Psychotherapy is a Practice of Engagement
The answer to life’s problems is not in your head. It is just as difficult for psychotherapists to understand this as it is for clients. Thinking has its benefits, but it also has its limitations, and overthinking ultimately leads nowhere. People have to get out of their heads and get in touch with their feelings, because this is what leads to change. Experiencing feelings is the quickest way for a person to get out of their head and back into their life.
The ability to reason things out is one of, if not the defining characteristic of what it means to be human, but reason alone is not enough to make people change or sustain them throughout life. Building a business, creating a family, finding one’s calling, falling in love—these experiences frequently defy logic but they are the ones that people are most impacted by.
Even David Hume, a philosopher and a rational man if ever there was one, said reason was incapable of dispelling the clouds of his life. For that he turned to nature, or food, or the company of his friends. He turned towards life.
However far thinking can carry us, in the end engagement is the answer to life’s problems. There comes a point when a person must move past thinking, commit to a choice, and leap into action.
This is what psychotherapy is about—supporting the client as they explore their freedom and eventually decide how they want to exercise it. It is a relational process that includes engagement between the therapist and the client, the client and themselves, and the client and their world.
Both happiness and meaning, the primary goals for most people, are by-products of engagement. Neither comes as a result of sitting around and pondering all day long. They come from making the leap into living. Engagement with life makes it so that the questions don’t even matter, which paradoxically brings one closer to the answer. To paraphrase Wittgenstein, another philosopher, “the solution to the problem of life is to make the problem vanish.” It vanishes because it is subsumed by active living. Engagement with life provides structure and coherence. It gives shape to one’s existence.
The psychotherapist’s job is to engage the client to the greatest extent possible and in doing so, serve as a model for them. All clients have an innate ability and desire to engage with life, but they must be helped to reconnect with this desire and helped to remove the barriers to it.
The therapist’s primary tool for achieving this outcome is their willingness to engage the client authentically, along with their willingness to be fully engaged in their own life. The therapist’s ability to be present and not fall into the trap of being in their head too much is the strongest indicator of whether or not they can help others do the same.
Are You Basho or Tennyson?
People often come to therapy because they are suffering from a lack of purpose. They are seeking guidance on how they should live and what they should live for.
This presents a significant challenge for the psychotherapist who is sometimes lured into the trap of thinking they can actually guide another person directly towards their life purpose. They can’t—the best a psychotherapist can do is act as witness and preside over someone else’s journey as they discover what makes them come alive.
What we do know is that purpose requires more than rote and mindless striving. It requires moving past the superficial and exploring the deeper boundaries of one’s experience. Part of the problem seems to be that we obsess over discovering the purpose of life through the intellect instead of being open and responsive so that we can experience as much life as possible. We incorrectly assume that purpose is a prerequisite to full living when it is the opposite.
The answer to the question of whether one is Basho or Tennyson deals with the way one chooses to approach their life. Each man shared their view on living through the expression of their poetry. Life can be treated as an object meant to be dissected or it can be treated as a mystery meant to be experienced.
Tennyson’s poem expresses the first sentiment:
Flowers in the crannied wall,
I pluck you out of the crannies;—
Hold you here, root and all, in my hand.
Little Flower—but if I could understand
What you are, root and all, and all in all
I should know what God and man is.
If the flower is a symbol of life, Tennyson intends to poke and prod and probe at it until he can understand its secrets. He wants to drill down to the very root of it and understand its essence. This same idea frames Tennyson’s approach to searching for life purpose.
Meanwhile Basho is uninterested in digging and is content to simply marvel at what is. His poem reads:
When I look carefully
I see the Nazuma blooming
By the hedge!
Basho acts as witness and allows himself to be filled with excitement at the sight of existence. Because he looks carefully he does not have to probe as deeply. For him, the essence of things is right there on the surface and there is nothing to ponder and nothing to struggle with.
Both approaches are valid, and the main error is in seeing life through only one lens. There is beauty in analyzing and formulating ideas, but there is also beauty in harmony and integration. There is beauty that comes from stepping into one’s purpose and there is also beauty that comes from stepping outside of it.
