Jeweled Net: Virtual Therapy, Real Lessons

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COMMENTARY

In Mahayana Buddhism, the idea of a net or grid of saving power surrounding and interpenetrating all things is reflected in the metaphor of Indra’s net. There is no single source point from which it all arises. Every jewel is intimately connected with all other jewels in the universe, and a change in one jewel means a change, however slight, in every other jewel.

I am not actually a Buddhist—just a psychiatrist with a penchant for metaphor. I had come across the story of Indra’s net in 2019, around the same time Jimmy Eat World released their album Surviving. Every few years over the past couple decades, Jimmy Eat World replaces a sizable chunk of my thoughts with their song lyrics for the first few weeks after each new album they release. In 2019, reading about Indra’s net sparked an association to their song “Diamond”:

When I find myself awake, I put my thoughts down on a page

Half asleep, I’ll make a list, then read back all my greatest hits:

Should meditate, should work out more

Should read until my brain gets sore

Meet someone, go far away

Try being socially less strange

That’s how a diamond grows, you give yourself the right chance over time

Don’t believe them if they try to sell you something quicker

Music and Mirrors

When I was a kid, for a decade and a half, I took dance lessons. As a senior in high school, I performed a dance solo to the song “The Music and the Mirror” from my favorite musical, A Chorus Line.

“All I ever needed was the music and the mirror, and the chance to dance for you,” an auditioning dancer pleads to a casting director. Then the music abruptly changes to mark her dance solo. She turns around toward a line of mirrors near the back of the stage to dance, leading the audience to watch not her body, but her reflection. At 17, I left it all on that stage, popping with jazz hands, in homage to the show that made me want to move to New York City to become a dancer.

I did move to NYC a decade later, not to dance on Broadway, but to complete my residency training in psychiatry. Nevertheless, over the course of my career as a psychiatrist, mirroring has been one of the most essential tools I need to perform at my best. After my residency training at Columbia, where I studied Kohut’s theories on the mirror transference, I moved on to work in far grittier settings (but, sadly, none of them a stage). I have come to experience the act of reflecting my clients’ inner light back to them as one of the main objectives of my work. It is a little like the concave mirror a dentist uses to look at the back of your mouth, but instead of searching for black holes as markers of cavities of pathology, I just look for the light, try to magnify it, and reflect it back. When it happens, it is beautiful, and much more powerful than any medication I have ever prescribed.

Seeing the Light

What if we all knew there was a hidden safety net below us, a jeweled web to lift us when we hit rock bottom? Can anybody else see it? I can, sometimes. And it is beautiful.

I started a private telehealth practice after the COVID-19 pandemic hit. Just over a year into the pandemic, I now have about 150 clients. It still amazes me that during the most isolating year of our lives, I have met 150 interesting and unique people over the internet, and yet not a single one of them knows about any of the others. Last month, I liquidated my retirement savings to purchase a piece of property on the Upper East Side (of Detroit), and hired a team of like-minded therapists, to expand into a full-fledged brick-and-mortar organization called Uncaged Minds Detroit. There, I hope to create a space where that hidden network can finally reveal itself: an “in real life” community where each jewel must simply look around and notice the brilliant reflections of light to appreciate its fundamental interconnectedness.

The first item on the renovation list, after replacing the roof, is tearing down a couple walls to make a yoga studio. I have found myself fantasizing about using the same space as a dance studio, for myself if no one else. This would require the studio to have a large wall mirror. I have been to some yoga studios with mirrors, some without; they have their pros and cons in that setting, so I have been waffling a bit on whether I want one. Today I decided, yes, I definitely want a mirror.

To explain why, I will have to rewind a bit to last December. I evaluated a new client in my telehealth practice, a single Black mother of 2 young children who had reached out for mental health treatment for the first time in her life because her anxiety symptoms had become unbearable. She had been working as a nursing assistant at one of Detroit’s main hospitals, and her floor was one of the first in the hospital to be declared a COVID-19 ward. Almost overnight, the job she once enjoyed became a daily barrage of suffering and death. In the wake of George Floyd’s murder, the idea of those stacked bodies in Detroit hospitals, most of them Black, traumatized many of my clients, but she was the first client I had seen who had actually been on the front lines.

