Movies: "A Fantastic Woman:" Maintaining Dignity and Self Respect in a Hostile World

Sebastian Lelio's film, "A Fantastic Woman," which has been nominated for the Academy Awards Best Foreign Film category, is about a transwoman, Marina (wonderfully portrayed by Daniela Vega) and her perseverance in maintaining her dignity and demanding respect as a human being, despite the grief of losing her romantic partner and dealing with prejudice and harassment.

Movies: "A Fantastic Woman:" Maintaining Dignity and Self Respect Despite a Hostile World 

Marina and her boyfriend, Orlando (portrayed by Fernando Reyes) live together in Orlando's apartment in Santiago, Chile.  They are a happy, loving couple who are kind and generous to each other.  But one night Orlando gets sick suddenly and Marina takes him to the hospital.

Within a couple of hours, Orlando dies from a brain aneurysm.  Alone with no one to console her at that point, Marina deals with the shock and grief on her own.

Since she fears losing her job as a waitress if she does not show up, she goes to work that day and acts as if nothing happened while her heart is breaking.

She also has to deal with close-minded hospital staff, abusive police officers and Orlando's emotionally and physically aggressive relatives who don't understand why Orlando, who was married before and has a young child, was with a transwoman.

We don't learn a lot about Marina's personal history or much about her family background, except that she has a sister and brother in law who take her in after Orlando's family kicks her out of Orlando's apartment after his death.

We do learn that she has not received her identification card yet indicating that she is a woman so, as far as the outside world is concerned, she is a man.

She is also subject to humiliating and degrading acts by the police who, ostensibly, want to "help" her in case she was abused in her relationship with Orlando (despite the fact that she tells them that she was not abused).

The one bright spot in her life is her love of music and singing.  And, despite all the obstacles that are thrown in her way, Marina perseveres.

Marina grieves for Orlando, but she also knows that life goes on, and she is committed to persevering with her singing career as well as do what she can to make ends meet financially.  She will survive and thrive on her own terms.

Ultimately, A Fantastic Woman is an inspiring movie due to Marina's resilience and uncompromising demand for respect as a human being--even if people don't understand her.

It's wonderful, for a change, to see a movie about a transwoman triumphs.

If you haven't seen this movie, it's well worth seeing for the acting, wonderful plot, and inspiration.

About Me
I am a licensed New York City psychotherapist, hypnotherapist, EMDR and Somatic Experiencing therapist (see my article: The Therapeutic Benefits of Integrative Psychotherapy).

I work with individual adults and couples.

One of my specialties is working with LGBTQ clients.

To find out more about me, visit my website: Josephine Ferraro, LCSW - NYC Psychotherapist.

To set up a consultation, call me at (917) 742-2624 during business hours or email me.

Resources:
The LGBT Center in New York City
National Center For Transgender Equality
Transgender Law Center
Gender Proud

Relationships: Gaslighting and Infidelity

In previous articles, I've discussed various aspects of infidelity.

See my articles: 

Infidelity: Married, Bored and Cheating Online

Infidelity on Social Media Sites

Infidelity - Your Spouse Cheated on You: Should You Stay or Should You Go?

Getting Involved in a Love Triangle to Avoid Dealing With Problems in Your Relationship 

Broken Promises: Surviving Infidelity

I'm focusing on a particular aspect that often occurs when there is infidelity, which is gaslighting, in this article.

Relationships: Gaslighting and Infidelity

In her book, The State of Affairs: Rethinking Infidelity, Esther Perel, discusses, among other things, the psychological concept of gaslighting and how people who are cheating on their partners use this form of psychological abuse to hide affairs (see my article: Are You Being Gaslighted in Your Relationship?).

What Is Gaslighting?
Before going any further, let's start with a definition of gaslighting.

As I mentioned in my prior article, the term stems from a 1944 film called Gaslight with Charles Boyer and Ingrid Bergman.  In the movie, Boyer's character tries to manipulate his wife (Bergman) into thinking that she is losing her mind by secretly making the gaslights in their home flicker on and off. Since the wife trusts him and she doesn't know that her husband is manipulating her, she begins to doubt her perception of things, which is what he wants.

A contemporary situation involving gaslighting and infidelity involves a partner manipulating the other partner by lying about an affair.  The partner, who is having the affair, might be so convincing that the partner being cheated on doubts his or her own perception--even when there's clear evidence of the infidelity.

It might seem incredible that someone would doubt his or her own perception, especially when there's evidence of cheating.  But it's important to understand that the person cheating is often very convincing and the person being cheated on is often in denial about what's going on.

Being in denial is understandable when you consider that to acknowledge an affair could not only ruin the relationship and life as the two people in it have known it.  It also raises many questions:  Who is this person you're in a relationship with that you thought you knew?  What's real?  Is the whole relationship false?  Can the relationship survive?  Do you want to try to salvage the relationship? (see my article: Betrayal: Coping With the Sudden Realization That You Don't Know Your Spouse).

A Fictional Clinical Vignette:  Gaslighting and Infidelity:
Ann
Ann began therapy shortly after she found out that her romantic partner of 10 years, Rob, had been cheating on her for their entire relationship.

Relationships: Gaslighting and Infidelity

She had her suspicions during the last year, especially after she received a call from Rob's former secretary, Jane, who told Ann that Rob and she had been having an affair for a year and he broke it off because Jane was demanding that he leave Ann to be with her.  Jane told Ann that, when she was his secretary, Jane was aware that Rob had many affairs, and she thought Ann should know.

Ann could hear that Jane was angry and hurt.   Ann realized that, even if there was any truth to Jane's story, Jane was getting back at Rob by calling Ann.

When Ann confronted Rob about the call from Jane, he got angry and indignant with Ann.  He told her that he just couldn't believe that Ann would even think that he would do such a thing.  He said Jane was making up this story because he rejected her when she came on to him.  Then, he told Ann he thought she was incredibly gullible for even entertaining such an idea.

Ann felt terrible and apologized to Rob.  She told him that she was sorry that she ever doubted him.  But after he left her apartment, he ignored her calls and texts for a few days until he was ready to accept her apology.

A few weeks later, Ann received an email from Jane.  At first, Ann was going to delete the email without even opening it.  But she was curious, so she opened it.

