Ben Yalom on Narrative Therapy, Theater, and Writing with my Father

An Intellectual Heir to my Father?

Lawrence Rubin: I’m here today with Ben Yalom psychotherapist, theater-maker, and author. His book, Hour of the Heart, which he wrote along with his father, Irvin Yalom, explores the complexities of human relationships and personal transformation based on one-hour consultations between the senior Yalom and his clients. In addition to his therapeutic work, Ben is the founder and artistic director emeritus of fools FURY Theater Company in San Francisco, where he directed numerous acclaimed productions.

You’ve now written a book with your father, as his light is fading. I wonder if you consider yourself to be his intellectual heir.


Ben Yalom: I think I am “an” intellectual heir to my father [Irvin Yalom] to the extent that there are some things that I can do that he has done, and others that I can’t. I could never be my father’s full intellectual heir because I would have 40 or 50 years of reading to catch up on first!

But there are many things that we’ve experienced together, beginning when I was growing up. My parents were further along in their careers, and at that point, there was only one of me because my three siblings were already grown. So, I imagine that their dinner table conversations were a little different from the ones I had with my parents, which were definitely weighted towards their interests. So, almost by osmosis, I probably gathered a lot of knowledge in the humanities. I imagine my siblings did as well, but I think I probably was more exposed in many ways. That’s just in my DNA, or what might pass for my foundational upbringing.

I have done some thinking lately because I’m working on some essays and a book proposal, on what it would mean to sort of take up the mantle of some of my father’s and my mother’s intellectual work and writings. As I say, I don’t think I can ever really be my father’s heir or equal in the sense of having that deep wealth of knowledge about philosophy and therapy and the humanities that went into his writing.

But another very important aspect of his writing that resonates with therapists and students of therapy is that he’s extremely open and honest about himself and his flaws, as well as in the sharing of his ideas. And those are things I very much can do in my writing. In that regard I think I can deliver on his way of being and his way of sharing and his way of teaching.

I’ve certainly reached a place in my life which is quite relevant to the book we just completed, Hour of the Heart. I’ve reached a place in my life where I’m very willing to be quite transparent about most things in my life with my readers and with people who come to ask me for help, I am already finding that this is helpful, much in the way that my father describes in his work. One other aspect that I’m trying to bring into my work, both as a writer and a therapist, is my background in theater.

While that background and foundation does not come from mountains of books that I have not read, I do have something analogous to that in my 25 years in making theater. Particularly in doing types of theater that are deeply engaged in mining the richness of the actors’ lives, rather than the psychology of characters that comes from a script written by someone else. My experience in theater centers around working with peoples’ experiences and psychologies and stories, and in understanding how the body can be used along with the connections between the bodies and emotions in storytelling for character development.

This knowledge is quite real and substantive and can be very powerful for a lot of people. It has taken me some time to understand how to use it therapeutically. I’ve been trying to find my way to weaving these things together in a deep and compelling way to help people, and I’m now starting to see real results, which is exciting.


LR: You’re speaking of the FoolsFURY Theater Company. What was your role in it?
BY: I founded and led the company for most of its existence. I first went to the Iowa Writers Workshop for graduate school, to write fiction. But when I got out, I learned very quickly that I didn’t like sitting alone in a room writing. And all along I’d had a parallel passion which was doing theater.

But I found that I was not that interested, or satisfied, by the theater I was seeing produced. Even in a pretty interesting and experimental place like San Francisco, much of the mainstream work was very traditional American theater. That is, a script was given, people performed on a stage, and it was almost like in many ways, putting a movie on the stage. That’s a vast oversimplification, but to some extent it’s true.

I became really interested in ideas and concepts that could be expressed in metaphor and movement, and that tackled deep themes. I was much less interested in realism. What I really wanted to explore was “What could be unique about the experience of live theater?” which was completely different from trying to put realism on stage. So, I started exploring and meeting people in theater companies in the Bay area, trying to get them to hire me to direct plays. But I found quite quickly that people were interested in working with me, but nobody was going to hand over the keys of their theater company to let me create my sort of experimental vision. Finally, my mentor came to me and said, “Okay, well, I guess that means it’s time for you to start your own company.” So, I started a company to produce one play at the time, and when it came time to actually put it on stage, I was told I needed to have a company name.

You asked earlier about the name foolsFURY. I dreamt this up as a collision of fool – our absurd and comic human position in the universe – and fury at the injustices we do to one another. I meant only to do one or two plays in order to put my name on the map. Then it became a 20-year endeavor, because we got to do the things that I wanted to do artistically that nobody else was ever going to hire us to do––to raise complex questions and be deeply curious. It was a place of experimentation and research, and ultimately a place where we hosted many other companies and nurtured their creative visions, all working in this sort of space between somebody delivering a script versus the actors and the designers and the directors creating original plays.

What I wanted was people who could do powerful realist scenes but also explode the stage, do everything that was possible to create an experience that one had to be involved with live, and that could mean the type of immersive theater that we’re seeing very strongly now, 25 years later. It might mean acrobatics. It might mean dance. It might mean breaking out of realism into some sort of crazy imagination, stylized work, and then back into realism.

At the time, most of American theater, and definitely most of the mainstream theater that was happening in the Bay Area, as well as what all the major conservatories were teaching, were variations on realist acting and was psychologically driven from the top down. I had to become an expert in things that moved from the outside to enter the bottom up; start with the body, get to the mind as opposed to starting with the mind and getting to the body. So, my expertise is very much in a number of contemporary forms that are bodily-oriented, driven by impulses in the body, or understanding a feeling in the body and how that might come out, or how a certain use of the body might generate an emotion as opposed to the inverse.


Beyond Thought and Language

LR: How have you made the transition from the theater to the therapy space?
BY: I am trying to bring this “bottom up” orientation into some of my therapeutic work. This means developing ways of getting people to find or explore—if we think about Narrative Therapy—stories of self, not verbally, but through exercises that are more physically oriented. And my feeling is that one of the challenges of traditional talk therapy is that it’s so talk heavy; this works really well for some people, but not for others. The discursive, rational language that we use isn’t the easiest way for some clients to explore themselves, or to express what they find when they do. So, I’m trying to build some tools that go with narrative and existential therapies, but which help people explore and express themselves in a less language-centered way.

LR: It’s interesting that we started the conversation around the question of whether you are ‘the’ or ‘an’ intellectual heir to your parents’ careers, particularly your father’s and specifically with regard to therapy and your understanding of the human condition. But it sounds like your work in the theater, and how you’re integrating it into therapy is almost anti-intellectual or contra intellectualism.

BY: I’m not going to disagree, but I’d say it’s more a different angle than an anti-intellectual one. The first thing that comes to mind when I’m asked about my theory of change is that peoples’ living understanding of what is meaningful for them is critical. That might look like identifying their “quest in life” or their search for meaning in the universe, and then living in ways that are more aligned with those meanings or ethics. To me, that’s a very existentialist approach through which I’m saying, “What do you find truly important in your life at a deep level?” This is inherent in my father’s work, but I don’t know that all people can answer that solely through thought and language. I think meaning exists within the framework of all the other existential questions, but I don’t think that peoples’ understanding of what is meaningful for them is always easy to articulate verbally.

LR: How do you use movement or poetry or other experiential types of explorations to help your clients make sense of some of the larger existential questions?

BY: I’m doing it based on many, many years of experience with certain theatrical forms. I also have a great network of mentors that I’ve met over the decades that have guided me in explorations or exercises that allow people to go to deeper places within themselves both individually or within a group. Often, they come out with words on the other end, but the theatrical and dramatic and dance work is usually inspired by the internal work they’ve done or are doing.

Over the decades I’ve watched some of the best theater makers and dance makers I know do this kind of deep work, and I’m constantly reminded how powerful their experiences have been. My goal has been to use these highly developed skills and expertise to help therapy clients reach those deeper, meaningful places within themselves, and between themselves and others.

An Embodied, Experiential Journey

LR: Can you give me an example of a client who you helped to bridge that divide between word and experience?

BY: Right now I’m doing this work in groups. Maybe someday we’ll get to a point where I’ll bring it into individual sessions.

One person I was working with lived with a great deal of shame. She was a Middle Eastern woman battling the shaming cultural practices that came from being a woman and from her parents. Her constant pattern in life was to hide from her parents and then dig her way out and do the things that her parents then disapproved of. None of them were particularly bad things, but those things didn’t fit the culture.

Sometimes before group sessions, I will do what I call a “mission interview.” This is a format Tom Carlson, Garret Rutz, and I are working on which is basically a very short, intense, Narrative Therapy-based re-authoring exercise, in which I would say something like, “How did you decide that you wanted to become a therapist?” or, “Can you tell me a story about a moment where you made that decision by going down one path?” or, “What were the things you were fighting against in your life that then led you to take up the mantle of fighting against that?” The mission that she developed, should she become a therapist, was to provide a place where people could come to put down their shame and be treated with love, and that she would be the person to greet them with love and offer them a place of safety. So essentially, what I created in that hour for her was the opportunity to think about a story about where she came from, the practices she was up against in her life, what she was doing to combat those practices, and the solution or power or passion that she pursued to fight against those shame-inducing practices.

She understood the mission you jointly articulated for her, at which point I said something like, “We can do this verbally, or we can do it non-verbally where you can get into their body.” She picked, and we continued working together. I offered her some guidance, asking “As you reflect on what you’re really up against in your life, see what that feels like in your body? What is the power, the thing that’s driven you to keep fighting on it against this?” So, we work either way. We identify where they came from, what her big challenges in life are, and hopefully determine what are the strengths and skills or hopes and dreams that she has to fight against this.

Okay, that’s the conceptual background. Then I’ll get them into their bodies and teach them quickly what it is to make a gesture, because it’s the smallest building block of a dance. That seems to be much easier for people to instead of me saying, “go make a dance,” which can be very intimidating. For example , I can say, “Larry, make three gestures, and then let’s put them together.” You just created a little dance!

So then we’d do an exercise where they really get into a meditative space where they spend about 15 minutes just letting their body move, really articulating it and that becomes a bit of a meditation in its own right. I’ll ask them to follow one part of their body which may have begun as an impulse, and I ask them to start paying attention, trying to let their mind and body work together. At that point, I start to bring in the image of the thing that they’re up against in their life. I’ll ask, “How does that feel when you bring that into your story, into your body? Where does it go?” Usually, they’ll go on a little internal journey that’s physical and emotional.

From there, I’ll ask them to bring in the thing that they use to fight against that or to overcome that which takes the meditation in a different direction. I might ask them to just notice at some point and pull a couple of gestures that come up out of those two sides—the thing they’re up against and how they stand up to it. So here they are building a little vocabulary of movement related to their specific stories

Two more steps! They can then do something that’s called a “container exercise” where I ask them what it feels like if they’re inside a container or something that’s holding them in and feeling what that’s like. At some point I’ll say, “I want you to start finding your way out using your specific strengths and skills. And then go back into the container and force your way out again. Then I might say, “The thing that you identified as your challenge in life is that container…that’s the thing that’s forcing you when you go through that…so, how do you use your skills to get out and what does it feel like to get out?” They do it over and over again, and I ask them what they learned from that experience. (And just to note the lineage here, this is a modification of an exercise I learned from the brilliant teacher Steven Wangh, and which he in turn modified from work with the great Polish theater maker and theoretician Jerzy Grotowski.)

