Family Counseling With High-Conflict Separated Parents

Abstract

When parents separate and divorce, they and their children often suffer dire emotional consequences, especially when the parents have a “high-conflict” relationship. When the parents are able to have a more collaborative relationship, however, outcomes are more positive. Family counseling can be an excellent resource for these parents, but the literature in this area is sparse. This article reviews a framework of understanding high conflict in the context of separated parents. After establishing this base of understanding, common challenges in working with high-conflict separated parents are presented, along with nonmodel-dependent strategies for meeting these challenges. Case examples are provided to illustrate both the challenges counselors may face and the strategies that are suggested for meeting those challenges.

Keywords

Divorce Co-parenting High Conflict Conjoint Counseling

Parents who are divorced or separated from each other often experience tension and conflict around issues of child-rearing (Garber, 2004, 2015; Joyce, 2016). Courts and other professionals label some of these families as “high-conflict couples,” though there is little consensus within that literature as to what “high conflict” is (Anderson, Anderson, Palmer, Mutchler, & Baker, 2011; Johnston 1994). When the term high conflict is used, however, it is often connoting negative outcomes for the parents and children involved. Indeed, various research has noted negative outcomes from highly conflictual divorces and separations (e.g., Amato, 2010, 2001; Cummings, Merrilees, & George, 2010; Kelly, 2000). Negative effects have been seen for young children (Amato, 2010; Stadelmann, Perren, Groeben, & von Klitzing, 2010), adolescents (Amato, 2010; Grych, Fincham, Jouriles, & McDonald, 2000), and young adults (Hetherington & Stanley-Hagan, 1999; Sobolewski & Amato, 2007). Furthermore, negative effects from such divorces have been seen to last up to 20 years after the fact (Ahrons, 2007). The current article will provide a description of high-conflict separated parents (HCSPs), identify common challenges that counselors may face in working with them conjointly, provide supporting case examples, and offer strategies for effectively managing those challenges.

Definition of High Conflict

In their extensive literature review, Anderson, Anderson, Palmer, Mutchler, and Baker (2011) conceptualized high-conflict couples using two clusters of characteristics: pervasive negative exchanges and the presence of a hostile, insecure emotional environment. This framework can be applied specifically to HCSPs.

Cluster I: Pervasive Negative Exchanges

The first cluster contains five features of high-conflict interaction: pervasiveness, defensiveness, aggression, escalation, and negative attribution with dualistic thinking (Anderson et al., 2011). Many clinicians cite pervasiveness and researchers who have strived to define and work with high-conflict clients (Anderson et al., 2011; Emery, 1999; Mitcham-Smith & Henry, 2007; Parkinson, 2000). A cycle of aggression and defensiveness is characteristic of HCSPs. Aggression in these former couples tends to be verbal and instrumental attempts at control, while at the same time responding defensively to the partner’s aggression. Sometimes, former couples begin exchanges with a harsh startup (Gottman, 1999), while other times they may attempt to have a constructive conversation, but find themselves being emotionally reactive to perceived insults or threats, which can lead to a rapid escalation of conflict (Anderson et al., 2011). This reactivity and escalation occurs in the context of negative attributions and dualistic thinking about the partner. In brief, each partner sees themself as the “good parent” who must protect the children from the former partner—the “bad parent.” Thus, each person feels simultaneously under attack and on the offensive (Anderson et al., 2011). When there is high risk for severe mutual violence or battering among high-conflict couples, they should not be seen conjointly in treatment and are not discussed in the current article.

Cluster II: Hostile, Insecure Emotional Environment

The second cluster contains an additional five features of high-conflict interaction: strong negative affect, emotional reactivity, lack of safety, triangulation, and mutual distrust (Anderson et al, 2011). Predictably, parents involved in a high-conflict divorce have high levels of anger and hostility toward each other. These feelings likely contributed to the divorce/separation and have intensified since that time (Johnson, 2007; Mitcham-Smith & Henry, 2007). Such negative affect often contributes to high levels of emotional reactivity, making even seemingly innocuous interactions more volatile. Not being sure of when the other parent may lash out emotionally contributes to the creation of an unsafe emotional environment. The parents may feel unsafe interacting with each other, and that lack of safety often trickles down to negatively impact the children (Elrod, 2001). Experiences of an unsafe and volatile emotional environment lead to increased mistrust between the parents (even more so that may exist in the course of a less conflictual divorce/separation). This distrust can be related to the ability to care appropriately for the children, and it can be related to a fear that one parent may strive to alienate the other from the children and other important people involved with the family (Johnston, 1994; Sauber, 2006). This distrust can motivate the parents to form triangles with children, family members, court representatives, and counselors, often to deleterious effect (Garber, 2015; Neff & Cooper, 2004).

