My Therapist's Journey: Play Therapy

The second biggest pillar of my early training was play therapy. I probably did more play therapy than anything else during grad school because I had a part time job placed in an elementary school treating about 15 children per week.

Children taught me a lot about how to bring spontaneity and playfulness into my work. Children will not put up with a neutral, distant person and will tell you whether you are doing right by them, whether you like it or not. If you listen, they will teach you how to be the therapist they need, but you still need to play and experiment for them to know "yes, more" or "no."

When I was thrown into play therapy, I never really received any clear instruction on how to be therapeutic. I even took a semester-long class on child therapy but didn't learn a thing about technique, just a bunch of theory. Now, it is true that some of the developmental and dynamic theories were informative and I found that children's imaginative play often paralleled real-life themes. For example, one five-year-old only watched Lion King up to the point of the father's death and then rewound the tape over and over again. Other children play out generalized themes of powerlessness, fear, family stress, social stress, anger or sadness. But, this work was plodding and it was often difficult to know how to make this play helpful in the real world. Furthermore, many young children quickly grow out of pretend play beginning around age 7 and move into board games and other rule bound games.

It was through hours of playing Uno and Sorry and Trouble that I began to understand that children at this stage were practicing a variety of skills: turn-taking, following the rules, reciprocity, fairness, impulse control, controlled aggression, good sportsmanship, decision making, frustration tolerance, planning, etc. I really began to understand moment to moment activities in terms of what skills or neuro-cognitive functions were being expressed and exercised.

I also had the amazing fortune of learning Ross Greene's Collaborative Problem Solving Approach early on and co-led parenting groups with him in an outcome study comparing his approach to Russell Barkeley's Defiant Child approach, which is a classic behavior management approach. I was beginning to see behavior as being the shaped by external reinforcements (as highlighted in behavior management), neurocognitive drives and deficits (Ross Greene), and internal psychic and relational drives (psychodynamic).

I was becoming more and more interested in diving deep into the moment-to-moment world of play and overlaying these paradigms onto the immediate behaviors and experiences. I started to care more about how things are being said and done versus what was being said or done. In fact, I rarely ever asked children how they were doing or bothered with helping them "open up." Instead, I just played as hard as I could. I tried to really imagine all of the imaginary actions happening between characters. I competed in board games with gusto. I began to figure out what the issues were as they emerged in moment to moment play and tried to figure out ways to correct them without leaving the play.

This obsession with the moment to moment process has carried with me throughout my work and remains a core aspect of how I work and what makes me effective. I listen and observe on so many levels at once: what's being said or done, how, when, why now, how it's connected to history or to other relationships, what's the deficit or the struggle, what's the yearning or aspiration, what's the hurt and pain?

In future posts, I'll give a nod to cognitive-behavioral approaches and then spend a lot more time on modern relational approaches as applied to individual and family work.

The Truth about Trauma Work

I was working with a couple terrorized by demons of severe trauma experienced as children, re-inflicted on each other. They lashed out at each other trying to cause as much pain on the other as they felt themselves. 

And I dove in head first with barely a safety line in tow. 

Read More

My Therapist's Journey Part 1: Insight.

I've learned so many different types of therapies over the past 20 years and continue to take from everything I’ve ever learned. In a series of posts, I'm going to share what I've personally learned about therapy and becoming a therapist. I hope these posts help future therapists embrace their own journeys and help patients feel more informed and empowered to seek good and smart therapists rather than good and smart therapies that fit their needs in their current moment. 

Read More

Ode to A Depressed Person

I know someone who always feels like ending her life. I told her that I admired the way she lived, which is a ridiculous thing to say. Why would anyone admire someone who is always at baseline suicidal? I tried to unpack what I meant by it and this is what came out:

Read More

My Patient's Lovely Description of Our Therapy

It's like you hold up a mirror and I really don’t want to look into it because I think I am so ugly, but deep inside I wish I were cute and pretty (she tears up). But, you keep holding up the mirror and show me that I just have some dirt on my face and you help me brush it off. Then I begin to realize that maybe I’m not so ugly...

Read More

Today's Touching Family Moment

Today a man,
who just months ago
was unsure
whether he wanted family therapy
(at least with me)
then only wanted to work on problem solving,
then only wanted to intellectualize,

finally cried
about missing his father,
grieved the imminent loss of his favorite uncle,
and shared how he suffers
a desperate longing
to connect
with his teen-age son
(who can't make sessions
because of other commitments).

And his wife and daughter
leaned into his pain
with tears in their eyes,
not talking,
not problem solving,
only conveying
love
and gratitude.

