers and I’m still wanting to finish some damned book.

I think that the bottom line for me is that the demon just won’t budge, because it is about core safety. Maybe I have to celebrate lesser forms of creativity where the emotional stakes and pressures are lower. An article, maybe, though articles aren’t easy either! I haven’t found ways to conquer the demons of darkness, but I do intend to continue to work on this block through some kind of inner demon work. I haven’t quite given up. Not quite!


John and I worked together for the next three years, chatting via Skype once a month. There were many downs, but also enough ups that John did manage to finish a draft of a book, deal with its several revisions, send it on its journey into the world of academic presses, tolerate the criticisms and rejections his book initially received, enjoy the moment when it was accepted for publication, and so on. I kept reminding him, “This is the process,” and at some point, he began to laughingly beat me to the punch and become the first to announce, “I know, this is the process!” And throughout the process, he used reflective journaling and writing prompts to hold important conversations with himself and deal with the demons that were never going to fully go away.

A second client was a Parisian painter, Anne. At the time we began working together, Anne was hiding out in Provence, licking her wounds after an unsuccessful show of her paintings at a prestigious Parisian gallery. She was barely communicating with the world and painfully wondering if she should continue as an artist. The fact that she has sold paintings previously, that she had had successful shows previously, and that she was still something of a darling of the art world seemed to amount to nothing. Not in the aftermath of what she dubbed “that monumental disaster.”

We chatted over Zoom. One of my goals was to help her change her perspective. Her career certainly had taken a hit. But for her to dwell on that “disaster” amounted to a serious mistake and a recipe for despair. Focusing on that event was only one lens through which to look at her career. I quietly and carefully explained to her that she was fortunate to have had the successes she had had, that this one event might or might not signal anything in particular or auger anything in particular, and that her best path was to get on with her life and get on with her art-making—the act of which, fortunately, had lost none of its luster for her.

I asked Anne to detach from the show results. I also asked her to invite a postmortem from the gallery owner. How brave that would be, to ask him why he thought the show had produced no sales! She wasn’t sure if she was equal to that. I explained that she might get “more equal” to that bit of bravery by doing some reflective writing, maybe on her turbulent childhood, maybe on her bullying father, a famous painter who always belittled and minimized her efforts, or maybe in a more “in the moment” way by writing about her feelings about communicating with Claude, the Parisian gallery owner.

We chatted a week later. It turned out that she had journaled every day that week using the prompt: “Do I dare write to Marcel?” She explained that she had learned a lot about herself in the process, especially about her habit of fleeing at the drop of a hat. In childhood, she hadn’t been able to flee. She had been watched, controlled, commanded, and punished for taking even the smallest step out of bounds. Now, as an adult, because she could physically flee situations, that’s what she did—and far too quickly, she now understood.

Indeed, she returned to Paris, bravely met with Claude, and had that painful conversation. It turned out that Claude had very little to offer by way of explanation. People “loved the paintings.” People were “wild for the paintings.” Many expressed what Claude felt was a completely genuine desire to make a purchase. Yes, nothing had sold. But, Anne explained to me with relief, Claude was not down on her, had no intention of reducing her presence in his gallery, and in fact expressed his intention to redouble his efforts on behalf of her and her paintings.

Over the months, I learned that several paintings from the show had sold for fancy prices and that her new suite of paintings were progressing nicely. She still had to endure all the challenges that creatives must regularly endure; but her “monumental disaster” seemed clearly behind her. “And I now have a sturdy tool in my tool kit,” she explained. “I now have conversations with myself in writing where the part of me that wants a good outcome can coax my wounded self in the right direction. I now have a friend who is nicer to me than I usually am. And that friend knows all about my tendency to flee! She knows all about it—and she knows how to talk me out of running away.”
 

***


It’s likely that many of your clients have been adversely affected by an authoritarian: by a close family member like a father, mother, sibling, or mate, by someone else close, like a mentor, teacher, clergyman, or boss, or by authoritarian leaders and others in high places.

What ought you try if your client is suffering from an unhealed authoritarian wound that has produced adverse consequences? You can try any of the tips I’ve provided, any of the tactics and strategies you routinely use, and the writing exercises I’ve described. By working in this way, you will help increase your clients’ personal power, aim them in the direction of useful daily practice, help them envision and plan for the future they want, and, in the process, help them upgrade their personality, heal, and grow.


References:

Maisel, E. (2018). Helping Survivors of Authoritarian Parents, Siblings, and Partners. New York: Routledge
 

Digital Technology and Parenting:

Posted on by Psychotherapy.net Team

As a trauma therapist I am always interested in learning about my clients’ childhood attachment patterns. Growing up with parents who were either emotionally unavailable, inconsistently responsive, frightened by or frightening to their child has a profoundly negative impact on social, behavioral, emotional, and neurological development. “Trauma-informed care” includes assessing for adverse childhood experiences and reframing clients’ subsequent “symptoms” and struggles as the inevitable by-products and coping strategies of attachment trauma. However, I am concerned that a newer version of attachment trauma has invaded even the most “loving” families. Our reliance on, and, in some cases addiction to, digital gadgets and technology has hijacked the face-to-face parent-child interactions that are necessary for consistent, sustained and secure attachment.

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Is this scenario familiar? After standing in line at the post office for fifteen minutes—a somewhat inherently traumatic experience in and of itself—I witnessed a two-year-old having a complete meltdown. Her mother’s immediate response was to hand her an iPad. In her wisdom, the child initially rejected it. In a soothing yet frustrated tone, the mother said “Use your iPad! Do you want to look at pictures? Play a game?” The child was not appeased and continued to wail. As the woman bent towards the stroller, I felt a sense of relief, assuming she was about to pick up her dysregulated child. Instead, she turned on the tablet and said with greater agitation, “look at the pictures on your screen!” After several more minutes of crying, the child realized that what she wanted and needed—to be comforted by her mother, not an inanimate object—was not going to happen. I watched as she went into collapse, emotionally shutting down and compliantly staring at the screen.

Believing her baby was now soothed allowed the embarrassed mother to comfort herself with a cellphone, tapping and swiping until it was her turn to buy stamps. In essence, they were two strangers in line together. I have seen similar scenarios countless times: in airports, malls, restaurants, and my waiting room. Preoccupied parents entranced as they stare at their iPhone, seemingly oblivious to their child’s needs. They are content to use digital gadgets as pacifiers and babysitters. They are not only modeling the excessive use of cellphones, tablets, video games, and laptops, they are actually encouraging their children to be just as hypnotized, and potentially, addicted.

At the risk of sounding old fashioned and judgmental, I believe this phenomenon is worrisome. Eye gaze, appropriate loving touch, and soothing words are the hallmark features of secure attachment. In families where there is abuse or neglect, these experiences get weaponized. Eye contact becomes a vehicle for threat or intimidation, or the neglecting parent avoids eye gaze, leaving the child feeling demeaned or invisible. Touch is either physically abusive, sexually inappropriate, or unavailable to the child. Words are bullying, shaming, hypercritical or lacking in love or support. This is why caretaker perpetration is such a betrayal and profound breach of trust.

But those three critical resources for attunement are also lost when a child is offered a screen rather than the loving and grounding experience of an available parent, which makes them feel safe, calm and connected to others. It may seem unfair to associate abuse or neglect with the disconnect that happens when a child is comforted, distracted, or cajoled by a digital appliance. But what is the long-term toll it takes on healthy attachment, affect regulation, and socialization skills? Mental health researchers and therapists alike need to assess for and explore that impact, as digital technology is not going away. Questions to consider:

  • Are kids with excessive exposure to digital gadgets less comfortable with face to face interactions and more likely to struggle socially?
  • Is it harder for them to read and accurately interpret nuanced facial expressions and body language?
  • Do these kids have a healthy ability to regulate their fluctuating or overwhelming emotional states?
  • Are these kids less likely to use relationships for soothing and comfort, and more likely to numb with endeavors that are hypnotic or dissociative?
  • Despite growing up in families that are well-meaning and financially secure, are these kids actually experiencing avoidant or insecure attachment?
  • And if they are, will they struggle with the same emotional fall-out and symptomatology as abused or neglected kids?

Since technology has made our lives much easier and resources more accessible, stakeholders may be reticent about tackling this issue head-on. I believe it is our ethical responsibility to address these dynamics with the families we treat. We must empower parents to set much stricter limits on screen time and to reconnect with the relational, face-to-face-benefits of parent-child time and family time. Many kids and teenagers need to be weaned from their overuse of digital gadgets—a kind of digital detoxification—so that they can reconnect with peers and re-access their own imaginations.

For traumatized clients, the reparative experience of secure attachment often happens within the therapeutic relationship. Therapists may need to be more mindful of addressing this issue with kids who have been overexposed to digital gadgets as a resource for comfort and soothing. They should keep technology out of the therapy room and model attunement, eye gaze and appropriate words and touch so that kids and parents alike can rediscover the power of relationship. Otherwise, the next generation risks losing the ability and the desire to be fully present with others and fully engaged in the world. 

Paying It Forward: A Fulfilling Reframe

Posted on by Psychotherapy.net Team

In one of my recent blog posts, I wondered aloud why the cobbler’s children have no shoes, and by association, the therapist’s kids don’t heed their parent’s sagacious advice. This bit of wondering was the epilogue to the latest chapter in our family’s chronicle, “children, can’t live with them, can’t live without them.” My subsequent blog was on the therapeutic use of metaphor as a means of making sense, when none seems apparent.

I don’t believe that I told you that every living creature that draws breath in our home was born elsewhere. This includes cats, dogs and our two precious children. Yes, they are both adopted. When I was more actively practicing as a psychotherapist, I sought out and perhaps was sought by families immersed in the drama of adoption which I consider to be sacred clinical ground. And I do strongly believe that adoption is in so many ways a drama whose seeds are sown in loss. Nancy Newton Verrier went as far as to refer to adoption and both its antecedents and consequences as a primal wound.

Mind you, not all adoptions are fomented in or are the result of trauma or leave deep and unyielding wounds. In fact, the flipside of adoption-related loss is being found or finding ways to connect either with birth parents or adoptive families…like in ours. And psychotherapists who work in the field of adoption would do well to appreciate the sheer joy, fulfillment, and connection experienced by multitudes of adoptees, adoptive parents, and families.

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However, the very real and oftentimes enduring legacy of disrupted attachment, loss, trauma and a lifetime search for connection do indeed swirl around and roil within the lives of those impacted by adoption. Just as the joys of adoption have been identified by clinicians and researchers in the field, so too have they chronicled the very real challenges, pains and manifestations of the adoption narrative in the lives of those involved in the process.

So, with that said, and as I typically do, I refer to a recent experience that my wife and I have been trying to reconcile as both of our adult children are now “out there” in the world, free perhaps of our immediate gravitational pull, and trying to either find or make a place in their own worlds that makes sense to them. Perhaps in this telling, adoptive parents, adoptees, and psychotherapists who work with these individuals will benefit.

If you promise not to tell anyone, I will reveal a confidence known only to my wife and myself. And that is: we secretly take credit for the wonderful characteristics that our children display and blame the rest on genetics. Nature versus nurture working for us. Yeah, baby, or should I say "yeah adult adoptees." It has been a most useful reframe for us during those painful moments when our kids’ behaviors have made no sense and my wife and I look at each other and say, “where the hell did that come from, must be genetics.” On the other hand, when our children shine, my wife and I are the first to belly up to the self-congratulatory bar and bedrink ourselves into comas of self-satisfaction-patting ourselves and each on the back for a damn good job of nurturing. I am fully mindful that some of you analytically-oriented clinicians out there might label this at best cognitive distortion or denial, and at worst, “folie a deux.” I, however, like to consider it as a self-serving reframe. Don’t we use these every day in our therapy practices if not in our own lives? I paraphrase Jeff Goldblum’s “Big Chill” characterization of a radio shrink who dryly asserted (as only he can and still does), “I can’t get by a single day without at least one good reframe.”

