Story about Integrating Self-Parts

My patient is a powerful and charismatic person who was terribly abused as a child. We journeyed in his mind to the little boy who was beaten for squirming in his chair and left alone in the back room of the church. The boy in his mind embodied him today and wailed, "Why do they beat me?!" to himself, to his parents, to God, and to the reverberating aether. The depth of this access swelled my heart with tears.

I told him to ask that little boy if he could hold him. He hugged him, rocked him and whispered loving words to him: "You did nothing wrong. It's not right what they did to you. You didn't deserve it. It's over. I love you. Come with me. You can grow up now." He wept and wept, and rocked and rocked, until the pain was slowly held and slowly healed.

As he gained access to this wounded child, he also began to see other parts of himself that he had developed to protect himself: a smart man, a fierce man, a charming man. They each had different names based on when they emerged in his life and reflected the actual variations of the names he went by at that time--names like Little Timmy, Tom, Alexander (his strong middle name), and Thomas.

We began to appreciate that each of these self-parts was vital for his survival ,and he began to embrace them all. His smart part helped him gain recognition and praise. His fierce part helped him become powerful, realize his dreams and prevent others from taking advantage of him. His charming part made sure that others liked him and would follow him. He realized that he used to think that this last part was his true self, but he slowly realized that this part was the most duplicitous of them all, for it would never show vulnerability, only obsequious catering and manipulative insincerity.

Awake to and accepting of all of these parts, he began starting his day by gathering his self-parts together for a pep talk. "Timmy (who had now grown to be a strapping young man), keep me joyful and playful. Tom, I need you to figure things out. Alexander, watch my back and get me through the tough times. And, Thomas, take care of other people with true heart. Thank you all for being with me. Stand beside me but not in front of me. I love you all. Now, let's go!"


Favorite YouTube Thread (about Evil)

on my most recent YouTube post titled The Opposite of Trauma is Presence, someone posted some really profound thoughts on how trauma can’t be used to explain away the existence of evil. I thought I’d share the actual thread because it’s so cool. The commenter is named Alex_006.

Alex: The statement "this is the human condition" reminded me of a great paper by Murray Stein called "Jung on Evil" (.pdf freely found on google). What would love and goodness be without evil. What would we be without good and evil. Did you hide parts of yourself or did the overcoming of evil make you. I think the "survival parenting" concept is perhaps a bit soft on evil. I'm not an expert, I haven't worked in the field, but I do not believe that trauma is simply caused by the absence of good. A father who, drunk or not, sadistically beats his innocent child regularly and with growing intensity is not just "in survival mode" and in the absence of good parenting. There is such a thing as evil. And while trauma has played a role in going down this dark path, it is not the sole reason for it. Many people are bullied but don't become bullies themselves, even without much outside help. I think that the battle of the soul between good and evil is the crux of the matter. We cannot separate psychology from theology if we want to see reality as it actually is. So was glad to see a rabbi chiming in on this one. Together, you two will be unstoppable forces for good. Ending quote of the aforementioned paper: "While it is important for consciousness to throw its weight on the side of good, of life, of growth and integration, it must be recognized that this is a struggle without hope for final victory. For victory would be stasis and so would spell defeat anyway from the point of view of evolution. The evolution of reality depends upon the dynamic interplay of forces that we call good and evil, and where the evolution of consciousness and spirit is finally headed is still beyond our knowledge. The best we can do is to participate in this unfolding with the greatest possible extent of consciousness. Beyond that we must reconcile ourselves to leaving the outcome up to the Power that is greater than ourselves."

Jacob Ham: Alex, this comment has blown my mind... I fully agree that there is evil in the world and that much of my life is coming to terms with its reality. Then the next step for me personally is to not let myself be overwhelmed by evil and to not let myself lump traumatized people into that category of evil. It's an incredible delicate act. I don't have an answer for it. But, I do agree with Jung that consciousness is the transcendent answer to this struggle. Much of my life has been in the service of not turning a blind eye to evil, while seeking and willing pockets of beauty, in the way that Nietzsche originally compelled us to do. Thank you so much for taking the time to comment.

