Case Study

A Dog Wanders into My Session

Taking a New Direction in the Therapy Room

Magazine Issue
May/June 2023
Illustration of a person with a map along with a couple and a dog | Illustration by Sally Wern Comport

As a newly licensed therapist, I felt unsure every day I met with clients. Because I didn’t have years of experience under my belt, I had no choice but to surrender to the uncertainty inherent in untested techniques I’d learned in graduate school and in certification programs. In sessions, my insecurities translated into a willingness to make mistakes. Because I couldn’t rely on the past to predict outcomes with clients, my most dependable guidepost was the here-and-now. I was constantly reorienting myself to what was right in front of me—recalculating, like a human GPS, alternate routes between where my clients and I had just been a moment earlier, our current location, and where we seemed to be heading.

After 15 years of treating people in hospitals, outpatient mental health centers, and private practice, I’ve learned a few things. Most of the time, I’m confident about the interventions I use. I know—from experience—what tends to bring results and what doesn’t. My mental tool kit is filled with time-tested, familiar strategies and organizing clinical maps. I tend to do what I’ve done countless times before—to mirror, affirm, circle back, invite, challenge, or track clients in ways that bring a degree of predictability to the intricate, complex, and at times volatile work of psychotherapy.

Recently, though, something unusual happened with Felix and Isabel—a couple whose longstanding contentious dynamic I’d been trying to help them alter for nearly a year. An unexpected visitor disrupted the flow of one of our telehealth sessions, and I found myself wondering, for the first time in a while, what should I do now? On a whim, I tried my hand at a portrayal, a technique I’d always felt intimidated by, especially after seeing other therapists do it brilliantly in video sessions they showcased at trainings. What I learned through the process was a fundamental truth new therapists sense intuitively: being willing to be a beginner again can have more value for our clients than our polished expertise.

What Should I Do Now?

“Can you see us okay?” Isabel asks. Her thick, brown curls block my view of Felix. “I’ve been having trouble with my camera lately.”

“I can see you fine,” I say. “Except you’re cut off from the neck down.”

Felix reaches for the screen, but it’s Isabel who gets there first, bringing their torsos into view as well as the squeaky leather couch they’re sitting on. It’s clear the whole set up is precarious from the way everything wobbles.

I’d met with Felix and Isabel in person in my office a few times. Once the pandemic hit, we switched to virtual sessions. Originally, their fights had revolved around Isabel’s mother, who spoke fondly of Isabel’s exes and criticized the amount of time Felix spent focused on his graduate studies. She also mocked him for being an inch shorter than Isabel and implied that their decision to postpone having kids reflected poorly on his virility.

“She means well,” Isabel would say in her mother’s defense.

“I’d have grandkids by now if only my Isabel had stayed with Miguelito.” Felix seemed to enjoy assuming a haughty, high-pitched voice and contorting his face into a sour expression. “You’re going out in public dressed like that? People will think my Isabel’s dating a beggar!”

“She’s just being funny,” Isabel would argue.

Today, I guide them to close their eyes and notice two things: what goal they’re coming into the session with and what they’re hoping to leave with.

“I want validation,” Isabel says. “We’re so disconnected. It makes me sad and angry.”

I gesture toward Felix like a conductor prompting a violin solo, but Felix doesn’t need my guidance. He knows what to do.

“You’re sad and angry and you want validation,” he paraphrases in his well-practiced, I’m-doing-therapy-now voice, which he keeps convincingly neutral. To a trained ear, however, there’s a hint of emotional trouble in it—an undercurrent of long-suffering self-pity.

Isabel nods. The muscles around her mouth depress slightly. When it’s Felix’s turn to share his goal, he says he wants to express his feelings because he’s also sad and angry, and he’s tired of ignoring it and pretending everything’s fine.

“What are you sad and angry about?” Isabel’s expression morphs into a scowl. “I’ve been doing so much! I’ve made sure you have time to study. I’ve taken the car in to have the brakes replaced. I’ve cooked dinner five nights this week. I’m always trying to cheer you up.”

“They’re his feelings, Isabel.” I redirect her while I still can. If she jumps into one of her familiar, slippery rabbit holes, and Felix jumps in after her, the session could instantly devolve into the three of us talking over each other as I try to get us back on track.

“Fine, you’re sad,” Isabel concedes. “And angry.” She’s giving an inch—not a millimeter more.

“This is why I don’t express myself.” Felix shakes his head.

“But I just validated you.” Isabel turns to me for corroboration. “Didn’t I?”