So, my wife and I received a phone call today from our son who recently, and seemingly abruptly, relocated two thirds the way across the country to live with new friends and their family. With distress, he told us that a member of that extended family was in dire need of support, so he was going to drive yet further into the wilderness to render the equivalent of missionary salvation services. This revelation came while we were still trying to make sense of how and why our daughter has herself seemingly adopted her own new extended family.

Desperate to make sense of these life choices that our children were making, which are so distant from the plans we had for them (which is probably the rub), my wife and I again turned to each other and rather than blame genetics, the adoption narrative, or the experience of loss for our children’s decisions, we invoked Article 1 of our adoptive parents’ constitution: when in doubt, reframe! And like magic, it worked. Because, in that moment, we were able to fully acknowledge and embrace the beauty of the adoption narrative which we chose to center around saving and being saved. Our children were simply yet powerfully paying it forward.
 

When the Snow-Globe Shatters: A Counselor

Posted on by Psychotherapy.net Team

Many clinicians are comfortable and familiar with suffering – the suffering of others, that is. But what happens to us when our personal world is rocked by tragedy? Fulfilling the duty to which we are called is not an easy task when we are hit by the loss of a relationship, financial devastation, or a terminal illness that befalls us or a loved one.

Several years ago, I suffered a heartbreaking tragedy as my first marriage ended after a long separation. The years of separation were filled with marriage counseling and numerous attempts at reconciliation, but in the end, my former wife chose a different path for her life. In the wake of this were two little girls whose worlds got turned upside down. As if this wasn’t bad enough, in the years following I endured a long custody battle that involved years of court and attorneys, as I attempted to be a part of my daughter’s lives. The aftermath of all of it left me devastated financially and emotionally, and I found myself seriously doubting if I could continue on in the profession to which I had dedicated my life.

Did I mention that I’m a therapist who works with kids, teens, and families? I can’t tell you how many kids from divorced and blended families that I have worked with and when this happened, it was like staring into a black abyss of reality that was going to swallow me whole. Suddenly, it was my kids asking why mom and dad didn’t live together and begging us to work it out. It was my kids who cried when it was time to go back to the other parent’s home. I was the one scrambling to defend myself in court and keeping time logs for the attorney and being summoned to depositions over ridiculous accusations. It was me having sleepless nights wondering about the emotional and mental damage my children were having to endure, and worrying about how this would impact their future development and relationships.

Our training and expertise is a gift when it comes to helping others. But when our personal lives start to crumble, all that knowledge can work against us in knowing exactly how to deal with it. What does the clinician do when this happens? How can we endure a personal tragedy but still effectively do our work? Here are a few things that I did that kept me held together while weathering the storms of my personal tragedy.

The first thing I did was seek personal counseling. Thankfully, I found a seasoned non-biased clinician who comforted me where it was needed, but also challenged me when it came to my denial about my abilities and how my personal issues may affect my professional work. Second, I kept the vision that tragedy represents growth opportunities and the goal isn’t just to survive it, but to thrive as a result of going through the process. I took the mindset of a client in regards to addressing the issues going on in my personal world. I set to work on confronting my denial and fears. I journaled daily, addressing my thoughts, emotions, and staying grounded to the moment. Third, I took an honest look at my caseload to see which cases I needed to refer to other practitioners. This was very hard for me, but looking back was very beneficial both to myself and to the clients. I reached out to colleagues and received excellent consultation.

Now, looking back, this period in my life was one of profound suffering but also immense growth. Here are some things I learned and gained from this experience. First, I identified with my clients in a new way. Emotional pain, fear, and the experience of loss struck deep chords within me that were new levels of suffering. I became more connected to my client’s emotional experiences and found new levels of empathy upon hearing their stories. Second, I became grateful for the small things. This sounds very cliché, but the suffering made me notice the tiny kindnesses of others, the wonder of nature, and forced me to look outside of myself. Third, I learned to value relationships in a new way. It is easy in our work to see people as appointments, a simple slot on yet another full calendar of events. My time with my daughters became sacred – the time with those that loved me and the encouragement they provided was like a steady drip of precious water that one craves during a desert experience. I slowed down and took in the moments. Fourth, I came to love our profession even more after realizing that counseling and psychotherapy are effective! I realized from a client viewpoint that my life was drastically improved despite the hardships by intentional focus on different areas of myself and by following the protocol for change upheld by theory, research, and practice.

We will no doubt suffer personal tragedies during the course of our careers. We are not immune simply because we are people-helpers. However, my experience taught me that we need not abandon our work when we encounter personal challenges, and in fact, as I found, working through the challenge may produce a better person, clinician, father, and partner because of the experience.  

Lynn Ponton on the Challenges and Joys of Working with Teens

Posted on by rezendevknowfully.com

A Delicate Balance

Rachel Zoffness: Lynn Ponton, you are a practicing psychiatrist and psychoanalyst who has been working with teens for over thirty years, and are author of the books, The Romance of Risk: Why Teenagers Do the Things They Do and The Sex Lives of Teenagers: Revealing the Secret World of Adolescent Boys and Girls. Let’s start with some of the salient issues that come up when you’re working with children and teenagers. I find that confidentiality when working with kids and teens is often a tricky subject because teenagers have rights as clients and they want to maintain their privacy, which is critical to the alliance. But at the same time parents want to know what’s going on with their children. How do you maintain this delicate balance?
Lynn Ponton: I think it begins with the first session, and even before, when you talk with the parents on the phone—you have to alert them about how you run your therapy practice and your work with kids. I almost always say that I try to encourage privacy with the teens so that they feel open to talk with me, and I will tell their child during the first session that I’m going to try to keep things confidential, but that there will be some exceptions, and I let parents know that right away on the phone. In general, I meet the teen with the parents before I even start and I alert everybody to the parameters and the boundaries around confidentiality.
RZ: So that both the teenager and the parent are on the same page and know exactly where you stand.
LP: Exactly. The kinds of things I would need to share with parents, which I’m clear about right from that first session, would be drug use that was risky or risky behavior that would result in serious self-harm. And sometimes other things—abuse when it’s disclosed has to be shared with the parents for a variety of reasons, and because I’m a mandated reporter.

It’s often hard for a teenager to tell their parents these things directly, so I’ll offer to meet with them and their parents and we’ll work together to help them disclose this material. Collaboration with the young person assures them that even if they do tell me something, it’s not going to be reported over the telephone to their parents. They’re not going to find out about it by surprise. Instead, we’re going to collaborate together as a team to make sure that parents know this.

Of course there are times when this doesn’t always work perfectly. Having worked with kids for more than 35 years, there have been exceptions where I’ve found out quickly that a teenager is suicidal and I have to let the parents know. Maybe we have to work toward a hospitalization period or something like that, but I try as much as I can to have the teenager be part of this process and be involved with it.

Cutting

RZ: You mentioned a very hot button and interesting topic, cutting, which to me seems to have become almost a contagious and trendy behavior among teenagers. What’s your thought about that?
LP: Well, self-mutilation in all of its forms is something that therapists have to learn to feel comfortable with working with teenagers. It’s a big part of our work to connect with them, to know about it, to seem comfortable with it and not put off by it when we hear about it in a session. I first saw it about 30 years ago and wrote a paper on it in the ‘80s, which talked about self-mutilation as a communication. As you point out, it’s a contagious risk-taking behavior. In a group of teenagers, one will do it and the others will copy. They’ll think, “I’ll try it and see what I can learn from it.” That’s how that process really starts. In the ‘80s there were big concerns about self-mutilation because of sharing of implements and a lack of understanding around HIV risk, so we had to be very careful about that until we better understood it.

I think it’s often scariest for parents. So how do you work with teens around the cutting for parents? How do you help a teenager who is cutting really find other ways to cope with some of their feelings and to develop identity in a healthier way? In general I try to educate teens about cutting. I often employ them to get involved in it, to look online, look up articles about cutting. We’ll have conversations about it so that it’s really an educational process with them.

Some teens don’t want to engage in that process.
They may tell you they’re cutting, but they don’t want to learn about it, they want to do it.
They may tell you they’re cutting, but they don’t want to learn about it, they want to do it. This is something private that they’re going to do to help themselves feel better, so I’ll respect that, but I’ll still engage in conversations with them about it. I want to make sure that if they are cutting that it is safe in other ways. There’s significant risk of scarring, of infection—there’s a whole lot of risks that are associated with it.

Many teens cut because they say they feel better afterwards. A number of papers point to the beta endorphin release with cutting—the focus then becomes the physical cut and not the emotional pain that they’re feeling. So it accomplishes a lot for teenagers, but it is an unhealthy coping strategy and risk-taking behavior that you have to work with teens to limit. There are many different ways to do that.
RZ: The way you talk about cutting, it sounds like it might serve an important function for the teenagers who are doing it. What would you say to people who say that it’s just an attention-seeking strategy?
LP: Your question is well placed because I think a lot of times therapists who work with teenagers are faced either by teachers or parents or even other therapists who say, “I don’t want to work with those teens. They’re engaged in a lot of attention-seeking behaviors. How do you handle that?”

I think many behaviors in life are attention-seeking, and often we’re seeking greater attention from ourselves, that we pay attention to our own pain. Teens usually cut because they’re in pain and they don’t necessarily understand their own emotional pain but when they cut, it allows them to at least understand that it’s a painful thing that they’re dealing with. So, yes, it is attention-seeking, and adults will often be drawn in to it. Teachers at school are shocked when they find out about it and they’re worried other kids will cut.

But I think there are a lot of other factors that play in to cutting besides seeking attention. I’m also interested in questions about molestation with cutting. Were they ever hurt? Did they ever suffer abuse? Are they using that in the context of cutting? Has it become very ingrained, so it’s a behavior that they use as a coping strategy that they may have done thousands of times and they find themselves unable to stop? How does it fit in with their family?

Does their family know much about it?
There are many, many reasons why young people cut, and attention-seeking is only one of them.
One of the cases that I worked on for a long time, a girl cut because her father was a surgeon. He talked about cutting all the time, a different kind of cutting, but she imitated him in a kind of identification with her father. It took a long time to unravel, as it wasn’t obvious at the beginning of her treatment. There are many, many reasons why young people cut, and attention-seeking is only one of them. And it’s not often the major one. You have to address the complexity of the behavior and also the feelings that go with them.

Five Perspectives

RZ: I think some professionals are concerned that giving too much time and attention to cutting might be positively reinforcing. So it seems to me that as a clinician addressing it you want to find a balance between over-reacting and under-reacting.
LP: I think that’s more of a strict cognitive behavioral model way of looking at it, and it gets to the question of models and how they affect our work. Cutting is a behavior, but it’s attached to many other perspectives that we look at when we’re engaged in therapy. I try to look at things from at least five perspectives.

One is the more dynamic-relational, where you engage and are looking at aspects of the relationship—how it affects you, the parents, the cutting behavior, all of that. How disclosure plays a role in that. Attachment. Therapeutic alliance. Then there’s the behavioral model. A lot of therapists don’t use that model, but I think it helps to focus on the behavior. I often have kids keep a timesheet or a workbook on their cutting behavior and have them draw their feelings at the time that they’re cutting in addition to recording the number of times they cut. It’s a kind of cutting journal that we look at from a behavioral perspective. We also look at their thoughts that are occurring at the time that they’re cutting, so we can target really negative thoughts.