Alex_006: The way I understand evil, based much on Jung, is that evil has a reality of its own but it needs our cooperation. It is like a dance with the devil. This is ultimately an optimistic view because it means that people are never completely evil in themselves, but have rather given in to this force out of weakness, or to the wind blowing through men as Rumi called it. It also would mean that anyone can theoretically turn away from evil, repent and make amends; thus freeing themselves of bondage to it. Sadly, this is probably a rare exception when the hold is deep. And I agree, coming to terms with evil is a life-defining task that feels sometimes unbearable. I have also very much been impacted by Nietzsche's words of how the whole universe can be justified by a single moment of happiness, no matter the darkness before it. I've experienced the feeling myself; it was while feeding ducks with a woman I really like. I still find it incomprehensible that all of history was needed for that moment to take place. How you have not turned away from evil is what has made you a good and brave man. Life is glad to have you. Here is another quote that I felt would fit: “What does love look like? It has the hands to help others. It has the feet to hasten to the poor and needy. It has eyes to see misery and want. It has the ears to hear the sighs and sorrows of men. That is what love looks like.” – St. Augustine

Jacob Ham: You are a long lost brother of mine... in the words of Cormac McCarthy: He thought that in the beauty of the world were hid a secret. He thought the world's heart beat at some terrible cost and that the world's pain and its beauty moved in a relationship of diverging equity and that in this headlong deficit the blood of multitudes might ultimately be exacted for the vision of a single flower.

Alex_006: Beautiful words. Really encapsulated this strange view I've had formulating in me for a while now, thank you.

My patient's anecdote of how therapy helped her

I’m always struggling with how to describe how the way I work works—especially that last post about living the question that was titled How to fix everything wrong with you. What does it mean to live the question?!

Well, this one amazing person I had the pleasure of working with shared this anecdote about how she lives the questions.

“So yesterday I was having a conversation with my husband, and I kept interrupting him. I tend to do that a lot, especially in conversations that I am very distressed or passionate about. He got very annoyed with me at one point and showed it clearly.

I noticed a terribly uncomfortable feeling and the urge to react. Either to defend myself or to flip the tables on him and get angry at him back. But I didn't give into that urge right away. Somehow I had been able to slow down my observation of what was happening inside of me, so I was able to have that space between the uncomfortable feeling and the urge to react. That space gave me the fortitude not to act on my urge. Instead I just observed the uncomfortable feeling and tried to notice what it was.

I recognized it as shame. I never tuned into shame on quite this level. I knew it is wrong for me to interrupt him so much, and the shame that came with it was so big that I have always felt the need to repress it or hurt the other person who is shaming me. Because its too unbearable.

So in that space of observation, I asked myself why it was so unbearable. And I realized it was because in my mind and psyche, doing something bad/wrong/stupid denies me the right to even exist. My body and mind think that I am only worthy of existing if I never do anything wrong. I then was able to gently tell myself that I can make mistakes, even ones that get other people upset, and still be worthy of existing. It was so incredible to be able to hold both possibilities side by side.

It was the notion that I cannot exist if I do something wrong that made the shame unbearable. When I recognize that I do not have to be perfect to exist, I can suddenly be okay with the shame. It isn't unbearable. It just is and I can handle it.”

how to fix everything wrong with you

So many of my patients ask me for urgent, hurried answers for their distress. As soon as we discover what the issue is, they want to know, "Ok, now how do I fix this?" "How do I stop being so afraid?" "How do I stop running and hiding?" "How do I open myself up to intimacy?" "Why can't I stop being so mean to myself?" The essence of the questions boil down to: how do I stop being the way I've been my whole life because I hate this thing about me and it causes me pain and suffering I so desperately need to be free of now!

Often the answer is actually very dissatisfying because it doesn't provide immediate relief and only lays out the road ahead. The answer to most of these questions is often a transformation and elaboration of the questions themselves. Why did this way of being come about in the first place? How did this way of being help you survive? How does this way of being help you today? What does it protect you from? What does it help you avoid? How can you be different in this very moment of asking your question? How are you treating yourself as you ask these questions? Is there love and compassion or irritation and renunciation? Can you savor the seed of change that buds within you right now? Then, once you do that well, how can you be open to doing it again in the next moment? And, how many repetitions of this are you willing to do? This moment is all there is and ever will be, again and again.