An expert fixer and problem-solver, Isabel feels most loved when she’s able to help the people she cares about, including—and at this point especially—Felix. She’s been helping her parents navigate life in the United States since they emigrated from El Salvador to Los Angeles when she was 10 years old. Growing up, she was their interpreter, accountant, medical advisor, and legal advocate all rolled-up into one brilliant, over­extended, parentified child who single-handedly helped her family sidestep most of the tragedies that can easily befall immigrants seeking asylum in the US. Fixing things gives her a sense of purpose. It also helps her avoid unpleasant feelings like helplessness. She tends to take Felix’s anxiety, irritability, and dissatisfaction as a sign that she’s failed to fix something.

“I just don’t know how you can still feel angry and sad when I work so hard to take care of you,” she sighs. “I try to help you in every way I can.”

Felix raises his hands in a classic gesture of despair.

“Exactly! Stop helping me! How many times do I have to say it? You know what my life was like growing up. Parents, teachers, counselors, psychiatrists—everybody making me the problem.” Felix’s hands drop to his lap. He looks deflated. “Just accept me as I am.”

“I accept you all the time,” Isabel says grimly. “I accept you every day.”

“Can I say my goal for our session?” Felix’s face takes up more of the screen as he leans forward like a kid in the front row of a classroom asking to go to the bathroom. He’s already speaking before I can respond. “I want to talk about setting boundaries with your mother.”

Isabel groans, rolling her eyes.

“What’s under that eyeroll?” I ask Isabel gently.

“Did I roll my eyes?” she says. “I didn’t even notice.”

I turn to Felix, but he’s not facing me anymore. He’s not looking at Isabel, either. He’s focused on something in the middle distance of the room, a few feet beyond the screen.

“Come here, Stella,” he says quietly. “It’s okay.”

Isabel’s attention shifts toward the same point in space that’s mesmerized Felix. Is Stella a visiting relative? A trusting neighborhood child—a Girl Scout, maybe, who came in through the back door to deliver cookies? I hear a faint, asymmetrical clacking sound: clickety clack-clack, clickety clack. It reminds me of when my son comes in from a soccer game and forgets to take his cleats off by the front door.

Isabel vanishes from the screen momentarily. When she reappears, there’s a ball of black and white fur in her arms. I search for my glasses.

“She’s a mutt,” Felix explains. “Part Brussels Griffon, part poodle, part Shih Tzu. We did a DNA test a few years ago. She’s got a little bit of everything in her.”

“Nice to meet you, Stella.” With my glasses on, the source of the clacking is clear—four paws, one of them bandaged, and a set of dark, soulful eyes. Hello, you’re talking to a dog, I tell myself. We’re getting derailed.

Stella rests limply in Isabel’s arms. Felix scratches her head.

“Her kidneys are failing,” Felix sighs. “Plus, she tore her CCL—that’s like an ACL, for dogs. She’s been limping around for a few weeks and it’s not improving. We took her to the vet yesterday, and they said it’s time to put her down. We can’t do much except ease her pain.”

What should I do now? I wonder, holding my breath.

A Small Grave

I can redirect them back to the topic Felix introduced before Stella distracted us: his desire to explore setting boundaries with Isabel’s mom. Or I can stay focused on Stella, whose existence I was unaware of till this moment, who’s not connected to any of their current or previously stated goals or problems, and who—it seems to me—is a sidebar to our session.

Also, I know nothing about dogs, except that I’m allergic to them.

I notice—and make the split-second decision to follow—an impulse to try something new. “Would you be willing,” I ask Isabel, going against—it seems to me—my better judgement, “to have a conversation with Stella?”

Isabel bursts out laughing.

“Are you serious?” she responds, with the emphasis on serious.

I nod and shrug, feeling self-conscious, suddenly.

“You mean, like, out loud?” she continues, dumbstruck.

What was I thinking? A prickly sensation has started to work its way across my scalp. I wish I could rewind the session to the moment before I suggested she talk to Stella. My anxiety is interfering with my ability to think straight as I try to formulate the words to redirect us back to where we were before: anger, boundaries, Isabel’s mom.

Luckily, I pause long enough to exhale and notice the shift that’s taking place between the three of us—almost like we’re on an airplane that’s begun its descent without any of us realizing it. It feels like there’s been a palpable change in the emotional cabin pressure. Am I imagining things? I reach up and touch my glasses. They’re on my face. Isabel looks younger—a lot younger. Her eyes fill with tears.

“Let yourself feel this,” I invite her.

As she turns her attention inward—still cradling Stella—I sense we’re heading into the initial stages of a therapeutic process I’ve heard referred to as a portrayal. I first learned about portrayals in Accelerated Experiential Dynamic Psychotherapy trainings. I tried to do them years ago and wasn’t very good at it. As I understand them, they’re improvisational, imaginary scenes rooted in affective and somatic experiences. Ideally, they emerge organically in session. They’re led by a therapist with the goal of unlocking and integrating affect that’s been intellectualized, buried, or repressed. Done well, they’re transformative.