Then there is the family system. Cutting is usually very much connected with parents in some way or another—they’re worried about the parent’s reactions; they’re worried about feelings they have that they feel the parents can’t help them with. A lot of our kids have trouble with self-soothing, so they’ll cut to self-soothe. The parents might like to learn how to help soothe their teen, or help their teen gain self-soothing mechanisms, but they don’t even know the cutting is going on so they can’t focus on that area with them. Or they, themselves, may be unable to self-soothe and not know that it’s an important skill that you need for raising teenagers.

Carl Whitaker always said, "You lose the parents, you lose the family, you lose the case."
And then there’s the aspect of meaning for the teenager. What does cutting mean to them? Do they think about suicide? Some cutting is related to suicide. Self-harm that is related to suicide is very important to pay attention to, not just for our board tests but in our office with our kids.

Lastly there’s the biological perspective. With some kids that I work with, they carry biological conditions which may lead to increased cutting behavior. Prader-Willi Syndrome is one of those that has some increased cutting and self-harm. You want to be thinking about underlying conditions that might contribute to this behavior.

All of those things are going through my mind, so I’m not thinking, “if I pay attention to this behavior I will reinforce it.” Instead I’m working on all of these levels if I can. I didn’t start with this in the first year or two of being a therapist working with kids, but the longer I’ve worked with kids, the more I’ve been able to see the complexity of so-called simple behaviors.
RZ: I really appreciate that more systemic approach to working with families because when you work with children and teenagers you’re never just working with a child. You’re always working with the family and the larger system.
LP: One of my greatest teachers was Carl Whittaker, a well-known family therapist I worked with as a young medical student therapist in Wisconsin. He always said, “you lose the parents, you lose the family, you lose the case, Lynn.” I kept that in mind and it’s really helped me with all of these cases.

Manualized Treatments

RZ: Apropos of what you just said, I was trained in manualized treatments and I do see a use for them. But a lot of therapists think they’re mumbo jumbo and that they don’t address and can’t respond to the spontaneity of what happens in treatment face to face with clients. How would you make a case for manualized treatments, if at all, or what would you say to people who don’t believe in them?
LP: Well, there are now manualized treatments in dynamic relational work. There are over 400 manualized treatments that I know of in working with children and adolescents from a behavioral modality. Family therapy, too, has manualized treatments. I don’t think there are any in the more existential perspective, because it kind of runs counter to manualization. In biological therapies they have always had manualized treatments for how you evaluate symptoms and work with things.

When I work with young therapists—and I supervise a lot of residents, fellows, psychologists, psychiatrists who are at all stages of training—I really encourage them to pick one or two manualized treatments and really learn them—go away for a day or a weekend, learn the strategy, practice it, and try to become familiar with it. Even if you’re going to be a strict psychoanalyst or family therapist, I think they’re valuable because they teach you how to focus on specific things, how to evaluate. Often manualized treatments have an evaluative component built in, so you have to look at your actions and evaluate how they’re working at the end. That’s a very important part of all therapy.
RZ: Measuring one’s progress?
LP: Exactly. That’s the key, I think, in mastering some of our work. Now, which ones would I recommend? I think one of the best ones to know about is the basic cognitive behavioral therapy approach as developed by Aaron Beck at Pennsylvania. He was my supervisor when I trained there as a resident, and it’s a very successful modality to use. It helps us understand the impact of negative thinking. Another supervisor of mine was Joe Weiss, who worked on Control Mastery theory—which is about negative thoughts and ideas and the power of unconscious beliefs. I admire Marsha Linehan a great deal and the Dialectical Behavioral Therapy model. I’ve had some wonderful conversations with her about her work with adolescents and I think she really grasps what it’s like to work with high-risk adolescents. I would encourage almost anyone to look at her book on working with high-risk adolescents. It’s a wonderful model and it adds much to the work we do with young people. A third area that I think people should look into is trauma. We work so much with trauma as child and adolescent therapists. There is a trauma focused interview that we can do with kids that I use all the time. It’s very useful in diagnosis and at looking at symptom category.

I think learning a little bit about any one of these models helps any child and adolescent therapist function in a more complete way.
RZ: So it sounds like what you would advocate for is an understanding and knowledge of these manualized treatments because it gives you, as a clinician, more tools in your tool belt to pull out for individual clients as they come to you with their individual differences.
LP: It’s one of the reasons the tool belt concept is helpful. But it also makes you feel more comfortable as a therapist, knowing that you have some grasp of these different ideas. Knowing that you’re not following one dogma, but are open to new ideas, because I think ultimately as therapists we end up constructing our own way of working. The theories that we use to support our work, the collection of tasks and techniques that we define and use—these form the basis of our work . It’s very valuable to look at other people’s constructions, integrate them into our own work and say, “hey, this is useful for me. It works with these patients. I can really take this and run with it.” I mentioned five perspectives that I’ve accrued over maybe 35, 40 years of work, but I anticipate over the next 40 years there are going to be others that will greatly benefit our work as child and adolescent therapists.
RZ: There are therapists and other mental health practitioners who would say that defining yourself as eclectic dilutes your work. Do you believe that that’s true? How do you define your theoretical orientation when asked?
LP: I remember that same question from 35 years ago in residency. I think having multiple perspectives strengthens our work, and there are multiple perspectives within each of these theories, so it’s not like people who belong to one model are necessarily doing some ossified therapy that was created by some individual or group of individuals. In my work, I want to stay open and patients open me up.

One reason I like adolescent work, even though I feel like I’m getting older, is that it keeps me young. It keeps me open to new ideas. My patients actually taught me how to text on my cell phone; my patients are coded in by their first name so that they can call me and have a relationship with me.
My patients actually taught me how to text on my cell phone.
I remember one of my other supervisors, Hilda Brook, who worked a lot with eating disorders, was working with teens into her 70s and early 80s in a wheelchair, and she had greater facility with them than even I have today in my 60s. We can continue to grow in our work with teens if we stay young in other ways.

Texting

RZ: You bring up a very important and hot button issue when working with teenagers, which is texting. And I think doing therapy with teenagers and kids today is a whole new world because teenagers and kids are used to communicating through their technology. What are the upsides and downsides of deciding to be a clinician who texts with your clients as you are?
LP: I think it’s important to be aware of some of the legal parameters around texting. Many of us work with large organizations, and it’s important to be aware of HIPAA regulations and such. HIPAA doesn’t regulate all therapists, only certain therapists who are involved with electronic billing, which you might be if you work in a large institution and you bill electronically. In that case you are HIPAA regulated and with regard to texting, HIPAA states that you cannot be sending clinical decisions through a texting modality or an unsupervised modality. You have to have some regulations around it.

When I worked at UCSF for 35 years, I was in a large system that was HIPAA regulated. My texts, which I did with teenagers for 10 years during that period, dealt with scheduling, and if they texted me about an issue that I was clinically concerned about, I’d have them come in so that we could then talk about it and then work on it in person.

But the texting connection I think is very, very important with teens and therapists. Not all therapists can do it for a variety of reasons. Not everyone feels comfortable with it and not all teens have phones. I’ve done a lot of work with homeless teens, who usually don’t have phones, so you have to figure out other ways to communicate with them.

But the bulk of teens out there today do have access to texting and they will communicate that way, often just to check in with you. They may just want to know you’re there and I think that sets up a relationship with them. I don’t always respond to those texts, but they know that I’m receiving and reading them.

But let’s say you’re not HIPAA regulated, so you can put anything on text. I would still say if you’ve got a big clinical concern with a teen—let’s say they text you, “I’m cutting, I think it’s out of control, I’m feeling really anxious”—I’m going to call them immediately rather than text, and most likely try to get them in to see me if I can. So it’s not that I’m sending long texts back and forth about that type of behavior. I’m really using it as a way to communicate to stay in touch.

Other ways that teens will keep me informed, they’ll often text me, “Saw an article you should be reading, doc,” or “thought you’d like this.” Those things are important because it is a reciprocal relationship. I’m largely involved in educating young people, but they help me a lot, too, and I get a lot from them.
RZ: For therapists in private or group practice who don’t work for large organizations, is there a downside to texting? For example, what if you lose your phone?
LP: I think that gets back to just have their first name, maybe an initial afterwards, but no way that they could really be identified. And if they’re very sensitive texts you can also erase them, although we all know that things are out in the cloud forever. So be aware that that information is out there.

This is also one of the things that you should discuss in the first session. I often discuss with my patients my availability, how they can get a hold of me, so they know that I will have their first name on the cell phone, and their phone number, and that I’m fairly easily accessible. I believe one of the reasons I’ve been so successful with teenagers and their parents is because I have very good accessibility. I take my cell phone all over the world when I travel. I do have somebody on call to cover, but I’m available in that way. But let’s say that cell phone is lost, and I’ve never lost my cell phone, though I fear it all the time, Rachel. I’m looking around for it and I worry about memory loss and loss of cell phone. But if it’s lost I think you have to alert the patients, especially those that you’re texting with, that there is a risk and the cell phone was lost. Most of them are not that concerned about it because their whole name is not out there. There’s not a lot of information out there. But I think it’s important to do that. But I also know from forensic cases that you can actually remove data from a distance off of a cell phone, which might actually be required if you work for a university or large organization.

Sexting

RZ: Technology and internet use seems to be a primary source of conflict between parents and kids. Do you see this a lot in your practice? And how do you go about addressing it both with the parents and with the children?
LP: Very young kids, 9, 10, 11, 12 are using the internet or videogames or other media for large periods of time, and parents are often seeing symptoms—kids are struggling with school, their concentration is impaired, and they’re not engaged in other activities or relationships.
Some boys are being prosecuted for texting sexual photos and parents of boys are very concerned about this.
I think that that’s a very important area to be aware of. Parents need education around the signs to be looking out for when kids are struggling. We need to think about their media profiles, how much time are they on TV, how much time they are playing videogames, how much time are they on internet, and what different modalities they’re involved with.

When families come in, I’ll have both the kid and the parents keep a journal and write their feelings down about what’s happening when there’s a confrontation at home regarding this behavior. And all of that comes back into the session. I often will use the family modality to meet at that point and we’ll talk about what’s going on in that type of interaction.

The other area that comes up frequently with teenagers is sexting—texting sexual material. During the past five years I would estimate I’ve had 50 teenagers referred to me who have been involved in sexting activities.

In general, the girls are involved in sexting pictures, nude photos of themselves that have caused some great difficulty. These are often selfies where the girls will hold the camera out in front of themselves, often in their bedroom or bathroom, sometimes partially clothed, sometimes not, and then they’ll text the photo to a friend or friends, and then it gets texted everywhere. That type of interaction is very important to pay attention to and I’ll generally work with the teenage girl alone and talk with her about what happened. The feelings around sexual development are very private and tender, and it’s deeply shocking that this is suddenly exposed to a large group of people. I work with the family around this behavior, too, and sometimes will meet with parents alone to help them understand why this behavior might have taken place.

I would say a smaller number of the sexting cases, roughly 20%, are boys texting nude photos of themselves, but they’re mostly texting nude photos of girls. There are also laws involved with this and I’ve been involved with the FBI and other law enforcement officials around how to handle these cases. There’s awareness in high schools now that they have to report these cases when they discover that boys are texting sexual photos of girls. Some boys are being prosecuted for texting sexual photos and parents of boys are very concerned about this.
RZ: How do you handle those cases when they come in?
LP: First be aware of the legal ramifications. Second, encourage them to get legal advice, because we as therapists can’t provide all of that. Third, I often will meet with the boy individually and try to get a sense of what happened and work with them around that. Many boys are shocked that this has happened. They may have thought they were doing what the other guys at school were doing, that it was cool, they were getting more status. But I’ve also seen boys who’ve had long-standing problems and the texting of the sexual photos is connected to other sexual difficulties that they’ve been struggling with. They may have been molested. They may have molested another person. So to be aware of that, to be open to hearing about that is very important.