And I too honestly
felt moved
like listening to Adele
or singing Karaoke :-) 

And I reassured the father
that this new man
will draw his son
inexorably
like love
is wont to do.

 

Revisiting the Fractal Nature of Relationships and the Therapeutic Process

I was debriefing with a trainee about a therapy group we co-led. We were talking about how to feel comfortable in the chaos of the conversation. The trainee is used to having only delivered structured treatments in which each session is fully prescribed. I explained that to be comfortable in chaos, I work very hard to make sure each moment can be explained with some framework or another, the most important of which is to intensely track the process and trust that working in the here and now will always reverberate into the depths of the person’s psychic needs and issues. 

So, what I really believe happens in therapy is that our past experience with primary caregivers leaves an indelible mark on our psyches in ways that most people don’t realize. It’s not as straightforward and obvious as “if you have been neglected in your life then you will fear being neglected again.” This much may be true. But, the interesting thing is what happens to your mind and how it plays out in the here and now. 

Continuing with the example of neglect, the deeper thing that neglect does is to make it harder to know what one actually feels let alone express it. Neglect leads to feelings of loss, abandonment, rage and self-loathing all covered over with a patina of dissociation and apathy. In the dark recesses, the neglected person feels like they must not deserve to be loved. Whenever they need someone to comfort them, they shut that need down. As if they think (though never actually hear or realize), “Don’t ask for comfort. No one will comfort you anyway.” Or, “Who are you to deserve that?!” Rage at being abandoned is redirected to the self for needing others in the first place. “Why are you so weak, selfish and pathetic? You should be a better person. Don’t be a bother.”

Then, what happens in the here and now conversation is that the neglected person in some way checks out of the conversation. They can become vague or confusing, quiet or cliched—talking a lot without say much. The listener can feel lost or confused. The listener may also feel unimportant or invisible because suddenly the neglected person is lost in their own head and unaware of the listener. The listener can’t get a word in edge-wise or can’t get the neglected person’s attention. The neglected person has hidden themselves either explicitly or in subterfuge. 

In these moments, the therapist tracking the here and now process can help the neglected person reclaim awareness of the given moment in a safe and tolerable way. The therapist can intervene in so many creative ways consistent with their own style and comfort level or in ways that are appropriate to the given moment or appropriate to the historical relationship with those in the conversation. The therapist can point out what they observe to be happening in the neglected person, in the listener or therapist, or between the participants. (e.g., “I notice that you suddenly changed the topic and began telling us a story that doesn’t seem to relate to the point” or “Hey, where’d you go? All of a sudden you seem to disappear”). They can simply break down what they saw unfold moment to moment, or invite participants to share how they are experiencing the moment  (“I just noticed that when XX asked for an explanation YY moved on without answering the question. What happened?”). Once this space for experience and need is made, the therapist can help the neglected person express their need for comfort in an assertive way that implies, “I have hope that you may comfort me” and, as equally importantly, “I deserve to be comforted.” And, in these small moments, the neglected person is not neglected. And, the legacy of neglect is kneaded out. 

Then, we do this again and again.

The Nurturance of Being Known

A young infant cries, because that is almost all they know to do. An attentive parent says, “Oh, so tired!” and picks her up. The infant quickly settles.

Another infant waits for his mother’s gaze. When caught, he smiles; she smiles back.

A toddler is playing in a new and strange waiting room, sees a curious object across the room and looks pensively at her father. He says, “It’s okay.” She gathers herself and proceeds to the object, assured that her father still watches.

Leaving my office, a preverbal two-year old cries “broke!” because the head of his lollipop fell off. His mother, rushing to leave, says, “Forget the lollipop. Let’s go! There’s another one in the car.” The boy stays, absorbed in the tragedy. She threatens to leave him and walks towards the exit. He cries harder, “Broke, broke!” I say, “Oh no! The lollipop broke?!” He says “yeah” despondently, settles, moves on.

A verbal toddler watches traffic pass by, while I converse with my friend. He sees a truck, points and says, “truck.” My friend ignores him to continue our conversation. Growing agitated, he insists louder and louder, “truck, Truck, TRUCK!” Without missing a beat, my friend turns to him, says, “Truck!” and returns to our conversation. He settles; resumes his watch.

A preschool child yells, “I hate class! I don’t want to go! You can’t make me!” Her father asks, “Are you nervous about going to class?” The child looks down, settles comforted, waits.

A colleague shares her pain in our secondary trauma support group. The rest of us sit in silence, allowing our full presence to hold her pain among us, restraining our urge to make it better, fix it or hurry it away.