Ann was shocked that Jane's email contained pictures of her and Rob together having sex.  Jane gave dates, times and names of hotels when she was with Rob.  Ann realized that Rob told her he was away on business trips on those dates.  But according to the information that Jane sent, Rob was in town with Jane.

When Rob came over that night, Ann showed him the email from Jane and Rob blew up.  He told her that Jane was obviously a very disturbed woman, he wasn't the man in the picture, and Jane obviously Photoshopped the pictures to make it seem like it was him, but it wasn't him.

Before he stormed out of Ann's apartment, Rob told her that he needed time to think.  He said he was very hurt and he wasn't sure if he wanted to remain in a relationship with a woman who insinuated that he was a cheater and a liar.

Afterwards, Ann was confused.  Even though she loved Rob and she wanted to be with him, she wanted to know the truth, so she contacted Jane and met her for lunch the next day.

After their lunch together, Ann's head was reeling.  Jane showed Ann more texts with sexual messages from Rob.  She also told Ann that she heard from other women, who were also having affairs with Rob, and she showed Ann those emails as well.

Ann felt so betrayed.  She wondered if Rob ever loved her and if anything about their relationship was real.  She also felt like a fool for ignoring the obvious signs that he was cheating.

Feeling lonely and confused, Ann called her best friend, Liz and told her what happened.  Liz came over and comforted Ann as best as she could.  When Liz asked Ann what she was going to do, Ann said she wasn't sure.  She didn't know if she wanted to break up with Rob or tell him that she wanted to go to couples counseling to try to salvage their relationship.

Ann could tell that Liz thought she should break up with Rob, but Liz was hesitant about giving advice.  At that point, Ann was so shocked, she couldn't think straight.

When Rob called Ann a few days later, she asked him to come over so they could talk.  Before Rob arrived, Ann hoped that when she confronted him with what she knew from Jane that Rob would admit that he cheated with Jane and other women and they could agree to go to couples counseling.

But when she confronted him with the new information that she now had, Rob blew up again and went into a rant--calling her names and berating her for believing "such nonsense."

At that point, since Rob couldn't acknowledge the affair--much less express his remorse--Ann was devastated.  She knew that their relationship was over.  When she told Rob that she couldn't trust him, so their relationship was over, he continued to act angry and indignant.  Ann was amazed at how he was still trying to manipulate her and how he had manipulated her all along.

Now, sitting in front of her new psychotherapist, aside from feeling angry, Ann felt ashamed that she allowed Rob to fool her.  Her psychotherapist explained gaslighting to Ann and told her that she was having a common response.

Over time, Ann worked in therapy to overcome the traumatic experience of feeling betrayed by Rob.  Her current trauma was exacerbated by her family history, which included her father cheating on her mother.

Aside from working on the current trauma and the history of family trauma, Ann and her psychotherapist also worked on Ann overcoming her shame and building back her self esteem.

Conclusion
Gaslighting is often part of infidelity.  The person who is cheating manipulates in order to keep the affair a secret.

Many relationships cannot withstand the combination of infidelity and gaslighting, especially if the person who is cheating doesn't ultimately admit cheating and doesn't feel genuine remorse for the pain that s/he caused the other partner.

However, many relationships survive infidelity and gaslighting when the person who was cheating stops having the affair(s) and the couple work towards strengthening their relationship and rebuilding trust, if possible, in couples counseling.

One of the common misconceptions about infidelity is that it only occurs in relationships where the person who is cheating is unhappy.  Contrary to this common misconception, many people go outside their relationship even when they still love their partner and are basically happy in the relationship.

The reasons for the infidelity are numerous and vary with each relationship.  While no reason can justify infidelity, an understanding of why it occurred can be helpful to each person whether they decide to stay together or not.

Often, it has more to do with how the person who is cheating feels about him or herself or how s/he wants to feel (see my article: The Connection Between Infidelity and the Need to Feel Desirable).

Getting Help in Therapy
If you are struggling in your relationship, you owe it to yourself to get help (see my article: The Benefits of Psychotherapy).

A skilled psychotherapist can help you to work through the complicated emotions that are usually experienced after infidelity and gaslighting have been discovered (see my article: How to Choose a Psychotherapist).

About Me
I am a licensed NYC psychotherapist, hypnotherapist, EMDR and Somatic Experiencing therapist (see my article: The Therapeutic Benefits of Integrative Psychotherapy).

I work with individual adults and couples.

To find out more about me, visit my website: Josephine Ferraro, LCSW - NYC Psychotherapist.

To set up a consultation, call me at (917) 742-2624 during business hours or email me.

How Far Do You Want to Go in Your Psychotherapy?

In a prior article, Psychotherapy is an Active Process: The More Engaged You Are In It, the More You Get Out of It, one of the issues that I discussed briefly was the decision as to how far you want to go in psychotherapy--everything from symptom relief to delving deeper into your unconscious process to get to the root of your problem.

How Far Do You Want to Go in Psychotherapy?

As I mentioned in that article, each client makes this decision in consultation with the psychotherapist.  But, ultimately, the decision is up to the client.

If you're new to psychotherapy, you might not understand what your choices are and the implications of these choices.  So, I will provide describe different types of therapy.

Choices in Psychotherapy
The following scenarios describe various choices in psychotherapy for the same client, Ted, at various points in his life:

Short Term Symptom Relief Therapy:  When you choose short term symptom relief, you're usually choosing brief therapy to get rid of a symptom and you're not delving deeper into the problem once you start to feel better.  Ted had his first experience of attending psychotherapy when he saw a psychotherapist to deal with his panic attacks.  Since Ted wasn't interested at that point in more than symptom relief, his psychotherapist taught him how to do breathing exercises and to meditate.  Within a few weeks, Ted was feeling better and he decided to end therapy (see my articles: Tips For Overcoming Panic Attacks, What is the Difference Between Fear and Anxiety? and Getting Help in Therapy For Anxiety Disorders).

