The Unspeakable in Therapy. Frontiers Friday #170 ⭕️ (Part I)

What are the things that don't get spoken about, from both clients and therapists?

You would think that therapy would be the one place you can speak the unspeakable, and talk about the unspokens in one's life.

Unfortunately, this doesn't always turn out to be the case.

But why is that? Why is it that people find it hard to talk about the shadows in their lives, when therapy is meant to be the space and time to welcome and delve into these topics?

“Who do you follow?”

City Hall, Singapore. Victoria St was the place I used to roam when I would skip school.

When I first sought help around 16-17, in the first meeting, I said nothing about the specifics of my distress. In fact, I was so overwhelmed and inarticulate I hardly spoke in the first half. I proceeded to talk about the map on his wall, and asked about why that he hang it there; totally irrelevant to why I was there.

Thankfully, this person made room for my meanderings. He stayed with me and fostered an attentive patience that welcomed of all parts of me to come into the conversation. He talked about the map on the wall. He responded some more about my questions about him. This ultimately allowed me to talk about my troubles in our future meetings.¹

Said in another way, he listened to me into speech.

The profound impact of the help I received back then still ripples today. This experience was instrumental to how I got into this helping profession.

Some years later, when I started as a youth worker around 2001, and then got my credentials as a psychologist in 2004, the social and political landscape was nothing like today.

Not only is the divisive polarisation of politics seeping into the personal and relational sphere of our lives, I can’t even be sure if the person in front me is reading the same kind of news. Are we reading the same topics about the world today from an entirely different angle? Are we now the proverbial 6 blind men and the elephant, or are some of us hallucinating?

In fact, especially with the younger population, I found myself needing to ask, “Who do you follow?”² I press for specifics. On IG, TikTok, YouTube, etc. When I come across someone or some topic I’m clueless about, I’d have to look it up after the session. This was definitely not a question I would to ask 10-15 years ago.

A few years ago, a male client in his early adulthood told me he followed Andrew Tate. I could tell he was watching for my response, as he was hesitant to divulge. He added, “My mom keeps telling me to stop watching his BS…”

I have to tell you, I feel a visceral recoil in my body. I knew enough about this person he was talking about, and I was also worried if I was touching on an unnecessary landmine—or was it relevant?

This was supposed to be a therapeutic conversation, not an ideological debate. That said, it strikes me as something worth initially exploring.

“Hmm… well, you and I know about the controversy behind this person. I could see also that you were somewhat hesitant to talk about this… but tell me, what is it about what’s his stuff that clicks with you?”

He went on to describe about how he was a hot mess in his early teens, and there was something about “taking responsibility” i.e., get your shit together that appealed to him. He also mentioned following Jordan Peterson.

At the back of my mind, I kept Dr. Robert Closs, one my undergrad lecturer’s words close to me. “You have to earn the license to confront.”

I couldn’t evade the topic at hand, and neither should I invade and chastise him. In light of the therapeutic goal of his, which was wanting to foster better intimate relationships, two things was clear to me that we had to address:

1. The pre-changes he was already making when he experienced a sort of turning-points in taking full responsibility for his life rather than succumbing to a victim mentality based on his circumstances, and

2. How he relates with others, especially with the opposite sex.

It turned out to be a fruitful endeavour to up-pack this. He made a decision to clean up his act and live more healthily. At this stage, he wanted some help in therapy with some strategies in social situations. Later, he revealed he was also somewhat conflicted with the idea of what healthy masculinity means for him and wanted to explore that.

I thought about this, and how it could have easily gone south. Could the alternative be to evade talking about hot-topics?

Let’s pause for a second. Why is it relevant in our current cultural and political climate to ask, “Who do you follow?” Do you think it’s important?

Examples of the Unspeakables in Clinical Practice

I’m thinking, how many other clients that I do not know of, who didn’t get a chance to bring to speech, to share in conversation, some of the inner-stirrings and outer-politicisation that is swirling in our midst.

In a Frontiers Friday 167, I asked the question,

If you as a psychotherapist, and have been impacted by the political with the individuals you’ve worked with, I love to hear from you about this.

