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For the Love of the Game

Posted on by rezendevknowfully.com

Have you ever had a client who asserts they do not need counseling, yet there they are, sitting with you? I have experienced this on more than one occasion. With these clients, I must often find creative ways to connect with them that offer a less threatening entry to the idea of talking to someone about life and their feelings about it.

A Reluctant Player Picks Up the Ball

One client in particular stands out, and I’m especially grateful to one of my counselors-in-training who helped build the bridge that allowed me to break through the client’s defensiveness. That moment opened the door to a genuine connection—one that invited him to work alongside me to improve his quality of life.

George was a 35-year-old male sitting in my office because his wife told him to get help or that she was going to leave. He had heard of me from a friend and that I was “good with military stuff” and since he was a Veteran, “well, here I am.” During our intake, George shared that he did not think his military time was relevant to his wife’s ultimatum. He said that she was often frustrated that after returning from work he would rather spend time watching sports than spending time with her. George didn’t perceive this to be a problem and thought she might simply be experiencing a period of neediness.

Around the time I was working with George, I had a counseling student/basketball coach who often used basketball metaphors for his own clinical skill development. Talk about opportune timing! I remember during one particular skills class he said that he had to overcome hurdles to complete one of his more challenging assignments. He said that this process wasn’t much different from reviewing a game replay film. This is when I realized how much I was learning from my student, so I decided to reach out to him to collaborate on this essay. I’m grateful to share that this marked the beginning of our journey together.

The Game Plan: Basketball as a Metaphor for Counseling

Working alongside my student taught me a great deal about the parallels between counseling and basketball, success in which depends upon continuous, real-time collaboration between the coaches and players to overcome barriers to victory.

Off the court and in the therapy space, making changes, evaluating resources, and identifying barriers are necessities. Often, clients start by presenting all the resources and support that are available to them. They discern throughout their counseling what issues they need to take to the court and which can remain on the bench. This process is parallel to the moment when coaches have to make the decision to bench a particular player for their own good or for that of the team.

In basketball, a player may indeed be able to score a few points, but giving them the chance to do so may not support the needs of the team as a whole or the be the best strategy for winning. Winning, even with the best players can still be a challenge. Unpredictability on the court is common and upsets happen. Just as in life, and in the therapy space in particular, unpredictable twists and turns must be considered, and strategies need to be revised. When working with George, where I was the counselor, but also a coach of sorts, we had to work together in order to discern clear goals and his true desires for the marriage.

The concept of “team” offered a useful metaphor for George’s place in the family. While I was working with him individually, I had to keep my eye on his team, or system. I had to account for both him and his “team.” He had come to counseling because his wife, his teammate, provided him with an ultimatum to go, or their marriage would end. The idea of losing her was not something he was willing to risk. That was not his goal, so we needed to strategize to come up with a game plan that would lead him, and his wife, to marital victory.

I was able to carefully navigate George’s system to understand his role within it, as well as explore his personal perception of what marriage and family meant, and the behavioral implications for not just him, but his “team.” I was able to reflect on his circumstances as if we were reviewing a game film. And just as game videos help players understand the difference between what occurred on the court and what they want to do differently next time, George was able to review, re-evaluate, and strategize before he resumed ‘marital play’ with his wife. Together, we created a therapeutic locker room, a nonjudgmental space to examine not only what was best for him, but also for his team.

This “locker room conversation” led to an exploration with George about his relationship with his wife, what he had to offer, and what he wanted in return, or in short, what he brought to the court of his marriage and what he needed in return. Even when players are at the top of their game, there are times when they need to come off the court and onto the sideline for both their own benefit and that of the team’s. The metaphor of shifting to the sideline and the “bench” to calmly and objectively re-evaluate his “game plan” seemed critical at this juncture in his marriage. Consultation with the coaching staff—me, in this case, served as a useful, and hopefully, productive “time out” in which George could decide what changes he wanted to make, if any.
I was able to process George’s strengths and weaknesses to support his awareness, processing, and empowerment towards goals. Coaches aid their athletes in understanding their skillset, areas in need of growth, and seek to empower them to improve upon their abilities to excel. To reach goals and excel requires analysis of strategies. Some skill sets may be more beneficial at specific times while others need to take the bench and allow their teammates to perform in order to obtain the overarching goal.

Collaboration between the clinician and client(s) and the coach and athlete(s) are essential to advance towards goal attainment. During George’s last session with me, he shared his fondness for a basketball movie called, For the Love of the Game. It was an apt ending for our work together, the results of which he could hopefully take back onto the court of his marriage.

Takeaways

I could have spent hours researching the sport, but true understanding only came through learning from someone who genuinely loves the game and is eager to share that passion. In the same way, I’m grateful to model for my student that even the most seasoned clinicians remain open to growth and committed to refining their skills.

Postscript: In working on this piece with Dr. Arcuri-Sanders, I (Daniel) was touched and honored to hear how she incorporated some of my thoughts and love for basketball into her clinical work with George. I felt validated in my pursuit of counseling licensure, my passion for basketball, and being able to connect the two.

Reflections on How to Live with Hardships in Life

Posted on by rezendevknowfully.com

The central question of my latest book, Shh…it Happens: So What? Reflections on How to Live with Hardships in Life is: How do we go on when life refuses to grant us peace? Some pain lingers like an old debt; some wounds never fully heal. Perhaps wisdom lies not in overcoming, but in learning to carry what cannot be undone.

Pain Isn’t Meant to Teach Us Anything

I’m not sure how this idea could serve as a therapeutic tool. But through my work with Holocaust survivors, and others who have endured severe trauma, this perspective has gradually become something I deeply believe in.

Shh…it happens is often all we can say when life falls apart, and when we recognize that some things defy response. There is no clever comeback to death, no simple answer to betrayal, no quick fix for what breaks us. Shit happens—and not just once, but again and again, in forms both visible and hidden, personal and global, trivial and devastating. No one is immune. No life is spared from it.

Our culture doesn’t like that. It wants action and solutions. There’s a constant stream of advice: stay strong, be positive, find the silver lining. But what if we can’t? What if we’re not ready to move on, let go, or come to terms with it? What if all we can do is sit with it?

This is not a call for despair. It’s a call for honesty.

For decades, I’ve sat with people in pain—clients, friends, family, and myself. I’ve witnessed how quickly we rush to make sense of the senseless. We reach for explanations, spiritual frameworks, psychological theories, anything to tame the chaos. We want to believe that suffering has a purpose. That it fits into some larger arc of redemption.

But what if it doesn’t? What if some pain isn’t meant to teach us anything? What if the most human, most courageous thing we can do is to stay with the discomfort, without turning it into something else?

That’s the heart of what I’ve come to call a “so what?” philosophy. Not as resignation, and certainly not as indifference. It’s not a shrug—it’s an act of quiet resistance. A refusal to force meaning where there is none. A willingness to sit in the shadow of what has happened and say: This is real. I don’t understand it. But I’m still here.

Lessons from Experts in Survival

We are meaning-making creatures, but not everything in life offers us meaning. Some events simply are: A child dies. A diagnosis lands. A future dissolves. No explanation makes it right. There’s only the living with it.

And in that living, there’s something else—not healing, perhaps, but presence. A kind of dignity that doesn’t come from overcoming pain, but from carrying it honestly.

The “so what?” stance is not about dismissing what matters. It’s about letting go of the pressure to be wise, composed, or productive in the face of grief or absurdity. It’s about recognizing that we don’t have to justify our sadness or spin our suffering into virtue. We can just sit with it. Let it be part of our story without needing it to be the whole story—or the final word.

