Problem: Low self-esteem

Tools Used: Cognitive Behavioral Therapy

Her voice had started strong and confident on the phone, but when I asked Batsheva what she was seeking support for, she got stuck.

“I don’t really know what I need. I just feel low-level anxiety and bad about myself, and I don’t know why.”

We booked a Zoom appointment. I missed the energy of shared space with my clients, especially getting to see them in “real” for the first time. I let Batsheva in from my Zoom waiting room, and a young, stylish woman with a long, dark sheitel smiled back at me. After a brief hello, Batsheva launched right in.

“I feel unsettled most of the time. I have, and do, so much, but I’m always feeling… off.”

“Batsheva, it’s really good that you’re attuned to what you’re feeling, even if it’s difficult to identify exactly what that is. Can you tell me anything in general that you’d want me to know about you?”

“I’m 28 years old. Married for eight years to Akiva. We have three kids — all girls — and I’m expecting our fourth in a few months, iy”H. I used to work as a sheitelmacher, but as Akiva’s business has grown, and the girls are getting older, I don’t work that much anymore.”

We continued a general intake that included a genogram of Batsheva’s family and some general medical and personal questions. As our initial intake session was coming to a close, I asked Batsheva what she considers to be her strengths.

She froze.

“I, uh… I don’t know really. I try to be a good mother and wife. But sometimes, you know, I get really overwhelmed…” She trailed off hesitantly.

“Being a good mother and wife requires a lot of strengths and skills, Batsheva.”

“Well, I don’t think I actually pull it off most of the time. It always seems like everyone else does it more easily? Better?”

“Tell me more about that.”

“Let’s say I make a nice supper. I’m always missing an ingredient or don’t plate it well or don’t time it well, or something like that. The food is just an example, this happens with everything, and I just feel like…” Batsheva’s face clouded over. “Never mind. I’ll tell you another time.”

“Okay. I’m glad you stopped yourself if you didn’t want to share, Batsheva. If you say something you’re not ready to share, it might negatively impact treatment, so I’m so glad you drew that boundary.”

Batsheva’s face cleared in relief, and we wrapped up the session.

The following week, Batsheva described that she was feeling good albeit with that “off,” almost sad feeling in the background.

“How long have you been experiencing this feeling, Batsheva?” Batsheva was currently in the middle of her second trimester, and I wanted to rule out any peripartum depressive and anxious episodes, and see if I needed to refer her to a doctor.

“For as long as I remember, but sometimes it’s stronger than others. I think it never goes away completely. It’s just a lot of self-doubt. I remember it more at certain times, like when I started high school, or seminary, my first job in a salon, when I was dating.”

Batsheva paused thoughtfully. “When I was first married and we moved, it was bad, and I think also it gets worse around the time of being pregnant or giving birth. See?” Batsheva laughed, sweet and tinkling. “It’s like all the time.”

I smiled. “Actually, it sounds more like it’s during high stress times or times of transitions.” I paused to let that sink in.

“Yes! You’re right. Like new situations cause this feeling to flare up a lot. Like they — employers, family members — are going to find out I’m a big faker. I don’t remember it so much during the quiet day-to-day.”

“So you mentioned self-doubt. Would you also call this ‘off’ feeling ‘sadness’?”

“No. Not like a depression. More like… ugh. It’s this thing again. I, um, didn’t want to share it.” Batsheva blushed.

The post Full Worth first appeared on Mishpacha Magazine.

The Problem: Challenging adolescent behavior

Tools used: Psycho-education on the teen brain, learning boundary setting, and empowering resilience

When Devorah called me, she sounded like she was at the end of her rope. She felt that the behavior of her third child, Miri, was out of control, and she couldn’t handle the family dynamic any longer. We scheduled an appointment with her and her husband, Yitzchak, for the following week.

Devorah and Yitzchak arrived with tentative smiles. After filling out the intake documents, they settled comfortably onto the couch.

“It’s so nice to meet you both,” I said. “I spoke with Devorah briefly on the phone, but can you tell me more about why you’re seeking support?”

Devorah looked imploringly at her husband. He gave the universal gesture of parental exhaustion: the temple rub. “I actually don’t know how we got here, because Miri is a good kid. It’s like it went from fine to completely unmanageable, but it’s hard to pinpoint exactly why. That’s why we pushed off getting help for so long.”

“We should’ve come two years ago,” Devorah said with a sigh.

“You’re here now and that’s a brave step. Do you mind sharing what’s making it feel so unmanageable?”

“Don’t misunderstand me. Devorah is an amazing mother. She’s dedicated and organized and everything generally runs well. Life’s busy, and the house is running okay, so I guess unmanageable isn’t the right word…” said Yitzchak.

“It is, Yitzchak. It’s so unpleasant at home, I don’t think I can manage it one more day. She’s generally at least somewhat respectful to you, but she has no filter with me anymore.”

“Let’s back up a bit. Can you tell me who’s in your family? As you talk, I’m going draw a genogram — that’s a simple pictorial diagram that will include your kids’ names and ages and anything you want to tell me about them.”

“Sure. So Gavriel’s our oldest. He’s 17. He’s a sweet boy, helpful when he’s around, loves to learn, and is in yeshivah most of the time,” said Devorah. “Shevy’s 16. She’s quiet and responsible. As a child she had some learning difficulties, but we got her extra help, and she’s doing fine. I mean, I hope she is. She’s never been the expressive type, but she toes the line, so I guess that’s a good thing.”

I nodded as I wrote, allowing the parents to choose their words and reflect on their children with thoughtfulness.

“Miri’s next, and she’s the impetus for our call. She’s 14.” Devorah looked weary just thinking about her. “I don’t even know how to describe it.”

“She’s rude,” Yitzchak offered. “Obnoxious. Entitled. But not always. She’s a firecracker. Funny and inventive. She can be very helpful and sweet one day and a tyrant another. That’s why we’re so confused.”

“Yeah, she doesn’t fit the typical rebellious teen profile at all. She does pretty well in school. Sometimes I get calls that she skipped class or she talks too much and is disruptive, but nothing crazy. But her attitude, especially at home, can be so unpleasant, and it affects us all.

The post The Teen Tightrope first appeared on Mishpacha Magazine.

Goals: Maslow's Hierarchy of Needs

Tools used: to reduce the sibling rivalry in HIndy's home

When Hindy called me one frosty January evening, I heard desperation in her voice. It sounded loud and frenetic in the background. She said she was calling in regards to her children, but couldn’t elaborate on the phone. I put her on my cancellation list for the earliest possible session as she said it was urgent.

The following week, Hindy arrived at my office five minutes late. She seemed harried and distracted as she took a seat.

I explained the intake process to Hindy and waited as she filled out the forms. When she finished signing the necessary documents, she looked at me and burst into tears. Horrified, she quickly grabbed a tissue and tried to gather herself together.

My heart constricted as I watched Hindy remove her glasses, swipe her eyes, and finally meet my gaze.

“I feel terrible,” she whispered.

I spoke softly. “It looks like you’re holding a lot of pain, Hindy.”

“I feel that I’m failing my kids. I can’t do it anymore,” she said.

“Do what?” I gently asked.

“The day-to-day is very hard with them. My husband helps, but he works a lot and learns at night. It’s mostly just me at home, and I’m failing my kids.”

“In what way?”

“The kids fight nonstop with each other. Like brutal fighting, all the time. If it’s not this one, it’s that one. I must be doing things wrong if my home is such a battlefield.”

