Addressing the Relational Impact of Mental Illness

While it can be isolating, mental illness is not an isolated experience. It affects more than just the individual: it impacts friends, family, spouses, significant others, and co-workers. I recall working with a married man who developed Major Depressive Disorder around the time his wife had their second child. He became emotionally distant, socially isolated, lethargic, couldn’t focus, took time off work to the point of being fired, and lost interest in sex. His wife struggled bitterly. She felt completely overwhelmed with the care of two young children. Her husband, on whom she once depended, was no longer contributing. She felt like she had to care for him as well and try to keep the family financially afloat since she was the only one working. Despite the challenging circumstances, she tried to keep their intimacy intact, but he had no interest in sex, going out, connecting with their friends, and he struggled to track during conversations. As you can imagine, this put a strain on their relationship, which they eventually ended. Neither one of them wanted the divorce, but the wife hit her breaking point, and her husband couldn’t find the energy to fight for the relationship. This is a sad story that is reflective of how mental illness impacts a marriage, a career, parenting, and personal finances.

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When working with clients, I try to keep in mind the relational impact of mental illness in all its facets. Mental illnesses, like depression, affect the individual in every sphere of their life, including the social/relational. The above example illustrates how lonely the man felt, and how inexpressible his psychological and physical experience was to his wife. There were no words that existed in his mind or in their relationship for him to utilize. He and she were left in a wretched state of ambiguity. And despite her best efforts, she could not intimately access the depths of his depression. She, too, had no words. She couldn’t prevent feeling shut-out, as if she had been barred from his heart. Her dream was to feel unimaginable connection and joy at the birth of their child, but what she got was facing single-parenting while married.

Needless to say, there is a ripple effect of depression. The man’s relationship with his child will forever be changed. Certainly, it is within his grasp to foster a loving and connected relationship with his child, but he will have to do so with additional barriers due to the divorce, physical distance, child support, navigating co-parenting, and potential co-step parenting.

From my perspective as a clinician, problems are compounded when family and friends don’t understand the nature of mental illness, however, this is not always obvious to my clients and their loved ones. When trying their best to understand their loved one’s struggle, some may conclude that they aren’t trying hard enough, that they don’t care, or that they are seeking attention. Without information, without a sufficient explanation, bad interpretations fill the void, which only lead to judgment and alienation. As a clinician, I step into that void with accurate and compassion-filled information. My aim is to coach clients who are struggling with mental illness as well as their family members and explain that they may be tempted to personalize or create a negative attribution for their loved one’s behavior. It is tempting, natural, and understandable why they would do this, and yet, it is often a mistake in judgment. I try to explain that if their loved one had cancer, they wouldn’t take it personally or judge. Certainly they might have big feelings of sadness or anger at God or the universe, but there would be no assignment of blame to the diagnosed individual. They wouldn’t think, “Why did she choose to have cancer? They must want attention.” That would be absurd, and the vast majority of people would never think this.

So why would a wife, husband, partner, child, friend, or family member personalize a loved one’s depression, anxiety disorder, or phobia? I encourage my clients and their social network to make a genuine effort at understanding mental health disorders. It is natural to want to know as much as possible about a disease when a loved one may be diagnosed with a medical disease. As a clinician, I encourage clients to take that same impulse and learn as much as possible about their loved one’s mental health diagnoses. Ignorance only creates barriers to relationships, and my hope is to remove any barriers to social connection in my client’s way, as well as within their social network. A client is only as healthy as their community. Therefore, I want to empower clients to empower their communities, to mobilize those around them to seek out information and more deeply understand the psychological realities they are dealing with. And to find that middle ground of embracing the mental illness of your loved one but resisting the urge to define them by it.

***

Thinking back to my client mentioned earlier, I wonder how things would have been different if both the husband and wife had more awareness about depression. I wonder how the two of them may have pulled together, rather than apart, if they had known earlier on that the husband was being affected by a mental health disorder. If they had only had the words and concepts to understand not only the husband’s experience of depression, but also the relational impact that depression brought to their marriage and family. The wife was just as much a sufferer of depression as was the husband. This new understanding could have been a catalyst for collaboration, support, mutual understanding, and shared problem-solving.

Stefani Goerlich on Becoming a Kink-Affirming Therapist

Defining Our Terms

Lawrence Rubin: Hi, Stefani. Thank you for joining me today. I’m just going to get right into it and ask you—especially for those readers who may not be fully aware—what is kink?
Stefani Goerlich:
kink is nonnormative sexual and relational expression
Kink is a very broad term, but at its most basic, simply means any sort of sexual or relational expression that falls outside of the social norm or mainstream for the people who are engaging in it. What is normal, obviously, varies from culture to culture. But kink is nonnormative sexual and relational expression.
LR: Are there certain standards for normative sexual behavior across cultures that make a place for kink?
SG: When it comes to relational models, polyamory versus monogamy here in the States for example, polyamory is considered a form of kink expression. They’re often sort of rolled in together. But if you go into parts of Europe or the Middle East, polyamory is a cultural norm. On the other hand, things like sadomasochism and sensory exchange tend to be considered somewhat atypical across the board. So there are some things that lend themselves more towards universal kinks and others that are much more culturally contextualized.
LR: For some of our readers unfamiliar with these terms, what are “sadomasochism” and “sensory exchange?”
SG: Within kink, most of what people talk about is BDSM, which actually encompasses several different, smaller sorts of acronyms. It’s a multipurpose concept that includes bondage and discipline, which is an exchange of control. Usually this means control of movement, control of behavior. Then, there’s DS—dominance and submission—which I explain as an exchange of authority between the partners. This may or may not include control of behavior. But often, authority involves decision making sort of power. S&M is sadism and masochism, which we as clinicians think about as pain, giving and receiving pain.

But pain is a very subjective term and varies widely based on the individual. When I’m training other professionals, I talk about sadism and masochism as the exchange of intense sensation. So, within kink relationships, we’ll have one or more of those three—an exchange of control, an exchange of authority, or an exchange of sensation.
LR: So, that exchange of sensation does not necessarily include sexual sensation—direct stimulation of the genitals, which is only one subset of sensory exchange or pain?
SG:
We tend to assume that kink is sexual. But kink, in its most basic, is relational
Absolutely. That’s actually true for all three. We tend to assume that kink is sexual. But kink, in its most basic, is relational. Kink can sometimes be sexual in how it’s expressed. But ultimately, it is a relational form. So you’re right that the exchange of sensation might never involve sexual contact. It could be temperature. It could be impact. It could be electrostimulation. There’s a wide variety of sensations that can be exchanged that never involve removing one’s clothing.

50 Shades of Confusion

LR: How has American pop culture impacted consumers’ (therapists included) understanding of BDSM?
SG:
I think that pop culture has definitely sexualized BDSM
I think that pop culture has definitely sexualized BDSM, but I also think that is true historically. I’m working on a new conference talk and potentially a new journal article that looks at 500 years of how BDSM practices have been portrayed in popular media. And they’ve often been conflated with deviant sexual behavior regardless of whether the people engaging in kink view it as sexual. So that lends itself to this perpetuation of kink stigma. We typically see BDSM signals or cues, like leather or somebody wearing a collar, and immediately sexualize those in a way that they perhaps might not mean for themselves and their relationship.
LR: I go immediately to my only pop culture experience with BDSM, 50 Shades of Grey. Given that therapists are certainly part of the consuming public, did the movie and book help or undermine our understanding of BDSM?
SG:
Unfortunately, the actual relationship the 50 Shades books portray is incredibly abusive
I’m deeply conflicted. I have a conference talk that I offer—or, now, in COVID times, a webinar—called “Kink Affirming Practice: What Your Clients Wish You Knew but Are Afraid You’ll Ask.” And I noticed that my rooms started becoming much fuller after the 50 Shades book and then the movie came out.

On one hand, E. L. James did a great job of bringing kink dynamics into the mainstream, where soccer moms, housewives, and school teachers were reading about this kind of relationship. It was no longer the secreted experience of buying the pulp novel from behind the counter at the adult bookstore. So from that perspective, it was fabulous.

Unfortunately, the actual relationship the 50 Shades books portray is incredibly abusive. It is not a healthy model of kink. And in fact, the only time I mention it in my intro talk is as a case example where I walk people through a case study and offer a few different scenarios. I then ask the participants to tell me if the various scenarios represent consensual kink or domestic violence. At the end, I ask them if they recognize my case study, which is 50 Shades. So, it’s done wonders for normalizing conversations about and knowledge of BDSM. But I think it’s done a lot of harm in terms of how people understand BDSM relationships to actually be.
LR: So 50 Shades sort of limited our understanding of BDSM by grabbing our focus and making it sexual and, as a result, the line that separates BDSM from intimate partner violence was blurred.
SG: And its normalized dominance as a form of coercion, as opposed to dominance as a gift that the submissive gives to their partner.
LR: This may seem like a weird analogy, but when the movie 101 Dalmatians first came out, the breeders were going wild breeding dalmatians. And around Halloween, black cats are oversold and many later abandoned or abused. Did 50 Shades of Gray drive people to the therapists’ office, partners wanting to experiment and their partners not being open to it? Did it increase your practice?
SG: I saw an increase in my conversations with members of the BDSM community who expressed frustration with an influx of people who had read these books and had decided that they wanted to explore kink, but who were coming into it with this unhealthy understanding of what kink should look like. And so a lot of my already kinky clients were very, very frustrated and upset with the sort of change in the zeitgeist of the community, and the way new dominants were expecting submissives to respond or were expecting behaviors to be okay that are not. And newly-identified people who wanted to explore their submissive side seeking out really unhealthy dynamics because they weren’t clear on what healthy kink looks like. So what I saw in my practice was long-time kinksters being very frustrated with the sort of new people that 50 Shades brought into that world.
LR: And I wonder if it also resulted in an influx of clients with already very disturbed patterns of relationships who now wanted to incorporate kink without having a sound, healthy relational foundation. I’d imagine that there needs to be a reasonably healthy pattern of communication and awareness of power dynamics before adding in kink.
SG:
the problem is when people who have never identified as kinky before start to take on a BDSM identity as a way to rationalize or contextualize their already problematic behavior
Absolutely! I think that in general, there is a lot that the BDSM community can teach the vanilla world about negotiation, about consent, about communication, about after-care. But the problem is when people who have never identified as kinky before start to take on a BDSM identity as a way to rationalize or contextualize their already problematic behavior.

When somebody who has struggled to form relationships because they have abusive patterns now decides, “Well, I’m a dominant and so the way I have a relationship with a partner who won’t leave me is to find a partner who likes being mistreated.” That sort of mindset misunderstands what it means to be submissive and also misunderstands what it means to be dominant.
LR: So this kind of person might say, “All these years, the people I’ve dated have called me abusive, but I’m really not. I’m just a dominant. And they’re not understanding. So, I need to find just the right submissive.”
SG: Exactly.