Longer Term Symptom Relief Therapy: Longer term symptom relief is therapy that is longer than short term therapy but shorter than more intensive therapy.  Ted managed well with what he learned in his short term therapy for a few months.  Then, he began a stressful new job and became symptomatic again.  He returned to therapy with the same psychotherapist, and he told her that he still wanted only symptom relief, but he was willing to stay in therapy for a longer period of time to deal with his panic attacks.  Since he stopped doing the breathing exercises and the meditation, his psychotherapist reinforced the stress management techniques she taught him when he first came to her.  She also added more coping techniques so he could deal with the current stressors on his job.  When he felt better and he was no longer experiencing panic attacks, he told his therapist that he wanted to leave therapy.  He understood that he could return in the future.

EMDR Trauma Therapy: Ted returned to his psychotherapist a year later.  He rarely had panic attacks anymore and when he had them, he knew how to calm himself.  However, he was now experiencing persistent anxiety after he met his father again for the first time since he was a young child.  Their meeting was fraught with tension on both sides.  Ted's father wanted to reconcile their relationship, but Ted was leery because he had a lot of resentment towards his father for abandoning the family.  In addition, Ted realized that his boss had similar characteristics to his father, and Ted was getting emotionally triggered whenever he had to work closely with his boss.  His psychotherapist recommended that they do EMDR therapy to work on the unresolved trauma as well as the current situation with his boss.  She explained to Ted that EMDR therapy tends to be faster and more effective than regularly talk therapy.  Gradually, Ted was able to work through his traumatic reactions within a year of beginning EMDR therapy.  He realized that he could have stayed in therapy to develop deeper insights into himself, but he told his therapist that he would return if he felt the need for delving deeper (see my articles: What is EMDR Therapy?, How EMDR Works - Part 1: EMDR and the Brain, How EMDR Works - Part 2: Overcoming Trauma, and What is Adjunctive EMDR Therapy?).

Grief Work in Therapy:  Grief work is focused specifically on helping a client to grieve and mourn a loss.  It can be short term or long term.  With regard to Ted, a couple of years later, Ted found out that his father died.  At the time, they were not speaking because they were not able to reconcile their relationship.  When he received the call that his father died, Ted felt profoundly sad for the loss of his father as well as the loss of not ever having a father that met his emotional needs.  He also felt sad because any chance of reconciling their relationship was gone, and he felt very guilty about this as well.  He returned to his psychotherapist and they did grief work to help Ted get through this difficult time.  Between sessions, Ted kept a journal and wrote about his feelings about his father.  He also organized a photo album with pictures of his father and himself from when Ted was younger.  He was able to work through his grief, and he let his therapist know that he was feeling better and he wanted to discontinue therapy (see my articles: Grief: Coping With the Loss of a Loved One: Common Reactions, Complicated Grief, The Theme of Complicated Grief For a Mother in the Movie, Phantom Thread, Holding Onto Grief as a Way to Stay Connected to a Deceased Love One and Trying to Understand Your Father).

Contemporary Psychodynamic Psychotherapy: Psychodynamic psychotherapy is a form of psychoanalysis.  Generally, it focuses on the unconscious mind and might include dreams and daydreams.  It usually also includes exploring transference issues.  When Ted returned to therapy, he felt lost.  He had just ended an enmeshed two year relationship with a woman that he loved very much when they first started seeing each other.  Gradually, they grew apart, and Ted sensed that he contributed significantly to the demise of the relationship because he had problems committing to his then-girlfriend.  He believed that he had issues with trust and this is what made it difficult for him to make a long term commitment.  He felt he was now ready to delve deeper into his unconscious mind to get to know himself better.  He agreed to attend open ended contemporary psychodynamic psychotherapy with the understanding that he could leave therapy whenever he wished; however, his therapist recommended that it would be better to work together towards termination in therapy when the time came.  Sometimes, Ted brought in dreams to discuss with his therapist.  He was also interested in exploring the unconscious underpinnings of his problems.  Gradually, his therapist helped Ted to make connections between his original panic attacks, his history of childhood emotional neglect, the loss of his father, and his problems with making a commitment in a relationship.  Ted also felt more emotionally integrated in contemporary psychodynamic psychotherapy (see my article: Discovering the Unconscious Emotions at the Root of Your Problems and What Unconscious Decisions Have You Made That Are Impacting Your Life?).

Conclusion:
The scenarios above show how one person can choose various forms of psychotherapy over a period of time depending upon the problem and what the client is ready to deal with at the time.

Each form of therapy mentioned above serves a particular purpose and could be appropriate at various times in a client's life.

Getting Help in Psychotherapy
When you decide that you would like to attend psychotherapy, the first step is to contact a psychotherapist for a consultation (see my article: The Benefits of Psychotherapy).

During the consultation, you give an overview of your problem and asks the psychotherapist questions about how she works, what type of therapy she does, her expertise and so on.

The psychotherapist will usually make a recommendation within a few sessions as to what form of therapy she thinks would be best for the client given his or her particular problems.  There are usually a few different ways to work, as outlined above, and depending upon the therapist's expertise.

The choice as to which type of psychotherapy is generally up to the client, unless the therapist thinks that the client needs a higher level of care or a different type of therapy.

Over time, as shown in the examples above, a client can return for different types of therapy (assuming that the therapist does these different forms of therapy) or the client can go to a different therapist (see my article: Returning to Therapy).

If you have been unable to resolve problems on your own, you could benefit from seeing a licensed mental health professional to help you to resolve your problems (see my article:  How to Choose a Psychotherapist).

Freeing yourself from problems that are hindering you from maximizing your potential can lead to living a more fulfilling and meaningful life.

About Me
I am a licensed NYC psychotherapist, hypnotherapist, EMDR and Somatic Experiencing therapist (see my article:  The Therapeutic Benefits of Integrative Psychotherapy).

I work with individual adults and couples.

To find out more about me, visit my website: Josephine Ferraro, LCSW - NYC Psychotherapist.

To set up a consultation, call me at (917) 742-2624 during business hours or email me.

Psychotherapy is an Active Process: The More You're Engaged in Your Therapy, the More You'll Get Out of It

As I tell clients who come to see me in my psychotherapy private practice in New York City, psychotherapy is an active process.  The more you're engaged in your therapy, the more you'll get out of it (see my article: Getting the Most Out of Your Psychotherapy Sessions).