“That sounds exhausting. Can we back up a bit? Can you tell me who’s in your family?”

“My husband, Shaya, is a contractor and runs his own business. We have seven kids ranging in age from two to seventeen.”

“Can I have their names and ages? You can also tell me anything you initially want me to know about each one.”

“Sure. Shmuel is 17. He’s away in yeshivah now. Rivky just turned 15 . She’s very helpful, a little bossy, and fights all the time with the one directly under her, Shayna. Shayna is thirteen and a creative type. She can be spacey, leibedig. She creates a lot of fun at home. Esti’s eleven. She’s sweet and quiet. I don’t like the dynamic between her and Rivky. They gang up on Shayna, which is weird because Esti is so much younger.

“Then there’s Yossi. He’s nine and officially has ADHD, just got diagnosed last year. He can be very difficult. Shimon is under him. He’s five. He’s a sensitive child, and also very active. The baby, Levi, is two. He’s adorable and a rascal. Shimon torments him.”

“Sounds like a beautiful, busy family, Hindy.”

“Baruch Hashem, but the fighting…”

The post Fighting Chance first appeared on Mishpacha Magazine.

The Problem: Trauma causing anxiety and panic
Tool Used: EMDR

Previously in Therapy Toolbox: Rikki came for treatment for a single-incident trauma. She’d had a kitchen fire and became crippled by panic and anxiety since. In the first installment (issue 696), Rikki learned about trauma and the brain, developed mindfulness practice, and learned panic-reducing strategies such as developing an imaginary safe space and other resourcing techniques. In the second installment (issue 713), Rikki learned about memory making, the basis of EMDR therapy, and practiced visualization and the EMDR eye movements.

The next week, Rikki came in determined.

“Abby, I’m ready. I practiced mindfulness, safe space, and deep breathing. I spoke to my husband about what I’ll need after this session for space and time to process if necessary, and I practiced my visualization. Let’s do this!”

I laughed. “You got it, Rikki. We can start today for sure. It’s great you’ve been so diligent in practicing all those strategies. First, though, how was your week in terms of your fire anxiety?”

“It was okay. When I cooked, I tried to visualize a successful outcome beforehand. And I think it helped. But I still have a knot in my stomach when I get near the stove. I just want to get back to normal.”

“Got it. It’s wonderful you’re back to cooking on the stove, even if it feels uncomfortable. Okay, let’s start the EMDR. Just remember: With EMDR, it’s the same rules as always. If there’s something you don’t want to talk about, or if you just want to take a break, it’s up to you.

“I’m going to move my hand back and forth, and I want you to stop me when you want. You can do it like this.” I put my hand out like a traffic cop to show her how to signal to me to stop. Rikki and I practiced EMDR on a smaller, less intense memory. For the first EMDR practice, it’s important to try something with a low level of distress. That way, you can get used to the EMDR process without becoming too flooded. Typically, I go chronologically with my clients, starting at their earliest memories and building up to the ones that cause the most distress.

Because Rikki came for a single incident, and she wanted the focus to only be healing this one, it was important that we at least try one “test run.” After we processed a low level, almost neutral memory (when she was cut off on line in the grocery store the other day), Rikki felt ready to go ahead with her target memory.

“Okay, Rikki, you want to target the memory of your kitchen fire. I’m going to ask you to do something a little different now. Just for a minute, imagine this whole event was a dream. If you had to go back into this dream, what would you need to feel safe?”

“A fire extinguisher… and my husband. My husband holding a fire extinguisher. Why are we doing this?”

The post Fear Ignited, Part III first appeared on Mishpacha Magazine.

The Problem: Trauma causing anxiety and panic

Tool Used: EMDR

Previously: Rikki came for treatment for a single-incident trauma. She had a kitchen fire and afterward became crippled by panic and anxiety. In the first installment (Issue 696), Rikki learned about trauma and the brain, developed mindfulness practice, and learned panic-reducing strategies — such as developing an imaginary safe space and other resourcing techniques.

Rikki was running late for session when my phone pinged. “Traffic. Kids sick. Dog ate my homework. Sorry. B there in 10.”

I laughed as I reviewed Rikki’s file. I was looking forward to hearing if she’d had a less stressful week since I’d seen her. Rikki bounded through the door, her energy tangible.

“Hi! So sorry,” she said breathlessly, as she collapsed onto the couch. “Crazy day. Week.”

“It’s okay. Catch your breath, take some time to land.” I handed her a water bottle. “Want a mindful drink?”

Rikki accepted the water. “Yes! I actually love this mindful thing. I did the candy exercise that you taught me with my kids. We actually did it with raisins. I didn’t tell them I do it with candy. It was a fun, calm activity for about four minutes before chaos descended again.”

“It’s awesome that you’re teaching strategies you’re learning here to your kids.” I paused while I watched Rikki take a slow sip of water and then begin to examine the bottle. After about three minutes of mindful drinking she looked up, clearer and calmer than before.

“Great job. So, how was the week?”

“My panic wasn’t terrible. I’d say it improved with the things I learned. But I feel a bit stagnant now, like as long as I don’t do certain things that trigger those memories, I’m fine and generally managing well. But what happens when I try to cook with oil or something again? I’m scared I’ll be back to square one.”

“Yes, could be. You’ve said that you were really surprised by the intensity of the panic — both right after the fire and also the extreme anxiety you feel when you think about the incident. Do you feel up to looking at that today?”

“Yes! I just want to be panic-free — able to cook normally and not fear the stove.” Rikki nodded expectantly.

“Great. That’s a really clear goal, Rikki. As we discussed, we’re going to try to treat the cause, what we’ll call core belief, of the problem, not just the obvious symptoms.

The post Fear Ignited: Part II first appeared on Mishpacha Magazine.

The Problem: Single incident trauma causing anxiety and panic

Initial Tools Used: Psychoeducation on how the brain interprets trauma and stress-relieving strategies, including mindfulness.

Rikki was back. When I saw her number on my caller ID, I smiled, recalling her quick wit and exuberant personality. I’d had a total of four sessions with Rikki to help her process job dissatisfaction and assist her in finding a different career trajectory (Therapy Toolbox Issue 669). In the six months since I’d seen Rikki, I wondered how her new administrative position was working out. Did she need more support in the professional realm?

We set up an appointment for the following week.

“Hi, Abby!” Rikki warmly sang out.

“Welcome back, Rikki.”

Rikki settled back into the same side of the couch she always sat, and immediately started fiddling with the small throw pillow next to her.

“How’s it been going since I last saw you?” I asked.

“So, the administrative hours I was given at school are amazing. I’m totally loving it. It was a bit weird at first, transitioning out of my teaching role into a new one. And a bit awkward with some of my colleagues.

“But it’s been fine since the first few weeks, so that’s good. I’m enjoying my teaching hours more than I have in the past, although not as much as I’m loving the admin work. I hope I’ll prove myself to the principal this year and she’ll have more administrative options for me for next year.”

“I’m so happy for you that it’s working! So…” I smiled expectantly. “If your career is on the upswing, what brings you to the couch this time?

Rikki giggled. “I know. Is it weird I came back to you?”

“What do you mean?”

“Like, I came for one thing, and now I’m coming back for something totally different.”

“Not at all. I’m glad you felt comfortable enough to come back. That’s great.”

“Okay, phew,” Rikki said, mock wiping sweat from her brow. “So I’m here for something very different….”