Parents of boys are often very angry about this process. They feel that the boy is at a disadvantage because though he sexted the photos, it was the girl who originally sent the photos out so it should be her responsibility. Helping the parents see that we have to take a deeper look at what’s going on with their son under these circumstances is really, really important and not easy to do. You have to stay open to their feelings about their boys being scapegoated, but at the same time point out this is something we have to pay attention to.

The intersection of online work and sexuality is really a key area to focus on, to get as much help as you can as a therapist. Sometimes if I have a question, even today I’ll go to another therapist that I think has more expertise in this area and get supervision.
RZ: Are there particular resources for therapists who want to learn more about how they can be better clinicians when addressing something like sexting?
LP: Yes. I’m not going to toot my own horn about this, but I’ve written an article that’s online about sexting and working with clinicians that I think is very helpful. It has a literature review of a couple of cases and ten guidelines for parents and therapists around this area. There are not recent and current books because it’s a fairly new topic, but I think it’s something we’re going to see more of in textbooks and articles. A lot of young psychologists’ dissertations have been done on sexting, and those are valuable if you can get a copy and read them.

Learn to Like Kids

RZ: What advice do you have for beginning clinicians treating kids and teens?
LP: The most important thing about doing this work is that you have to be knowledgeable about your own childhood and adolescence. You have to have thought about it, its impact on your own development, the issues that you might bring to the work, questions and preconceptions about it, etc. I encourage almost all therapists to have their own experience in therapy and to explore some of these issues.

Second, what helps the most in this work is really loving children and adolescents. Having a strong love for that age group or working toward it. Let’s say you don’t love it, you’re kind of afraid of it, maybe you’re going to work toward a passion in that area. You’re going to learn why you’re afraid of that age group and you’re going to try it out and get supervision with somebody who is really very good at it. It is a group that is fun to work with, is very challenging, and can really be a growth opportunity for you as a therapist. But I’d say try to develop a passion for it. Learn to like kids. Learn a lot about child and adolescent development. I think either being a parent or playing a role with your nieces and your nephews and other kids is really important.

Third, you’ve got to be able to work with parents. When I was younger and starting out one of my mistakes was that I thought I knew what it was like to be a parent long before I was a parent, and I was often angry with how parents treated kids. By now I’ve gone through decades, I’ve had my own kids and I see it differently. I see myself as a valuable resource to parents and I have great empathy for them.

Sometimes I have to do very difficult things with parents.
Once I had to climb through a glass window when a young mother was holding her new baby and was psychotic and trying to do something to the baby.
Once I had to climb through a glass window when a young mother was holding her new baby and was psychotic and trying to do something to the baby. The police were there and there was obviously a lot involved with this, but we had to save the baby and rip the baby out of the mother’s arms. So there are things that you often have to do in this work that are not very easy with parents and I think I’ve learned how to do those with concern and empathy as I’ve grown older and become an older therapist. But at the beginning I would say stay open to the work with parents. Keep your eyes open. Realize you don’t know everything.

Fourth, Don’t just accept a dogma. Try to integrate and construct your own idea of how to do the work. I talked earlier about the five perspectives I use but think about those that work best for you, yourself, as a therapist, and with the patients you’re working with.

Lastly I’d focus on the first session and developing a good alliance with kids relatively quickly. That first session is really important—how you connect to your passion, staying open, not being judgmental. Watching tapes of other therapists do first sessions can be really helpful, or being in a study group where you share information about your sessions with kids. Or even observing preschool teachers, who are often very good with kids, welcome kids into the classroom, integrate them, and get them playing and involved in activities. All of that adds to our abilities in that area.
RZ: What do you think has helped you become a better clinician?
LP: Years of experience have helped a lot. Reading widely has helped a lot. Having my own children has helped a lot. I have four—two step sons and two daughters—and I’ve learned from all of them. It’s not been easy.

Supervising younger therapists has also been really helpful, because I’ve listened to their problems and I really try to figure out what they’re going through, which keeps me more in touch with what it’s like to start this work. This is not easy work. There’s a lot to learn. We make a lot of mistakes in it, but we do a lot of good.

Maybe the last thing I’d say about it is I’ve been so impressed over all the years of working with adolescents how many return. They bring their own kids back for treatment. That keeps me in it more than anything—having the kids come back with their own children, and seeing that they’ve shared things I said to them. This is not everybody, of course, because I’ve had over the course of my career two adolescents who killed themselves. I’ve gone through a lot of difficult experiences, as have my patients, but I am impressed with this type of work and how much we can help kids if we stick with it.

It’s wonderful work that makes you feel very good about your life’s work at the end of it. I don’t see myself at the end of it, but I have talked with others, like James Anthony, a role model of mine who was a wonderful child therapist who worked with Anna Freud. When I was a very young student I had the opportunity of working with him in London. He loved the work and he still continues to teach me things—and he’s in his late ‘90s. He talks about having patients come back and treating the grandchildren of the children he saw. That is an amazing thing. It’s a chance to be very connected with others in life really.

Suicide

RZ: It sounds incredibly powerful to have had such a positive impact on someone as a teenager that they want to bring their own teenagers to you once they have had children. It also sounds incredibly powerful to have lost an adolescent client to suicide and I’m wondering if you feel comfortable talking about that a little bit.
LP: It’s a reason that a lot of therapists seek out supervision.
RZ: It’s admittedly my worst fear.
LP: I think it is for all of us. It’s not just the legal aspects of it. We all carry liability insurance and we’re worried about that part of it—but it’s also just the connection. I will say that I really remember these patients and their treatment very, very well because of going through this and thinking about it a lot. The first was a young man who killed himself when I was the director of the adolescent unit at UCSF.
RZ: How old was he?
LP: He was 19 and he had very severe bipolar disorder. He stopped his medicines when I went on vacation and then went into the woods and shot himself. I had arranged for somebody to cover me during this period of time. It was a short vacation, but still enough for this to happen. I’ve thought about it a great deal, of course. It’s changed the way I take vacations. I still take them, but I’m very alert, thinking about coverage and concern about these teenagers and children when I leave.

I spent several months working with his family. They had anticipated it more than I had and that surprised me. I went to the service and worked with them in a collaborative mode, which I did not charge them for, and they were very grateful. I’ve stayed in touch with them in some ways, though that happened I’d say roughly about 30 years ago now.

The other suicide was about 20 years ago and was a patient I’d worked with for years. She had a chronic psychotic condition. She was a very bright young woman and I had spent a lot of time with her. She had promised me that she would not harm herself until she was 30 years old, and then she killed herself not long after her 30th birthday. So she stayed alive working with me for years I think to try to get better, and we tried everything. Family therapy, medications—and it was clear that she was going to be living with a chronic psychotic illness that was incredibly painful for her.

I still think about her all the time. I think she helped me in many ways to understand that sometimes we work with individuals who are suffering so much that from their perspective, their life is really not worth living.
Sometimes we work with individuals who are suffering so much that from their perspective, their life is really not worth living.
We can discuss that with them, we can work to help them, many different things can be done, but there are limits to the work that we do. She left me a number of drawings she drew and painted. I think a lot about her family. I worked in much the same way that I described with the earlier boy. I met with her family and had contact with them for a long period of time. I still think about her all the time.
RZ: I bet. I think this is particularly important to talk about for young therapists who are, as you mentioned before, maybe put off entirely by cutting because they’re so scared of it, or don’t want to work with suicidal clients because they’re so afraid of losing a patient. It’s really valuable for me as a young therapist to hear you talk about having gone through this worst fear with a couple of your clients and not only did you get through it, but it made you a stronger clinician ultimately.
LP: I think ultimately it did. Of course, a big part of this was questioning what I had done with them and if I had made the right decisions.
RZ: Of course.
LP: Had I done something wrong?
RZ: That’s natural.
LP: I think any therapist who has had a patient suicide question their work. Families question their interactions with their children after suicide. We all think about it. I work with many teenagers, especially here in the Bay Area, who have had friends suicide, and the young teens question what they could have done to help their friend. It’s not only us as a group of therapists who question ourselves, but it’s really the world that comes forward to question itself around suicides.
RZ: It seems like that’s the first question people ask friends, family, and therapists alike: What could I have done? Could I have done something different or better? And I think that is a real challenge.
LP: It’s natural and appropriate to ask those questions and explore them, but it’s also important to really understand that there are limits in life to what we can do. It’s important in this line of work to talk about this aspect of it.
RZ: That’s a very realistic and compassionate perspective. Thank you for your time and for your wisdom.
LP: And thank you for your good questions, Rachel.

Infertility on Both Sides of the Couch

Posted on by rezendevknowfully.com

Family Planning

"When are we going to start a family?" asked my husband.

I felt a boa constrictor wrapping around my throat. For months now, the topic of children had evoked tension, leaving us powerless and detached from each other. The argument had become a tradition on Saturday mornings. We would sit in the living room in an awkward silence, avoiding eye contact, until my husband pierced the hush with what he deemed a simple question about our future.

My husband was comforted by having a plan. Three years into our marriage—my second—we were in our mid-thirties, established in our careers, and financially stable. For him the next step in our lives was to start a family, but his need for a plan set off a vicious cycle. I felt ignored and disrespected in our relationship and couldn't justify bringing a child into a fractured marriage. I craved connection and love and was not willing to commit to having a child until we resolved our relationship problems. My resistance made him more insecure and unsure of his focus, and he would ask me about starting a family as a way to relieve his anxiety. Unfortunately, his persistence pushed me away, leaving me feeling trapped and controlled and leaving him stranded without resolution.

“I felt immense pressure both from him and from society to conform and have children. Gradually, I isolated myself from my husband and emotionally shut down, as my sense of self and my voice vanished.” Feeling alone with no one caring about my thoughts and feelings, I believed I was not enough for my husband and that he had married me solely for procreation. Meanwhile, I was inundated with inquiries from our family and friends about when we would be parents.

My mother-in-law often phoned my husband's siblings to convey that her children were failing her since she did not have grandchildren. While growing up, my husband's mother talked a great deal about heirlooms—each piece of jewelry or china was a link between past and future generations. Grandchildren were an essential part of keeping the family traditions alive and to not have them meant the family had failed. She made it clear that my husband was not enough, just as I felt I was not enough as his wife. My resistance to the "plan" was a clear message to him and his mother that I would not conform.

His side of the family was not the only problem. My stepfather had the impression that all couples wanted children. He frequently dropped hints about what a joy they are, pointing to his grandson and saying things like, "See, aren't these fun and not so bad?" For him, family represented connection and closeness. Initially this was endearing but it soon became annoying.

While at a party, I declined an alcoholic beverage, which ignited rumors that I might be pregnant. When I heard the gossip, a wave of heat washed through my body. How dare my friends speculate? It was as if I were starring in the reality show, "When Will Wendy Pop One Out?"

The Family System

In 2005, I started therapy with a psychotherapist who practiced from a Family Systems model, the premise of which is that the family is an emotional unit—systems of interconnected and interdependent individuals, none of whom can be understood in isolation from the system. Over the course of my therapy, I came to understand that my symptoms of sadness, loneliness, and detachment were a consequence of the recurring patterns and interactions within my family. The sense of powerlessness I experienced evolved from my marital dynamics, my family history, and the cultural expectations of a woman in her thirties.