There are many identified consequences for parents and children involved in high-conflict divorce and separation. Such consequences include delayed adjustment for all parties, strained parent–child relationships (including parental alienation syndrome), use of negative coping strategies (e.g., substance abuse), depression, anxiety, and child abuse (Anderson et al, 2011; Boyan & Termini, 2005; Donner, 2006; Gaulier, Margerum, Price, & Windell, 2007). Efforts to intervene with divorcing families have largely been psychoeducational and broadly focused on all divorcing and separating parents (Grych, 2005; Pedro-Carroll, Nakhnikian, & Montes, 2001). With notable exceptions, there is little work published when it comes to doing successful conjoint counseling with high-conflict former couples (Ellis & Boyan, 2010; Lebow, 2003; Lebow & Rekart, 2007; Owen & Rhoades, 2012). The methods proposed by these authors offer instrumental strategies for treatment through theory-specific lenses. In the current article, common challenges for all practitioners who work with HCSPs are presented along with suggested strategies for meeting these challenges. Discussion is based in the two-cluster conceptualization of high-conflict couples as suggested by Anderson and colleagues (2011). Each challenge and strategy is accompanied by a case example. The case examples represent amalgams of several former couples seen by the author and a cotherapist. Personal details have been altered to protect the clients’ identities.

Example Cases

Former Couple 1: Harriet and James

Harriet (41) and James (39) are never-married parents of Kelly (4). Harriet is a college-educated businessperson and James is a high-school graduate with a career in law enforcement. They separated when Kelly was 2 years old and had been embroiled in court battles regarding custody, visitation, and child support since that time. They were referred to conjoint counseling by a family court representative.

Former Couple 2: Mark & Erin

Mark (35) and Erin (33) are divorced. They are parents to Terri (15) and Bill (11). Mark is a college-educated athletic trainer and Erin is a college-educated actuary. They separated due to a history of mild mutual violence and due to Mark’s affair with a friend of the couple. They were referred to treatment by a family court representative at the outset of their legal divorce process. At that time, both were still residing in the family home on their lawyers’ advice.

Challenges and Strategies Relating to Cluster I: Pervasive Negative Exchanges

Challenge 1: Content Versus Process

Challenge description

Many of the issues and challenges that HCSPs face in Cluster I center around their focus on content rather than process. This can be attributed partly to the intensity of their breakup and partly to the legal divorce/separation and custody processes. The legal process requires a content focus—each parent must establish the reason why they should be awarded their desired custody arrangement. By definition, this includes focusing on stories that idealize one parent and demonize the other. Thus, their relationship has been defined by content. While this may be effective within the legal system, in a relational system, this mind-set may prevent the parents from working together effectively (Russell, Beckmeyer, Coleman, & Ganong, 2016). In the extreme, this can contribute to parental alienation (Elrod, 2001; Gardner, 1998). This is especially relevant for parents who are already prone to high levels of conflict. The challenge for counselors working conjointly with HCSPs is to refocus the parents from their rigid content focus to a process focus. This is complicated by the emotional investment each parent has in the different content stories.

Case example: Harriet and James

At the outset of treatment, Harriet and James were stuck in the content of their visitation exchanges. Harriet had remained in the family home and James had moved to a different location. When it was time for James to pick up or drop off Kelly from a visit, he would simply come into the home to do so. Harriet experienced this as a boundary violation and created a rule that he was not allowed inside the house—rather he was to ring the doorbell. He followed this rule for a short time, but began entering the house again due to “bad weather.” Harriet continued to be upset by this and forbade him from coming to the door. He was to remain in the driveway and Kelly would come out (or go in) on her own. Again, James followed this rule at first, but quickly began pushing the boundaries by coming to the door and occasionally entering the home. Harriet then forbade him from even pulling into the driveway, stating that she did not want him on her property. He was to stay in the street and Kelly would walk back and forth from the home to the car on her own. James refused to follow this rule, stating that it was dangerous for Kelly to walk out to the street. He continued to come to the door but ceased going inside the house.

