Category: Trauma/PTSD

How to Avoid Burnout and Find Joy in Corporatized Care Settings

Posted on by Psychotherapy.net Team

As a clinical supervisor and marriage and family therapist, I’ve encountered, as most in our profession have, a challenging paradox entrenched within today’s corporate landscapes: while our mission revolves around healing others, we often find ourselves navigating environments that overlook our own well-being. This striking contradiction serves as a wake-up call, signaling a pressing need for a radical overhaul in how we perceive and implement mental health care within corporate structures. It’s a reality I’ve witnessed firsthand as I guide my supervisees through overwhelming caseloads, intricate cases, and resource constraints; where chronic stress, pervasive burnout, compassion fatigue, and moral distress become all too familiar companions on our journey.

This reality underscores the urgency for change. Creating sustainable healing environments demands a fundamental shift in our approach — one that goes beyond individual self-care and embraces a paradigm of structural support rooted within organizations. In this article, I will explore the intricate dynamics of healing within corporate entities, aiming to shed light on the myriad factors influencing mental health care practices. Furthermore, I will confront the complicity of corporate structures in perpetuating the challenges faced by mental health professionals. This exploration serves as my call to action, as I advocate for a more compassionate and empowering approach that not only supports the resilience of mental health professionals but also enhances employee retention and overall well-being within organizations.

The Toll of Healing

Pressures in Practice

One of the most glaring issues facing mental health professionals in corporate settings is the overwhelming caseload they tackle daily. According to research, these professionals often find themselves swamped with numerous cases, leaving little time for rest or reflection (1). Moreover, the complexity of these cases adds another layer of challenge to their already demanding workload. The intricate nature of cases handled by mental health practitioners highlights the considerable cognitive and emotional resources required for effective navigation (2).

In conversations with my supervisees, a recurring concern emerged: many felt they had no time during their workday to engage in essential tasks like case conceptualizations. This left them grappling with their clients’ issues even after leaving the office, encroaching on their personal time meant for family and relaxation. Several of my supervisees expressed frustration over this predicament. They found themselves unable to fully switch off from work, constantly mulling over client cases while at home. This not only affected their ability to unwind but also strained their relationships with family and loved ones. In essence, the boundary between work and personal life blurred for these mental health professionals, highlighting the need for more support and resources within corporate structures to enable them to effectively manage their workload and maintain a healthy work-life balance.  

Adding to these challenges is the pervasive issue of resource deficits within corporate mental health settings. Roth (3) shed light on the scarcity of resources such as time, funding, and institutional support, acting as persistent barriers to effective mental health care delivery. This limited access not only hampers practitioners’ ability to provide comprehensive care, but also exacerbates feelings of frustration and helplessness.

Consequences

The cumulative impact of navigating overwhelming caseloads, intricate cases, and resource deficits reverberates throughout mental health care, resulting in many adverse consequences for practitioners. Chronic stress, a prevalent outcome of prolonged exposure to high-stress environments exacts a significant toll on mental health professionals’ physical and emotional well-being (4). The incessant pressure to meet the demands of their caseloads while contending with limited resources contributes to a sense of perpetual strain and unease.

Burnout, another pervasive consequence of the relentless demands placed on mental health professionals, manifests through emotional exhaustion, depersonalization, and a diminished sense of personal accomplishment (5, 6) underscores the toll of burnout on practitioners’ professional efficacy and personal satisfaction, highlighting its detrimental effects on both individual well-being and organizational effectiveness. Moreover, the phenomenon of compassion fatigue emerges as a significant concern within the field, as mental health professionals become emotionally drained and desensitized to the suffering of their clients. The empathic engagement required to provide effective care can exact a heavy emotional toll, leading to feelings of emotional exhaustion and detachment.

Furthermore, moral distress, defined as the psychological anguish experienced when individuals feel unable to act in accordance with their moral beliefs, further compounds the challenges faced by mental health professionals (6). The ethical dilemmas inherent in navigating complex cases within resource-constrained environments can evoke profound feelings of moral distress, contributing to a sense of moral injury and moral erosion among practitioners (7).

One of my supervisees faced a challenging case involving a client experiencing severe trauma that required Eye Movement Desensitization and Reprocessing (EMDR) therapy instead of traditional talk therapy. However, institutional policies limited the client’s access to EMDR sessions to only one per week. Despite our recognition of the urgent need for more frequent sessions to address the client’s trauma effectively, they felt constrained by these policies and unable to provide the recommended level of care.

As the supervisee continued to engage with the client’s case, they began to experience symptoms of compassion fatigue. The emotional toll of witnessing the client’s distressing experiences day after day left them feeling emotionally drained and desensitized. They struggled to support the same level of empathy and engagement that they once had, leading to a sense of detachment from their work.

As the demands of their caseload persisted and the constraints of institutional policies became more apparent, the supervisee eventually found themselves experiencing burnout. The emotional exhaustion, depersonalization, and diminished sense of personal accomplishment became overwhelming. Despite their dedication to their clients, the supervisee felt increasingly disillusioned and disconnected from their work, questioning whether they could continue in their role as a mental health professional.

In summary, the toll of healing within corporate mental health settings is multifaceted and profound, encompassing a range of challenges that imperil the well-being of practitioners and compromise the quality of care provided to clients. Addressing these issues requires a comprehensive understanding of the systemic factors contributing to practitioner distress and a concerted effort to implement structural interventions that prioritize practitioner well-being and enhance the resilience of the mental health workforce. It is imperative that organizations acknowledge and address these challenges head-on, fostering a supportive and nurturing environment that empowers mental health professionals to thrive in their roles and deliver optimal care to those in need.

The Irony of Healing

Contradiction in Practice  

I’ve witnessed firsthand the struggle mental health professionals face in prioritizing their own well-being while caring for others. This paradox is deeply ingrained in societal expectations that prioritize clients’ needs over practitioners’ self-care, perpetuating a harmful cycle of neglect and burnout. This cycle of neglect and burnout is deeply entrenched in societal expectations (8).

Despite my expertise in promoting mental wellness, I've observed many professionals, including myself, grappling with implementing self-care practices due to time constraints, stigma, and the normalization of overwork within the field (9). Moreover, the demanding nature of our work — dealing with trauma, emotional distress, and crises — often leads to emotional exhaustion and blurs the boundaries between professional and personal life, making it challenging to maintain a healthy work-life balance.

The contradiction inherent in the mental health profession, I purport, is exacerbated by systemic factors entrenched within corporate structures. I’ve witnessed the negative impact of hierarchical power dynamics, productivity pressures, and a pervasive culture of perfectionism as they dissuade mental health professionals from seeking support or acknowledging their vulnerabilities (10). Consequently, practitioners find themselves compelled to prioritize productivity over their own well-being, resulting in heightened stress, burnout, and diminished job satisfaction.

I have seen many pre-licensure practitioners facing significant challenges in accessing essential mental health support due to financial constraints, particularly with the burden of student debt. This lack of corporate prioritization and support directly contributes to the scarcity of resources, such as adequate time and financial assistance, leaving many practitioners struggling to afford essential mental health services. This systemic inadequacy further compounds the challenges faced by mental health professionals, exacerbating the toll on their well-being and hindering their ability to provide optimal care to their clients. 

Change to Address the Self-Care Deficit

In my assessment, addressing this irony demands a fundamental overhaul in how mental health care is perceived and administered within corporate frameworks. Instead of relegating self-care solely to individual responsibility, I recommend that organizations acknowledge it as a collective pursuit necessitating systemic backing and resources. Recognizing the intrinsic link between caregiver and client well-being, I suggest that corporations dismantle the obstacles upholding the cycle of neglect and cultivate environments that promote sustainable healing.

Self-Care Deficit Theory states that individuals possess an innate capacity to engage in self-care activities to uphold their health and well-being (11). However, when individuals face physical, psychological, or developmental limitations that impede their ability to meet these needs, a self-care deficit arises, leading to adverse health outcomes. Applying this theory to mental health professionals within corporate settings, it becomes evident that the prevailing emphasis on individual self-care imposes an unrealistic burden on practitioners, contributing to burnout and compromised care quality. To address this issue, I recommend that organizations acknowledge their responsibility in supporting and facilitating self-care practices among employees. 

One recommendation based on this theory is to implement self-care support programs within corporate structures. These programs could encompass educational workshops on stress management techniques, mindfulness practices, and boundary-setting strategies tailored to the unique needs of mental health professionals. Additionally, organizations could offer resources such as self-care toolkits, online forums for peer support, and access to counseling services to assist employees in addressing their self-care deficits and preventing burnout.

This transformative shift entails not only providing mental health professionals with the resources and support necessary to prioritize their own well-being but also cultivating a culture of care that values vulnerability, self-compassion, and work-life balance. This may involve implementing policies that promote flexible scheduling, providing access to affordable mental health care services, and offering ongoing training and supervision to help practitioners develop effective self-care strategies. Moreover, organizations must actively work to destigmatize help-seeking behaviors and create environments where individuals feel safe and supported in addressing their mental health needs. By recognizing and addressing the irony of healing within corporate structures, organizations can not only improve the well-being of their employees but also enhance the quality and efficacy of the mental health care services they provide. This requires a commitment to systemic change, one that prioritizes the holistic health and resilience of both healers and those they serve.

Unveiling Corporate Complicity

Corporate Culpability

Within corporate structures, I’ve observed how profit-driven motives often take precedence over employee well-being, creating a challenging environment for mental health professionals. The imperative to maximize productivity and minimize costs can lead to understaffing, excessive workloads, and limited resources, all of which contribute to increased stress and burnout among practitioners. As mental health services become increasingly commodified within corporate settings, the focus on profitability overshadows considerations of ethical practice and quality care. Consequently, mental health professionals like me and my supervisees may find ourselves pressured to prioritize financial goals over the well-being of our clients, leading to ethical dilemmas and moral distress.

Moreover, in my experience, the hierarchical nature of many organizations often creates power imbalances that inhibit open communication and transparency, making it difficult for employees, including mental health professionals, to advocate for their own needs. Decision-making processes are often centralized among upper management, leaving frontline workers feeling disempowered and undervalued. This lack of autonomy and involvement in organizational decision-making can contribute to feelings of alienation and disengagement among mental health professionals, further exacerbating issues of burnout and turnover.

In one poignant instance, a supervisee of mine, a compassionate mental health professional, opened up to me about their struggles within the organizational hierarchy. Despite their unwavering dedication to providing top-notch care, they often felt constrained by the rigid structure of the organization. Decision-making power remained tightly held by upper management, leaving them feeling voiceless and undervalued. They felt unable to advocate for their own needs, which left them feeling disconnected and disheartened. The toll of this environment weighed heavily on them, exacerbating feelings of burnout and having them considering abruptly quitting.

In my experience, the commodification of mental health care within corporate structures often prioritizes short-term financial gains over the long-term well-being of employees and clients alike. Cost-cutting measures, such as limiting access to therapy sessions or reducing staffing levels, can compromise the quality and effectiveness of care, ultimately undermining the mission of promoting mental wellness. Furthermore, the relentless emphasis on profitability may deter organizations from investing in preventive measures or comprehensive support systems for mental health professionals, perpetuating a cycle of crisis management rather than proactive care.

The Fallacy of Resilience

Despite the increasing awareness of mental health issues in the workplace, many organizations persist in prioritizing resilience as the primary solution to employee stress and burnout. This focus on individual coping skills fails to address the systemic factors within corporate structures that contribute to mental health challenges. It perpetuates the notion that employees should simply “tough it out” rather than tackling underlying organizational issues. While resilience training programs are well-intentioned, they often place the burden of responsibility solely on the individual, implying that better coping strategies alone can counteract the effects of toxic work environments or high-pressure job demands.

In my view, individual resilience, while valuable, cannot fully offset systemic deficiencies like excessive workloads, inadequate resources, or toxic organizational cultures. Additionally, I believe that the disproportionate emphasis on resilience may inadvertently stigmatize individuals who struggle to cope with workplace stress. It implies that their inability to “bounce back” is a personal failing rather than a reflection of broader systemic issues.  

Moreover, I assert that the expectation of unwavering professionalism can foster a culture of silence regarding mental health issues, causing employees to internalize their struggles and refrain from seeking help due to concerns about appearing incompetent or weak. This culture of stigma and shame can hinder individuals from accessing necessary support and perpetuate a cycle of secrecy and denial within organizations. In prioritizing the appearance of resilience over the actual well-being of employees, corporations are inadvertently fueling a culture of silence and denial surrounding mental health issues, thereby intensifying the challenges encountered by mental health professionals.

Ultimately, I believe the fallacy of resilience highlights the necessity for organizations to embrace a more comprehensive approach to employee well-being, one that acknowledges the significance of tackling systemic factors and fostering supportive work environments. Instead of expecting individuals to simply “tough it out,” organizations should take proactive measures to address the root causes of workplace stress and cultivate a culture characterized by openness, support, and compassion. It is only by addressing these underlying structural issues that corporations can establish environments genuinely conducive to the mental health and well-being of their employees.

Rethinking Corporate Dynamics

In my experience, I firmly advocate for a holistic approach to fostering employee wellness within corporate structures. This encompasses policy reform to incorporate provisions for mental health support, flexible work arrangements, and stress management initiatives. Adequate resource allocation is equally crucial, ensuring investment in mental health resources, training programs, and employee assistance programs. Moreover, fostering cultural shifts within organizations, promoting open communication, destigmatizing mental health issues, and prioritizing work-life balance, is essential for creating a supportive and thriving work environment.  

I’ve witnessed firsthand the toll that excessive caseloads can take on our well-being. That’s why I advocate for implementing manageable caseloads within corporations. By ensuring mental health professions have a reasonable number of clients to attend to, quality of care standards can be maintained, and burnout and exhaustion can be reduced or possibly prevented. Moreover, I firmly believe in the power of comprehensive training programs tailored to the needs of mental health therapists. These programs should not only cover clinical techniques and interventions but also prioritize self-care strategies and stress management techniques. By equipping therapists with the necessary skills and knowledge to navigate the challenges of their profession, corporations empower them to thrive in their roles while prioritizing their own mental health.

In addition to manageable caseloads and comprehensive training, access to mental health support resources is essential for the well-being of therapists. This includes easy access to counseling services, peer support groups, and supervision sessions. Having a supportive network and resources readily available ensures that therapists can seek help when needed and receive the support they require to maintain their emotional resilience in the face of challenging cases and demanding work environments.

Our Mental Health Heroes

In closing, it’s important for me to recognize the immense challenges faced by our mental health heroes within corporate structures. Their tireless dedication to the well-being of others often comes at a significant cost to their own mental health and resilience. Despite the barriers they encounter, these professionals continue to show up day after day, driven by a genuine passion for helping others navigate life’s complexities. Their commitment is both admirable and deeply impactful, yet it’s essential for me to acknowledge the toll it takes on their well-being.

As I reflect on the experiences shared in this article and those throughout my career, it’s clear that our mental health heroes are not immune to the struggles they help their clients overcome. Hindered by corporate structures, they grapple with burnout, compassion fatigue, and the weight of ethical dilemmas, all while striving to provide the best possible care in often challenging circumstances. Their journey is one marked by resilience and dedication, but it’s also one that demands acknowledgment, support, and compassion from the corporations that employ them.

In extending empathy to our mental health heroes, I must also recognize the inherent humanity within each practitioner. They are not invincible superheroes but rather individuals with their own vulnerabilities, struggles, and needs. By fostering a culture of empathy and understanding within corporate structures, we can create environments where mental health professionals feel valued, supported, and empowered to prioritize their own well-being alongside that of their clients.