I ask them to focus on any gestures or thoughts or words that came out of that such as poetic or metaphorical words or sounds. Next, I might say, “I want you to start on one side of the room in your ‘up against’ state, or the place where you’re fighting against or being contained, and then to move to the other side of the room using all of these gestures that we’ve created, and while going from there to there, somewhere in the middle, there’s going to be a transition, (which in narrative terms is like an agentive turn) where you shift into taking control of this thing. Sometimes people have to go back and forth—but eventually we help them move through to this side. And so they’re getting a very embodied, experiential sense of this inner journey, This is the bottom-up process!

Writing with My Father

LR: I always considered traditional Narrative Therapy to be a very literary, intellectual type of clinical venture, but it sounds like your orientation is to the non-literary or anti-literary, sort of in the way that your divergence from your father’s work led you to an anti-intellectual, experiential place.

BY: One of the things that I saw in Narrative Therapy, at least in the readings, were ideas about ritual ceremonies. Those really caught my attention,. And now, in addition to traditional sessions, I do these experiential exercises in group format that can run six-hours long, and even multiple day intensives.

LR: So, because of your background in theater, interest in Narrative Therapy, and willingness to depart from the written word, you’re no longer committed to that traditional template of one-hour talk therapy. It’s interesting, however, that you just finished co-authoring a book with your father called, Hour of the Heart, where the explicit purpose was to highlight his commitment to continuing his therapeutic career in the shadow of some limitations by offering one-hour sessions with people around the world. Can you share what that experience was like for you?

BY: Strangely, not difficult because my understanding of therapy goes way back to my first exposure through my father’s vision, our dinner table conversations, and later his writings, particularly Love’s Executioner. I read those stories in draft and gave him feedback on those. I did the same on pretty much every book after that so I understood his thinking about therapy and his desire to make a literary form that incorporated therapy, and featured the clinician reflecting on his own thought process and the therapeutic encounter. So, my formation was not only as a therapist but as a writer.


LR: So, it was a natural progression for you?


BY: We had worked together in the past. I had edited a book called The Yalom Reader years ago which was the first big omnibus of his work. In more recent years, I had given very significant feedback on a number of his books.

I did, however, decide that it was just too demanding for both of us to work together until the mountain of stories for Hour of the Heart grew and his memory began to decay. Eventually the manuscript grew to be between 45 or 50 stories, and it was too challenging for him to put them side by side while holding onto the threads that were going on between them.

Some of the stories were sort of repetitive of one another. It’s not because he wasn’t interested in the process or fully invested in each one of those stories, but because he had forgotten what he had written. For example, story 40 may have covered some of the themes already covered in story number 12. At a certain point, we agreed that in order to help him pull it all together, he needed somebody to work with who knew him well enough, knew his way of writing well enough, felt confident enough, and had enough of his confidence to really revise and rewrite. So that’s the work that I undertook.
Embodied writing


LR: From a Narrative Therapy perspective, what do you think your dad values in you that led him to invite you into this project, even though you have a challenging history of working with him.
BY: That’s an excellent Narrative Therapy question. I can only speculate. I think we have a pretty powerful bond and it’s different for all the children. But I am the one who was most engaged in writing. As I went through grad school and after, when I wrote plays and some fiction, I certainly always shared my work with him, and we would discuss it. Likewise, he would share his work with me, and we would discuss that.

We’re certainly not the same writer, and we have different strengths. I found at some point in my 30’s by the time I had children, that it wasn’t always easy for us to collaborate because he is an anxious, and often impatient, person. And for me, working with an anxious collaborator who would often send me a draft, and then call the very next morning saying , “Do you have the edits yet? was challenging. I would come back with “I have it, I haven’t read it yet, I’m trying to get it!” I had three kids to get off to school and whatnot. While we eventually decided not to write together often, we did co-author a column for Inc. magazine for a year, and I’ve edited chapters of many of his books.

But I understood his work well enough to be able to try to write like him in a way, and not to stick things into the stories that sounded out of place. That might have come from my way of thinking but at the same time, we had spoken enough about therapy over the years that I think there was a lot of trust there as well.

It really helped that I had turned the page in my life and decided to pick up the family business and had started my education as a therapist and started seeing clients. So, the questions I was asking were really informed by some experience, as opposed to purely from the writer’s perspective. The other aspect is that I had suffered with depression back in my 20s and 30s, and we had very long talks about that. And similarly, he has had periods of anxiety, and particularly in the years since my mother died. And we had some very long talks about that. So, I think there was a certain amount of trust in one another. And for him, in my psychological acuity and compassion.


Lessons Learned

LR: In his words, “fellow travelers.” Did the nature of your collaborative efforts change from the beginning to the end of the project?

BY: Absolutely it did, and it was really interesting. At the beginning of the book, I would say my father was more concerned about me being interested in doing this, but little by little, he gave me more rope, if you will. I would bring back suggestions that he liked, and he became more and more willing to trust me as a writer. At the same time, I think there was the process of him becoming a little bit less invested in the book, or a little less interested in the book, as time went on because with his clock ticking, and realizing that he doesn’t have that much time left on the planet, there were other things he wanted to be doing and paying attention to.

Those two things allowed him to give me more and more freedom. We also moved from really looking at pages together at the beginning, to more of my doing the work and coming back to him in a Zoom session and saying, “Hey, I’ve got some questions about therapy for you.”

After a certain point, which was quite a bit later, he couldn’t even really remember the individual stories. And sometimes he would reread a story and then we’d talk about it, but often it would be me. I might say, “I’ve written the story. I feel good about it, but I’m not sure about this particular therapeutic dialog in here or this intervention here.” So, I would go back to him and say something like, “Hey, is this something you would say or does this feel right?” I might ask him to imagine he was in this situation with a client, so he didn’t have to remember all the details of the particular interaction in the story.

For instance, if one of the stories was about suicidal ideation, I would ask him how he would address that. It got to a point where what we were having was almost supervision conversations where I was saying, “Does this feel like the right therapeutic move?” and he would say, “Yeah, that that would be good,” or “Here’s a problem with that approach.”

LR: Your father has written and worked around death, dying, grief, and, of course, he lost his wife, your mother, just a few years ago, and now his memory is diminished. What have you learned as a person, as a therapist, and as an author, about death, dying, and mortality that you want to bring into your own life, as well as your therapeutic work? You know, staring at your own sun.

BY: Yeah, it’s been really powerful. Thank you for asking that. I can’t separate it from my particular stage in life. These things are definitely affecting me as a 56-year-old man with young kids. There’s been a certain awakening on my part to the time that I have left. But I’m not coming from zero because I’ve always been having these existential thoughts, because they were part of the air I breathed as a child where the idea of how we confront death was always a common topic around the table.

So, I think now it has made me look at my life, my kids, and my wife and thinking, yeah, I have X amount of time, and I really want to make the most of it. So that is helping me say “no” to things in a way that I probably didn’t before, and also say “yes” to other things and to other people and their needs, in ways that maybe I didn’t before. I think it has helped me in my mission to be a kinder person. Because we all have frailty.

It’s been difficult watching my father diminish to the extent that he has, not only because he’s my father, and that I think it’s difficult for anyone, but also because there’s this the air of the great man being diminished. Because I’m in the field, and because I’m managing his Facebook page, I’m constantly responding to people about the emotional impact on them of his decline. Everybody wants a little piece of him and wants him to know that they wish him well.

That this book itself deals with the aging question and the memory question means that these were very direct topics of conversation for us. We were often looking specifically at, “What it’s like for you to be having these memories slip away?” And “Sometimes we disagree about something that happened in your past.” But then we can’t just sort of let it go sometimes because it’s actually relevant to the story that we’re writing, so we had to stay with those things that were uncomfortable, linger over them together, and decide how to address them, both in life, and in our writing.

LR: We started the conversation around the issue of whether you are your father’s intellectual heir. But as we move to the very end of the conversation, I see you as more of the existential heir. Would this book be one that beginning clinicians could pick up?

BY: I took on the mission of making this an accessible book to a broad range of readers. I think many of his central therapeutic ideas are laid out well enough that one could pick this up as their first book during training. My guess, however, and given that most people who are beginning their journeys as therapists are much younger, is that some of the questions about aging which do make up a lot of this book, are probably not as relevant. I think picking up the Gift of Therapy or one of the books of stories is probably a better place to start. But I don’t think you would go wrong if you began with this one.

LR: I agree, Ben, and on that note, I’ll say thanks for this deep and powerful sharing, and good luck with the book.

BY: Thanks Larry. I enjoyed it as well.

©2025, Psychotherapy.net

References

Yalom, I. & Yalom, B. (2024). Hour of the heart: Connecting in the here and now. Harper Collins.

Yalom, I. (2002). The gift of therapy: An open letter to a new generation of therapists and their patients. Harper Collins.

The Anxiety Disorder Game

The Anxiety Disorder Game

What causes someone to commit so strongly to the need to avoid doubt and distress?

Imagine a man standing in front of an audience and suddenly being unable to think clearly enough to speak his next sentence, finally stumbling through, putting a quick death to his speech and walking out of the room in humiliation. It would be expected that he would worry about how bad the next time might be, even envisioning himself in a repeat performance. Picture a woman on a bumpy flight, unexpectedly becoming terrified of deadly danger, and not being able to calm herself until the turbulence ended. It would be no surprise if she avoided future flights anytime the weather seemed less than ideal. Consider a father suffering from obsessive-compulsive images of choking his infant daughter. That graphic horror would compel any loving parent to avoid being alone with his child.

An almost instinctive reaction to these traumatic events is adaptation, however not all adaptation is psychologically healthy. Unhealthy adaptation could include exaggerated worries, anxiety, and inhibition of the capacity to act on their environment in an attempt to create a feeling of safety or avoid these threats in the future. If these maladaptive responses continue then the person will develop an anxiety disorder. If we look more closely, it seems that many of these same people begin to develop a general maladaptive framework for operating in the world. Safety becomes of paramount importance. The person with an anxiety disorder believes that losing control of their feelings or circumstances can come quickly and easily. Given that belief, avoidance is an easily adopted strategy. When the person with an anxiety disorder avoids, vigilance becomes their primary safety behavior. Once they recognize a potentially troubling situation, they want to end it immediately. If their heart starts racing and their head gets woozy, they fight to get rid of that discomfort as fast as they can. If the discomfort cannot be stopped by escaping, then they begin what they think is a problem-solving process, however this is not problem-solving but only excessive worry.

The goals of worry make perfectly good sense given the crippling anxiety people have experienced. The problem is that this strategy only serves to increase the problems that they are designed to prevent. When we resist the physical symptoms of anxiety, we ensure that anxiety will continue. The adrenals secrete that muscle-tensing, heart-racing epinephrine through the body, the brain matches it, and we will become more anxious.

Using worry to solve problems will backfire. Worry is a problem-generating process since it causes people to think more about how things might go wrong than about how to correct difficulties. “The human mind is built to worry. Worry helps us to prioritize our tasks, and provides us drive to get each task done by kick-starting the problem-solving process.” People who are prone to anxiety doubt that they have the inner resources to manage their problems, so they use worry to brace for the worst outcome in an erroneous belief that they are productively preparing for the negative event.