There is no clean arc to follow. No perfect lesson to extract. There are only fragments—of reflection, of feeling, of thought—offered here as a kind of companionship. No system. No stages. Just a shared recognition that life gets messy, and sometimes the best we can do is to pause, to breathe, and to say quietly: So what?

Because that’s where we begin again—not by solving the pain, but by making space for it.

While working at The Israeli Center for Mental Health and Social Support for Holocaust Survivors and the Second Generation (AMCHA)—a treatment center for Holocaust survivors and their families—I was granted a unique opportunity to learn from the very experts of survival. These were individuals who had endured the unimaginable, who had lived through horrors that seemed to defy the capacity of the human spirit to endure. It was, in many ways, a privilege—a rare chance to ask the question I had long pondered: How did they do it? How did they manage to survive the unspeakable, to continue living in the face of such loss, such devastation? What I learned, however, was that survival did not come without its own unrelenting cost.

The survivors I encountered—each with their own story, and their own scars—made every effort to continue their lives without being constantly haunted by the atrocities of the past. And yet, the memories had a way of returning, uninvited and unavoidable. They surfaced with all their accompanying emotions—grief, anger, fear—relentless in their return, like waves crashing against the shores of their minds. These memories could not be erased; they lingered, embedded deeply, despite all efforts to forget them.

Most survivors, however, showed an unusual degree of psychic strength, overcoming the effects of their harrowing experiences, their losses, and their exile. Yet, there was a minority, a clinical minority, whose wounds—those invisible scars—remained raw, continuing to affect them for years, even decades, after the war. The weight of those emotional scars lingered beyond what anyone might have expected. I tried to capture these findings, these complex realities, in my 2009 book, Holocaust Trauma—a humble attempt to summarize what I had witnessed, and what I had come to understand.

Perhaps the most telling description of endurance during the war happened during the death marches of the Holocaust. Prisoners were forced to march from one camp to another under brutal conditions, knowing that those who fell behind—too weak or too exhausted—would be shot on the spot. Every step they took was an act of defiance against a fate that seemed inevitable. The advice to “take one step at a time” finds its most literal and harrowing expression here. It’s a mantra we often hear when life feels unbearable: “Take it one day at a time.” It urges us to confront today’s pain, today’s hardship, without being consumed by the unknowable weight of tomorrow.

These aren’t stories with happy endings. They don’t offer neat resolutions or triumphs to celebrate. They are about enduring the unendurable—about surviving not because there is light at the end of the tunnel, but because continuing is the only option left.

I used to visit an elderly woman who had survived the Holocaust and once asked her gently, “And how are you today, dear?”

“Oh, you know,” she replied, her voice tinged with weariness. “Ups and downs, as always.” She paused. “I had hoped to put it all behind me, to find some peace. But it seems the past refuses to let go. It haunts my dreams, a persistent shadow.”

Her words, simple yet profound, laid bare the depth of her emotional turmoil. I had heard her recount her experiences during the war countless times, and there was no need to articulate what weighed on her mind. The past, an unrelenting burden, had etched itself into her being—a scar that even time could not heal. And yet, we must continue to live with what cannot be changed, carrying the weight of the scars as we navigate forward. It’s not about fixing or erasing the pain but learning to coexist with it.

Some shit doesn’t pass. It lingers, not as trauma in the clinical sense, but as residue. A faint tension in the body. A change in tone. A silence that settles into the corners of a room. We move on, but something in us stays behind.

We learn to live with this residue, not by resolving it, but by tolerating its presence. That doesn’t mean being passive. It means not turning away.

There’s a common belief that pain must be processed, worked through, or healed. And sometimes that’s true. But more often, we simply carry it better. We learn to contain what cannot be erased.

Containment isn’t control. It’s not about suppressing emotion. It’s about holding what’s there, without being overwhelmed by it. Like sitting with someone crying—not trying to stop them, not analyzing—just staying present. That’s what we do with our own pain, too.

To “come to terms” with suffering doesn’t mean to conquer it. It means to walk alongside it, to acknowledge its presence without letting it consume us. Perhaps then, we may slowly release our futile struggle to control the uncontrollable and begin to find peace in the messiness of life. As painful as it is to admit, this struggle isn’t separate from life. It is life. Suffering forces us to confront something deeper: who we are, how we endure, and the meaning we choose to create in the shadow of the unbearable. Some people rebuild. Some collapse. Most of us do something in between. We adapt. We patch. We find new ways to carry the same weight.

That’s what I mean by recycling shit—not transforming suffering into something beautiful, but giving it a new function. Letting it fertilize something else, even if we never asked for it.

Pain leaves a mark. But it also leaves material. Emotional scraps, memories, truths we didn’t want but now can’t ignore. If we’re lucky, we find a way to use them. That doesn’t mean we’re grateful for the suffering. It means we don’t waste it.

Some people make art. Others grow more tender. Some become fierce protectors of others who suffer. Some just endure—and that’s enough. Repurposing doesn’t have to be dramatic. It can be as quiet as waking up and doing the dishes.

I’ve seen people repurpose pain into humor, into music, into silence, into stubborn survival. Not because they’re brave, but because the alternative was to fall apart. Pain, when recycled, becomes part of who we are—not a scar to hide, but a seam in the story.

There is no promise here. No redemption arc. Just a reminder: pain changes us. And in that change, something new may form—not because the shit was good, but because we lived through it.

Recycling is not erasing. It’s carrying forward what cannot be undone, in a way that no longer poisons everything it touches. It’s not transformation. It’s a continuation.

The Contained Mess

We often speak of recovery as if it were a return, but most of us don’t return. We don’t go back to who we were before the shit happened. That version of us is gone. What we do instead is re-cover—layer over the wounds, stitch the fabric of life back together, however unevenly.

This is the heart of what I’ve come to believe: we don’t get over things. We don’t transcend. We carry, adapt, and make space. We contain, not in the clinical sense, not in the tight management of emotions, but in the old sense of the word: to hold. We become the container for the life we didn’t ask for. We hold the brokenness, the anger, the absurdity, the beauty. Sometimes it leaks. Sometimes it’s too much. But somehow, we stay upright.

For me, writing has been an exercise in containment. I’ve tried to reflect, not resolve. To stay with the mess long enough to see what it might become. And yet I wonder whether the act of writing is its own attempt at control—a way of taming the chaos with sentences.

Maybe this, too, is part of my own shit.

Still, I believe in the value of sitting with it. In not turning away. In saying, even when no answers come, I am here. This happened. I’m still breathing.

The world doesn’t need more advice. It needs more truth and more people willing to say: I don’t know what to do with this pain. But I’m willing to hold it.

That’s where these reflections end. Not with clarity or healing. With a container of shit, and the quiet hope that it holds.

This essay is a condensed version of the full book: Shh…it Happens: So What? Reflections on How to Live with Hardships in Life. The full version explores each of these ideas in depth, with stories, personal examples, cultural reflections, and philosophical insights. It’s not a manual, but a companion. A place to pause, to reflect, and to feel less alone in the shit we all face.

Encounter with Resistance

Posted on by rezendevknowfully.com

This excerpt is taken from Existential-Humanistic Therapy (3rd ed.) by Kirk J. Schneider & Orah T. Krug, 2026 (ISBN: 978-1-4338-4474-4) and printed here with permission of the American Psychological Association.