AI and Human Responsibility
As we move further into a world in which artificial intelligence is a part of everyday life, we must consider the psychological effects this technology is having on us individually and collectively. We have to keep asking ourselves what we want this technology to be, how we want to shape it and how we are willing to be shaped by it.
There is a fight going on currently between the United States government and Anthropic, one of the major AI tech companies. Though the debate centers on the government's ability to use Anthropics AI technology in its military operations, the outcome of this fight will have major implications for the relationship between humanity and artificial intelligence.
There is a contingency within the government that wants to fast-track the implementation of AI into military operations. This contingency, made up of government officials and military officers, view AI as a way to more effectively deliver violence. Such thinking reveals an underlying belief in the inevitability of violence, and perhaps in their mind, the worthwhileness of violence as an objective.
The military, like other organizations grappling with AI, must give significant thought to the potential human cost of developing AI without regard for the psychological effects this technology is having on individuals and communities. Some people think AI is dangerous, and this view may be justified as there does appear to be a dark and destructive vision of AI forming in some segments of the government. Military officials who support this vision view AI as a tool that can enhance and augment the ability to inflict mass destruction without being hampered by ideological constraints.
I’m struck by that phrasing—without ideological constraints—struck by how disingenuous they are. Ideologies are simply systems of ideas, they are a specific manner of thinking, and even the most vague and ill-defined patterns of thought can represent some form of them.
The dream of an AI that allows someone to operate without ideological constraint is a contradiction that doubles as an admission of a specific kind of ideology, one whose guiding principle is action without inhibition. If used in this way, AI will become a tool that further cements a pattern of relating amongst groups that hinges on their being a dominant and a subordinate party. This inevitably leads to more conflict and turns any notion of AI being able to usher in a new era of prosperity and flourishing into nothing more than a clever marketing ploy.
When it comes to the debate over the use of AI in the military, two camps seem to be emerging, which I will respectively call the functionalists and the aggressionists.
Functionalists seem to advocate for AI that can reduce the cognitive load placed on military servicemen so that they can focus on tasks that are more central to their missions. Functionalists believe that human operators should still be the ones making crucial decisions.
Aggressionists share some of the same goals as the functionalists, but they are also more bold in their ambitions. This group is more likely to view the development of AI as a new Manhattan Project. Beyond improved functionality, what they are most concerned about is winning what they believe is the new global arms race, with AI as the deciding factor.
Thus far the aggressionist viewpoint seems to be winning out. The powers of the judiciary are currently being turned on Anthropic and used as leverage in their dispute with the government. Vague and innocuous phrases like “supply chain risk” are being used to brand Anthropic as a serious threat to national security. It is difficult to make the CEO of a multi-billion dollar corporation into a sympathetic figure, but that’s the point we’ve somehow arrived at in this saga.
The view that unfettered access to AI is crucial to military success is complicated by the fact that success is being defined as the ability to create lethal effects at scale. We should all be leery of following such logic.
AI should be developed in ways that serve the interests of humanity and produce the most positive good. Such outcomes are only possible if we advance beyond narrowly thinking about AI only in terms of military power.
Diagnoses as Maps, Not Territories
Diagnoses are not static and discrete categories. They are subjective and to some extent arbitrary. Even as we improve our knowledge and understanding of mental health and mental dysfunction this is still the case.
Diagnostic categorization serves multiple purposes. It gives therapists a shared language we can use to converse with one another. It nurtures our need for intellectual stimulation. It gives a name to a common cause that we can call take up, but, at the risk of sounding cynical, it can also give us a common enemy we can direct our ire towards. This also happens.
To give someone a diagnostic label is to make a loud and declarative statement about them. You’re identifying a particular issue as the root cause of someone’s problems. Maybe even the sole cause.
The truth is that human beings are too complex for us to ever be so certain. The same diagnostic label can manifest in countless ways depending on the person and their context. Therapists who recognize this fact shift their focus away from labeling and towards learning how to be with uncertainty. The phrase be with uncertainty is used intentionally in order to make a distinction between being with and merely tolerating uncertainty. Being with uncertainty implies embracing it to the greatest extent possible.