“The suspense is killing me!” I laughed, but felt a more serious energy in the air and sobered up. “Take your time….”

“So, it’s really strange. Recently I, um, started to have some really severe reactions to stuff.”

“Want to tell me about it?”

“Like, it kinda came up out of the blue. But a few months ago, I had a small incident in the kitchen. A pot of oil caught fire. It was fine, except I’ve been having serious panic attacks since then.”

“Alright, can we back up a bit? Can you describe what happened with the fire?”

“I wouldn’t even call it a fire. It wasn’t so dramatic. I was making sweet potato fries, and I filled my pot with oil, got distracted, and then it caught fire.” Rikki’s face darkened.

“You seem a little nervous now. What are you feeling?”

“See, this is what I don’t get! I mention it and think about it and my heart starts to race and I feel like I’m going to vomit.”

“What don’t you understand?”

“It wasn’t that big of a deal! I’m so embarrassed that I’m reacting so extremely. Like, I even get nervous when I use that pot for anything else, and I haven’t attempted using a sweet potato since then. It was scary in the moment, but we were able to contain it, and just had some smoke on the backsplash. The only lingering thing was the horrible smell of burning oil.”

I nodded. “Something did happen,” I said. “A pot burst into flames. Your brain interpreted fire as danger, which it is, and you become fearful of fire. Does that sound crazy?”

“No.” Rikki paused. “But everything was okay in the end!”

The post Fear Ignited first appeared on Mishpacha Magazine.

Presenting Problem: Leah and Yehuda come for help with their daughter’s difficult behavior.

Tools Used: Structural Family Therapy

Recap: The C. Family came into treatment to seek help in managing the behavior of their third daughter, Shevy. Shevy is at risk of being expelled and her attitude is affecting the entire family. Her parents, Yehuda and Leah, are in the process of learning Structural Family Therapy. While two of the older daughters came for a session, Shevy refuses to attend.

The following week, Yehuda and Leah came alone. After I welcomed them, they sat down and got right into it.

“Shevy refuses to come. We met with her principal on Monday. Shevy was there. We shared that we were getting family therapy help, but Shevy started to cry and said she refuses to come.”

“How did that make you feel?” I asked.

“Honestly, a part of me was relieved to see Shevy cry. It showed she actually cares about something. But I’m concerned that she won’t even give family therapy sessions a chance.”

“I hear why that may cause you some anxiety, but remember, the essence of Structural Family Therapy is to look at the whole system. An individual’s symptoms are best understood when examined in the context of family interactional patterns. Everyone’s behaviors are interconnected.”

“Right. I guess I just find that hard to believe.” Leah looked at Yehuda. “But I’m willing to give it a try. At the school, we made up a behavioral contract together, and the principal said as long as Shevy stuck to the basic conditions of the contract, and we continue to seek outside support, then she can stay in the school.”

“It’s good they’re not forcing her to come, but are still setting strong boundaries. How is it going so far?”

“Well, it’s only been three days, but it seems like there’s less conflict at school. I think she sees we’re really serious. She doesn’t want to leave her friends and have that type of record. Shevy sees we’re coming here, united. I think she’s scared.”

“It’s amazing what a little bit of structure and consistency can do. That’s the reworking of boundaries and alliances in action. How about the other girls?”

“They would’ve come back if we forced them. But they were less than enthusiastic. Is it possible for us to act like ambassadors for the family? Can we come and learn the skills and bring it home ourselves?”

“Yes. SFT can be done even with just one person. It’s better with more people for the reenactment of scenarios, but if you can record the most problematic incidents that happen at home, and we can do the processing and reframing here, then you can bring it back home to share with your kids.

“I’d recommend everyone be there for your family meetings. Even if the others are quieter or not directly involved, the purpose is a joining of the family unit and developing the family’s strengths, which involves everyone.”

Yehuda and Leah agreed that they thought this would be possible. They earmarked Sunday evening right after dinner for family discussions.

The post Shifting Pieces first appeared on Mishpacha Magazine.

Presenting Problem: Leah and Yehuda are at a loss over how to deal with their daughter’s difficult behavior.

Tools Used: Structural family therapy

I’d seen “Unknown Caller” on my caller ID for several weeks, but it was never followed with a message. I assumed it was a telemarketer, or a distressed potential client, who wasn’t entirely sure she was ready to commit enough to leave a message.

One day, the caller finally left a message, and the latter proved to be true.

The message was brief and stilted, something about wanting help for her daughter. I called back. I did a quick intake over the phone with Leah, and ascertained that she was under heavy pressure from her daughter’s school to find support for her daughter — or else.

I explained to Leah that I don’t generally see adolescents, as my practice focuses primarily on adults and couples. However, I could see her daughter as part of a family therapy structure.

Leah hesitated. I heard her exhale. “That’s what the principal actually suggested,” she tentatively offered. “This is my fourth daughter in the school, all of whom have struggled. Not as badly as Shevy, but the principal insists we try something different.” We set up an appointment for the following week with either Leah alone or together with her husband.

The Issue

Leah and Yehuda came into session bringing with them a heavy energy. They spoke little as they arranged themselves on the couch. Leah looked at her husband pleadingly.

“Welcome to both of you. It’s clear you care about your daughter and would like some support with her behavior in school.”

“Her behavior in general.” Yehuda was looking around the room, uneasy.

“Shevy’s behavior would be on the normal end of teenage rebelliousness if it wasn’t for school, I think,” Leah interjected. I thought I detected a slight eye roll from Yehuda. There wasn’t outright hostility between the couple. However, their body language and tone indicated they were on separate pages when it came to their daughter’s behavior.

“Okay, well, before we determine that, let’s back up a bit. May I ask you some more general questions about who’s in your family to get a bigger picture?”

Leah and Yehuda both nodded, and I was struck by how they were mirroring each other: their mouths in straight, tight lines and their brows creased. “So, what would you like me to know about your family?”

“We have eight children. Six girls and two boys. The oldest is 19 and the youngest is 3.”

“Wow, beautiful. What’s the order, names, and specific ages?” I started to sketch. “I’m just drawing a visual sort of map of your family called a genogram. This shows me the family really quickly, and is useful to reference who’s who. I’m placing you — Leah and Yehuda — in the middle, and I’ll write your kids names below. As we go along, I can add anecdotes or notations to this genogram to help contextualize the family.”

“Okay. Esty is 19, Rivky is 18, Sarala is 16, Shevy is 14, Dovid is 12, Rochie is 9, Shmuly is 6, and Rina is 3,” Yehuda offered.

“Great, thank you. Is there anything you think I should know off the bat about any of the kids? Like unusual or important dynamics?”

Leah looked over at Yehuda cautiously. “Well, Esty struggled for a couple of years with a minor eating disorder. She wasn’t hospitalized or anything, but we spent a good couple of years busy with that. Sarala has some sort of processing disorder. We don’t really know what, but she’s struggled academically for years. And I’m pretty sure Shmuly has ADHD, but Yehuda just thinks I’m looking for problems.”

“I think Shmuly is six and an active boy who just started first grade. I think he’s too young for us to make any judgments.” Yehuda sounded weary.

“Right.” I validated. “Six is young, but Shmuly is lucky to have a mom who is so attuned to his behavior in case some early intervention is needed. The transition from kindergarten to first grade is a big one, too.

“You said that Esty struggled, past tense. Where is she at now with her eating disorder?”