Kink-Affirming Practice

LR: Shifting gears a bit here, Stefani, what exactly is kink-affirming clinical practice?
SG:
Kink-affirming practice understands that kink is its own distinct subculture, with strengths and resources and things that we can use in clinical work with our clients
Kink-affirming practice is the understanding that kink is not just something that we need to know about. Most clinicians that I encounter will say that they are kink-aware. They know what BDSM stands for. They have a general understanding of the idea of kink. But that’s about where their knowledge ends. Kink-affirming practice understands that kink is its own distinct subculture, with strengths and resources and things that we can use in clinical work with our clients, and that we can leverage their kink identities in our treatment planning, in our intervention strategies, and really work with that in the same way that we would use any other aspect of our clients’ identities. So it’s taking it beyond “I understand this” and moving it into “This is a key part of your identity. And we are going to weave this into our work.”
LR: Just as a clinician working with any client is interested in tapping into their resources, you’re saying that a kink-aware therapist uses the person’s kink identity as potential for resources. Can you give me an example of what kind of resources for healthy relationships kink clients bring to you as a therapist?
SG: Sure, but I want to clarify—that’s what I mean when I say, “kink-affirming.” Kink aware therapists understand what kink is, but they might not necessarily have a structure for using that in their work with their clients. They just know enough about it to not cause harm or to stigmatize their clients for being kinky.

In kink-affirming practice, we would look at the use of protocols and rituals to enhance the work that we’re doing with clients perhaps with a trauma history or with a rejection dysphoria. Working daily protocols with their partner into their treatment planning can be really positive for them. If we’re working with somebody with disordered eating, for example, working with their partner—their dominant partner—to help establish rules around that so that they have accountability in their relationship in a way that doesn’t feel focused on their eating but becomes an act of service to complete a meal, can be a really healthy reframing for them.

Another great example for a dominant partner would be—I had a client who struggled with their own med management, blood pressure medication in this case. But they were very busy, and because it wasn’t a huge priority for them, their health was compromised. So we actually worked together to make it an act of service for their partner to remind them of their meds. It became, “Sir, it’s 6:00. It’s time for you to take your medication.” In another context, or one that was not kink-affirming, this reminder could have felt bossy or nagging, controlling. But we played to the strengths of their dynamic and made it something that felt like service to them. Both of these examples reflect a DS context.
LR: These two scenarios are perfect examples of how kink and BDSM are not necessarily about sexual gratification, sexual stimulation, or sexual experiences. It’s about a relational process. One aspect of which might be sexual. You brought up trauma, which is a whole other area. But it made me wonder if it might be a dog whistle to a kink-unaware or non-kink-affirming therapists to search for trauma in the history of these folks who bring their kink identities or practices into therapy?
SG:
One of the biggest misconceptions and biases is that people who identify as kinky are kinky because they have a trauma history
One of the biggest misconceptions and biases is that people who identify as kinky are kinky because they have a trauma history. Actually, when you look at the research and the data, it’s fascinating because people who identify as kinky do not have—they don’t report a trauma history any more than the general population. So trauma within the kink community is on par with trauma in the general community. Where we see a difference is that people within the kink community tend to report higher rates of PTSD than vanilla people. And what that tells me is that you don’t necessarily have more traumatized people who identify as kinky. But what you have is a group of people who have found an outlet and a cathartic modality that works for them who are then coming to kink as a way to further their own healing. So, I can understand why on the surface if you’re working with a heavy population of PTSD, you might make that corollary that, oh, kink is more prevalent in people with trauma. That’s statistically not true. But more likely, people with PTSD may be using kink as an outlet to process those feelings.
LR: What do you mean in your book when you say that consensual BDSM for trauma survivors can be an effective way of processing trauma memories?
SG:
Kink is not, in and of itself, therapy
I want to be really clear. We don’t have enough evidence to say that BDSM play is an intervention. We have some people who are doing that research. But we’re not there yet. Kink is not, in and of itself, therapy. But my background is with sexual assault and trauma survivors, and for a lot of people who have had their control taken away, who have been in situations where they have lost agency, lost autonomy, literally lost physical control over their bodies and their voices, kink can be very powerful. Being able to put themselves in a situation where they can say, “These are my limits. This is what I want. This is what I don’t,” to know with absolute certainty that if they say stop, things will stop. It can be very, very healing to put themselves in situations that offer similar sensory experiences to their trauma in a controlled, safe setting. So it works almost similarly to exposure therapy with a phobia. But it’s self-directed and self-controlled.
LR: When you talk about the healing potential of kink, I think about people who have had chronic health conditions or who have had to undergo medical procedures that have involved involuntary intense pain or submission to painful procedures.
SG:
illness and medical trauma can often be supported and processed through the use of intentional sensory experiences like BDSM
Emma Sheppard is doing some phenomenal work around using kink as an outlet for chronic pain treatment and using intentional chosen pain to offset and to recontextualize pain that perhaps we don’t choose. I know Lee Phillips, in Virginia, does a lot of work around chronic illness and BDSM. So there is a growing sort of small but strong number of voices working on exactly that—on recognizing that illness and medical trauma can often be supported and processed through the use of intentional sensory experiences like BDSM.
LR: If there’s anything I want the readers to take from this interview, it is the importance of that simple finding from research and practice that BDSM and kink in general are not necessarily about sexual gratification, which was the misconception you mentioned earlier. Are there other kink-related myths and misconceptions?
SG: I think there are a number. One of the big ones that I encounter is the idea that people who identify as sadists are intentionally or are diagnostically problematic and that we need to be vigilant around these sadistic clients because they are more likely to be offenders who are sublimating this violent urge into their relationships. Which, on one hand, if that is true for a given client, I would argue that’s exactly what we want them to be doing.

If they have a consenting partner who enjoys receiving the kind of aggressive sensation they want to be giving out, then, yay, we all win, and nobody’s consent is being violated. But we also need to recognize that there is such a thing as prosocial sadism—people who enjoy evoking these reactions in willing people who, in turn, enjoy receiving these sensations. We need to be mindful as clinicians to not assume deeper social or psychological implications here simply because our clients enjoy giving or receiving these intense sensations.
LR: I know that as a clinician, you’re also a certified sex therapist, so would assume that some clients seek you out for sex-therapy related issues, and others do not. What are some of the main concerns that clients bring to you?
SG:
people that perhaps are kink-unaware or kink-uninformed rush to assume that you’re kinky because you’re depressed, or you’re depressed because you’re kinky
I would say that even within my general mental health clients, a sizable number of them come to me because they know that they are kinky and depressed or and anxious or considering divorce. They want to work with somebody who is not going to tie threads that don’t need to be tied. So often—and this comes back to the question you asked about myths—people that perhaps are kink-unaware or kink-uninformed rush to assume that you’re kinky because you’re depressed, or you’re depressed because you’re kinky, or you’re anxious because you’re kinky, or you want to get divorced. Sometimes my clients just need a clinician who understands the way they like to have relationships or the way that they like to have sex, and that this is not necessarily connected with their mental health issues.

Another good chunk of my practice is people who are experiencing desire discrepancy between themselves and their partners, mismatched fetish interests, mismatched kink dynamic interests. I’m starting to look at those sorts of cases more as a mixed-orientation marriage than as a libido issue, because when we look at things as a desire-libido issue, we’re operating from the assumption that one person’s libido needs to be adjusted. When instead we look at it as a mixed-orientation relationship, neither person is wrong. Neither person needs to be fixed or corrected or medicated. We simply need to find the Venn-connection between their common erotic maps. So helping these couples through a mixed-orientation framework has become a big part of my practice.

And the last group is couples and individuals who are newly aware of or newly willing to discuss their interest in kink or polyamory. They’re coming to me for guidance and for a place to talk through and process these new ideas and new experiences as they start to enter into those initial sort of explorations and community engagements.
LR: So a kink-unaware therapist or a therapist who might be conflicted around their own sexuality or relational dynamics might be predisposed to see a red light flashing over the head of a client when kink comes into the room, rather than sort of hold it as just one of the other elements of the person’s identity.
SG: Exactly. There’s also just the resource knowledge. If we have a client who’s struggling with a substance use issue, if we have somebody that’s perhaps overusing alcohol, we can—most of us—have a conversation around several different treatment options for them. We can talk about AA versus Smart Recovery versus Dharma Recovery. We can talk about intensive outpatient versus going to rehab. But if you’re not kink aware or kink affirming, and a client comes to you and says, “I really want to explore this side of me and I don’t know where to start,” most of us are totally unprepared to talk about what conferences are best for somebody who’s curious about pet play versus age play versus BDSM, where somebody can go for educational content without an expectation that there’s going to be any sort of public play component versus somebody who’s interested in polyamory but maybe not swinging. Those are resources our kinky clients need to have access to. And as clinicians, we need to be able to have those conversations with them in the same way we would about any other community resource.
LR: Might there be a profile of the clinician who might be more susceptible to countertransferential responses to a kink client—a kink-practicing client?
SG:
The clinician who is more philosophically conservative and wedded to the sex addiction model is more likely to struggle when working with kinky clients and to pathologize BDSM and kink
I don’t know if I could say there’s an evidence-based profile. I can tell you anecdotally what I’ve encountered. The clinician who is more philosophically conservative and wedded to the sex addiction model is more likely they are to struggle when working with kinky clients and to pathologize BDSM and kink. I have several local colleagues who have told me, verbatim, that I’m the one they send the weird sex stuff to, which is fascinating because the weird sex stuff they send me tends to be masturbation.
LR: Oh, my! Blindness next, right?
SG: I mean I have a lot of conversations with referrals who are sent to me because they’re told they have very problematic sexual behavior. In their intakes, I’m like, “You are well within the margins of normal. Nothing you are telling me is at all concerning to me.” And I’m not saying that as a kink-affirming clinician. I am saying that just as a sex therapist.
LR: One of the things our readers will not be able to appreciate unless they look you up is that you have pink hair, you’re sitting in a pink chair with a statue of Wonder Woman next to you, and that behind you is a beautifully colored floral wreath. I don’t know if it’s macramé.
SG: Embroidered lace I brought back from Romania as we were fleeing Europe ahead of COVID.
LR: So I wonder if a therapist who is not as comfortable in displaying themselves as freely as you or who is struggling in their own relationships is going to have much more difficulty accepting kink clients.
SG:
I try very hard to be very cheerful, very colorful, very approachable, so that I don’t look like what people picture when they picture a kink specialist therapist
It’s interesting that you bring up sort of the color palette of things. Because one of the things I very intentionally try to do in my practice is to be very approachable to avoid that sort of black metal, sleek chrome look—I don’t want my office to look like a dungeon space. I want to look friendly and cheerful and approachable, partly because it’s so important to me to normalize these relationships for my clients, for my colleagues. And a huge part of that is looking normal in the work that I do. I mean the pink hair, I suppose, is maybe a little bit atypical. But I try very hard to be very cheerful, very colorful, very approachable, so that I don’t look like what people picture when they picture a kink specialist therapist.
LR: I wonder if clients who are on the verge of experimenting with or beginning to wonder what kink is, and who approach a therapist who is not particularly approachable—if the relationship will not work.
SG: I will say that every single year, I ask my accountant if I can write my hair dye off as a marketing expense because I hear from so many people that I look friendly and like somebody they could talk to because I had pink hair.
LR: Stefani, I’m going to be presumptuous here and say that I think you need to explore the power dynamics with your accountant. Perhaps you should be telling your accountant what is to be written off and push your accountant into a submissive position when it comes to that. A practice-what-you-preach sort of thing. Sorry, I couldn’t resist that one.
SG: I’ll let her know you said so.
LR: Is the therapist who has not practiced kink at any level capable of working with a client who either is kink practicing or contemplating kink practice or experimentation?
SG:
I don’t think it’s fair to ask our clients to pay us to use their therapeutic hour to teach us what we need to know to do the work with them
I think so. I think that, in the same way that I don’t necessarily have to be gay to work with a gay male couple, I simply need to be willing to educate myself and empathize with them and respect them, that other people can work with kinky clients if they’re willing to do that same work. I actually think it can sometimes be easier because when I’m doing case consultation with peers who themselves are kink-identified, that’s where I see countertransference. That’s where I see, well, the way that their relationship is set up or the way that they’re doing kink isn’t the way I think that kink should be done. And so we have to have conversations around your kinks, not their kink. But that doesn’t make their kink wrong. At times, it might actually be easier to have somebody who is very affirming, but not necessarily kinky themselves, doing that work.