In essence, the empathy I extend to our mental health heroes mirrors the compassion they demonstrate in their daily work. Addressing the systemic challenges they face within corporate structures is crucial to paving the way for a future where both healers and those they serve can thrive in an environment of genuine care and support. This entails recognizing the toll of burnout, compassion fatigue, and ethical dilemmas, and actively working to alleviate these burdens through systemic change and support structures. I propose that high-quality client care is linked to the well-being of our mental health professionals, and this must be prioritized by corporations that employ them.

Questions for Thought and Discussion

What are your impressions of this author’s perspective on corporate mental health?

How might you work with a company or corporation to improve the mental health of its employees?

In what way have you been impacted by corporate mental health challenges and how did you address them?  

References
(1) Kim, J. J., Brookman-Frazee, L., Gellatly, R., Stadnick, N., Barnett, M. L., & Lau, A. S. (2018). Predictors of burnout among community therapists in the sustainment phase of a system-driven implementation of multiple evidence-based practices in children’s mental health. Professional Psychology: Research and Practice, 49(2), 132–141. 

(2) Maslach, C., Schaufeli, W. B., & Leiter, M. P. (2001). Job burnout. Annual Review of Psychology, 52(1), 397-422.

(3) Roth, C., Wensing, M., Kuzman, M. R., Bjedov, S., Medved, S., Istvanovic, A., … & Petrea, I. (2021). Experiences of healthcare staff providing community-based mental healthcare as a multidisciplinary community mental health team in Central and Eastern Europe findings from the RECOVER-E project: An observational intervention study. BMC Psychiatry, 21, 1-15.  

(4) Awa, W. L., Plaumann, M., & Walter, U. (2010). Burnout prevention: A review of intervention programs. Patient Education and Counseling, 78(2), 184-190.

(5) Bakker, A. B., Demerouti, E., & Schaufeli, W. B. (2004). Dual processes at work in a call centre: An application of the job demands-resources model. European Journal of Work and Organizational Psychology, 13(4), 393-417.  

(6) Jordan, K. B. (Ed.). (2015). Couple, marriage, and family therapy supervision. Springer.

(7) Canin, N. (2023). Exploring countertransference in psychoanalytic research: Reflecting on being a researcher, a psychotherapist, a mother and a human being in a neonatal high care unit. Psychoanalytic Practice, 31(1), 19-53.

(8) Adams, R. E., & Boscarino, J. A. (2005). Differences in mental health outcomes among Whites, African Americans, and Hispanics following a community disaster. Psychiatry, 68(3), 250-265.

(9) Greenberg, N., Docherty, M., Gnanapragasam, S., & Wessely, S. (2020). Managing mental health challenges faced by healthcare workers during covid-19 pandemic. BMJ, 368, m1211.

(10) Ocampo, A. C. G., Wang, L., Kiazad, K., Restubog, S. L. D., & Ashkanasy, N. M. (2020). The relentless pursuit of perfectionism: A review of perfectionism in the workplace and an agenda for future research. Journal of Organizational Behavior, 41(2), 144-168  

(11) Underwood, P. R. (1990). Orem’s self-care model: Principles and general applications. In D. Orem (Ed.). Psychiatric and Mental Health Nursing (pp. 175-187).   

Looking Beyond Trauma: A Neurodivergent Therapist Shifts Her Clinical Focus

Posted on by Psychotherapy.net Team

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

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Missing the Autism Tree for the Forest of Trauma

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

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

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

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

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

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

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

Postscript

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

Questions for Reflection and Discussion

How might you have worked with this client?

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

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

Teaching Prisoners to Lead Grief Support Groups

Posted on by Psychotherapy.net Team

A Novel Prison Hospice Program

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

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

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

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

A Clinician Embraces a New Challenge

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

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

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

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

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

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

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

A Surprising Place for Compassion

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

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

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

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

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

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

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

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

***

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

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

Thomas Doherty on Ecopsychology and the Ethical Imperative of Ecotherapy

Posted on by Psychotherapy.net Team

A New Kind of Best Practice

Lawrence Rubin: (LR): Thanks for joining me today, Thomas. You are a clinical and environmental psychologist, the latter of which is probably unfamiliar to many practicing clinicians out there, maybe less recently. What is ecopsychology?
Thomas J. Doherty: (TD): Ecopsychology is a doorway into different ways of thinking about psychology and therapy. That’s a good way to think about it. You know, the term ecopsychology became popular in the 1990s, and it was used as a banner for a number of environmental thinkers and psychotherapy thinkers who were bringing an environmental mindset into psychotherapy, notably people like Theodore Roszak and Sarah Conn. And there were some anthologies of writings in the ‘90s on ecopsychology. It's a really heterogeneous group of different kinds of people, but united in a general sense of connection with nature, the natural world, consciousness of environmental issues, pollution, and other related issues.  

Now, this would also focus on concerns about climate change; although, I think in the ‘90s, climate change was not the pressing crisis that it is now. Ecopsychology kind of came about like a lot of movements — outside of academia and outside of the mainstream schools of psychotherapy. In some ways, it was a reaction to them in the sense of the lack of obvious presence or mention of nature, the natural world, and other species in classic psychotherapy, which, in the lingo, we’d consider more anthropocentric, more human-centric. These folks were more eco-centric; they were thinking more in terms of ecology. And so, once you start to think more ecologically, it does bring all this stuff up. All these ideas in ecopsychology are pretty understandable now and actually have gotten well into the mainstream.

It’s about people thinking of their ideas — their identity — in the sense of their connection with nature, and the value of, as you know, being out in nature for our mental health. A lot of the research has caught up with these ideas as well. There’s a very robust body of research on nature connections and mental, as well as physical health. And so, yeah, ecopsychology, at least up to recently, has kind of existed on the outside, as a commentary.

When I was teaching, I would distinguish between environmental psychology, which is a subfield of psychology, and was started by researchers that were studying how people interacted with places and with buildings, and with architecture and landscape design. Issues such as why certain landscapes are more pleasing or easy to navigate, studying things like noise and crowding.

And then, environmental psychology, in the late ‘60s and early ‘70s became more environmental in terms of thinking about environmental problems, the design of recycling programs and things like that. It’s also separate from clinical practice. It’s not a therapeutic or clinical field; it’s an academic research field. But with ecopsychology, and with my work, and with what’s going on now, these things are kind of coming together.

If you draw a box that’s labeled psychology, we can put all kinds of things in that box and study all kinds of things from a psychological perspective. You know, we can study relationships; we can study human development; we can study pathology. We can also study our relationships with the environment from a psychological perspective. But it’s a different endeavor to create a box that’s called ecology, and then put a smaller box in there called psychology. Then we’re actually practicing psychology from a different base.

It helps us realize that “wow, I didn’t realize that traditional psychology had such a human focus which is really tied in with the enlightenment and the idea of human superiority over nature. I like that idea of thinking of ecology as a larger sphere, and then the question would become, “What could or should psychology look like if it focused instead on people, not apart from or above nature, but as natural beings on the planet?” It’s pretty interesting philosophically. And then, unfortunately, the press and distress of environmental issues broadly, and climate change more specifically and in the short term, have really put a lot of pressure on people to start thinking about this, essentially whether they like it or not.   

LR:
ecopsychology is a doorway into different ways of thinking about psychology and therapy
Would you say that the heightened attention on climate change has elevated the relevance of ecopsychology?
TJ: In many ways, the ecopsychology thinkers were just a bit ahead of their time and ahead of the game. What I’m finding is that many therapists now are interested in this. Connection with nature, the natural world, dealing with disastrous climate change, is now becoming a general kind of a best practice to know something about, much like therapy takes in new ideas all the time, new issues, new social problems, new disorders, and then it becomes something that everyone needs to know a little bit about. So, the therapy field is having to train itself up, in general, across all the different orientations about these issues, not only because the public is interested in this, but because therapists themselves are also experiencing it. The commonality is what’s unique about working with environmental issues and in therapy, issues like heat or smoke are shared experiences of the therapist and client.

Therapists might have to learn about a new disorder, a new form of treatment, or a social phenomenon like different gender presentations. But the therapists themselves might not personally be experiencing any of these things. But with climate, with the climate crisis, therapists, like everyone else, are experiencing disasters: smoke, heat, flooding, storms. They’re going through it right alongside everyone else. So, there's a double urgency here. And then, what happens is that as people get involved in this, they begin to realize, “Oh, I didn't know there was ecopsychology and environmental psychology, and that people have been writing books and thinking about this for a long time.” So, they’re kind of rediscovering these things for a new generation. 

LR:
connection with nature, the natural world, dealing with disastrous climate change, is now becoming a general kind of a best practice to know something about
So it’s not about therapists just opening their window on a cool autumn day or a warm spring day and letting some fresh air in, but it’s taking therapy out of the office and beyond the individual, and literally inviting the therapist and the client to be part of the larger ecosystem, if you will, to consider their shared place in it, rather than solely focus at the intrapsychic level. Sort of like expanding psychology and psychotherapy to the eco-psychic level.
TJ: The neat thing about it is that it’s both. We don't need to check our intrapsychic experience at the door to embrace ecopsychology. What I find really fascinating about all this is that the intrapsychic stuff exists also, and in addition to, our relationships with the natural world. So, I find all the therapy lineages, all the different therapeutic orientations, and the history and the techniques, they all have something to offer in this area. You know, one of my sayings is, “We have issues and Issues.” We have capital “I”, the big Issues that we want to take on in the world, you know, the issues that we want to devote our lives to, like poverty or social justice or peace or social issues, or even our own families, our own communities.

And we have our lowercase “i” issues, which is our stuff: our own personalities, our own strengths and weaknesses, our vulnerabilities, our losses, our traumas, our neuroses. So, when I'm working with people, I'm trying to hold both of those things in conversation; people obviously resonate with larger social issues that have some relevance for them personally, and then that could be an obvious undoing process from their own background or work, dealing with their own traumas in a classic sense. Or it just resonates with their values, or they’re seeing it playing out in their communities. So, all that intrapsychic stuff is relevant. 

The Elephant in the Therapy Room

LR: Whether clients bring issues of the environment or climate change into therapy, or are even not aware of them, do you sometimes bring them up?
TJ: Yes and no. Our orientation to psychotherapy is changing in general. I was just reading a nice article in the APA magazine, The Monitor, on spirituality and therapy and ways to work with spirituality. We do bring these things up in therapy, which may have been taboo before. But then we kind of realized that, in some ways, therapy could have been just holding up a status quo of taboos that wasn't productive or healthy, right?

So, what exactly is healthy, and what is the role of psychotherapy in promoting it? What has been in the shadows and largely ignored in therapy like spirituality, has turned out to be quite important? I think it is the same with environmental issues. I work with a lot of therapists that are seeking to be climate-conscious. They're either wanting to get some basic skills or they’re even wanting to specialize in this area. And part of how you specialize in any area is that you advertise your specialty.

People wouldn’t seek you out for any problem unless they somehow got a signal that you worked in that area. There’s a permission giving. There’s a permission giving to say, “Yes, I'm open to talking about these kinds of things.” unlike in past years, just mentioning LGBT somewhere on your webpage to acknowledge that you work with people of different sexual orientations is common now. It gives permission for clients to know that you deal with spirituality or trauma or workplace concerns or substance abuse. You get the idea! And so, it’s like an experiment and I’ll even encourage readers to think about this. Just add ‘environmental concerns and/or climate concern’ to your list of services and you'll be surprised.   

LR:
in some areas of the country, it’s very difficult to find a climate-conscious therapist, but people are looking and will look
See what you get.
TJ: People will bring it to you. There's a whole Climate Psychology Alliance group in the US and in the UK, and they have directories. People are seeking help in some areas of the country, it’s very difficult to find a climate-conscious therapist, but people are looking and will look. I have people contact me from all over the world, because it’s not that easy to find. The public is interested. And you’d be surprised — there’s kind of a self-fulfilling prophecy with this; if you don’t bring it up and you don’t talk about it, then people don’t bring it up, and then you’re kind of stuck.

I think we have an ethical responsibility to talk about climate and environmental issues because they are the biggest public health threat that the world has ever faced. And it is only going to get worse. We know very well from science that more climate-related weather problems and disasters are going to occur all over the US and all over the world, and people are going to be affected by these. To not talk about the greatest public health threat in history seems odd to me. So, I think psychologists and therapists have a responsibility to learn a bit about this.

But the rub is that it’s politicized, so it’s not a clean topic, and that’s another part of the climate elephant. I use this metaphor of the elephant in different ways with climate change. It’s the elephant in the room, obviously. It’s something that’s not acknowledged for a number of reasons. Partly, it’s an inconvenient truth, as Al Gore says. It affects our entire economic and political system to talk about these things. I think it’s ethically responsible to know a little bit about it and to let the public know that you’re open to talk about this if people want to.

People can take it further if they want. A number of therapists I know are personally interested in this for themselves and find that it’s something they want to get more deeply into. Because of my background doing the Ecopsychology Journal, I’ve had to learn a lot about this stuff. These are like extra degrees that I’ve picked up over the years. And so, there’s just a wealth of information out there. It can easily be a specialty or even just a personal exploration for someone’s own identity and health. There are a couple of different ways to approach it.   

What is Ecotherapy

LR: What's ecotherapy, Thomas?
TJ:
ecotherapy would just be any kind of therapy or counseling that has some sort of ecological attribute or component
Well, that’s another one of those big terms that has different definitions for different people. But ecotherapy, I think, is related to ecopsychology but is a more general term. Ecotherapy would just be any kind of therapy or counseling that has some sort of ecological attribute or component. It could be working in a traditional office setting, but also bringing in people’s concerns about nature, the environment, or beneficial effects of doing a group with people on stress reduction and depression treatment using outdoor activities.

Essentially, bringing environmental issues into the therapy room would be a form of ecotherapy, as would taking the therapy process either outside in terms of walking sessions, or sessions that are done in an outdoor space where the actual natural environment is more a part of the process. So, it can go in different directions, but there's generally some sort of intent there to recognize nature and the natural world and our ecological connections.

LR: So, one can identify as a solution-focused therapist or dialectical behavior therapist, or even a psychoanalytic therapist, and still practice some variant of ecotherapy? 
TJ: Exactly. I love therapy, and all different schools of therapy, and I'm just really always fascinated by them all. You know, therapy and therapeutic styles can either be a broad orientation or a technique, right? So, I can consider myself a trauma therapist or a solution-focused therapist, and that becomes a broad orientation. I see all problems through these kinds of lenses, and that’s how I tend to approach all different kinds of problems. Or I could just be a therapist that will employ solution-focused techniques, or techniques that are known to help with trauma. I can integrate EMDR or DBT or various techniques into my psychoanalytic base, or whatever it happens to be. So ecotherapy operates on both of those dimensions as well. It can be a broad orientation, or it can just be one of your tools, one of your tools that you use along with other kinds of tools. That’s a flexible way of thinking about it.

Many therapists don't necessarily think of themselves as ecotherapists, but they’ve integrated outdoor and walking since COVID. I find walking therapy quite interesting because it’s kind of its own thing. It’s a technique, but some people think of themselves as walking therapists; it becomes kind of an orientation. I was just meeting with a therapy group this morning with people from around the US, Italy, and India. We were talking about walking therapy, and if you Google walking therapy, even in the last year, you’ll see how it’s exploded. Walking therapy doesn’t automatically have the deeper ecological thinking component of ecopsychology, though it can be practiced that way. What it shares with ecotherapy is a different view of the container of therapy, and also adds a movement and experiential component. It doesn’t have the environmental-political angle of ecotherapy, which tends to be environmental, in terms of environmental politics. But walking therapy is quite fascinating.