“Well, I suppose it never just goes away. I’m still worried about her. But her weight has been stable for two years now. We were fortunate that we could send her to a small, nurturing seminary in Eretz Yisrael, with experience dealing with cases like hers, so that was a huge brachah. She’s currently working in a preschool and is in shidduchim.”

I nodded and regarded Leah and Yehuda. They seemed a little more at ease, but the tension was still present.

“Okay, so about Shevy. Can you tell me what’s been going on with her?”

Leah and Yehuda both started to speak at the same time. Leah deferred to her husband.

“She’s angry a lot of the time. She doesn’t do her schoolwork, and she rarely helps out around the house. She spends most of her time with her friends, or with headphones in her ears. She’s failing most subjects, but doesn’t seem to care, and when the school tries to enforce their policies, she just outright ignores them.”

“Sounds like she’s having a hard time,” I offered.

Yehuda was incredulous. “She’s having a hard time?! She’s having fun. She’s doing exactly what she wants to do!”

“It’s Esty who’s having a hard time! Poor girl. She’s in shidduchim, and with her history, she needs a rebellious sister tarnishing everything like a hole in the head,” Leah burst out.

“I can hear why that would be anxiety-producing for you. Aside from general chutzpah and lack of regard for school, do you see anything else that concerns you?” I asked gently.

“Like a particular issue? Something as concrete as an eating disorder? No. But you should hear how she talks to us and her siblings. She’s completely out of control. She does and says whatever she wants. She even influences her older sisters, especially Sarala who is right above her. I think the younger ones are afraid of her.”

“I hear how that’s very distressing to deal with every day. What’s your main goal in coming here?” I ventured.

“Well, I have a feeling Leah just wants to get the school off our backs, but I’m seriously concerned.”

“Don’t make me sound like I don’t care about Shevy and her issues!” Leah retorted. “It’s just that we spent years of time, energy, and resources on a real problem for Esty! I don’t see why this has to be blown out of proportion.”

“Leah, do you think Shevy’s problematic behavior isn’t real?” I turned to Leah.

“What I meant was, it’s nothing tangible?” Leah responded. “I dunno, it’s just teenage stuff, no.”

“I’m not sure. I don’t think I could guess at what is motivating Shevy’s behavior right now. There could be a serious core, or maybe not. But I’d venture to say that Shevy isn’t happy acting the way she is.”

“She seems very smug actually,” Yehuda countered.

“Yes, she may feel like that, or it may be a defense mechanism, or maybe she’s gotten used to the negative attention,” I suggested. “But in her heart, I doubt she’s happy always being in trouble.”

“You’re probably right,” Leah said. She and Yehuda exchanged glances.

“You know, sometimes it’s hard to see the kid under all the tough stuff, especially if she’s acting aggressive or like she doesn’t care. We tend to want to protect others, like Esty in shidduchim with her fragile history, or the younger kids who may become influenced. But the fact is that under that tough facade is a 14-year-old girl who needs love, nurturance, and attention just as much as anyone.”

“I hear.” Yehuda nodded.

Leah looked down at her hands, her eyes misty with tears.

“Structural family therapy is a treatment that addresses patterns of interaction that create problems within families. It identifies family hierarchies, and looks at boundaries and subsystems or sub-relationships within the family unit. It’s a holistic approach that involves the whole family. Do you think your kids will join?”

“Well, maybe Esty. And I’m not sure if Shevy has to, according to her school. I know she doesn’t want to. It’ll be a battle to get her here.”

“A battle — for now — is okay. We can process that in session. Your kids don’t have to be thrilled to come, but it will be better and the treatment will be more effective. Bring whomever you can next week. I’ll explain this treatment model a little more, and depending on who comes, we’ll see how much we can go into it. How does that sound?”

“A bit scary.” Leah bit her lip. “What am I supposed to tell them? That our family is failing, and we all need therapy?”

“Do you feel like your family is failing, Leah?”

“I guess not failing. But it’s not working well. There’s conflict all the time, and Shevy is literally on the cusp of getting kicked out of school.”

“Do you think your kids are aware of the tension and stress?”

“How could they not be? They live in a battle zone,” Yehuda said, looking sad.

“So there’s a problem. Systems aren’t working well. Everyone is aware of the problem. How about reframing coming here as an opportunity to acknowledge what isn’t working and learn strategies so your family system can work and home can be a happier place to be?”

“It sounds good. I’ll try to present it to them like that,” Leah said and wearily reached for her pocketbook.

“The kids will probably pick up on your and Yehuda’s energy about this. If it seems catastrophic and embarrassing, then that’s how they’ll view it. If you’re more casual about it, then their anxiety will be manageable as well.”

Yehuda nodded and Leah looked miserable. We scheduled an appointment for the following week, and they got up to leave.

The Work

As the appointment approached, I was curious as to who would walk through the door. First came Yehuda, followed by three girls, and Leah behind them all. Yehuda tentatively smiled as I brought out more chairs and arranged them in a circle. Yehuda and Leah took their same places on the couch and two of the girls sat down on the chairs nearby. There was one who didn’t sit down. She had headphones in, her back turned to me, facing the door, arms crossed.

Shevy.

“Shevy, don’t be ridiculous. Come sit down right now.” Leah sounded irritated. I watched. Shevy made no movement to come closer.

“Shevy!” Yehuda’s voice was slightly raised. “Stop it and sit down.” The only response was the audible change of decibel of Shevy’s music. She was drowning everyone out.

“It’s okay,” I soothed. “Shevy doesn’t need to join us right now. She can take her space and time.”

“No, she can’t. We have to report to the school that she’s actually attending these sessions. We verified with the principal, and they really mean business.” Leah’s eyes were desperately searching Shevy’s turned back.

“Batsheva! Sit down right now or I’m going to rip those headphones out of your ears and throw them in the garbage!” Yehuda practically bellowed. Shevy’s sisters, silent until now, colored, looking mortified. Shevy turned around. Yehuda looked momentarily pleased until he was met with Shevy’s withering glance.

“I told you. I won’t talk with some random stranger about how crazy our family is.” And with that, Shevy turned on her heels and walked out the door.

Leah buried her face in her hands. The older-looking daughter, who I assumed was Esty, got up to chase Shevy, but Yehuda held her back. “You don’t always have to do that. Don’t run to make her feel better. Let her go.”

“I agree with your father,” I interjected. “Let Shevy go and cool off. Maybe she’ll come back today and maybe not. I’m so pleased to see you though. Esty? And? Rivka or Sarala?”

“Sarala,” she murmured, still looking like she wished the floor would swallow her whole.

“I need to see where she is,” Leah suddenly said, and angrily got up and walked out the door after Shevy.

“Well, this is embar—” Yehuda stopped himself, looking at his daughters. “Um, not how I thought it would go.”

“I understand that what just happened is distressing for all of you. However, from the therapeutic end, this is exactly what is supposed to happen.”

“What do you mean?” Yehuda asked cautiously.

“Well, we haven’t spent a lot of time discussing structural family therapy (SFT), but real-life interactions like this are actually the ideal. I want to wait until Leah is back to discuss it more. What do you think is happening out there?”

“Either they’re fighting or they’re not. Mommy will probably be back soon,” Esty mumbled. Sure enough, Leah walked back in, cheeks flushed.

“She’s walking back home. I didn’t want to make a scene on the street.” Leah sank back into the couch.

“Thank you!” Sarala burst out. “As if this isn’t bad enough, we don’t need to make it a public show.”