Resistance

When the invitation to explore, immerse, and interrelate is abruptly or repeatedly declined by clients, then the perplexing problem of resistance—or, as we are increasingly framing it, “protections”—must be considered.

Resistance is the blockage to that which is palpably (immediately, affectively, kinesthetically) relevant within the client and between client and therapist. Existential-Humanistic (EH) practitioners assume that resistance, or protections, are concrete manifestations of clients’ inabilities to fully face and accept some life experiences—especially those that are particularly painful and devastating. EH practitioners consequently appreciate resistance behaviors because they illuminate the ways in which a client views their sense of self and the world. The following vignette from my (Orah Krug’s) work with Diana provides an illustration. Our session began with Diana describing, with evident pride and satisfaction, how she had accepted a challenging task from her supervisor and had successfully completed it.

In Session

OTK: You seem very pleased with your accomplishment.

Diana: (exclaiming strongly) Following through on a commitment is very important to me.

OTK: There’s a lot of energy there. Your statement seems to have a great deal of meaning for you. Can you go inside and explore its meaning a little more? Just let your mind relax and say whatever is there. (I intentionally slowed the process down here because Diana’s energy identified aliveness. I try to encourage more of that with a person who typically tamps it down, as was Diana’s tendency. I sensed that a part of Diana was attempting to emerge, and so I invited her to make “space” for it.)

Diana: It’s about being responsible, showing up in life, growing as a person. (Suddenly she stopped and laughed.) I don’t know where I’m going.

OTK: You’re doing just fine. (I immediately realized my mistake. My comment was an attempt to rescue her from her discomfort instead of allowing her to explore and understand what had just happened. I backtracked and tried to have her get curious about her process.)

OTK: Did you notice that your comment about not knowing where you’re going seemed to stop you dead in your tracks? Go inside and see if you can discover what’s happening there.

Diana: (smiling) I thought I was saying something stupid, blah, blah, blah, and I thought you thought so, too.

OTK: You know in that moment of stopping yourself, you stopped showing up for yourself. The irony is that before you stopped yourself, you were showing up for yourself. Perhaps showing up for yourself triggers some fear?

Diana: (quiet for a moment, and then with tears in her eyes) Yes, a fear of being out there and not knowing what’s coming—I squish myself.

OTK: So, when some feeling is emerging inside, you get afraid? Can you go slow and explore what scares you in the emerging?

Diana: I feel exposed, I feel vulnerable.

OTK: Can you imagine another feeling you could have instead of fear?

Diana: I could be curious—that’s how I was last week, when I went out with a group of friends from work. I realized I was attracted to one of the men in the group and felt that curiosity. I thought, there are a lot of men out there that I could feel this way with, instead of going to that fear place of there’s only one man and I must attach to him.

OTK: How is it to share this with me?

Diana: I feel a little shy, but okay. I didn’t realize how and why I stop myself, and it feels good to have us both knowing what goes on with me.

This crucial therapeutic moment could have been lost if I hadn’t recognized that reassuring Diana in her moment of discomfort was not facilitative. Diana needed support to explore her repetitive pattern of stopping herself when feeling “out there and stupid.” A more therapeutic response prepared the soil for her to embody her silent, constricted way of being constructed long ago to avoid feelings of vulnerability and exposure. Diana’s painful shame-based feelings were so palpable that I reactively tried to protect her from them. This experience emphasizes how quickly subconscious reactivity can take the place of conscious presence.

@2025, American Psychological Association

Toward a Critical Realist Understanding of Psychoanalytic Interpretation

Posted on by rezendevknowfully.com

Reflections on Psychoanalytic Interpretation

Psychoanalytic interpretation, though subject to the analyst’s own biases and limitations, should not be dismissed as merely subjective or arbitrary. While interpretations inevitably arise within the context of specific psychoanalytic traditions—such as Freudian, Kleinian, or relational theories—they are not devoid of epistemic value. Rather, these interpretations can be understood as provisional efforts to track psychological truths, albeit imperfectly and always open to revision. This view aligns with the philosophical stance of critical realism, which holds that reality exists independently of our perceptions, and as Margaret Archer and Roy Bhaskur suggest, our understanding of it is mediated through theory, language, and social context.

Applied to psychoanalysis, this implies that while interpretations are never final or infallible, they can be evaluated and refined over time in light of clinical experience, internal coherence, and therapeutic efficacy. Interpretations thus occupy a middle ground: neither purely objective “discoveries” nor wholly constructed “narratives,” but tentative approximations of deeper truths about the patient’s mind and its workings.

This perspective on psychoanalytic interpretation contrasts starkly with the views of many relational and intersubjective theorists who rely heavily on a postmodern worldview that is inherently skeptical of science and truth as found in the writings of Robert Stolorow and his colleagues. For these theorists, meaning is co-constructed in the analytic dyad without appeal to any deeper, mind-independent reality, thereby shifting the focus from discovering psychological truth to negotiating intersubjective experience. While this view underscores the ethical importance of mutual recognition and co-authorship, it risks eroding the epistemic ambition of psychoanalysis as a discipline committed to understanding the unconscious processes that shape thought, feeling, and behavior.

Previously, Nassir Ghaemi and Jon Mills have leveled critiques of contemporary mental health practices on this basis. Ghaemi, a psychiatrist, has argued that postmodernism has led to a gross expansion of the psychiatric diagnostic system, which since the 1980s has prioritized reliability of diagnosis over validity. To Ghaemi, psychiatry—and, by extension, psychoanalysis—have been infiltrated by a postmodern belief system that is largely unconscious but widespread. He contends that this epistemic shift has undermined psychiatry’s capacity to seek truth, replacing it with a relativism that favors consensus and utility over ontological clarity.

Mills, a formally trained philosopher, psychologist, and psychoanalyst, has offered his own views on postmodern influences on psychoanalysis, concluding that much of modern relational and intersubjective theory is philosophically unsound and scientifically illiterate.

He writes, for instance, that “postmodernism has become very fashionable with some relationalists because it may be used selectively to advocate for certain contemporary positions, such as the co-construction of meaning and the disenfranchisement of epistemic analytic authority, but it does so at the expense of introducing anti-metaphysical propositions into psychoanalytic theory that are replete with massive contradictions and inconsistencies.” Mills’ comments on relational theory’s rejection of the individual self are particularly relevant to discussions about psychopathology.

I wish here to add some thoughts on these trends, arguing for a critical realist orientation that neither retreats into the naive objectivism of classical positivism, nor succumbs to the epistemic nihilism of postmodernism. Such a position allows psychoanalysis to retain its interpretive depth while preserving a commitment to truth-seeking as a core value. It acknowledges the hermeneutic and contextual nature of all knowledge while affirming that some interpretations, through sustained clinical engagement and theoretical refinement, bring us closer to understanding the enduring structures of the human mind.

Critical Realism and Psychopathology

Critical realism provides a robust philosophical foundation for the psychoanalytic understanding and treatment of psychopathology. Take, for instance, borderline personality disorder (BPD), which object relations theory frames as a disturbance partly rooted in early relational trauma and developmental arrest. From this standpoint, BPD is not merely a discursive construct or a social convention, but a genuine, structured pattern of affective dysregulation, identity diffusion, and interpersonal turbulence. Simultaneously, critical realism recognizes that our knowledge of BPD is mediated by theoretical lenses and clinical judgment—rendering psychoanalytic interpretation both necessary and fallible.