As a tangent, just think of the explosion of psychedelic therapies in the last couple of years. I was just at the American Association for Behavioral and Cognitive Therapy Conference here because it met nearby. I was speaking on a panel on some of these environmental issues there. But it surprised me to see all the psychedelic therapy work there at this behavioral therapy conference. Things change rapidly; walking therapy is more accepted, psychedelic therapy, more accepted. Ecotherapy is more accepted as well for all the reasons we’ve been talking about.   

LR:
there’s a walk in nature, and then there’s a therapeutic walk in nature
I had mentioned the walking that I do in a local nature preserve where and I find myself deeply reflective on issues of life, death, continuity, extinction, the passage of time, significance, and meaning. Is there's something about nature that naturally triggers existential issues?
TJ: Yeah, well, let's hold that thought. Let’s stay with what you were saying about walking because I agree that there’s a walk in nature, and then there’s a therapeutic walk in nature. So, part of it’s the intent; it's the mindset that we bring to it. So as a person, many people walk and go in nature for their own time and relaxation and reflection. And sometimes people will bring an intent to it, like I’m going because I'm grieving, or I need to think about something, or I need to rest or a break. Sigmund Freud walked with his patients around the Ringstrasse in Vienna. He had his daily walk. So, walking therapy is not a new thing.

When I help therapists think about walking therapy, it’s actually quite interesting. I haven’t really thought about it directly in existential terms, but it is because we think about our existence as a being in relation to other beings and in time and in weather: it’s inherently transpersonal in the sense that it takes us out of ourselves. So, we can think of walking therapy as transpersonal. We can think of it as existential. I tend to think of it as an embodied approach because when I am walking and moving, my body, my brain works slightly differently than when I’m sitting in a room. And so, I think of it as a brain-based approach because it activates things similar to EMDR; it’s activating the brain in bilateral ways.

You might experiment with reflecting on something in a room in a stationary setting, and then reflecting on the same content while you’re walking. It’s hard to describe, but it feels different, and it’s more empowering. There was a great story in Outside Magazine this writer Erica Berry interviewed me about. We did walking sessions, and she wrote about it. She had a great quote. She said, “It was hard to feel powerless when you were reminded with every step of your power.” As we were walking, she shared feeling empowered. So, I totally agree with what you’re saying is that this modality does add all kinds of things. It’s quite healthy, and it’s more therapy-friendly than you think in terms of all the different orientations that are likely to come into play.

LR:
disasters exacerbate existing vulnerabilities in the community or in the person
I like your idea of the difference between walking in nature and therapeutically walking in nature is one of intent. It’s parallel to a conversation you can have with a friend and a therapeutic conversation. It’s about intent, as you said earlier. Are there clients who come to you with specific concerns about the environment, like eco-anxiety and environmental grieving, or because you advertise yourself as an eco-informed practitioner?  
TJ: You’re right on track with all this stuff. All of your intuitions, I think, are right on track. You know, broadly, if you want to simplify things, there’s two broad areas of emotional distress regarding climate and environmental issues, and they’re either anxiety, fear, and threat; or grief, loss, and depression. There are two big areas there. Obviously, there’s a sense of unease and fear and concern about disasters, and things like that which is a form of trauma. It’s an environmental trauma: heat, smoke, all these things. Just like any other thing, disasters exacerbate existing vulnerabilities in the community or in the person. So, if I’m already dealing with any of these issues, it’s going to make everything worse.

And so, it does exacerbate people’s natural tendencies to be anxious, and with someone who already has trauma or other anxieties, or have experienced earlier disasters in their life, then new ones can really tip things over. Young moms, postpartum moms who are already highly protective of their young ones, are going to be hyperactivated by smoke and heat because it is literally dangerous to babies. So, you’ve got all that to cope with. And then, of course, people feel natural concern and loss about issues like extinction and lack of places, especially when certain iconic places are destroyed, like Lahaina in Hawaii, or from the fires in California. The Hawaii fires were catastrophic, not only locally, but many people had emotional connections with that place, these places they had visited, Maui and Lahaina. And so, it touched a lot of people.

So that grief and loss is right under the surface. It’s a chronic issue when I talk to people. When you get people to open up, these issues come up. I don’t think I’ve ever met anyone who doesn’t have some of this going on. So yes, it’s important. Erica later said, “As we continued up the hill, I tried to recall where my train of thought had stopped, but it no longer felt important,” because we had seen a bird, and we were listening to the bird. And she said, “I had been talking about suppressing climate sadness because I didn’t want to sound like an evangelist or bum my loved ones out. But now, I was thinking about the bird, and wasn’t that the opposite of doom brain, tuning into all that lived around me.”

She added, “This sort of reflection certainly wouldn’t happen in a therapy office, but it wasn’t a bad thing. You know, the bird had, for a moment, airlifted me out of my anxiety.” So that idea of being present in nature and walking gives us this expanded scope, and you can think about these things and contain them, but you’re also living. You’re also in the moment in a way that’s just quite different. So, there is a tie-in between eco-anxiety and some of these modalities. People do seek out therapists that can help them with eco-grief or anxiety, either because the person’s highly connected with nature, or they’re an environmental professional or a climate scientist, or they’ve dealt with a disaster; or it’s just a developmental stage for them.

There’s a concept called the “Waking Up Syndrome,” where people just become aware — they have an ecological awakening of some sort. Many people have this in school, when they’re in college or graduate school, or when they’re studying things, they realize, “Wow, everything is connected, and there’s a system here, and I just didn’t realize, and I never realized the scope of some of these things.” So, there’s a natural developmental experience that most every adult can speak to where they kind of woke up to the world. They woke up to the state of the world. They became adults. They became aware of the systems, and of justice and injustice and identity and all these kinds of things. And sometimes we have a container to hold that and someplace to process that—a mentor or parent or counselor. Many people don’t. It’s like a rite of passage.   

LR:
there’s a concept called the “Waking Up Syndrome,” where people just become aware — they have an ecological awakening of some sort
I can see how important it might be to explore clients where they are in the developmental trajectory of their own ecological awareness awakening. Might there be such a thing as ecological countertransference, where the therapist perhaps is so invested and always looking for the opportunity to raise the client’s ecological awareness that they impose on the clients, or they filter what the client is saying through that ecological lens?
TJ: That’s interesting. I definitely think that countertransference comes up in eco or climate therapy; but my issue mainly is more of the therapists being so reticent to bring it up. It’s the opposite, actually; they stay away from it rather than pushing it. Where it comes up in practice is with therapists who feel inadequate to address the issue. That’s one of the deeper barriers to this kind of work is that the therapists need to work it out themselves first. In my experience, therapists generally aren’t climate or eco advocates; they’re pretty good about that. So, countertransference, like most countertransference, it’s more complicated than you think. If you can understand it, it’s probably not countertransference.

Countertransference is unconscious, right. And so, it’s really that kind of conspiracy of, “I’m not going to bring this up because I don’t know how to handle it. “I don’t want to expose either of us to something that we can’t cope with,” right? I think that therapists are coming to grips with this. They’re people, and they have their own environmental identity, right? You were hinting at this in your earlier comments. So, we have a sense of our environmental identity, our sense of connection, our sense of ourselves as a human in relation and nature in the natural world.

It’s implicit for everyone until we talk about it, just like any other form of identity: our gender identity, sexual identity, cultural identity; we have all the values and beliefs in action, but unless we’re taught to think and have a metacognition about them, we can’t necessarily elucidate it. It is similar to environmental identity. When therapists start to understand their own environmental identity and feel comfortable with it, they can better understand how, when, and when not to bring it into therapy.

We’re not perfect. We’re flawed people. Everyone wants to do more. We’re in a tough system. Most people are constrained. We’re hostages to a system that’s quite unsustainable. We don’t control it. Once we learn to forgive ourselves and to be comfortable with our own environmental story, then we can sit comfortably with other people’s stories, right? And then we don’t have to solve climate change. You don’t have to solve climate change to cope with it.

We don’t have all the answers to our clients’ problems. That’s not our job. Our job is to support our clients while they’re seeking the answers. But to get to that level of comfort with the material in the room and let go of it so it can just be there, that’s where the developmental task is for the therapist. Some issues are so difficult, we’re never fully comfortable with them. But we learn to have the capacity to contain them and be with them. A lot of the challenge with doing ecotherapy is developing the capacity to sit with ecological issues in the therapy room, knowing that we cannot solve these things, and we may not solve them in our lifetime, but we do have values, and existentially, we do what we can and be our best self.  

LR:
once we learn to forgive ourselves and to be comfortable with our own environmental story, then we can sit comfortably with other people’s stories
I know folks don’t really talk about Maslow much anymore because it’s not “evidence-based”, but would you consider ecological awareness and ecological identity development to be up there on the top of that pyramid, or right at the bottom?
TJ: I think we can consider ecological identity development an attribute of self-actualization. I do think our coming into some understanding and relationship with our place in nature and the natural world is part of self-actualization, even in terms of our own mortality. It is existentially what the world is demanding of us. As I joke in this manuscript I’m working on, “Some are born sustainable, some achieve sustainability, and some have sustainability thrust upon them.” I mean, we have no choice. Just like the world brings other existential issues to our doorstep, that’s the rite of passage. That’s the hero’s journey.

So, yes, I do think, for many, many reasons that understanding our unique connection with nature and the natural world, the outdoors, is just generally an essential life task. We’ve forgotten that we’ve evolved on a planet. We are creatures. We are animals. We didn’t come from a machine. We’ve forgotten all these things. Some people would laugh and say, “Well, of course, we forgot. How could we not?” But this speaks to our society and our culture not our essential selves. So yes, I do think it’s part of self-actualization. I think of Maslow a lot, too — all parts of his pyramid a

A Healing Journey: Developing Coping Skills in the Face of Trauma

Posted on by Psychotherapy.net Team

She had lived in a major city for years and felt confident and secure in her ability to negotiate public transportation. During the pandemic, she worked from home, like a large portion of the global population. Emerging from that dark time, as people returned to work, so did she. Barely a month back on the job, she was pushed against the wall by a man in the subway, had her purse snatched by a man outside a drugstore, was physically assaulted by a man in a pedestrian walkway that connected her neighborhood to public transportation, and intimidated by a man standing behind her at the pharmacy.

All these events occurred within her neighborhood, an upscale complex near an inner-city transportation hub. The final straw was a shooting incident in a public area she had to negotiate to connect with public transportation to work. Paralyzed with fear she withdrew to the safety of her home behind an iron gate and security cameras. If she ventured from the home, it was with Uber or her husband. She had lost her sense of safety and security. Working from home during the pandemic was safe for her, and returning to the office was not initially a problem. But in the shadow of these frightening events, she began experiencing obsessive thoughts, sleep disturbance, hypervigilance, flashbacks, difficulties concentrating, depression, and anxiety. She reached out for help via telehealth and with the devoted support of her husband, treatment began. In a short period of 11 months working with her, she was able to reclaim her sense of safety and security, and her confidence in negotiating her environment. She was to call that 11-month period, “The journey.” Her name was Sarah.

Preparing for The Healing Journey

Upon initial assessment, my strategic plan was to stabilize Sarah in the face of this crisis, reduce her symptomatic behaviors, evaluate her coping strategies, develop a de-sensitization plan, and incorporate EMDR into the process.

My first step was to remove the pressure of traveling to work so we could begin to address her anxiety as we began to focus on treatment. Fortunately, her employers were very supportive, only asking for documentation to process her request. She was the driver on this journey, so I sent her the document for approval before sending it to her employer. Sarah said when she saw the document, she cried because someone finally understood what she was experiencing. Her anxiety and mood instability diminished with the approval of her medical exemption to work from home.

I typically conceptualize symptom management and coping skills as “tools in the toolbox.” If they are willing, I ask clients to draw a picture of their toolbox and to put their tools inside it. This activity makes an internal process feel more real. I suggest that they add tools as we go along.

At the onset of treatment, Sarah preferred not to use medication. She already had many skills, resources and supports in place. These included her friends, work environment, pets, cooking, reading magazines, gardening, music, exercise, walking, yoga, and art. She and her husband were taking a self-defense program, and he had already purchased a handheld pepper spray for her, which she never left home without. Her husband was her strongest support, ally, and partner in the treatment process, working the plan with her from beginning to end.

During treatment, Sarah was able to share the trauma narrative by describing each incident that occurred. The first step in her desensitization was to describe the walk between her home and the transportation link. Next steps were to have her husband video record the walk for them to watch together which they did, several times.

One month after her first appointment, we discussed using behavior modification and progressive desensitization. Her homework was to develop the plan. She was to work the plan at her own pace, which she did eagerly, logging the steps as she took them, her physiological responses, feelings, and thoughts. We would discuss her journal entries in treatment, and she would modify the plan as needed, especially when barriers and roadblocks seemed insurmountable.

Addressing the Clinical Obstacles

Sarah’s environment provided unanticipated challenges that put her coping skills to the test. Multiple such incidents occurred in their neighborhood; a man fleeing from the police jumping into their backyard while they watched, a shooting in the lobby of a theater before they arrived, teenagers rioting over the weekend, and a man riding a bike in the neighborhood being attacked.

Initially, and each time one of these events occurred, Sarah’s symptoms would briefly re-emerge. During those times, we explored the incident in detail, and how she and her husband responded. We were able to reframe her responses as correct and resourceful choices. She began to recognize that different environments and events required their own unique, rather than blanket responses.

When Sarah did encounter either internal or external obstacles, she would modify her response accordingly, an example of which occurred around her visit to the local drugstore, which was frequented by vagrants. Everything in the store was under lock and key, and customers had to ask for help. During this particular instance, Sarah implemented what we called the “fire drills.” This involved visiting a same-named drugstore in a “safe” neighborhood, and recognizing that it was not the store, but the neighborhood that elicited fear and anxiety. Sarah and her husband concluded the environment they were living in was changing and no longer safe, and that it was time to make a change. Sarah was soon able to apply a related strategy to coping with her fears associated with the tunnel where one of her earlier traumatic experiences had occurred. We successfully added EMDR to her treatment plan.

We had been preparing for termination and scheduled our final appointment. When she came on-line for that session, she excitedly proclaimed, “You are not going to believe this.” She then detailed how she and her husband decided to take the subway home one night after leaving the theater, in front of which there was a protest.

Realizing that while many of her initial fears were justified, Sarah had re-gained control of her life and put her traumas behind her. She had completed her journey both literally and figuratively! She shared her final art project with me, which was a graphic reflection of her healing journey. A masterpiece in every sense of the word; it was being framed as we concluded our work, and was to hang in her new home, as a trailhead of sorts for the next phase of her journey.

Challenging a Beloved Therapist: A Catalyst to Growth

Posted on by Psychotherapy.net Team

A Break in Need of Repair

“I’ll wear a mask, unless you take a COVID test!” This was the message that I emailed Jeffery, my therapist of 29 years. It was a few days after he returned from a vacation that entailed a long airplane flight. My appointment was the following day.

“Wear a mask,” came Jeffery’s reply. He said he didn’t want to “stick something up my nose,” and was sure he didn’t have COVID because he was masked the entire flight. 

I was startled. His annoyed tone was out of character. I was also surprised to find I wasn’t devastated. In the early years of our work together, I’d been 100% emotionally dependent on him, a child beneath my grownup facade, and the thought that he might be annoyed would have been the end of my world. Now, I knew this was a temporary disconnect, one that could be repaired if we discussed it.

“Let’s do a phone session,” I emailed back. I was at risk for lung infections because of a health condition. Also, I would feel more secure on my own turf if the discussion proved difficult.