Diagnoses could be thought of as maps of the territory rather than the territory itself. This allows space to make necessary updates and revisions to the map as things become more clear and the territory reveals more of its secrets.
Unraveling: Rage & Loss in Louisiana
A third of the year has gone by. Spring is here and soon we’ll be moving towards Summer. We’ll be looking forward to vacations, barbecues, swimming pools, family gatherings, but we’ll also be privy to a violence that seems to follow along with the heat and encroach upon us. These warmer months seem to make us yearn for release, and sometimes in letting go we lose control in the most tragic and consequential ways. A third of the year has gone by—there’s more sunlight and heat, but this week we are also left shuddering at the violence that overtook a sleepy little town in Louisiana called Shreveport. One where the community is left to grapple with the deadliest mass shooting in two years. A rampage that resulted in the death of eight children.
People can be insensitive in how they go about satisfying their constant wish to be entertained, but as desensitized as we sometimes are, the thought of children losing their lives is still unsettling to us. It is one of the few tragedies capable of transforming our collective appetite for entertainment fodder into collective shock and grief.
A Mind in Decline
The facts as they have been reported indicate that all of this destruction stemmed from a dissolution, a conflict or conflicts that could not be resolved and resulted in the ending of a relationship. I doubt we will ever be free of such things, lover’s quarrels and all the stress and pain that they engender, but I do know that no quarrel between lovers should ever end in murder. Most don’t, but most still leaves far too many occurrences.
I want to consider Shamar Elkins, the man who perpetrated this, not to cover him in compassion or excuse his sins—I have no interest in that, and not to flatten and erase him with narrow opinions of who he was and what he did, but to understand what he represents.
There was at least some self-awareness of the fact that he was struggling mentally. He checked himself into a facility in January. Maybe he received a modicum of care, but most mental health hospitals are only designed for short-term treatment and immediate stabilization of symptoms. They are not designed for long-term treatment with the goal of helping patients engage in meaningful depth-based psychological work that is necessary to address deeper psychological problems and improve mental health outcomes.
Like most people in those situations, Elkins was granted a short reprieve from the stressors of his life before having to return to them and was ill-equipped to handle them. It’s likely that some of these stressors were self-created, but there is still something crushing about reaching out to ask for help only to be brought back to the same problems and insurmountable consequences that brought you low in the first place. This is especially the case for men who are loath to humble themselves and admit that they are struggling.
Shortly thereafter, like many other men in these situations, Elkins seems to have abandoned the idea of ever being helped again by another person. His reaching out became public pleas for God to guard his mind and help him reject “depression, anger, anxiety, and panic.” There is an arrogance also hidden inside of the humility that allows one to rely on their faith for assistance—one that covertly expresses the belief that only a divine source is capable of helping me, not another human being. Neither arrogance or divinity prevented Elkins from trying to kill himself in February, and shortly thereafter, threatening his wife that he would try again to kill himself and their entire family if she followed through with her attempt to leave him.
There were signs that something bad could happen, but it is difficult to believe that it could ever come to this. His descent is hard to fathom, but we know now that he was clearly a man who was spiraling out of control. A week of mental health care might have forestalled the outcome, but it was not sufficient enough to prevent it. To get and stay mentally healthy requires maintenance and upkeep, otherwise we are all vulnerable to dysfunction, especially during the most difficult seasons of our lives.
The Cost
The most egregious aspect of all of this is the fact that children’s lives were either lost or changed forever. Eight children were taken. Only a 12-year old child escaped, and I wonder what exactly did she escape to? Certainly not to safety. Her life is forever altered by these events, and the fight to reclaim some level of peace and stability will be long and arduous.
“I’ve lost eight parts of me.”
That’s what Troy Brown, the father of the lone surviving child had to say about the rest of those “precious babies” he helped take care of, the ones who are now gone away.