Strategy: Process focus

This example is one of many content stories that kept Harriet and James mired in conflict. Most of their stories revolved around power struggles, but when the counselors pointed this out, Harriet and James seemed surprised. Whenever Harriet and James became embroiled in a persistent argument about any content issue, the counselors refocused the discussion on the power struggle and dynamic. Another helpful strategy is to refocus the clients on themselves rather than on the other. This may initially lead to an increase in the anxiety of one or both clients. They have become so invested in their content and the actions of the other parent that the counselor refusing to be drawn into it could be interpreted as a lack of validation. To make this shift effectively, it may help to focus on a visible outcome. In the case of Harriet and James, their power struggles were in part related to boundaries. By focusing in-session discussion on how the parents’ boundaries needed to shift so that each felt emotionally safe and that Kelly’s needs from each of them was prioritized, the counselor was able to eventually prevent Harriet and James from continually getting stuck in content during sessions.

Challenge 2: Winning

Challenge description

Inherent in the legal process of divorce and custody hearings is the idea of winning. Each lawyer wants to win the case (which is, after all, what they are paid to do), and this attitude is often transferred to the parents, if they do not have it already (Baum, 2003). In the coparenting relationship, this focus on winning can be seen when each partner focuses on a story about when the other one was “wrong.” When one such story is brought up, the other parent frequently will bring up a different story in which their ex-partner was wrong. This pattern is similar to that of criticism, defensiveness, and countercriticism identified by Gottman (1999). The process often involves attempts at retaliation against real and perceived slights or harm caused by the former partner (Levite & Cohen, 2012). When this pattern is allowed to continue, the couple remains content, rather than process-focused, treatment goals are easily forgotten, and the coparenting relationship suffers (Baum, 2003).

Case example and strategy: One at a time!

The key to overcoming this challenge is twofold. First, the counselor must decide if the stories being told warrant content-level attention. Second, the counselor must focus the couple on taking on one issue at a time. Harriet and James displayed this focus on winning in their arguments about Kelly’s health. Harriet reported that Kelly frequently came home from James’s house with cuts and bruises—a covert (at first) accusation of abuse by James. James responded to this by stating that they play outside and go camping and sometimes she gets minor cuts and bruises. He then launched into a story about Kelly having frequent urinary tract infections. James reported that Harriet refused to take Kelly to the doctor for these issues, and when he took Kelly and got her medication, Harriet refused to give it to Kelly. Harriet responded with a direct accusation that James abuses Kelly, and he countered by accusing Harriet of medical neglect.

Clearly, these stories merit content-level attention since health and possible abuse are on the table. In counseling, we focused on each issue separately, being sure to redirect distraction attempts onto the issue at hand, through either nonattending or direct refocusing. Even so, this discussion of content must be housed in a framework of process—we focused not only on maintaining and improving Kelly’s health but also on how Harriet and James managed these issues. We made their attempts to “win” overt and redirected them to thinking about how Kelly could win rather than one parent or the other.

Challenge 3: Negative Attributions/Dualistic Thinking

Challenge description

A common mind-set that is seen in HCSPs is that they see themselves as the “good” parent and the other as the “bad” parent, with no room in between (Anderson et al, 2011; Cohen & Levite, 2012; Elrod, 2001; Levite & Cohen, 2012). This is likely due to a combination of the adversarial court process and the emotional trauma of the separation or divorce (Baum, 2003). When parents cannot move past this mind-set, however, they become very suspicious of one another. Any positive behavior by the other parent, whether in their relationship with the child or with the coparent, is ignored or seen as an attempt to manipulate. This emphasis on the negative and ignorance of the positive can be transferred onto the child, with negative consequences (Cohen & Levite, 2012; Grych & Fincham, 1990).