But I’d only seen them work with people—not with people and their dogs.

“See if you can talk to Stella directly,” I suggest.

“I hate seeing her in pain,” Isabel whispers. “I don’t want her to suffer.”

“That’s it,” I encourage her. “Tell her directly.”

Isabel’s face reddens. Stella lifts her muzzle and touches her owner’s chin.

“What are you seeing?” I ask. I remember that in these affectively charged situations, clients can connect with powerful images, memories, or visions that arise spontaneously.

“I see Felix. He has a shovel. He’s digging a small grave in our backyard.” The word grave catches on a sob. “It’s raining outside and I’m holding Stella. She’s wrapped in a blanket, the one I bought her when she was a puppy. It’s hard to say goodbye.”

Felix sits motionless, closely watching Isabel’s face.

“Thank you, sweet girl,” Isabel says quietly. “Thank you for being with me all these years. Thank you for always being happy to see me and wagging your tail every time I come home. Thank you for making me laugh. For jumping up on my lap whenever I feel lonely. For always forgiving my bad moods. For loving me no matter what.”

“She’s listening,” I say. “What’s happening now?”

“I’m putting her in the ground. Using my hands to scoop up dirt and cover her little body. I’m putting more and more dirt in the grave. I’m telling her I’ll miss her.”

“Can you sense what she wants to say to you?” I ask. “What does Stella want you to know before she says goodbye?’”

“You’ve given me a great life.” Isabel’s voice sounds suddenly calmer and steadier. Felix’s chin, on the other hand, has started trembling, and he closes his eyes. “I’m glad you’ve let me sleep on your bed and fed me so many treats. I’ve enjoyed our walks around the neighborhood. I’m glad you’ve picked up my poop all these years.” Her voice cracks with emotion. “You’ve been a great human mom.”

Felix wipes his face on his sleeve.

“I’m happy because I know I can leave and you’ll be fine,” Isabel sighs, continuing to channel Stella. “You’ve got Felix. And I know he loves me, too, even though he always complains about my hair getting everywhere and all the shoes I’ve destroyed.”

Felix and Isabel remain still for so long that if it weren’t for the occasional twitch of one of Stella’s paws, I’d have assumed my router had failed at a critical moment. But that’s not what’s happened. Isabel wordlessly transfers Stella to Felix’s arms. In the process, Stella successfully deposits a single, heartfelt lick on the side of his face.

“I guess I can’t fix everything,” Isabel says. “I need to let go.”

Becoming a Non-Expert Again

If there’s anything I’ve learned after years of doing this work, it’s to steer clear of assumptions about what I think my clients are experiencing as a session closes. My wishful thinking can color my perceptions.

“Can you share what’s going on for you after witnessing this?” I ask Felix.

He shakes his head. Then he looks up at the ceiling.

Isabel chews her lip and waits. It’s easy to picture her as a 10-year-old trying to help her family navigate the challenges they faced in a country that didn’t want them. She looks young and fragile when she lets go and trusts things to unfold on their own. What Felix says next matters—a lot. What if he says something insensitive? I worry. You need to guide the conversation and make sure this ends well. Thankfully, I hold my tongue and remain silent.

“It’s been hard,” Felix begins. “But good,” he adds quickly, perhaps sensing Isabel’s vulnerability and wanting to protect it while buying himself a little more time to think.

Isabel rises from the squeaky couch and disappears from the screen. A moment later, she returns and sits back down with a box of tissues in her hands.

“You know what it is?” Felix offers, pensive. “I just saw you give Stella what I need from you. She needs you to accept this situation and just love her through it without trying to fix it. That’s what I need you to do when I’m stressed out about school or unhappy. Love me through it. Trust my process. I think I finally understand how hard it is for you to do that.”

“Maybe I’m afraid,” Isabel muses. “That’s weird to admit because I’ve always thought I wanted more intimacy and closeness, and that you just wouldn’t give it to me. But I think I’ve been in survival mode for so long that I don’t know how to appreciate you—or us.”

I’m not exactly sure how we got here, but I’m grateful and a little awed by what’s happened. As a fledgling therapist, I may have lacked expertise, but even then, I realize, I still had something important that this session has reminded me to value and cultivate more: the courage to fly by the seat of my pants, on occasion, and try new things I’m not very good at—yet. Watching Felix and Isabel embrace, I realize I don’t want to lose this non-expert openness, even if it means embracing the discomfort of feeling like a newbie on a more regular basis.

Felix and Isabel turn back to face the screen. We all seem to be allowing ourselves to savor the sweetness, as well as the heartache, of the experience we’ve shared.

“See you in two weeks?” I ask.

They nod and smile. I wave and they wave back.