Consider a case example: a woman in her late twenties, diagnosed with BPD, seeks treatment after a cycle of stormy relationships characterized by rapid idealization and devaluation. She vacillates between clingy dependency and explosive withdrawal whenever the therapist enforces limits or plans time away. For instance, in one session, her reaction to the therapist’s upcoming vacation erupts into accusations of abandonment and betrayal. Rather than dismissing this response as merely capricious, the analyst, drawing on object relations theory, interprets it as the activation of split internal objects—“good” nurturing figures versus “bad” persecutory ones—echoing an early maternal rejection schema.

This interpretive move does not claim to unearth an immutable historical fact, but offers a provisional hypothesis: that the patient’s intense rage and despair stem from reactivated internal dynamics forged in childhood. In critical realist terms, the clinician’s account approximates the underlying mechanisms sustaining her borderline pathology. Over successive sessions, such interpretations can be tested against emerging clinical evidence—shifts in the patient’s capacity for affect regulation, moments of self-reflection, or changes in relational patterns—and refined accordingly.

By affirming BPD as a real psychological phenomenon while treating interpretations as revisable approximations, critical realism steers a path between naïve positivism and radical constructivism. It validates diagnostic categories as pointers to enduring disturbances in mental organization yet insists that every analytic formulation remains open to revision in light of new data, theoretical scrutiny, and therapeutic outcomes. In contrast to postmodern and constructivist approaches that reduce diagnoses to social artifacts or co-created narratives, this stance upholds both the ontological reality of BPD and the epistemic value of psychoanalytic interpretation in illuminating—and gradually transforming—the structures of the mind.

A Path Forward for Psychoanalysis

While postmodern approaches have rightly emphasized the importance of subjectivity and the therapeutic relationship, they risk, according to Mills, collapsing interpretation into narrative relativism, thereby undermining psychoanalysis’s commitment to exploring unconscious processes and enduring mental structures. Without a regulative ideal of truth, interpretation can devolve into rhetorical improvisation rather than a disciplined inquiry into the patient’s internal world. A critical realist stance retains the epistemological humility of relational theory—acknowledging that all knowledge is mediated and provisional—without relinquishing the pursuit of deeper understanding. It provides a framework in which psychoanalytic interpretations can still aim to track truths about the patient’s inner life, even if those truths are partial, revisable, and influenced by context. This philosophical grounding affirms the possibility of shared understanding and therapeutic change, grounded in the recognition of the patient’s psychic reality.

Moreover, critical realism may serve as a vital philosophical bridge between psychoanalysis and the broader domains of psychiatry and scientific psychology.

A longstanding critique of psychoanalysis is its epistemic isolation from empirical science, particularly its perceived resistance to diagnostic standardization or outcome-based measures. While this critique often oversimplifies psychodynamic epistemology, it underscores real tensions between hermeneutic and positivist models of mind. Critical realism offers a reframing of these tensions by supporting a layered ontology, where psychological phenomena can be real and causally efficacious even if not directly measurable.

In this view, constructs such as internal objects, splitting, and projective identification are understood as real mechanisms operating at the psychological level of analysis, even if they are not reducible to biological correlates or behavioral metrics. This allows psychoanalysis to retain its interpretive richness and depth while remaining engaged with scientific standards of explanation, coherence, and progress. It supports a pluralistic science in which meaning-based and empirically grounded approaches work in tandem to illuminate the complexity of human suffering.

In sum, a critical realist framework offers a productive middle path. Psychoanalytic interpretations, including those applied to complex psychiatric disorders like BPD, are shaped by theoretical models and clinical subjectivity, but they are not arbitrary constructions. They represent serious, good-faith efforts to make sense of unconscious dynamics and to promote psychological transformation. In this light, critical realism not only supports the epistemological integrity of psychoanalysis but also repositions it within the larger landscape of scientific psychology and psychiatry. It allows psychoanalysis to reclaim its rightful place as a discipline committed both to meaning and to truth.

Interpersonal Connection: Noticing the Needs of Others

Posted on by Psychotherapy.net Team

Ancient Roots

In my recent book, I introduced an approach to physical, emotional, and spiritual health called The Connections Paradigm. This is a technique derived from an ancient Jewish tradition that I have used successfully in my clinical practice with clients.

The idea behind the paradigm is that human beings, at any given moment, are either “connected” or “disconnected” across three key relationships. To be “connected” means to be in a loving, harmonious, and fulfilling relationship; to be “disconnected” means, of course, the opposite.

The three relationships are those between our souls and our bodies (Inner Connection), ourselves and others (Interpersonal Connection,) and ourselves and a Higher Power (Spiritual Connection). These relationships are hierarchical, with each depending on the one that precedes it.

I began learning about interpersonal connection early in my career as a clinician. Back then, I was meeting with patients who seemed to have every need you could imagine. Some of my patients had needs that were similar to my own; others had needs that I never personally experienced.

“I struggled to place myself in the shoes of people who lived in circumstances very different from my own”, like the time I worked on a geriatric unit and treated several older patients with age-related problems that I had never encountered. There were other patients from whom I learned about culture-specific needs that I will probably never fully grasp, let alone experience. In other cases, I saw needs associated with specific health concerns that I never had, and with dire personal and financial circumstances that I pray to avoid during my lifetime.

Through this process, I concluded that being sensitive to each patient’s needs—i.e., interpersonal connection—is one of the most important skills in being an effective therapist.

I have also observed the most common ways that people fail to notice the needs of others. Once, a twenty-nine-year-old male patient of mine named Danny completely disputed the importance of noticing other people’s needs.

“I’m more of a doer,” Danny told me. “I only feel like I’m making progress when I’m actively involved in something. And at the end of the day, getting things done is more important than thinking about other people.”

“But how do you know what another person needs unless you develop your sensitivity?” I asked.

“A lot of the time their needs are obvious,” he said. “And if not, they should tell me.”

“Doesn’t it feel better when someone notices your needs without you telling them?”

“Um?.?.?.??I guess so,” he said.

“And let’s be honest,” I said, “do people really always know what they need? There are times when everyone in someone’s life can see clearly what they need except them. And sometimes we are sure we need one thing, but someone else can see that we really need something else.”

“What’s your point?” Danny asked. “I just don’t want to sit and think about other people, I guess. Is that so bad?”

Danny’s Story

Danny first came to treatment after a brief psychiatric hospital inpatient stay for severe depression. He had lived at his parents’ home for several years after college until he finally got a job and decided to move out. Within a few months, however, he was seriously considering suicide and ultimately checked himself into a hospital.

“”I’ve always gotten depressed, but this was worse”,” he said. “When I was living by myself, I was not really thriving. I had a job I hated and not much of a social life. I thought about moving home, but my depression just kept getting worse until I knew I needed to go into the hospital. I had to stop working, and I didn’t really have enough money.”

After his hospital stay, Danny decided to move back home with his parents. “I just need some time to relax and not worry about bills,” he said.

Danny’s psychiatrists recommended outpatient care, and he came to my New York clinic a few days after he left the hospital. As part of his treatment, I stressed the importance of self-care, positive thinking, and staying active. His condition improved relatively quickly. But as he started getting better, he experienced a backlash from his siblings.

Danny’s parents were elderly and had health problems. His father, 84 years old, was going through the early stages of dementia, and his 75-year-old mother, who had suffered several bone fractures as a result of severe osteoporosis, could no longer go up and down the stairs without help. They both struggled to do basic chores to keep their house in order, and Danny’s siblings felt that he was putting pressure on them by moving back home.