"I want to beg you, as much as I can, dear sir, to be patient toward all that is unsolved in your heart and to try to love the questions themselves like locked rooms and like books that are written in a very foreign tongue. Do not now seek the answers, which cannot be given you because you would not be able to live them. And the point is, to live everything. Live the questions now. Perhaps you will then gradually, without noticing it, live along some distant day into the answer."
~ Rilke, Letters to a Young Poet

Pulsing Poignancy

In great therapy moments,
my body becomes a hollow body guitar primed
to resonate harmoniously
with another person's guitar.

Each string a different layer of self:
thoughts, emotions, intentions, identity and purpose.
Presence only full
when strings are tuned
through my own work,
my own healing.

Then, my guitar can coax another
to tune,
to heal,
to sing
soaring sonorously.

..."While my guitar gently weeps" - The Beatles

My patient's description of therapy in her own words

My patient wrote this very lovely and wonderful reflection on how therapy with me is helping her, even though she chides me for not knowing a thing about eating disorders. I asked her if I could share it with the world so that others may know what therapy can be like, sometimes:

Bulimia is one of my dirtiest and one of my best kept secrets. It leads to feelings of shame, disgust, and, what’s worst for me, isolation and crushing loneliness. My eating disorder tells me, “people won’t like the whole you especially once they really know you (who could like someone so gross)!” It tells me, “Maybe they only like the silly, smiley person you put out for the world.” So I play the role of someone who doesn’t have their own issues and someone who can be there for others and hold their pain, heartbreak, and anxiety without asking anything in return.

I’ve been in therapy for years with so many therapists, but recently therapy has begun to take on a new meaning. My therapist doesn’t get all the credit, but he deserves a lot of it. I began this new round of therapy to actually address my insomnia and debilitating panic …and oh my eating disorder, duh!

I had suspected, and with my therapist’s help, finally learned that so many of these symptoms were trauma. Therapy has helped me begin to see that my eating disorder’s voice doesn’t exist in a vacuum. Instead, it is the voice of multiple traumas manifested as bulimia, my eating disorder trying to protect me from uncomfortable feelings or people that will hurt me. However, it left me with an inability to face those things that hurt me in the past and an immediate and reflexive repulsion to doing or thinking about anything that might make me uncomfortable me today. But, I’m slowly learning that avoiding pain and relationships actually leaves me in even more pain …and even lonelier.

The other night after a session I began to really think about all of this. I was able to see that I am in fact likable and I do have friends. I make my therapist laugh, sometimes at the ridiculous things that come out of my mouth, but sometimes because maybe I am genuinely funny (maybe).

I also learned that the ways I cope don’t make me a bad person, a weak person, a gross person, or an unlovable person. What is truly healing about therapy and my therapist is that I am allowed to be sad, happy, angry, silly, narcissistic, petulant, avoidant, and lonely without judgement and even acceptance. Sometimes I do deserve an eye roll or two. He definitely gives me much needed feedback and reality checks, but I can be myself with the eating disorder or without it. All parts are welcome.

We need people in our life whether that be parents, siblings, friends, mentors, or partners. When we don’t have these relationships or when they hurt us, we feel insignificant, unlovable, and alone. To help me heal and begin to trust again, my therapist takes on many of these different roles at different times. This begins to make me whole, and at the end of the day, all we need is for people to see us and acknowledge us (even our most shameful parts).

I feel grateful that I have a space where my fragmented self (my eating disorder included) can be laid out and talked about. I want to remember therapy and my therapist as a person whom I trusted and finally opened up to, who didn’t reject me, and most importantly who kept a space in their heart for me. It feels scary and good at the same time.

I show up every week because I don’t want to be alone, I like being authentic, and I appreciate that he in turn shows up for me and bears witness. In a way I believe us showing up is how we honor each other’s existence and importance as humans. Therapy will be the place where I was accepted and began to accept myself. The hope then becomes that I can take these feelings and begin to experience that with others.

The Poetry of Therapy

My patient began session talking about how, after the work we had done, he is now able to watch parenting in movies and say how the parent should act even though he still couldn't act that way for himself. He had watched The Little Prince, in which a very successful, but busy professional parent only parented by creating intensive schedules of homework, chores and self-improvement lessons for her child. He drew comparison to how his father used to hate when he played video games as a child and one day even smashed his gaming console into smithereens.