Two other tendencies contribute to their struggles. Anxious people don’t want to make mistakes, believing they will have dire consequences. They also don’t want to feel any distress, and the goal of the worry is to stop or avoid uncomfortable symptoms as soon as they arise. That message—“don’t get tense!”—is a sure way to create a self-fulfilling prophecy.

All these tactics together become a powerful force structured within a powerful fortress that drives the decisions of anxious people. They follow a belief system—a schema—that tells them how they should respond to doubt and distress. The belief systems of some clients are so strong that they ride roughshod over the therapeutic strategies we employ. No matter what instructions and techniques we give clients, their overriding unconscious and usually conscious, goals are to end the doubt and distress.

Much of my understanding of these drives, to avoid discomfort and seek certainty at all costs, grew out of years of failures. If I began treatment by teaching someone brief relaxation skills, they would incorporate those skills into their strategy of trying to keep the anxiety at bay. If I offered assignments counter to their defensive belief system, clients would not follow-up on the homework, or they would become confused after leaving a session. If I were especially effective in persuading them of the importance of practicing skills, they would simply drop out of treatment.

For over twenty-five years I have gradually modified cognitive-behavioral treatment that included relaxation training, breathing skills, cognitive restructuring and exposure strategies, to address the special issues created by anxiety disorders. By 1992, for instance, I drew on dozens of discrete techniques, some old standards along with some new procedures, to help my panic disorder clients alleviate distress. But as the years passed, I felt that technique alone was insufficient. My experience taught me that if we focus on techniques without first challenging their beliefs, then their fear-based schema will overpower our suggestions.

Personifying Anxiety

Anxiety disorders have a clear strategy to dominate. They condition the person to three contexts: the situation that stimulated their fear, the fear reaction itself, and their use of avoidance as a coping mechanism. The person creates a defensive relationship with each of these: to become doubtful and anxious when approaching that situation, to feel threatened by their anxiety and want to get rid of it, and to avoid when necessary to stay in control. These strategies are incorporated both into the neurology and the belief system of the person. Each interpretation and behavior in response to anxiety is directly linked to this frame of reference. I use a cognitive approach in which most of the therapeutic time is spent addressing clients’ relationship towards the anxiety, not the anxiety itself. My goal is to teach clients therapeutic principles powerful enough to offset their faulty beliefs that they must battle anxiety and must become relaxed again quickly. Clients learn to mentally step back, away from a poor quality interpretation of the situation (“this is a threat”) and a failing strategy to respond to it (“I must stop it”).

In most ways, this approach matches the standard cognitive-behavioral protocol. However, this is also where I begin to diverge from some standard CBT strategies. To win over fearful anxiety, I believe the therapeutic strategy must meet the following conditions.

1. It must be able to compete with the power of fear and distress. This includes creating an emotional shift that is strong enough to match the drama of anxiety.

2. It needs to have a simple frame of reference that makes sense to the client. My most consistent task with anxiety clients is to keep a clear-cut message at the heart of our discussions. The sharper I am about a few points, and the more emphatic I am about using them as guiding principles, the more successful I am at influencing the client’s point of view.

3. It needs to provide a clear system to follow, with simple rules that guide their actions during fearful anxiety. Otherwise, consciousness gets swallowed up by the fortress of conditioning.

4. It needs to permanently influence neurology or, said another way, their physiological reaction to anxiety.

5. It needs to involve tasks that they feel are within their skill set.

6. It needs to help them feel in control instead of out-of-control. Anxious people regard themselves as victims of the anxiety condition. I want clients to feel in charge, to see themselves as the subject, not the object.

7. It needs to be simple enough and available enough for them to utilize during a confusing, anxiety-provoking situation.

Shifting the Client’s Game Plan

Anxiety disorders play a mental game and they create a game board with rules stacked in their favor. Anxiety wants to distract us by getting us to focus on the content and then to attempt to prevent problems being solved within that content area. For instance, in OCD the content is the possibility of causing harm to self or others through carelessness. In generalized anxiety disorder, it is worry about health concerns, money, relationships or work performance. In social anxiety it is the fear of criticism or rejection from others. This is a clever misdirection, since the true nature of the game is the struggle with the generic themes of doubt and distress. The end result is that the actual problems and solutions to the problems that drive the anxiety are not clear to the client.

The disorder only wins if clients continue to play their expected role. If instead they can see the pragmatic opportunities for viewing their anxiety as a mental game, then we can begin to generate a framework to manipulate. Early in treatment I want to accomplish two goals. First, I want clients to recognize this distinction between the content they have been focusing on and the actual issues of doubt and distress that they must address. Second, I want them to take a mental stance and take actions in the world that are the opposite of what anxiety expects of them. “Anxiety wins when clients seek certainty and comfort. “My goal is to persuade clients to go out into the world and purposely look for opportunities to get uncertain and anxious in their threatening arenas.

For instance, learning the skills of relaxation can be a great asset to recovery. But in training to win against anxiety, it is counter-productive to try to stay relaxed. It is best to seek out discomfort. This is one of the biggest early struggles for clients in treatment: to honestly take the stance of wanting to face the symptoms.

Fortunately, I wasn’t alone in creating such a new strategy. In addition to Eastern philosophy and principles of Zen Buddhism, my guides were Victor Frankl’s paradoxical intention, Paul Watzlawick’s reframing, which stems from the Mental Research Institute’s concept of second order change, and Milton Erickson’s fractionation and pattern disruption. Frankl’s work encourages the client to generate the physical symptoms he most avoids. Watzlawick and his colleagues were the first to define reframing as altering the perception of the problem, the solutions and client resources in such a way as to reinforce therapeutic interventions. Erickson’s fractional approach and pattern disruption aim to make small changes in the pattern of client behavior and the external circumstances instead of opposing the behavior and circumstances.

The Moves of the Game

There is an existential game to learn when dealing with anxiety symptoms. People make a judgment that the symptoms of anxiety are unwanted intruders and threatening enemies and they want the trouble to end. They keep hoping that one day they won’t experience any of these symptoms. Thus, they become trapped by their expectations. Existentially, there is no need for such judgment. The symptoms of anxiety disorders can simply exist, without being deemed good or bad. The anxiety disorder wins when clients judge the symptoms to be wrong and to be banished. In order to win over anxiety, they need to start by stepping back from their current experience, observing it and labeling it as acceptable to them in the present moment. Sounds simple enough in theory, and in the end, clients who recover will master this skill. They learn to stop playing the game by anxiety’s rules. But initially it takes all the clever persuasion a therapist can muster to unhinge clients from their old frames of reference.

In Chart 1 you will see some possible responses to the symptoms of doubt and distress. Clients enter treatment in the position of resistance. In their most resistant position they say, ‘This is horrible. I’ll lose if this happens.” Even the stance of “I don’t want this to happen” gives anxiety the upper hand, because the mind and body will move into battle mode. Ideally, if clients can respond by saying “yes” to the encounter, and accept exactly what they are experiencing in that moment then they will be back in control.

But for many, the anxiety disorder has become so dominant that the client cannot make such a shift directly. As they attempt to accept their doubt and distress, they do so in order for that discomfort to go away. They are still oriented in their natural position of resisting the symptoms. They are more likely to say, “Let me try relaxing into this situation, and I hope this works, because I’ve got to get rid of this feeling.” The skills associated with permitting the symptoms to exist often allow the client to slide right back into resisting.

For those cases, the game takes a different tact. We re-direct the attention of clients away from fighting the symptoms and purposely toward encouraging them. They choose to act as though the symptoms are good instead of bad, and something to be held onto, even encouraged instead of rejected. As clients master this game and learn its lessons, they develop the insights needed to shift toward a non-attached relationship. If they can endure the discomfort, they can learn. I created this framework of a game to help them endure and to teach them three overarching goals.

1) Step back and identify it as a game
The first critical move is to step away from the drama, observe the event and name it. In meditation and in moments of relative quiet mindfulness, when the struggle isn’t great, you simply “step back.” You let go of your attachment to the thoughts. With anxiety disorders, in order to step back, clients must be able to label the event as one in which the anxiety is trying to dominate their mind. During threatening times, the drama is often too enticing to easily drop. They have already generated an automatic and rigid label that identifies the situation as one in which they should become aroused and worried, for example, “This is a true threat to me.” I encourage them to replace this with any message resembling: “OK, the game’s on: anxiety’s trying to get me to fight or avoid now.”

This is one of the advantages of the game. By training clients in a specific protocol and by strongly reinforcing that protocol, they begin to look for opportunities to practice and they become more astute observers of these moments.

2) Stand down 

Once they step back, they need to engage in a strategy to convey to their mind that it is time to “stand down.” The body and mind need help in backing away from the fight-flight mode. If, in the face of a threatening situation, they attempt to say, “I want this experience,” then the mind begins to have a choice other than battle stations.

Clients also need to stand down from the ego’s archetypal win-lose predisposition—winning by domination—and replace it by a more paradoxical strategy of winning by manipulating the challenger’s moves instead of blocking them.
Chart 2 details this next set of moves in the game. Resisting will play right into anxiety’s hands as the expected move. Instead, clients begin the process of standing down by using one of two strategies. Each move is designed to embrace doubt and distress instead of pushing them away.

Standing Down–The Permissive Skills

The first level of the game is to allow the anxiety to continue instead of trying to stop it.

This is manifested in the supportive statements, “It’s OK that I’m anxious,” “I can handle these feelings” and “I can manage this situation.” This approach has a paradoxical flair to it that people often miss. You take actions to manipulate the symptoms while simultaneously permitting the symptoms to exist. With physical symptoms you are saying, “It’s OK that I am anxious right now. I’m going to take some Calming Breaths and see if I settle down. If I do, then great. But if I stay anxious, that’s OK with me too.” We attempt to modify the symptoms without becoming attached to the need to accomplish the task. This is a critical juncture in the work and the therapist must track closely the client’s expected move of, “I’m going to apply these relaxation skills because I need to relax in this situation.” No! While it is fine to relax in an anxiety-provoking situation, it is not OK to insist that you relax. That’s how anxiety wins.We reverse a common American catchphrase by saying, in the face of anxiety, “Don’t just do something, stand there!” When enough epinephrine pumps through the body then the brain yells, “Run!” Consciously overriding this impulsive message takes great courage, but pays great dividends. It differs from desensitization where we help the client gradually approach the feared situation under relaxed conditions. Here we confront their instinct to seek out comfort and encourage them to remain physically anxious and mentally as calm as possible. Instead of believing that there is something broken, they simply accept the status quo.

Going Toward–The Provocative Skills

Many people consider acceptance a weak strategy in the face of the fortress of fear that has been built in the mind. They need to shift from the permissive stance (“It’s OK this is happening”) to the provocative stance (“I want more of this discomfort!”). Here they learn to encourage the symptoms instead of just accepting them. This strategy is extreme and can be thought of as fighting fire with fire. Fear is intense and acceptance is soft. Fear will trump calmness and acceptance every time. I help clients shift to an attitude of provocation that is equally as powerful as, and can compete with, fear. I teach them to use their willpower and conscious intention to seek out an even more rapid heartbeat, to encourage their feeling of contamination to grow even stronger, or to hope someone will notice their hands shaking.