When we Facetimed, I saw that Jeffery was home, not in his office. Though dressed in his usual button-down shirt, he was stuffy and hoarse and looked as if he should have been in bed. But he was back to his usual cordial stance.

“Do you have COVID?” I asked.

“Just a cold. I don’t have any fever.”

By then it was common knowledge that fever wasn’t the gold standard for making a COVID diagnosis. I didn’t pursue the repair. He obviously wasn’t ready. I was glad to see him — he’d been away six weeks — but the session was superficial, not emotionally satisfying.

Before our next appointment, Jeffery texted that we should do another phone session, because he had COVID. Again, I was surprised at myself, this time for not wanting to say, “I told you so.” I understood that he could be wonderful 98% of the time and not wonderful 2% of the time.

When we spoke, I tried again for the repair, explaining that I was afraid of getting sick. He said he thought I was telling him what to do, but once he understood why, he was OK with it.

I saw that Jeffery was trying to be conciliatory, but it didn’t make sense. He’d known for a long time that I was afraid of getting sick, in part because I dreaded needing someone to care for me. We had been working on that in sessions. Also, he had never before gotten annoyed when I told him what would make me feel safe, even if he chose not to comply. Most likely, my COVID test request had triggered something in him that had nothing to do with me.   

I grew up in a home that didn’t model the best way to resolve conflict. If my father was displeased at something my brother or I did, he flew into a rage that involved prolonged and intense yelling, often accompanied by physical punishment. If he was displeased with something my mother did or opinions she had, he just yelled. She would answer softly, almost meekly, then later do as she pleased. If he found out, there would be more yelling. Early on, I learned not to rock the boat, a skill that traveled with me to adulthood. I was afraid that people would stop liking me if they became annoyed or angry, so I did everything I could to keep the peace. Now I was stymied.

It was rare that Jeffery let his own issues interfere with our work. In 29 years, that had happened only four other times, the last more than a decade earlier. This was by far the least consequential, but it was the first since I felt like a grownup through and through. I knew that before a meaningful discussion could begin, I would have to wait until he was ready to acknowledge what happened. If this was anything like the other times, that could take months. In the past, I would have discarded the 98% while I waited, just because I wasn’t happy with the 2%. It was a testament to our work together that I didn’t do that now. But gray was a lot harder to navigate than all black or all white.

Healing through Empathic Attunement

At 51, when I began seeing Jeffery, I had already spent 35 years in the mental health system. I’d been hospitalized three times with a misdiagnosis of schizophrenia, lived in a halfway house for a year, and had seen six therapists, each for several years. Though high-functioning at two jobs — weekdays as an I.T. systems analyst, weekends as a librarian — inside I was in emotional pain so great it felt like organ failure.

Relief came only through escape to an imaginary world I called the Atmosphere, where kindly invisible people, more emotionally reliable than real people, understood all my feelings and thoughts. That, and the knowledge that I always had an out: I could kill myself. The one place in the non-Atmosphere world where I was relatively comfortable was at work. I worked seven days a week — to stay alive and to pay for therapy.

Five years earlier, at 46, I learned I had what was then called multiple personality disorder (MPD) and has since been renamed dissociative identity disorder (DID). I was shocked that such a sensational-sounding diagnosis could apply to me. At the same time, I was relieved to finally have a plausible explanation for so much of my past: feeling not real, watching myself from outside myself, talking to faces in the mirror who were not me, functioning on a high level at work yet feeling psychotic outside of work. The diagnosis let me know I was not an alien species. I had a condition documented in clinical literature, said to have been caused by ongoing childhood trauma. That part fit, too.

It was one thing to have a diagnosis, another to find a clinician skilled in treating multiplicity. It would be another five years before I found Jeffery, recommended by a member of the dissociative disorders support group I had begun attending.

Jeffery soon realized that the Atmosphere, which was more real to me than the real world, had developed in response to early attachment trauma. The Atmosphere had been helpful when I was a child, providing the emotional connection I wasn’t getting from my parents, but when I became an adult, it got in the way of my having meaningful relationships with real people. Jeffery believed the Atmosphere had to be dismantled before healing of the multiplicity could take place. His theory, unbeknownst to me until years later, was that I needed to have an Atmosphere-like experience — perfect and unbroken attunement — with a real person: himself. I would then transfer my attachment from the Atmosphere to him, and eventually to other real people.

Over many years, with infinite patience and kindness, Jeffery saw me through the stages babies and toddlers go through when attaching to their caregivers. I may have been in an adult body, but parts of me who were very young still had to learn things as basic as object constancy — that people and things exist even when you can’t see them. Jeffery understood that to my magical way of thinking, I had two versions of him. In-person Jeffery waved goodbye to me at the end of each session, then froze, hand in the air, and stayed that way until I returned. The moment I walked out of his office, Atmosphere Jeffery materialized and remained with me 24/7, knowing everything I thought and felt and did until the start of my next session when in-person Jeffery would be right where I had left him.

In that way, he was with me continuously. Whenever something happened to let me know this was not so (his socks were another color, or he’d gotten a haircut, or worse, I saw the patient before me leave), I would berate him for his betrayal and call him a “deceiter.” He would explain that he hadn’t abandoned me, that I was always in his heart, even if he wasn’t physically with me. His words would soothe me — until the next time.

What went on in any given session depended on which of my parts was “out” (present). There was a sliver of me who was grownup, in particular an administrative part I called AlmostVivian. She kept me functioning in the world but had no depth. The more three-dimensional, feeling parts of me were largely children. These “littles,” who were causing most of the chaos and pain inside me, saw that Jeffery was a safe person, and they gradually began revealing themselves to him. Sometimes the only way I could communicate was by talking in nonsense syllables or writing backward on a piece of paper he had to hold up to the light to read. Other times, a feeling was too big to fit inside me, and I screamed, or hid behind a chair, or wordlessly locked eyes with him in an attempt to connect. And sometimes, ashamed to be visible, I could talk only in the dark, so he turned out the light.

At the start of a session, Jeffery would wait to see where I chose to sit. If it was a chair, he sat in a chair, too. If it was the floor, he would sit on the floor with me. If I was unable to talk, he and I might draw a picture together, taking turns adding a squiggle or something representational, like an eye or a bird. Sometimes we passed a computer back and forth, typing to each other in conversation. I likened our sessions to emotional surgery, where Jeffery dug deep but never more than I let him know I could tolerate. We would both make sure to leave enough time at the end to sew me up, so I could go out into the world and live my life until our next session. The sewing-up routine came to include having toast together, my ultimate comfort food. As we ate, chatting about seemingly mundane things, I would slip in something about my itinerary. “Before I go to work tomorrow, I have to take my mother to the dentist.” Atmosphere-Jeffery always knew where I was. I needed in-person Jeffery to know, too.

There were many bumps along the way, but the more I got from Jeffery what I had previously gotten only from the Atmosphere — feeling seen, acknowledged, understood, and cared about — the more I began connecting on a deeper level with outside people. My cubicle-mate at my I.T. job said, “You seem different lately. More sparkly.” My sister-in-law said, “It’s much easier to talk to you now. You’re more connected.” In my writing workshop, instead of hurrying out as soon as class was over, I began lingering to chat.

It took years, but I finally did “lose” the Atmosphere, and with it, the Atmosphere version of Jeffery. Concurrently, my internal parts were becoming more conscious of one another. While these developments were ultimately positive, adjusting to a new mental map of who I was and how I related to other people was not easy. For a few years, I felt lost from Jeffery, even when he was sitting across from me. A children’s book, Farfallina and Marcel, helped. I kept a copy in Jeffery’s office, and we often closed the session by reading it together. It’s the story of the friendship between a caterpillar and a gosling. One day, the caterpillar says she doesn’t feel well and climbs a tree. The gosling waits below, but the caterpillar doesn’t come down. A long time later, when the gosling has become a goose, he meets a butterfly. As they talk, they find out they each feel bad because they each lost a friend. A while after that, they realize they are the friends they thought they had lost. They look different, but they’re still the same inside.

Confrontation Revelation, and Repair

Jeffery had been my sherpa through decades of monumental changes that literally gave me back my life. Now we were having a tiff about something as trivial as a COVID test. At least I thought we were. From his point of view, the air had been cleared as soon as he understood I was simply telling him what would make me feel safe. I loved this man and wanted everything to be OK between us, so I did my best to ignore the elephant and go on as we had before. But six months later, when he was scheduled to take another trip — brief, but it involved a long flight — the elephant was still there.

“I don’t suppose you want to take a test when you get back, so let’s plan on a phone session,” I said, hoping to start a discussion.

“It’s not going to happen,” he said, smiling as if at a shared joke.

I smiled back, but inside I felt a great loss. The one person who had completely seen and understood me no longer did.

When Jeffery returned, I decided to confront him. I told him again that saying he didn’t want to stick something up his nose had been hostile. He could have just said he wasn’t comfortable taking a test. I repeated that this issue had more to do with him than me. He said he saw it differently. He had always shielded me from things that annoyed him. Now he was allowing himself to be more spontaneous. Then he clarified. During a session, he always saw my point of view, but outside of a session, he felt freer to let his annoyance show.

This initiated a new worry. How many other things had I done over the years that annoyed him? I asked for a list. All he could think of was something from two decades earlier, during the period when I could talk only in the dark. If my session was in the daytime, he had to hang blackout curtains, then take them down when I left.  

In our next meeting, I realized it was up to me to get the discussion back on track. I told Jeffery I had been caught in his forcefield, so I’d gone along with his explanations, but they didn’t make sense. His response: “Just because I disagree with you, that’s a forcefield?” This, too, was out of character. I said I didn’t want to know exactly what sticking something up his nose meant to him. I just wanted him to know that whatever it was had more to do with him than me.

There was silence for several long minutes, during which Jeffery’s eyes went up diagonally, the way they did when he was thinking through a complicated issue. At last, he looked at me and said humbly, “You’re right. There is something. I didn’t know it until now. Thank you.”

This was huge, but I didn’t stop. I brought up what he said about being annoyed outside of a session but not during a session. I told him that was hard to deal with. I needed to know he was a consistent person. Jeffery agreed he shouldn’t have said that. “It was mean and not true. I was just rationalizing my behavior.” That might be, I said, but it still hurt. He nodded his acknowledgment, holding my eyes.

We talked about it for a few weeks. I told Jeffery he was so near perfect that it was hard to know when it was legitimate to call him on something, especially when he kept insisting on his point of view. He admitted he didn’t like to think he had faults as a therapist, so he didn’t see when his own issues got in the way. Then he told me a little about his childhood, no details, but enough to let me know that what occurred between us most assuredly had nothing to do with me. I felt a surge of gratitude to him for his honesty. This couldn’t have been easy. But the elephant was gone.  

Incremental Progress, Monumental Change

At first, I was just glad to have my therapist back. But within months I found myself acting differently outside the therapy room. I had always been surface-friendly with everyone, easy to be around. I rarely became involved in deep discussions because I rarely had strong opinions. Whenever I did have one, if it was contrary to someone else’s point of view, I soon came to feel the other person was right. Now I was finding myself less inclined to remain safely on the sidelines, more willing to take cautious risks and become involved.

Shortly after the air cleared between Jeffery and me, I was asked to become co-chair of an organization I belonged to. While I liked the group and its mission, the thought of having to run meetings where there were sometimes opposing viewpoints — and hurt feelings — was daunting. I declined, explaining my reluctance to the person trying to recruit me. “But you’re so good at handling that kind of thing,” she said. I knew I was, but it was a skill that came with a toll. I was constantly vigilant in my interactions, never fully relaxed. Still, when she continued trying to convince me, I was flattered. She was someone I respected. After a month, during which I thought long and hard, I accepted, having decided it would be good for me to step out of my comfort zone. 

Of all the changes I went through since the start of my therapy with Jeffery, none had announced itself with an ah-ha! moment worthy of documenting in a progress note. Change was so incremental, like the slow movement of tectonic plates, that I never noticed it until a seemingly minor incident, like the COVID-test brouhaha, let me see how far I had come.

It has been said that in psychotherapy, in addition to whatever expertise the therapist has or what their approach is, it’s the relationship that heals. Jeffery was a safe person for me to challenge, and I had become strong enough to trust my instinct that something about his protestations didn’t ring true. While he didn’t agree with me at first, he didn’t try to crush me but allowed a discussion. I saw that we both wanted to reconcile and were negotiating in good faith. Ultimately, the fact that he was big enough to step back and take an honest look at himself, despite his discomfiture, was healing for me.

In my new role as co-chair, I have already been challenged by several disagreements. Each time, I’m initially sorry I accepted the post, but after the issue is resolved, I feel good. When I was on the sidelines, I never took a stand or tried to shape an outcome for fear of upsetting someone. Being involved is more difficult, but also more gratifying. It’s as if I had been snacking before and have only now sat down to a satisfying meal.

At 81, I am still becoming. 

Donald Meichenbaum on Coping with Loss and Traumatic Bereavement

Posted on by Psychotherapy.net Team
Lawrence Rubin: Hi, Don. Thanks so much for joining me today. You are most widely known for your foundational work in developing CBT but it is equally important that our readers know that for these last 35 years, you have been the director of research at the Melissa Institute for Violence Prevention and Treatment in Miami, Florida.
Donald Meichenbaum: (DM) Thank you for the invitation.
LR: You had previously requested that my first question be about the tragic and unexpected death of your wife, Marianne?

The Irony of a Trauma Specialist’s Tragic Loss

DM: We were married 58 years. My wife and I were vacationing in Clearwater, Florida, escaping the snows of Buffalo, where our permanent home is. My wife was tragically hit by a car at a pedestrian crossing. You know they have flashing lights, and this is sort of a warning sign. She was hypervigilant about not trusting people to stop, so obviously she would not have stepped off the curb if the vehicle had not stopped. But for whatever reason, the vehicle continued on and hit her. And in fact, she was lifted by a helicopter from Clearwater down to the trauma center in Saint Pete.I had called her on her cell phone thinking that she was late because she had a Zoom yoga meeting that she usually attended. I got a male voice, and he indicated that she had been hit and taken by helicopter down to the trauma center, but they would provide me with a police car to drive to the trauma center. I got there and the trauma physician indicated that she had already died. I asked to see her, went in and she was covered by a sheet. I pulled down the sheet, and she was pretty messed up from the accident.

I’ve worked with head injured, so I’ve been involved in seeing such incidents. Remarkably, her hand was still warm when I caressed it. There was a chaplain sitting next to us and I asked her to take a picture of me holding her hand. I actually sent that picture to my daughter-in-law who made it into a pillow. So, it was a traumatic bereavement kind of situation.

The irony is that morning I was giving a Zoom lecture for therapists in China on how to cope with traumatic bereavement and prolonged and complicated grief. And by four o’clock that afternoon, I was living my lecture. So, one of the interesting aspects of all this, and I’d be happy to discuss it with you, is what is the immediate and more long-term impact on an individual such as myself, who is in some sense is an expert on the area of interventions — having developed cognitive behavioral techniques.

Interestingly, there are hundreds of these kinds of accidents, many in Florida, of people — for whatever reason, where the driver is not complying with the pedestrian crossing. And there are multiple accidents and deaths in this particular way. So, the issue of traumatic bereavement as compared to a kind of prolonged complicated grief is an issue that I have been preoccupied with. And moreover, I’ll just add this final note before we open it up for your further questions. There are two aspects that are really quite fascinating in the aftermath of such traumatic bereavement.