It is difficult to understand the kind of rage that drives a man to snuff out innocence, but we know that it must be dark and cruel and terrible. It must exist outside the confines of human decency and it must be just as abhorrent as it is vicious.
Louisiana is as much my ancestral home as any other place will ever be. I know it by its contradictions—it is a place defined by its longing and its fullness, its excess and its impoverishment. A place with the best food, the nicest people, and the prettiest women, where de facto segregation still exists, where power is still hoarded, and poverty is still an institution. I am reminded on weeks like this just how unsettling it can be—the combination of all this beauty and terror.
The Governor categorized Elkin’s acts as evil, which is undoubtedly how many people feel, but once again my concern is that doing so flattens and reduces him. It absolves him and our society which produced him of responsibility. To label him as evil forces us to beg the question, how could we expect anything else from evil incarnate?
Sophia Nelson phrased it better when talking about a similar tragic event that occurred recently. “Domestic violence can occur in any family in any place.” She’s highlighting the fact that domestic violence is a social problem that is endemic, not an isolated act of evil.
If there is something that is befitting of that designation, it is the all too common belief that a relationship implies ownership. It is only within that framework, that men are able to justify and be excused for denigrating, dominating, and killing women, all in the name of keeping their entitlements.
It’s notable that while much has been said about the kind of mother Elkin’s partner was—caring, doting, loving—very little has been said about who she was as a wife. Even without that history, it’s already clear that whatever her virtues or shortcomings, none of them warranted her and her children being executed. If anything, the silence on the matter is another indictment of the many among us who upon hearing about such incidents first respond by asking, well, what did she do?
Maybe Shamar Elkins was overcome by some kind of emotional torment, some kind of temporary insanity, but it's clear he was also fueled by something else. A hatred, a sickness, a malice towards women that made him believe that he was entitled to take what was not his.
Something broke inside of him, little by little, and then all at once, or maybe nothing broke at all and whatever was inside of him was simply revealed. He could not face it so he fled from it instead and now we must, in the absence of the wicked and the innocent, carry this burden, always and forever.
Kaiser’s One Rule: Why Communication Heals
Hellmuth Kaiser was one of the first psychotherapists to recognize the significance of loneliness. To him, the problem of loneliness was so pronounced that he described it as the “universal conflict” that all men and women are bedeviled by. Man is constantly trying to overcome his feelings of isolation. Constantly trying to close the gap between himself and others and if unable to do so, then instead trying to erase his own awareness of the fact that the gap between himself and others exists.
From the universal conflict springs the “universal symptom.” Kaiser described this symptom in multiple ways. He called it duplicity, ingenuineness, and transference. What’s interesting is that while being duplicitous and being ingenuine have much in common, transference does not initially appear to be similar enough to be considered an easy replacement for either of these terms. To be duplicitous is to show certain parts of oneself while hiding other parts. All with the intent to fool others into believing something that is not true. To be ingenuine is closely related as the word simply implies a lack of sincerity or inauthenticity.
Transference, on the other hand, is understood as the displacement of unconscious feelings and wishes onto current individuals which were originally directed toward other important individuals from one’s past. This definition does not easily fit next to the others, but given Kaiser’s grouping of them, he must have thought all three terms shared basic core elements.
Is transference a form of inauthenticity? A method of being duplicitous? When you study the meaning of transference, it becomes clear that it is. To transfer thoughts and feelings, whether consciously or unconsciously, from one situation to another and treat them as though they are the same is to engage in a form of inauthentic behavior. Hence the connection between all three terms. Each of them charts a course to the same destination. A path towards an inauthentic mode of being that develops into neurosis once the underlying psychological processes and the associated behaviors have become sedimented.
Communication as the Antidote
The core focus of this essay is to examine Kaiser’s contention that the way out of this universal conflict is through communication. Kaiser believed “it was the ability to communicate freely that prevented the universal conflict.” To add clarity to this expression I would say that communicating freely implies one does not feel restricted in what they can say, regardless of whether or not they actually choose to say it. They feel unimpeded in terms of how they express themselves. Without this freedom a person enters into this universal conflict, which they compensate for by living in a state of delusion.
