Jun 27

“Fleabag”: First Therapy Minutes Make Impact

One brief scene early in season two of Phoebe Waller-Bridge‘s popular TV series Fleabag packs a lot of important content about what can happen in someone’s first therapy session.

Whether you’ve seen the show or not, this is worth a watch.

Without a gift voucher from her father the Client, “Fleabag” (Waller-Bridge), wouldn’t be there at all. How many people have started therapy this way? Probably not many. But how many have started therapy because someone somehow prodded them into it? Pretty many.

Right off the bat, we know that the use of humor is not appreciated by the seriously dry unnamed Therapist (Fiona Shaw). Too bad for our Client, who regularly employs it as a defense mechanism.

Fleabag, whose inner thoughts are frequently directed toward the viewers, fails to please Therapist with her jokiness. In one instance Client remarks to us, “Tough crowd!” 

In response to Therapist’s questioning, Fleabag concisely and effectively states several life problems that probably made her dad think she needed counseling. She then proudly tells her viewers, “I’m good at this.” Glibly summarizing issues is easy enough; going deeper is usually considerably harder.

Therapist asks about closeness with family, friends. Client has had significant losses: both her mother and best friend have died. When asked probing questions, however, she laughs. A more comfortable alternative to crying and other expressions of vulnerability.

A pivotal point is when Fleabag hears Therapist reframe a couple of her main issues. Abby Robinson, Digital Spy:

…(I)t’s really the only time Fleabag has vocalised her misery and it’s incredibly powerful, a moment laden with painful truths.

‘Just a girl with no friends and an empty heart… by your own description,’ says the therapist and Fleabag is floored. She’s visibly devastated, because saying it aloud makes it real.

It almost takes your breath away, until you check yourself and remember that we’ve always known that her mental health is in tatters.

Fleabag insists to Therapist she has plenty of friends. Wink wink. (Because we the viewers are now her friends.)

Testily now, “I don’t need to be analyzed. I have a nice life.” Frankly, Fleabag just wants to exchange her voucher for money. Really? Why make an appointment just for that? Why submit to Therapist’s questions? Surely part of her knows she can benefit from professional help. But she’s afraid.

Therapist isn’t having it. Brief pouty silence before Client feels compelled to blurt out her secret desire. If you insist on me being here (Therapist doesn’t), I’ll have to open up. 

As Allie Pape, Vulture, recaps the confession and ensuing exchange, “Fleabag insists she’s conflicted about her lust for The Priest, but the therapist knows better.”

Fleabag: “Can you just tell me what to do?” Then I can blame you when things don’t go well.

“…You already know what you’re going to do…” Therapist has decided this in an instant.

“So what’s the point in you?” Maybe to help you come to terms with your choices?

Therapist and Client argue about whether Fleabag already knows what she’s going to do.

Guess who turns out to be right?

Whether because Therapist was actually right or whether because Fleabag was influenced by Therapist’s confident proclamation, we’ll never know.

Aug 07

In Therapy: Swearing, Crying, Laughing

Ever feel self-conscious in therapy about your words and/or actions? Three commonly expressed areas of concern are swearing, crying, and laughing.

I. “Oops–can I do that?”

Regarding swearing, Ryan Howes, PhD, Psychology Today, offers a therapist’s perspective I agree with:

Yes, you can swear in therapy. At least you can with me and the therapists I know. Of course, if your cursing actually gets in the way of direct communication we’ll probably raise that concern (to help you swear more efficiently, perhaps?). Otherwise, therapists really shouldn’t prohibit moderate profanity…

I’m not trying to incite a vulgarity revolution, but I do support the battle against defenses and inhibitions, especially in the therapy office. Sometimes that internal censor just needs to back the fudge (link is external) off.

And what about therapists swearing? Linda Esposito, LCSW (Psychology Today) echoes Howes on this (and again, I’m on board as well): “I follow the client’s lead about swearing. If they’re uncomfortable, I keep it clean. There’s no need to add another layer of stress to the issues at hand.”

II. “Sorry for crying.”

As in the rest of life, some people cry more readily in therapy than others; some don’t cry at all. Some who do cry feel the need to apologize; some who don’t cry kinda wish they could. And so on.

Bottom line: Therapists who don’t allow clients to cry freely aren’t doing them justice.

“How can therapists help clients have a therapeutic cry?” asks Jeffrey Von Glahn, PhD, in Psychotherapy Networker: “It’s really very simple: have the utmost respect for this natural process and be patient. Tears can help people heal from hurtful psychological experiences in life, just as there are natural body processes that promote physical healing. Creating the right conditions for therapeutic crying begins with developing the bond of trust and safety that enables clients to share their hurts with you, however circuitous the route may be. It’s through that bond and the experience of released emotion that people can reclaim parts of themselves that they’ve felt too frightened to acknowledge and own.”

Do therapists cry sometimes in sessions? Occasionally we might—we’re human. But, if a therapist seems to cry too often, seeking consultation about one’s triggers may be appropriate.

III. “I shouldn’t be laughing in therapy.”

No, really, if you have a sense of humor, please do.

Meaghan Mobbs, Psychology Today, on the benefits of humor and laughter in therapy:

Humor moderates stress. Creating a humorous narrative about a stressful situation can result in reduced physiological stress response, less emotional distress, and lower negative emotions (link is external). Black humor in particular typically takes a negative event or experience and reconsiders it from a less threatening point of view. This allows the person who experiences the negative event to look directly at what is painful but see and interpret it in a less harmful or threatening way…

The act of laughing itself improves oxygen consumption, and its after-effects include slower heart rate and lower blood pressure due to changes in the body’s endocrine system. Moreover, the function of laughter potentially serves as a release of nervous energy—which is why people might laugh uncontrollably when enormously angry or grieving (link is external)and it promotes group cohesion. Literally, cracking up keeps you from cracking up.