Psychotherapy is an Active Process: The More You're Engaged in Your Therapy, the More You'll Get Out of It 

What Does It Mean to Be "Actively Engaged" in Your Therapy?
Many clients who are in psychotherapy for the first time think that psychotherapy is a passive process, but this isn't the case for contemporary psychotherapy.

New clients, who have never been in psychotherapy before, need psychoeducation from their psychotherapists in order to understand how to be actively engaged in psychotherapy (see my article: Why It's Important For Psychotherapists to Provide Clients With Psychoeducation About How Psychotherapy Works).

Being actively engaged in your psychotherapy sessions means more than just showing up, although, of course, on the most basic level, that's important.  But beyond showing up, you will get much more out of your psychotherapy sessions by:

• Being Open-minded and Curious About Your Therapy:  Psychotherapy isn't something that is "done" to you.  Your psychotherapist has certain skills and experience to help you overcome your problems but, as you know, your therapist doesn't have a magic wand to make your problems disappear, so you will get much more out of your therapy sessions if you begin therapy by being open-minded and curious about the psychotherapy process (see my article: Starting Psychotherapy With a Sense of Curiosity and Openness).

• Asking Your Psychotherapist Questions: Whether you're new to psychotherapy or you've attended therapy in the past, if there's anything that you don't understand or you have questions about, ask your therapist.  It's your therapy.  You're spending your hard earned money and time to be in therapy.  It's important that you understand what's going on and what you might expect.

• Understanding That Psychotherapy is a Process: Psychotherapy is different from going to see your medical doctor who might give you a shot or a prescription so you can overcome your problem.  Psychotherapy is an individualized process that unfolds over time.  Each psychotherapy client's process will be unique.  When psychotherapy is going well, the work in therapy usually builds on itself over time.

• Considering How Far You Want to Go in Psychotherapy: Sometimes, I compare psychotherapy to home repair as a metaphor.  When you make home repairs, you decide if you want to do a little painting and spruce up the place or if you want to do major repairs.  It's the same with psychotherapy.  Your psychotherapist can make recommendations and you would do well to consider them.  But, ultimately, it's up to you whether you want symptom relief or you want to get to the root of your problems.  You might be alright with symptom relief now and maybe you'll consider delving deeper your next time in therapy.  Or, you might want to delve deeper now so that you overcome your problems beyond symptom relief.  Similarly, you can make choices as to whether you want to focus on short term or long term goals.  Once again, it's up to you--not your therapist.

• Spending Time Reflecting on Your Psychotherapy Sessions: If you want to get more out of your psychotherapy sessions, rather than forgetting what came up in your session once you leave therapy, spend time reflecting on your thoughts and feelings soon after the therapy session.  Even though you've left the session, the process continues to go on for you in your mind unconsciously.  That means, whether you realize it or not, you're never in the same place when you return for your next session.  Why not try to reflect on what's changing for you by thinking about it between sessions?

• Spending Time Writing Between Psychotherapy Sessions: Writing between sessions is something I recommend to my clients because it helps you to reflect on what's happening for you and how you're changing as a result of your therapy.  Many clients ask, "How will I know if psychotherapy is helping me to change?"  One way is to reflect and write about what comes up for you between sessions and the changes that you notice.  You can choose whether or not you share your writing with your psychotherapist or not.  Aside from writing, some people draw pictures or write stories--whatever works for you to help you to be actively engaged in the process between sessions (see my article: The Benefit of Journal Writing Between Psychotherapy Sessions).

Psychotherapy is an Active Process: Journal Writing Between Therapy Sessions

• Talking to Your Psychotherapist About Something That's Bothering You About the Therapy: Maybe you're changing in ways that you don't understand.  Maybe something got triggered in your last session. Maybe your therapist said something that you didn't like or you misunderstood.  Maybe your therapist misunderstood you.  A lot can happen in a therapy session.  Your therapist might sense that you're having a problem, but maybe she won't, especially if you're good at hiding when things bother you.  In that case, how will your therapist know unless you tell her?  You need to provide feedback to your therapist whether she elicits it from you or not (see my article: How to Talk to Your Psychotherapist About Something That's Bothering You in Therapy).

• Understanding That "Feeling Better" Might Not Necessarily Mean Your Problems Are Resolved:  As I stated above, it's up to you to decide if you want symptom relief or you want to work deeper on your problems.  If you decide that you want symptom relief, you need to understand that this might mean, even though you're "feeling better," your problems might not necessarily be resolved--depending upon what you want to get out of therapy.  If you know this and you're okay with it, the choice is yours.  However, as an informed consumer, it's important to know what you have opted to do once you've decided that you want to end therapy (see my article: Starting to Feel Better in Therapy).

Conclusion
Psychotherapy is an active process for the client and the psychotherapist.

The more you're actively engaged in your psychotherapy sessions during and in between sessions, the more you'll get out of your therapy.

Getting Help in Therapy
The decision to start psychotherapy, especially if you've never been in therapy before, can be a difficult one.

It takes courage to take steps to change (see my article: Developing the Courage to Change).

If you've been unsuccessful in overcoming your problems on your own, you could benefit from seeing a licensed mental health professional (see my article: The Courage to Change).

A skilled psychotherapist can help you to identify and work through your problems so that you can live a more meaningful life (see my article: How to Choose a Psychotherapist).

About Me
I am a licensed NYC psychotherapist, hypnotherapist, EMDR and Somatic Experiencing therapist (see my article: The Therapeutic Benefits of Integrative Psychotherapy).

I work in a dynamic, interactive and collaborative way with individual adults and couples.

To find out more about me, visit my website: Josephine Ferraro, LCSW - NYC Psychotherapist.

To set up a consultation, call me at (917) 742-2624 during business hours or email me.

Focusing on Your Inner Self is More Effective to Overcome Shame Than Focusing on Your Outer Looks

Although most people aren't aware of it, shame is often at the root of many emotional problems (see my article: Healing Shame in Psychotherapy and Overcoming Shame That Keeps You From Starting Therapy).  Many people focus exclusively on their appearance, in an attempt to overcome shame.  While it might help to a certain extent to deal with external issues, shame is usually deeply rooted and without getting to the root of the problem internally, it's difficult to overcome shame that's having a negative effect on your life.