Then, he shared a recent event that left him feeling terribly rejected. He had a scheduled a "catch-up" call with a casual friend, who was demonstrably more successful than he, but this friend couldn't take the call because they were in the middle of working on a project with someone famous in their industry. He felt furious at himself for not being worthy enough to be chosen in that moment. He assumed that this friend didn't value him at all, even though his friend rescheduled the call for later in the week. He felt that the call would be an audition to prove his worth and was thinking about canceling it.

He resolved his obliterating shame by directing anger at his friend instead, judging them for being inconsiderate and irresponsible with scheduling and time management.

He knew his reaction was too extreme but didn't know how else to get out of it, so he asked me how he should think about it instead. My gut already told me not to comply (especially since I am loathe to give concrete advice), but I couldn't figure out why. So, we entertained some other possible explanations for his friend's behavior, many of which were more charitable in their assumptions, but he grew more and more angry and eventually smashed his laptop on his bed (and I saw the ghost of his father enter the room). I asked him what made him so angry and he shared that he imagined fake "enlightened" people pretending to be better than him patronizingly telling him how he should act.

I told him that my gut was right to think this line of discourse would prove unproductive. I didn't think the issue was how to change the way he should positively reframe the event but rather how he should feel even before the so-called "rejection" had ever occurred. You see, he carries a deep-rooted presumption that he is always worthless and undeserving and he spends a great deal of time and effort in his life proving otherwise. I told him that I thought that this event triggered an emotional flooding of that core experience and that we needed to get to the root of that experience.

He asked how, but I had no idea!

He couldn't think of anything that literally mapped onto a similar experience, such as a historic rejection from his peers, though granted he had experienced more than his fair share of bullying and ostracizing.

While looking at his father's ghost metaphorically lingering in the air, I said that I think it's about his father. He didn't see how that memory connected.

I didn't know either!

Then, I was given the memory of a conversation with another patient and also how our session started with The Little Prince, and I realized that in his rage he was feeling, "I'm never good enough am I? I can be the perfect son with perfect grades and perfect arpeggios but you still don't care enough about me that you would want me to just play and have fun, let alone play with me."

He solemnly nodded that maybe this was right and he settled into this feeling just a bit.

Exiting the session as we had come in, the muse guided me to ask him what he as a parent would say to this child who felt so rejected. He said he would do something fun, like take the child outside to play catch. Visualizing my own child, I added that I would tell the child, "I love you so much! No matter what!"

And tears uncontrollably fell over his crumbling expression, released from its prison of pain after all these years.


Sitting on the Balcony Overlooking a Fog of Fun House Mirrors

Today, my dear patient came in angry and confused by our last session. She couldn’t remember the mantra that she was supposed to take away and left feeling even more confused and agitated. Over the week, she eventually realized that what she felt at his core was a shame that had been building subtly and inexplicably over the past many weeks. Maybe it started after she had forsaken her abusive father, now apologetic, but enfeebled in his advanced age. But, this explanation didn’t quite settle her.

So, we reconstructed our conversation in the minutiae.
Then, we recalled a repulsion to whining and neediness,
fended off with barks of nastiness and meanness,
which, sure, sounded like her father,
but also sounded
very much like
herself…

In this swirling vortex of shame,
she in turn assumed that
others were mean and nasty back
—her fear of always being one disappointment away
from rejection taking purchase again, like a tightening claw around her throat.

She didn’t want anything to do with anybody
and was reprimanded
for being
impatient,
rude
and condescending.
She dreamt of being trapped in a tiny room with me,
wishing she could shove me out!

She cried out in confusion, panic and redoubled shame
at the return of such depressive agitation.
She begged me
to tell her what to do
, but knew she would resent me if I answered.

Instead, I beckoned her to sit on the balcony overlooking her shame.
I showed her how
the inside mirrored the outside, and
the outside rattled the inside.

I showed her how
her divided
self
apparated like swirling reflections
in a haunted
house of mirrors,
at times, projecting the whiny self
while embodying the resenting self,
at other times, projecting the critical self,
while filling herself with shame.