Communication as Kaiser saw it, was an antidote to this condition. The most positive quality of communication is not how it impacts the other, but what it does to and for the person communicating. It makes them more genuine and authentic, which allows them to resolve at least some of the issues that lead to neurosis.
Successful therapy hinges on the ability to provide this kind of space for the patient. Kaiser believed that the therapist was able to heal the patient simply by being with them.
It is of course impossible for a therapist to always guarantee they will be able to provide such a space for their patients, but there are certain characteristics common to therapists who achieve this outcome more often than not. These characteristics are having an interest in people, not having views that interfere with the therapeutic process, the absence of neuroticism, and receptiveness.
The first is self-explanatory—a genuine interest in people is a prerequisite to being an effective therapist. Secondly, the use of the term non-interfering views implies that the theoretical orientation of the therapist must support the underlying goal of the patient learning to communicate freely. If the therapist’s orientation and subsequent interventions aren’t moving the patient towards this goal it is unlikely they will achieve it on their own–if they could they would be less likely to end up in therapy in the first place.
The next characteristic also feels so intuitive that it could go without saying. It is impossible to help the patient recover from their own neurotic tendencies if the therapist is still suffering from their own. A therapist who is dealing with their own unresolved issues will have a hard time helping patients to communicate more freely. Receptiveness, the last characteristic, is closely related to this concern. As a therapist you have to stay open and receptive in order to be attuned to the patient and accurately analyze their experience. You must be able to stay aware of all the subtle ways there are for patients to engage in duplicitousness in order to help them overcome these behaviors.
Kaiser’s One Rule
Kaiser had only one rule for therapists—communicate. This was his only requirement for what therapists should do. All other dictums pertained to what therapists should be. The success of psychotherapy does not hinge solely on what the therapist does, but more so depends on who the therapist is. Psychotherapy is the process of healing someone by helping them go from isolation to relationship. The work is inherently interpersonal, therefore it is impossible to avoid considering the person of the therapist.
Through learning how to relate to the therapist without duplicity, without inauthenticity, without transference reactions, the patient inevitably changes. They grow and develop into psychological maturity. But, in order to experience the full benefits of this maturation, the therapist must at the very least possess the characteristics that were identified by Kaiser. They must be willing to move past technique and relate to the patient genuinely. Otherwise the patient’s growth is impeded.
For the patient to be able to not only experience but share in this level of genuineness and authenticity teaches them that they are also capable of generating it themselves. This is the key to the effectiveness of the therapeutic encounter. As a relationship, therapy is always temporary, but the experience of therapy can stay with the patient forever and reverberate in their lives well after the therapeutic relationship has ended.
What Kaiser is saying is that the willingness to communicate is what matters. Technique does too, to a lesser extent, but not more than the person of the therapist—the parts of themselves they bring into therapy and who they choose to show up as.
It is the Relationship that Heals: Freedom, Encounter, and the Heart of Psychotherapy
I encountered two popular therapeutic maxims when reading Irvin Yalom’s Existential Psychotherapy.
The first maxim states that “the goal of psychotherapy is to bring the patient to the point where he can make a free choice.” The second maxim is a simple reminder that “it is the relationship that heals.”
Work as a psychotherapist long enough and you will see these maxims get restated in multiple ways, all of which contain the same essential truth, but I still find it helpful to return to this version of them. The practice of psychotherapy is complex, which is why Yalom also says a separate and distinct psychotherapy is needed for each client. There’s truth in that as well, but I find it comforting and helpful to have a mooring post.
I suspect the general public is mostly unaware of the fact that multiple research studies show that the quality of the therapeutic relationship is the strongest indicator of therapeutic success, by a wide margin. There are some therapists working hard to make you think otherwise, that there is a single technique that can accelerate growth and healing, but data doesn’t actually support this.
The real question, which these maxims are alluding to, is why does the therapeutic relationship matter so much? Even more so than therapeutic techniques.