Why this line of attack? Because we want to interrupt the dysfunctional pattern in the most effcient way possible. The straightforward way, using acceptance, is not necessarily the most effcient way because it tends to be susceptible to the clients’ dominant paradigm of resistance, for example, “Let me try to relax here and I hope this works, because if I panic that will be awful!” Consciousness only has so much attention at any given moment. During an anxious moment, I encourage clients to commit themselves to play the game, and to focus their limited attention on following the rules: try to get anxious on purpose by encouraging symptoms. If they will bring their attention to the task of encouraging, even cajoling symptoms to become more uncomfortable, or for doubt to grow exponentially, then they automatically withdraw attention from their fearful goal of ending the doubt and distress.

When I suggest homework activities to clients, I use expressions like, “how about playing with this move?” and “perhaps you can fool around with these responses.” I imply that these strategies are malleable and temporary: “What do you think about just experimenting a few times with this move and see what happens? We can talk about it next time.” For some, we will literally play a game in which they score points for various types of responses to their worry or anxiety, or they will have to pay a consequence when they avoid or engage in some ritual to help themselves feel safe instead of threatened. An example of this strategy can be seen in the case of Samuel. One of Samuel’s fears was that he might unknowingly have cuts around his fingernails and cuticles that would expose him to the AIDS virus while shaking hands at work. Throughout the workday he conducted brief checks of his ?ngers. I gave him the following assignment:

  • Go to the bank and get 40 fresh one-dollar bills.
  • As you leave home in the morning, fold them and place them in your left pocket.
  • Each time at work that you compulsively check your fingers you are to move a bill from your left to your right pocket.

This is a simple intervention, but I gave it to someone who was already oriented to the game. He knew that the only way to keep those dollars in his left pocket was to go toward his distress of not knowing if he was being exposed to AIDS. As he began the game, a typical email from him would say, “By the end of the day, I only had $10 in my right pocket!” There was something about adding that “game” that refocused his attention just enough to lower his struggle and raise his success rate.

I hear this from clients time and again: when they focus on scoring points, or avoiding a therapeutic consequence that we create together, they notice that they become less attentive to fighting the symptoms. When they disrupt their on-going relationship with anxiety by struggling to play the game, they spontaneously become more tolerant of the situation and their distress diminishes. Over time, as they learn the surprise benefits of this pattern disruption, they can congruently adopt the permissive style.

As you might imagine, these people are not easily persuaded to really want this experience. However, this is not the point of the exercise. The point is that they try to associate themselves to the task even if their initial attempts are clumsy. Clients can be encouraged to pretend to want their anxiety, like a role in acting class. This is a cognitive skill, so the work is directed to what they are mentally saying during practice. As they try to subvocalize as if they want to increase their doubt or discomfort, they will automatically dissociate from their typical negative interpretations.

If a client has trouble encouraging the physical symptoms, for example, “I can never want my hands to sweat,” then I suggest a minor shift in their focus. Instead of directly requesting physical symptoms to increase, I ask them to request that the anxiety disorder make the symptoms stronger. Instead of saying, “Come on! I really want to faint right now!,” they say, “please, anxiety, make me more dizzy.” This seems to be just enough misdirection and dissociation to make it tolerable to them, and accomplishes the same goal of competing with their resistance.

The central strategy of the game is for clients to want to embrace whatever the anxiety disorders want them to resist. One of the primary ways I convey the logic behind this wanting is by first defining the process of habituation: prolonged exposure to a feared situation, bringing about a significant decrease in fear.

Wanting Habituation

Habituation requires three elements: frequency, intensity and duration. You have to expose yourself to your feared situation often enough or you won’t progress. When you practice, you need to get up to a moderate level of distress. Practicing while you try to keep yourself calm actually slows your progress. Practicing between 45 to 90 minutes seems to be the ideal amount of time according to the research. These three components of habituation guide all homework assignments.

I think there is a fourth element missing: the spirit of wanting to experience what you need to experience. Clients progress much more rapidly when they desire to have the habituation experience. Unless they are seeking and wanting frequency, intensity and duration as they go toward fear, then by default, they will be trying to do the opposite. They hope they don’t get anxious, that the symptoms don’t get very strong and distress doesn’t last very long. This makes no logical sense to me. If frequency, intensity and duration of exposure to distress and doubt are needed for me to get better, then I want to stumble upon a situation which stimulates my anxiety. I want to do that often, and I want my distress to last, and I want the sensations to be strong. These elements create habituation and habituation is my ticket out the door away from suffering.

Cognitive-behavioral therapy does not teach this specific orientation to clients, although I think it should. If it did, it would alter clients’ disposition toward the problem, help to guide their practice, give them motivation and I’ll bet that it would alter neurochemistry as well. Analogously, if we are receiving chemotherapy for cancer treatment, it would be poor therapeutic form to go to each appointment dreading it, despite the fact that the side effects can truly be dreadful. Instead, you should see the chemotherapy as your friend, augmenting your body’s natural ability to heal. That’s good placebo.

The most important benefit of applying the skill of wanting is that it speeds healing by truncating the habituation process. Clients learn rather quickly that if they invest in the stance of wanting, it returns to them the gift of a rapid reduction in their anxiety. They gain insight sooner in the process, after fewer practices and after fewer minutes within each practice. When they apply the skills of the game during practice, they actually have quite a hard time keeping their distress high (try as they might) or having it linger around for those 45 minutes. By paradoxically applying the orientation of wanting, clients have an “aha” experience during practice that brings freedom.

3) Master the skills of the game through applying technique and practicing (or being a “good student of the work”)
I discuss with my clients the idea of “being a good student of the work.” Good students, of course, are clients who commit to following through on a homework assignment, and then work hard to keep their commitment.

One of Moira’s many OCD compulsions involved her needlepoint work. Frequently she felt compelled to tug on the thread ten times as she tightened a stitch. I offered her a new ritual to adopt. Each time she tugged more than once, on that next stitch she was to tug ten-plus-two times (12). The next stitch she had to subtract three to the number, tugging nine times. Ten on the next stitch, add two, and so forth, until she reached one tug. Her ten-tug stitch became a ritual involving 113 tugs in the next seventeen stitches. She hated that! But she did it, because she was a good student of the work. By forcing herself to stick with our little game, she increased her conscious awareness of her thoughts, feelings and urges during the moments just prior to her compulsive action. At the moment of the urge to pull more than once, she became alert to the punishing consequence. This strengthened her ability to turn away from it. Within a week, that compulsion was of her list of troubles.

Skills Meet Challenge

Doubt relates to clients’ perception that their skills won’t match the challenges they face. If their assignment is within their skill level, then they will be more willing to go forward. This usually means we must lower the challenge and offer them a performance goal within their perceived skill level.

If I am an OCD checker, and I think I have just run someone over, I may yet have the skill to resist my urge to turn the car around and check the highway again. But how about pulling over and running around my car one time before I turn around? I can do that. And now I have interrupted the pattern, which provides me an opening for further changes. One day, as I am having the urge to check, remembering that I now must pull the car over and run around it (again), I might spontaneously decide that that is simply too much effort. At that point I will drive on, and thus experience, with little suffering, exposure to my feared outcome without engaging in my ritual.

Score Points! Win Prizes!

The assigned tasks can be so challenging, so threatening to clients’ frame of reference that they refuse to practice. Even if they do practice, their early efforts may give them only small gains. I mentioned earlier that I create a frame of reference of addressing anxiety as a game in which you can score points. For some clients I create prizes as extrinsic rewards in the early learning phase. Sometimes I offer them metaphorical images, for example, “Imagine that if you walk all the way to the back of the store and stay there 10 minutes that I will magically transfer $10,000 into your savings account. Could you do it then? Play to win, as though your life depends upon it.”

Currently, I have a large woven basket full of prizes, wrapped as gifts. In my anxiety group I bargain with clients: “Anyone who completes three practices this week can draw from the basket.” I have been hiding a $5 bill within two of the prizes as an extra incentive. Last month I rewarded the group member who earned the most points over the previous week with her choice among 12 new self-help books.

Recently I have generated a competition in the group during a several-week period. I agreed that for each member who practices at least 3 times I would contribute $5 into a weekly “pot” of money. I devised a point system to be used for every practice session. Each person decides where and how he or she will practice. Whoever scores the most points, wins the pot. The winnings can grow to be $90.

As you review Chart 3, you can see the essence of the provocative game and the weight of each type of activity. These illustrate the goals I want them to set during practice. They reflect the essence of paradoxical action in fearful situations:

In a threatening situation, step back and become an observer of your process, not be 100% the actor in the drama. Decide to be glad about having the doubt or distress. Put a little light smile on your face or in the back of your mind to reflect it. Then, invite whatever struggle you are having, whether physical symptoms or worries, to stay. Work on trying to mean it. If possible, try to strengthen your move by intensifying your reaction. [For example, I offer nine different choices, such as the previously discussed demand that anxiety make the symptoms stronger.] No matter how strong the doubt and distress becomes, you should treat it as if it is never enough. Reward yourself for every minute you actively invite the symptoms to stay or to get stronger. Accept that other people might notice some problem you are having and for extra credit: hope that they do! Then, when you are done with the practice, learn to support yourself. Drop that critical, disappointed voice.Creating the point system has a number of benefits. The client and I establish a broad strategy together that is manifested through specific actions during practice times. But they pick the practice times to apply the skills. They answer the question, “What can I do today to create some strong uncomfortable feelings for a while?” As they act on this choice, they are empowered and feel a sense of control. Once they are in the anxiety-provoking moment, the point system directly guides them to the therapeutic action.

It is poor strategy to get into a threatening situation and then decide how to act. In that setting, they are competing with a well-habituated set of instructions (“brace, worry, and avoid if necessary.”) Clients are much more likely to regress back to their safe actions, or inactions. When they understand the rules of the game and commit themselves to follow those rules, then recall them as they face threats, they have the best chance of winning

Social Anxiety Strategies

Social anxiety disorder gives clients shaky hands, a quaking voice and worry about the critical judgments of others. Here is the role that it expects of the client: to not want the experience, to avoid it when possible, and to try to get rid of it. When choosing to play the game they ask for the opposite of what anxiety expects: they want anxiety to make their hands shake, their voice quake and their sense of threat heightened. Not only do they request those experiences, but they want them to stick around as long as possible! The clients then attempt to exaggerate their wanting of this experience, and might “desperately plead” for social anxiety to generate shaky hands, or to “cajole” the anxiety to make the experience stronger. They can increase their score by hoping that people will criticize their boring talk or question their shaky handwriting. Earn enough points, win a prize! They refuse to play the game that the anxiety disorder expects. They take charge and push that game board away and pull up their own game board of seeking out doubt and distress when anxiety wants them to defend or run.

Julie

Julie decides to practice facing her social anxiety by eating lunch out alone. She walks onto the lunchtime crowd of “Moe’s Southwest Grill” and is instantly greeted by the cooks and other staff. “Hello! Welcome to Moe’s!” they yell, and the other patrons turn to see who’s entered. Julie begins to feel the flush of red rise in her face as she smiles and nods her head in acknowledgement. Then inwardly she smiles and says to herself, “Yes! Another point.”

Here she describes the process. I’ve added my comments in brackets to her key statements.