Mar 28

Therapists on Therapists: Five Nonfiction Books

The following five nonfiction books feature therapists writing about the process of therapy—in other words, therapists on therapists.

I. Letters to a Young Therapist: Stories of Hope and Healing (originally 2003; paperback 2016) by Mary Pipher

Publishers Weekly: “Even the most cynical psych snob will find that visit-a series of seasonally themed letters to a fictional graduate student describing psychotherapy from the inside out-refreshing, informative and insightful.”

Sample quotes:

Writers and therapists live twice – first when they experience events and a second time when they use them in their work.

Therapy isn’t Radio. We don’t need to constantly fill the air with sounds. Sometimes, when its quiet, surprising things happen.

II. The Gift of Therapy: An Open Letter to a New Generation of Therapists and Their Patients (2017) by Irvin Yalom.

Psychiatrist Irvin D. Yalom has written many books regarding therapy, but this is one of his most recent and most educational regarding both sides of the couch.

Sample quotes:

Life as a therapist is a life of service in which we daily transcend our personal wishes and turn our gaze toward the needs and growth of the other. We take pleasure not only in the growth of our patient but also in the ripple effect—the salutary influence our patients have upon those whom they touch in life.

If you make a mistake, admit it. Any attempt at cover-up will ultimately backfire. At some level the patient will sense you are acting in bad faith, and therapy will suffer. Furthermore, an open admission of error is good model-setting for patients and another sign that they matter to you.

Sometimes I simply remind patients that sooner or later they will have to relinquish the goal of having a better past.

III. On Being a Therapist (Fifth and final Edition, 2017) by Jeffrey Kottler.  

From the publisher’s blurb:

For more than thirty years, On Being a Therapist has inspired generations of mental health professionals to explore the most private and sacred aspects of their work helping others. In this thoroughly revised and updated fifth edition, Jeffrey Kottler explores many of the challenges that therapists face in their practices today, including pressures from increased technology, economic realities, and advances in theory and technique.

IV. When Therapists Cry: Reflections on Therapists’ Tears in Therapy (2017) by Amy Blume-Marcovici.

In addition to psychologist Blume-Marcovici, various other contributors comment not only on therapists crying but also on expressing other unexpected-from-shrinks emotions.

As therapist Julia Fraga writes (The Cut), “One study found that 72 percent of therapists have cried in session, suggesting that tears are the norm rather than the exception.”

From Blume-Marcovici (via Fraga): “I believe that the stigma associated with therapists’ tears comes in part from misunderstanding what they express. We often associate tears with weakness, lack of control, and a lack of professionalism, instead of understanding that they can be an expression of grief or an empathic response to the pain we see in others.”

V. Why Don’t Psychotherapists Laugh?: Enjoyment and the Consulting Room (2016) by Ann Shearer.

While I find this premise foreign myself, I do recognize that many therapists are humor-challenged, whether on purpose or innately.

According to the publisher, “Why Don’t Psychotherapists Laugh? is the first book of its kind about a neglected and even taboo topic: the place of enjoyment and good humour in psychotherapy.”

Sep 12

Over-Labeling: David A. Levy Spoof Gives It a Label

In the spirit of recognizing that things often defy easy categorization, I present an over-labeling (spoof) “diagnosis” proposed years ago by psychologist and professor David A. Levy in an article called A Proposed Category for the Diagnostic and Statistical Manual of Mental Disorders (DSM): Pervasive Labeling Disorder.”

The main symptoms and features of PLD are as follows: “(1) an uncontrollable impulse, drive, or temptation to invent labels and to apply them to other people, (2) a repetitive pattern of trying to fit people into preconceived categories, (3) an increasing sense of fear or inadequacy before committing the act, (4) an experience of overwhelming triumph or relief at the time of committing the act.”

Furthermore, “Persons with PLD operate under the fallacious belief that, by having named something, they have therefore explained it. Research indicates that many persons with PLD are exceptionally adept at seeing in other people the flaws they cannot see in themselves…”

And here’s the kicker: “…(M)any people have found a means to obtain reinforcement for this disorder in socially acceptable ways by becoming psychiatrists, psychoanalysts, psychologists, astrologists, Scientologists, evangelists, cult leaders, authors of self-help books, politicians, and interview guests on radio and television shows.”

Usually people with PLD remain undiagnosed until they’ve reached “a position of social power.” Furthermore, “(r)ecovery from PLD rarely occurs once the person’s annual income exceeds six figures.”

Other David A. Levy Quotes

On a somewhat related idea to over-labeling, David A. Levy is also known to have said, “There are two types of people in this world — those who think that there are two types of people in this world, and those who don’t.”

And let’s not stop there. Here’s a collection of other quotes from Levy’s lectures on “Humor in Psychotherapy” (2007):

  • There are three things needed to eliminate human misery. Unfortunately, nobody knows what they are.
  • When a psychoanalyst takes on the role of a blank screen, all he really learns is how the patient responds to people who try to act like they’re a blank screen.
  • To the optimist, pessimists are neurotic; to the pessimist, optimists are deluded.
  • I used to fear that taking medication would change my personality; now I fear that it won’t.
  • To be neurotic is to spend one’s life perpetually replacing one worry with the next.