Case example and strategy: Reframing

A strategy for overcoming this challenge is to reframe each parent as both good and bad. In this way, we can acknowledge the things that each person does well without ignoring struggles that may be salient in the coparenting relationship. The goal is to have each parent see the positive qualities of the other. For example, we can again look to Harriet and James’s conflict about Kelly’s health. Before we were able to redirect away from the “winning” stance, James had stated that “Harriet doesn’t care about Kelly’s health, so Kelly shouldn’t spend time there.” This, of course, was countered by Harriet’s statement that “James abuses Kelly and she shouldn’t spend time there.” Thorough assessment of these issues revealed that neither parent was abusive or neglectful. Both parents acknowledged that this was likely and that they were caught up in the battle. We shifted focus to discussing what the other person does well as a parent. This is a difficult transition to make; however, it is an important step toward forming a positive coparenting relationship (Ahrons, 2007). Eventually, both Harriet and James were able to identify strengths that the other person had as a parent.

Challenge 4: “The Truth”

Challenge description

This final challenge in Cluster I can often be the most difficult. Many HCSPs get stuck in the stories of the end of the parents’ relationship or in struggles during early separation. This is a time of intense emotional upheaval and can be traumatic for some (Taylor, 2004). When the parents have different versions of the story of their breakup or of the story of a notable incident in family life, it can feed the negative attributions discussed previously (Cohen & Levite, 2012; Levite & Cohen, 2012). Each person sees their own story as “the truth” and takes the position that the other person is lying or trying to manipulate the situation, the parent, or the counselor (Bernstein, 2007).

Case example and strategy: Present focus

An important step in overcoming this challenge is to separate preseparation conflicts from postseparation conflicts (Bonach, 2005; Russell et al., 2016). Here we emphasize that the couple relationship is over and that those conflicts will never be resolved. Instead, we encourage parents to focus on the children and the coparenting relationship. In instances when such conflicts consistently recur, we often use a metaphor of putting the issue “behind the curtain” or “in a box.” By taking this stance, we acknowledge that the pain resulting from that conflict is not gone, simply that it is not primary. For example, we can look to Mark and Erin. Due to the history of mutual violence, they were seen separately at first. In Erin’s session, we asked about the challenge of both of them remaining in the home. She stated, “It’s been terrible. I’ve been sleeping on the couch, and just this morning I woke up when Mark stormed into the living room and started screaming at me and throwing pillows at me for no reason!” In Mark’s session later the same day, we asked the same question. He told the same story of sleeping on the couch and being woken by Erin screaming and throwing pillows at him. It is likely that at least one person is lying about this story. In this instance, however, the objective truth does not matter¹—these were stories about not feeling safe in their shared home. In future conjoint sessions, when Mark and Erin tried to convince us that their own version was the truth and that the other was lying, we encouraged them to put the content of that argument behind the curtain and refocused on the process of maintaining a safe environment while they were still forced to share a home. Thus, the issue of safety could be addressed without becoming embroiled in a content-based and likely endless argument.

Challenges Related to Cluster II: Hostile, Insecure Emotional Environment

Challenge 5: Stonewalling

Challenge description

The damaging power of stonewalling—refusing to overtly communicate—in committed relationships has been well-documented (Gottman, 1999). While the nature of a relationship between coparents greatly differs from that of intimate partners, stonewalling remains a powerful relational maneuver that is often a barrier to successful coparenting relationships (Cohen & Levite, 2012; Levite & Cohen, 2012). In counseling sessions, stonewalling can be seen when one parent chooses not to participate by remaining silent or by leaving the counseling room. One must use caution when interpreting stonewalling as a power move in this context, however. The history of conflict in the relationship, both pre- and postseparation, may reveal stonewalling to be an adaptive choice—it may be self-protective rather than manipulative (Gottman, 1999).

Strategy: “Safe” environment

While it is likely that neither partner will never perceive the relational space between them as truly safe, it is incumbent upon the counselor to make the counseling environment as safe as possible. Part of this includes reframing the stonewalling as an expression of power or a part of a power struggle between the parents. How did the power struggle escalate to the point of stonewalling in session? Focusing both clients on their interactional processes can clarify this. A frequent pattern seen in practice is that one or both partners make overt attempts to push the other’s buttons to the point of explosion (Anderson et al., 2011). The stonewalling challenge can be overcome by the clients refocusing on the point of the counseling—coparenting the children. To assist in this process, it is helpful to establish interactional ground rules that help maintain an appropriate focus. It falls to the counselor to reinforce these rules in session by refocusing clients away from power struggles and onto the coparenting issues. Individual sessions to prepare clients for the challenges of counseling may also be helpful.