A new patient leaves me a voice message angry that I suggested an exposure exercise for homework. She has just read a news story in which another trauma expert derided exposure therapies. When she comes for therapy, I explain how the exercise is different in a way that satisfies her. I see the fractal of her infant self crying, desperate, and tell her, "Right now, I hear you also saying, 'I’m scared to start therapy and face my traumas, and I am not sure I trust you yet.'" She tears, breathes and settles, telling me how afraid she felt the night she called.

The need to be known is universal and devastating when denied. It’s rooted in an infant’s cry and flourishes into thou and I. 

random inspiration from therapy

Sometimes change is hard. As a person changes in therapy, they become a better self. Some people feel really bad about who they were before therapy. For instance, many people become more caring for others and regret having lived so selfishly in the past. I think these people had to be selfish in the past because caring was too dangerous. When people have experienced significant interpersonal hurt, connecting with others just leads to more hurt. One’s self-protective instinct says, “Don’t you dare open up again!” Yet, as one grows in love, self-acceptance and healing, it’s hard to keep disconnected from others. Therapy heals the heart and when the heart opens it necessarily begins to connect with others. That’s its function: to remember and extend our interconnectedness. So, if this interconnected caring feels too unfamiliar, strange and frightening, remember what you really value and care about, which for most people includes love and being loved.

If anxiety and fear drives you, your only chance of thinking clearly is to remember what you value most. ...a soldier’s courage carried by love for fellow soldier, a patient’s perseverance for the sake of self waiting to be born.

How Therapy Works (Sometimes)

(Originally posted on drjacobham.com)

herapy is such an interesting, magical thing and there are so many ways that it can help and for such a variety of issues. It's honestly hard to describe what makes it work, and I think most therapists would struggle to summarize an answer. I’ll give my favorite answer to how therapy works, recognizing that it’s definitely not the only answer.

Therapy helps people heal interpersonal wounds and build trust and love with other people and more importantly with themselves

Most people who seek therapy struggle in their relationships with others and this struggle often reveals struggles in people’s relationships to themselves, which in turn is often reciprocally due to earlier problems in their relationships to primary caretakers. It’s as if all relationships at every interpersonal and intrapsychic level are literally fractal--that is, they echo each other at different scales of experience. Even a person’s relationship to their therapist echoes this core, fractal pattern of relating. I personally enjoy working in this way and pay careful attention to my experience in the room with another person and the moment-to-moment nuances in our interactions. I trust that what happens in the moment is a fractal of the core issue, so exploring and healing the moment will heal relationships that expand out into the real world and pierce inwards towards one’s relationship to the imagined “Others” in one’s heart and to one’s relationship to oneself.

I find that this careful, attentive listening works really well when working to heal all types of family relationships too. This approach seems to help people get out of the rut of having the same fights over and over again. Most family fights happen because people are too afraid to speak from the true place of vulnerability and hurt. Instead, they lash out and attack back when they feel they’ve been attacked. People also have a hard time acknowledging and listening to each other, desperate to make sure their own voices don’t become diminished or drowned. At other times, ghosts of relationships past, self-hate and self-criticism haunt us and distort everything we hear into the messages we most fear hearing. For instance, we hear “I wish you wouldn’t do that” as “I think you’re stupid and disgusting.” Or, more commonly, we hear  “I’m tired of fighting with you” as “I hate you and I’m leaving you,” which scares the heck out of all of us!

If my approach doesn’t fit with you, that’s okay. I think the fractal nature of  experience means that many kinds of therapy can heal because the healing has a ripple effect across the levels of experience. For example, a cognitive therapist might focus on uncovering and challenging destructive core beliefs about oneself or others; a behaviorist might focus on coaching specific ways to change one’s behaviors in real relationships outside the therapy room; or a psychoanalyst might explore childhood history and/or its impact on the here and now of the therapeutic relationship.

So, the most important thing to consider when finding a therapist is not what type of therapy they practice, but how they make you feel when you talk to them. All consumers of therapy know this implicitly and act on this knowing by either showing up every week or missing appointments and avoiding therapy (I wish that more of clients would express their dissatisfaction with verbal feedback, instead, so therapists can learn and become better therapists).

There is such an incredible amount of hurt that flows like a deluge across the world. It crashes through us one interaction at a time as we are hurt and then hurt the next in return. The only way to stem the tide is to actively and defiantly say “I will no longer allow this hurt to pass through me and poison me.” Then, this commitment needs to be made again and again, because the tide of hurt is big and deep. It wells around us and springs from us. But, someday, the momentum can change, such that being light becomes a little more easy, less work. I promise. Be patient. In fact, that patience is one of the first and most important acts of love and light that stems the tide.