Focusing on Your Inner Self is More Effective to Overcome Shame Than Only Focusing on Your Outer Looks

People often associate shame with external issues, like their appearance.  As result, they try to overcome their shame by trying to deal with these external issues alone rather than looking within themselves to discover the internal roots of their shame.

While it would be helpful, for example, to lose weight for health reasons and it might to feel better, when someone feels ashamed of themselves, focusing only on his or her appearance usually doesn't get to the root of the problem.

Our culture, which glorifies youth and beauty, tends to shame middle aged and older men and woman, especially women.  As a result, women tend to be more susceptible to feeling shamed of themselves as they are.

For instance, older women often complain in therapy about feeling "invisible" in a world that elevates youth and denigrates aging.  And, while it's probably true that not as many people are admiring a woman who is older, as compared to when she was younger, it is also probably true that how she feels about herself and what she projects to the world contributes to this feeling of invisibility (see my article: Making Peace With the Aging Process).

The solution that many people seek, especially women, is to seek products or surgical procedures, like face lifts and breast augmentation as a way of feeling less ashamed of how they're aging.

But these products and procedures usually only give temporary, if any, relief from shame. They  reinforce the idea that you're not alright the way you are and you need to continue to make changes to your outer appearance in order to feel better about yourself.

Fictional Clinical Vignette 

Focusing on Your Inner Self is More Effective to Overcome Shame Than Focusing on Your Outer Looks
The following fictional vignette illustrates these points:

Cindy
Cindy started therapy because she was suffering with debilitating shame.

A year before she sought help from a psychotherapist, Cindy contemplated having a face lift because she couldn't stand looking in the mirror and seeing that her facial skin was sagging.

But after she discussed it with her husband, who still found Cathy to be beautiful, and considering the risks of surgery, she decided against plastic surgery.

Then, Cindy focused on losing weight, even though her doctor told her that she didn't need to lose weight for health reasons.  She thought she would feel better about herself if she lost 10 pounds.  But after she lost 10 pounds, she still felt ashamed of herself.

Next, she attempted temporary non-surgical procedures and creams to firm up her facial skin.  Although the procedure combined with the weight loss reduced the appearance of sagging skin, Cindy still felt deeply ashamed and it was affecting her personal life as well as her career.

She felt so unattractive that she no longer wanted to have sex with her husband, even though he still thought she was attractive and sexy.  No amount of reassurance from her husband helped, and after a while, they began to argue about the lack of sexual intimacy in their marriage (see my article: Have You and Your Spouse Stopped Having Sex?).

At work, she no longer liked to go out on sales calls because she assumed that her customers would prefer to see a young, attractive salesperson rather than an older woman.  As a result, she was making fewer sales visits to customers and this reduced her compensation.  Her boss also complained and told her that she needed to have more customer contact to bring in business.

Not knowing what else to do, Cindy saw her medical doctor to seek advice, and he recommended that Cindy attend psychotherapy.

Cindy told her new psychotherapist that, as far back as she could remember, even when she was a child, she felt ashamed of herself.  But after she went into menopause, she felt increasingly unattractive and ashamed.

Her therapist asked Cindy about her family background and she described parents who were highly critical of Cindy and her siblings.  Her mother, who suffered from low self esteem herself, was especially critical of Cindy, who looked a lot like her mother.

Cindy explained to her therapist that her mother often criticized Cindy for how she looked--her weight, her clothes, her posture and overall demeanor.

In hindsight, Cindy realized that her mother was also highly self critical. Her mother criticized Cindy for all the things she felt self conscious about herself.  Looking back on it, Cindy recognized that her mother was projecting her own insecurities and shame onto Cindy.  But as a child, she felt defenseless against the onslaught of criticism.

Cindy told her therapist that, by the time she turned 18, "I blossomed from an ugly duckling into a very attractive young woman."  Feeling attractive, she felt more self confident, especially after she went away to college and no longer heard her mother's criticism on a daily basis.

In college, Cindy overcame her shyness as she became aware that she was sexually attractive to men.  This also made her feel more confident around men, especially after she became sexual.

After she graduated college, she met the man who eventually became her husband.  She said he was "head over heels about me when we first started dating."  She indicated that, even now, he continued to tell her that he thought she was beautiful and sexy, but she didn't believe it, especially when she looked in the mirror.

Looking back on her life, Cindy realized that most of her self confidence was based on her appearance so that as she got older, her confidence began to falter again, just as it did when she felt like "an ugly duckling" as a child.

When she was younger, even though she did well in college and she was told by her professors that she was intelligent, she assumed that her looks were what got her by.  And now that she was older, she felt like she had nothing to offer.

"I know this sounds shallow, "Cindy said to her therapist, "but it's how I was raised and what I have believed for all my life.  But now these feelings are threatening to ruin my marriage and my career, so I know I need to do something to overcome them."

Cindy's psychotherapist provided Cindy with psychoeducation about shame and how traumatic her parents' criticism of her were when she was younger.  She also provided psychoeducation about how psychotherapy could help (see my article: Why It's Important For Psychotherapists to Provide Clients With Psychoeducation About How Psychotherapy Works).

The therapist explained that Cindy internalized her mother's criticism and her mother's own shame and this was traumatic.  She recommended that they focus the therapy on overcoming this early trauma.

Using EMDR therapy, over time, Cindy and her therapist worked on helping her to overcome the shame that was instilled in her at an early age (see my articles: How EMDR Works: Part 1: EMDR and the Brain and How EMDR Works: Part 2: Overcoming Trauma).

Gradually, Cindy became aware that not only was she still attractive but, more important than that, she had much more to offer than looks--she had intelligence, generosity, warmth and creativity.

Focusing on Your Inner Self is More Effective to Overcome Shame Than Focusing Only on Your Outer Looks

Eventually, Cindy began to feel sexual again and she and her husband went on vacation to rekindle their relationship.  She also felt more confident about making sales visits to her customers, which increased her compensation

Conclusion:
Many people use their looks to try to boost their confidence and compensate for their shame.  But looks change, so they are not a reliable source for overcoming shame.

Overcoming shame requires deeper work into the root of the shame.

Shame often begins early in life and usually has a traumatic source.