Therapist, Vivian Baruch replied with her Substack post, How an inverted world view has impacted my work as a psychotherapist. Worth checking out.

Given my experience in therapy and as a therapist, I’m curious about is how clients self-censor what they say in the room. This could be fear of how the therapist might react and how they might be judged.

Here are some examples:

- I have no interest in being being a career or being a "boss-bitch" or whatever. Through the work in therapy I actually discovered that I would like to be a “stay at home” mom for my kids. Would my therapist, who runs her own highly successful group practice—and does a marvellous job—think I am devaluing myself as a woman?

- I lost my job because I objected to taking the COVID vaccine. After lots of reading, I thought long and hard about it. This has impacted our finances at home as I’m the sole bread winner. I want to talk about why I made that decision in therapy, but I'm not sure if my therapist would thing I simply fell prey to the ‘conspiracy thinking.’ I'm not sure if my therapist actually understands the conscientious choice that I’ve made, as he has taken the vaccine and said previously in passing that he couldn’t understand why others wouldn’t “do the right thing."

- I know it sounds pedantic but I disagree with my work wanting me to add my pronouns next to my name in our virtual calls. This has landed me in abit of hot-soup at work for not being a team-player and standing up for diversity. As a woman, I do stand for women’s right…I'm not sure if I should bring this in therapy. Would my therapist think that I’m being too old-school and not keeping up with the times?

- I have strong religious beliefs, but my therapist made a comment before about his liking of Sam Harris’s work—and even recommended his app— but this public figure seems to debate against religion. I'm not sure if I should voice how much my spirituality plays in my life...

- I want to embrace what being a man means for me, as I didn't grow up with a guiding father figure. But I'm not sure if my therapist appreciates this viewpoint and not lump me into the meme of "toxic masculinity."

- I can’t help but feel unfair as an academic that the research grant went to someone else who met the diversity quota criteria rather than based on merit; I’m less likely to get that grant as a straight white male. I’m hesitant to bring up the specifics as my therapist is from a minority race in this country.

- I really love my wife, and want to make couples therapy work. But I'm not sure if my therapist is actually taking sides with my wife. I feel like the bad guy in the picture.

- I want to explore my sexuality, but I'm not sure if my therapist is open or equip on this topic.

- I have feelings of waves of guilt after the abortion. It was my partner’s choice… I mean, it’s her body and I respect that. But I’m can’t stop thinking about this. Will my therapist think I’m too obsessed with my own feelings, as technically I’m not the one who had the abortion?

What else? If you were in therapy before, were there things that you hesitated bringing up?

Therapy and Social Justice

Last year, The Free Press published an article titled, How Therapists Became Social Justice Warriors.

Many of the anecdotes were illuminating signs of our times.

One story stood out.

Lily Cooney was fully committed to social justice. In the wake of George Floyd’s death, the now-26-year-old writing tutor marched proudly in Black Lives Matters protests through the streets of Portland, Oregon.

But the culture in which she was steeped began to take a toll on her mental health. As a white person, she felt responsible for America’s racist legacy of slavery, and worried about her relationship with her Asian American girlfriend. “I felt like I was hurting her, harming her, just by being white,” Cooney told me.

Though she knew she was a lesbian, she began to identify as nonbinary, a result of her understanding that being a “cis woman” was “associated with colonization and white supremacy and oppression.”

But an incident on June 2020 shook her. She unleashed a tirade against the next-door neighbour’s friend, a white male who supported BLM but had cops in his family whom he supported, too. She said,

“I had this moment afterwards where I was like, ‘This is not how I want to behave. I don’t want to be a person who just screams at people because they’re white.’ ”

Her mental health spiralled, and had trouble concentrating at work.

“I started just going a little crazy.” She decided she needed therapy to work on both her “internalized white supremacy,” her “white guilt,” and to “become a better person.’ ”

In January 2021, Cooney sought help from a black therapist in Portland she found through a therapy database, who agreed to work with her around issues of race and gender.