I think that one caveat I would add is we need to be willing to let clients teach us about their dynamic and the way that they do kink. I do not think we should be looking to our clients to educate us about kink in general. We need to be pursuing continuing education. We need to be reading books or watching documentaries or attending conferences written by members of the kink community. We need to be educating ourselves, and then asking our clients, “What does this look like for you?” I don’t think it’s fair to ask our clients to pay us to use their therapeutic hour to teach us what we need to know to do the work with them.

Hard Places and Soft Spots

LR: When should a therapist consider referring a client who may be reconsidering their relationship style and/or sexual practices to include kink practices?
SG: I think, if it’s not something that you’re willing to—if it’s outside your scope of practice and you’re not willing to do the work of learning, then you need to refer. And it’s okay to be uncomfortable with something. I’ve worked with clients whose individual practices or particular fetishes made me uncomfortable. I’ve referred a couple of people out whom I simply know I can’t provide unconditional positive regard to. Not because there’s anything wrong with them. But because I just know where I’m at. So if you are encountering a client you are unprepared to work with and unwilling to educate yourself to do the work with, you have an ethical obligation to them to connect them with somebody who can and who will.
LR: You said that you will refer some clients and you talked about fetishes. Are there some fetishistic behaviors that go beyond your level of moral acceptance? I mean, when would a person’s fetish be such that you would need to refer them, since I’m sure you have seen and heard it all.
SG:
Moral is tricky because my clients, both kinky and non-kinky, engage in all sorts of behavior that I have moral issues with
Moral is tricky because my clients, both kinky and non-kinky, engage in all sorts of behavior that I have moral issues with. If somebody’s stealing from their employer, I have a moral issue with that. I think that we tend to ascribe socially greater moral weight to sexual things than to nonsexual things. But that doesn’t make it any more or less moral. So I don’t know that I want to define it as a moral thing.

But for me, in terms of comfort, really diving into the details of somebody’s experience, where I’m able to sit and hold space for a given narrative, people who are zoophiles—that’s something that I personally struggle with.

Thankfully, I have colleagues I can refer out to. And I do. And again, I’m not necessarily putting a moral weight on that. It’s just I can’t be what they need. I work with people who struggle with pedophilic urges. And I’m comfortable doing that. I’m a member of the Association for the Treatment of Sexual Abusers. I’m comfortable working with non-offending pedophiles. I don’t work with actively offending pedophiles. But for the most part, those are the two big ones for me. I have people that engage in a lot of niche fetishes that some of my peers struggle with, like coprophilia. So, most things I am fully capable of holding space with. For me, really, just in terms of being able to sit and hear the stories and process and be present for, those are the two that I refer out for, personally.
LR: So, like any competent clinician, you have your boundaries. What kinds of concerns around BDSM do you hear from parents who have concerns for their children and teens?
SG:
I have such a soft spot for kinky adolescents because they are completely adrift
I have such a soft spot for kinky adolescents because they are completely adrift. There are very few ethical resources available to young people who identify as kinky. And it’s tricky because when we interview kinky adults, most of them say that they first recognized an interest in kink starting around age 10, if not a little bit earlier. So, most people who are kinky knew they were kinky early.

And we have a huge population of young people who know that this is a part of how they form relationships, how they give and express affection. And yet they can’t attend kink conferences. They can’t go to BDSM events. And absolutely, we have to be aware of predators and of problematic situations. That’s because, when you’re talking about power exchange in young people, you want to make sure that they’re capable of consent. So, there are really no great answers. I think where I focus with parents is on recognizing that BDSM is a healthy relational expression, on normalizing BDSM as something that can be done in a safe, consensual way, on recontextualizing power exchange as not coercive and grooming behavior, but as a future relationship model their children may aspire to. Even though they’re not adequately able to enter into a dynamic like that now.
LR: Research tells us that children who are victimized by sexual and physical abuse are at higher likelihood of becoming abusers themselves. Is kink interest in children and teens a potential risk factor for them? Especially for trans youth, who are at even higher risk for adverse outcomes?
SG:
providing gender-affirming care to young people is so fraught and contentious that we haven’t even gotten as far as people being able to have a conversation around affirming kink identities
I honestly don’t know that I could speak to that. I don’t know that there’s been enough research. And I think right now, the conversation around simply providing gender-affirming care to young people is so fraught and contentious that we haven’t even gotten as far as people being able to have a conversation around affirming kink identities in gender nonconforming young people. I think that might cause heads to explode in ways that are not fair to young people.
LR: I’m wondering if there’s a hierarchy of kink practice and kink fetish that can be ranked in terms of likelihood of bringing ire to parents and people in general?
SG: SG: I think somebody’s gender identity is such a core aspect of who they are that that has to be supported and affirmed before any sort of relational preference or sexual expression could ever be hoped to act on. They can’t have a happy, healthy, consensual power exchange relationship or engage in a happy, healthy, sensory exchange relationship if they’re not happy and healthy in who they are as a human. And so their ability to engage in any sort of relationship model—kinky, vanilla, or otherwise—is really predicated on our first affirming them and their gender identity to start with.
LR: So healthy kink practice requires healthy personality development first.
SG:
I don’t know that we necessarily need to be rushing to include kinky young people in the broader kink community
Absolutely. As you know, the last part of the brain to develop is the area that controls cause and effect thinking, good and ethical decision making, and being able to anticipate outcomes. And all of those skills are necessary in order to truly negotiate with a potential partner and especially when it comes to BDSM and kink—in order to be able to consent to some of the things that kinky people do. So, I think that supporting young people in their identity formation, in affirming their gender identity, in teaching strong consent culture early and often and bodily autonomy and sex positivity—these are all ways that we can support kinky young people. But I don’t know that we necessarily need to be rushing to include kinky young people in the broader kink community. I think that we need to give them space to be able to have the adult conversations that kinky people have around negotiation of scenes and relationships.
LR: What might be the relationship between the age of the therapist and their capacity to embrace broader elements of identity like kink? Or is it more a matter of the developmental level of the therapist rather than their age?
SG: I don’t know that I would want to speak to that. I feel like it might be far more generational. I think that my son’s generation is so much more inclusive and eager to affirm and accept people with diverse identities and experiences in a way that my parents’ generation really struggles with. And I know that as a Gen-Xer, we try really hard to always get it right. So, I don’t know if it’s an age thing so much as it is a generational thing.

Unanticipated Outcomes

LR: That makes a lot of sense. From your own clinical experience, can you share an unanticipated success story and an unanticipated unsuccess story—I won’t call it “failure”—around working in the kink domain?
SG:
it broke my heart a little bit because they deserved to—whatever their identity was—be affirmed in that
When I first went into private practice after leaving agency settings, I was still in sex therapy supervision. And my very first gender nonconforming client was a person who had lived as a heterosexual man their entire life, who had always struggled with thoughts that perhaps they would be happier as a woman and had come to therapy to explore this. Being me, I was very, very, very excited to help explore this. And we had many wonderful conversations and I offered lots of activities and resources. One day, they came in and said, “I don’t want to do it. It’s too hard, and the payoff isn’t worth it. If I were to announce that I am a woman, I would lose my children, I would lose everything I have. I’ve been doing it this long, I can keep doing it. Sure, it would be nice. But, at the end of the day, the reward isn’t worth the risk and having these conversations is just too painful. So, I’m done.”

There was nothing I could say to that. You have to respect everybody’s process. But it broke my heart a little bit because they deserved to—whatever their identity was—be affirmed in that. Whether that was a heterosexual cis-man that just liked wearing dresses every so often, or whether that was a complete reshaping of their gender identity, I wanted them to be loved and accepted for who they were. And after having so many conversations about what it would be like if they could have that, to have them come in and say, “I just decided it’s not worth trying,” was really—it made me very sad for them.
LR: Perhaps it’s the therapist or supervisor in me that says, maybe it wasn’t really a failure. You created a space for the conversation. And they weighed the pros and cons and did what was best for them, even though you would have hoped that they could have done what was better for them, rather than just best. How about another experience from the—you’re glowing—oh, my God—this was wonderful and…
SG:
I am very much—as you might guess—not a kink-shaming person
I had a client who said that she was in a 24/7 DS relationship, but that it didn’t feel comfortable for her and she wanted to work through her feelings because her dominant was telling her that she wasn’t doing DS right. He wanted her to come to therapy to figure out how she could be a better submissive. And I am very much—as you might guess—not a kink-shaming person. But about two months into this, I paused mid-conversation and said, “I want to print something off, and I want to show it to you.” I went to my laptop and printed off the Duluth Model of Domestic Violence Wheel of Power and Control. I said, “I want you to tell me whether or not anything here looks familiar to you.” And she pointed out—I gave her a highlighter—and she started highlighting a whole bunch of things. And she said, “Well, yeah. But this says, ‘Power and Control.’ This is just what DS is.” And I said, “But how much of this did you agree to?”

I then asked her, “How much of this is okay, because not everything on here can be healthy. And sure, there are things on the Wheel of Power and Control that can be negotiated. Absolutely. Name-calling—absolutely. If that’s your thing, go for it. But there are some things like threatening to harm pets or children that are never a part of—and it seems sort of counterintuitive considering the conversation you and I have had.” Looking back on that powerful interchange, I was able to help somebody understand that they had been gaslighted by their partner into thinking that she was just a terrible submissive, and, if she was just a better submissive, they would have a great relationship. She understood at that moment that this was not kink, that this was a really abusive relationship—and that was very hard.

That was the start of about two years’ worth of work. She ended up moving out. He ended up making some threats to me. I had to have security walk me to and from my car for quite a while. And then she terminated. And I was worried about her. But last summer, out of nowhere, I got a text message saying that she had moved across the country and she had gotten her dream job and she had a new dog that she’d always wanted to have that he would never have let her have. It was a very lengthy text message. And she was just living her best life. And she told me that she would never have thought that she was capable of doing that if she hadn’t had me look at her and say, “This isn’t what kink looks like.”
LR: It is wonderful to have those kinds of memories. I could not possibly end this wonderful conversation, Stefani, without asking you the significance of the Wonder Woman action figure on your desk.
SG:
Wonder Woman originally was intended to represent a new vision of womanhood that was intended to challenge patriarchal norms
I love Wonder Woman. William Moulton Marston, the creator of Wonder Woman, not only invented the first lie detector, but he created the DISC personality profile, which is one of the first attempts to actually use the concepts of dominant and submissive. He tried to sort of codify what those personality types looked like. And Wonder Woman originally was intended to represent a new vision of womanhood that was intended to challenge patriarchal norms and to challenge relationship models and to give young people a new vision for what relationship dynamics could look like.
LR: Does Gal Gadot capture the essence of what Marston envisioned?
SG: As a Jewish woman myself, I love having a Jewish Wonder Woman. She is my favorite.
LR: There was an ad in a magazine in the ‘40s that featured Wonder Woman strapped to a lie detector. I wonder if that was a subtle domination image—not so subtle actually.
SG: Not so subtle. Golden Era Wonder Woman had some pretty overt bondage themes. Marston was in a DS relationship with his partners—a DS poly relationship with his partners.
LR: Well, we’ll leave our readers with that, and I thank you, Stefani.