“I know, sweetie,” Leah soothed. “This is why we’re here, to hopefully stop these types of things from happening.”

“Leah, I don’t know why you chased her. I told Esty not to go….” Yehuda, though talking in a muted tone, sounded angry.

“I’m her mother, and I needed to see what she was going to do. If she was safe. I’m not a child, and I can make decisions as I see fit as an adult.”

Esty and Sarala exchanged desperate glances.

I chose to leave the adults’ discussion for now. “Leah, we were just talking about how what transpired, and even what’s happening now, is really essential and actually good for our therapeutic process.”

“How is that possible? The main subject of all of this isn’t here!”

“Well, yes, Shevy’s behaviors at school and her attitude at home certainly prompted your coming to session, but I bet there are larger family dynamics and relationships that Shevy just fits into. That’s the concept behind SFT. A child’s behavior is usually a result of certain family patterns or interactions.

“We’re going to look at the family structure as a whole, as well as everyone’s other, naturally occurring networks, like friends, extended family, school, work, etc., to identify areas of strength and weakness. Because the behavior of one family member can only be understood when examining the context in which it occurs.”

“Fine, but I can’t believe what she said, though, that our family is crazy!” Leah responded. “And that she has no shame to call you random in front of your face. You’d think she would care about making a normal impression.”

“Leah, I understand that what Shevy said and how she said it is upsetting. However, here the focus is much less on what’s said and more on how the interactions occur. Basically, less focus on content, more focus on process. When we look at the bigger picture — or the process — we can start to see patterns of interaction that are sort of universal in your family. These interactions are what we’re looking to change. So Esty, no pressure, but if you could, try to describe the process of what happened before.”

“Um, okay. Basically, we all came in, except for Shevy, who was being rude. Ma asked her to come, Shevy ignored her. Ta yelled at her, and Shevy left. I went to go make her feel better, Ta said no, and then Ma went to see where she went. And me and Sarala almost died of embarrassment in the meantime.”

“Wow! That’s amazing. Great summarizing, Esty. That’s exactly what’s meant by focusing on process — not the content, but the behaviors and general emotions. Just to go back to explain how we can make change, SFT uses three main techniques: working in the present, reframing, and working with boundaries and alliances. Some of the ways that we can work in the present in session is through enactment of typical situations at home. We actually didn’t even need to recreate something, because an authentic situation happened. So Esty just really beautifully ‘worked in the present’ by describing the process that went on.”

The Next Step

“I see,” Yehuda said. “So then we reframe that? What does that even mean?”

“Great question. Reframing is a tool for viewing negative and apparently ‘uncaring’ emotions as positive and caring ones.”

Leah was indignant. “Hold on,” she said. “There’s no way that we can pretend Shevy’s outburst was caring and positive.”

“You’re right. It’s not about pretending that behavior that was unacceptable is okay. It’s about looking at the core of the process. So for example, Yehuda, you were pretty angry.”

“Yes, I didn’t mean to have an outburst like that. It’s just that that’s how she acts all the time. And worse. I’m so tired of it.”

“Of course. I’m not criticizing your reaction. I was just naming your evident emotion. Were you angry?”

“Yes.”

“And where do you think that anger comes from?”

“Exhaustion?” Yehuda asked imploringly.

“Could be. But I’d venture to reframe that. What do you think if I’d say that your anger is more likely coming from love?”

Yehuda was silent, thinking. His wife and daughters were watching him closely.

“Maybe… I mean in the moment, I don’t feel an outpouring of love. But I suppose there are lots of different emotions — fear, sadness, and shame — but they all stem from the love I have for Shevy. I’m worried about her and what she’s doing to the family. I suppose if I didn’t love her, I wouldn’t care so much.”

“Exactly. It’s important never to justify anger in the name of love; the point of this intervention is to recognize the love underneath the pain and change how you react. And at the beginning, being able to name all those complex emotions is a wonderful place to start. There are probably a lot of different feelings that can happen simultaneously. It’s not about if they all feel positive or negative. Think of that more as the content, and the underlying impetus — in this case love and care — as the process. Can anyone else see the core of their motivations in what happened earlier?”

The girls looked down. “Leah?”

“Obviously, my going after Shevy was out of worry and care for her. I did want her to come back, and I did feel embarrassed, so I can’t say it wasn’t totally my motivation, but of course I wanted to know where she was going to be and if she would be safe.”

“Correct. Another response that comes out of love. Girls?”

“Well,” Esty started tentatively, “I wanted to go after Shevy. But I can’t say it’s because I cared about her. I’m actually pretty done with her behavior.”

“So what motivated you?”

“My parents. I guess it was out of love and care for them. I hate how she hurts them. I felt like maybe I could make it better.”

“So care was at the core. It’s not always about directing those feelings toward one particular person, it’s more about acknowledging that this family structure is often motivated by love and care, which is beautiful.”

Yehuda and Leah looked at each other meaningfully. I took that opportunity to move onward to the next stage.

“Esty and Sarala. We have a few minutes left, and I’d like to talk to your parents alone. Would you mind going to my waiting room, and then I’ll call you back for some closure?”

The girls looked grateful to have a breather and left the room quickly.

The Core

“The next part of SFT is about working with boundaries and alliances,” I explained to Leah and Yehuda. “While this is something we’ll look at in the whole family structure, it starts with the two of you. I’ve observed some frustration between the two of you over the fact that you aren’t always on the same page.” The couple nodded simultaneously.

“I’ve also noticed that you share the same goal of a peaceful home, that you care very much about all of your children, and you can both feel exhausted and overwhelmed with the circumstances.”

“Yes. That’s all true. Sometimes I feel very frustrated that Leah doesn’t take Shevy’s behaviors seriously enough or she just responds how she wants in the moment, which may be contradictory to how I would respond.”

“That does sound frustrating, Yehuda. When we feel charged with emotion, it’s really hard to step back and consider all of the different viewpoints and ways of reacting. Leah, how do you feel about what Yehuda shared?”

“I agree that we’re on different pages sometimes. Yehuda feels everything is a capital offense. As to reacting differently, I don’t know. It’s not like we have a system or something in place.”

“Excellent point, Leah! I think establishing a certain ‘response protocol’ would be really helpful. Something that you can compromise on and something that’s thought out before. I’m going to give you that for homework before next week. Can you sit together and identify some reoccurring behaviors of Shevy’s and concretize how you could both respond?”

“We could try.” Yehuda looked at Leah, who nodded in assent.

“There are many reasons why reestablishing alliances and boundaries is so important: Shevy will see you as a unified unit and know what to expect. Consistency is crucial for a sense of personal emotional safety. She won’t be able to play one against the other. You’ll both feel more supported and less isolated, and the other children may not feel as anxious about whatever is happening in the moment and feel like they have to fix it — as Esty demonstrated today. Sound good?”

“Yes,” Leah said. “We’ll work on this together for next week.”

“Great.” I opened the door and invited the girls back in. “As we wrap up, can someone share how they’re feeling?”

“I’m feeling hopeful. I like what you said about us being motivated by care and love.” Yehuda’s voice was steady as he spoke.

“I’m honestly still feeling overwhelmed, but definitely more positive than before,” Leah shared.

“I don’t know how I’m feeling. I kinda just want to go home,” Sarala ventured.

“Totally understandable. This was an intense session. Esty?”

“I think this process is interesting, I just don’t know if it’s going to work.”