Out of the blue, she declared
with streaming tears and quivering lip,
“Sometimes, I think I was bad
because
I was hoping that my father
would notice.”

And, I can’t help but let slip, “…beautiful!” as I look over the dawning light dissipating the fog.

I tell her that the mantra to remember is this:
and I put my arms up as if
holding my baby
patting his bottom,
saying, “there, there…
It’s ok.
It’s ok.
”

New Journal Article on the Importance of Relationships in Trauma Therapy

As you have probably guessed based on my blog, I have a beef with the misrepresentation of effective trauma therapy as being narrowly evidence-based, which often leads people to conclude that the best therapies are the most studied, which often defaults to cognitive-behavioral therapies. But, what the general public less frequently hears about is the vast evidence-based, research literature showing that the therapeutic relationship is the most important ingredient in effective trauma therapy (and therapy for lots of other disorders for that matter). Here’s a really cool new article that supports this fact.

Norcross, J. C., & Wampold, B. E. (2019). Relationships and responsiveness in the psychological treatment of trauma: The tragedy of the APA Clinical Practice Guideline. Psychotherapy, 56(3), 391-399.

http://dx.doi.org/10.1037/pst0000228

Abstract

The therapeutic relationship and responsiveness/treatment adaptations rightfully occupy a prominent, evidence-based place in any guidelines for the psychological treatment of trauma. In this light, we critique the misguided efforts of the American Psychological Association’s (APA, 2017) Clinical Practice Guideline on Posttraumatic Stress Disorder in Adults to advance a biomedical model for psychotherapy and thus focus almost exclusively on treatment methods for particular disorders. Instead, the research evidence, clinical expertise, and patient preferences and culture (the necessary triumvirate of evidence-based practice) should converge on distinctive psychological guidelines that emphasize the therapy relationship, treatment adaptations, and individual therapist effects, all of which independently account for patient improvement more than the particular treatment method. Meta-analytic findings and several trauma-specific studies illustrate the thesis. Efforts to promulgate guidelines without including the relationship and responsiveness are seriously incomplete and potentially misleading. The net result is an APA Guideline that proves empirically dubious, clinically suspect, and marginally useful; moreover, it squanders a vital opportunity to identify what actually heals the scourge of trauma. We conclude with recommendations for moving forward with future APA practice guidelines. (PsycINFO Database Record (c) 2019 APA, all rights reserved)

Podcast: The Long Arm of Trauma

This is a powerful must listen. Comedian/actor Darrell Hammond, Director Michelle Esrick and I talk honestly about the impact of childhood trauma on the Road to Resilience Podcast. This is what inspired the recent blog post, Transforming the Ember of Rage.

To learn more about the movie, click here. You can host a screening of the film here.

Saturday Night Live veteran Darrell Hammond, filmmaker Michelle Esrick, and Mount Sinai psychologist Jacob Ham, PhD, discuss childhood trauma, complex post-traumatic stress disorder (PTSD) and healing. Dr. Ham is director of the Center for Child Trauma and Resilience at the Icahn School of Medicine at Mount Sinai.





The Center of the World

A set of parents took a step back to ask if our discrete trauma treatment for their children was taking into account the impact of the horrible event on them, a question their couple’s therapist had asked them to ask. Without fully understanding what was meant, I shared the itch gnawing my intuition: I didn’t know the husband yet and his presence often disappeared from the room. The wife agreed that her husband wasn’t “therapized" like she was. He defended by saying that he’s been in plenty of years of therapy.

But, she’s been in therapy for years and years, and therapy revealed to her that she had been living in the world as is, but there was a floor beneath the world—one filled with nuance, complexity and layered meaning. Over the years, she realized that the floor was actually just a hallway to floors upon floors until you reach the center of the world, and she loved living in that world, exploring its ever changing and revealing landscape. Her husband only visited a few floors from time to time.

I actually freaked out for a second. How did she know about this world?! Who showed her?! I felt both validated and banal and needed to know the name of her therapist.

Afterwards, the nature of our trauma work plunged into the gravity of Kairos.