“I was really nervous walking in there. I felt like everybody noticed that I was by myself. But that was OK, because that was the point of the whole practice. [She is listening in to her inner conversation and she is permitting her feelings instead of blocking them.] Then having to find a place to sit and making that conscious decision: Am I going to sit with my back facing everyone? Am I going to sit and actually have to look at everybody while they look at me? I made the choice to sit and look at everybody while they looked at me. [She is taking control of the situation by listening in on her process and choosing the more intimidating option.] …I reminded myself that the longer I could stay and the longer I could be nervous and be OK with it, then the better it would be for me. [She has adopted a new belief system about her goals in the fearful situation: stay anxious to win.]

“I thought about how I could make it stronger. I thought that facing everyone while I ate would keep the anxiety going. I was just trying to think of ways to keep the anxiety going. [She is actively strategizing how to provoke symptoms as a powerful way to help her stop resisting.]

“I’m not as afraid of social anxiety as a word because I’ve taken social anxiety and I’ve turned it into a person instead of a condition. It’s not a mother, it’s not a father, it’s just this person or this entity and she wants me to take care of myself. She doesn’t want me to be embarrassed. When I do something that she thinks I could not do, she is impressed. I really like that because it is not a judgmental thing. It is like someone saying, ‘You really should wear a jacket, it’s going to rain.’ But you go out there without a jacket and it doesn’t rain, and they say ‘OK, you did it; you’re still a good person.’ So that’s how I’m thinking about it. [She now comprehends that those ogres, worry and anxiety, have been in her life to help her. They just do it in a clumsy way and she has found a better way. Julie will win this game for good.]”

OCD Strategies

OCD wants the person to try to get rid of any doubts about safety and to take any actions necessary to remove distress. Many OCD clients who fear contamination really do believe that at the moment of exposure they must repeatedly wash to save their life or the life of someone they love. Personifying OCD, I emphasize how it needs them to believe the specifics of their fears. Clients who win over OCD will hold fast to the belief that this is an anxiety disorder. As such, their battle should be with the physical symptoms of anxiety and the urge to end doubt. They should by no means battle with the content of the obsessions. It is never about germs or rabies or salmonella. It is always related to the fear of feeling distressed about threat. To play the OCD game clients set the overarching goal of seeking out doubt and distress.

Eventually, everyone in OCD treatment will do exposure (of the feared stimulus) and ritual prevention, which is the standard treatment for this disorder. But modifying the ways clients obsess or how they perform the ritual is the most efficient starting point for many. Starting with small, lower-threat changes allows clients to practice their new skills and experience early success. Instead of not washing their hands at all after they feel contaminated, clients can change how they wash, where they wash, or what they are doing mentally while they wash.

Jai

Jai was living in a residential program for teens. He struggled with about a dozen different types of washing and cleaning rituals, especially when it was his turn to handle the after-meal cleanup. One ritual required that after he was finished with his (thorough) cleaning of the kitchen, he was to squeeze the sponge ten times while rinsing it under running water.

In our first treatment assignment I asked him if he would fool around with the ritual by switching hands each time he squeezed. In this case, Jai got to keep squeezing and keep counting. He simply altered hands, and switching hands was only a minor threat to him. This is what I call throwing the symptom cluster a bone. You leave in place major components of the ritual or obsession, thus lowering the threat level. However, it is still a change that begins to erode the original fortress of symptoms. He agreed to the assignment, and returned the next week to report how easy that task was. I then suggested this further revision: would he be willing to explore his ability to toss the sponge in the air and catch it with the other hand for each switch? Again, he agreed to this small, silly shift and returned the next week reporting no problems with the task. The following week, he simply squeezed one time and set the sponge down without struggle.

Jai’s playful approach to modifying his ritual became a relatively painless means to arrive at exposure and ritual prevention. It served as a building block for some of his more difficult later encounters with OCD.

Jordan

Jordan, a physician, feared contamination with germs that might come in contact with her clothes during the workday at her medical practice. One of her primary rituals was to spray the entire front of her body with ammoniated Windex® as she left work. She used that same Windex® throughout her home when she felt threatened by germs. Ironically, while Jordan obsessed about becoming sick, her husband, who was also a physician in her practice, was developing serious respiratory problems from inhaling the ammonia. Over months, Jordan worked hard to tolerate switching the Windex® to vinegar-based, then to dilute it to a 50% solution and finally to a 33% solution. Each of these steps increased her doubt just enough that she could tolerate it and experiment with the change. Once she implemented the change, she incorporated it into her routine without much struggle.

But we could progress no further with this or the other safety rituals she performed. Jordan was stuck on the content of her obsession: things had to be clean enough. I failed to persuade her that her attention actually needed to be focused on the strategy of confronting doubt and uncertainty.

Vann

Vann came into treatment struggling with OCD checking rituals that lasted up to five hours a day. Often his concern was that he had missed seeing something he should have noticed: new scratches or dents on the trash can, dust particles under the telephone, an inappropriate item in the basement. Other times he checked as a way to prevent a disaster: an electrical cord will be wrapped around the trash can; his son will trip over some item on his bedroom floor; a fire will start in the kitchen or a flood will occur in the basement. Some days Vann would check a particular item over a hundred times.

Our first ploys involved gently modifying his relationship with his symptoms. For instance, he would check the trash can, but only in slow motion, ever so gradually picking it up and unhurriedly rotating it in his vision. Or he would study the telephone, but not allow himself to touch it. These were his first playful explorations into uncertainty and distress. By the sixth session we added a strategy of postponing. OCD would give him the impulse to check the basement immediately. He would choose to wait thirty minutes before he acted on that urge, again learning to tolerate his discomfort. Through this gradual exposure to the principles, by session nine he was able to avoid locking his house for five days.

Here is how he described his progress by session 10:

“In the past I would pull out the backseat of the car, and if there were dirt there, I would have to clean it up. If a bolt was there I would look at it and get stuck on the backseat, focused on that bolt. Now I do this intentionally. I lift up the backseat and try to make something really bother me, try to feel anxious. I feel that anxiety, replace the backseat, shut the back door of the car and walk away.

When I first started walking away I felt really anxious. I wanted to go back and look at something under that seat again. I felt as though I didn’t look at it hard enough and I’d want to look at it again. I would sweat a little bit, my heart would beat faster, I’d become very irritable and I felt very compulsive. I wanted to go check again! But I just decided I wasn’t going to do it. Sure enough, about two hours later the desire went away.”

Vann completed his treatment in eleven sessions over 5 1/2 months. In a follow-up twelve years later, he remained symptom-free and medication-free.

Conclusion

I began this conversation saying that when I work with anxious clients, I keep my points broad and simple and I focus on them repeatedly. My goal is to influence clients’ perspectives and shift their orientation. I encourage you to try the same.

Help clients to turn away from the content of their fears whenever possible. You cannot always ignore content, because clients will be wrapped up in it. But get past content as soon as you can and move into the core themes of people with anxiety disorders: their struggle with doubt and distress.

The central strategy is for them to want to embrace whatever the anxiety disorders want them to resist. They have two choices. They can “stand down” by choosing to let go of their fearful attention and accept the reality of the current situation. This is the permissive approach. When they have completed treatment, this will be their most common response: to say, “I can handle this situation” and to allow their body and mind to become quieter. The other option is to choose to stay aroused on purpose and actually encourage anxiety to dish them more trouble. This provocative choice is an excellent option during treatment, because choice number one is so difficult to embrace during early encounters. Conditioning and a set of false beliefs are calling the shots; they cannot simply relax on cue. Some treatment protocols will suggest that you help them expose themselves to the fearful stimulus and learn that they can tolerate it. I am suggesting that you put a twist on that set of instructions. Help them to take actions in the world that are opposite of what anxiety expects of them. Persuade them to go out into the world and seek out opportunities to get uncertain and anxious in their threatening arenas. This is a shift in attitude, not behavior. The behavioral practice is not to learn to tolerate doubt and distress, it is to reinforce the attitude of wanting them.

Our ultimate goal is to teach clients a simple therapeutic orientation that they can manifest in most fearful circumstances. Early in treatment, however, you will also need to provide a specific system to follow, with simple rules that guide their interactions with fearful anxiety. Using behavioral practice, encourage them to repeat this new interaction again and again, in all their fearful situations.

You can assume that one of the biggest obstacles to success will be poor planning just moments before the encounter. Whenever they wait until they are scared before deciding the best course of action, then conditioning and faulty beliefs will dictate that they struggle or avoid. In that setting, they are trained by fear to mindlessly seek safety and comfort. Before they enter any situation that is potentially threatening, they should review their objectives and remind themselves of their intended responses.

Thinking of their relationship with anxiety as a mental game offers both a broad therapeutic point of reference and specific actions that manifest it. Initially, your skills of persuasion and their belief in you will push them to challenge their faulty beliefs. After that, experience will be their greatest teacher. Once they have acted on these beliefs and gotten feedback during the fear-inducing event, that learning will put the power in their new orientation and it will be self-sustaining. They will then have a set of instructions, such as “anxiety, please give me more” or “I’m looking for opportunities to get distressed” that will point them toward simple choices during difficult times. And they will have a skill set (that I laid out in Charts 2 and 3) that they believe will match the challenge of the situation.

Practicing Philosophy on the Frontlines of Suicide Prevention

Philosophy begins in wonder. And, at the end, when philosophic thought has done its best, the wonder remains.
— Alfred North Whitehead

From as early as I can remember, I was haunted by questions others found inconvenient: why does anything exist at all, what does it mean to be free, why do we suffer? I wasn’t trying to be difficult. I was just wired for inquiry, a child tugging at the loose threads of meaning, compelled to see what might unravel.

Long before I read Socrates, I was unknowingly walking his path: questioning what others accepted, resisting the comfort of simple answers, and learning to live in the company of uncertainty.

Philosophy didn’t save me. It found me.

In college, I wasn’t pursuing a career path. I was chasing something I couldn’t yet name—a kind of metaphysical resonance. Philosophy gave me a language for that longing. But what began as an intellectual exercise eventually evolved into something else: a practice. A kind of internal activism. A spiritual discipline rooted in presence, curiosity, and the courage to stay with the unresolvable.

Today, I work as a 988 Suicide & Crisis Lifeline counselor, and it’s here, more than anywhere else, that my philosophical training feels most alive.

Sitting with the Void

Since its rollout in 2022, the 988 Lifeline has radically reshaped how we respond to mental health crises in the United States. With phone, text, and chat options, people in acute distress now have access to real-time support 24/7. It’s a public health victory, but on the ground, it’s something more intimate: a space where people can speak the unspeakable.

As a counselor, I don’t pathologize in these moments. I listen. I co-regulate. I hold. I stay.

It strikes me often how deeply philosophical this work is. Each call is a miniature encounter with what Martin Heidegger called Being-toward-death—the raw awareness of our own impermanence, vulnerability, and aloneness. But in that awareness, something else emerges: the possibility of connection.

When someone in crisis reaches out, they’re not always asking to be “fixed.” Often, they just want someone to witness their pain without flinching. To reflect it back without trying to erase it. That’s not just counseling. It’s the praxis of phenomenology. It’s existential accompaniment.

Myth-Busting as Moral Work

Many of us in the field are familiar with the myths surrounding suicide, but part of our task, especially those of us working outside traditional therapy offices, is to actively dismantle them:

  • “Suicide is selfish.” This myth misunderstands the psyche in pain. Most callers believe their death would be a relief to others.
  • “Talking about suicide encourages it.” We know the opposite is true: silence kills. Dialogue saves.
  • “Only the mentally ill die by suicide.” Suicide is a crisis of meaning as much as a crisis of mind. It stems from loss, trauma, disconnection, and despair, all deeply human experiences.
  • “Once suicidal, always suicidal.” Suicidal ideation is often transient. With connection and care, people do recover.