Confessions of a Student Counsellor

Both Sides Now

At the time of this writing, I have one semester to go before completing my Master of Counselling degree, and I am sixty-five hours into the one hundred required hours of counselling contact hours of my student placement. I am still unsure as to who has received the lion’s share of therapy during these sixty-five hours, my clients or me?

This has not been my first exposure to the rudiments of counselling, however—I had some years of experience in addictions counselling and case management and no shortage of support work in various fields to ease me into the relative displacement of a professional counselling placement. At forty-seven years of age, I have undergone many transitions and life experiences.

Nevertheless, the Masters has been quite a proficient primer and prodder of the all-too-many things I didn’t (and still don’t) know about counselling practice, and of the myriad of things that I need to know in order to provide effective and ethical therapy for a range of concerns and to a broad demographic.

Having had experience in various counselling settings—and being quite familiar with both sides of the counsellor’s chair—together with the fact that I consider myself an avid collector of knowledge, particularly in this field, I still felt a strange cognitive dissonance of both excited preparedness and complete inadequacy to the task at hand at the commencement of my placement. But that was then. At sixty-five hours in, I am a worldly veteran!

The first thing that stood out to me about my placement experience was how pretty much every session turned into a countertransference case study from my ethics class, except that I was the subject. I knew about countertransference. I had studied it. Experienced it. Was consciously aware of it. Prepared, I thought. But I never really had that meta-cognition before that one develops, both while counselling and in the post-session self-flagellation…ahem, reflective practice.

Almost every session seemed like a mirroring of the personal life struggles I had faced, parallel processes of my current situations, relatables that were bone deep. The client I was sitting with was recounting the very relationship issues I had struggled with. Of course I was batting for him! My heart was filled with sympathy, my responses were, albeit textbook, empathetic, while my mind was firing off mostly Andrew-shaped responses ready for delivery. Often, I would catch myself before essentially counselling myself instead of my client. Sometimes I was too late and would realise, embarrassingly, later that day or week. More often than not, in supervision. Or because of past supervisions.

Or I could be sitting in front of the horrifying ghost of my mother-self. That is, this particularly triggering, discomforting, and disquieting quality that my mother possessed which I painfully one day realised I had inherited, now (mostly) exorcised out of me (thank you therapists circa 2000-2004, 2008-2009, 2012-2013 and 2020-2021; you know who you are). Noticing the life force draining from my being, I would sometimes sit across from the ghost-client in a sorrowful-seething state of frustration, compassion, bewilderment, intrigue, and hopelessness. I could swing between feeling annoyed and way out of my depths to such misguided compassion that I would feel the urge to take them home and care for them.

Going it Alone

Something I knew before but re-experienced in a fresh new light during my placement is that a significant part of learning to be a counsellor is essentially done alone. There is generally no direct supervision. There is no one in the room to monitor the minutiae of one’s work. There is no direct feedback loop. It is not as if your supervisor has a document to proofread. There is no material structure to assess for imperfections or to correct. No one is surveying clients at the end of sessions to establish trainee performance. No one is there to say, “Hmmm, maybe when you froze for a minute and a half with silence…” or “Perhaps Texas Hold ’em Poker isn’t the most appropriate game to play in a session with a six-year-old…” Of course, there are opportunities to be observed by colleagues and supervisors or to record sessions and review them. But this is limited in its scope and practicability. And daunting as hell! Or as daunting as having my own personal therapy sessions broadcast to the world, perhaps. Being utterly exposed. Vulnerable.

Sitting with clients who have just expressed something, there are a plethora of potential responses in any given moment of a therapy session. Sometimes they flow readily and easily. At other times they feel forced. And in some cases, when a response hasn’t felt right, an also potential plethora of self-reflective doubt and questioning can follow: “Did I say the right thing?”; “How am I going with this client? Doesn’t seem to be any progress being made”; “What is the correct intervention to use here?”; “They have been coming for three sessions now, why won’t they volunteer something… anything?!” Being left to one’s own devices (well, me to mine) can leave one unsure at times about particular interventions to use, ways of progressing through impasse, whether or not to refer, whether I am beyond my professional competence, and one’s capacity to be a counsellor, which can undermine self-trust and even self-worth.

And then at other times, when I am feeling in my flow, when I have recognised counselling greatness in myself—you know, when a client has expressed eternal gratitude or you witness a breakthrough or an insight emerges—then I can quite easily develop that very shiny, bulletproof sheen of self-satisfaction and self-congratulation, feeling like the king of the counselling castle! Either polarity can be both misguided and unhelpful to me, I have discovered, and, left alone with such musings, can be a potentially missed opportunity to see beyond my own perspectives and to develop my practice.

Thank goodness we are not completely alone during this, at times, trial by fire. Having practicing colleagues around is such a comforting and valuable scaffold of support. I am fortunate to be doing my placement in a medium-size clinic providing both psychology and counselling services, so there are usually at least a few others to talk to or debrief to if needed. I am aware, however, that others’ placements are more isolated and devoid of such support, and I have witnessed the emotional and psychological strain that this can take. I am very grateful to be developing in the kind of environment where I feel supported and not alone. Hmmmm, maybe there’s a market for a Tinder-like app for counsellors in isolation?

I think there is a limit, however, to how far collegial support can go. There are certainly limits to my own (and I am guessing other humans’) capacity to expose oneself in the workplace. Especially as an up-and-coming trainee counsellor, wanting to exude competence and confidence at every opportunity (I am willing to admit that could just be me, but I suspect not). Clinical supervision during my counselling placement has been a great support and I think the site of my most focussed learning during this Masters and certainly during my placement. I am fortunate to have both group and individual clinical supervision. They are both supportive, instructive and provide opportunities to develop and learn from others’ practice. I have found that it is in individual supervision, however, that I have the greatest opportunity to be vulnerable and to shed light on the more shadowy areas of my practice. It feels a bit safer than group supervision and I like its structure, containment, consistency, and predictability.

Maybe Not Completely

I am fortunate that I was paired with an external clinical supervisor by my university placement team whom I like and respect, but, most importantly, with whom I feel safe. Safe to say (almost) anything to. Safe to expose my insecurities and doubts to, to be able to tell them what I did and said in a session, for example, without any debilitating apprehension. They provide safety and security in calling me out when needed, ensuring I understand my limits and blind spots. Kind of like a parent’s love in providing firm and consistent boundaries to an overly exuberant child. They encourage me and validate me, sharing their own stumbles and falls. But the catch is, as I recognised a while ago, I must be willing to be vulnerable and uncomfortable and wrong, again and again, to gain the most from this. I must be willing to be a beginner again and again and again if I am to grow and develop as a person and as a therapist. But this is hard to do at times. For fear of judgement (self and other), feeling inadequate and for (the generally unfounded) fear of finding out that maybe I am not cut out for this profession. The most satisfying, albeit challenging, learning I have experienced during this placement, and the Masters too, has been exposing myself in supervision.

Like when I reluctantly discussed a client I had seen once whom I suspected to be beyond my scope of competence. Reluctant because I was personally and professionally very curious and they claimed they weren’t in a position to engage in costly treatment options and so I really wanted to keep working with them. And I suspected that if I spoke about them in supervision (and to my line manager) that they would advise referral. But I did. And it was right. And I referred. It was frustrating and challenging, but a great experience to have in the sandpit. And I incidentally had reflected to me my potential for a hero complex. Ouch! But yes, probably accurate. Or when I spoke about how I responded to an awkward situation with a child client and their mother, suspecting I didn’t handle it very well and wanting input. And then getting feedback that challenged as well as expanded me, reinforcing that I really do not know what I do not know as well as not knowing what I do know, too. These things can sting for a bit, but I am a better counsellor for it.

Just like when I have been in therapy myself, the more I am willing to be vulnerable and uncomfortable and reveal those shadowy parts of myself, so too in my counselling role (especially as a trainee), the more I allow this, the more space I make within myself to expand. I make the space for learning and growth and development and career and life satisfaction and ideally to be a more effective therapist and, of course, to do no harm.

***

I recall a brief conversation I had with a university lecturer this year, a seasoned counselling psychologist and academic. I was reflecting on the challenges of not knowing it all and bemoaning if I would ever feel competent as a counsellor. Their response was heartening to me, then and now. They related to this feeling, stating that they still occasionally felt this way. But they also knew that they are a damn good therapist and a valuable resource for their clients. Nice.

Countering Client Hostility with Radical Candor

“No offense, but I don't need self-awareness,” said Michelle. “That's not what I'm paying you for.” After a brief pause for emphasis, she proceeded. “I am not telling you how to do your job, but I need tools!” she demanded forcefully with a pen and notepad in her hand.

Michelle was self-referred after receiving multiple messages from friends and family that she was “difficult to deal with” and that she did not know how to “empathize” with others.

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Caught off guard, I sat silently and nodded. At that moment I felt powerless and ineffective. I also noticed my abdomen brace, as if preparing for a fight. I thought I had been doing well by actively listening to my client and helping her to feel understood. She had a gift for verbosity, which made it almost impossible for me to get a word in. By the end of the first session, however, I felt an impulse to refer her out. I even recall mentioning to her that I would find a list of providers who conducted strict CBT, as it appeared she would benefit from the structure. However, something in me then uttered out, “Let’s try my way first and if, after a few sessions you aren’t happy, I can provide you with some referrals.” I don’t know if I was slightly intrigued by the challenge or that I knew it would be difficult for Michelle to receive treatment elsewhere.

While Michelle’s intensity continued session after session, I began noticing patterns. The session would begin with some pleasantries, move seamlessly into an onslaught of reprobation, and then conclude with a slight glimmer of hope. I had never experienced anything like this.

She would admonish me for the session by saying that “it’s only me talking”—despite not allowing me to speak—and demanding that “in one of these sessions, I am going to need you to do most of the talking.” Further, she compared being in counseling to being in a “hospital” (the first time I had heard this reference).

“Don’t enact your rage on her,” said my own therapist, after I vented extensively about my exasperating and confusing sessions with Michelle. In my therapy, I would go on ad nauseum about how I wanted her to drop out of treatment. I even mentioned how I had dreams of Michelle being much larger than me and picking me up and repeatedly slamming me down. My therapist cleverly pointed out that being with Michelle felt like a rollercoaster ride (I am terrified of roller coasters). My therapist also helped me to realize that despite my criticism and Michelle’s seeming intractable intensity and displeasure with me and our work, she kept returning.

I persisted and became more optimistic over time as I noticed Michelle becoming easier to deal with, which I disclosed to her. She dismissed my praise by stating that I was lying and that the positive reinforcement was incentivized by the fact that she was paying me. I reminded her of how she had been telling me that her family noticed positive changes as well.