I diagnosed her with posttraumatic stress disorder (PTSD), which I am no stranger to treating after 6 years working in the US Department of Veterans Affairs system. However, I am much more familiar with treating the kind of PTSD that affects veterans, not the kind that hits soldiers. Her trauma was still happening, every day, and her choices were to continue to endure it or be out of a job. I told her, honestly, that medication might help, and that using her medical leave from work would definitely help. I reassured her, before we were even done with our interview, that I would be happy to sign her paperwork. The look of relief on her face confirmed that my immediate gesture of material support would help me forge a therapeutic alliance with her. (This is of the utmost importance for me as a white psychiatrist in situations like these, where I am the first mental health professional a Black client has ever met; here, I am working against many years of deep-seeded and perfectly reasonable mistrust in individuals who look like me and do the job I do.)

When I asked in her initial interview about childhood sexual abuse, she told me that when she was 6 years old, the man her grandmother had married molested her. Afterward, she had told her grandmother it hurt “down there.” Her grandmother stood up, took a can of Crisco out of the kitchen cupboard, and rubbed it on my client as a soothing balm. No words were spoken about it, that day or any to follow, but her grandmother never let her out of her sight again when she came to visit. As I took notes during the interview, under the developmental history section, I simply jotted down the word “Crisco,” knowing I would recall her story immediately when I sat down to write her evaluation note. The gesture seemed so tender and yet so heartbreaking; so careful and yet not careful enough.

A couple months into our work together, the client emailed me to let me know she had just found out her own 6-year-old daughter had been molested by her father, a man my client had broken up with several years prior while she had been living in Georgia. They had no formal custody agreement, but my client allowed her daughter to stay with him in Florida for a couple weeks every summer. She was devastated she had “let this happen” to her own daughter, despite it being one of her greatest fears, given what she herself had experienced at that same age.

At her first visit after that email, I invited her to elaborate about what her daughter had told her, how it all came to light. She took a deep breath and told me, “You’re the first person I’m going to tell this to.” I will not retell an unspeakable story here.

She kept it together until she told me something her daughter had said: “I thought parents are supposed to protect us.” I am not sure, even now, she understands her daughter was not talking about her. It is clear to anyone with just enough distance from this mother’s tortured soul that her daughter was referring to her other parent—the father who had abused her.

She broke down a second time during the interview, when she brought up the upcoming fourth anniversary of her mother’s death. Her mother had been her best friend, and she told me how desperately she needed to talk through this with her, like they would talk through every problem together. “My mom did it all. She was everything for everybody. I need her now.”

COVID-19 stacked up the bodies in Detroit hospitals and gave this client PTSD. COVID-19 was also the underlying necessity mothering the invention, or at least the rapid advent, of teletherapy. As it turns out, telehealth is incredibly convenient and efficient, and I took pretty easily to it. That being said, therapy over Zoom is not without its challenges; technological issues pop up occasionally, and I have spoken to more than one client while they were seated on their toilet (the only private place they could manage for our session).

On this particular day, the uniquely-telehealth therapeutic quirk was around camera positioning. At this point in the interview, while my client spoke of how she longed for her mother, her camera was positioned in such a way that the light from the lamp behind her glared like a radiant burst that filled the entirety of the rest of the screen. I saw only her face and that light. And I listened to 2 voices at once—my client’s, telling me her terrible story, and the one coming from the light behind her, holding space for it for all 3 of us. I could see it, that glaring light behind her. But I knew she could not.

After she was done speaking, I waited a moment, then pointed out how her lamp was affecting her appearance in the Zoom screen. She chuckled and apologized, reaching to adjust her camera, but I stopped her and told her that for me, the light behind her helped me feel her mother’s presence very powerfully. She started to cry. It was simple. I saw light. I reflected it back to her. I did not feel like a medium, but I also did not feel like a psychiatrist. I was just a mirror. I sort of started to cry too.

I told her what I could hear her mother trying to say from behind her. Her mom was saying, as she told me how she longed to speak to her: Girl! You’re talking to me right now!

Her mom was saying, No one can be everything for everybody. But look around. We do the best we can. We lift and we are lifted. Look around.

Her mom was saying, look behind you, you see that light?

Look below you, you see that diamond?

Look around. We are a jeweled web. We are everywhere. We are everything.

Dr Dykema is the cofounder and Clinical Director of Uncaged Minds Detroit, a mental health and wellness resource for low-income Detroiters, with a special focus on the LGBTQ+ community and those impacted by the criminal justice system. She is also a part-time law student and Public Psychiatry Fellow at Wayne State University.