My parents divorced when I was thirteen years old. I was an unplanned pregnancy and the reason my parents had married. It was bad enough that I was a mistake, but I resented my parents even more for their divorce, and the struggles that I encountered during my teens trying to navigate through the turmoil of their divorce played a role in my delaying the start of a family.

During my first marriage, I was enrolled in graduate school and wanted to wait until completing my program to start a family. We would have been in our early thirties by then and my ex-husband wanted to be a father sooner. He had an affair and decided to leave. This time around I wanted to make sure I was in a healthy relationship, that we were not introducing a child into a doomed family. I did not want to recreate my childhood trauma for my own children.

At Christmas in 2006, my stepsister announced over dinner that she was pregnant with her second child. I broke down sobbing at the table. A hush blanketed the room as everyone stared at me. Although embarrassed and humiliated, I could not stop crying.

Two weeks later, my stepbrother shared the news about his wife's first pregnancy. My sister-in-law had planned on not having children but had changed her mind. I was consumed with feelings of betrayal. I was my own childless island in a world that demanded parenthood. I dove deeper into despair.

Couples Therapy

My husband finally realized that our marriage was at stake and agreed to couples counseling, but I wondered whether it was too late, as by this time my rage had evolved into numbness. I recalled our minister's marriage sermon encouraging us never to throw in the towel when things were broken, but another part of me was tempted to do just that. “You don't need a man, you survived a divorce,” the voice said. "Trust me, you’ll be much happier single." I contacted therapists, but they either did not return my calls or have any openings for new patients. Was the universe telling me it was too late for my marriage? The battle inside me grew more crushing until finally after three months, I found us a therapist.

Couples therapy became our new Saturday tradition. My husband had never been to therapy, hated conflict, and had always made choices with tremendous caution, sometimes over the course of many years. Therapy for him was about finding ways to manage his stress. If he knew when we would have a baby, he could plan accordingly. Should we reserve a slot at the day care now, since there could be a waiting list for a couple of years? “Should we start putting money into a college fund? Or should we begin grieving about not having a child?”

For me, therapy was about maintaining autonomy and establishing a healthy marriage. I wanted the freedom to make choices within the marriage, but feared he would leave me if I did not have a baby. It felt like an ultimatum. And for my husband, despite his discomfort about the therapy, he began utilizing what he learned about me. He realized that asking questions about starting a family was torture to me, so he stopped asking. As a result the perceived threat of the ultimatum faded.

In my professional life, I had wanted to open a private practice. Should I be saving money for the grand opening of my business or for a divorce? The marriage had to be healed before the practice could be born.

During our treatment, I wrote my business plan. My husband was proud as a peacock and bragged to others that I was making my vision come alive. I opened my practice in mid-2007, feeling finally alive after an emotional coma. When I purchased the new office furniture, my husband questioned the size of the sofa, believing it should be larger. Prior to our therapy, this question would have offended me and I would have felt undermined in my judgment. Instead, I confidently explained that the sofa worked well in the room. Understanding his tendency to err on the side of caution, I did not personalize.

He went ahead and assembled the office desk and filing cabinet and moved the sofa into the suite. To this day, he tells others it was a good thing that I ignored his advice because the sofa barely fit into the space. This was the sexiest thing he had ever done. Life was wonderful. I was enough as a wife and my business was thriving. Without pressure to conform and have a child, I decided to go off the Pill.

For three years we did not get pregnant.

Mystery Solved

From the time I was a teenager, I had a history with difficult menses. Like clockwork I got my period every 18 days and bled for 10 days, uncertain what PMS symptoms I would experience. My blood flow would be heavy, dark and impossible to keep up with, changing my tampons and pads every four hours and during the night bleeding onto my bed sheets. At times to get through my school day, I took over-the-counter pain pills for heavy cramps, lower back pain, or headaches. For my peers and teachers I maintained a pleasant façade, but what I wanted was to retreat into a corner and savagely eat raw meat and growl or be in my bed weeping and eating salty chocolate. I applied copious amounts of zit cream to my face attempting to fight a hopeless battle with breakouts. My bra and pants would restrict my breathing because I was bloated. During my annual exams, a range of doctors had explained these symptoms were stress-induced by my parent’s divorce, my divorce, and graduate school, and had prescribed birth control pills.

Now while off the pill, my life was good and I had no stress on which to blame the problem. I was receiving holistic care and yet was still physically and mentally suffering. Why was I having the same problems I had as a teenager?

I made an appointment with an OB/GYN specialist with little faith that I would find answers, but for the first time, a medical doctor was eager to learn what was going on with my body. He believed my symptoms were pathological and not related to stress and ordered blood work and an ultrasound.

A month later, the OB/GYN nurse escorted my husband and me to the doctor's office for my consultation. He was perusing my test results with a look of concern on his face when we walked in. Gazing up at us, he said, “I am unsure where to begin.” The blood work was perfect. The ultrasound, however, revealed why I’d suffered for decades and had not become pregnant during the past three years. Both of my ovaries were smothered in various types of growths (some were thyroid tissue), my fallopian tubes had blood, my uterus had polyps and was malformed, and as a result I was unable to carry a pregnancy. The doctor recommended a full hysterectomy.

My symptoms were not stress related. They were not my fault. A sense of calm flowed over me; my eyes welled up with tears. My husband took my hand and asked questions while I continued to absorb the news.

Judging Claire

Meanwhile, my professional life was evolving beautifully. I had the satisfaction of seeing my vision coming to life, and I loved owning my own business. For several years I had been seeing Claire*, a married and successful professional in her mid-thirties with a significant history of depression and anxiety. She had a warm sense of humor and loved to learn about herself. During the first couple of years working together, she feared her future children would be genetically predisposed to suffer from similar aliments and struggled between the desire to feel a child growing inside of her and her desire to adopt.

During the course of our therapy, Claire forgave herself for having a diagnosable mental illness; she realized the illness did not define who she was. She began to consider that she had plentiful and warm offerings as a mother and decided to conceive naturally. After a year of not getting pregnant—this was around the same time I went off the pill—Claire was diagnosed with infertility.

By then I was secure in my marriage and waiting to see if I got pregnant, but I struggled to maintain my alliance with Claire. Still vulnerable with my own triggers, I had my own opinion about the infertility treatment process and our sessions evoked strong emotions for me.

One in ten couples struggle with infertility issues. According to the medical model, infertility is a disease of the reproductive organs, and usually the first option in treatment is a daily injection of medication to stimulate the ovaries to develop eggs in the follicles (the structure in the ovaries that contain developing eggs). The side effects can include bloating, weight gain, headaches, and nausea. If this is unsuccessful, IVF (in vitro fertilization) begins, in which eggs are surgically removed from the ovaries and combined with sperm. Weekly ultrasounds and estrogen blood levels drawn twice a week assist the doctors in determining the best time to retrieve the eggs. The last resort for infertility treatment is the egg donor cycle, where an embryo formed from another woman's egg is transferred to the uterus of the woman trying to conceive. More coordination and time is involved since two women are being monitored for transfer.

As I witnessed Claire’s physical and emotional agony and the suffering in her marriage it caused, I began to judge her harshly. “How could she brutalize her body from treatments and spend so much money to conceive and carry?” I hated her for choosing to participate in the infertility treatment process and holding faith in the medical model. I felt lonely and betrayed that she conformed to society's pressure to attempt pregnancy at all costs. I wanted her to join me in rejecting this awful and debilitating process and to redirect her energies toward adopting a child.

Though I had every intention of becoming a mother, once I realized I was infertile, I never considered infertility treatment or adoption. Both seemed too unpredictable and a setup for repetitive grief and loss. It was disturbing to have such an intensely negative reaction to a client, so I began to repress these feelings and thoughts in an attempt to protect both of us. In the process, however, I became increasingly disconnected from Claire.

What was happening between us put strains on my belief in the humanistic approach, which emphasizes that we are in control of our destiny, our choices, and the discovery of meaning for our life’s narrative, and makes use of the relationship created between the therapist and patient as a catalyst for exploration and change. A safe arena was vital for Claire to share her narrative and to discover the meaning of her experiences—the energy in the room could then provide an atmosphere conducive for healing. Regardless of my opinions and beliefs, I wanted to support her in her destiny and choices. But did I have the freedom to accomplish this?

As a therapist, I participate in a weekly supervision group. While disclosing the pain of my challenges with Claire, I shared about my sensitivity to the fertility topic and my beliefs about the infertility treatment process. My peers validated me and understood why I felt threatened, but also challenged me about my countertransference and helped me to work through it. Other colleagues were offended by the infertility treatment process and called my patient "greedy." A few of them had been adopted, and were exasperated that it wasn't Claire's first choice. Others were sympathetic with her plight and could relate to her need to biologically conceive a child. Through the group process, I was able to witness all the different parts of myself being voiced through my peers, and I felt safe enough and free enough to get to some of my own core fears and doubts about infertility. Ultimately this freed me up to be much more present with Claire in the coming months.

Working Through and Joining With

During a subsequent session, Claire tearfully shared how painful it was to have no control during the infertility treatment process. My inner voice whispered, Ask her if she feels she has the choice to stop the infertility process. Before working through countertransference with my supervision group, I would have suppressed this voice, believing it was my own “stuff" and would not be helpful to Claire. Now my heart pounded; I couldn't help but speak up: “Who says you need to continue to fail with the pregnancy attempts?” Something in the room shifted. After a pause, Claire affirmed, "I could stop." I exhaled. We had finally found a moment of empowerment and connection.

Claire continued to participate in the infertility treatment process, and I joined the emotional roller coaster with her. This freed up much more space to explore her process and mine.

Therapy is not immune to the disruption of the infertility treatment process. “The scheduling of appointments revolved around Claire's menstrual cycle and she cancelled appointments due to the side effects of medications and clinic appointments.” We had lapses between appointments while waiting for the doctors to contact her for the next treatment cycle. All of this meant that I needed to figure out what would take care of me during her infertility series. That involved answering questions such as: How do I cope with my anger? How do I keep from getting stuck in her holding pattern of waiting? Do I charge for missed appointments?

With the ongoing support of my supervision group, I continued to explore my emotional reactions. Claire and I collaborated about payment for missed appointments—she willingly paid and the joint conversation made her an active participant in an otherwise helpless period. The medical doctors had no clear diagnosis about why she didn't get pregnant for three years and she suffered continuously from a sense of loss. She had always dreamed of being a mom and having a family and now she had to face the fact that it might not happen.

Claire tried to detach from her emotional turmoil and did her best to function at work, but the clock ruled her while she anticipated lab results. Her job performance began to suffer and the cost was guilt, shame, and embarrassment. Work became heavy and dreadful. Her depression ignited, leaving her brooding in isolation and sleeping for 17 hours or more every day. Her “should” cognitions were in overdrive and kept her paralyzed.

The Breakthrough

"I'm afraid you're mad at me for the last minute cancellation last week," she said. "I'm failing at everything." In fact I was angry about the appointment. Missed appointments touch on my vulnerability around not being recognized as valuable. But our agreement for her to pay for missed sessions, combined with my own awareness of the reasons behind my countertransference, made it possible for me to process my response outside of session and bring my full attention to figuring out what she was enacting and what it meant for her. I responded, "You think you should be able to manage life better. But things are dropping all around you: your relationship with your husband, your work, your friendships, and especially not getting pregnant. You're feeling so alone." I watched her reach for a tissue, look down at her lap, and wipe her tears. "What are the tears saying right now?”