Getting Help in Psychotherapy
Working through the source of the trauma in psychotherapy usually helps you to overcome shame that is having a negative impact on our life (see my article: The Benefits of Psychotherapy).

If shame and trauma are having a negative impact on your life, you owe it to yourself to get help from a licensed mental health professional (see my article: How to Choose a Psychotherapist).

Experiential therapy, like EMDR, Somatic Experiencing and clinical hypnosis are usually an effective way to overcome shame as opposed to regular talk therapy (see my article: Experiential Therapy, Like EMDR, Helps to Achieve Emotional Breakthroughs and EMDR Therapy When Talk Therapy Isn't Enough).

If you're experiencing the negative effects of shame and emotional trauma, rather than suffering on your own, you owe it to yourself to get help from a licensed psychotherapist who is skilled at experiential therapy and helping clients to overcome shame and trauma.

Once you have overcome the shame and trauma that are creating obstacles in your life, you can lead a more fulfilling life.

About Me
I am a licensed NYC psychotherapist, hypnotherapist, EMDR and Somatic Experiencing therapist (see my article: The Therapeutic Benefits of Integrative Psychotherapy).

I work with individual adults and couples.

I am a trauma-informed psychotherapist, and one of my specialties is helping clients to overcome shame and trauma.

To find out more about me, visit my website: Josephine Ferraro, LCSW - NYC Psychotherapist.

To set up a consultation, call me at (917) 742-2624 during business hours or email me.

Ethical Issues With Using Managed Care For Psychotherapy

In a prior article, I discussed why it has become so difficult to find a psychotherapist in New York City on managed care panels.

This is a problem not just in New York City but all over the country.  In the current article, I'm expanding this discussion to include ethical issues involved with using managed care for psychotherapy.

Ethical Issues With Using Managed Care For Psychotherapy

The purpose of this article is to provide information to clients who are considering using their managed care benefit to attend psychotherapy so that clients can be informed consumers.

Ethical Issues About Using Managed Care For Psychotherapy
Managed care companies' main focus is saving money.  Although most managed care companies would deny it, their allegiance is to their shareholders--not to their subscribers.  When saving money is the main focus, this inevitably leads to certain ethical problems, including:

• Problems With Client's Privacy/Confidentiality:  When a psychotherapist enters into a contractual agreement with a managed care company, she will, most likely, have to share your confidential information with managed care representatives because it is demanded by the managed care company.  In effect, not only is the confidential information shared with the representative on the phone (or sometimes by mail or on the insurance company's website), but the information also becomes available to hundreds of other employees at the managed care company.  This is becoming even more of a problem than when I wrote the about this before because in the last few years there have been breaches in confidentiality when insurance companies sites were hacked.  This exposed thousands of insurance subscribers to having their personal information used illegally, possibly including information about their psychotherapy sessions.

• Problems With the Intrusive Nature of Managed Care: Managed care representatives often contact in network psychotherapists to find out why clients are still in therapy; to make "suggestions" about how psychotherapists should change clients' treatment plans, including referring clients for medication, even when clients have made it clear that they're not interested in medication; and, possibly reducing the frequency of sessions from weekly to every other week or less.  Often, the managed care representatives demand that psychotherapists justify their clients' treatment in writing in order for clients to be able to continue in therapy.  This often involves the representatives asking for detailed personal information about the clients' problems; what else the clients have attempted to do, aside from going to therapy (e.g., joining support groups, seeing a psychiatrist, etc) and so on. 

• Potential Conflicts of Interest For Psychotherapists on Managed Care Panels: To save money, managed care companies prefer short term treatment, even, at times, when clients are in crisis or very depressed and they need longer term treatment.  Many psychotherapists who are on managed care panels are aware that they are more likely to get referrals from managed care if they do brief therapy--even when clients need more intensive therapy.  This often leads to psychotherapists, who are on managed care panels, making decisions based on their financial needs rather than the needs of their clients.  In other words, if a psychotherapist is aware that a managed care company prefers psychotherapists who do brief treatment, he will be placed in an ethical dilemma because he knows that the managed care companies will look at their records to see which therapists only keep clients for a short period of time before terminating treatment so, in the long term, it is in his financial interest to keep clients for only a few sessions so he can get more referrals from the managed care company.  This often leads to poor treatment because the psychotherapist might only be focused on "shoring up" clients rather than helping the client to make meaningful change.  Clients might "feeling better" for a short time and then, after a while, they need to go back several other times to the prior therapist or to a new therapist because their problems were not resolved in short term therapy.  It also discourages clients from seeking help in therapy because, after going through several cycles of short term therapy with poor results, clients will often conclude that "therapy doesn't work" rather than that their therapist might have been pressured by managed care to provide suboptimal care.  This is not to say that all psychotherapists on managed care will choose less than optimal care because many will do what is best for the client, but it is a potential ethical dilemma.

Ethical Issues With Using Managed Care For Psychotherapy

• Potential Problems With Quality of Care:  As mentioned above, when psychotherapists on managed care panels are pressured by the insurance company to provide short term therapy, even when the client needs longer term therapy, the quality of care often suffers.  In order to justify longer treatment, psychotherapists often must go through a lengthy and time consuming process of providing increasingly more detailed information as to why clients need more therapy sessions.  Not only is this time consuming for the therapist, it also compromises confidentiality, as mentioned above.

• Pressure From Managed Care Regarding Medication:  As mentioned above, managed care companies often pressure psychotherapists to refer clients to psychiatrists for medication, even if the clients do not want to take medication and, in many cases, do not need medication.  Often, the representatives making these clinical "recommendations" are Bachelor's level employees, if that, and far less qualified to make these clinical decisions than the psychotherapist treating the client.  Once again, the focus is on saving money rather than  providing quality of care for clients.  

• Restricted Choice of Psychotherapists:  In order to save money, most managed care panels are narrow with a restricted number of psychotherapists listed by zip code.  This saves the managed care company money because there are fewer psychotherapists to choose from and the ones who are on the panel, who are often are other managed care panels, are forced to take many clients in their private practice in order to make financial ends meet due to low managed care reimbursement.  This usually meets that it is very hard to find a psychotherapist in your area who has openings because therapists are all booked up.  Also, many of the therapists (although not all) are new therapists who are starting their private practice and willing to take managed care until they can build their practice.  