“I hear that, Esty. There are a lot of different moving parts. Right now, it’s about committing to the process and seeing where it can take us.” Esty smiled slightly, and they all got up to leave. We booked a session for the following week.

I was curious to see who was going to attend. It would be ideal to have Shevy come back, but I had a feeling it would take a few weeks, or a serious threat from the school, until I saw her again.

Due to the fact that there seemed to be many different dynamics and a range of ages and needs in the family, it would probably take some time to see progress. I was confident, however, that due to Yehuda and Leah’s willingness and the openness of the children I’d met so far, that this family was going to be able to make real changes and start looking for solutions, communicating appropriately and sticking to boundaries, ultimately creating a safe and harmonious environment for everyone.

A continued, in-depth look into the family’s treatment with SFT will be explored in the next column.

Abby Delouya maintains a private practice in Montreal and works in schools as a youth and addictions counselor.

Disclaimer: This article is for psycho-educational purposes only, not diagnostic purposes, and does not serve as a replacement for individual therapy. Situations are a composite of people and situations and all identifying details have been changed.

(Originally featured in Family First, Issue 678)

The post All in the Family first appeared on Mishpacha Magazine.

Presenting Problem: Rikki doesn’t know what her next steps should be professionally.

Tools Used: Career counseling strategies and motivational interviewing

It was a humid summer morning when I first met Rikki. Her cheeks were flushed and her sheitel somewhat sticky.

“Hi! Water?” I offered as an opener, handing her a chilled water bottle.

“Yes! Thanks. It’s brutal out there. Thank G-d for a/c.” Rikki made a brachah and took a long sip. “Phew. Okay. Now I can focus. Hi!” she said with a smile that reached her dancing eyes.

“Great to meet you, Rikki. Why don’t you tell me why you’re here?”

“Well, basically, I have no clue what I want to do with my life,” Rikki said with a laugh. “I did the typical: seminary, clepped a BA, and then went into teaching. Got married, had five kids in eight years.” She paused. “I’m so blessed. Everything went smoothly, baruch Hashem. My husband is still learning, and my kids are great.

“The fact is that my husband is still in kollel and while he tutors to make some extra income, I need to work. However, I can’t see myself teaching anymore. It takes up tons of energy. I teach fifth grade, there’s lots of prep and marking, and I don’t have to tell you that the salary isn’t exactly plum. I’m bored, and my students sense it. I’m dreading the start of the school year, but I don’t know what else to do.”

“That’s a difficult place to be in.”

“Yeah. Any idea what I should do?”

“Rikki, I’ve known you for approximately three minutes!” I said with a smile. “Also, this process isn’t about me dictating to you what I think you should do. I can definitely help you and give suggestions, but this is about you discovering more about yourself, what you excel at, and what works for your family. Through different questionnaires and also a technique called motivational interviewing (MI) I’ll hopefully help you get some clarity.”

“Shucks. I thought this could be like a one-time ‘Hi, tell me what to do, okay, bye’ session.”

“I’m not sure there are any good or ethical therapy sessions that look like that. So now that you know more about what the process requires of you, do you want to do the work together?”

“Yes. I was kinda joking. Kinda. What’s that motivational interviewing thing you mentioned?”

“Okay, so motivational interviewing is a way of working together that’s goal-oriented and focused on your strengths and interests.”

“But I don’t know what those are.”

“Correct. That’s one of the reasons you’re here. Although I’m certain you can name some strengths right now.”

“Well, I know that I’m a good, solid wife and mother. But I can’t exactly get paid for that. Although if I could, then it would be the best gig ever.” Rikki giggled. “Imagine — I wonder if I’d get paid a salary or per laundry load?”

“Yes, that would be awesome, Rikki. However, as of today, no one is paying you for the countless hours of hard physical labor and emotional energy expended for your family,” I said with a smile. “It’s excellent that you can so easily identify your strengths! There are so many individual skills and abilities wrapped up in the roles of wife and mother. It’s a great place to start.”

The post Her Career Was at a Crossroads — Now What? first appeared on Mishpacha Magazine.

Goals: To help Sarah overcome her Internet addiction

Tools used: Reality Therapy

Recap from Toolbox 7 (Chained) : Prompted by her husband, Sarah came to therapy for her technology addiction. She scored high on the Internet Addiction Test (IAT) and eventually came to accept that her phone and Internet use were making her life unmanageable. She joined an online 12-Step support group and was committed to trying to maintain sobriety, one day at a time. Sarah’s husband, Chaim, joined a Codependency 12-Step group, and sought help from a therapist. Sarah commits to regular therapy as part of the process of understanding what fueled her addiction.

One day, about two months after I first started seeing Sarah, she had a relapse.

“I don’t understand. I work so hard, I do the stupid meetings, I’m coming here, I’ve made tangible progress, and this happens!” she said. Her chest heaved from emotion and her fists were clenched. “It’s ridiculous. I know tons about addiction. We’ve spent so much time talking about it. And I saw it coming, but I couldn’t stop it. I told myself it wouldn’t happen, that I’d be fine.”

“Sarah, why don’t you back up? Start from what happened since I saw you last.”

“What happened is that I got a flier in the mail with an amazing offer on a new phone. I hid it, but it felt like it was burning a hole in my purse. So I went to the kiosk in the mall that had the promotion, and I got a new phone.”

“Okay…” I ventured.

“Then I told Chaim I was having a one-day training workshop for my job and checked into a hotel so I could surf uninterrupted. I barely brought enough food, but I didn’t care — I didn’t need anything else. I felt like I had my oxygen back. I was up the whole night. The only problem was that my coworker called looking for me in the morning for something stupid, and she totally blew my cover.”

Sarah paused, waiting for my reaction.

“Oops. What happened next?”

“Chaim called me all hysterical. We got into a huge fight. He’s barely been speaking to me since. And I had to get rid of the phone, and pay a huge penalty to get out of the contract.”

“Okay. Then what happened?”

“Abby! When are you going to react? Tell me what I deserve to hear?”

“What do you mean?”

“Why don’t you just yell at me? Tell me I’m wasting your time? That I’m a horrible mother and wife, and I should just get divorced and leave everyone well alone…?” Sarah’s voice cracked, and for the first time, I saw she was fighting tears.

“You know what the literature says. You’re sick, not bad. You’re struggling with an addiction, and you had a relapse. I honestly don’t think relapse has to be part of the process, but it’s certainly not anomalous. All your hard work didn’t disappear in those 24 hours.”

“Then why does it feel like that?”

“Does it?” I challenged.

“Yes. No. It doesn’t actually, but the shame I feel is suffocating, and Chaim’s being disgusting to me. He barely acknowledges when I walk into the room. He told me he’s ‘detaching for his serenity,’ but he could try to be nice!”

“It sounds like you feel rejected.”

“Rejected. Embarrassed. Worthless. Yup, that’s me. A real loser.”

“Hold on, Sarah. Before you get into self-deprecation, I want to back up. You said that you ‘saw it coming.’ What does that mean?”

“I didn’t totally know this would happen. But I felt myself getting itchy. Losing some steam, I guess. Two words: family simchah.”

“There was a simchah that was difficult for you?”

“All family simchahs are difficult for me. There’s a reason I live here in Montreal, and not near my family. But I couldn’t avoid this. My grandmother had her 90th birthday. I had to go in. And it was a disaster, as predicted.”

“It’s interesting that you didn’t mention anything about it in session. Do you know why?”