Case example: Mark and Erin

Mark was a very assertive person, while Erin was more withdrawn. Frequently, Mark would talk over, interrupt, or otherwise try to overpower Erin in conversation. The counselors interrupted this process by setting a rule that only one person could talk at a time. When Mark broke that rule, the counselors would interrupt him and ask him to be quiet, which was frequently effective. Even when the counselors successfully refocused Mark, Erin would sometimes storm out of the office. The counselors framed Erin’s stonewalling as the only way she knew to exert power. We worked with Mark to help him stay focused and resist the urge to antagonize Erin. We worked with Erin to “rise above” her discomfort and stay focused on coparenting topics. At the outset, we agreed that Erin could leave the room if she became overwhelmed and we would take a 5-min break. Over time, we worked with Erin to be able to manage her discomfort more effectively, and she was eventually able to stay engaged. This coincided with Mark’s increased ability to stay focused on coparenting topics.

Challenge 6: Triangulation and Transference

In most forms of couple and family counseling, triangulation is a salient issue. Clients expend a great deal of energy attempting to align with the counselor in resolving a conflict. With intact couples, such triangulation can make for difficult counseling (Bowen, 1978). With HCSPs, triangulation can become crippling to the counseling process (Lebow & Rekart, 2007; Neff & Cooper, 2004). The parents have become used to working within the legal system. The court system can be translated (albeit roughly) into counseling language—you must triangulate the judge onto your side. Combined with a mind-set of having to win (Cluster I), this can lead to a tug-of-war in which each parent attempts to pull the counselor(s) to their own side. When one parent feels as though the other is becoming successful at this effort, their own efforts are increased. Alternately, the “losing” parent may interpret perceived counselor support of the winning parent as betrayal, severely damaging the working alliance (Friedlander, Lee, Shaffer, & Cabrera, 2013; Neff & Cooper, 2004).

Strategy: Working alliance

Having a strong working alliance in the first place is the key to overcoming this challenge (Friedlander et al., 2013; Lebow & Rekart, 2007). Counselors must strive to have a strong bidirectional alliance with both clients. This can be accomplished by using multidirectional partiality (Boszormenyi-Nagy & Spark, 1973; Lebow & Rekart, 2007). When multidirectional partiality is displayed in conjoint sessions, each client observes the counselor supporting or challenging their own statements and ideas and sees the counselor supporting or challenging the other parent’s statements and ideas. If this process were to happen in individual sessions, each individual might leave that session convinced that the counselor was on their “side” and try to use that against the former partner. Because of this risk, we do not recommend seeing clients individually. In order to minimize triangulation and to help build a supportive alliance, cotherapists are frequently employed (Lebow & Rekart, 2007). When working with heterosexual couples, effects of the gender of the counselor can be mediated through the use of a male and female cotherapy team. In this context, the clients experience their same- and opposite- gendered counselor as accepting and rejecting both themselves and their partner.

Case example: Harriet and James

Over the 5 months of Harriet and James’ counseling, both consistently tried to triangulate both counselors to their side. This took the form of being entrenched in patterns of winning and overfocus on the truth. When the counselors responded to efforts at triangulation by using multidirectional partiality and attempting to help each person see the legitimate portions of their former partner’s “side,” both were emotionally reactive. Over time, both were able to adapt their approaches in counseling sessions so that more productive work could be done. This change was not permanent, however. Eventually, Harriet’s inability to triangulate the counselors onto her side led to early termination of counseling. Harriet specifically stated that she was ending treatment because the counselors would not side with her. She did not perceive, however, that we had sided with James.

Challenge 7: Expectations

For most HCSPs, the idea of “couples” counseling for their coparenting issues seems bizarre. Many expect that their divorce or separation means that they do not have to interact with each other anymore. Some come to counseling suspicious that this is an attempt by their ex-partner to manipulate them. Sometimes, it is an attempt to manipulate one another—a way to reenact painful moments in order to get revenge upon a partner who has caused pain (Bernstein, 2007). Others still harbor hopes of resurrecting the intimate relationship. Unless both parents are congruent in their goals—improving the coparenting environment for the benefit of the children—successful counseling is unlikely (Lebow & Rekart, 2007; Levite & Cohen, 2012).

Strategy: Setting the tone

From the outset of conjoint counseling, the counselor must be clear both about what the counseling is and what it is not. This counseling is not aimed at healing wounds each parent suffered in the relationship and the separation. It is not aimed at reconciliation. The only goal of this counseling is to help the parents build a cooperative coparenting environment, thereby preventing negative outcomes for the children. As such, the counselor must be aware of attempts to direct the course of counseling in other directions and refocus onto coparenting when appropriate.