The Complexity of Free Choice
Before getting to that, let’s start with the first maxim and the notion of making a free choice. Most people assume they need no help with this. They make choices daily that testify to the fact that they are free and in a literal sense this is true, but a closer look reveals the relationship between freedom and choice is more tenuous, more complicated.
Freedom implies more than being able to act without opposition. Freedom implies awareness of the psychological forces and inner motives that underlie one’s decisions., as well as an awareness of the consequences. To be free is to claim agency over one’s choices so that they become self-determined, which is more difficult than it seems. Study yourself and you’ll realize that many of the choices you take for granted are at least partially influenced if not wholly generated by a confluence of external factors. People look to friends, family, media, and everywhere else for guidance. There’s nothing wrong with that, but most go a step further and allow their choices to be solely based on the thoughts and opinions of others.
Clinical Implications
Psychotherapy is unique amongst the helping professions precisely because it does not seek to satisfy the client’s desire for easy answers. Instead, psychotherapy provides a space for people to grapple with their own thoughts and feelings and arrive at their own answers. Therapy is a space where choice becomes possible rather than prescriptive.
There is a dizzying effect when people start to peel back the layers of their own existence and discover parts of themselves sitting at the center of their existence, covered in conditions, but still capable of giving them the awareness they need to make their own free decisions. Passing through this stage of psychological vertigo is necessary in order to experience the freedom that exists on the other side.
It is the Relationship that Heals
After nearly ten years in this profession, saying “it is the relationship that heals” feels self-evident. Of the many clients I have worked with in various capacities, none of them has ever praised me for my interventions or clinical acumen. Which is not to say that neither is relevant, but time and time again, clients make it known to us that what is most important to them is the way we relate to them.
The support we provide and the trust we instill through therapy is more important than any interpretation, technique, or orientation. Or any one kind of diploma for that matter. In truth, these things are only useful if they allow us to establish a real connection with our client, without which any and all therapeutic interventions will be rendered ineffective.
Emotional Demands of Therapeutic Practice
The psychotherapy relationship is a new kind of relational encounter, and it succeeds by providing the client with a corrective emotional experience. One that is defined by presence, authenticity, and mutual recognition. The relationship is the mechanism of change, and its effectiveness hinges on the therapist's ability to be with their own humanity and use it as an instrument of healing.
Reflecting on all of this reaffirms my belief that the demands of being a therapist are misunderstood, including by therapists themselves. These demands are intense and constant—therapists are required to be self-aware, emotionally available, and tolerant of uncertainty well beyond what is required of the average person. By necessity clients are unaware of this burden, but therapists are never far from it.
People come to therapy or get sent to therapy with the hopes of being fixed. If they stay long enough past the disappointment of realizing that’s not what therapy is about, they can gain something of greater value. An opportunity to meet themselves. An opportunity to be seen and heard and understood in the context of a relationship that restores their dignity and full humanity. A relationship where healing comes from connection and not solely from correction.
Both maxims speak to the view of psychotherapy as a practice whose foundation is based on the willingness to meet another person where they are at. It is a view worth preserving.
From Home to Higher Care: Strategies for Difficult Conversations
I recently found myself in the midst of a brief, but difficult and illuminating conversation. I was called and asked to provide information to a patient and their family about skilled nursing facilities, the places people sometimes go to recover and regain their strength after an injury or significant illness. Some of these facilities are standalone and some of them are housed inside of nursing homes, the mention of which can stir up significant anxiety for patients and families.
I walked into the patient’s room ready to hand them the usual list of information that we provide in these situations. My plan was to quickly introduce myself, state my reason for being there while simultaneously handing someone, anyone, the paper and then quickly exit from the room.
Upon entering I was greeted by two women. One of them was older—she was seated a few feet away from the hospital bed the patient was laying in. Her smile was kind. The other woman was much younger and seated much closer to the patient. Her chair had been pulled up right next to the hospital bed and she was positioned only a few inches away from it.
They both greeted me, which was clearly something the patient would not do. Not for lack of want or know how, but simply because he couldn’t. His illness had affixed him to hospital bed and left him weak and confused. His eyes looked distant and I doubted if he could understand anything that was happening.