• Diagnosis and Stigma: Managed care for psychotherapy is usually based on medical necessity, which means that a client must have a diagnosis that the managed care company deems necessary to cover this client.  As a result, psychotherapists must provide a diagnosis to the managed care company for each client that the managed care company will accept.  Once again, this brings up issues around confidentiality and privacy because these diagnoses are on the managed care computer system.  Also, as mentioned above, when a managed care company's website is hacked, the client's confidential information, including diagnosis, could be exposed (see my article: see my article: Psychotherapy: You Are Not Defined By Your Diagnosis).

What to Do to Avoid or Mitigate These Problems With Managed Care
Obviously, there are many clients who must use their managed care plan because they cannot afford to self pay for therapy.  If this is the case for you, you should, at least, enter into this process knowing what is at stake.  If this is the only way that you can access mental health treatment, it's better to use your managed care insurance than not to go to therapy at all.

Steps To Take to Be An Informed Consumer

• Find Out If Your Company Has a Health Savings Plan:  This is an alternative to using your managed care benefit that many people use.  Your human resources or health benefits representative should be able to tell you if your company has a health savings plan, if you are eligible for the plan, and how to use it.  If your company does not have health savings plan, you and other employees can advocate for this benefit.  Express your concerns to your concerns about these issues and find out what steps the company can take to remedy them.

• Find Out If Your Insurance Allows Out of Network Psychotherapy: When you go out of network, your benefit is not managed by the managed care company, although there might be some restrictions with regard to the deductible and how much the insurance will reimburse you depending upon the plan that your company negotiated with the insurance company.  If your company does not offer out of network benefits, you and other employees can advocate for it.

• Discuss Your Concerns With Your Psychotherapist: If your company does not have a health savings plan, out of network benefits or if you really need to use your managed care benefit, speak with your therapist about your concerns regarding diagnosis, confidential/privacy and quality of care.  You have a right to know the diagnosis that your psychotherapist is submitting to the managed care company.  You also have a right to know what information your therapist is providing to the managed care company if the insurance representative indicates to your therapist that they must do a review of your case.  You can stipulate what you want/do not want shared.  However, be aware that if your therapist does not share information that the managed care company considers necessary to approve additional sessions, you might not be able to continue in therapy.  This is another ethical dilemma.

Ethical Issues With Using Managed Care For Psychotherapy

• Consider Your Priorities:  Only you know your financial situation.  There are times when you might be forced to use your managed care health benefit to access therapy because you cannot afford to pay out of pocket.  This is understandable.  But it is often worthwhile to look at your priorities and assess how your spending your money and how you want to spend your money.  Take a look at your budget and make decisions based on what is important to you.  At certain times, it might be worth it to you to forgo certain expenses, like buying packs of cigarettes or buying expensive coffee in order to have quality mental health treatment.  

• Consider Sliding Fee Scale Mental Health:  There are certain mental health centers that offer sliding scale therapy based on household income.  Most of them will request proof of household income in order to assess your fee.  Many of the psychoanalytic institutes have referral services to their candidates in training where you can see a licensed psychotherapist in their training program for a reduced fee.  These students are usually supervised by senior clinicians.

Getting Help in Therapy
Many people need to use their managed care health benefit in order to access psychotherapy.  However, many of those same people are unaware of the issues involved with using managed care benefits for psychotherapy.

No one who needs mental health services should ever go without treatment regardless of whether you use your managed care benefits or not.   At the same time, it is important to be an informed consumer.

If you have problems that you have been unable to resolve on your own, you could benefit from seeing a skilled psychotherapist who can help you to overcome your problems (see my article: The Benefits of Psychotherapy).

A licensed psychotherapist can help you to overcome the problems that are keeping you from maximizing your potential (see my article: How to Choose a Psychotherapist).

About Me
I am a licensed NYC psychotherapist, hypnotherapist, EMDR and Somatic Experiencing therapist (see my article: see my article: The Therapeutic Benefits of Integrative Psychotherapy).

I work with individual adults and couples.

To find out more about me, visit my website: Josephine Ferraro, LCSW - NYC Psychotherapist.

To set up a consultation, call me at (917) 742-2624 during business hours or email me.

Taking Risks in Your Therapy

Many clients who are in therapy avoid expressing their reservations or negative feelings about therapy or their therapists.  Some clients, who were discouraged from expressing their feelings when they were children, continue the same pattern without even realizing it in their relationships and in their therapy as adults (see my article: Growing Up Feeling Invisible and Emotionally Invalidated).  

Deep down, they don't feel entitled to their feelings.  Other clients are afraid that they will offend or alienate their psychotherapist by expressing negative feelings.  But in order for the therapy to be alive, meaningful and valuable for clients, they need to take risks in their therapy because, if not, these unexpressed feelings contaminate the therapy and have a negative impact on the relationship between the client and the therapist (see my articles: Why Being Honest With Your Therapist is the Best Policy and How to Talk to Your Psychotherapist About Something That's Bothering You in Therapy).

Taking Risks in Your Therapy 

A Childhood History of Feeling Invisible and Undeserving
Clients who grew up in a family where they were discouraged and, possibly, even punished for expressing their feelings learn quickly to keep their feelings to themselves.  Over time, they also learn not even feel their feelings, so they are unaware of their feelings on a conscious level.

This pattern is often carried over when they become adults in their personal relationships and relationship with their psychotherapist without their even realizing it.

Therapists who recognize this pattern in clients need to provide a safe therapeutic environment (see my article: The Creation of a "Holding Environment in Psychotherapy).

Psychotherapists also need to help these clients to identify their feelings so they can express them.  Many clients, who are having the experience for the first time of expressing negative feelings might begin by having big reactions that frighten them once they begin expressing their feelings, so the therapist also needs to help these clients to manage their emotions.

Learning to express negative feelings after a lifetime of bottling them up can be challenging, so clients need to learn to respond instead of react when expressing themselves (see my article: Responding Instead of Reacting).