One of the strategies that seemed to be effective with Michelle—in addition to the basic attending skills—was my authenticity and self-disclosure. For instance, I disclosed the fact that working with her felt like entering a boxing match, and how I experienced her attitude as an attempt to push me away—even my dream about the rollercoaster.

With regard to payment, Michelle had mentioned the transactional nature of our relationship numerous times. For instance, she once accused me of using her to pay my phone bills. I wanted to be gentle but honest. “You think this is really about the money?”—pausing while Michelle nodded affirmatively—“I lose $700 per month by working with you, not including if you skip a session.” I noticed Michelle smiling. After inquiring about how she experienced my disclosure, Michelle mentioned that this was “good to hear” and inquired further about why I continued to see her at a reduced rate. This led me to mention that based on the way she initially presented herself, it would have been very difficult for her to find another therapist (she also had complained about struggling to find one in the past) and that it would cost her a lot more money for treatment that might not have been as effective (i.e., brief CBT as opposed to more ongoing relationship focused work).

***

Michelle still has moments that make it painful for me to work with her, but I do consider our work to be successful. She is recently much more likely to notice her maladaptive behavior in the moment. She often praises me for her progress, but I do not think I deserve it. I was simply the first person in her life whom she couldn’t push away. I was also honest about how her behavior affected me without discarding her.

I believe that we can do good work with most—if not all—clients if we are willing to travel with them despite their efforts to avoid meaningful connection. I also know that honesty is the best policy when it comes to engaging people who are resistant. Sitting with the discomfort that hostile clients like Michelle can stimulate and being the one person that stands by their side has often resulted in positive change for these clients—and for me.

When Psychotherapist and Client Share Similar Crises

It’s been almost nine months since I found out that my husband has been unfaithful, and my life and world have been turned upside down and inside out. It has been almost nine months of being in a seemingly unrelenting state of shock, disbelief, distraction, exhaustion, and overwhelm. From the start, sitting in my psychologist chair and doing my psychologist thing have felt fraudulent. How can I listen, really listen and comfort another, when I am in this raw and vulnerable place? I can’t say for sure, but I have been. In fact, my job has been the one consistent thing in my life that hasn’t really changed. It has been a welcomed distraction to focus on others rather than spending all of my waking hours being lost in my thoughts and the vast array of emotions that I feel on a daily basis.

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I am an empathic, highly sensitive person who also happens to be a psychologist who can become engrossed in the feelings and pain of others. This is likely why I was drawn to the field. Over time, however, I have learned how to create boundaries between myself and those for whom I care so that I don’t burn out. Yet as a caretaker, the potential for burnout remains ever-present.

Let’s take this one step further. In the midst of learning what the red flag signs were and are and understanding what my legal rights are as a divorcing parent, I recently began working with a woman who is slowly awakening to her sense of unhappiness in her marriage—a woman whose story is eerily familiar to my own. In one breath, it is difficult to reflect back on all of the accusations, fights, and sequences of events that she is facing, and that I have faced and continue to. In another, I can judiciously share some insights with her that I’ve gained in hopes of helping to foster her sense of self, her self-confidence, a trust in her instincts, and to acknowledge and respect her feelings of marital dissatisfaction.

Just as I was met with scare tactics and threats about my own marital relationship and its dissolution, she is too. Rather than becoming intimidated, my hope is to help her find her strength to do her own research and gain her own information to help reach her own conclusions.That is because if her story is anything like mine, she may be thrown off by inaccurate information that will disempower and wear her down.

These sessions have not been easy. On some days, they’re painful, as I listen to her story and feel the visceral reactions that I have and still experience and that she is having now. I experience flashbacks after the sessions, but my hope continues to be to try to change her story in an effort to process my own. On the flip side, I have found that being able to help another person in a similar position is cathartic and empowering for me. If I am able to give another woman a little bit of direction so that she is not blind-sided by the upcoming phases she may pass through, I can begin to find solace in my horrific experience.

Although I am still in the midst of the divorce and grieving process, there are a few things that are helping to keep me chugging along.

Self-Care

As a psychologist, I continually reflect on the need for self-care. However, it didn’t really click with me until I arrived in this very place. Self-care means different things for me right now:
It’s okay if I don’t cook dinner every night
It’s okay if my house is not as neat as it usually is
It’s okay to want to sleep more
It’s okay to want to be left alone
It’s okay to give myself a break and not beat myself over it
It’s okay if I didn’t accomplish as much as I intended because I’m fatigued
It’s okay to cry often

Self-care has also taken on the additional meaning of being forgiving and stopping when I think I should keep going on my to-do list. My sense of self-care has taken on the additional and much-welcomed elements of self-compassion and self-forgiveness for the upheaval that is now my and my children’s life. Self-care is the growing understanding and appreciation that this won’t be forever, but it is for now.
Self-care, at a more basic, moment-to-moment level is also:

Drinking enough water to stay hydrated on the days when I don’t wish to eat or drink
Getting enough sleep
Taking my vitamins
Exercising—walking, jogging, lifting weights, stretching, yoga
Taking a shower
Changing out of my pajamas even on the days when I’m not seeing patients in person or virtually, and accessorizing too
Dying my roots and getting a haircut
Scheduling a manicure and/or pedicure
Scheduling a massage and/or facial

Know When to Take a Break

I like to consider myself a diligent, persevering individual who can push beyond fatigue for the sake of learning something new or helping another person to find emotional relief. That high level of motivation and ability to delay gratification is what helped me to get through earlier challenges, including comprehensive exams, dissertation, licensing exam, post-doctoral training, and all of the other intensive training we psychologists have completed. The downside, if there is one, to my diligence is that I haven’t always acknowledged the importance of slowing down, pausing, putting on hold, rescheduling, or just stopping. My personal and professional experiences have centered around the axiom, “Keep on going until I reach the finish line.”

One thing I’ve learned is that I need—I mean really need—breaks on a daily basis. I need time to stare out my window or sit in the sun. I need to sometimes leave my desk and work on something monotonous like laundry because it’s a welcomed break from thinking so much. It’s okay to take that break even when there are phone calls, emails, texts, case notes, and invoices to prepare. That list will never be short, nor will it ever be “all done.” I’m embracing the unfinished nature of my work and realizing that it’s okay to walk away from my desk or office.

Grieving, Boundaries and Growth

Logically, I know that divorce is a loss, a huge loss. Now that I’m in it, I deeply understand that it is the true death of the life that I thought I was going to have, the life I thought I had, and the loss of the family unit that we created together. The sadness that I feel is quite unbearable on certain days and it drains my energy and results in physical pain (i.e., headaches, stomachaches, joint pain, muscle soreness). This experience gives me a new perspective on having a broken heart. Not only in divorce, but in loss by death and break-ups for people of all ages. Loss is loss.

And now, more than ever, in the shadow of this immense sense of loss and emotional exhaustion, it is an incredibly important time for me to set boundaries around when I start my work day and when I will end it. I am a bit of a workhorse, and I balance my practice with my three children and home life by keeping a hand in all three arenas—all day long. I can’t do this right now. I’m learning to understand that if I invest a few hours into a work project, then I won’t get to the items for my home. I need to let it go for another day or enlist the help of my children. And vice versa; if I invest a few hours into a project in my home, I will not be able to also accomplish work tasks.

This also means saying no to social plans or volunteer opportunities for my children’s school or activities. It means prioritizing what I need to get done and what I have energy for.

***

As a psychologist, I, like many of my professional colleagues, believe that I need to “pull it together,” because that’s what we do and because that’s the implicit expectation our clients have. We are “available” to others, and sometimes, that means our “stuff” has to take the side or perhaps even the back seat. However, what happens when personal issues and conflicts take over? It has and will continue to happen, because we are all humans, and psychologists are no different
 

A Path Towards Self-Compassion and Healing

Foundations of Relationship

To be in an intimate and interdependent relationship with another person is one of the most challenging endeavors in life, which is why conflict in relationships is one of the major reasons many come to me for therapy.

Clients often reach out to me because they are in pain and struggling with a significant relationship break-up. It is particularly difficult for my clients to be in a close relationship with others if they do not have a conscious relationship to their own self. Thus, an important task in therapy is to identify what it means for them to first be in an intimate relationship with themselves. This may include learning how to sit with their feelings of emptiness, being present with their bodily sensations and emotions, and examining their past. Therapy can be challenging, but it also offers clients the opportunity to heal wounds and to reclaim the forgotten and disconnected parts of themselves that may be unconsciously re-enacted in current relationships.

Many women come into my office suffering with low self-esteem, depression, and anxiety. They feel isolated, alone, and long for a sense of purpose in their lives. They long for connection and believe that closeness with another will help them feel complete, that being in love will alleviate their emotional pain. Close contact with others in reciprocal and enduring relationships is both a biological and psychological need, which increases their urgency to be in close partnerships with others.

Many of the relationship problems I work with are fueled by the belief that another person can fill their emptiness and replace the pain with feelings of love and passion. However, as my very wise mother once said, “we fall in love to the same degree that we are lonely,” fall being the operative word. In this context, if a client falls in love out of distress, to fill a void or erase the emptiness, there is a good chance it will lead to more distress. Family therapist John Fogarty asserts that our emptiness and pain are related to our relationship to our most distant parent. If that is accurate, then healing comes when we can help clients reclaim the hurt child of the past and repair their wounds there. If not, they are at risk of getting trapped in the past and replaying their early stories in adult relationships. To help ensure that dysfunctional patterns of the past do not get re-enacted, unlocking and facing the past becomes an important goal in therapy.

The Case of Alana

Alana was referred to me by a clinician from an inpatient substance abuse program who had diagnosed her with Post-Traumatic Stress Disorder (PTSD) and a severe Cannabis Use Disorder. Her clinician explained to me that since Alana entered the program and stopped using marijuana, she had become flooded with horrific memories of child abuse. The referring therapist was concerned that Alana would be at risk of relapse if her PTSD symptoms, which included flashbacks, were not addressed. I have found that it is not uncommon for people to turn to the use of substances to manage their PTSD symptoms of flashbacks and hypervigilance.

When Alana walked into my office for our very first session, her fragility was immediately apparent. She was small in stature, five-feet tall and thin. Her head was down, her shoulders drooped, and she did not make eye contact. She talked softly, almost inaudibly, and had long pauses between sentences. She was easily startled, and when she heard the door in the waiting room close, she jumped, and her body tightened. This was certainly a shaky start for this fragile and uncertain woman.

A year into treatment, Alana entered one particular session smiling and happy. She had had a lunch date with someone she had met through a friend. During lunch they discovered they had a number of commonalities: they both loved animals and had dogs, they loved to hike and travel, they were both teachers and enjoyed working with young children. At the end of lunch, they exchanged numbers and he “promised” he would be in touch. Alana was happy, and I was happy for her. She had worked hard in therapy and was gaining a stable foundation in her life without the use of substances. I interpreted her desire to reach out and make a connection with another person as a sign that she was moving forward in her recovery. Four days after this particular session, I received a call from Alana who asked for an “emergency session” because, in her words, “I am not doing well.” During the session, Alana was shaking and could not stop crying. She said she felt she was going down a dark abyss and was fearful she would never return. She had reached out to me because she was desperately trying not to “spiral out of control.” She was afraid she was going crazy. Contacting me for that emergency session was her attempt to anchor and ground herself. Alana explained the trigger that brought her into the emergency session was that Michael, the man with whom she had been on a lunch date, had “promised” he would be in touch with her but she had not heard from him. In the four days since they had lunch, Alana texted him and tried calling him a number of times, but he was not responding. She drove to his house to check if his car was there and if he was home. The lack of contact with Michael was bewildering, and Alana began to doubt if the positive feelings she experienced during lunch were “one way” and “all in my head.”