To engage with these misconceptions isn’t just educational. It’s ethical. Every time I resist reductive narratives, I expand the space for people to see themselves differently. To imagine a future again.

Philosophy in a Clinical World

In my early years, I often felt that philosophical inquiry was dismissed as irrelevant to real-world problems. People would ask, “But what can you do with it?”

Working in suicide prevention has given me an answer: you can show up to suffering without needing to control it. You can name the void without trying to fill it. You can ask better questions when answers fail.

I don’t carry diagnostic manuals into a crisis conversation. I carry silence. I carry questions like:

  • “What’s keeping you here, even now?”
  • “What would it mean to stay for just one more day?”
  • “What part of you wants to be heard right now?”

These aren’t philosophical riddles. They’re lifelines.

One of the most humbling aspects of this work is realizing how often people just need permission––permission to grieve, to rage, to doubt, to feel lost. Not every call ends in resolution. Some end in quiet. Some end in tears. Some end with nothing more than a single breath that wasn’t taken before.

And that’s enough.

Philosophy asks us to live with paradox. Psychotherapy invites us to do the same. The intersection, I believe, is where some of the most sacred work happens between presence and uncertainty, holding on and letting go.

As therapists, social workers, peer supporters, and crisis responders, we are often taught to do. But what I’ve learned from both philosophy, and the hotline, is that our greatest power lies in our capacity to be, to sit still inside someone’s unraveling and trust that staying is in itself a form of intervention.

A Final Note

In a time when anti-intellectualism is rising, when nuance is collapsed into binary thinking, and when complexity is mistaken for elitism, practicing philosophy—practicing psychotherapy—is a quiet act of rebellion. It resists the machinery of numbness. It says: We are not here to obey. We are here to awaken.

If you or someone you know is struggling, the 988 Suicide & Crisis Lifeline is free, confidential, and available 24/7 via phone, text, or chat.

And if you’re a clinician on the verge of burnout, compassion fatigue, or existential dread, you’re not alone either. This work changes us. Let it.

A Neurodivergent Clinicians’ Personal and Professional Journey of Self-Discovery

My journey of self-discovery is probably similar to those of many others, with the exception that becoming a therapist, at least to me, is unlike any other career. The things I witness, hear, and experience, have no comparison. For the sake of myself and my clients I must continue to evolve, grow, and remain a lifelong learner. The space of shared stories and experiences is the one from which therapeutic connections can, and have, been made; where I join fully as a human being, and can bring together the various intersectional elements of my own identity. And just like my clients, I have my own story.

Recently, a student asked me about working with neurodivergent clients who have not experienced trauma. I thought it was a great question. In my experience as a neurodiverse therapist and citizen of the world, society is not set up for neurodivergent people and this binary of trauma or no trauma must yield to a more fluid, continuum-based way of thinking. Simply existing can feel traumatic for those who are neuroatypical.

In researching this topic through the scientific lens of my academic identity, I’ve simply not been able to keep pace. There is so much! Through another lens at the intersection of my identities, that of practicing clinician and neurodivergent, I have come to recognize the limitations of purely empirical investigation and have begun visiting social media sites in order to better understand the autistic and neurodivergent community through the lens of experience. I learned more from direct, and very personal narratives, than I did from any textbook or any clinical training.

Working with Bee: An Answer Deferred

Years ago, I worked with an older teenager, Bee, in a rural community who identified as queer. She initially came to see me because her gender fluidity and sexual orientation created conflict with her mother and her mother’s belief system. I want to emphasize the conflict was not between her and her mother, per se, but with the mother’s religious beliefs. This is not an uncommon experience where I practiced. While Bee had social anxiety and low self-esteem, she did have a good support system with her family and friends.

I worked individually with Bee and did some relational work with the family as well. Throughout our time together, she was able to build self-confidence and find employment. By her senior year, she was doing all kinds of things including taking on leadership roles as she fully embraced the trajectory into adulthood. It was for all intents and purposes, an effective therapeutic relationship in which we met the goals of treatment, individual symptomatology diminished, and her relationships improved, as did her attachment experiences and communication skills.

I remember one point during our time together when Bee asked me if she “could have ADHD or be autistic?” I said I wasn’t sure, so I did an ADHD screener, which was diagnostically inconclusive, after which we had several discussions about the results. I even talked about referring for a more comprehensive psychological evaluation, but did not really see the need for it. I talked about some traits but nothing within the clinical range. To support this, I pointed out to Bee that she was doing well socially, involved with extracurricular activities, had friends, and an active social life. At that point, we ended our work.

Through some happenstance around 2-3 years later, Bee’s family reconnected with me to share all the positive things that had occurred in their lives. I met this invitation with openness and curiosity. After the update of Bee going to college and studying a topic of her choice, I immediately shared my need to apologize. Bee asked what I meant. I remember asking, “do you remember when you asked me if you were neurodivergent and I said I really do not think so?” She quickly replied affirmatively.

I went on to tell Bee that I had spent the last several years learning about autism and ADHD, and that in retrospect, she was right. I admitted to her that I was neurodivergent, and that, “I believe you are too.” We shared a laugh about the experience. I was glad she was not angry and that she didn’t feel dismissed but said that “it would have been okay if you had been upset with me.” She knew back then that I genuinely did not think she was on the spectrum, but she was personally unsure. She knew I was not trying to dismiss her and reminded her of my recommendation for a comprehensive evaluation. But those evaluations were not as accessible or affordable as they later became. This was where the field was at that time, and it is where I was along my own path of self-discovery. Statements like the one I made back then, “You have some traits but don’t really meet criteria,” were likely very common before the idea of spectrum was more fully embraced. A few observable traits no longer mean that deeper pathology is being masked, awaiting a full assessment followed by a definitive diagnosis. Neurodivergence means just that…divergence, or variation on a theme. And that variation extends to race, gender, culture, and age.

I am glad I could repair, at least from my perspective, what I considered a therapeutic rupture, although Bee did not experience that rupture in a traditional way to the point that therapy hits an impasse or ends abruptly. The version of myself that spoke with Bee that day knew that she presented with all the “usual” observable symptoms that accompany autism, and that had I dug deeper, the diagnosis would have been clear. I missed or perhaps had resisted the diagnosis because I had not yet found a place for that label in my own identity. I could have let Bee’s narrative lead the way rather than the dictates of my formal training and that of impersonal scholarly investigations. Just as I now have a far clearer understanding of the complexity of my own intersectionality, I now more fully embrace the importance of honoring my clients’ narratives.

Postscript

Quite a while after my work with Bee and her family, I had taken my son at age 7 for an ASD evaluation. The psychiatric resident looked at him and said, “he is not autistic, you see this is the autistic bible––” he slapped his book on his desk––“I can tell by looking that he is not autistic.” My son returned to the room with blue cupcake icing on his face. I felt flooded with embarrassment and rage. I wanted someone to tell me why my son was struggling in so many ways in his life. I firmly said, “I want to see my attending physician.” She subsequently met me with compassion and kindness; however, not even an ADOS was performed.

The irony, or better yet, outrage I felt was because my son had classic symptoms of autism–– hand flapping, lining up toys, and a host of other stereotypical stuff for most of his early childhood, some of which reduced somewhat by age 7. Maybe the resident, and my attending, thought he was too old to be first considered for the diagnosis. But then again, I really don’t know the basis for their preemptory conclusion. I do know that the experience left me angry, feeling rejected, and dismissed, and like there was no help.

To have personally attended a state university that provided evaluations, only for the doctor to not even ask me any questions about my son was so disturbing, if not insulting. I am sure the progress note read something like, “Mother was emotionally unstable and reactive.”

I knew from that moment on I never wanted anyone else to feel that way. At the time of that visit with my son, I had been working on my PhD which paved the way for my own self-study and re-orientation to the whole experience of autism and neurodivergence. The research is clear, at least to me, as a citizen, parent, and clinician.

The field is failing neurodivergent people––kids, teens, adults, families, and couples. Social media has become a substitute, or perhaps a primary place for validation because they can’t receive it from the professional world. When clinicians and the medical community correct clients and dismiss the importance and validity of self-diagnosis, what can be expected? I view this very differently since social media was the source of my own self-discovery of neurodivergence, and a tool for assisting my clients on their own journeys. The entire experience, from my work with Bee to the evaluation of my son to my own self-acceptance, has awakened a deeper awareness that has highlighted the importance of embracing and advocating for the evolution of the professional landscape.

Therapy as a Rehearsal Ground of Courage

“I just don’t know if I can say it,” a client whispered in session the other day, eyes darting toward the door as if the world outside might overhear. Moments like this are becoming increasingly familiar to me. In a society saturated with political conflict, social media outrage, and a nonstop news cycle, clients struggle to trust that therapy is a truly nonjudgmental space. In a country that prides itself on freedom, fear has taken root so deeply that honesty may be perceived as dangerous. This is the world many of my clients now inhabit—a world shaped by social media outrage, relentless news cycles, and political extremism.

They come in carrying the weight of public scrutiny before they even open their mouths. They judge me, assuming I hold beliefs or biases that may harm them. They expect I know every misstep they’ve ever made. And they sit there, waiting for judgment—even when I have never met them before. Social media has changed the rules—it has made people hyper-aware of how they are seen, feared, and judged by the world.

The Collision of Social Media, News and Psychotherapy

These fears have intensified post-pandemic. Many of my clients enter the room with palpable anxiety—not just about their personal lives, but about the world at large. They recount violent events, ideological extremism, and tragedies they have seen on their social media feeds. They speak of a constant fear: “What if saying what I really think could get me hurt?” And they do not mean hurt in a metaphorical sense—they mean physically. In this climate, self-expression can feel like a risk too high to take.

As a clinician, these dynamics add yet another challenge to my practice. Real growth in therapy requires honesty, yet fear can paralyze even the most willing client. And how can I fault them? Everywhere they look, there are examples of people punished for their beliefs. Even I, trained in the ethics and boundaries around the therapeutic space, feel the need to tread carefully in daily life.

Yet this fear also underscores the vital role of counseling. Therapy is uniquely positioned to provide a safe place for my clients to explore their values, confront their fears, and consider alternative ways to cope with anger and frustration. For those on the edge—clients who feel tempted toward harmful behavior, therapy offers a way to process intense emotions without causing harm. It is a space where honesty is not punished, and curiosity is welcomed.

Every day, I watch as Americans relinquish freedom—not through law, but through fear. Fear of judgment, fear of reprisal, fear of being misunderstood––therapy can counteract that fear. It can teach clients that differences in opinion do not have to lead to conflict or violence. It can empower them to embrace their values and navigate the world safely, with empathy for others and themselves.

Case Illustration from the Front Lines of Therapy

A client once shared with me, “I want to tell him how I feel, but I also need a job. I want to tell my mom how I feel about her comments about my parenting, but I need all the help I can get. I want to tell my landscaper I am not happy, but he is the only one I have hired that has shown up. I have so much I keep burying deeper and deeper because I am scared to be abandoned when I need help most—even if what they are doing is not to my liking and even hurts me.”