*shared with permission

Transforming the Ember of Rage

I met a man who experienced unbearable, unspeakable
and unspoken horrors at the hands of his
parents. He observed
that when they died he
grieved for just a moment, before
moving to the comfort of anger,

anger at the fact that they
would never be
able to restore his childhood
so violently wrenched. Then,
for the next ten minutes, he lost himself
in this rage against the world.

When he spoke of this grieving rage, I imagined
sifting through the ashes of a dying fire
discovering a weak ember of life.

But, as his rage engulfed, this ember
turned into a blaze of Pyrrhic victory burning
everyone.

I hurriedly gathered that ember
gingerly nursing it without igniting it,
to light a torch illuminating
the path to what he is truly fighting for.

I told him that he should fight
to reclaim his childhood—to be
surrounded by the safety
of love, so he can finally
play.

*shared with permission

Fighting for Love

A beautiful autumnal woman dragged her handsome winter boyfriend in
for one last desperate attempt to make this miracle work.
Her history of abandonment triggered by his enacted history of neglect.
He yearns for her, like tiny arms reaching for the mother
who left him stranded on a front yard
at an age too young
to understand in any other way than
he’s not worth taking.

He’s slipped past therapy his whole life,
a lesson in never letting anyone get close enough to hurt him or see his un-worth.
Christmases in the Caribbean, avoiding all reminders of love and family.

But, for her,
anything.

So she lashes him with wet tears,
angry when he turns away,
scared that this will push him away,
guilt-ridden knowing his history, but blinded by her own pain
and her own needs.

I help her see
herself as fighting,
fighting for love, fighting.
Fighting for “I deserve better.”
“We deserve better.”

He shrinks in self-absorbed self-flagellation, reliving
his unworthiness in every
cell. A prisoner
of his pain.

Now, I get angry.
I refuse to let him disappear.
I yell, “Do not leave her!
And, do not leave yourself on that front yard again.
Fight for her! Fight for yourself!
Open your heart and embrace her pain.
The greatest challenge and the greatest reward
left undone in your life is
to feel
to hurt
to love
to hold
and never, ever, let go again.

*shared with permission

The Wisdom of Negative Emotions

Part of the work with one patient revolves around this question: What is the value of sitting in uncomfortable emotions?

My patient tells me that his teen-age cousin from out of town is visiting him over the holidays. This is a cousin whom he wishes he could know better and support more. They and some other family members are having a holiday meal. My patient asks the teen what gift she is giving her mother for Christmas and the teen says, "Nothing, I hate her." My patient understands that the teen and her mother are struggling quite a bit, but he doesn't like the negativity displayed so publicly during a holiday meal. Over the course of the meal, my patient grows more and more annoyed by the teen's endless chatter about nothing and can't wait for the evening to end. He ends up feeling guilty for harboring such negative feelings towards his dear cousin and thinks maybe he's just not very patient with teenagers and is a bad older cousin.

After receiving his permission to offer some advice, I tell him that he can't dismiss his annoyance because it holds wisdom and insight about what he really cares about. His annoyance is telling him that he is frustrated in his desire to have a meaningful moment with her so that he can really get to know her as a person, a longing he himself expressed earlier in the session when he said so beautifully,

"I don't really know if my father ever thinks about me when I'm not in front of him."

Secondly, his annoyance is telling him that he really cares about feeling gratitude for the moment that they are able to share together with other family members during that meal.

At the same time, I remember how deeply he appreciates his mother's love for him. I visualize one of the earliest memories he has shared with me--sitting on her lap while reading a book--overlaid onto an image of the same energy holding him over the phone while she listens to him speak as an adult. I don't mention this explicitly, but feel it settling into my heart and coloring my experience of the moment.

Next, I imagine how he might be guided by what he cares about. I tell him I imagine him whispering to his cousin, "I wish we had more time to really talk and
get to know each other."
Like a hug.


Then, I imagine his cousin's energy settling and easing
out of her anxious wanting to be seen while being afraid of being judged,
manifest as the endless babble about nothing.

And in that same moment,
my patient's energy is settling,
his self consolidating, as
he sees himself more
compassionately
and imagines himself more
powerful and effective
in the world, achieving
the knowing he wishes for his cousin
and for himself.

*shared with permission

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.