Initially, they practiced mindfulness and self-compassion techniques, from forgiving oneself out loud to the “butterfly hug,” crossing arms and tapping the chest. The therapist even cried with her when she cried about sexual assault or feeling unsupported in relationships. Cooney felt supported and eventually, more in control, more accepting of herself as female.

This is why things started to turn in unexpected ways.

The stronger and more mentally healthy she felt, the less Cooney viewed the world through the lens that had informed her activism—a binary perspective that split all people into categories: white and black, oppressor and oppressed, victimizer and victim.

“I care about equality, I care about racism, I care about homophobia, I care about trans people being safe. I just don’t want to walk around in the world where everyone’s thoughts, feelings, and behaviors are dictated by their identities,” she said.

Cooney wanted to share her newfound realizations, but feared being canceled and ostracized—by her friends, fellow activists, perhaps even her girlfriend. The burden weighed on her, and therapy seemed the place to address it.

When she first tried to do so, in June, 2022, Cooney’s therapist reacted badly. She told Cooney that critiquing cancel culture was giving in to “white supremacy culture,” and said Cooney was making her feel “unsafe” as a black woman. By the end of the session, the therapist had given her an ultimatum: they could continue to work together and keep cancel culture discussions off the table, or “the relationship was over,” Cooney said.

Cooney continued with the therapist for six more months, but her therapist seemed to emphasize Cooney’s victimhood, reiterating that other people were responsible for her oppression as a gay woman. “She said, ‘You’re not free because of homophobia and sexism. You’ll never be free.’ ”

Cooney began pushing back, expressing views the therapist had declared taboo such as not wanting to categorize people based on their identities, or asserting that too many people were being shamed and punished for minor supposed transgressions. Finally, her therapist told Cooney their relationship was finished.

Ultimately, the thing she had feared the most—being canceled for her views—had happened, by the person with whom she was supposed to be able to share her deepest secrets. “I was just totally in shock, just kind of dead inside,” Cooney told me.

The Unspeakable from Both Sides

I doubt Cooney’s incident with her therapist speaks to the majority of therapists. By the sounds of it, Cooney had certainly gone on her own inner-journey and done the work. But what happens when our clients views expands and evolves, and God forbid, ours doesn’t? Do we just “fire” the client?³

On the flipside, as co-host of This Jungian Life and analyst, Lisa Marchiano alluded to the fearful landscape among those in the mental health field:

Good therapists are afraid to do good therapy. They want to get away from this topic altogether.

Marchiano was referring to laws and guidelines that prohibit exploratory therapy for people who are experiencing gender distress. Instead, therapists must provide ‘gender-affirming care.’

This means the therapist cannot explore possible sources of dysphoria such as traumatic childhoods, sexual abuse, and family homophobia. It’s also well-documented that many gender-dysphoric young people have numerous other mental health conditions that need addressing. These include autism, ADHD, eating disorders, and self-harm.

From my observation, I doubt most therapists I know would not explore issues in-depth and just blindly ‘affirm’ without discernment. But it is strange to observe where the West has been going.

Interestingly, under the Council for Choices in Health Care (COHERE), an uber-progressive country like Finland has came to a conclusion , which is quite different to the majority:

The first-line intervention for gender variance during childhood and adolescent years is psychosocial support and, as necessary, gender-explorative therapy and treatment for comorbid psychiatric disorders…

In adolescents, psychiatric disorders and developmental difficulties may predispose a young person to the onset of gender dysphoria. These young people should receive treatment for their mental and behavioral health issues, and their mental health must be stable prior to the determination of their gender identity.

Clinical experience reveals that autistic spectrum disorders (ASD) are overrepresented among adolescents suffering from gender dysphoria (all emphasis mine); even if such adolescents are presenting with gender dysphoria, rehabilitative interventions for ASD must be properly addressed.

Though this article is not about ASD per se, the last point is worth highlighting. A systematic review and meta-analysis was conducted in 2022 examining the overlap between autism spectrum disorder (ASD) and gender dysphoria/incongruence (GD/GI).