If there was any level of understanding of what was happening and an emotional reaction to it, it was being reflected through the face of the young woman sitting next to him. She looked anguished, on top of looking exhausted. Her weariness only became more evident as we began to talk about the process of sending her loved one to a facility.
The conversation actually was relatively brief, due to the fact that I wasn’t very effective in terms of providing easy answers. As is often the case in this profession, the thing that ended up being of most value was my presence rather than any instructions or perspective that I could provide.
This experience is a reminder that in situations like these, the role of a social worker and a therapist is to provide an emotional container and act as an ethical guide and translator of the patient’s reality.
Understanding the Emotional Landscape
It’s important to understand the emotional landscape the therapist is traversing. By the time this conversation takes place the patient is dealing with a whole host of things. Loss of independence as well as the potential loss of their familiar environment. Both of which can transform into a fear of institutionalization and grief over their declining abilities. The therapist must find a way to act in the best interest of the patient while also preserving their dignity and sense of autonomy however possible.
While doing so they must also manage the emotions of the family members. Their consideration of options such as placement in a facility does not come without its own modicum of shame and guilt. For the family, acting in the best interest of the patient can simultaneously feel like supporting them and giving up on them. This ambivalence can be a source of significant intrapersonal and interpersonal conflict and it is also the therapist’s job to help manage these feelings.
Reframing the Decision: From Placement to Support
One way of managing these challenges is by reframing the situation and finding new language to describe what is happening. Usually in these situations, the mild euphemism that hovers in the background, the elephant in the room, is that asking for more help is framed as giving up on your family by wanting to put them in a nursing home.
This negative association can even exist within the belief system of the therapist. If so, the therapist must clarify first for themselves and then the patient and family members, that increased care does not equal decreased love from the family.
Strategies for Facilitating the Conversation
I felt anxious before walking into the patient’s room on account of the fact that I did not know what I was walking into. Reviewing a medical record can provide some clues about the problem you’re addressing, but it cannot reveal who a person is or how they will behave in the exact moment you encounter them. For that reason it can be helpful to ground the ensuing conversation in the factual. In this situation, that would include discussion of medical complexity, mobility issues, and concerns about safety. None of which should be talked about in a way that implies blame or judgment, but as realities that are the natural result of multiple developments and need to be addressed.
Validate Without Amplification
My job was to provide resources, which I did, but more importantly I provided presence. I sat with the patient and family in the midst of their ambivalence and tried to help them parse through it. To separate the facts from their feelings.
This implies listening and reflecting back what has been said, and more crucially, what hasn’t been said, but has obviously been felt. What it does not imply is that the therapist should offer up empty platitudes or false assurances. Rather than offer false hope, the therapist should simply allow space for mourning the loss of what was.
Nothing I did would strengthen the resolve of the tepid-looking woman I now knew was the patient’s wife. Nor could I do anything to lift the fog of exhaustion on the daughter who was seated at the bedside. I wasn’t supposed to—answering their questions and attending to their concerns was enough.
Include the Person Needing Care Whenever Possible
The patient remained distant, at a safe remove from the conversation. Even in such cases, the therapist still has an obligation to look for moments of lucidity within the patient. To locate their capacity for understanding and try to safeguard it. To the extent possible, conversations about the patient should never take place without them. Their voice should be included. Their preferences and values respected, even if only in ways that are small but meaningful.
The therapist can help the family to balance their need for autonomy with the need for safety. Their value lies in their ability to be engaged without over-identifying, which allows them to act in the best interest of the patient while maintaining appropriate professional boundaries.
Holding Care & Compassion
It is necessary to help the patient and the family to acknowledge the fact that there is no “perfect” option in these situations. At least not from an emotional standpoint—the choice is always difficult. If the patient and family can accept this limitation it frees them up to make a good enough decision. One that prioritizes seeking care, even if it means making significant changes. One that can rightly be viewed as an act of love and responsibility.
The job of the therapist is to help others by showing them how to tolerate complexity rather than by eliminating their pain. It is not about making the specter of choice painless, but making it more humane.