“I basically do whatever my parents ask me to do,” Danny said. “We have a good relationship. They say they’re happy that I’m home. But my brothers and sisters say I’m making it harder for them. Last weekend we all had a ‘siblings meeting’ to talk about Mom and Dad, and they basically ganged up on me. They said the house is dirty and that I’m not keeping up with the laundry and stuff like that. My older brother comes just about every day and he’s been giving me the stink eye for months, and I really didn’t know why until this weekend. We used to be really close. But now that I know how they feel I’m really annoyed.”

Danny was spending a lot of time applying for jobs and making sure he was taking care of himself so that his depression would not return. “They think I’m just sitting around doing nothing,” he said, “but I need to focus on getting back on my feet. And really, the house is not that messy. My parents have complex medical issues, but basically they’re doing okay.”

“You said you do everything your parents ask you to do,” I said. “So what are those things?”

“They don’t even ask me to do much. Sometimes my mom will ask me to help her get up the stairs, or my dad will ask me to help him to move something heavy. But they like to handle things on their own.”

With Danny’s permission, I spoke with his parents and siblings and got an entirely different story. “Danny was simply not aware that he was creating a significant financial and interpersonal burden on his parents and making their old age much more stressful”. He expected that his mother would cook, clean, and do laundry for him, and he would routinely leave his belongings around the house, even though they presented a tripping hazard for his parents.

His siblings were frustrated and even exasperated with his selfishness, to the point that they wanted to throw him out of their parents’ home even if it would lead to rehospitalization or worse. I managed to calm the siblings down, with the hope that I could get through to Danny in therapy.

During the next few sessions, I continued to discuss the core concepts of interpersonal connection with Danny, and he eventually acknowledged that his interpersonal style was a significant contributor to his depression over time.

Other Peoples’ Needs

“Years ago, when I lived in California with a friend after college, it was my highest point of functioning. I had a job, a girlfriend, and things were going pretty well. But over time, my friends got fed up with me because I have this unhealthy tendency to focus on myself more than others. I grew apart from my girlfriend and also my roommate, and eventually moved out on my own. But the costs of living were so expensive, and the next thing I knew, I was in major debt. It’s been a bad situation ever since.”

“There are ways to improve how you connect with others,” I told Danny, and he seemed interested to learn more. “Interpersonal connection starts with noticing other people and what they need, and eventually making an effort to make them happy. Being sensitive to others’ needs helps us to remain connected to others and helps us to feel more confident and happier ourselves.”

As a preliminary exercise, I encouraged Danny to make a comprehensive list of someone else’s needs. Danny initially wanted to focus on his older brother, but I encouraged him to choose one of his parents instead. “You see them a lot more often,” I said, “so you have a better perspective on what they need. And they seem to have a lot of difficulties right now, so many of their needs are more noticeable.”

Danny reacted negatively to my suggestion, suspecting it indicated my agreement with his siblings that he was not caring for his parents’ needs. “I’m not making any judgments on how you’re behaving in your relationships,” I said. “You’re my patient. I’m focused on helping you.” Danny reluctantly complied with my recommendation, and we spent nearly half a session making a list of all his parents’ needs.

The exercise turned out to be a powerful experience for him. He became especially conscious of the consequences of his parents’ physical health decline, and how he had indeed become more of a burden to them than he had previously acknowledged.

At our next session he said, “It’s hard for both of them to go out anymore. My dad used to be so active, he took a lot of pride in his work. Now he can’t do anything but sit at home and watch TV. It’s definitely not easy for my mom that she can’t go out to see my nieces and nephews. She used to take care of them every day, but now it’s too hard for her even to go visit them at all.”

It was slow going, but we were getting somewhere.

In truth, Danny had already been aware of his parents’ needs, but verbalizing them made them more visceral. I asked him to focus not only on his parents’ emotional needs but also on their physical needs. “Well, when it comes to physical needs, I guess they have enough money, so they’ve got that taken care of.”

“But your mom is in a lot of pain, right? Relief from pain is also a very strong physical need,” I said.

“That’s true. But I can’t do anything about that.”

“Maybe, but the point is to consider her needs, not necessarily to solve them. What about your dad?”

“He moves okay and he’s not in pain, but I guess his dementia makes it hard for him to handle all the basic things that he used to do to feel good. We put notes around the house because he doesn’t always remember where things are or how to use them. My brother told me we’re all going to start wearing name tags when his dementia worsens.”

Danny became emotional as he began taking serious stock of all the ways his parents were struggling to meet their own needs. “The thing is,” he said, “I still can’t see how it helps for me to get upset about it. It’s not like there’s anything I can do.”

“Maybe not,” I replied, “but being mindful of other people’s problems is important. That feeling of empathy you’re experiencing now is interpersonal connection. I can see now why it’s hard for you. The truth is that you really feel their pain. It’s very hard for you to see them suffer. It’s actually because you are a caring person inside that it’s so challenging for you to acknowledge that they are suffering.”

Danny started to cry, and then a wellspring of emotion came forth. He was visibly distraught with how his parents were suffering and how he had contributed to their pain. Over the following month, Danny’s behavior started to change. He not only improved his self-care but became much more considerate of his parents’ needs, and even his siblings.

Danny also became less introverted and eventually found a decent-paying job, where he developed friendships with several of his coworkers. A few months later, he said, “If I’m being honest, I’m not doing that much more to help anyone, but even thinking about other peoples’ needs has given me much more perspective. I have more interesting conversations with people now. They open up more since they see that I’m focused on what they’re saying, and that I care about them. Even my conversations with my siblings are better.”

***


As my work with Danny illustrates, interpersonal connection requires noticing other people’s needs with true sensitivity. Doing so enhances our ability to help them when they do not explicitly ask for our assistance. Furthermore, the importance of noticing others’ needs goes beyond improving their wellbeing; our own connection benefits as well when we develop finely-tuned empathy for other people.
 

Online Therapy: An Unexpected Space of Freedom

Posted on by Psychotherapy.net Team

Taking Risks

The dramatic story of the Saudi teenager Rahaf al-Qunun¹, who fled her family and country in order to request asylum elsewhere, resonated with many people in different ways. The oppressive background in which women like her evolve is generally far from our eyes, but I have, through my online therapy work, experienced several very touching stories from women in the Middle East.

Engaging in therapy is something that even Westerners do not enter into lightly. It requires taking a risk in opening themselves to a stranger to exercise the power of vulnerability. For women from countries such as Saudi Arabia, this entails a completely different level of personal risk and exposure. The fear of being misunderstood, judged, medicated, or reported to their family and consequently punished harshly, makes it nearly impossible for them to reach out for face-to-face psychotherapy.

As I grew up in Soviet and then post-Soviet Russia, I have firsthand experience of feeling trapped in a place where state-imposed values and rules did not align with my own. The exercise of one’s intellectual freedom turns into a road to salvation when other freedoms are unattainable.

For women in hardline Middle-Eastern countries, online therapy offers a safe space in which to exercise intellectual and spiritual freedom—they can explore their religious doubts, talk openly about their sexuality, voice their frustrations and anger, and eventually find meaning in their experience.

In an interview in The Guardian, Rahaf al-Qunun points out that in her country, no matter their age and life experience, women are treated like children. In a society governed and controlled by men, they are stripped of all power and infantilized.

These women continually strike me with their courage and resilience. One such brave woman was Laila (an amalgam of Middle Eastern women with whom I have worked in online therapy).

Laila’s Story

Laila was 36 and unmarried. She had a stable and reasonably well-paying job at a bank. When she received a promotion, she was allowed to move out of the family home to a nearby town in order to take the position. She was allowed to do this because her youngest brother lived in the same town and worked at the same bank. He was also unmarried and they lived in the same block of flats. He drove her to work every morning, as she was not allowed to drive herself.