Case example: Mark and Erin

Mark and Erin self-identified as “born-again Christians” and as such, both had very strong feelings about divorce. Erin reported that through prayer and meditation, she had come to accept that divorce was the “right” decision for her and came to counseling with that mind-set. At the outset of counseling, Mark had not developed a similar perspective on their relationship and tried several times to turn the counseling toward reconciliation. Each time, the counselors refocused the conversation, stating that the relationship has changed to parenting only. It was also recommended to Mark that he consult with his pastor and/or an individual counselor to help him deal personally with the transition in his relationship with Erin.

Challenge 8: Countertransference

Challenge description

The experience of working conjointly with HCSPs can be intense and overwhelming due to the intensity of the sessions and the various challenges discussed in this article (Levite & Cohen, 2012). Consistently dealing with HCSPs’ attempts to manipulate and triangulate both one another and the counselor can be draining. Progress, when it happens, is frequently slow, with many relapses, which can increase a counselor’s frustration with clients (Lebow & Rekart, 2007; Levite & Cohen, 2012). When the counselor struggles to manage their own reactions well, progress can become even more difficult or clients can be harmed (Levite & Cohen, 2012).

Strategy: Collaboration and supervision

A cotherapy team can be very helpful in working with HCSPs in general and can be protective against inappropriate countertransference reactions in particular (Levite & Cohen, 2012). The two counselors can consult with each other before, during, and after sessions to help keep the counseling on target and to deal with the professional and self-of-the-counselor challenges that may arise. Supervision is another resource counselors of HCSPs can use to prevent negative countertransference reactions (Levite & Cohen, 2012). Regardless of the presence of a supervisor or cotherapist, counselors must be patient—with both themselves and their clients—and sensitive to their own self-of-the-counselor issues while engaged in work with HCSPs.

Case example: Marian with Mark and Erin

Marian was my supervisee and cotherapist with Mark and Erin. At the time we were working with the clients, Marian was dealing with some challenges in her own family life. In session, the clients were discussing Mark’s use of the children against Erin, which included withholding them from church-based youth group activities. During this interaction, Marian became overwhelmed and expressed this by berating Mark for his behavior. Since I was present as a cotherapist, I was able to refocus the session on dealing with the issue and maintain a working alliance. Marian and I addressed her self-of-the-counselor and countertransference issues in supervision.

Case Dispositions

Harriet and James

Over 5 months of treatment, Harriet and James seemed to be making good progress. They were able focus their interactions outside of counseling on parenting issues. They developed methods to communicate about sensitive issues when Kelly was not present and kept their interactions civil. Throughout this time, the counselors maintained a stance of multidirectional partiality. During what turned out to be the last session, Harriet and James relapsed into an argument about Kelly’s health care, during which we focused them on the process of solving their issue rather than taking sides. The day after this session, Harriet called the office to state that she felt our refusal to take sides was a betrayal of her, and she would not be returning to counseling.

Mark and Erin

Despite the difficult start and issues with countertransference, Mark and Erin made consistent progress over 10 months of counseling. Through our use of the strategies discussed in this article, the clients were able to refocus their relationship on parenting only. They decreased the intensity of their conflicts with each other and focused their energy on the children. The decision to end counseling was a mutual decision between the counselors and the clients.

Conclusion

Many of the challenges discussed in this article are amplifications of challenges that arise in other forms of couple counseling. The dynamics that accompany parenting between high-conflict separated and divorced parents make it more difficult for both the clients and the counselors to overcome these challenges. These challenges align with the two-cluster definition of high-conflict relationships identified by Anderson and colleagues (2011). Approaches to these challenges cut across theoretical orientation and emphasize process over content and a high-quality working alliance.

Working with HCSPs is a very challenging work, and progress is very slow. As can be seen in the case of Harriet and James, progress is easily lost. The case of Mark and Erin, however, shows that even when counseling seems unlikely to succeed, a focused counselor or cotherapy team can do good work.

Footnotes

Acknowledgment

I would like to thank Melanie Vartanian St. Germain—my fearless cotherapist for many of the cases described in this article—for her hard work and inspiration.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Note

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