Alana’s levels of fear and anxiety were high. In general, I have found that when a client’s feelings are exaggerated and seemingly out of proportion to the current situation, it is a signal that their emotional response has roots in unresolved experiences from the past. When these clients are in a highly emotional, reactive, and anxious state, a rational response actually raises their level of apprehension and serves to exacerbate the client’s sense of disconnection from the therapist. With this in mind, I asked Alana if she was willing to slow down, breathe more deeply, and focus her awareness inward on her body. We had done similar exercises in the past, and Alana was not new to this type of therapeutic inquiry. However, familiarity does not always make this journey any less challenging. It takes courage to sit with and explore the bodily sensations and feelings that are experienced as overwhelming.

I was aware of Alana’s abuse history and her terror associated with feeling abandoned and alone. As a result, I used phrases like “You are not alone—we can take a look at this together.” I could see she found these words soothing and the words helped her to self-regulate. Her face relaxed, her breathing became easier, and her words and the quality of her voice softened. The following is a segment from the session (C represents client and T represents therapist):

T: Is it okay to take a few moments to breathe and go into your body?
C: Yes.
T: What part of your body wants to talk now?
C: My stomach and throat.
T: How do you know your stomach and your throat want to talk?
C: My stomach and throat feel tight.
T: Anything else?
C: My stomach feels tight, like it wants to throw up, and my throat feels like it is hot and on fire.
T: Your stomach feels tight like it wants to throw up, and your throat feels tight like it is hot on fire—anything else?
C: No.
T: Which do you want to take a look at first—your stomach or your throat?
C: Stomach.
T: Is it okay to stay with the sensations in your stomach?
C: Yes.
T: Your stomach is tight and wants to throw up. If you could give it a feeling, what would the feeling be?
C: I don’t know.
T: Breathe… What would tight and wanting to throw up be—mad, sad, glad, or scared? Breathe into the tightness in your stomach, just for a moment. Can you give the tightness in your stomach permission to relax? Then it can tighten up again.
C: It feels scary.
T: Can you stay with scary?
C: Yes—I am alone, and it’s dark.
T: Is it okay to give room for scared and alone in the dark?
C: [With eyes closed she nods yes]
T: Breathe… I am right here with you. What might happen if you let yourself feel scared and alone in the dark?
C: I would disappear and never come back.
T: What would happen if you disappeared and never came back? Breathe and stay with the tightness in the stomach.
C: I would never be able to find my way out of the darkness.
T: What would happen if you could not find your way out of the darkness?
C: I would disappear and be lost forever—I would not know how to find my way back.
T: Can we go into the nausea?
C: [Nods. After a few moments] The tightness and nausea help keep me in my body.
T: So the tightness and the nausea in your stomach protects you and keeps you connected to your body so you do not get lost in the darkness?
C: Yes.
T: Is it okay if we go to the sensations in your throat?
C: Yes—It is tight and hot like it’s on fire.
T: If tight and hot like it's on fire could talk, what would it say?
C: There are no words—just a sound.
T: What sound would it make?
C: A long, wailing cry.
T: Can we stay there?
C: Yes—the wailing cry is the sound of all the fear and pain in my stomach.

Alana started to sob. She was finally able to put words to her visceral experience which, until this moment, was out of her awareness. As the session continued, Alana was able to explore the childhood event that was fueling her current experience with Michael.

C: For as long as I can remember, my father would beat me and pushed away my attempts to get close to him.
T: When was the first time you can remember being pushed away from your father when trying to get close to him?
C: I can remember when I was three or four years old and my father was sitting in the living room chair watching television, sipping on what I know now was a glass of scotch. I was staring at him from across the room. I knew I needed to be quiet and almost invisible so as not to get him upset. While sitting on the floor, I slowly and quietly moved closer and closer in proximity to where he was sitting. I just wanted to be near him and hear him breathing. I wanted some kind of connection. When I finally got close to him, he stood up from the chair, and without a word he kicked me and I curled up in pain. I could hear the door slam behind him as he left our apartment.

Alana was able to stay with the bodily sensations that eventually led her to this memory. As the session continued, Alana made the link between her past and the pain and fear she felt when Michael did not contact her. Over time, Alana came to understand that her relentless and arduous pursuit to contact Michael served as a protective function—to avoid the pain associated with the memory of her father’s abuse. Michael’s lack of contact triggered the despair that she struggled with in dealing with her most distant parent—her detached, angry, cold, and physically abusive father. Alana had spoken about this emptiness and pain in previous sessions. She was keenly aware that her substance use that began at the age of 11 was a way to soothe the pain of rejection and abuse from her father. At these crossroads, when the present felt like the past, Alana was at risk of relapsing and resorting to past mechanisms to self-soothe. For Alana, this included drinking alcohol and using substances.

In later sessions, Alana named this trigger as “wanting connection and being kicked by my father.” Naming the trigger allowed Alana to achieve awareness and take control of her emotions and behaviors when she perceived a disengagement from others. The awareness allowed her the space and time she needed to self-regulate, re-evaluate, and think of more appropriate and rational responses to perceived rejection.

When Alana finally heard from Michael, he explained that he had not been in contact because his father had a heart attack and Michael was called home to be with family. Michael also explained to Alana that he did not think this was a good time for him to begin a relationship, because his free time would be spent with his parents during his father’s recovery. I also assumed that Michael was overwhelmed by Alana’s frantic attempts to get in touch with him. Alana’s desperation had its origins in her early life experiences. Michael became an object of Alana’s distress, which was manifested in the barrage of compulsive texts and phone messages. This objectification contributed to the rupture in their relationship—a rupture that occurred soon after meeting one another, when the lack of a strong relational history did not promote efforts towards a possible repair.

As with most of my clients who experience trauma-related distress, Alana expressed a desire for a secure, comforting, and safe relationship. Despite this desire, Alana’s connections with others could be depicted as highly dysregulated, frantic, and fraught with friction and misunderstanding. Many of the women I have worked with who have histories of trauma are more likely to undergo autonomic nervous system (ANS) responses of fight/flight and/or shutdown/collapse. These physiological states are mechanisms that assisted them in surviving overwhelming physical and/or emotional experiences. However, over a long period of time, after the threat passed, these states no longer served a protective function. Instead, fight created more animosity, flight kept them running in fear, and collapse didn’t allow them energy to live life fully. Eventually, these protective states interfered with their ability to think clearly and make thoughtful decisions. In Alana’s situation, the lack of response from Michael put her in a hyper-aroused state, causing her to be vigilant and unable to maintain calm, think about consequences, and come up with alternative solutions. From this hyper-aroused position, Alana misinterpreted Michael’s distance as rejection and responded with a high degree of emotional intensity and pursuit behaviors. Her attempts to restore the connection was her misguided approach of trying to soothe the feelings of terror associated with being kicked and rejected by her father. Alana believed (just as her three-year old self had) that her only relief from the pain and emptiness was through reconnecting with Michael.

My goal with Alana and clients with similar challenges is to bring the unconscious to conscious awareness by remembering and examining the early experiences and emotions that fuel their current reenactments. One method I have used in many cases is exploration of core beliefs, which creates a psychic prism from which all experiences and relationships are perceived. In therapy, I explore core beliefs with my clients, the feelings attached to each belief, the origins of the belief, and how the belief and feelings are exhibited in present-day behaviors and one’s worldview. Beliefs often include, but are not limited, to such thoughts as “I am defective,” “unlovable,” “a misfit,” “alone,” or “a failure.” The associated feelings are just as varied and include feelings of grief, sadness, loneliness, shame, anger, and fear. If an individual’s core beliefs and the source of those beliefs remain out of awareness, then the person is at risk of reenacting the past in the present, always with the hope of a different and more affirming outcome. The chronic, painful, and recurring patterns of our lives can be reframed as our younger and fragmented parts of self that are calling out for attention.

The child in all of us hopes to be seen and heard, yearning to be found and reclaimed. This can be framed as a call to bring us back to ourselves. It is in reclaiming our earlier selves that our emancipation and release from the past begins, and that we can start our journey toward rebuilding lives that resonate with our authentic intentions, desires, and values.

Clients with complex and relational traumas share stories of unthinkable acts of abuse that they experienced as children. For many clients, the therapeutic process challenges what they have learned in order to defend, protect, and keep themselves safe and, for some, to stay alive. The therapeutic journey requires the client to expose their vulnerability, fragility, and imperfections. For survivors of trauma, to be vulnerable is equivalent to being weak and at risk for being hurt. Thus, to allow themselves to be vulnerable takes great courage. Courage is the place where they confront fear, anger, sadness and/or shame. However, clients also bring hope—hope that somewhere, in all the confusion, desperation, and negative internal dialogue, life can be different, and that on the other side awaits a better way of being and living in the world. When the client doesn’t have hope, the therapist can hold it for them.

***

The women I interviewed for my book on survivor moms emphatically stated that their relationships to their therapists served as the model they used to develop healthy relationships. The therapist and the therapeutic process taught them how to effectively communicate. In therapy, they learned how to listen, ask questions, talk about feelings, solve problems, tolerate strong emotions, and stay composed when engaging in difficult conversations. Their therapists offered the means to increase feelings of self-worth, enhance self-care, and create a compassionate connection to themselves. This fostered inner confidence and the capacity to develop healthy and intimate relationships with others. Their therapists’ abiding presence offered them an opportunity to sit with, feel, and explore their deepest wounds in a safe and contained relationship. The therapeutic process also afforded the opportunity to become more deeply attuned to themselves and others and enabled an understanding of both the vulnerability and resilience of being human. The knowledge, tools, and wisdom that comes from one’s own healing could then be transferred to the ways they interacted and responded in their relationships with intimate partners, family, friends, and, as importantly, with children—the next generation.

Imagining the Way to Self-Compassion Using the Ideal Parent Figure Protocol

“I know I’m supposed to be self-compassionate, but I don’t know how to do that, and that makes me feel even more like crap!”

My patient Sally has struggled with years of chronic depression. Through hard work in therapy, she understands that her rough childhood has set her up with a tendency to be harsh with herself. She understands that energy wasted on self-criticism and negative emotion leaves her less free to take initiative and connect with others. But when she wakes up in her apartment alone, all that wisdom seems to fly out of her head, and she feels crushed by a load of self-loathing.

Much the way we learn language, we learn patterns of relating to ourselves early in life. John Bowlby and researchers who followed him described this process as the formation of secure or insecure attachments to a caregiver. People lucky enough to have warm and sensitive parents can develop a secure attachment, which leads to the development of kind and encouraging ways of being with oneself. This inner soothing and encouragement support brave engagement with the world that helps reinforce a sense of the self as capable, and of the world as responsive to one’s needs. A smoothly functioning emotional system allows wise choices in response to the present situation in accord with one’s values.

