Reflections from the therapist’s chair
By Sarah E. Burgamy, PsyD
Every morning, I set up my clinical space — I have a penchant for the chair facing into the room, back to the door, window and outside world. As a true habitual creature, I place my Day-Timer (yes, Day-Timer…and a shameless plug for the merits of the Franklin Planner) in the back corner of the table between the chairs, grab a coaster (Type A much?), rest my coffee into its morning hour cockpit and prepare myself to ground out in this therapeutic space for much of the next eight hours. Day after day, year after year, it goes much the same.
In a way, I set this scene for two purposes; one, to offer some description of my daily base experiences as a clinician preparing to work with my clients each day, and, two, to convey something of the “normal” I have created and come to expect from most days, whether in my clinical chair or out in day-to-day life, running odd errands at odd times of day between clinical hours. I am sure many of you, my fellow clinicians, have found yourselves in something of a twilight zone since Nov. 7, 2016.
Personal political affiliations or leanings aside, the November election virtually hijacked the sacred clinical space with so very many of my clients. In my practice, I specialize in identity development, specifically along the lines of sexual minority/diversity competency as well as transgender and gender variant issues with adults, adolescents and children. Roughly two-thirds of my clinical caseload concerns folks who embody a target (see Hays, “Addressing Cultural Complexities in Practice, Second Edition: Assessment, Diagnosis, and Therapy”, 2008) status in these arenas of human identity. I work with children as young as 3 years old, along with their families, up to adults in their 50s and 60s. Here is a rough sample of the kinds of concerns and fears I have heard just before and since Nov. 7, 2016:
- “I am afraid we’ll be rounded up in camps, like the Japanese internment camps during World War II.”
- “I am more afraid more than ever to use the public restroom.”
- From a 13-year-old: “I just don’t go to the bathroom while I am at school.”
- From a parent of a 5-year-old, calling in a panic: “Should I go ahead and get [child’s name]’s passport and social security card changed to the other gender? We might only have a small window. I don’t know what to do. Should I do that just in case?” We had only barely begun clinical work together.
- From the parent of a 15-year-old, same panicked voicemail: “I know we don’t see [physician in Colorado with speciality competency working with children and adolescents with gender dysphoria] for another few weeks, but could you do something to help us get that DMV [Department of Motor Vehicles] letter signed? I want to make sure we can get [client]’s gender marker changed before it becomes impossible.” Tearfully: “I don’t want my child to suffer.”
- “I’m afraid my marriage [same gender] will be nullified.”
- “Now people will feel permission to hate me out loud and without being checked.”
- Client reacting to President-Elect (at the time) Trump’s cabinet appointments: “I don’t know how to feel better. Every time I think things can’t get worse, they do.”
I am certain many of you could add to my list. The things you have heard; the fears your clients have expressed. What do you say? It is generally considered a culturally competent best practice to validate “healthy paranoia” — some level of increased vigilance for target status individuals. In essence, fear of mistreatment, prejudice or oppression is real, even if covert, and some elevation of vigilance for one’s safety, both psychological and physical, is considered healthy and functional. Pertaining to gender identity work, this aspect of personal gender expressive presentation can be a fine line between healthy paranoia and maladaptive social anxiety. I know how to do this work with my clients. After Nov. 7, as a clinician, even I could not tell the difference at times.
What do you do when the world you have learned to expect — the one you have come to anticipate in all its imperfect glory, but reasonably predictable variation — suddenly turns on its ear? I found myself in very unfamiliar territory. The kind of territory where “expertise” has significantly exacerbated limits. In the days immediately following the election, as I heard some rendition of the above summarized comments on repeat, I found myself sitting more and more with how self-disclosure was or was not clinically relevant or necessary. How much disclosure was therapeutic; how do I maintain therapeutic distance or, better yet, be authentic yet manage countertransference? Even though I was accustomed to not having the corner market on assuaging anxiety and fears in people’s unique lives, I felt more without an anchor to assuage anything at this time. I had no more of an idea as to what the future held than did my client. What did people need?
Trauma theory or even models of grief processing were the closest theoretical scaffolding I could settle on to capture what was happening, in my therapy room, session after session, day after day, week after week, as November turned to the holiday season and a resurgence of anxiety and preoccupation with our nation’s political climate appeared once more nearing Jan. 20, 2017. At times, I disclosed my own surprise/shock, if it matched that of my client; I shared the uncertainty and validated their fear of the unknown. I made these decisions, case by case, and also discovered I had not actually allowed myself the time and space to process my own emotional and cognitive reactions to the political tide change. There are those times, when, as a psychologist, I find myself swimming — at times drowning — in the same ocean of collective experience as my clients. As a professionally out, identified lesbian and gender variant/queer/androgynous woman, some of the collective cultural experiences of my clients are also my own. But the timing of things is often not up to me. When something occurs — the Orlando Pulse nightclub shooting comes to mind — I am called to show up as clinician, to help my clients process their reactions, fears, anger, and make sense of the senseless. To hold space. Sometimes, these events occur so rapidly, or the reactions are so immediate, there simply isn’t the time and space to drop out of my professional role, just tell my clients to “hold, please” while I find a quiet space to absorb, experience and process my own human reactions. This has been a challenging time. I have spoken with other colleagues about similar sentiments. Consultation with colleagues, whether formal or informal, has been instrumental in this process.
So what I have I done? Many of you may be concerned that I’ve been sitting in my chair, my coffee long since gone tepid in temperature, swimming/treading water/trying not to drown in my own psychology. Fear not.
Back to basics: Part of the beauty of such a significant level of day-to-day worldview disorganization is the abrupt interruption of auto-pilot (see any mindfulness literature ever), and reinnervation of awareness. Ironically, the sudden life disorientation of many of my clients has also yielded a very powerful focus on personal values. In a way, some of my therapeutic guidance around coping with newfound stress and anxiety related to political climate has been to encourage my clients to passively absorb less — less social media bombardment, fewer auto-alerts from CNN, a reduced number of hours watching television network news. No, I have not suggested everyone go bury their overactive frontal lobes in the proverbial sand. Instead, I have borrowed technical psychotherapeutic “pages” from Acceptance and Commitment Therapy (ACT), Cognitive behavioral therapy (CBT), and a potpourri of psychodynamic theories and asked my clients to focus on what they value. To clarify what they believe is good, just and meaningful. To engage in behaviors that are deeply rooted in their most treasured personal ethics. In many ways, this period of time absolutely brought me back to basics. An emphasis on building self-efficacy in ways each individual has immediate and significant agency — persuasion over their own behaviors, and investment of energy and time.
In fact, I’ve also taken a note from my own psychological oeuvre and offered myself the time and space to get out of the office — go for a hike (I’m a Coloradan, after all), a walk, and just to stop and take several deep breaths. I sit on my porch and watch birds leap and flutter from limb to limb. Disruption exists; there appear to be definitive reasons to be concerned about the civil rights of my clients, for them to be concerned for themselves and their loved ones. But how to live a sustainable existence amidst all this uncertainty?