Fear was ever-present in this client’s life. Fear existed for her in the realities of the world—fear that speaking openly about her beliefs or setting boundaries might result in rejection, loss of resources, or even emotional harm.

As her counselor, I did not dismiss these fears as irrational; instead, I acknowledged their legitimacy while also helping her see where she could exercise agency. Together we carefully distinguished between relationships where safety was truly at risk and those where her voice could be tested. In our sessions, I offered space to rehearse language, weigh possible outcomes, and build confidence in her ability to respond if conflict arose. Therapy became both a sacred shelter for her buried truths and a rehearsal ground for courage, allowing her to honor her feelings while navigating a world that sometimes punishes vulnerability.

A Call to Action

I offer these reflections as a call to action for my mental health colleagues. Share your work with your community. Let people know that therapy is more than a conversation—it is a protective space where they can confront fear, unpack judgment, and reclaim agency in their lives. Let those struggling with violent thoughts know they can explore these feelings without harming themselves or others. Encourage the vulnerable to uncover what they value most and find constructive ways to live it out.

America celebrates freedom, yet fear threatens it every day. Mental health professionals are in a unique position to reclaim that freedom—not through grand gestures, but through quiet, consistent, ethical, and compassionate work. Our expertise allows us to illuminate the power of difference, foster understanding, and help clients navigate fear without being consumed by it.

Nonjudgmental spaces are not just ideals…they are lifelines. And in times of division, outrage, and uncertainty, the work we do matters more than ever.

We counselors are uniquely positioned to educate, model, and empower communities during politically discordant times. By combining advocacy, education, and skillful facilitation of communication, we can help communities navigate change with empathy, respect, and informed action. In the last few years, I have learned to accept that political leadership and policies will continue to evolve, and communities may face challenges as a result.

With my clients, I have had to emphasize resilience, informed decision-making, and equitable engagement to help communities thrive despite adversity. I model active listening and authentic sharing, emphasizing the importance of validating each person’s voice. I strategically infuse examples from counseling, such as couples in disagreement, to illustrate how respectful dialogue can bridge differences. I work with clients using social cognitive learning to help others recognize that small, intentional steps in promoting understanding and respectful communication can lead to broader good. I spend extra attention guiding individuals on how to validate what they hear or see before responding, ensuring their perspectives are shared constructively.

During times of political discord, we are called into action as advocates. I find myself in these times desperately seeking others to join me with advertising our space as a lifeline for everyone.

Shaped by Experience: What a Brain Bleed Taught Me About Therapy, Grief, and Presence

From the Ashes of Crisis

Alone in the ICU, tethered to machines and unable to see my family due to COVID protocols, I realized I was about to learn lessons no textbook could teach. I never imagined that a single medical crisis could teach me more about therapy than years of clinical training––surviving a brain bleed during my final semester of internship turned the ICU into the most intense classroom of my life.

Some nurses became my anchors; others showed me what I never wanted to become. I learned lessons about presence, compassion, and patience that no textbook could offer. My neurosurgeon was like a balm for my fears. Some nurses offered calm steadiness when everything felt terrifying. Others were brusque or cold, teaching me just as powerfully what I want to avoid in my work.

Even months into recovery, lingering symptoms—burning headaches, balance issues, heightened sensitivity—forced me to slow down. I had to set limits. As my internist said bluntly, “Focus on yourself.” This is advice we all need to hear sometimes—especially when life feels overwhelming. That process of slowing became a gift: I learned how to sit fully in stillness, tolerate uncertainty, and meet suffering without rushing to fix it. And humor? It can diffuse suffering. I realized it can be a quiet lifeline, reminding us of our shared humanity even in the darkest moments. The following lessons about presence and patience became especially relevant in my work with clients navigating profound loss.

Sitting with Grief: Aaron’s Story

Aaron came to therapy shortly after losing his partner in a sudden and tragic accident. The shock and anguish he carried were crushing. In the early months, he found ways to honor his partner’s memory through personal rituals that gave him small moments of connection, purpose, and meaning.

I drew on my own experience with vulnerability and life-altering uncertainty to simply sit with him, without judgment or pressure to “fix” his grief. Sometimes, just being present felt like the only thing that mattered. Over time, we explored the idea of growing around grief, which lifted some of the pressure to “get over it” within a certain timeframe—pressure that Aaron sometimes felt from his family, who were anxious for him to move on. Healing, we discovered, doesn’t erase loss—it expands around it, letting life continue alongside the grief.

Slowly, Aaron began to imagine a future where his partner’s memory stayed with him, while leaving room for new relationships, moments of joy, and perhaps one day having children—a future shaped by both love and remembrance.

Shared Vulnerability: Duncan’s Story

Another client, a young adult in their twenties, came to therapy struggling to access emotions after a loved one had died about a year and a half earlier. At first, they couldn’t cry and often felt numb, as if the grief had shut down their ability to feel. Over time, they learned to open to vulnerability, explore deep questions about life, and celebrate meaningful milestones.

Later, a sudden and tragic medical crisis, similar in intensity to my own brain bleed, involving a close family member shook them to the core. Sitting with their grief stirred my own memories of helplessness and survivor guilt. In the past, I might have redirected those feelings in the name of “professionalism,” but now I could simply bear witness—being fully present alongside their suffering.

Silence became a space where emotions could surface. Through that silence, Duncan was able to access feelings that had previously felt blocked. For me, as the therapist, the long bouts of silence were challenging, yet holding that discomfort became part of supporting him. For this client, it allowed grief to breathe, tested trust, and revealed the quiet power of shared human vulnerability. My steady presence, sometimes wordless, reinforced that being truly present can matter more than saying the “right” thing.

Takeaways for Readers

  • Presence is powerful: Sometimes simply being there matters more than advice or solutions.
  • Grief has no timeline: Healing is nonlinear, and growth can happen around, not just after, loss.
  • Shared vulnerability fosters connection: Authentic empathy strengthens bonds, both in therapy and everyday life.
  • Humor can coexist with hardship: A gentle laugh can remind us of resilience and shared humanity.

Just as I learned to sit in the stillness of an ICU room, tethered to machines yet alive, I now witness grief and healing unfold—messy, nonlinear, and profoundly human. In therapy, and in life, the greatest gift we can offer one another is simply to be present.

Therapy, for me, is about ensuring no one feels alone in their suffering. My ICU experience didn’t just shape my approach—it deepened it. I show up with attunement, patience, and care rooted in lived experience, creating space where clients can meet their own pain with courage, curiosity, and even a little laughter.

Rebuilding Connection after Grieving the Loss of a Desired Relationship

The other day, one of my clients asked me, “Isn’t it unfair to know that they [people around me] still can’t figure out that I am going through something and that I have to spell it out every single time, even after all these years?”

Unmet Expectations

I sat there in quiet surprise as I remembered asking the same question to myself a few days before. I thought, this is going to be interesting!

Lately, many of my clients have been dealing with the feeling of disappointment in their close relationships when they’ve come to realize that these bonds may not be as they once believed them to be, even after years together. It can be a parent, spouse, or close friends—it doesn’t matter. As their therapist, I have found myself sailing in the same boat, and I am at a crossroad when I am with them in that room trying to hold space for their disappointment—while allowing for my own. I am realizing there is another person who creeps into that space; my own outside-of-therapy-self who is learning to deal with the weight of similar disappointment with those in my life. It’s uncanny how these clients came into my life at the same time. I don’t think this is just a coincidence.

Sometimes, I treat the people in my life in ways similar to how I secretly want them to treat me. I extend my heart in kindness, my eyes to truly witness them, my ears to listen, and my words to comfort them—hoping silently that they will do the same for me.

A client might be sitting in front of me, saying all this as the realization suddenly hits them that their disappointment and anger may be coming from an unmet personal need to be cared for or about. Eventually, the other person falls short of these unspoken expectations, and they sit there enraged, but mostly feeling hopeless and disappointed with the inevitable reality of unmet expectations.

They, like I, build a certain image of a person and our relationship with them in our minds which keeps us from seeing them as they are—humans with flaws. And this can come with a sense of grief of having to let go of a version of a relationship they—and I—hoped for, but that simply was never there or that doesn’t exist outside of the mind’s eye.

From Disappointment to Acceptance

The period of transition from disappointment with and acceptance of people as they are knows no age bounds. The realization can come at any stage of life. And when the realization does come, it is important for the person to accept that the origin of the disappointment is not in the other person, but the result of their own unmet, and likely longstanding inner need for validation. These versions of relationships aren’t lies; they were (and are still) survival tools. In difficult times, they were needed to support the idea that the bond existed. That belief, even if idealized, was sufficient.

As both a therapist and citizen of the world, I believe the mask also comes off only at the time when my clients are ready to see reality as it is. The reality in itself is not bleak; it’s just different. The challenge lies in the decision to take the next step—to fully embrace the reality of a changed relationship with the imagined person who disappoints, rather than continued anger and disappointment. It’s about considering the new, altered relationship rather than expecting it to change. That decision can be made well when it comes from a clear mind and not while in the throes of grief.

Inside the therapy sessions, I see my clients face this disappointment and ask the important questions. Initially, it used to make me feel as helpless as my clients felt. Once we are able to talk about the helplessness, and acknowledge the disappointment that comes with it, we reach a point where I can address their unmet needs that led them to hold on to those versions of relationships that never existed. This, then, opens space for addressing how together, we can fulfill these needs outside of the existing relationships. Only then is there hope that my clients can open their hearts to reconnect and renew older connections with a new perspective.

The message I try to communicate is to be open to the grief and to sit with the disappointment. I ask my clients to open a space for grief related not to the relationship per se, but to expectations that the relationship will or might change. As a therapist, I invite clients to make space for that hopelessness, while as a person, I feel privileged to have clients whose lived experiences I get to learn from and seek support. I thank them for giving me that space, too, unknowingly. This is what happens when a therapist and a client walk through the same storm together. I have not known a greater community support than this!

The fluidity of relationships is beautiful. They shift, stretch, and evolve. They permit me and my client(s) to come out of fantasies in our own time. It allows for a new light and a fresh definition of connection with them. Disappointment is not the end of a relationship but the beginning of a truer one. When my clients—or I—make a space for grief, there is the possibility of re-connection.

Case in Point

I once worked with a client who came to me with the complaint of feeling angry most of the time. “Kunal” was a well settled person in his 30s who had been married for a long time. At the time he was coming in, he had been feeling frustrated in every conversation he was having with people close to him. In our sessions, he would ask questions like, ‘They understand when I am happy, why do the bad moods need to be spelled out?’ Every time, I could see the disappointment and sadness spread across his face.

It took us some time to reach the point where he could acknowledge that relationships often come with disappointment and to digest the ever-changing nature of relationships. As he described these situations, he attempted to soothe himself as he processed the years of disappointment that came with this realization. My goal was to be fully present, mirroring his feelings. This understanding paved our way for communication with a fresh base and a new outlook to look at his existing relationships. An important lesson learned!

Christoffer Haugaard on Collaborating with Clients Who Hear Voices

Lawrence Rubin: I’m here today with Christoffer Haugaard, a Danish Narrative clinician who has a particular and fascinating interest in working with clients who hear voices. Welcome, Christoffer.

Christoffer Haugaard: Thank you, Lawrence!