In her soft voice, Claire answered, “I'm afraid my husband will be angry at me for not controlling my emotions. My anxiety is through the roof. I want to be in my bedroom with the covers over my head. It's unfair to expect my colleagues to do my work. I want to be with my friends but it hurts too much because they have babies or are pregnant.” She believed she needed to be perfect and worried about disappointing everyone around her, including me.

But this conversation about failure and disappointment positioned Claire to begin healing her marriage and bring her husband, family, and friends back into her life. Through addressing her loneliness, Claire articulated her envy about her friends being pregnant or having newborns. “She felt conflicted about whether to maintain her connections or isolate herself because it was too painful to be subjected to swollen bellies and to the innocent scent of newborns.” She also acknowledged she pushed her husband away because she did not want to be perceived as a "burden." He had a demanding job that made him unhappy, but it provided them with medical insurance to pay for the infertility treatment. She secretly fantasized about him attending medical appointments with her and being readily available to abruptly leave work to provide comfort when she received bad news. I encouraged her to share her emotional burdens with her husband, to let him feel her burden, as that is part of what it means to be intimate with another person. She began to feel less guilty and apologetic about her struggles and to share the craziness of the process with him. They became closer and her sex life began to thrive again.

Over the two-year period of her IVF treatments, Claire's visits to the reproductive health center would evoke a sense of helplessness and lack of emotional safety. She often felt rushed because she didn't get satisfactory information to her questions, and the clinic became increasingly more uncomfortable and sterile. As our work progressed, she was more assertive and less apologetic about demanding the attention of the nurses and doctors until she was satisfied with the gathered information. To increase her comfort at appointments, she brought her own pillow and blankets.

Unfortunately, Claire was given a lot of unhelpful advice from her own support system of family and friends, even medical doctors. She was told, for example, to "just relax" because her stress could be interfering with the infertility process. In the therapy sessions, we worked on how to handle unwanted and sometime hurtful advice and not absorb the harmful implications. When she deemed it appropriate, she informed people about what would be helpful or harmful.

Different Kinds of Pregnant

When the IVF failed, Claire opted for the final remaining option: an egg donor. Our sessions were spent with her describing how a donor was selected and the various reasons they donated their eggs. It was a surprisingly fun process for both of us.

After her second cycle with the egg donor, she curled up on the sofa in my office, hugging a pillow with a distant look in her eyes. Her lip trembling, she said, "For four days, I was pregnant. Now, I am pissed off.” Her rage demonstrated no guilt. She did everything right but was unable to carry her first pregnancy.

The following month, her third attempt was successful.

One day, well into her second trimester and beaming with life, Claire effused, “My boobs are huge!” She shared her ultrasound pictures of her healthy son and we talked through her stress about finances with the arrival of her baby. In her desire to save money and prepare for the baby's arrival, she requested a break from therapy. I encouraged her to go and create a loving home for her son. Tearing up, she said, “I can’t believe I can hear ‘my son’ after all of this.” Claire would soon be a mother.

Through quite a journey, Claire and I mirrored each other for a couple of years. My marriage and business were at last breathing life. I scheduled my hysterectomy, knowing my body would be cured. I learned a valuable lesson: Psychotherapy is a fertile process.

* Claire's name had been changed to respect confidentiality.

Violet Oaklander on Gestalt Therapy with Children

Posted on by rezendevknowfully.com

An Unorthodox Notion

Rafal Mietkiewicz: Violet, what makes me curious is that you are trained as a Gestalt therapist and people connect you with Gestalt therapy, but Gestalt therapy was mainly considered, at least here in Europe, to work primarily with adults. How did you find your way to do Gestalt therapy with the kids?
Violet Oaklander: I was already working with emotionally disturbed children in the schools when I got interested in Gestalt therapy. One of my children became very ill and died. I was very depressed. My friend was going to Esalen Institute to be in a group for a week with Jim Simkin, so I went with him, and I was so impressed with what happened to me. It made such a difference for me that when I came back, I started training in the Los Angeles Gestalt Therapy Institute, and while I was training, I thought, “How could I apply this to children?”It seemed very organic to me. Fritz Perls talked about the body and senses and all of that. I found that it fit my work with children and child development. And of course, over the years, I started using a lot of creative media, like drawing and clay and puppets and music, because that’s the only way it would interest children. But behind that, the basis of my work was Gestalt therapy theory and philosophy. And I developed it more and more as time went by. That’s how it got started.

RM: That’s what you wrote in your book—that children already know, but they are wearing special glasses, so you just take the glasses off?
VO: Yeah. I have many stories working with kids. I’m trying to think of when I first started. When I first began, I was working in the schools with maybe a group of 12 children. And they were older—maybe 12 and 13 years old, all boys. These were kids that didn’t make good contact; they didn’t connect very well with other children.I started doing things that were sort of different. I would have them finger paint. I’d line up the desks so it was like a table, and they’d stand around the table finger painting. At first, they didn’t want to do it. “It’s for babies.” But while they were finger painting, they would talk to each other, make really good contact. And of course it was important to establish boundaries—what they could not do and what they could do. So that was very clear.

Another thing I started doing was bringing in wood, and they would build things. These were children who weren’t allowed to hold a hammer or a saw because they were very disturbed children—it was dangerous. But I saw other classes had wood and got to build things, so I got that. And they had rules: they couldn’t swing the saw or the hammer, or else they had to sit down that day.

I wouldn’t let them build guns, but they could build boxes and birdhouses, and they would work together because they had to share the tools. You would not believe they were emotionally disturbed children. They were making such good contact and really enjoying this. I did many things like that.

RM: You look like you really enjoy your work.
VO: Oh, yeah. I even had the old empty chair. I had two chairs in the front of the room, and when a kid would get really upset and angry, I would have him sit in the chair and talk to the empty chair.And the child that he was angry at might be in the room there, but he would be talking to the empty chair. And then I’d have him switch and say, “Well, what do you think he would say back to you?” and it was so amazing because he would realize that he was projecting. They didn’t know that word—they didn’t have that insight. But they could see that they were projecting their own stuff on the other boy.

It would be so amazing. They would come into the room and say, “I need the chairs.” They would talk to a teacher who had yelled at them outside. They would talk to that teacher, and then they would begin to see that the reason the teacher yelled at them is because they did something they weren’t supposed to do. They knew this, but when they sat in the empty chair, they’d say, “Well, I yelled at you because you hit this other boy!” And then I’d say, “Now, what do you say to that?” They’d say, “Yeah, I guess I did. I did do that, yeah.” It was just little things like that that I began to do, to experiment with some of the techniques.

After I left teaching and I was in private practice, I thought a lot about what I was doing, and I started developing a therapeutic process that was based on Gestalt therapy, beginning with the “I-thou” relationship, and looking at how the child made contact, and then building his sense of self and helping him to express his emotion.

RM: It seems like you combine a bunch of techniques and approaches in your work—like expressive art therapy or child group therapy.
VO: Yeah. We do a lot of sensory work. I mentioned finger painting—anything they can touch. Clay is incredibly sensory and evocative. If it seems like they need to do some movement, we do that. Sometimes we play creative dramatics—charades—because to show something, you have to really be in touch with your body. We might start with fingers: “What am I doing? Now, you do something.” And they think of something and they have to use fingers to act it out.And then maybe we do a sport—they have to show with their body what sport they’re playing, and I have to guess. It might be obvious, but they enjoy doing that anyway—maybe catching a ball or hitting with a bat or tennis racquet. They have to get in touch with their body to do that.

The projective work with drawings and the clay is also very important, because this is how they can project what’s inside of them and then own it. One example is a boy who had a lot of anger but he kept it inside. He presented himself as just very nice and sweet, and nothing was wrong with his life. It was only after I asked him to make something, anything—I usually say, “Close your eyes and just make something, and then you can finish it with your eyes open”—he made a whale, and told a whole story about how the whale had a family—a mother and a father and sister.

What I always do after they tell the story is try to bring it back, so I said, “Well, does that fit for you? Do you have a family like that?” He said, “No, my father lives far away because he and my mother don’t live together. I never see him.” “Well, how do you feel about that?” And then we started talking about his father, which he would never have mentioned, and all this feeling came up. It’s very powerful.

The First Session

RM: How do you approach the first session with a child?
VO: I always meet, if possible, with the parents and the child the first session, because I want the child to hear whatever the parents tell me. I don’t want the parents to tell me things and have the child not know what they told me.Even if the parents are saying bad things about the child, the child needs to hear what I hear from the parents.

Usually in the first session, I have a checklist, and very often I would put it on a clipboard. First I would say, “Why are you here?” and all that. Then I would ask the child these questions. “Do you have a good appetite? Do you have bad dreams?” A whole list of questions.

Sometimes the parent would chime in, but mostly it’s to the child. It was a way of really making a connection with the child. Of course, if they were very, very young, four years old, maybe I’d still ask these questions, but not everything—and use language they could understand.

That’s always pretty much the first session. But if there are no parents involved—because I saw many kids who were in foster homes or group homes—the first session is an important one to establish some kind of connection or relationship. Sometimes I’d ask the child to draw a picture on that first session. I’d ask them to draw a house-tree-person. But I wouldn’t interpret it. It’s not for interpretation. It was to say to them when they were done, “Well, this picture tells me that you keep a lot of things to yourself. Does that fit for you?”—because maybe they wouldn’t draw many windows. And they usually would say “yes.” Or, “This picture tells me that you have a lot of anger inside of you. Does that fit for you?” If they’d say, “No, I’m not angry,” I’d say, “Oh, okay. I just need to check out what I think it tells me,” and we would have that kind of a session.

I did that once with a very resistant 16-year-old girl who at first said she wouldn’t speak to me. And when we finished, she wanted her sister and her mother to come in and do that drawing. So it’s a way of connecting.

But we don’t always do that. If it’s a child who is very frightened—I had a girl, for instance, who was very severely sexually abused for many years, and it finally came out when she was about 11, and she was removed from the home. So she was in a foster home, but the foster mother was very devoted to her and came in, too.

But she was very, very frightened and didn’t want to talk to me. So in the beginning we would take a coloring book, and we’d both color in the book. And we wouldn’t really talk about anything. I’d say to her, “Should I use red for this bird? What do you think?” and just begin to connect with her that way. Pretty soon I was asking her, “Well, what do you think the bird would say if it could talk?”—that kind of thing.

Pay Attention

RM: It’s my guess that you don’t really diagnose kids in clinical terms.
VO: No. I mean, sometimes I would have to for an insurance company. But it’s a matter of seeing where they’re at, where they’re blocked. I had one boy who walked very stiffly all the time. He was 11 years old. And I thought, “Maybe we need to do something to help him loosen up before we even talk about his feelings”—that kind of diagnosis.
RM: So, you don’t find clinical diagnosis useful in therapy?
VO: Not very much, no.
RM: You trust in what you see and what you feel about the kid.
VO: What I see, yeah.If, for example, the child has a lot of difficulty making a relationship with me, that’s what we have to focus on, because I can’t do anything unless we have that relationship. Sometimes children have been very hurt and damaged so early, they have trouble making a relationship. So we have to figure out how we could do that.

I used to see a lot of adolescents who were arrested by the police because they had committed a crime. I was involved in a program where they would send these children to counseling. It was a special program they were trying. So this one girl came in. She had to come—she had no choice. She was 14. She wouldn’t look at me, she wouldn’t talk to me. She just sat there. Naturally when a child does that, it makes you have to come forward more. Well, it didn’t work. So I thought, “Maybe I cannot see this girl. Maybe I have to refer her to another person.”