Her brother was much younger but had more rights. Laila “needed” him for assistance with the most routine tasks—for example driving her to work or for travelling out of the country for a professional conference. This is how things work: women are made to need men.

Laila was different. At a deeper level, she did not believe or feel that she needed men. She did enjoy the company of some of her male colleagues and rare friends, but she did not desire them. Leila realized this about herself as a teenager, when back at school she felt compelled to kiss the beautiful face of her female best friend.

One of the duties Laila was not able to escape was mandatory attendance at family gatherings. She would sit there, her face uncovered, surrounded by women talking about their children and their little sons running around—already enjoying their privileged status in front of their sisters—and painfully feeling how little she belonged there.

All this fuss around men felt ludicrous to her. It was an ironic situation after all—she had to uncover her face with women to whom she felt attracted and was expected to be separated from men who represented no risk to her emotional balance.

Laila knew that she would never be able to live the life that she dreamt of. She loved her brothers, despite often feeling angry with them. She also loved her father, even if he would not listen to her or take her achievements seriously. She knew that, for her family, she was “damaged goods” and she would remain so, as she would never marry and give them children.

Laila eagerly waited to get old enough to stop receiving proposals from men that she did not know, who, as she grew older, wanted her as a second or third wife. In the meantime, she had occasional moments of joy with her few female friends and secretly experienced excitement and lightness in the body-less company of her virtual friends from the online community of women just like her.

Autocratic states use mental health stigma to control their citizens.Laila was very scared of being accused of being mentally ill. This is exactly what happened to Rahaf al-Qunun who, in the statement released by her family after her escape, was labelled “mentally unstable.”

An Online Refuge

As a therapist who works online with clients, my personal background helps me to understand and relate to what these women experience. Mental illness was stigmatized in the USSR, easily exploited by the authorities to punish and isolate any individual not complying with the strict rules of collective functioning. Therapy was almost nonexistent and was considered a medical treatment for alienated sick people. Online therapy was not an option as it is now, offering an opportunity to reach out to someone from a different culture, which can be useful when someone is trapped in an unfriendly world.

The effects of living in an autocratic country on individuals’ mental health are many. My female clients from hard-line Middle Eastern countries suffer from depression, anxiety, insomnia, dissociation, and difficulty trusting others.

Their individual boundaries are constantly transgressed and violated. The psychological effects of being raised in such an environment are like those experienced by a child growing up in a narcissistic family: the needs of the parents’ system (the society) take precedence over the needs of the child (the individual).

The only way to avoid being mistreated by a narcissist is to limit their power over you or to stay as far away as possible. Oppressed women like Rahaf al-Qunun have every right to rebel and protest as do children of narcissistic parents—they entirely depend on their caretakers and cannot freely leave their country or their family.

Individuals raised in cultures where they must abide by a very strict set of rules that do not take into account their needs, learn how to hide, to keep secrets, to lie. This is a natural way of adjusting to a system that does not accept parts of you; it becomes a question of survival. Such secrecy leads to an impression of living a double life. The cost of such fragmentation is often a lack of intimacy with parents and disconnection from those who are not aware of the “other” life that quietly happens inside or in the online space.

In a way, as their therapist, I must play a part in this secret parallel world, as my clients also hide from their families the fact that they are in treatment. Therapy, especially with a Western therapist, is seen as a transgression. My clients must come up with a plausible pretext for isolating themselves with their computer in a private room within the family home without being disturbed. I am often presented as a colleague, or an online English teacher. Here, the fact that their older family members do not speak fluent English comes in handy. The second language creates the much-needed safe and private space, in which they finally can explore their inner worlds, and the conflicts with the outer world in which they live.

Behind the Veil

I do not share a mother tongue with many of my clients so we must speak in English. Such use of the third, neutral language plays an important role in how the therapy evolves. It facilitates sharing thoughts and dreams that are defined as unacceptable in the clients’ original culture. Speaking English also provides us with an opportunity to play on even ground—as fluent as we are in our second tongue, we are still both foreigners, negotiating our accents, sometimes looking together for the right word. This experiment in equality has an additional reparative value, as being fully recognized as equal is not an easily obtained right in these women’s world.

As a Western woman with a limited knowledge and experience of Middle Eastern cultures, I let my clients guide me through their personal stories shaped by the culture, family, and place into which they were born. With them, I become an avid learner as we move towards a shared goal—a better understanding of who they are and who they want to be within the limits of their world. As we advance, pushing these limits becomes an existential necessity. For any transcultural therapist, this is a rather familiar role, but online therapy expands this in an extraordinary manner.

I have also had the opportunity to work with some Saudi women living outside of their country in Europe or elsewhere. Those with liberal, well-to-do and open-minded parents can study abroad. The sudden freedom comes with another set of psychological challenges—these young women must adapt to the transition and find a place in this new world, negotiating an acceptable balance between their original cultural values and the norms and expectations of the new place and culture.

During this stressful time, therapy offers them a space for dealing with conflicts and dilemmas that arise along the way—to wear or not to wear a headscarf; how to explain to their foreign peers the values and rules they choose to abide by; how to deal with anxious parents’ visits and a stressful life in an unfamiliar environment. Interestingly, they still retreat back to the familiar online space—which feels safer—to find friends or develop romantic relationships.

“Why does it matter that we, freer men and veil-less women, understand the struggle of women in these regions of the world” where many types of freedom are restricted? Will our understanding of their condition and our empathy change anything for them? My intuitive answer is ‘yes’; otherwise I could not do my work as a therapist. But how so?

Humans are social creatures, and the way we are looked at by others very often matters. We all have secret stories about how bad or how exposed we felt when people around us looked at us, judging our looks, words, or differences. In these circumstances, we feel shame. People with a handicap, sexuality difference or cultural/ethnic difference, all those who differ in some ways from the majority know far too well the emotional toll of such unwanted exposure.

How can a woman wearing the full veil feel when walking in the street in a tourist area of a big Western city? She is entirely covered in a black veil, her face hidden. On both sides of the veil we feel uncomfortable. The veil is a barrier, and, when we do not see the face behind it, we struggle to empathize with the individual. Behind the veil, there is sometimes deep discomfort and a feeling of shame. They may feel trapped, and our misunderstanding of their condition and our judging them for choices they do not have, may add to their suffering.

To connect with others and to be understood, without their body being seen, can be a challenge for these women. It is another reason why the online communities of Saudi women are thriving. Probably this is also what makes online therapy a hopeful space in which they can develop a connection with a Western therapist who represents this “other.”

As with any therapist, I am here for those who have psychological difficulties and struggle with some form of conflict. Surely, many women living in the strict Middle Eastern countries are happy enough with their circumstances, and not all of them would relate to my clients’ stories. But even if women I meet in my practice are a minority, it is important for them to be seen and acknowledged in their struggle, and to be offered a safe space like online therapy in which they can feel recognized and strive toward a better life.

Resources
1 Rahaf al-Qunun: “I hope My Story Encourages Other Women to be Brave and Free”

Bare: Psychotherapy Stripped

Posted on by Psychotherapy.net Team

Editor's Note: The following is an excerpt taken from Bare: Psychotherapy Stripped, by Jacqueline Simon Gunn, published by University Professors Press © 2014 and reprinted by permission of the publisher.