One has to do with dealing with the grief. And the other aspect that is not readily discussed by clinicians is the sequelae that follow the sudden death of a loved one. And I will give both you and the readers to this presentation, a keyword that will change your life forever. This is the most important thing you should take away from our discussion. And the one word that you need, Larry, that will change your life if you do not already have it in your repertoire, is “passwords.” If you do not have the password of your significant other who died in a traumatic fashion, you are screwed.

LR: You’ll lose access to everything.
DM: Yeah, right. So, at a moment of intimate repose for your listener, they should lean over to their loved one and say, “I love you, but do you know our passwords and how to retrieve them?” So, you know I can fill you in and turn this into a kind of therapy session? And tell you the kind of trauma events, both dealing with the aftermath of the loss of my wife, but also the police reports, the autopsy reports, the life insurance, the banking, all of the credit cards — everything that goes with it.And the interesting thing is, if you are a clinician, one of the things you do in helping me is assessing, what is the lingering impact of this, what was the aftermath like? But it’s unlikely that you would have done that and asked does your social life change, and then a whole bunch of other questions that I’ve put together. In fact, the lecture that I was giving that morning to Chinese therapists, that entire 80-page handout that I provided them with is available to your listeners.

So, if they go to Google – Meichenbaum, Donald, Melissa, Institute – they will be able to download my 80-page tool plus other items on how to treat individuals who have traumatic bereavement and prolonged and complicated grief. So, if there’s anything I say that might be of help, I’m glad for that. And moreover, if there are people who want to contact me, they could do so through the Institute.

LR: I’m fascinated by the one word that you said clinicians, spouses, partners, family members should know, which is “password.” What’s the significance of imparting that piece of wisdom of knowing your partner’s password? And how did it play out in your journey?

DM: To access a number of accounts, my life was such that my wife Marianne was a wonderful wife, a very competent person. She was an actress, and she was a June Taylor dancer. She looked after all of our finances. I’m not a very competent person other than psychology. I’m a really good psychologist. I know a lot.

But when it comes to life, she was what I would characterize as my surrogate frontal lobe. And therefore, I never knew how to run appliances or bank machines or any of these kinds of things, and she looked after it. So, to gain access to that information, you really need the passwords. Fortunately, I have four wonderful children who are competent and loving and supportive, and that helped a great deal. So, we were able to, over a lengthy period of time — trust me, it took more than an entire year — to settle accounts related to adaptive functioning and financial issues and the like.

I won’t trouble you and your audience, but to highlight how unfriendly, how totally unfriendly the system is, to the 1,000,000 people who lost loved ones due to COVID. You know, the 20,000 individuals who died by interpersonal violence. You know, the incidence of mass shootings and all the other kinds of episodes, you know, the 48,000 who have to survive the suicidal death of a loved one. So, this discussion is absolutely remarkably timely, let alone the loss of natural disasters. I mean, just think of all the people at Maui whose lives are just upturned, and the many wars and the like. So, dealing with loss, grieving, traumatic bereavement, and mourning has to be on the top agenda of every clinician.

Difficult Therapeutic Conversations

LR: Working with adult children of elderly parents, clinicians have to enter conversations about what their plans are with and for them. And it seems to really behoove clinicians to engage these clients about the possibility of traumatic loss and unanticipated loss without pre-traumatizing them. How can we do that?

DM: We have to remind ourselves that what makes us effective therapists is the quality and nature of the therapeutic alliance that we establish, maintain, and monitor with our clients. So, to answer your question, I would advise clinicians to not enter that discussion without the permission of their clients. If I were in that situation, I would say something like, “I recently had a personal loss and I had a lot of lessons that I learned. And I was wondering if you would be interested or willing for me to share those.” So, my notion of being a good therapist is always to solicit permission from my clients, no matter what it is I want to ask. The third thing I would do is to say that, “you should feel free if this is not a good time or this is what we want to do, to put you in charge.” Remember that we, as therapists, need to be person-centered rather than protocol driven.

So, it sounds like, Larry, you had a whole bunch of to-do tasks that you think this elderly client or loved one should go through, right? You said you don’t want to traumatize them. Well, I agree totally. You know, so treat them with the same respect that you would want.

LR: How do we have conversations with our clients who may not even have elderly parents, but who are aware that they live in a world where there are dangers around every corner. How do you help clients prepare for the unpredictable without pre-traumatizing them?
DM: I have a kind of style of therapy, and I’ve actually highlighted this. I just put together a legacy course on what makes people expert therapists. As it turns out, 25 percent of therapists get 50 percent better results and have 50 percent fewer dropouts. So, my legacy course is, what characterizes those 25 percent of people and how can I elevate clinicians to that level? I have a kind of interpersonal style of respectful curiosity. And I really want to convey that to the client and wonder if they’re curious as well.I might say things like, we live in — how should I describe it — precarious times. With the COVID epidemic, with unpredictable violence, with multiple disasters and I must confess that I personally wondered to myself, and I wondered if you wondered to yourself about, given the unpredictability of life ever occurring, are we and our loved ones prepared for that? I mean, that’s my style of interacting. So, what I’m doing in that is actually sharing the rationale, and I’m extending an invitation.

My client might choose to take that invitation or not. And moreover, if I am going to see that person again in the future, all I want to do is plant the seed, then I will be able to follow up. I would say maybe this isn’t the right time or I’m not the right person. But as I look around, I think it might be advisable. And even something as simple as knowing the password of your loved one might be a good starting point. So that’s my way of engaging people.

LR: As simple as that. Simple, but complete.
DM: The key, or perhaps the challenge, is to deal with difficult issues in a non-traumatic engendering fashion.

Lessons on Grieving through Personal Loss

LR: In what ways, looking back, has your own clinical work and research helped you in your journey of grieving?
DM: Now that I’ve talked about the sequalae, let me take a moment and talk about the grieving thing. One of the things that’s really important for your audience to know — and there’s good research by George Bonanno and others that in the aftermath of loss — is that whether it’s due to traumatic, violent episodes like this, or whether it’s due to more prolonged, complicated grief as a result of having someone who’s been ill for a long period of time; there’s an expectation and different kinds of deaths have different kinds of impact.The bottom line is you need to recognize that most people are highly resilient. If you look at the data, most people don’t develop prolonged and complicated grief. So, the key aspect is, what distinguishes those who do versus those who don’t? And I even wrote a book called Roadmap to Resilience, that examines this and deals with it. In fact, your audience is welcome, in honor of my wife’s death, to view this and also my legacy course in her memory. So that’s one way of transforming pain into something good that will come of it.

And in fact, the Roadmap to Resilience has been downloaded for free on the Internet by 45,000 people in 138 countries. So now, let’s get to the heart of your question. In fact, George Bonanno wrote a really nice book called The Other Side of Sadness, which I recommend. It’s a nice little extrapolation on the kind of resilience engendering behavior. Therese Rando has also developed a concept that I’d like to comment on, that she calls “STUGs,” Sudden Temporary Upsurges in Grief.”

And in monitoring my own behavior, since I’m a psychologist and good observer, I’ve tracked my own STUGs. These kind of substantial or sudden kinds of upsurges of grief. And there are two kinds of STUGs in my life that I’ve discovered that have important clinical implications. The first STUGs are sort of sudden and unexpected. A song comes up, an invitation comes up to go to dinner with someone who doesn’t know about my wife’s loss. A couple walks by holding hands and lovingly convey their intimate connection.

And that hits me in an unexpected way. I’m moved to tears, and I have a sense of loss and the like. And there’s nothing wrong with that. In fact, I’ve come to believe that each tear that I experience in loss is not only a reflection of the loss and the grief and how much I miss her and the like, but it’s also a tear of appreciation. Of how lucky I was and grateful to have her in my life all these years. And then, I would have never had this career and all that without her. I’m a cognitive behavior therapist, so the whole thing is not that you cry, not that you feel losses.

It’s what is the story you tell yourself and others about that emotion? Each of us, each of your readers of this interview are not only Homo Sapiens, but they’re Homo Narrans. That we’re actually all storytellers. And the nature of the story we tell will determine — I’m going to suggest — whether you fall into the 20 percent who develop prolonged and complicated grief, or you’re part of the 70 to 80 percent who, in spite of the loss, everlasting loss, your STUG is this kind of sudden reminder.

LR: Unexpected!
DM: I sort of expect them, but they come out of the blue, right? The other kind of STUG which is interesting is something that’s a reflection of a prolonged type of routine or activity that we would have engaged in. So, I’m in Cape Cod, one of the things we would do is go down and have our sunset drink on the beach. A saxophone player would often be playing in the background from their beach house, you know, some Cape Cod song that we would have toasted to, kind of thing.Or we have our favorite restaurant, or our favorite hike or something like that. And I’m now doing those activities on my own. There’s another really interesting aspect to this, and that is, is the person who’s surviving the death, male or female? Okay, so most of my social contacts here in Cape Cod, and in other places, are a derivative of my being a partner of Marianne. So, she had a remarkable social network. She was just lovable and likable. There wasn’t anyone who didn’t fall in love with my wife.

And when she died, those social contacts sort of evaporated. People sort of give you occasional email and a “how are you doing?” But you don’t get invited to the same social occasions or dinners or other kinds of activities, so your network is really an important issue. And the important predictor here, especially among men, is loneliness. Okay, and there’s a higher incidence of husbands dying soon after the death of their wife, about 30 percent and so forth, and having other kinds of physical ailments than the other way around.

And then you need to distinguish between loneliness and isolation. Some people choose to isolate — they like being alone and so forth. Loneliness is yearning for this. And so first of all, in the aftermath of both traumatic bereavement and in terms of the mourning process, that becomes important. The other thing that your readers should take away is that there are no stages of grieving. So Kubler-Ross and Ron Kessler’s stuff about going through stages has no scientific basis for it.

And not only do you not have the five stages, but the expectation on the part of the clinician that people need to go through stages, and the failure to do so is a sign of pathology, is indeed problematic and possibly stress-engendering. So, when people don’t get angry, okay, then it’s deniable or they can’t handle their emotions. And I had a pretty good cause to be angry. This happened in Florida, okay? So, the guy who killed my wife got fined 160 dollars and lost his license for three months.

That was the total consequence. Not only that, in Florida — this is a wonderful state to live in if you’re going to retire — you don’t have to have liability insurance on your car. Okay? All you need to do is pay insurance up to 10,000 dollars. The helicopter cost of taking my wife from Clearwater to the trauma center was 68,000 dollars. So not only do I have, look, how much time do we have? You want me to go on and on? So, what am I going to do? And anger we know, gets in the way of processing trauma memories. Of all the emotions, that’s the one you don’t want to give up to. And that’s the one that clinicians should ask about in the aftermath.

So, if you go to the handout that I have, I have put together the most important diagnostic questions that clinicians should ask. Yeah, I give workshops on grief, and I actually bring my pillow and tell people. And I ask, if I’m your client, Larry, what questions do you think you should ask me? You’re a gifted clinician. What do you think are the most important questions you should ask me to see whether I’m going to develop prolonged grief disorders? Because there are now effective treatments. Shearer and others have created really good cognitive behavioral interventions, when I go on and on and review all the literature. So, I can make this a two-way street. I could ask you, what question do you think you should ask me first?

LR: What comes to mind is, how has your life changed?
DM: Wrong question!
LR: Okay, I could probably guess 20 times wrong.
DM: No, no. The first thing you should ask is, “how long ago has this occurred.” Okay, if this happened like last week or last month, that’s different than if it occurred a year ago. Okay? You know, and then there’s a whole set of questions you could ask about the circumstances, like you did at the outset. Okay, so getting to the notion of how you handle this has a kind of implied judgment on your part that I should be handling it.So, am I going to tell you how bad off I am or am I going to say oh, it’s not that bad, right? So, you have to establish a good therapeutic alliance with me, where I’m going to be open and honest. You know, I have trust engendering things, so I don’t know what your agenda is. Anyway, go to my handout.

LR: I will. I will.
DM: Please, I didn’t mean to put you on the spot.

LR: It’s refreshing and intimidating at the same time. What other guidance are you offering to clinicians who maybe are sheepish about asking the questions, or will not openly receive or seek out clients who have experienced loss? 

DM: The first thing — over and above the comment on stages — is that the field of psychotherapy is absolutely filled with bullshit. I wrote an article with Scott Lilienfeld called, How to Spot Hype in the Field of Psychotherapy. The next thing for therapists to understand is that the various therapeutic procedures are equivalent in outcome, and that there are no winners in the race. So that’s the next thing, just don’t believe the hype in these workshops where these people are saying that, “X, Y, and Z works better.”That traumatic bereavement is a common response, will lead to grief and mourning that leads to deteriorating performance is just not the case. So, the second thing that’s really important is that you need to ascertain from the client how to do therapy in a culturally and religiously, and gender-related kind of fashion. You need to ask the person — in my case, whether I’ve had other losses besides Marianne. You need to make me a consultant to you. Okay. And then you need to probe. How did I handle those? And is there anything I learned from them? So, you need to see me as a client as a resource person rather than someone you’re going to treat because you went to some workshop. Okay!

And apropos of the loss and transition website by Neimeyer and colleagues, they have a lot of techniques. Some of them are expressive. Some of these are customary activities that people engage in. So, you, the clinician, need to honor the way in which I want to cope with grief. Okay? And I recently went to a workshop by Mary Francis O’Connor who wrote a book on the grieving brain. And you need to recognize that some of the losses that people experience are natural and a reflection of love.

So don’t pathologize people’s grief or their coping techniques. If I want to avoid certain activities, I don’t go and get rid of the clothing and so forth. And there was a movie that Tom Hanks made that his wife produced called, A Man Called Otto. It’s a bit of a Hollywood version, but they did a really good job on talking at the gravesite. And doing the thing on the clothes. Here’s a wonderful thing that happens. When I cleaned out my wife’s closet, I found out that for the five years that we courted each other, we had written letters. And mind you, that was 1961. She saved all those letters. In 1961, a stamp was four cents. I read those letters as if she was present, each night I take out a couple. I’m now up to 1963, you know that stamps now cost $0.08 in 1963? Her presence, my storytelling, my doing this interview, my reading the letters, are all my own personal ways to honor her memory. The fact that I put the Roadmap to Resilience online for free in her memory.

If you go to the Melissa Institute website, if you’re interested, if you like this interview, go there and make a donation in my wife’s name. We’ve already raised 25,000 dollars for the Institute against violence prevention for her. I’m now in the midst of having done this legacy course of ten one-hour lectures on what makes someone an expert therapist, and then how to take those core principles and the transtheoretical behavior change principles and apply them to a whole host of diverse problems like grief and PTSD and anger and the like.

Each of those courses is only going to cost 150 dollars. Okay, that’s 15 dollars per CEU. All that money is going to go to the Institute in memory of Marianne. So, if you want more of what we’re talking about, track down this legacy course. If you do, there’s the likelihood you’ll be in the 25 percent group and you’ll be able to honor my wife’s memory. You get CEU’s for cheap.

The Role of Resilience in Healing through Grief

LR: You mentioned something earlier on, Don, about resilience as one of the really powerful predictors of how someone will move through their grief journey. Can you say a little bit about what a resilient griever looks like?
DM: In the aftermath of trauma or victimization, and with regard to whatever form it takes, resilience has been equivalated with notions of the ability to bounce back and with dealing with ongoing adversities. And it deals with the notion of personal growth. Margaret Stroebe and her colleagues have an interesting distinction within which people oscillate. That is, they have a variety of coping responses that are loss-oriented or restorative, and future-oriented. One of the things that’s interesting is that people can deal with it as a kind of Viktor Frankl type of observation.That people could deal with any kind of how in their life, as long as they have a kind of why in their life. Some sense of meaning, making purpose. This fits into my constructive narrative perspective that everyone is a Homo Narrans, or a storyteller. So, one of the things that becomes really interesting is how people transform their loss into some kind of effort to help others. So how did the Melissa Institute come about and my involvement therein? So, in the tragic killing of their daughter, Melissa, when she was at college in Saint Louis at Washington University, they have transformed the last 28 years – her loss — into a meaning-making activity.