“I didn’t feel like getting into it. It’s so exhausting. And…” Sarah trailed off and her cheeks colored slightly.

“And… you didn’t want to tell me so we wouldn’t discuss a game plan so you could feel justified in acting out?” I said lightly, knowing the answer.

“Exactly. Isn’t that horrible?”

“Sarah, let’s take a break from all the criticism. Remember, behaviors like this are just a symptom of a problem, not the be-all, end-all of your personality. So, you know that family events are a trigger. Can you share a little bit more about why?”

“I’m really not in the mood to go there today. I feel so drained from everything.” She looked utterly exhausted.

“No problem. Do you want to talk more about what’s going on with Chaim at home?” I asked gently.

“Yes. I get where he’s coming from. He was so hopeful, and then I lied to him and went behind his back. But I wasn’t trying to hurt him. I wasn’t thinking about him, actually.”

“Right,” I interjected. “And that probably hurts him a lot.”

“I know. I hear how bad that sounds. But I have needs, too! He always makes it out like I’m the bad one, the selfish one, the one who needs to make amends. And I get it, I have to make it up to him and the kids. But what about me?”

“So, you feel that some of your needs are going unmet? Let’s talk about those needs. What do you think your basic human needs are?”

“Um, happiness?”

“Yes, but that’s very broad. Let me rephrase it. There were probably needs that you had as a child that may have gone unmet, and those may match the needs you have now that are going unmet.

“It’s likely that one of the main driving forces for your addiction is to fill these needs. So, what needs are fulfilled for you when you go online?”

Sarah spent several moments thinking. “Fun?”

“Yes, that’s one.”

“Freedom.”

“Good!”

“Belonging and acceptance?”

“Excellent, Sarah! You could add ‘love’ to that, as well.”

“Wait, this is a thing.”

“Yes, it’s actually ‘a thing.’ It’s called Reality Therapy, and it was conceptualized by a psychologist named Dr. William Glasser. The premise is that psychological issues and stress occur when our basic human needs go unmet. The theory is also pretty solution-focused, as it reinforces the fact that when we choose to change our own behavior rather than attempting to change someone else’s, we’re more successful at attaining our own goals and desires”

“Okay, so how many needs are there?”

“There are five. You already guessed three of them. Let’s break them down a bit. Fun is feeling a sense of satisfaction and pleasure; freedom is being independent, maintaining personal space and autonomy. Belonging and love is to feel part of a family and/or a community. There are two more needs: power, which is a sense of achievement or a sense of self-worth; and survival, which is food, shelter, etc.”

“That makes sense. So you’re saying when someone doesn’t have one of those needs met, then they can become addicts?”

“More accurate is when at least one, but sometimes all of those needs don’t get met on a consistent basis, we try to create those feelings for ourselves in potentially maladaptive ways. So, let’s say you’re feeling ostracized by your family, but you have unconditional acceptance in your online group or forum. Obviously, you’d seek connection with the person or people who are meeting your needs. Or perhaps you feel controlled or without as much personal choice in your life as you would want. You find freedom online where you can assert yourself on your own terms.”

“I totally get it. But there’s one problem… I never actually feel better after going online in a binge.”

“Correct! That’s because it’s maladaptive. The autonomy or belonging there isn’t the true freedom or connection you crave. It’s superficial and fleeting, but does fill a need in the moment. The goal of Reality Therapy is to be more aware of any negative thoughts and changing your actions so your needs are met in a healthy way.”

“So, with my Bubby’s birthday, I should’ve focused on what needs would go unmet there and then found better ways to fill that void?”

“Yes! Sarah, you’re really insightful! For homework, can you think of more specific needs within those categories and how you could meet those needs in a healthy way?”

“Okay! You know I hate homework, but I’ll at least think about it.”

“Great!”

Sarah and I scheduled a session for the following week, and she left looking less troubled than when she came in.

As Needed

When I saw Sarah the following week, she handed me a piece of paper.

“What’s this?” I inquired.

“I wrote down a few thoughts about my needs, and it ended up taking me back to some childhood stuff. I thought instead of avoiding it, we could look at it together.”

“Fantastic.” I handed the paper back to Sarah. “Why don’t you read the parts you want to share?”

“Um, okay. Well, the first thing that came to me was belonging. I never really felt comfortable at home. I have three sisters and two brothers. I’m the youngest, and the girls came first, then the boys. I have early memories of my sisters playing dress up with me. I was essentially their doll.

“But as I got older and developed a personality of my own, I suddenly had three additional mothers. They were always bossing me around and being critical of every little thing. My mom would sometimes intervene, but she was a little overwhelmed with the family, and later with her work commitments. She was just grateful for all the help my older sisters gave her so she didn’t step in too much. I got along well with my brothers, but then they went away to yeshivah, and there went my allies.”

“So you never felt part of the sister dynamic?”

“Exactly. I was either a source of their bonding, like the ‘what to do with Sarah’ conversations when I started acting out a bit as a teenager, or totally excluded. By the time I was bas mitzvah, my oldest sister already had two kids, and the next one was a kallah. They'd show up at the house and just expect me to do all the work or help with their kids as ‘payback’ for all they'd done for me when I was little.”

“That does sound both alienating and frustrating. Has it gotten better now that you have kids of your own?”

“No. We have this family chat, but I never post. And six months ago they went on a sisters’ trip to Florida. They told me like two days before they left — clearly an afterthought — and asked if I wanted to join, but it was so half-hearted, I'd never have gone with them and embarrass myself like that. And of course, Bubby’s celebration was planned to a T by the incredible trio, and got lots of praise and accolades from my mother. I was asked to bring cookies. Thanks very much.”

“By being excluded by them, it sounds like you’re missing out not only on belonging, but also on feelings of self-worth and fun.”

“Yes! And believe me, I’ve tried to talk to them. I know this is an issue and have tried to work it out in therapy before, but they don’t even hear me. They either wave it off or tell me that I’ve always been a spoiled brat.”

“That’s really painful, Sarah. I’m just thinking back to some of the things you’ve shared about Chaim and when you feel the most resentful toward him. It’s usually when he’s shutting you out. While that’s never a pleasant feeling, I’m wondering if it’s exacerbated by your history with your sisters. Perhaps old deep wounds are being activated in the context of your marriage? What do you think?”

“Yeah, I agree. Sometimes I even feel that way with my kids. It’s embarrassing to say, and I know it’s not logical, but when they want to do something with Chaim or go off with their cousins or something, I usually feel rejected. And then I feel stupid, because of course I want my kids to be happy.”

“Well, remember that emotional wounds and triggers are not necessarily logical. Often, they’re not part of the rational part of our brains, and so it would be excellent not to judge that reaction. Instead have compassion for yourself, or rather that ten-year-old inner child who may be kicking and screaming and feeling left out.”

“Okay, so I just sit here and have compassion for myself. What next?”

I laughed. “It’s not just about sitting around. At the heart of Reality Therapy is the idea that we can’t control others or change our pasts. The central question really is: What can I control about myself?”

“Uch, I hate control. Well, I mean I love it, but I hate when people try to control me.”

“Right. It gets problematic when people try to control other people, or when people use addictions — substances or behaviors — to give them a false sense of control. Obviously, there are many things that are out of our control, but healthy control means deciding how to respond to life events, and how to be in relationships with others in a mutually satisfying way because of the behavioral decisions you make.”

“Okay, so how do I deal with all the hurt and stuff with my sisters?”