I think Dostoevsky was right, that every human being must have a point at which he stands against the culture, where he says, this is me and the damned world can go to hell.
—Rollo May

Please Don’t Let It Be Her

“Jacquie? Is that you?”

Oh no, please don’t let it be her. The voice came from behind me.

But of course it was, the slightly nasal, overly enunciated voice always unmistakable. My body tightened. Of all the people to run into — in Bloomingdale’s, no less — while looking the way I did: sweaty, smelly, and disheveled. Served me right for doing my training run, then squeezing in an errand before showering, while convincing myself I could manage to escape notice of someone I knew. The Big Apple may be big, but it is not that big.

“Jacquie? Jacquie.”

Her voice doesn’t sound close. Maybe if I move fast enough, I can get lost amongst the shoppers. But then I heard the distinct sound of hurried heels clacking on the tiled floor, and
before I could slip into the crowd, a hand touched my shoulder.

“Jacqueline!”

I bolstered my spirits, and turned to face the inevitable. Maybe it’s time I bring this relationship to a close.

Tess was my newest patient. I had just earned my psychologist’s license a few months prior to our first meeting, and subsequently accepted a full-time staff position at the Karen Horney Clinic. I had already been employed at the clinic for two and a half years, first as an intern and then as a post-doc fellow, so when they offered me the position — nearly nine years ago now — the decision to accept it wasn’t difficult. I could continue with my current patients while I received some additional supervision, all providing me with the ability to slowly transition into private practice.

A colleague who had been working with Tess for nearly two years referred her to me. Another client would pack my schedule, as I was carrying a nineteen-patient caseload at the time, so I initially felt hesitant to take on a new client. After extensive consideration, I agreed. “I wholeheartedly believed I was ready to push myself professionally.”

How could I have known what would happen or the effect she would have on me?

My colleague had to prematurely terminate her work with Tess because she and her husband were moving out of state. At my request, she gave me only a small amount of background information; I am not a fan of learning about a new patient second-hand. I have found it more beneficial to be exposed to patients’ narrative directly from them. The referring therapist did tell me that Tess was 61 years old, suffered from chronic depression, and having an inordinately hard time with the aging process.

She added, “You’ll be a good match.” When I wondered why, she responded, “Tess needs a tolerant, warm and empathetic therapist. I think you’ll work well together.”

I was not finding that to be the case.

Appearances

When Tess came in for our initial meeting, I immediately noticed her striking appearance. She was quite attractive, small framed and perfectly made up. What I found most significant was her choice of attire; dressed impeccably, she reminded me of someone clothed for a night at the theater. Though curious about the façade she put on display for the world, it was much too soon for such a personal inquiry, so I held my thoughts and associations in abeyance to be brought up later in therapy.

Within just the first moments of session, however, I managed to ostensibly muck things up. I called her Contessa. Tess does not like to be called Contessa, which I soon discovered. And her displeasure spoke to that fact through her terse reaction. “It’s Tess.”

Though my colleague had referred to her as Tess, I noted in her file that her given name was Contessa. Nicknames can be a highly personal experience, and I did not want to presume familiarity too soon. So I called her Contessa. But I knew better. I should have asked her outright what she preferred to be called. Just like a nickname can be personal, so too can a given name be a source of anxiety, as well as a seedbed of myriad emotional triggers.

“Tess, I’m sorry. I didn’t realize you dislike Contessa.”

“I hate Contessa. It’s a family name. And it reminds me of someone who’s ancient and stodgy.”

And just like that, with tightened lips appearing like she’d just sucked on a sour candy; she folded her arms in a resolute stand against distasteful nomenclature.

“Really? I think Contessa is a beautiful and rare name. It evokes such elegance.”

“Nonsense.” She dismissed my opinion with a wave of her hand and flutter of eyelashes. “Now, Tess. That’s fun and youthful. Tess is a model’s name.” Her eyes twinkled when she said that, encouraging me to make the leap, to associate her with models. And honestly, though I am normally savvy enough to avoid that slippery slope, she did carry herself like one. And that is exactly where my thoughts landed. I bet she could’ve been a model in her day. I wonder if she was.

As the session moved along, Tess began describing her long history of depressive episodes, her numerous hospitalizations, and her propensity to isolate from others. I had so many questions for Tess, but I wanted to allow her the liberty to express herself without interruption during this first session. Some clinicians prefer to perform an extensive intake evaluation during the first few sessions, in order to collect adequate background information. I find this sort of structured interview interferes with the patient’s process of describing personal information, so I allowed Tess to tell me her story while I listened attentively with compassion and empathy.

I learned in the first session that Tess lost both of her parents at a young age; she lost her mother first when Tess was 17, and then her father when she was 24. I felt a twinge of pain as she revealed this; it was only the first session and I already could feel the heaviness, the burden she was carrying, and I felt sad as I listened. She was also married for ten years, from 36 years old until 46 — when her husband, who was having an affair during the last year of their marriage, left her for another woman.

Now 15 years later, she still had not recovered from this. I began to notice through her narrative that she blamed herself for the numerous hardships she endured in her relationships — and this was only the beginning. “Throughout our treatment together, I would hear many heart-wrenching stories from her past”, as well as experience and bear witness to her suffering resulting from some serious and frightening occurrences that happened during our course of therapy.

As I listened, I also wondered about her feelings surrounding the termination with her previous therapist. I found it significant that she didn’t bring this up. In my experience, premature termination most often brings up mixed emotions for our patients: abandonment, anger, betrayal, loss. Why wasn’t Tess bringing this into the room? We were near the close of our session when I realized this — too late to bring it up now — so I made a mental note to inquire about this at our next session.

With only five minutes left, Tess began to inquire about me. How old was I? Was I married? (She did not see a ring and assumed that I was not.) Did I want children? When questions such as these come up at the end of a session, it is always difficult to negotiate how to respond.

Early in My Training

Early in my training, I almost never answered patients’ personal inquiries. I was trained from a classical psychoanalytic perspective. Residing under this particular model of psychotherapy, personal disclosures are looked down upon and are thought to have a negative impact on the evolving of transference — the response of the patient to the therapist, both conscious and unconscious. This level of neutrality never felt quite right to me; it truly felt inauthentic, but I was still in training and didn’t have the confidence yet to feel comfortable following my intuition. My own way of working, which at times involves personal disclosures, evolved slowly over the years.

Though it was not official at the time, I considered Tess my first private practice client, so I wanted to display a sense of confidence and maturity that I believed I should possess. It was more for me than anyone else, really. I had counseled countless patients prior to Tess, so I was confident about my abilities; however, since I was not yet seasoned, I floundered when she riddled me with personal questions. Tess challenged almost every aspect of the delicate balance that I eventually learned was a key factor in using self-disclosure as a therapeutic technique. In psychotherapy, as in life, experience is often the best teacher. Well, Tess, she was akin to a full-time professor.

I felt anxious; I did not know Tess well enough yet to have a real understanding of what these questions, and my choice of whether or not to respond, meant to her. I acknowledged her inquisitiveness and replied with what I hoped embodied an empathetic tone, “We can talk about these questions at our next session.” What an unoriginal answer. I quickly berated myself, but I really needed to understand her better before I could make a decision about how to handle these quite personal inquiries. By the time she left the session, I was exhausted. I also felt the urge to cry. I really needed to think about what was going on for me; these feelings obviously communicated something quite essential about our dyad.

I would find out soon enough.

A few nights later I had the most unnerving dream. I arrived at an important psychoanalytic conference, preparing to present on self-disclosure in the treatment setting. I walked in, my flowing mint-green dress billowing with each step. My most favorite frock. I felt confident. All eyes were on me. The dress had done its job.