You can go to the Trevor Project on suicide. You can go to Mothers Against Drunk Driving. There are numerable examples, I give multiple websites of how people have transformed their pain into something good. That doesn’t mean that you don’t continue to have an everlasting sense of grief. There’s nothing wrong with grief. It’s like any other emotion. The key is, what do people do with that emotion? Do they withdraw? Do they isolate? Do they become lonely? Do they use addictions? Do they self-medicate?

So, the key question is not, apropos of the resilience, or that people grieve. The fact that people are in touch with their grief is, in fact, a sign of resilience, right? It’s coming to, how do they honor? How do they memorialize? I deal a lot with returning soldiers. And the other kind of thing is that there are different kinds of losses. There’s loss of people, but there’s a thing called missing loss also. Like imagine people who have individuals who go missing in action. You don’t know if they’re dead right, or in Maui — you know, they haven’t found certain bodies. I mean, does that mean, is there more?

How do I, do I sort of get preoccupied and ruminate about the loss of my loved one, and how I wasn’t there? If I have guilt, shame, humiliation, if I have anger, if these kinds of negative emotions are that which drives me, then that’s the person, those are the folks who are going to be more likely to get stuck, who have hot cognitions and the like. So, you can talk about resilience being the absence of negative stuff, or resilience could be the restorative process on the other end. I don’t know if I’m getting close to your concerns, but…

LR: That resilience, and there are certain personality attributes and certain experiences that predispose people to resilient ways of being, and those people are probably in a better place to move forward in their lives after a loss.

DM: Here’s one of the things I failed to mention. The research indicates that people who have had a prior major depressive disorder are significantly more likely to develop prolonged and complicated grief. So, when I was asking the question, I ask, “Have you had similar losses in the past” and so forth? What we could do is look for vulnerability factors, okay, that are red flags as another tip. To see who would warrant evidence-based interventions, we’re pretty good.

If you look at my core task, there’s a whole way of how we, as therapists, do psychoeducation to educate people about grief. Or how do we help them develop various kinds of coping strategies? And how do we get them to follow through? The big thing is how do you get people who need help to want to come for help? And help them stay there? That’s the artistry of therapists.

LR: Is it more likely that those who have historically reached out to others for help, who have built lives that are rich in community, are just naturally predisposed?

DM: Well, a lot. There’s a fair amount of research by Camille Wortman and Roxanne Silver. Obviously, one of the building blocks for resilience is relationships. I mentioned I have four loving kids who really came to support, I have other people — professionally and others — who’ve come to support. But Wortman then really found a whole bunch of things that people do that are unproductive, that actually make people worse.

They have identified a variety of things that people provide support for, and actually make people worse. Like moving on statements. Things like, “You’re still a young, attractive, bright guy. You’ll find someone. How much longer before you die, You’ll be able to join him. This was God’s mission, He knew something.” So, there are lots of things that social support people offered, so that’s one of the questions you need to ask.

What, if anything, have people done or failed to do that you found helpful or unhelpful, right? Because you want to make sure that you, the therapist, aren’t doing something that I perceive as being unhelpful. So, if you’re a really good therapist, let your patients teach you how to do therapy. Don’t think just because you went to graduate school or took some workshop that you know how. Ask your patient, “What do you think is causing you to still have this lingering grief? And what do you think it will take to help you to move on? And what is it that I, the therapist can do to help you in that process?”

LR: You know, Bob Niemeyer suggests that therapists working in the arena of grief need to be what he calls the guide on the side, rather than the sage on the stage.

DM: Yeah. I like that. That’s a good metaphor. I like him a lot. I’ve read all his stuff. And, you know, my thing is, don’t be a surrogate frontal lobe for your patients. Don’t let the person’s emotions hijack their frontal lobe.

LR: And don’t, as the therapist, let your emotions hijack your presence in therapy. What about those therapists who themselves have had complicated losses, or unfinished business with their own children, parents, and spouses who have died?

DM: Well, I guess those therapists need to be honest with themselves and wonder how it impacts their therapeutic process. Those therapists need to be honest with themselves and decide whether, in fact, they need some therapy. That could help them deal with the issue. And the third kind of issue is, can they strategically use that self-disclosure in a way that facilitates or benefits the patient’s recovery? Rather than saying, you think you’ve got problems with your wife? You want to know what living with cancer has been like? And not only that, my father has Alzheimer’s, and now all of a sudden I have to listen to your shit, right?

So, you can judiciously, strategically say words are inadequate to describe what grief is like. I’ve been there myself. It’s not the occasion for me to share the details, but I want you to know I’ve felt the pain. Okay, I don’t know what the right words are, and you have to say it in an effective way. You can’t say, you think you got problems?

LR: In what way are you — are there any ways that you’re still practicing as a therapist now?

DM: I do a lot of consulting. I work with the head injured thing when people have cases, I train therapists who are doing supervision. I’m not seeing patients now like I did in the past, because I’m not in one place. I’m kind of a peripatetic clinician, so it’s hard to make a commitment to someone being there. I do some consultation with patients by telephone, since COVID.

LR: We could talk for hours Don and I do I hope we talk again. I appreciate your kindness and generosity.

DM: Thank you for the compliment and for inviting me on this journey.

©2024, Psychotherapy.net

Supporting Recently Traumatized Youth in a Crisis of Dissociation and Self-Harm

Posted on by Psychotherapy.net Team

Case Background

Samantha, a 15-year-old African American young woman, was referred for psychotherapy by the hospital where she was taken after she was gang-raped while passed out at a party after drinking more than she ever had. This is Samantha’s first ever outpatient psychotherapy session, and she finds herself experiencing disorienting and, at times, overwhelming waves of depression and hopelessness as well as dissociative fugue states. Trying to calm herself, Samantha also finds herself involuntarily scratching at her arm and sucking her thumb, both of which give her a comforting sense of emotional and physical numbness.

Samantha’s friends describe her as a beautiful, kind, and honest person with a great sense of humor, an A student, and a star athlete. Samantha attends an exclusive private high school on scholarship; there, she is one of very few students of color. Her dream is to get a scholarship to an Ivy League university. When not studying or on the lacrosse field, she volunteers to help children and families in need in the community and for human rights causes. Older boys have frequently asked Samantha out, but she has never agreed because her parents are strict about dating and don’t want her to get entangled in a romantic relationship and lose her focus on college.  

Samantha’s family lives in urban public housing, where drug abuse and community violence are common occurrences. When she was 10 years old, Samantha witnessed her older brother, Andre, get shot and killed. He was walking her home from school, and they were caught in the crossfire of a gang fight. At the time, she didn’t understand what had happened when he suddenly fell down and blood was all over the sidewalk around him. She tried to get him to wake up and get up, but he wouldn’t open his eyes, move, or speak. She remembers neighbors taking her home and her mother screaming and sobbing when told that Andre had been shot. Samantha recalls that her mother “never was the same” after that; She wouldn’t go out except to go to work and return home.

Samantha frequently found her mother seemingly in another world, sobbing and saying, “My boy, my boy!” After the shooting, Samantha’s father also started drinking alcohol to the point of intoxication several times a week. Samantha has learned to stay away from him when he is drinking because he changes from being a loving and kind man to an angry and violent person she doesn’t recognize.

Samantha’s parents kept their jobs; They worked long hours and encouraged her to get scholarships and do well in school and sports. Samantha feels very grateful but also guilty that her parents are stressed and working hard while she seems to be enjoying school and sports in a sheltered school setting. Girls in her neighborhood, though, call her an “Oreo” (because she is Black, but they see her as trying to act like a White girl) and have stopped being friends with Samantha.

At school, girls pick on the way she speaks, saying she sounds like a “ghetto girl,” and that she only got into the school because of charity or government handouts. She has a solid group of male friends but sometimes feels like she doesn’t really fit in with the other girls at school. Girls are also jealous of her because of the attention she gets from boys, which has made making girlfriends even more difficult. She has one close female friend, Lily, who is also on the lacrosse team.

At the end of Samantha’s junior year, after she had aced a very difficult AP (Advanced Placement) chemistry exam, Lily convinced her to go to a senior summer kickoff party. A graduating senior, Jack, who had been asking Samantha out since she was a freshman, was hosting the party and wanted both girls to come. After prodding from Lily, Samantha decided to “let loose” for one night and attend the party. Samantha told her parents that she was sleeping over at Lily’s. Jack made a big deal of Samantha’s being at the party and offered to “grab drinks.” Although he was enthusiastic, Jack had always been friendly and had never been aggressive in his pursuit of Samantha. Samantha had only experimented with alcohol, but she wanted the full party experience, so she decided to “go for it.”

Samantha began by slowly sipping on a drink, but then got pulled into a drinking game with Jack and his guy friends. She quickly became intoxicated. Jack asked her if she wanted to go somewhere quiet to talk, and Samantha agreed. Jack helped her walk precariously to his bedroom, and the moment she sat on his bed, Samantha passed out. Realizing that she needed to be taken care of, Jack went to find Lily. This took quite a while with the raucous party spilling over into all parts of the house.

When Jack and Lily returned, they saw four very intoxicated guys nervously coming up the hallway from the direction of Jack’s room. When Jack and Lily entered the room and turned on the lights, they saw Samantha sprawled out and mostly undressed on Jack’s bed, still unconscious. Lily called an ambulance and Samantha’s parents.

Samantha woke up in a hospital room with Lily, Jack, her parents, and a nurse. “What happened?” she mumbled. “The last thing I remember was being with you, Jack. Something’s wrong. I feel all numb but like my body’s been run over by a truck. Did we get into an accident?” The next several weeks were a nightmare for Samantha, and for her parents and friends. She felt depressed and scared because she could tell she had been assaulted, but she had no memory of it.

When she met with a sexual assault counselor working with the police and learned that one of the boys had confessed and that she might have to go to court if criminal charges were pressed, she felt terrified and like the whole world would know she was “dirty.” The sexual assault counselor got her an appointment with a female therapist who worked with girls and women who have been sexually assaulted. Samantha delayed starting psychotherapy for several weeks by canceling several sessions. Her parents finally insisted that she talk with the therapist and drove her to this, her first, psycho-therapy session.

Session Transcript, Annotations, and Commentary

After the annotated session transcript, I present a summary of Samantha’s observations and reflections on her experience in the session. Following this summary is commentary highlighting key themes and take-home points for handling this or similar crises, and questions for reader self-reflection.

THERAPIST: So, Samantha, tell me a little bit about you.

SAMANTHA: (Stares at her lap) I’m in school.

THERAPIST: Mm-hmm.

SAMANTHA: (Still looks down but glances furtively at the therapist) And I’m into my senior year. I like to play volleyball.

Therapist’s Inner Reflections: Samantha seems very withdrawn and in a lot of pain and emotional turmoil. She looks haunted; there’s definite fear in her eyes, and she’s glazing over and just barely holding it together. Looks like she’s heading for an emergency and a breakdown. I want to help her reorient to the present, so I’ll engage her in focusing on who she was before the rape with an emphasis on her physical self so that she can become more aware of her body and slow down the flood of ruminations that she appears to be experiencing.

By orienting to the strengths and abilities she had—and still has—this can help her do an SOS [as discussed in Chapter 5, SOS refers to slowing down and sweeping her mind clear, orienting to a thought that helps her feel safe, and self-checking stress level and level of personal control] and begin to feel more personal control despite the intense distress she’s feeling. I’m not going to introduce the SOS formally to her because that would seem too didactic and intrusive, but I can help her do an SOS and begin to focus herself by showing an interest in her interests and strengths.  

THERAPIST: Excellent. I know that you know this—I met with your parents a little bit before you, so they told me that you have been a great athlete for a while. So, volleyball is now your favorite sport?

SAMANTHA: (Hunches over, looks at her feet, no longer glances at the therapist) Uh-huh.

THERAPIST: Excellent. Wonderful. Okay. And, um, I also know that things have been rough the past 3½ weeks . . . and that’s why you’re here today. So, I want you to know that—that we can work on this, that this is actually gonna be, um, a little bit hard at the beginning, but I know that you will—we will figure out ways that you can really overcome this terrible thing that had just happened to you. I’m sorry. So, because you’re a good athlete, I know that you work hard . . .

SAMANTHA: (Relaxes slightly) Mm-hmm.

Therapist’s Inner Reflections: I’m not going to ask her to tell me what’s triggering the distress for her because that probably seems obvious to her (even though it’s more complicated than she fully recognizes). By acknowledging the trauma in general terms, I’ve signaled to her that I do recognize what’s triggering her but that I’m not going to dredge up what’s happened or how she’s feeling because she’s probably trying very hard to not be aware of the shame and betrayal that I expect she’s feeling—and to not think about the rape, even though she probably can’t stop having intrusive memories, especially because she was not conscious while the rape happened. For the sake of Samantha’s sense of security in talking with me, which is very new and fragile — with this being our first session, the betrayal she’s experienced, and her damaged sense of self and efficacy—I’m going to emphasize her ability to accomplish difficult goals at this point.

THERAPIST: . . . and also your parents told me that you are a very good student, too.

SAMANTHA: (Looks up tentatively) Uh-huh.

THERAPIST: You have worked for—for everything that you have now. Right? And you really just have to finish your senior year the same way that you have, you know, have worked so hard your whole life to be where you are. So, your parents are telling me that they are concerned because you’re not going to school. Hmm. That has been really hard on you.

SAMANTHA: (Looks at the therapist, then down) I just don’t feel like going to school anymore.

THERAPIST: Mm-hmm. Yeah. So, tell me some of the reasons why you don’t want to go to school.

Therapist’s Inner Reflections: I’m sure there are many reasons that may seem obvious to Samantha, but I’m asking her to support this shift she’s just made from being passive and numb emotionally to being able to actively express her point of view. She’s engaging, even though the first signs are anger. Let’s see what more specific triggers she recognizes.

SAMANTHA: (Looks directly at the therapist, eyes blazing) I don’t wanna see certain people. (She sits back, strokes her ear reflexively with one hand, and sucks on the thumb of her other hand.)

Therapist’s Inner Reflections: The distress she’s feeling is intense. I see her doing several forms of reflexive physical self-soothing to tolerate the distress. As she does that automatically, she could put herself into a dissociative trance. I’ll support her intention of self-soothing and see if I can gently help her to do it consciously and to access other forms of self-regulation as well so that the self-soothing doesn’t lead to a dissociative shutdown.

Dissociation could lead to the healthy self-protective and self-assertive anger she’s understandably feeling to leak into her self-soothing in the form of unconscious or barely conscious self-harm. I’ll start by returning to the first part of the SOS: helping her focus on her breathing and being aware of her body.  

THERAPIST: Mm-hmm. Mm-hmm. Okay. It’s hard to, to see some of your friends or your acquaintances? And now I can see that it is really hard, Sam, to just talk about this. And I can also see that your body is telling you that probably right now you need to be soothed. So, one way of doing it, and I bet it’s helping you, is by touching your ear—yeah? And sucking your thumb. We can explore other ways that can also be helpful. Can I show you some other ways? (Samantha nods.)