I went out into the waiting room the next time she came, and she was reading a magazine. I sat down next to her and I said, “What are you reading?” She flashed the cover at me. I said, “I didn’t see it,” so she held it up.

RM: And that was the beginning of contact.
VO: Yeah. Already we were making contact. And it was a music magazine about different groups. I said, “I don’t know anything about that. Could we look at it together?” So we went into my office and looked at the magazine, and she was telling me about the different groups. It was mostly heavy metal. And she was all excited, telling me about the groups and which ones she liked.We tried to find the music on the radio because I said, “I don’t know what it sounds like.” We couldn’t find it, so she said she would bring in a tape. The next week, she brought it in and we listened together. Some of the songs were so amazing—all these feelings and anger. So we just started working with that. And we had a relationship.

But we need to do that—start with where they are. Pay attention. I wasn’t paying attention in the beginning. It was only when I thought, “What am I going to do?”

RM: So apparently the child therapist must be very in touch with his own senses. I guess it’s more important than clinical knowledge.
VO: I think you’re right. You have to know things, but that’s most important—to be in touch with yourself. It’s not easy to be a child therapist. An adult comes in and says, “This is what I want to work on,” or, “This is what’s happening.” When a child comes in, she doesn’t have a sense of what she needs to do. And you have to talk to parents, and you have to talk to teachers, and that kind of thing, too. So it’s different.
RM: Do you do something particular to help bring each session to an end—to help bring the child back to “regular life?”
VO: I think the job of the therapist is to help the child express what’s going on inside. But I notice that most children will only express what they have the strength to, and then they get resistant or they close down. They take care of themselves better than adults that way.But if they do open up a lot, we have to pay attention to what I call “grounding” them. I have a policy that children have to help me clean up whatever we’ve used. So we start cleaning up and then I’ll say, “Well, that was hard. Maybe we’ll talk some more about it next time, but where are you going now?” or “What are you having for dinner?” or “What did you have for dinner?” We talk about regular things to help them come back to ground.

RM: I know that Gestalt therapists hate “shoulds,” but using a paradox, are there any “shoulds” that a good child therapist should obey?
VO: Nothing comes immediately to mind, other than things I’ve already said. But speaking of “shoulds,” it’s worth noting that children have a lot of “shoulds.” People don’t realize that, but children are very hard on themselves. They’re split—there’s a part of them that’s very critical of themselves and then a part of them that, of course, rebels against that. Sometimes we help them understand that, especially if they are adolescents.
RM: Do you touch or hug your clients?
VO: Sometimes, but I’ll always ask them. I might say, “Can I give you a hug?” I don’t just do it. I have to ask them. Or I might put my hand on their shoulder. I can tell if they pull away that that’s not a good thing to do. Or sometimes we shake hands. We do a little bit—not a lot.

Working with Parents

RM: Do you often talk to parents?
VO: Oh, yes. This girl that I just mentioned, she lived in a foster home, and they didn’t care about her, so they weren’t interested. They just did what they had to do. But yes, parents come in. Every three or four weeks they have to come in with the child. Sometimes we just have a family session and I don’t see the child individually. It depends. You have to just decide which is the best way to go.
RM: We have agreed that it’s important for therapists to be in touch with their own feelings. What other qualities should one have to be a good child therapist?

VO:

You have to understand child development so you have a sense of if the child is not at the level she needs to be at. You have to understand the process. You have to be in touch with yourself. You need to know when your own buttons are being pressed—in psychoanalytic vocabulary, they call it transference. You have to understand when you have some countertransference, and to deal with that and work with that.

RM: In your Child Therapy Case Consultation video, a therapist is presenting a case of a child who is acting aggressively. You state at one point that kids can’t change their behavior with awareness. Is this why you often use art or have kids smash clay or other activities, versus just talk therapy?
VO: Yeah. What I mean is children don’t say, “This is what I’m doing to keep me from being happy or satisfied.” Even adults have trouble being aware of what they do to keep themselves stuck. So, with children, these drawings and clay are powerful projections. And it’s the way they can articulate what’s going on with them, without bypassing the intellect, but coming out from a deeper place. And at some point, they will own it. They will say, “Oh, yes, that fits for me.”When children feel stronger about themselves and they express what’s blocking, their behaviors change without having to force it or say anything. I mean, what makes children do what they do? All the behaviors that bring them into therapy are really ways of not being able to express what they need to express—of not being heard or not feeling good inside themselves.

RM: How do you measure progress in your work with children?
VO: It’s important to help the parents see the small changes, and not to expect complete reversal. And, of course, we have to work with the parents, too. Often the parents have a lot of difficulty with their own anger, and we have to work to help them understand how to express these feelings without hurting people around them. We can often do that in family sessions—help them to express what they’re feeling and what they’re wanting and what their sadness is about.One of the things I’ll say to parents is that I don’t fix kids. But what I do is I help them feel better about themselves. I help them express some of their deeper feelings that they’re keeping inside, and help them feel a little happier in life. We do many things to make this happen. And that’s what you have to look for. So when a parent comes in a month later and I say, “How are things going at home?” and the father says, “I think he’s a little happier,” then I know that this father has got it, and he’s seeing some progress here.

I am thinking of this was a boy of maybe 14 who was stealing, and the father wanted to send him to a military school because he couldn’t control him. There was a lot of reason the boy was like that, but that doesn’t help to understand the reason. It’s good to understand the reason why he’s like that, to help him change and be different.

So that’s how I look at progress. When they’re doing better out in life, they’re going to school and have some friends, and doing some of the things they have to do at home, and doing their schoolwork, then you’re seeing progress. They may not be altogether different, but they’re functioning in life.

The other thing that’s important is that it has to be at their level. Children can’t work everything out. They have different development levels. So the girl who was very severely sexually abused, we did a lot of work about that. But when she was 13, she had to come back into therapy for more work—things came up. They reach plateaus. They have to go out and be in life, and then maybe more things come up.

Becoming a Child Therapist

RM: Does it happen often that, when therapists work with a kid, the therapists’ trauma from childhood appears?
VO: Absolutely. That’s something one has to really know about—be in therapy, have a therapist. I have several people who come to me for supervision who are very experienced therapists, and that’s the reason they come. I think it’s really good for a child therapist to have somebody to talk to and consult with because it’s very difficult sometimes. You can’t always see what’s going on.
RM: How long does it take to be fully trained as a child therapist?
VO: Oh, gosh. For many years, I did a two-week training. People would come from all over the world. And sometimes they would get it in those two weeks, and other times they didn’t, so I don’t know. Two weeks is not enough, but it was the most that people could give of their time. Sometimes they’d come back two or three times to the training, but those were people who actually got it the most, because they were so committed to learning more.I can’t define a time. They have to have the experience of working with children first, I suppose, and understand about children. You have to have patience when you work with children. If one thing happens in a session—if they say, “I’m like that lion. I get so angry, just like that lion,” or whatever—if they say one thing, sometimes that’s it for a session. You have to be patient.

RM: What are the most frequent mistakes that therapists make when they work with kids?
VO: Usually what happens is therapists get stuck. They don’t know where to go next or what to do next.
RM: But why do they get stuck?
VO: Maybe they’re just not able to stand back and look. Sometimes, in a supervision or consultation, I’ll give a suggestion, and they’ll say, “Oh, of course, why didn’t I think of that? Of course, I know that.” They get too close to it and worry about doing the right thing. They’re afraid to make mistakes, really. I always tell them, “No matter what you do, you can’t really go wrong.”
RM: If you were to give the best advice to the young therapists about working with children, what would be this advice be?
VO: I might say if you’re working with children, you have to like children!

If you’re working with children, you have to like children!

What Keeps Me Going

RM: My last question is personal. How do you manage to keep so vital?
VO: You know, I’m 84.
RM: You don’t look it.
VO: I don’t know. I am who I am, I guess. I’m still working some. I have this foundation (The Violet Solomon Oaklander Foundation), and we’re having a conference this weekend at a retreat center, and I’m going to do a keynote. So every now and then I still do something like that, or conduct a supervision. That’s what keeps me going. I do a little writing. I read a lot.I lived in Santa Barbara, California, for 21 years. And my son, who lives in Los Angeles, decided I was getting too old to live there by myself. So he tore down his garage and he had a little cottage built, and that’s where I live now, in this little cottage behind their house.

I miss Santa Barbara. I had a lot of friends. I’d be more vital if I was back in Santa Barbara. But I am getting older, and I had a little heart attack this year—little. I’m okay. But I was in the hospital a few days. So it’s good that I’m near my son and my daughter-in-law.

RM: It is obvious for me that you, at 84, have still have so much to give to the others.
VO: Thank you very much for those nice words. I will, as long as I can.That’s what keeps me vital: just doing as much as I can, as long as I can. I just have to learn to take it easy.

The Path to Wholeness: Person-Centered Expressive Arts Therapy

Posted on by rezendevknowfully.com

When art and psychotherapy are joined, the scope and depth of each can be expanded, and when working together, they are tied to the continuities of humanity’s history of healing. —Shaun McNiff, The Arts and Psychotherapy

Part of the psychotherapeutic process is to awaken the creative life-force energy. Thus, creativity and therapy overlap. What is creative is frequently therapeutic. What is therapeutic is frequently a creative process. Having integrated the creative arts into my therapeutic practice, I use the term person-centered expressive arts therapy. The terms expressive therapy or expressive arts therapy generally denote dance therapy, art therapy, and music therapy. These terms also include therapy through journal writing, poetry, imagery, meditation, and improvisational drama. Using the expressive arts to foster emotional healing, resolve inner conflict, and awaken individual creativity is an expanding field. In the chapters that follow, I hope to encourage you to add expressive arts to your personal and professional lives in ways that enhance your ability to know yourself, to cultivate deeper relationships, and to enrich your methods as an artist, therapist, and group facilitator.

What is expressive arts therapy?

Expressive arts therapy uses various arts—movement, drawing, painting, sculpting, music, writing, sound, and improvisation—in a supportive setting to facilitate growth and healing. It is a process of discovering ourselves through any art form that comes from an emotional depth. It is not creating a “pretty” picture. It is not a dance ready for the stage. It is not a poem written and rewritten to perfection.

We express inner feelings by creating outer forms. Expressive art refers to using the emotional, intuitive aspects of ourselves in various media. To use the arts expressively means going into our inner realms to discover feelings and to express them through visual art, movement, sound, writing, or drama. Talking about our feelings is also an important way to express and discover ourselves meaningfully. In the therapeutic world based on humanistic principles, the term expressive therapy has been reserved for nonverbal and/or metaphoric expression. Humanistic expressive arts therapy differs from the analytic or medical model of art therapy, in which art is used to diagnose, analyze and “treat” people.

Most of us have already discovered some aspect of expressive art as being helpful in our daily lives. You may doodle as you speak on the telephone and find it soothing. You may write a personal journal and find that as you write, your feelings and ideas change. Perhaps you write down your dreams and look for patterns and symbols. You may paint or sculpt as a hobby and realize the intensity of the experience transports you out of your everyday problems. Or perhaps you sing while you drive or go for long walks. These exemplify self-expression through movement, sound, writing, and art to alter your state of being. They are ways to release your feelings, clear your mind, raise your spirits, and bring yourself into higher states of consciousness. The process is therapeutic.

When using the arts for self-healing or therapeutic purposes, we are not concerned about the beauty of the visual art, the grammar and style of the writing, or the harmonic flow of the song. We use the arts to let go, to express, and to release. Also, we can gain insight by studying the symbolic and metaphoric messages. Our art speaks back to us if we take the time to let in those messages.