A good video explanation of this paper from Healthy Gamer channel, by psychiatrist Alok Kanojia, aka Dr. K.

In gist, this was what the researchers found:

1. If you have ASD or traits of it, you are 4 times more likely to endorse gender dysphoria/incongruence (GD/GI)

2. Flipping it around, for kids, if you have GD/GI, 3-21% of them will endorse ASD or traits. For adults, 4.8-7.8% will have ASD or traits.

This can be a challenging topic to discuss with clients facing gender identity issues. However, when it is relevant, this point must be raised, given what we know from empirical findings. As Dr. K in the video said,

If you're someone who struggles, who's been diagnosed with autism or has high levels of autistic traits, and you haven't really explored gender identity issues, but maybe this kind of manifests, this is kind of what I've seen, is that people with autism, sometimes this manifests as difficulties forming relationships.

And you may sort of think, okay, this is a lack of social skills, but sometimes what I've actually found is part of the reason that it's difficult to form romantic relationships is because there's some amount of confusion about my own gender identity.

If you've got gender identity variants, you should potentially get evaluated for autism spectrum disorder. And then the last thing is that if you're a clinician who's listening to this, I think it's really important because these percentages of comorbidity are incredibly high.

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Conclusion: Healing a Fractured World

I have to admit, I found this topic of the “unspeakable” difficult to coherently address. There are many pieces to expound without getting lost in the weeds. Meanwhile, I want to bring this back to the ground of the practice of psychotherapy.

Recently, a client came back reconnected for sessions. After the initial conversation, she revealed that she felt ashamed that she didn’t get to tell me about other stuff that was lurking in the background for her. She was making progress, and she felt affirmed by me for the developments and in turn, didn’t want to bring up the other stuff that wasn’t going so well. Weeks passed, and she didn’t book another appointment. I only got to learn about the stuff that she didn’t speak about when she returned after a year.

Once again, this made me wonder, who knows how many other of my clients didn't get to talk stuff that was “unspeakable” in sessions because I was not cognisant and perceptive enough.

To conclude, one therapist said,

Woke therapy weakens the client.

Woke therapy weakens the therapist too.

The world is fractured at this point. We need to find a way to speak the unspokens and the unspeakables. And let the healing begin.

My takeaway is this:

1. Climb down the ladder and move from the political to the personal. At times, we need to climb up that ladder to figure out how much of the political ideology is influencing the personal realm of their inner-life.

2. Learn to listen to the “will say,” “won’t say,” and “can’t” say—and allow our clients to take the time that they need to trust you.

3. We must be fiercely patient and gently challenging with our clients, helping them discover their original goodnesss, so that they can come alive and bring their gifts to others.

Let us continue to exercise consciousness, the ethics of rights, and the ethics of responsibility to the wide-ranging, messy and beautiful work when two minds coming together in conversation, of which we call psychotherapy.

When we look upon human life without the blinkers of preconception, we must conclude that both consciousness and responsibleness play the basic roles in the drama of existence.
…Being human means being conscious and being responsible.
Both psychoanalysis and individual psychology err in that each sees only one aspect of human existence—whereas the two aspects must be taken jointly to yield a true picture of man. These two schools would appear to be diametrically opposed to each other; but closer examination reveals that they are complementary, that there is a link of logical necessity between them.

~ Viktor Frankl, from The Doctor and the Soul.

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Reflection

“A little knowledge of the greatest things makes us happier than a lot of knowledge of lesser things.”
~ Aristotle? Thomas Aquinas?

Daryl Chow Ph.D. is the author of The First Kiss, co-author of Better Results, The Write to Recovery, Creating Impact, and the latest book The Field Guide to Better Results.

1. The First Kiss book, about undoing the intake model in psychotherapy was dedicated to this person.

2. Curiously, if someone asked you this question 20 years ago, “Who do you follow?” would sound more like “which cult group do you belong to.”

3. Some months ago, a friend told my that as soon as she was diagnosed with a complex mental health diagnosis, her therapist “ghosted” her (i.e., didn’t pick up her calls for booking further appointments and nil replies).