For those who did not internalize a relationship with a sensitive and encouraging caregiver, life is harder. They can become overwhelmed with feelings of shame, helplessness, anger, and fear, or they may feel depressed, deadened, or cut off from experience. Unregulated or silenced emotions inhibit healthy exploration, which reinforces negative images of the self, generating further negative emotion and inner harshness. Self-compassion can seem like a strange and distant land.

Enter the Ideal Parent Figure visualization protocol, developed by Daniel P. Brown, PhD. as a method for healing attachment disturbances in adults (1). His method relies on the fact that the unconscious mind does not distinguish between images that derive from memory and those that come from the imagination (in fact, most images that we think of as memories are imaginary reconstructions of events). With deliberate visualization practice, we can come to “know” something we did not directly experience. In this method of treatment, I ask Sally to visualize herself as a young child and to imagine ideal parent figures that are perfectly suited to her and responsive to her needs. From there, I ask her to imagine herself playing and exploring with the ideal parent figures offering perfect support and encouragement. Once that imagery has been established, we will have her use these Ideal Parents to respond to her in moments of distress, giving her a visceral sense of an attuned, soothing, and encouraging relationship, and a vivid sense of how she can treat herself.

Sally was dubious. “That sounds kind of cheesy,” she told me. “Also, I can’t really imagine what ideal parents would be like.”

That’s exactly the point. Kids who grow up with parents who were unable to provide good-enough care will stop hoping for something that never comes. We protect ourselves by not thinking about what we can’t have, which reduces the pain but, if practiced repeatedly, can create a deliberate (though unconscious) failure of imagination. The Ideal Parent Figure visualization protocol seeks to reverse that. It turns out that no matter how terrible and abusive one’s childhood was, each of us knows what we needed to thrive. I find this to be a wondrous and hopeful thing.

Ideal Parent Figure visualization uses the process of exploration to discover the kind of support that fosters further exploratory behavior. This method provides a solution to Sally’s frustration of “not knowing how” to be self-compassionate: she will explore until she comes upon the experience. As the therapist, I will provide her with support and light guidance as she navigates this uncharted territory. I’ll be prompting her to imagine Ideal Parent Figures who have five key features: 1) The Ideal Parent Figures are reliable and consistently present—they provide a deep sense of safety and refuge that creates a secure base from which to explore. 2) The Ideal Parent Figures are perfectly attuned; they see us and accept us exactly as we are, which sets us free to be completely and authentically ourselves. 3) The Ideal Parent Figures know exactly how to soothe us, so if we get distressed or over-excited in our exploration, they help us settle down, so we can return to pursuing what is interesting and meaningful to us. 4) The Ideal Parent Figures are delighted by us. We can see their faces light up when they connect with us—not because we have achieved or accomplished anything, but because of our being ourselves. 5) Finally, the Ideal Parent Figures understand we are growing and developing, and they encourage us to become our best selves.

Importantly, the specific imagery comes from the patient herself; she is tapping into the wisdom of her own imaginal experience to create parent figures ideally suited to her. And because these figures are ideal, they will provide a source of support and resiliency more effective and powerful than anything a fallible, human parent or therapist can provide.

Insights during Ideal Parent Figure work often have the feel of a lightbulb turning on. The insights my patients have experienced have included the following:

“My parent figures would NEVER hurt me. They are strong enough to protect me.”

“When I feel safe, I naturally get curious and want to explore.”

“My ideal mother figure understands my mistrust, and she doesn’t pressure me to come close before I am ready.”

“My parent figures don't turn away while I am angry. They stay interested and want to know why I am upset. It’s okay to be angry.”

“My ideal mother figure is delighted by me, even when I am being bad and she is setting limits—I can see it in her eyes.”

In our first few sessions, Sally quickly became frustrated. “Nothing is coming up, I can’t imagine anything.” This frustration is normal and is a sign that she has come to the “edge of her imagination.” Exploration requires trying things, running into blind alleys, trial and error, persistence. “That’s good, keep going,” I encouraged her. “Imagine that your ideal parent figures are with you, sensing exactly what is wrong and responding in exactly the right way. They love being here with you as you explore. They know you can figure this out, and they will stay with you as long as you need, for hours, days, weeks, or even years. Imagine what that would be like.”

In our fourth session, Sally’s imagination “popped.” “They know I can get this!” she said with a smile, “that’s how they can be so patient. They’ll stand by me as I figure this out.” Her expression changed, and what followed was an eruption of grief she had missed out on when she was little. She broke into deep sobs while imagining being held, forever if she wanted, by her ideal mother. The moment was anything but cheesy. Afterward, she felt an unusual sense of peace and hopefulness.

After that point, when that feeling of frustration or sadness emerged during visualization practice, she could reliably call up the image of her ideal mother to soothe herself. Becoming more confident, she started to have fun and looked forward to visualization sessions. Meanwhile, she reported that her mood improved, it had become easier to get things done, and she was reaching out more in relationships. “Well,” she told me with a smile, “I think I’ve figured out how to be self-compassionate.”

References

(1) Brown, D. P., & Elliot, D. (2016). Attachment disturbances in adults: Treatment for comprehensive repair. W. W. Norton and Co.

Many thanks to George Haas of mettagroup.org for his exploration of the language of encouragement.
 

The Upward Arrow and the Golden Rule

My client Leslie sits across from me, her shoulders slumped. She has come to me for help with her marriage. Despite having a core of love for each other, for many years Leslie and her wife have been sharing mutual recriminations and dismissals of each other’s feelings. Their marriage has moved through time like a net, trapping resentments. We’ve been focusing on a moment when she complained to her wife about a critical comment her wife made about her in front of their kids.

I ask her the “Miracle Cure” question to clarify her goal in today’s work. “Let’s imagine that a miracle happens, and you got exactly what you wanted out of this session. What would that look like, what would be different?”

“She would see that I’m right, and she’d apologize,” she responds quickly.

Like so many people who say they want to improve their relationships, Leslie is stuck in blame. She is having a hard time conceiving anything that could help the relationship beyond having her wife do the changing.

As Dr. David Burns (1) has pointed out, a stance of blame is incompatible with healthy intimacy. When we blame, we fall into distorted thinking patterns and place all the badness and problems on the shoulder of the other person. In doing so, we cast ourselves in the role of victim, powerless to effect any changes that would move us to our goals. But the problem goes further than that. Relationships are reciprocal—when we approach someone with blame, they will naturally respond in kind. The Golden Rule is fundamentally a self-compassionate one: treat others as you would like them to treat you…because, well, what comes around goes around.

But how to help Leslie feel that with her heart, and not just in her head? In previous sessions, I had validated the hurt behind her wish and then redirected her, reminding her that her wife wasn’t asking me for help and that any changes need to come from Leslie herself. But today, I encourage her. I call this line of questioning the Upward Arrow, akin to the technique called the Downward Arrow. In the Downward Arrow technique, we ask a person why a negative thought is upsetting, which leads them to make contact with the negative beliefs that underlie the thought. In the Upward Arrow technique, by contrast, I ask my patient to elaborate on her wish for her wife to acknowledge her as right and apologize. The goal is to help her make contact with the healthy longings that underlie the problematic wish.

At first, she is confused by my line of questioning. She closes her eyes and shakes her head. She has a hard time imagining her wife apologizing. I encourage her to keep going, even if she draws a blank at first. She makes another try, but her anger and bitterness reemerge.

“She never listens, she’s always poo-pooing my feelings.”

I redirect her gently back to the task at hand. “Yes, you’ve felt so dismissed by her. See if you can put those thoughts aside for a moment. Instead of thinking about how badly she has been treating you, let yourself think about what you’d most want to hear from her. You said you’d want her to see that you are right and to apologize. That makes so much sense to me—can you elaborate on that? What would that mean to you, why is that important?”

“Well, it would mean she understood me. We wouldn’t have to keep arguing all the time. I wouldn’t have to keep defending myself.”

“Yes, that would be so much better, wouldn’t it? And can you keep going? Why would you want that, to not have to argue and defend yourself?”

A look of sadness crosses her face, and her eyes moisten.

“I could let my guard down, and relax, and just tell her how I was feeling. I could just be myself with her.”

“That would feel so good, wouldn’t it? To just be able to be yourself, without worry.”

“Yes,” she softens, “that would be such a relief.”

“And what would it be like to be with her, if she apologized to you, and you were feeling able to just be yourself?”

“We’d be on the same team. We’d be able to work together instead of fighting with each other. We’d be better parents.”

 “Close your eyes for a moment and really imagine that. What would that feel like, in your body, to be with her like that? What sensations do you have?”

“I feel calmer. My chest feels more open. I feel like I can breathe.”

Can you see what is happening here? She is starting to self-regulate, using her own imagination. She doesn’t need her wife to say exactly the right thing—with a little guidance she can bring herself to this state of mind. She has woken up to her own self-compassion using an idealized image of a partner.

I bring her out of the visualization and check-in. She’s still enjoying a feeling of ease.

“And you know what is cool?” I ask her. She tilts her head, inviting my answer. “You came to this state without her having to be different. You didn’t need her to say the right thing to be able to feel this sense of ease. This is something you created in yourself.”

“Yeah,” she nods. “Just imagining being treated this way allowed me to relax and be less defensive.” She widens her eyes as she realizes something. “And what is also interesting is that I feel more warmly toward her.”

“When we started this conversation, you said what you most wanted was for her to see that you are right and apologize.”

She gives a short laugh. “Yeah, that would be nice, I guess. But what I want more is for the two of us to be on the same page.”

She pauses, then continues. “What if I accept that she’s feeling hurt and defensive too? If I treat her the way I want her to treat me, maybe she’d relax and be more open to working this out.”

“I think you have just articulated a famous rule,” I notice.

“A golden one!” she says with a smile.

References

(1) Burns, D. (2020). Feeling great: The revolutionary new treatment for depression and anxiety.
PESI Publishing and Media.
 

Center of the World

“She tells me I’m completely self-absorbed, that I’m acting like I’m the center of the world. I’ve spent our last three years trying to figure HER out and how to connect with her! How on Earth is that self-absorbed?”

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David Burns, creator of TEAM-CBT (which stands for Testing, Empathy, Agenda Setting, Methods), teaches us that a key moment in diffusing a conflict comes when we use the Disarming Technique. Instead of defending ourselves, we lay down our shields and find something to agree with in what the other person has said. But however much we may tell ourselves we want a good relationship, many of us find this step challenging. How can we agree with something that feels so wrong and unfair? And what happens when we see the kernel of truth in an accusation?

“It wouldn’t be honest for me to agree with her that I’m completely self-absorbed.”

“I have to agree with you,” I tell my patient, and we both smile as he recognizes me using the disarming technique with him. “You aren’t completely self-absorbed, or you wouldn’t be trying to improve the relationship.”

He sits back in his chair, tilts his head and motions for me to keep talking.

“So, is there anything you could find to agree with in what she said. I mean, really whole-heartedly agree with?”

“Well, I can agree that she seems to think I’m self-absorbed!”

He’s making a common mistake in the disarming technique—we call this a ‘faux disarm.’ “How would you feel hearing that from someone?” I ask him. “Suppose I said to you, ‘Dave, I can see that you really seem to think I’m self-absorbed.’ Would you feel heard and validated?”