A Fictional Clinical Vignette: Taking Risks in Therapy
The following fictional vignette illustrates the points that I've made above and how psychotherapy can help:

Beth
Beth, who was in her early 30s, began therapy because she thought she was being taken advantage of in her two year relationship.

She told her new psychotherapist that her boyfriend, Alex, would often assume that when they went out that Beth would pay because she made more money that he did.  She said that, although she didn't mind paying sometimes, she didn't want to pay for their dinner, movies and theater tickets all the time.  She especially didn't want Alex to assume that she would always pay, which he did.  She felt that, although he made less money than she did, he made enough money to offer to pay sometimes.

Taking Risks in Your Therapy

Beth also mentioned other issues in the relationship where she felt taken advantage of.  When her psychotherapist asked Beth if she ever discussed this with Alex, Beth gave her a blank stare and then she gave all her reasons why she had not spoken to Alex about these issues, "It wouldn't make a difference anyway," "He's just like that--he won't change" and so on.

Eventually, over time, Beth came to see these "reasons" as rationalizations and excuses for her passivity.  But, at this point in her therapy, she believed her rationalizations.

It turned out that Beth had so much bottled up resentment towards Alex over the two years that they were in a relationship that she no longer wanted to be sexual with him.  But, until she came to therapy, she never made the connection between her unexpressed anger and resentment and her lack of interest in having sex with Alex.

When Beth thought about it, she said she had always been a sexual person, and she had been very sexually attracted to Alex during their first year together.

Before discussing this in therapy, she just thought that the decrease in her sexual interest was a normal part of being in a two year relationship. But now she sensed how her resentment and anger contributed to the cooling off of her feelings for Alex.

When her new psychotherapist asked Beth if she had ever been in therapy before, Beth told her that she had been in therapy with several different therapists over the last few years, but she left each of her therapists when they said or did something that she didn't like.

When her therapist asked her if she ever spoke to any of her therapists about her misgivings, Beth realized that she never did--she just left abruptly (see my article: When Clients Leave Psychotherapy Prematurely).

Beth described her parents as being emotionally distant and preoccupied with their careers.  As an only child, Beth spent much of her time alone.  She never saw her parents argue, but she also never saw them being affectionate with each other.

She remembered times when she tried to tell her mother about feeling lonely at home and at school, but her mother never wanted to hear it.

Her mother especially didn't want to hear any complaints from Beth about anything going on at home or about Beth feeling angry towards her parents.  So, eventually, Beth learned to keep her feelings to herself, and she approached her romantic relationships in the same way.

Beth's therapist helped Beth to feel comfortable in therapy and encouraged Beth to tell her if she had any misgivings about the therapy or her therapist.  She told Beth that she wanted her to be able to talk about any problems in therapy rather than Beth just disappearing from therapy as she did in her prior therapies.

As Beth continued to attend her therapy sessions, she got more comfortable with her therapist.  At one point, when Beth felt misunderstood by her therapist, Beth broached this topic with trepidation.  Beth felt that her therapist didn't understand what she was trying to say, so she got up her courage to tell her therapist.

But when she began to talk about it, she felt such uncontrollable rage welling up inside her that she couldn't get the words out.  She felt unable to breathe, her heart was pounding, and it was as if the words were stuck in her throat.

Her therapist helped Beth to calm down enough so she could breathe and feel grounded.  Then, even though she still had difficulty, Beth was able to speak clearly and articulate her feelings.

Taking Risks in Your Therapy

With the help of her psychotherapist, she also made connections between her family history of feeling  invisible and undeserving and how this affected her adult relationships.

Over time, Beth gradually became more comfortable taking risks in her therapy. She was able to speak up when she felt misunderstood or something occurred that she didn't like.  Unlike her childhood experiences with her parents, Beth saw that her therapist was open to talking about any problems in therapy and there were no negative repercussions.

Similarly, when Beth felt there was a rupture with her therapist, after she talked about it with her therapist, she also saw that these ruptures could be repaired (see my article: Ruptures and Repairs in Psychotherapy).

This helped Beth to feel more confident in other areas in her life, including her relationship with Alex.  As a result, she was able to talk to him about the areas in their relationship where she had misgivings, which helped to clear the air and also helped them to make positive changes in their relationship.

Conclusion
When clients have problems expressing negative feelings about aspects of their therapy or about their psychotherapist, there is usually a long history of this problem that goes back to childhood.

For these clients, in the short term, it's easier to leave therapy abruptly than take the risk of expressing their feelings and dealing with their fear of rejection or some form of retaliation by the therapist.  This usually results in a string of aborted therapies over time which, in the long run, is usually damaging to the client.

By the same token, these same clients often tolerate inappropriate behavior in their relationships, similar to Beth in the fictional vignette above.  Their anger and resentment have the same effect--they either leave the relationship or the relationship slowly dies because the relationship becomes buried in these unexpressed negative feelings.

If clients, who are reticent about expressing negative feelings, can learn to express these types of feeling in therapy, they can use this skill in their relationships.

At first, it might feel uncomfortable but, over time, clients can become more comfortable expressing themselves, which leads a greater sense of authenticity as well as more authentic relationships.

Getting Help in Therapy
The unspoken and, possibly unconscious, fear that it's dangerous to express negative feelings is very hard to overcome on your own because it's usually so ingrained.

A skilled psychotherapist can help you to recognize and express uncomfortable feelings in an effective way.  She can help you to develop the necessary tools so that you don't feel overwhelmed by your own feelings (see my articles: The Benefits of Psychotherapy and How to Choose a Psychotherapist).

She can also help you express yourself in an effective way--without your minimizing your feelings or overreacting in ways that would be overwhelming to you or to others and make your communication ineffective.

Rather than struggling on your own, you could benefit from getting help in psychotherapy so that you will eventually feel more comfortable and confident in yourself.

About Me
I am a licensed NYC psychotherapist, hypnotherapist, EMDR and Somatic Experiencing therapist (see my article: The Therapeutic Benefits of Integrative Psychotherapy).

I work with individual adults and couples.

I have helped many clients to take risk in therapy so that they can lead more fulfilling and authentic lives.

To find out more about me, visit my website: Josephine Ferraro, LCSW - NYC Psychotherapist.

To set up a consultation, call me at (917) 742-2624 during business hours or email me.