Although interesting and sometimes dramatic products emerge, we leave the aesthetics and the craftsmanship to those who wish to pursue the arts professionally. Of course, some of us get so involved in the arts as self-expression that we later choose to pursue the skills of a particular art form. Many artist-therapists shift from focusing on their therapist lives to their lives as artists. Many artists understand the healing aspects of the creative process and become artist-therapists.

Using the creative process for deep inner healing entails further steps when we work with clients. Expressive arts therapists are aware that involving the mind, the body, and the emotions brings forth the client’s intuitive, imaginative abilities as well as logical, linear thought. Since emotional states are seldom logical, the use of imagery and nonverbal modes allows the client an alternate path for self-exploration and communication. This process is a powerful integrative force.

Traditionally, psychotherapy is a verbal form of therapy, and the verbal process will always be important. However, I find I can rapidly understand the world of the client when she expresses herself through images. Color, form, and symbols are languages that speak from the unconscious and have particular meanings for each individual. As I listen to a client’s explanation of her imagery, I poignantly see the world as she views it. Or she may use movement and gesture to show how she feels. As I witness her movement, I can understand her world by empathizing kinesthetically.

The client’s self-knowledge expands as her movement, art, writing, and sound provide clues for further exploration. Using expressive arts becomes a healing process as well as a new language that speaks to both client and therapist. These arts are potent media in which to discover, experience, and accept unknown aspects of self. Verbal therapy focuses on emotional disturbances and inappropriate behavior. The expressive arts move the client into the world of emotions and add a further dimension. Incorporating the arts into psychotherapy offers the client a way to use the free-spirited parts of herself. Therapy may include joyful, lively learning on many levels: the sensory, kinesthetic, conceptual, emotional and mythic. Clients report that the expressive arts have helped them go beyond their problems to envisioning themselves taking action in the world constructively.

What Is Person-Centered?

The person-centered aspect of expressive arts therapy describes the basic philosophy underlying my work. The client-centered or person-centered approach developed by my father, Carl Rogers, emphasizes the therapist’s role as being empathic, open, honest, congruent, and caring as she listens in depth and facilitates the growth of an individual or a group. This philosophy incorporates the belief that each individual has worth, dignity, and the capacity for self-direction. Carl Rogers’s philosophy is based on a trust in an inherent impulse toward growth in every individual. I base my approach to expressive arts therapy on this very deep faith in the innate capacity of each person to reach toward her full potential.

Carl’s research into the psychotherapeutic process revealed that when a client felt accepted and understood, healing occurred. It is a rare experience to feel accepted and understood when you are feeling fear, rage, grief, or jealousy. Yet it is this very acceptance and understanding that heals. As friends and therapists, we frequently think we must have an answer or give advice. However, this overlooks a very basic truth. By genuinely hearing the depth of the emotional pain and respecting the individual’s ability to find her own answer, we are giving her the greatest gift.

Empathy and acceptance give the individual an opportunity to empower herself and discover her unique potential. This atmosphere of understanding and acceptance also allows you, your friends, or your clients to feel safe enough to try expressive arts as a path to becoming whole.

The Creative Connection

I am intrigued with what I call the creative connection: the enhancing interplay among movement, art, writing, and sound. Moving with awareness, for example, opens us to profound feelings which can then be expressed in color, line, or form. When we write immediately after the movement and art, a free flow emerges in the process, sometimes resulting in poetry. The Creative Connection process that I have developed stimulates such self-exploration. It is like the unfolding petals of a lotus blossom on a summer day. In the warm, accepting environment, the petals open to reveal the flower’s inner essence. As our feelings are tapped, they become a resource for further self-understanding and creativity. We gently allow ourselves to awaken to new possibilities. With each opening we may deepen our experience. When we reach our inner core, we find our connection to all beings. We create to connect to our inner source and to reach out to the world and the universe.

Some writers, artists and musicians are already aware of the creative connection. If you are one of those, you may say, “Of course, I always put on music and dance before I paint.” Or, as a writer, you may go for a long walk before you sit at your desk. However, you are not alone if you are one of the many in our society who say, “I’m not creative.” I hope this book entices you to try new experiences. You will surprise yourself.

I believe we are all capable of being profoundly, beautifully creative, whether we use that creativity to relate to family or to paint a picture. The seeds of much of our creativity come from the unconscious, our feelings, and our intuition. The unconscious is our deep well. Many of us have put a lid over that well. Feelings can be constructively channeled into creative ventures: into dance, music, art, or writing. When our feelings are joyful, the art form uplifts. When our feelings are violent or wrathful, we can transform them into powerful art rather than venting them on the world. Such art helps us accept that aspect of ourselves. Self-acceptance is paramount to compassion for others.

The Healing Power of Person-Centered Expressive Arts

I discovered personal healing for myself as I brought together my interests in psychotherapy, art, dance, writing, and music. Person-centered expressive therapy was born out of my personal integration of the arts and the philosophy I had inherited. Through experimentation I gained insight from my art journal. I doodled, let off steam, or played with colors without concern for the outcome. Unsure at first about introducing these methods to clients, I suggested they try things and then asked them for feedback. They said it was helpful. Their self-understanding increased rapidly and the communication between us improved immensely.

The same was true as I introduced movement, sound, and freewriting for self-expression. Clients and group participants reported a sense of “new beginnings” and freedom to be. One group member wrote: “I learned to play again, how to let go of what I ‘know’—my successes, achievements, and knowledge. I discovered the importance of being able to begin again.” Another said: “It is much easier for me to deal with some heavy emotions through expressive play than through thinking and talking about it.”

It became apparent that the Creative Connection process fosters integration. This is clearly stated by one client who said, “I discovered in exploring my feelings that I could break through inner barriers/structures that I set for myself by moving and dancing the emotions. To draw that feeling after the movement continued the process of unfolding.”
It is difficult to convey in words the depth and power of the expressive arts process. I would like to share a personal episode in which using expressive arts helped me through a difficult period. I hope that, in reading it, you will vicariously experience my process of growth through movement, art, and journal writing in an accepting environment.

The months after my father’s death were an emotional roller coaster for me. The loss felt huge, yet there was also a sense that I had been released. My inner feeling was that his passing had opened a psychic door for me as well as having brought great sorrow.

Expressive arts served me well during that time of mourning. Two artist-therapist friends invited me to spend time working with them. Connie Smith Siegel invited me to spend a week at a cottage on Bolinas Bay. I painted one black picture after another. Every time I became bored with such dark images, I would start another painting. It, too, became moody and bleak. Although Connie is primarily an artist, her therapeutic training and ability to accept my emotional state gave me permission to be authentic.

Also, I went to a weekend workshop taught by Coeleen Kiebert and spent more time sculpting and painting. This time the theme was tidal waves—and again, black pictures. One clay piece portrays a head peeking out of the underside of a huge wave. My sense of being overwhelmed by the details of emptying my parents’ home, making decisions about my father’s belongings, and responding to the hundreds of people who loved him was taking its toll. Once again, my art work gave free reign to my feelings and so yielded a sense of relief. Coeleen’s encouragement to use the art experience to release and understand my inner process was another big step. I thought I should be over my grief in a month, but these two women gave me permission to continue expressing my river of sadness. That year my expressive art shows my continued sense of loss as well as an opening to new horizons.

As is often true when someone feels deep suffering, there is also an opening to spiritual realms. Three months after my father’s death, I flew to Switzerland to cofacilitate a training group with artist-therapist Paolo Knill. It was a time when I had a heightened sense of connectedness to people, nature, and my dreams. Amazing events took place in my inner being. I experienced synchronicities, special messages, and remarkable images. One night I found myself awakened by what seemed to be the beating of many large wings in my room. The next morning I drew the experience as best I could.

One afternoon I led our group in a movement activity called “Melting and Growing.” The group divided into pairs, and each partner took turns observing the other dancing, melting, and then growing. Paolo and I participated in this activity together. He was witnessing me as I slowly melted from being very tall to collapsing completely on the floor. Later I wrote in my journal:

I loved the opportunity to melt, to let go completely. When I melted into the floor I felt myself totally relax. I surrendered! Instantaneously I experienced being struck by incredible light. Although my eyes were closed, all was radiant. Astonished, I lay quietly for a moment, then slowly started to “grow,” bringing myself to full height.

I instructed the group participants to put their movement experiences into art. All-encompassing light is difficult to paint, but I tried to capture that stunning experience in color.

Reflecting on these experiences, it seems that my heart had cracked open. This left me both vulnerable and with great inner strength and light. A few days later another wave picture emerged. This time bright blue/green water was illumined with pink/gold sky.

These vignettes are part of my inner journey. I share them for two reasons. First, I wish to illustrate the transformative power of the expressive arts. Second, I want to point out that person-centered expressive therapy is based on very specific humanistic principles. For instance, it was extremely important that I was with people who allowed me to be in my grief and tears rather than patting me on the shoulder and telling me everything would be all right. I knew that if I had something to say, I would be heard and understood. When I told Paolo that I had the sensation of being struck with light, he could have said, “That was just your imagination.” However, he not only understood, he told me he had witnessed the dramatic effect on my face.

Humanistic Principles

Since not all psychologists agree with the principles embodied in this book, it seems important to state them clearly as the foundation for all that follows:

  • All people have an innate ability to be creative.
  • The creative process is healing. The expressive product supplies important messages to the individual. However, it is the process of creation that is profoundly transformative.
  • Personal growth and higher states of consciousness are achieved through self-awareness, self-understanding, and insight.
  • Self-awareness, understanding, and insight are achieved by delving into our emotions. The feelings of grief, anger, pain, fear, joy, and ecstasy are the tunnel through which we must pass to get to the other side: to self-awareness, understanding, and wholeness.
  • Our feelings and emotions are an energy source. That energy can be channeled into the expressive arts to be released and transformed.
  • The expressive arts—including movement, art, writing, sound, music, meditation, and imagery—lead us into the unconscious. This often allows us to express previously unknown facets of ourselves, thus bringing to light new information and awareness.
  • Art modes interrelate in what I call the creative connection. When we move, it affects how we write or paint. When we write or paint, it affects how we feel and think. During the creative connection process, one art form stimulates and nurtures the other, bringing us to an inner core or essence which is our life energy.
  • A connection exists between our life-force—our inner core, or soul—and the essence of all beings.
  • Therefore, as we journey inward to discover our essence or wholeness, we discover our relatedness to the outer world. The inner and outer become one.

My approach to therapy is also based on a psychodynamic theory of individual and group process:

  • Personal growth takes place in a safe, supportive environment.
  • A safe, supportive environment is created by facilitators (teachers, therapists, group leaders, parents, colleagues) who are genuine, warm, empathic, open, honest, congruent, and caring.
  • These qualities can be learned best by first being experienced.
  • A client-therapist, teacher-student, parent-child, wife-husband, or intimate-partners relationship can be the context for experiencing these qualities.
  • Personal integration of the intellectual, emotional, physical, and spiritual dimensions occurs by taking time to reflect on and evaluate these experiences.

The accompanying figure shows the Creative Connection process and principles, using expressive arts therapy. It shows how all art forms affect each other. Our visual art is changed by our movement and body rhythm. It is also influenced when we meditate and become receptive, allowing intuition to be active. Likewise, our movement can be affected by our visual art and writing, and so forth. All the creative processes help us find our inner essence or source. And when we find that inner source, we tap into the universal energy source, or the collective unconscious, or the transcendental experience.

Come with me, if you will, on a journey of inner exploration to awaken your creativity. Perhaps you are a writer who shies away from visual art, or an artist who says,”I can’t dance,” or a therapist who would like to discover methods for enhancing the counselor-client relationship. I invite you into your own secret garden.