“Um, no,” he said with a touch of sulkiness. “I just don’t feel like I’m being self-absorbed! I’ve been working so hard to figure out how to connect with her. When she throws that at me, I feel so taken for granted.” The muscles in his jaw tightened. I see I may have pushed him too far. In TEAM-CBT, the correction for this is to ‘fall back’ to empathy and what is called ‘paradoxical agenda setting’ in which we support someone’s good reasons not to change.

“You have been working really hard on this,” I agree. “You said you feel taken for granted. I can imagine you must have felt pretty hurt and angry when she said that to you. And maybe you are also feeling hurt and even a little annoyed with me right now. Am I reading you right?”
He nods, silent, his face shifting from anger to sadness; his jaw relaxes. “I was a little annoyed at you, but I get it, you are trying to help me. It’s okay, let’s keep going.”

I’m hearing that he’s trusting me, so I move forward, but rather than continuing to push him directly as I did before, I shift to using paradox to support his resistance, and give voice to what I think is holding him back. “Maybe at a moment when you are feeling that hurt and angry, it’s understandable that you aren’t wanting to get close to her or see where she is coming from. Your priority is to protect yourself.”

This seems to have landed. He nods ruefully. “That’s right.” He puts his hands over his eyes for a moment, turns inward. “When she hurts me like that, I do want to defend myself.”

I stick with supporting his resistance. “Ouch. That makes sense to protect yourself from that pain.”

He doesn’t respond right away. I let the pause linger, sensing that something is shifting. “But I care about her, and I do want to understand where she is coming from, not just protect myself.”

He’s starting to convince me that he is ready to lay down his defensiveness, but I stay paradoxical to see if he’s really committed to working in that direction. “But is that wise? You said she hurts you.”

“It does hurt, but I don’t think she really wants to hurt me.”

“Where does the hurt come from?”

He makes a face. “Oh, you’d probably say it’s because I’m stuck on the idea that I should never be self-absorbed.”

I shrug an acknowledgment, “Yup, I probably would say that a belief like that would cause pain.”

He gives me a small smile. “Thanks, as it happens, I agree with you. And I get it. Of course, she’ll experience me as self-absorbed if all I’m doing is defending myself. But I don’t always do that. Isn’t she giving me one of those distortions you talk about, all-or-nothing thinking? I still don’t want to agree that I am completely self-absorbed.” He chews on this for another moment. “Maybe I don’t have to agree that I’m completely self-absorbed, just that I’m being self-absorbed at that moment?”

“I like where you are going with this—it sounds like you have found a kernel of truth in what she said. What would that sound like if you told her that?”

“Well, how about ‘Samantha, you are right, I’m being self-absorbed right now.’”

“Nice,” I respond. “How does it feel to imagine saying that to her?”

“It’s humbling,” he replies, and I see a mix of feelings on his face. “I feel sad realizing how many times I’ve been too busy defending myself to hear what she’s saying. No wonder she feels like I’m always being self-absorbed. And at the same time, I’m noticing that I’m actually starting to feel curious about what is going on with her. And that feels much better than defending myself.” His face opens as he looks at me. “Have you ever heard that expression, ‘I’m the piece of crap at the center of the world?’” I give a laugh, and he continues, “It’s a relief not to be the center of the world!” 

Blind Side

Empathy Creates a Blind Side

“Empathic personality style” has a nice ring to it. In counseling classes and practicums, we are taught the importance of empathy and how to convey it to our patients. Empathy is part of every counseling skills curriculum, yet much of its application, the post-coursework expression of empathy, emanates from one’s persona, not from a professor or a textbook. We know empathetic traits when we see them. A smile and a thumbs up gesture, a phone call to a friend after a major event, a pep talk during a rough patch at work are all perfect examples, worthy of Hallmark commercials. If such gestures are second nature, then this is a good thing — right? Many therapists were first prompted by a strong innate level of empathy to become interested in psychology. A curiosity about others, a sense of what it may feel like to be them, and a motivation to help them with improvement are all essential traits for therapists.

Empathy Without Caution

There isn’t a paint by numbers pathway to success in any one profession, but there seem to be similarities in the backgrounds of those who enter the helping professions. Often, the adage about circumstances not making a person but revealing them applies. Is it that the sensitive person meets emotionally charged circumstances or that such circumstances bring out one’s capacity for sensitivity? We all know correlation does not prove causality, but correlation is not to be dismissed. As I reflect on my own peer supervision groups, early counseling classes and colleagues, so many of our histories seem like chapters in an open book, clear as day in my memory. The caring guy who returned to grad school to build a new career after a bitter divorce from a woman with untreated alcoholism. The A-student who began to address unresolved issues with her critical father. And there was Lisabeth, my former supervisor and mentor, who grew up in an emotionally abusive family where her parents were charming to the outside world and could teeter on being just healthy enough when on display. Their personas had so much flip-flopping that the dichotomy drove her nuts at times. Finally, my own abandonment by my father and the ripple effect of his abusive behaviors that predated his leaving. Therapists tend to have emotionally rich histories and a capacity for a rich emotional awareness. But are these histories and qualities enough to ensure future success as a clinician?

Just as it is physically impossible to be in two places at the same time, it is impossible to fully operate from more than one emotional state of being. Often, therapists don’t shift easily from the mode of helping a patient in the professional realm to the mode of self-protection in the private or social realm. Factor in the dynamic of therapists’ innately having sensitivity towards the point of view of others, and it is easy to understand why therapists often have a blind side when it comes to looking out for themselves.

Mary’s Story

Mary was the picture of the YAVIS patient as she sat on the couch across from me, smiled politely and asked if I was ready. She was new to working on her own therapy but had been a therapist working with veterans and their families for about seven years. She had graduated from a prestigious university and had a quality of poise and presence.

After polite pleasantries, Mary’s face suddenly seemed to fall into her hands. She was talking in fragments, hands now molded to her face, and I had to fight the urge to ask her to speak louder.

“He told me I was making him crazy. He said I had no right to hate his family.” She became silent, as if she were digesting what she had just said. Therapeutic silence seems to move five times slower than real time. She then smiled and her voice became stronger.

“Don’t you just love recent history? Such a tricky phrase that takes you into two different directions at the same time. If it were so recent, it wouldn’t really be history, now would it? And is history ever really history? There is no such thing in the Land of Oz and certainly not in therapy. But I guess that is where we start, of course. How in God’s name one Ken doll protégée could morph into…”

“She started laughing to the point that any more would have been like a Bette Davis scene from Whatever Happened to Baby Jane“.

We were close to ending the session and Mary sounded close to ending her marriage, citing endless criticisms she had endured. The criticism and “picking,” as she called it, typically happened when they were alone, but had recently expanded to being played out in front of others. Often, their audience was his children. Steve had two grade school age daughters from his first marriage. Mary described Steve as being fragile during their courtship.

“At times I’d come away from an evening or early morning with him to head back home and feel like I had to shower all of his pain off me. He would start out as a strong, strapping guy wanting to take me to dinner, movies, or whatever, but by the time the evening took off, it was texts with his ex-wife and children, a sad, vacant look in his eyes and tuning out whatever was left of our conversation, followed up with, well, odd word, but — pleadings for me to see him again.”

I was just about to ask her what that was like for her, but she continued her recall and continued making it all about Steve.

“It was just awful for him.”

I pursed my lips to keep from saying too much after my one-word response of “Him?” followed by what a client used to call my owl-eye stare.

“Well, him, yes, at that time. I know what you’re getting at, but I was okay with him being the center focus at that point. Relationships are like seesaws, and this was the time for me to lift him up.”

“Mary, can you pinpoint at what point it became not okay for you? At what point was Steve’s behavior towards you not okay?”

Through hands that made their way in nanoseconds back to her face, Mary cried suddenly.

“I became a laughingstock. He made it so. Right in front of his kids, ex-wife, ex-neighbors. It had been a risky proposition for me to even go, but then…” Tears formed and she grabbed a tissue from the end table and dabbed her eyes in what seemed like a deliberate patten of four dabs each eye before continuing, “He posed for family photos with his ex and children, ignored me the entire night. “It was as if he was deliberately trying to break me”. I left with him feeling like the child I used to be when my mother and sister each forgot to pick me up from school and I had to ask my teacher for help.”

She threw out the term “gaslighting” as she described the ride home with Steve after the party at his ex’s. Her slightest bit of revealing her feelings was met with Steve’s psychological evaluation of her and “diagnosis” of immaturity. In the next breath, she said, he practically begged her to stay the night with him, that he needed her and would think about what she had said. She was shaking her head as she described ignoring her own upset in exchange for focusing on his wants. It seemed like her emotional pendulum would swing often in this relationship. In a possible attempt to distract from looking at her pattern of focusing on Steve at her own expense, she asked if now was the time to recap her toilet training and her childhood in England. I thought about redirecting her back to the car ride but decided to let this pattern of putting others first, even when their behavior was abusive, have a wider net that could possibly include her life before Steve. My expression of encouragement by curiosity was enough prompting.

“I was always okay, you know. I was the nurse when we kids would all play hospital. Funny, not the doctor, anyway, nurse it was.”

“You can picture it?”

She nodded, “Oh, clever.” Her face became once again hidden by her long hair and her hands, but I knew she was crying. I was prepared to keep her focus on what Mary described as cold, unaffectionate parents and then later in future sessions delve more into the present ground we had initially covered. However, like a detour on a road trip that leads to more and better, Mary processed a direct link between her teenage years and her marriage. Though my own bias and historic blind side in therapy is to identify a plan of action, I yielded and let Mary’s insight be the focus. Insight about trying to win her parents over and this being replayed in her marriage took the focus of the next few weeks. Forever the Freudian, Mary described seeing repetition compulsion in red ink every time she saw her husband. The cognitive behaviorist in me saw this as a concrete decision on her part to change her thinking. No matter the modality, the door was open, and Mary was about to walk through it to freedom.

“Mary recalled baking pretend cookies for her mother when her father was working late and saving a couple “cookies” in a tin for when her dad came home”. She described singing and dancing whenever he was around. Our mutual smiles were slammed shut when she jumped up and started stomping, hands on hips.

“I cowered in the corner when my father’s arrogant, holier-than-thou, pseudo-intellectual family mocked me for having a lisp. And what did I do whenever this happened — and always did whenever any of them seemed displeased? I’ll tell you. I sucked up. I kissed ass. I was a doormat baking fake cookies and singing songs and learning to be gutted by predator animals in the real world my whole fucking life.”

I hesitated before asking what the baking fake cookies behavior looked like in her teen and adult years. She smiled, “I became a good listener. An observer of everything. A helper. The teacher’s pet, the best daughter, sister, student, friend.”

“Others could rely on you for understanding and caring. How did that benefit you?”

Smiling after another pregnant pause, “Well, people don’t bite the hand that feeds, especially while they’re being fed.”

***

Therapy eventually became targeted on how Mary had learned to focus on others at the expense of caring for herself — the origin of her blind side in both her professional and personal life. Mary had simply adapted to focusing on the needs of others, at the expense of her own. Effective personal and therapeutic confrontation were already in her toolbox, but what was needed — what we worked on — was creating another kind of therapeutic confrontation. This was one through which she implemented an internal filtering system that she could use in order to silently confront other people’s words and deeds to herself. Not an actual confrontation, since it was to be only internal; however, it would be as real as those formidable fake cookies. Actual external confrontation was the homework for future sessions.