“Well, from this perspective, the past shows us your wants and needs — to feel part of the sister dynamic — and it shows us that you respond to rejection by seeking control in unhealthy ways. Learning from that, you can decide what and who you want in your ‘quality world.’ Your quality world is an ideal, yet realistic depiction of your life.”

“How do I create this quality world?” Sarah asked curiously.

“Excellent question. What it means is taking an experience, past or present, and then focusing on how you can think or act differently in that situation, with the ultimate goal of connection in mind. Ask yourself: Is what I’m doing getting me closer to the people I need?”

“Wow, alright. So what does that look like with my sisters?”

“What do you think it looks like with your sisters?”

“I guess instead of dreading Bubby’s birthday and expecting them to leave me out, I could’ve been proactive a few months before, so I would’ve had more opportunity to be involved.”

“Yes! How do you think that would've played out?”

“Well, that’s the problem. I don’t trust that they would’ve responded properly and actually included me.”

“That’s a good point. There’s a risk that the positive action you take and the change you make will be rejected if the people you’re trying to reconnect with aren’t safe or stable figures in your life. This is where judgment and instinct do come into play. Developing your quality world has to be realistic, which means accepting that you can’t change others, only yourself. However, is it possible that from their perspective, you were never that interested in connection, and they may welcome a reframing of your adult relationship?”

“Maybe.” Sarah was lost in thought. “It’s hard to go there. There’s a lot of pain accumulated over many years.”

“Okay, so who is safe to practice that question with?” I asked Sarah.

“Chaim. I think Chaim’s safe. He also makes sense to work with because it’s a more present, daily relationship. So, do I have homework for next week?”

“Why don’t you keep a journal of a couple of interactions with Chaim, and if they were difficult, or even neutral, ask yourself, ‘What am I doing to make myself more connected to Chaim?’ ”

“Why do I recoil at the thought of asking myself that? It’s not like I have a bad marriage. I mean outside of all of this addiction stuff, we have a good relationship. I love Chaim. He’s a great person. But that question makes me cringe.”

“Totally. Emotional vulnerability can be cringeworthy when you’re not used to it. When you’ve had a long history of disconnection, or illusionary connection on the Internet, real connection may be difficult to achieve without a concerted effort.”

New Paths

“Okay, I’ll try it for this week and report back.”

The following week when Sarah walked in, she was practically triumphant.

“You won’t believe what happened!” Sarah breathed as she fell onto the couch. “I shared what you told me in a meeting and made an accountability arrangement with my sponsor to encourage me to do the homework.

“I got in a fight with Chaim over something. I don’t remember what. I think something to do with the kids. It was a total battle of the wills. And after some heated words, I got up and went into my room to grab my phone. I was just about to log into one of my chats, when I asked myself, ‘Am I connecting or disconnecting?’ I put down the phone and went to speak with Chaim. We worked it through, and the night was totally saved. It actually felt amazing!”

“Wow! That’s fantastic! On an emotional level and also on a neuro-biological level!”

“What does that mean?”

“Remember early on, in our first sessions, we discussed how your brain has been rewired to seek pleasurable reward feelings from your activities on the Internet?”

“Yes, you described it like a well-worn path. It’s an easy road to pleasure town.”

“Exactly. So, now, with this new, healthy interaction, you started paving a new path. It might feel like an overgrown jungle now. You may have to whack through some plants and trees, but eventually, it’ll become as comfortable as that other path. Our brains are super adaptive. The new, healthier route will soon replace the old one, if you keep taking positive action and taking charge of what takes place in your ‘quality world.’ ”

Sarah and I focused on her relationship with Chaim and her children each week. She practiced staying in the present and being in control of her current behaviors. This was all complemented by her 12-Step work and commitment to recovery. At this point, she’d connected to an all-female, frum 12-Step group for help with Internet addiction, and though it was based in New York, she went on two weekend retreats to connect to her fellow members and meet them face to face.

While she did have to confront her past in the course of her 12-Step work with her sponsor, which included making amends to her husband and children, she was able to balance the processing of her past with taking positive action in the present. Instead of blaming her past or using it a reason to justify acting out, Sarah used it as a tool for self-improvement and to provide information on how to develop her quality world and make positive choices.

One day, about a year into us seeing each other, Sarah came in with a big smile, her face clear and open. “Guess what? I’m going to Miami for four days.”

“That’s fun! When?”

“It’s more about with who… my sisters!”

“Wow! How’d that come to be?” I was delighted.

“I asked them if there was going to be a sister trip again this year, and then we started planning one altogether. I can’t say I’m not a little nervous. Our work has mostly been just about me or Chaim and the kids, but I feel strong enough to give it a try. I realize there may be moments when I may feel triggered, but I’ll go to an AA meeting there if I need to, I have my phone meetings and members to reach out to, and I have the tools to care of myself.”

“That’s incredible! I hear so much recovery and self-awareness. Amazing!”

She walked out of session that day grounded and happy, the complete opposite of how she presented one year ago.

Sarah’s journey continues, and I still see her at least twice a month. The depth of her progress and recovery was evident last Motzaei Shabbos at 11:48 p.m., when my cell pinged.

Hi Abby. Gut voch. Sorry to bother you, just wanted to let you know that the trip with my sisters was a success, and I didn’t even have an emotional crash when I came home. I spent Shabbos reconnecting with Chaim and the kids, and I just turned on my phone — three hours after Havdalah! I can honestly say that for today, I feel serene and an incredible sense of personal freedom.

I sat there, reflecting on how adaptive and resilient human beings are, and I was both humbled and inspired by Sarah’s journey.

Abby Delouya maintains a private practice in Montreal and works in schools as a youth and addictions counselor.

Disclaimer: This article is for psycho-educational purposes only, not diagnostic purposes, and does not serve as a replacement for individual therapy. Scenarios are a composite of people and situations and all identifying details have been changed.

Reality Therapy

There are several different interventions that can be useful when treating addiction. The Stages of Change framework (which I used with Sarah at the beginning of our treatment, see previous column), Motivational Interviewing, and Reality Therapy are the three most widely used interventions. They tend to be solution focused, yet require a lot of empathy, understanding, patience, and client empowerment and insight.

Reality Therapy is most effective only after a strong therapeutic alliance has been formed; in fact, this connection is considered by reality therapists to be the most important dynamic in facilitating healing.

Those in therapy can learn how to best strengthen relationships outside of therapy while in the “safe” therapeutic relationship, and as a result, be able to more easily expand on those methods in daily life.

By the time I introduced Sarah to the concept of Reality Therapy, she’d been coming to session for several weeks and there was a tangible connection and sense of safety and trust that had been developed. Part of Reality Therapy is to avoid blaming, criticizing, and judging. This is to model healthy external relationship behaviors that develop connection and also to focus on taking positive action for effective change.

An important part of Reality Therapy is the client’s constant evaluation of her current behavior, both to gain insight and to allow her to make her own judgments about her life and relationships, thereby exercising healthy control over her life.

Make it Yours

Want to bring Reality Therapy into your own life? Here are some questions to ask yourself:

1. Am I feeling upset/sensitive/angry because my needs are currently going unmet?
2. What needs are lacking? Freedom? Belonging/Love? Fun? Survival? Power?
3. What positive action can I take for myself, knowing that I can't control others?

 (Originally featured in Family First, Issue 659)

The post Quality Control first appeared on Mishpacha Magazine.