And then my gaze swept across the room. The crowd milled about clad in black (mostly suits), their formal outfits a stark contrast to my lustrous gown! Sudden discomfort settled in. My skin burned from embarrassment.

I woke up drenched in sweat. Even in the dream, I remember thinking, “What a curious dream.” And despite its obvious disconnect from reality, I couldn’t shake the residual uneasy feeling. Quelling all the thoughts spinning around in my mind — I know this dream, there is something so familiar about it — I attempted to set aside my strong desire to self-analyze, and instead prepared to leave for my office with a lucid mind.

Flowing Mint Green Dress

While still trying to distract myself from ruminating about the meaning of my dream, I ruffled through my closet deciding what to wear. And there it hung: my flowing mint green dress. I shuffled past it, searching for the right outfit for Tess — For Tess? Why for Tess? — but my eyes repeatedly returned to the green dress. What an odd juxtaposition. I usually wear my most professional clothes when seeing a new patient (partly to set them at ease, partly to establish professional boundaries), yet here I stand, still trying to divert my attention away from the green dress that hung in my closet before me, hindering my ability to avoid the dream and to find some “appropriate” clothes to wear. My experience that morning, after only one meeting with Tess, already began to mirror the difficult relational dynamic that would infiltrate our journey together.

Tess came to our second session flawlessly dressed and made up. Again, images of my flowing mint-green dress distracted me. However, this time I associated thoughts of the dress to the feeling I had when observing Tess’s attire; she looked lovely, but over-dressed for a therapy session. This time I observed her posture and cadence as she walked in. It was incongruent with her impeccable makeup and high fashion. She walked with her head down and back slouched, a remarkable difference from her model-like stature of the previous session. I associated her demeanor with someone who was just beaten up.

She slumped into the chair.

“I’m boring, right? I have nothing in my life except my dog.” She frowned and averted her eyes.

“Boring?” On the contrary, you’re absolutely fascinating. “It actually seems that you have quite a bit to talk about. Where is this feeling coming from?” It was then that she began to tell me about what I eventually dubbed “Her Fall from Glory.”

Tess had been a well-recognized author and editor; she and her former husband actually met while she was working as an editor of a reputable magazine. She also published a book about her personal experience battling and overcoming breast cancer when she was 49 years old. Before her breast cancer, which eventually led to her losing her breast (she made sure to add that she had an implant), she had many friends, an exciting social life and a loving partner who stood by her through her year-and-a-half ordeal.

““I was beautiful, so beautiful; I had many men. Many.” Her pain permeated every word.” “Now men don’t even look at me when I walk down the street.” She sighed, heavy and long. “See? I have nothing.”

Now this is a telling statement!

“Nothing.” She repeated, overly enunciating it, drawing out, then punctuating, each syllable — each sound — with the kind of attention to detail one might find in a pillow embroidery.

My mind raced with all the different paths of inquiry she left open for me to explore, but the amount of information she generously offered so overwhelmed me that the session ended before I realized it, leaving me no opportunity to explore any of her story or encourage her to elaborate. I did want to give her something to leave with. This is vital to the therapeutic process — giving the patient a part of you by acknowledging what they have shared and offering some empathetic insight.

“You’re a fascinating woman, Tess, and I have so many questions for you.” I noticed her curious expression. “You’ve been through so many hardships.”

“Interesting? Really?” Her remark took a sad turn. “But I have nothing now, Jacqueline. You’re young. Don’t wind up like me.” Is that a little envy in her tone? Or was it hostility? And she just glossed over my comment about her hardships? She gathered her belongings, moving with slow sadness, and left looking even more broken-down than she did when she came in. Again, I felt like crying. And again, I forgot to ask about her experience terminating with the previous therapist.

Tess began therapy with me on a twice-weekly basis. I typically prefer to understand a patient’s internal dynamics and interpersonal style before increasing the frequency beyond once per week. What one might think would be helpful for a patient — added stability, consistency and containment — may be too much for them in the early stages of the treatment. But since Tess was seeing her previous therapist twice a week during their second year of treatment, we collaboratively decided to keep this therapeutic frame. As I thought about Tess after our second meeting, I sensed that twice-weekly sessions were ideal for her, but I did wonder if it might become a bit overwhelming for me.

The content of her narrative — losing her parents at a young age, cancer, divorce — as well as the feelings being evoked while sitting with her, already felt overpowering. “During the first month of treatment with Tess, she spoke endlessly about her “Fall from Glory.”” I sensed that she felt shame about where she was in her life now; in order to sit with me and expose her current situation; she desperately needed and wanted me to know who she was prior to her “fall.” I would later understand that this “fall” happened as a result of losing her breast, coupled with her almost complete emphasis on her outward appearance as defining her. For Tess, I came to understand relatively early in our treatment, outward appearance was all she believed she had to offer; it was who she was. This was at the core of all her issues and eventually established a quite frustrating dynamic between us.

Having conceptualized her dynamics early on, I decided that my therapeutic position should be to listen attentively to who she was prior to her breast cancer. I believed it would help her feel less shame when, in later sessions, I would be encouraging her to focus on where her life was in the present. Through this active listening, I gathered a lot of background information; although I did notice that when I tried to explore her early childhood experiences, particularly her relationships with her parents, Tess met me with harsh resistance. Okay, so I guess this is important. Though I made a mental note, I didn’t push her; this was obviously an area of great devastation for Tess. We would get to this material at some point, but definitely not yet. She had other, more pertinent, news to share with me.

“Everyone cheats.” This came out of her mouth with the nonchalance of someone placing a dinner order. She wasn’t making an observation solely about the men in her life because “everyone” included Tess. During her ten-year marriage, she confessed to multiple liaisons with other men. For some reason — likely having to do with my sense that she thrived on external validation of her desirability and worthiness from men — this information didn’t surprise me in the least; but it piqued my curiosity.

“Tell me more about this?” And she did. She went on to describe the many sexual partners she had through her twenties and thirties. In fact, all her friends had extra-marital affairs and, she reiterated, cheating was merely a part of marriage. I experienced a visceral reaction as she provided this information. How strange to hear those words come from this 61 year old woman sitting across from me.

“I pondered why I felt strange learning about Tess’s clandestine liaisons.” I don’t get it. I’ve heard countless stories like hers, especially from all those sex workers I’ve counseled who have repeatedly described having sex without any emotional connection. I guess this Tess, the Tess-Post-Fall-From-Glory, is not the same woman who enjoyed those extra-marital affairs. This Tess is depressed and broken. I found it difficult to imagine her with the sexual prowess she described, of being a woman who ostensibly detached emotion from many of her sexual experiences and enjoyed sex for the pure physical pleasure it offered. It was clear that she did; that is, before she came to see her body as deformed.

One of the men she had an affair with, Barry, was the man she eventually developed an ongoing and quite serious relationship with after her divorce. She described Barry as “the love of her life” and the man who stuck by her during her fight against her breast cancer. He eventually left her for another woman once her battle with cancer was over and she was healthy again. When Barry informed her a few months later that he was married to this other woman, Tess described feeling abandoned and devastated. This, too, added to her “Fall from Glory.” Tess was 51 when this relationship ended.

“I haven’t been with another man since.” Tess broke eye contact with me. She focused on the floor and kept her gaze there.

Interesting. Men make up such an integral part of her life. She thrives on their attention and affections. That’s a long time to keep yourself alone.