THERAPIST: So, let’s try to focus on your breathing, Sam. Can you breathe for me deeply? Can you feel the air coming in from your nostrils? Can you do it maybe one time? Can we try another one? (Samantha looks down and begins rubbing and then scratching her arm.) This is too hard. This is painful. Is the scratching helping you? Hmm. Can we explore other ways, too? (Samantha stops scratching her arm and instead rubs it more slowly and gently. She begins to tap her feet vigorously.)

So, I can see that you’re moving your feet. Can you feel your feet on the floor, Sam? Yeah? Can you tell me if your feet are warm or cold? Yeah. Let’s try to keep on moving your feet. Keep on moving them. Yeah. Can you move your other foot? Yeah. Alright. Can we breathe a little bit more? Let’s do three times this time. Okay? One . . . two . . . three.

SAMANTHA: (Shifts from rubbing her arm to scratching with increasing intensity; begins to hyperventilate.)

Therapist’s Inner Reflections: Samantha’s escalating into emotional dysregulation and what looks like a dissociative state. Helping her to relax may be unintentionally leading her to lose track of her ability to self-regulate, I need to stay with the focus on body awareness but step up and gently but firmly guide her with very specific small steps to doing so without hurting herself.

I think she needs to see what I’m talking about, both to be able to cognitively process what I’m saying and to reorient herself to being present and not alone but supported by me. I’ll keep the focus on her being in control of herself so that she doesn’t experience me as taking control away from her in the way that those boys did by sexually assaulting her when she was unconscious.

THERAPIST: And, instead of scratching, can you touch your other hand and your arm like this? How does that feel? Can you feel your arm? Can you feel your wrist? Yeah? Keep breathing. You’re in a safe place, Sam. Nobody’s trying to hurt you here. Okay. I like this. Do you feel that your body likes it? When you try to soothe yourself like that, how does it feel?

THERAPIST: (Samantha gradually breathes more slowly and deeply with a more relaxed torso and legs.) Nice.

Therapist’s Inner Reflections: As Samantha calms down and comes back into the room, I can feel the tension draining out of my body as well. I’m primarily focused on Samantha, but I’m noticing that it helps me personally to self-regulate by doing these simple self-awareness actions along with Samantha. Now I can help Samantha not only feel calmer but also safer and protected. I’d like to give her a hug myself to comfort and reassure her, but I know I’m not her mother (even though I’m thinking about my daughters and wanting to hold them when they’re upset or hurt), and she needs to know that no one will intrude on her in this therapy. So even through it seems kind of silly, it makes sense to help Samantha to hug herself, and she’ll know that I am contributing to that hug without intruding on her personal space in a physical way that could feel like a replication of the rape (and her brother’s murder). 

THERAPIST: Nice? Alright. Have you ever given yourself hugs? No? Sometimes I give myself some hugs. Sometimes that helps me. Try it—maybe not here but later on. Okay? I’m wondering, you know, how we’re gonna find ways that soothing yourself is going to be part of your daily routine, and, at the same time, you can soothe yourself and only you will know that you’re soothing yourself. Alright? So, we did that sort of breathing a, a little bit of deep breathing, so you know that you’re breathing deeply because you want to focus on the here and now, putting your feet on the floor and making sure that you know that you’re feeling it, feeling your hands. Right? Feeling different parts of your body and focusing on, you know, where you are.

Therapist’s Inner Reflections: If I help Samantha connect these simple breathing and body awareness actions with her athletic skills, that can make this something she can do intentionally both to reduce the intensity of her hyperarousal and to tap into her self-confidence. And I will emphasize the core goal of keeping herself safe, which is what she feels she and her friend (as well as the boys who perpetrated the rape) failed to do. Then I can link the goal of being safe to her withdrawal, which is a problem and a symptom of depression because it keeps her trapped in survival mode but also is an adaptive attempt to protect herself.

THERAPIST: Okay? It’s almost like playing volleyball, you know? I bet that you’re so good at volleyball because you are actually practicing, and when you practice more and more, you get better and better, right? So, it’s the same thing here with our emotions. The more that we try to stay in the here and now, the more that you’re gonna feel a little bit safer. Okay? And, so, the more that you feel, you know, that you are in safe environments like—I bet that you’re spending a lot of time in your house right now. Is it—is your house a safe place for you? Does it feel safe? (Samantha nods.) Okay.

SAMANTHA: (Continues to visibly relax; makes tentative eye contact with the therapist) Yeah, it does.

THERAPIST: Okay. Are there any other places that are—make you feel safe? No? Only your house? Okay. Alright. So, tell me a little bit about what would going back to school look like. What do you think that you need in order to feel calm, in order to feel that you can soothe yourself utilizing healthy ways so you can go back?   

Therapist’s Inner Reflections: Samantha now is associating the main goal of safety with calmer body feelings that represent a main emotion (feeling “nice,” which seems to mean that she feels a sense of peacefulness emotionally) and a main thought (that she is not trapped in horrible distress but has active ways to enable herself to feel better). With safety as a main goal that can organize her complicated emotions and thoughts, we can begin to explore her options for achieving the goal of protecting herself (and the related goal of returning to school and resuming her life and progress toward future goals, such as success in school and sports).

SAMANTHA: I have my best friend.

THERAPIST: Mm-hmm. Your best friend. So, tell me, what is your best friend’s name?

SAMANTHA: Lily.

THERAPIST: How long have you known Lily?

SAMANTHA: Since high school started.

THERAPIST: Okay. Since freshman? Wonderful. So, you’ve known her for 3 years now?

SAMANTHA: Yeah.

THERAPIST: Okay. And you can trust Lily? Has she been contacting you? Yeah? So, has she been supporting you these past 3½ weeks? Yeah? How does she support you? What is she doing to help you?

SAMANTHA: (Smiles shyly) She’ll check up on me like every day or so.  

Therapist’s Inner Reflections: Samantha is such a resilient young woman! Without my bringing it up, she went right to what’s probably the single best way to begin restoring her sense of relational security, which had been shattered by her friend Jack’s neglect and the other boys’ betrayal and exploitation.

Samantha is a little fearful of trusting that her best friend Lily won’t also let her down or even reject her, but she can see that her friend is standing by her. The sense of being cared about and valued, and watched over in a helpful and nonintrusive way are clearly crucial for Samantha’s recovery. I’ll explore that as a potential path forward for her.

THERAPIST: Mm-hmm. Mm-hmm. Wow. So, is she actually contacting you quite often? Yeah. Alright. Have you been able to keep up with some of the work at school? No?

SAMANTHA: (Shifts back to a tense fetal-like position; withdraws eye contact) No.

THERAPIST: Alright. Okay. Is that something that you would like to do? Yeah. Okay. So, you’re a very brave young woman who has gone through a lot, and your body is very wise and knows how to calm and soothe you. So, I’m wondering if, for next week, maybe you can visit your friend Lily at her house before next week and see how that goes? Would that be something that you are willing to try? Is that something that you think that you can do?   

Therapist’s Inner Reflections: That was a mistake and a close call. I jumped ahead by implying that I was urging Samantha to go back to school. I got caught up in the relief that Samantha (and I as well) was feeling when focusing on the security that her friendship provides. I’m glad I caught that by noticing Samantha’s nonverbal signaling and stepped back to suggest a much more manageable first step of just going to the friend but not facing the much larger set of stressors and triggers that she’ll encounter when she returns to school. One step at a time. I’ll help Samantha build a behavioral chain of small steps that can help her reengage with her relationships and her particular areas of strength and success: schoolwork and athletics.

SAMANTHA: (Looks thoughtful, determined, and then makes eye contact) Yeah.

THERAPIST: Okay. Alright. And I’m also wondering if you can start talking with Lily about some of the things that you can start doing at home or maybe with her, some of the schoolwork, especially about the good subjects that you really like and enjoy? Is that something that you think that you might want to focus on this week?

SAMANTHA: (Continues uninterrupted eye contact) Yeah.

THERAPIST: Alright. And the last thing, Sam. I’m also wondering, since you are an athlete and you got this—right—I’m wondering if there is anything that you can do this week that can help you to maybe jog a little bit or walk fast or—or do something like that around outside—around your house, where you can . . .

SAMANTHA: (Nods and continues to make eye contact) Yeah.

THERAPIST: . . . do some exercise?

SAMANTHA: Mm-hmm.

THERAPIST: Is that something that you think that you can do? Yes?

SAMANTHA: Yeah. I can do that. Yeah.

THERAPIST: Alright. Well, I’m really looking forward to seeing you next week. Okay? Thank you.  

Samantha's Observation

In a post session interview, Samantha said that she had been feeling that she didn’t recognize herself anymore and that her parents didn’t look at her in the same way as before. She was ruminating constantly about the party, berating herself for being so stupid and wishing she had never trusted Jack and his “so-called friends.” She had secretly started cutting herself to make the pain and shaking stop and sucking her thumb to comfort herself. In the session, she initially felt physically tense because she didn’t want to have to answer more questions from another adult about the assault and about how she was feeling and coping now.

She was surprised and reassured when the therapist was very gentle and accepting, but then she felt that she let down her guard and started to space out: “I kind of went somewhere else.” She felt extremely embarrassed when she realized that she had begun to suck her thumb in the therapist’s presence, but she didn’t know how to make herself stop. She felt a strong urge to hurt herself when the therapist brought up the earlier experience of witnessing her brother being killed. Samantha described having felt a sense of confusion and shock related to witnessing her brother’s murder that she realized was very similar to how she had been feeling about being assaulted. That realization helped her to understand why she felt unable to stop thinking about the assault: “It was another time when I was powerless to stop something terrible from happening to someone I cared about, and no one else protected them or me, either.”

Samantha emphasized that she found the therapist’s guidance to be helpful in enabling her to be “more in my body” and more aware of the present moment and surroundings. She found being able to be more aware gave her a feeling that she wasn’t powerless, that she could “take back some control.” She also felt calmer and safer, which was very different than the brief feelings of relief that she’d gotten from sucking her thumb or cutting herself—and she also didn’t have to deal with feeling ashamed of herself and embarrassed, which had been making things much worse for her emotionally.

By the end of the session, Samantha was feeling a small amount of hope that, with the therapist’s help, she could talk about the assault and her brother’s murder and figure out how to not feel so terrible that she couldn’t stop thinking about those horrifying memories. She also had hopes of figuring out manageable steps she could take to work toward returning to school and “getting back to having a normal life.”  

Commentary

As the session unfolded, the therapist clearly was focused on three primary goals:

  • building an alliance and instilling hope by interacting with Samantha in a way that was nonjudgmental, accepting, nonintrusive, and responsive, and that facilitated a sense of relational security, resilience, active problem solving, and hope for solutions
  • assisting Samantha in regulating her emotions and becoming nonjudgmentally aware of the understandable emotional turmoil she was experiencing by identifying and adapting her intuitive ways of coping with memories and emotions, and supporting her by affirming, highlighting, and drawing on Samantha’s many personal strengths
  • assisting Samantha in setting and emotionally committing to an over-arching goal that reflected her current concerns and that enabled her to organize her complicated emotions and thoughts in a manner that provided her with a path forward to restore the parts of her life and the aspects of herself—as an outstanding student and athlete, and as a valued friend—that she had relied on as a source of inner security, pride, and hope for the future  
The therapist navigated a number of crucial and challenging choice points in working toward these three goals. As the therapist’s inner reflections indicated, a first challenge was to help Samantha to remain sufficiently oriented to be able to self-regulate and benefit from the support and guidance the therapist could provide. Without explicitly teaching the first FREEDOM (focusing, recognizing triggers, emotion awareness, evaluating thoughts, defining goals and options, making a contribution; see the Introduction) step, the SOS for focusing, the therapist helped Samantha begin to be aware of her body and present circumstances for the very beginning of the session (the first “S” in SOS).

She also helped Samantha to orient (the “O” in SOS) by highlighting her ability and interest in sports. And she helped Samantha track not only the intensity of distress she was feeling (using body feelings rather than verbalized emotions as the guide) but also her sense of personal control (again using breathing and tactile self-awareness as a practical way to feel in control).

A common challenge faced when working with clients in or on the verge of crisis is establishing rapport and trust while determining how— and when—to best help the client disclose the memories and emotions that are causing severe distress. In the post session interview, the therapist confirmed that she was aware of recent traumatic events that had occurred for Samantha but did not ask Samantha to talk about those events. This signaled to Samantha that she could trust the therapist not to be intrusive, which was crucial in light of the traumatic violation Samantha had experienced and the many questions that she and others were asking her about what happened.

By alluding to the events, the therapist also was communicating indirectly to Samantha that it is important to consciously recognize the triggers that remind her of the traumatic events. In addition to simply being in therapy (which almost inevitably brings up memories), the therapist identified other key triggers, including going to school and Samantha’s experiencing distress in her body. Rather than inquiring about the specific triggering stimuli and circumstances, the therapist immediately focused on helping Samantha to respond to triggered distress with body awareness and breathing.

Doing so communicated to Samantha that conscious recognition of triggers does not mean that there is any pressure to dwell on or even talk about the traumas, the triggers, or both that elicit trauma-related memories. In this way, the therapist helped Samantha to recognize—rather than simply react to—current triggers for distress as well as the trauma-related memories. Samantha’s reaction of increased d

Working Effectively and Developmentally with Traumatized Adolescents in the Juvenile Justice System

Posted on by Psychotherapy.net Team

Would you ever want to go back to adolescence? I cringe at the thought. What a torturous time of peer pressure, identity development, and naivete about one’s own mortality. I’m sure there are a few folks out there who would happily re-experience this time in their lives, but my gut tells me it would be a small group. When I reflect on this time in my own development and then consider my experiences working with incarcerated youth, I can’t help but feel immense empathy for what they are going through, knowing they now have this experience of incarceration to contend with that will further impact everything from their self-image and their behavior to their comportment in the world. When you further consider the diagnoses that start to present themselves as these youth ages, it can become gut-wrenching to imagine how they are going to navigate life after incarceration.

Longing for While Sabotaging Connection

In my work with Zed (fictional name), I’ve seen an adolescent who so desperately wants connection, but is so afraid it won’t last that he rapidly and abusively sabotages his positive relationships. He is profoundly adept at putting on a tough face and acting as if he does not feel lonely, sad, and hurt when this transpires, and he ultimately carries the belief that people always leave, so it is better to strike before being struck. This belief has become a self-fulfilling prophecy of sorts and is heavily characterologically entwined with every facet of his being.

When Zed was younger, he ended up in the foster care system while his parents were struggling with addiction, and inevitably found himself in and out of the juvenile correctional system, transient, and in group home settings. Zed is not without insight — in fact, he frequently states, “I was acting up in those placements; I wanted to be back with my parents.” It’s important to verbalize that although it is true that he may have exhibited self-sabotaging behaviors, Zed’s presentation is directly entangled with the broken attachment and trauma that he experienced, culminating in a recent diagnosis of Borderline Personality Disorder (BPD). This diagnosis has somewhat shocked Zed and he has been persistently reluctant to accept it, and understandably so. As a teenager whose brain is still developing, the idea that your behavior is being pathologized rather than viewed as a response to injustice would be immensely overwhelming. In a session, I once offered Zed the adage, “Hurt people, hurt people.” The idea behind sharing this was to hopefully leave him with a mental nugget to come back to and ponder. However, the response I got from Zed that day was that it’s justifiable for hurt people to hurt people, particularly if it’s someone who has hurt them already. I could feel Zed’s desire for others to feel his pain — it was practically streaming from him, along with the deep injustice he felt he had experienced and the unfairness of it all to such a young person. My inner dialog was saying, “Wow, this person has experienced so much emotional pain, it is practically blinding him and those around him.”