As I click the box that says, “Leave meeting” and the telehealth window goes dark, I can feel the lump in my throat release. Little Stella—with her dark, soulful eyes—hasn’t just helped Felix and Isabel reassess their priorities. She’s helped me reassess mine, too.

 

CASE COMMENTARY

By Erica Turner

After reading Alicia Muñoz’s case study, I paid it the highest compliment—I took a risk with one of my own cases that I’ve felt stuck with. Like Muñoz, I’ve been in the field for some time, and have found ways of working that are typically effective. But from time to time, I find myself stuck—caught in the same amber the client is trapped in. In response, I end up should-ing myself: I should know what to do here. A better therapist would know what to do. That self-doubt stifles the very thing that helps you get unstuck—spontaneity, creativity, and the ability to take needed risks. Qualities that Muñoz exemplifies in her piece.

Muñoz took what could’ve been a digression (the appearance of Stella, Isabel and Felix’s dog) and used it to build a moment of connection between the two partners. Moments in couples therapy where partners share an emotional reality are a powerful and important part of the work. Highly distressed couples rarely have moments like these, so whenever the therapist can foster them, it’s worth doing, even if it seems “off topic.” And in this case, the partners were able to tie their conversation with Stella back to what they need from each other.

For me, the figure of the mother looms so large that I wouldn’t be able to resist exploring how Isabel feels about her mother’s jabs. In front of Felix, she’d likely be defensive and focus on protecting her mom. Because of this, I’d meet with Isabel individually to see if I could help her connect to her own feelings about their relationship. While her mother’s comments are seemingly a judgement of Felix, they’re also implicitly a judgment of Isabel and her choices. I’d work to soften Isabel to the point where she could reflect on and access her own emotional response to her mother, and in turn empathize with Felix’s perspective.

I’d also meet with Felix individually to help him share his pain from Isabel’s mother’s statements. At present, he seems understandably stuck in anger and frustration. I’d try to help him access how it feels when Isabel’s mother makes hurtful statements and Isabel doesn’t defend him, and have him connect to those more tender feelings. Once both partners seemed able to express their more vulnerable positions, I’d bring them back together in session. While they may never confront the mother’s behavior, and she may never change her ways, if Felix and Isabel can be united in the face of it, it becomes a point of connection instead of a point of contention.

The other potential avenue I’d explore is Felix’s stiff recital of therapy words. This is a growing problem as therapy phrases leak out into social media and the larger culture, often without the necessary context. Usually, when I have a client who performs empathy, as Felix does, they’re cut off from both their own and their partner’s emotions. They’ve found a way to say the right answers without having to be vulnerable or even present. On some level, Isabel knows that she’s getting Felix’s representative when he does this, so she doesn’t experience the catharsis of being seen and validated.

I’d want to push Felix a bit, first by asking him what he’s feeling as he’s delivering “empathy talk” to Isabel. I’d then invite him to be curious about how he’d gotten into the pattern of saying the right words, have him reflect on whether it seemed to work when he did this, and ultimately ask him to sit with how Isabel might experience these emotionless recitations on the other side. Hopefully, he’d then be able to recognize his own emotional detachment and figure out what he needs so that he can express genuine empathic support to Isabel.

There’s nothing unusual about Felix and Isabel—they seem like dozens of couples I’ve worked with before. And that somehow makes it even more frustrating to feel stuck with a case like theirs. It can add, at least for me, a more powerful sense that I should be getting it right. Helpfully, Muñoz offers an illustrative reminder about taking needed risks in the face of client and therapist immobility. I tell clients, if you don’t know what to do, do anything different. Any action that moves you in a new direction. One new step in the dance changes the whole sequence.

Illustration by Sally Wern Comport

Alicia Muñoz

Alicia Muñoz, LPC, is a certified couples therapist, and author of four relationship books, including Stop Overthinking Your Relationship: Break the Cycle of Anxious Rumination to Nurture Love, Trust, and Connection With Your Partner (New Harbinger Publications, 2022). Over the past 16 years, she’s provided individual, group, and couples therapy in clinical settings, including Bellevue Hospital in New York, NY. Muñoz currently works as a Senior Writer and Editor at Psychotherapy Networker and as a couples therapist in private practice. She connects with her readers and followers through monthly blogs, newsletters, and podcasts as well as InstagramFacebook, and Twitter. Muñoz is a member of the Washington School of Psychiatry, the American Psychological Association, and the Mid-Atlantic Association of Imago and Relationship Therapists. You can learn more about her at www.aliciamunoz.com.

Erica Turner

Erica R. Turner, LMFT, is the owner of Rosewater Therapy, as well as an Adjunct Faculty member in the Couple and Family Therapy program at the University of Maryland, College Park. She’s the cofounder of Therapy is Not a Dirty Word, an events and advocacy program that works to bridge the gap between therapists and the public. Visit www.rosewatertherapy.com.