As someone working closely with someone with BPD, it is easy to imagine how other staff members who perhaps do not have much in the way of mental health training could become easily overwhelmed, frustrated, or fearful when working with a teen like him. When Zed perceives injustice, judgement, or simply does not receive the information he would like, he can escalate and become both physically and verbally aggressive. However, the reframe of this, which I have found myself discussing with other staff members, is that he is screaming out to be held, if not literally — which may indeed be true — but figuratively. I’ve found that in instances like this, boundaries are the equivalent of being held, along with unconditional positive regard. When a resident with BPD is actively upset, they are banking on (somewhat unconsciously) the self-fulfilling prophecy of, “I am too much for others. People will always leave me,” becoming fulfilled.

What to do in moments like these, when it would otherwise be so easy to punish and control, is critical not only for their treatment, but as potential lessons of life they can take forward with them. For example, I’ve found that self-injury is often utilized as a method of power and control by someone who is diagnosed with BPD, which in turn, can make clinicians and staff fearful. They then might inadvertently reinforce the self-injurious behavior by acquiescing to what the patient demands just so the self-abusive behavior will cease. This is immensely harmful in the long-term, as the patient will utilize this strategy consistently if it proves fruitful.

When experiencing periods of time where Zed has actively engaged in self-injurious behavior, I approach him with one goal in mind: safety. It is during these periods of crisis when I remind him that I will only be able to do in-depth work with him when he can maintain safety for himself and others. Without this basic element of safety, there is no foundation, and nothing can effectively be accomplished. When I am successful in helping all of those working with Zed in this regard, it becomes much more likely that he will return to a place of equilibrium and avoid harmful behaviors.

Perhaps the biggest challenge I’ve experienced while working with Zed, is maintaining my sense of the “long-game.” Solution focused remedies won’t propel us there, but consistent unconditional positive regard, setting of boundaries, and supporting the therapeutic alliance will. While the gains often feel minimal and fleeting, consistency and determination go a long way in equipping teens like Zed with the tools for a more successful life outside of institutional walls. The most important thing I can do with teens like Zed is to remind myself and others around, that diagnosis is NOT all that these clients are. It is simply a marker and reminder that they have experienced significant and sustained trauma and potentially disrupted attachment, and they can be helped.

***
If we tell people there is no hope that they can grow through a diagnosis, we are neglecting to give them all the tools in the toolbox. And as carriers of the toolbox, it is our job to provide those we treat with the proper tools for the task at hand.

Questions for Thought and Discussion

  • What are your impressions of Zed and how this therapist addressed his therapeutic needs?
  • How does your work with clients diagnosed with BPD differ from hers?
  • What might you have done differently with Zed?

Using A Holistic Approach to Therapy with Clients Experiencing Chronic Illness, Disability, and Mental Health Challenges

Posted on by Psychotherapy.net Team

Prevalence of Chronic Illness/Disability in the United States

The presumption that “typical” abilities and wellness encompass the norm is a viewpoint that pervades United States policies, infrastructures, and societal expectations. The reality is that the majority of the US population grapples with chronic illnesses and disabilities, challenging the conventional definition of “normalcy.” While many associate illness with isolated incidents, dramatic and prolonged interruptions in otherwise regular lives — along with the prevalence of chronic conditions — indicates that illness is, in fact, more typical of the human experience than not.

According to data from the Centers for Disease Control and the Rand Corporation, over half of Americans (51.8%) contend with at least one chronic condition, whether physical or mental. Some estimates are that 42% of the population faces multiple chronic conditions. By comparison, according to the European Council of the EU, one in four, or 25% of European adults live with a chronic illness/disability. These statistics not only reveal the widespread impact of chronic illness but also emphasize the need to shift cultural perspectives surrounding health and ability. To be absolutely clear, in the United States, chronic conditions are the norm, not the exception. In his recent book “The Myth of the Normal,” Gabor Maté challenges prevailing notions of normalcy and underscores the ubiquity of trauma and illness within the diversity of human experiences. Exploring biopsychosocial aspects of chronic illness and disability, Maté exposes fundamentally unhealthy cultural constructs that shape our understanding of what it means to be “normal.” Moreover, in response to an unhealthy environment, Maté asserts that illness is a valid response. His work resonates deeply with my practice, as it highlights the importance of acknowledging the sequelae of trauma in the vast spectrum of human existence.  

As a Clinical Rehabilitation Counselor, my training encompasses both the medical and psychosocial aspects of chronic illness and disability. Moreover, my own personal journey as a cancer survivor and someone diagnosed with Crohn's disease enables me to meet clients from a perspective of lived experience. This experience underscores the importance I place on applying a comprehensive holistic approach to mental health in the context of chronic conditions many of my clients experience. My work in a small group practice specializing in supporting clients with trauma, chronic illness, and disability is a testament to the prevalence of such experiences.

Within my caseload, 95% of clients navigate the challenges of multiple chronic physical and mental conditions, often relying on state-subsidized insurance for healthcare. Among these individuals, approximately 60% identify as female, 25% as gender fluid or transgender, and 15% as male. Their narratives underscore the multifaceted nature of dependence and autonomy across various dimensions of life. From physical and financial to emotional and sexual realms, the complexities of living with chronic conditions influence every aspect of their existence.

For individuals grappling with chronic illness, the connection between past trauma and present health challenges cannot be overlooked. More often than not, these clients report elevated Adverse Childhood Experiences (ACEs) scores, revealing a complex interplay between past trauma and present health challenges. My integrative approach encompassing trauma-informed care, empathy, empowerment, and holistic healing includes attention to my client’s experience of their body. Attention to physical sensations including interoception and proprioception, breath, movement, and reflex patterns, allows me to guide them towards a path of resilience, self-acceptance, and well-being. Recognizing the intricate threads that weave together past experiences, present struggles, and future aspirations creates a space where my clients feel heard and equipped to navigate the complexities of their health journey with resilience and clarity. 

Relationships and Chronic Illness/Disability

One of the prevailing challenges faced by individuals with whom I work who have chronic illness and disability shows up in power dynamics within close relationships. Dependence on a partner for various types of support including financial and logistical, coupled with chronic pain and the struggle to balance gratitude and self-worth, can erode an individual's sense of agency. For those grappling with conditions such as Crohn's disease, fibromyalgia, multiple sclerosis, or rheumatoid arthritis, the unpredictability of their conditions makes planning for the future a daunting task. As a result, vacations, celebrations, and even daily routines are frequently disrupted. The demands of work often deplete their energy, leaving their partners to shoulder the responsibilities of managing a household and caring for children. The strain on intimacy and sexual relationships adds another layer of complexity.  

Partners of those with chronic illness and disability experience their own set of challenges, leading to feelings of frustration and helplessness. Their desire to provide support can transform into a sense of powerlessness as they navigate the complexities of medical interventions, lifestyle changes, and emotional well-being. The dynamic between partners can quickly shift from a place of caring support to caregiver exhaustion and burnout, a source of resentment that creates a cycle of mutual dissatisfaction.

In my therapeutic practice, it is not uncommon for clients to request involving their partners in sessions. Drawing from my unique perspective as someone who navigates a chronic illness while also being a partner to someone with health challenges, I provide insight that resonates with their experiences. This shared understanding fosters open dialogues that explore the intricacies of relationships within the context of chronic conditions.

One poignant example underscores the profound impact of childhood experiences on an individual's journey. A client shared a harrowing memory of their father monitoring their food intake during meals — threatening punishment if they exceeded a prescribed number of bites. This history of food-related trauma has woven itself into their present struggles with Small Intestinal Bacterial Overgrowth (SIBO), a condition marked by pain, diarrhea, gas, and bloating due to bacterial overgrowth in the small intestine. While the impulse to connect trauma to illness is compelling, the client's journey also involves a series of infections necessitating antibiotic treatment over time.

This client’s partner, in their well-intentioned efforts to support, inadvertently triggers their traumatic memories when attempting to manage the client’s food choices. The need for a restrictive diet as part of SIBO treatment further compounds their emotional turmoil, fostering feelings of deprivation and punishment as they strive to heal. Addressing this intricate interplay of trauma and health within the therapeutic space requires a delicate balance.

In a joint session involving both the client and their partner, I employed empathetic communication to navigate their complex dynamic. While acknowledging the partner’s genuine desire to provide assistance, I simultaneously asserted the client’s agency and authority over their own body and treatment. Employing the metaphor of the client as the “captain of their ship,” I emphasized that their body is their vessel, and they remain firmly in control. This approach is of paramount importance, particularly for individuals who already feel a sense of bodily discord and lack of control.

Additionally, it is helpful to recognize the partner’s role in the client’s healing journey. Acknowledging the partner’s commitment to honoring the client’s autonomy becomes an act of spiritual significance, aligning with their broader values. This dual recognition — empowering the client’s autonomy while honoring the partner’s supportive stance — fosters a therapeutic environment that not only addresses the physical aspects of chronic illness but also attends to the emotional, psychological, and relational dimensions.

In another case, my client grappled with chronic Lyme Disease within a relationship plagued with communication challenges, describing their partner as “unresponsive.” When they came for a family session whose purpose was to help them talk about the ramifications of her disease, I realized her partner was very likely on the spectrum. Though not his counselor, I was able to introduce both of them to this possibility, explain how this might be contributing to their difficulties, and help him connect with a counselor of his own.

Finances, Work, and Future Self in Chronic illness/Disability

For those clients navigating a chronic condition on their own, their lives are often precariously situated on what feels like the brink of financial ruin and collapse. With chronic pain or with an unpredictable condition exacerbated by stress, work is a double-edged sword. On the one hand, it may confer some security, sense of accomplishment, and self worth. On the other hand, it may aggravate certain illnesses by contributing to stress and may prevent people from qualifying for federal or state aid.

Most of my clients with chronic illness have applied for disability and are on their second or third appeals. They hang in a limbo where making money can compromise what little chance they have. Barring paralysis or a progressive condition, their chances of receiving disability are slim to none. These clients often seek work they can do from home. They are unwilling to take on student loans because of the precarity of their health. Some earn a living from piecemealing several jobs.

Whenever possible, I try to coordinate care with vocational rehabilitation (VR) services offered by the state which helps people find and obtain work suitable to their strengths and limitations.  

In one case of a client with chronic depression and difficulties which led to him losing his job, I advocated for him to receive a neuropsychological evaluation. Both the client and I felt he was on the spectrum. This enabled him to receive help from VR for job placement and support. By helping him find work that made use of his strengths while limiting his interactions with people, his depression improved along with his self-esteem. Whether living with a chronic physical or mental condition, it is important to remember everyone has strengths as well as limitations.  

Moreover, chronic illness, disability, chronic pain, and trauma can profoundly alter one’s sense of self. As mentioned earlier, the challenges posed by unpredictable and intermittent conditions make it challenging for individuals to plan for their future. This absence of foresight can have far-reaching consequences, undermining clients’ ability to envision a future version of themselves — a capacity often taken for granted. This lack of future-oriented thinking leaves clients susceptible to a multitude of setbacks, affecting their physical, mental, reproductive, financial, and educational well-being.

The ability to manage finances is a skill, yet those who lack both financial resources and a sense of their future self tend to make choices that perpetuate their financial struggles, leading to increased poverty. I’ve come to understand that these clients find it difficult to delay immediate rewards for a future date. Without a clear vision of their existence in the next 5-10 years, they prioritize immediate gains, which is understandable.

A client who was in the foster care system and spent a period of time houseless in their teens worked in the food service industry. Though experienced, their lack of formal education meant they often worked under managers with a degree but less actual experience than they had. Frustration with poor management led to frequent job dissatisfaction. Chronic but unpredictable illness limited their ability to work more than 25 hours per week. This kept them stuck in tip-dependent but ultimately unsatisfying work. Their dissatisfaction influenced their feelings about work in general.

During a period of unemployment, I encouraged them to explore alternative options. It became clear that they had only the barest sense of how much money they actually needed to cover expenses. A critical therapeutic intervention involved helping them create a budget in order to more accurately assess the benefits of a job that offered no tips, but more hourly pay. Even at 25 hours/week, they stood to cover their costs better than with sporadic food service work.  

To arouse clients’ sense of possibility, I lean on existential humanistic and Buddhist psychological teachings. None of us knows when we are going to die. People with long-standing conditions, both physical and psychological, live long and productive lives. To come to terms with having a finite amount of time with no sense of how much time is left is an essential human challenge. My clients experience grief over unlived possibilities. These feelings must be acknowledged and included. One client whose career was interrupted by an ependymoma (a spinal tumor that recurred twice) has grappled not only with ensuing disability from the spinal tumor, but ways she never took her career seriously even before the onset of the disease. Often disease itself becomes a catalyst for deeper exploration and participation.

Wellness Culture, Community, and Chronic Illness/Disability

Our culture’s pervasive and inescapable preoccupation with fitness, appearance, and social status is another hurdle facing people with chronic illness or disability. Research has demonstrated the undeniable mental and physical benefits of engaging in exercise and community. But for those who struggle with chronic illness and disability, these arenas are often outside their reach. These clients find themselves frequently isolated by the exigencies of their illness.

Socializing requires energy, and in the face of household or work demands, friendships fall by the wayside. The COVID pandemic resulted in yet another barrier for people with chronic illness and disability who are at risk of more serious infections. For those with mobility issues, opportunities to exercise are limited. One client with Cerebral Palsy receives only 6-10 sessions of physical therapy per calendar year.

Part of providing holistic therapy is helping clients discover ways to include movement and connection in their daily routines. As an example I work with severa,l clients affected by Ehlers Danlos Syndrome (EDS). EDS is a genetic condition that affects collagen, our body’s connective tissue. It ranges from mild involvement that creates hypermobility in the joints, requiring avoidance of extreme movement practices, to so severe it can cause heart and other organ failures.  

I frequently incorporate QiGong movement exercises in sessions, or I provide clients with short videos to follow. QiGong, a 4,000-years-old mindfulness based movement practice used throughout Asia for health maintenance, healing, and longevity, has been shown to mitigate pain, lower cortisol levels, and improve self-efficacy perceptions. The movements are gentle enough to not strain the body, yet require focused attention. They can be performed standing, seated, or supine. 

For those clients who are housebound much of the time, the need for community is often met by online connections. One client maintains an active online presence and connects through advocacy and providing education about their condition. For a trans teen client attending online school however, face-to-face interactions with peers is missing and contributes to their feeling alone. Like many people his age, he’s reluctant to learn to drive, and though he has applied for many kinds of work, he’s not been able to find employment due to his age. These circumstances compound his isolation. Group therapy has sporadically met those needs, but isolation remains a significant issue for those with chronic illness.


***

In my personal and clinical experience, addressing the mental health needs of individuals with chronic illness and disability requires a holistic and empathetic approach. As a therapist, I have found it essential to challenge prevailing cultural norms, advocate for the acceptance of diverse abilities, and provide a safe space where clients can explore their unique journeys.

At the outset, chronic illness and trauma can feel like burdensome lead, weighing down the spirit and clouding our sense of self. The challenges posed by these experiences may appear insurmountable, the darkness can be overwhelming. Yet, it’s in the crucible of adversity that a profound alchemical process unfolds.

In essence, the alchemical journey of turning lead into gold mirrors the transformative power of the human spirit when faced with chronic illness and trauma. It reminds us that within the depths of our struggles lies the potential for profound growth, healing, and the emergence of our most radiant and precious selves. By fostering open conversations, cultivating self-advocacy, and nurturing supportive relationships, I, and hopefully fellow clinicians reading this, can empower their clients to embrace their identities and navigate the complexities of life with resilience and grace.