The Multiplicity of the Mind

LR: I know there are a lot of clinicians who will be reading this and want to know simply, how do I work with clients who hear voices? But I don’t want to start there. Instead, I’d like to start in a somewhat different place by asking what you’ve learned or are learning about the human experience by working with clients and their voices?

CH: I think what I’ve learned is that, based on the phenomenology of what voices appear to be and how they behave when you interact with them, the mind doesn’t seem to be unified. There seems to be multiple agencies, multiple perspectives that at least can be present and seem to have their own existence and are in some way tied to a particular person.

You can interact with these agencies or entities or whatever you want to call it. And, from my experience in working with people who hear voices, they respond favorably. The voices respond favorably to being treated as some kind of person, to being respected as having a perspective and their own agency, their own opinions, rather than being dismissed or rejected or taken to be not real, or only a symptom or a representation of something. They tend to appreciate being treated as if they are people too.

LR: Have you had to shed any preconceived notions along the way or divorced yourself from any common ideas about voices in order to reach that place where you recognize the multiplicity of the mind.

CH: That’s complicated. In a way it wasn’t a stretch for me because personally, I was already quite familiar with other ideas about reality of the mind, other ontologies. I’ve always been interested in indigenous societies, shamanism, animism, that sort of thing, where people experience entities or agencies outside themselves or related to the world and interact with them.

So, that way of thinking was actually quite familiar to me, but I didn’t connect it to my work as a therapist at all. I thought of psychopathology as being something distinct from that. Or at least I didn’t have any particular interest in connecting those two things. So, I regarded voices as being dissociated thinking patterns that were on repeat in peoples’ heads.

My change in view happened because we made a discovery about it by coincidence. I was working with one of my patients, named Max, whose story has been published. He considered that maybe his voices had good intentions to begin with, and I just took that idea at face value. I suggested that I try to address these voices and tell them that we had these ideas about them, that maybe they had good intentions, and tried to explain to them that Max needed them to behave in a different way so they could assist him in life.

Max thought that was a crazy idea because you can’t talk to a mental illness, but he was kind enough to not tell me that. He just said, “yeah, sure, go ahead.” So, I spoke to the voices, and they responded very favorably to that. They enjoyed being respected and acknowledged for their good intentions, and they actually changed their behavior.

From that point onwards, Max was able to appeal to them using my words in the form of a letter. In five minutes, he could quiet them down. They had terrorized him for years but responded to this immediately. That required me to change my thinking. This certainly didn’t seem to be some thinking that was dissociated and stuck in his head on repeat like a broken record.

This was something living that was responding with an opinion, and had feelings that were different from Max’s feelings. I brought that idea with me to other patients where we were stuck and we found that treating voices in this way, acknowledging them as having their own perspective, their own opinions, being persons of some kind was very effective. We then collaborated with more and more people where we were able to confirm this.

And of course, that required me to dissociate myself from normal psychological and psychiatric thinking. I was working in a psychiatric hospital where the general idea was (and still is) that voices are false. They are hallucinations, and people should not involve themselves with them. They should reject them and not listen to them, and they should be medicated to go away. I had to dare to step completely outside of that idea. I think maybe I was willing to do that because I was familiar with that way of perceiving the world already. I just never connected it to my work as a clinician before. I had a predisposition, you might say, to think that way.

So, it wasn’t a big leap for me personally, but it was something I had to dare to do in a psychiatric context, where that was not how you thought about things. I had to deal with the possibility that other clinicians would think that I was indulging people’s insanity or entertaining their delusions. But to think that that helped me to not be persuaded by such doubts or such ideas was the fact that it was just very effective.

There was just a very immediate response from these voices and nothing else had worked. I was sitting with patients who had been medicated, sometimes heavily, and who had tried many different kinds of psychotic medication for years and years; and tried psychotherapy for years and years, and it hadn’t worked. It hadn’t made any difference to these voices. And now these voices were responding in ways that were entirely novel to these patients.

They were immediately surprised that the voices were responding like this. It was useful. They could suddenly find ways to deal with these voices so that they stopped being a menace to them. Their need for hospitalization decreased, and some of them even stopped needing it. The voices ceased to be a threat to them, something they could live with. Even in some cases, they came to appreciate the input of these voices. They changed their behavior, became more reasonable, more kind, stopped going on and on about people killing themselves and stuff like that, and becoming more constructive when they were engaged in a dialog. And that was very persuasive for me and for my patients that this happened.

And when I saw that happen and the difference it made to my patients, it was it was a no-brainer really. I did have concerns about how honest I should be about what we were doing. Should I tell my patient’s psychiatrist what we were doing? But that became easier along the way because it was working.

LR: I need to dissociate myself from the popular conception that voices are equivalent to psychopathology, just as you had to. I’ll go so far as to channel Travis Heath here by suggesting that for you, accepting the reality of, and working with, voices was an act of rebellion.

CH: Yeah, and I already had a rebellious mindset. That’s why I became interested in Narrative Therapy to begin with. I was dissatisfied with how these peoples’ experiences were pathologized and just rejected as being just wrong and not worth listening to, not worth understanding, and just something that should be medicated until it stops. I was dissatisfied with how these people were not engaged in a more equal dialog about meaning and what might be helpful for them.

I had already been creating a group therapy format and participating in psychoeducation, where you tell people about diagnosis and treatments and all that. I’d become dissatisfied with being a clinician telling these people what to think about their experiences and describing it as something that was wrong with them. In the group format I developed, I invited patients to participate and interviewed them about their experiences and then together, reflect on what might this mean.

It was important to not privilege a psychiatric understanding. I wanted these people to participate in understanding their own lives and their problems instead of having to listen to yet another psychologist tell them stuff out of a textbook. I’d already done that before making these discoveries about voices. So, yeah, I definitely had that kind of rebellious mindset about it.
LR: Have you found colleagues who have attempted to adopt your philosophy about working with these clients, and have failed because they’re not you?
CH: As far as I’m aware, none of my colleagues had tried it out. It’s sort of just became a thing I did. Sometimes they would bring along a patient and ask if I could “talk to this guy or can you talk to this woman and see if you can do your thing?” So, it was more a thing I did after having published some of these accounts, circulating this knowledge, and making it available to people who hear voices. I have been contacted by people who have tried it out and found it to be effective. Not a lot. I hope there are more people out there using it that I’m not yet aware of.

A Relational Framework for Understanding Voices

LR: My guess is that because of Western culture’s hyper-emphasis on pathology and our dependance on insurance companies for greenlighting treatment, this might not find as welcome a home here as it does in Europe, or outside of Narrative Therapy circles. How does the traditional notion that voices are simply split-off and projected unpleasant or unwanted parts of ourselves fit your model?
CH: Mostly I’ve been dealing with this in a very pragmatic fashion and haven’t worried too much about that, really. Treating the voices as people was just very effective. Trying to work out what voices mean in terms of ontology or psychology has not been a concern. My patients didn’t care about that, and it wasn’t necessary to figure that out in order to do the work with them. To my mind, people are free to make sense of their voices in whatever way works for them, you know? Some people will think “this is probably a part of myself in some way,” even though that’s actually not how the voices appear.

They actually appear and behave like something of their own. But, you know, a patient who prefers to interpret that as being parts of themselves, of course, is free to do so, and it doesn’t seem to actually be important what people think of it. Voices respond to it, no matter what the host human might think of it. Right? But it doesn’t seem to depend on what the patient believes, and we don’t have to figure out what to believe about it. We have to pragmatically make the assumption that voices are people — they have their own perspective, their own desires and intentions, and we treat them that way. As soon as people have the experience that voices respond to this, they really stop caring about how crazy it might seem. It just doesn’t matter when it works. I, of course, have been interested in trying to get some idea of how we can make sense of that

I think the more traditional psychological idea that these voices must be “split-off” parts of the self presumes that the self is supposed to be unified and that this splitting is not how it’s supposed to be. Thinking that way doesn’t lend itself to acting the way we did .

You know, it becomes sort of pretending. The therapist is pretending that the voices are persons, but they really think they’re not. So, if we want to develop an idea about what voices are that actually supports literally treating them as persons, we might need a different idea about voices. It seems to me that psychology, and certainly psychiatry, is not a very good place to look for that, because these ideas are very tied to a Cartesian way of thinking about the mind and very tied to particular notions of what’s normal that are really based on industrial Western societies in the last t couple of centuries.

Basically, much of psychology doesn’t take other societies into account, or how Europeans thought just 300 years ago, which was in many ways radically different. This idea of a self-contained subjectivity is quite recent, and historically not very normal, actually. Psychology and psychiatry are very tied to such a notion of what a mind is supposed to look like. But when you start looking at the history of religions as well as anthropology and ethnography, very different ways of how the mind operates begin showing up. And a concept that has become more popular and recently redefined in anthropology is animism, which seems to be a way of understanding the world and the mind, which is pretty much universal.

All societies that have been studied either are or used to be animistic.Animism used to be considered an erroneous attribution of mind to things that actually don’t have minds. Like the “so-called” primitive belief, for example, that trees are alive or that a stone is alive. That was the original notion of animism in anthropology. And it was used rhetorically to demonstrate that religiosity in general is a primitive, irrational thing that should basically be rejected, and that the religions of civilized societies are just refined versions of this primitive animism. that was the idea back at the beginning of anthropology.

But animism has since been redefined as being an epistemology that takes the subject to be the starting point for knowledge of the world. To interact with the world socially is a way to know the world, which is different from the rationalist scientific idea of taking the object to be fundamental. In scientific, rational thinking, we want to divorce subject and object from each other, such as in Cartesian mind-body dualism. And in this vein, we then want to remove subjectivity as much as possible from the object of study, because real knowledge is supposed to be objective, independent of perspective, independent of context. It seems that many societies, indigenous societies, assert just the opposite; to know something is to invest subjectivity in it, to interact with it, to be socially engaged with it.

To know the forest then, the forest must become a person. It must become a subject. We must see through the eyes of the forest to know the forest. . As such, a spirit is not an irrational belief in a non-empirical entity. A spirit, then, would be the subjectivity of a relationship with something in the world. And in that sense, it’s a way of knowing. Instead of regarding the world as consisting of a bunch of particles in causal relationships with each other, the world can be understood to be a set of social relationships, and that the world is fundamentally social, not just between humans, but between humans and trees and animals and so on and so forth.

In this sense, animism, may be an ontology and an epistemology, a way of engaging the world that makes a different bet to rationalism and modernity. I think these notions of subjectivity, where the mind is not closed but porous, relational, and elastic, seems to be actually a very universal way of operating for our species.

And in that light, hearing voices isn’t that difficult to understand. You can look at voices as a way of understanding your life. When something in your life begins to speak to you, it’s a personification and investment of subjectivity in some aspect of your life that is problematic that you need to deal with. That’s why it begins to talk to you, so developing the right relationship with it is the road to healing. These voices mustn’t be rejected. They must be listened to because they’re trying to tell you something, and you must establish good relations with them instead of rejecting them or ignoring them or battling them.

In Relationship with Voices

LR: It almost sounds like people who don’t hear voices are at a disadvantage in some way, or that they’re not living fully in the world, as are those who are open to the experience of voices.

CH: I guess you could say that the process of modernization has been closing human beings off from the world. In making the distinction between subject and object and presuming that humans are exceptional and separate from the natural world, from our bodies, from other beings—we are asserting that we’re somehow entirely different and that only we possess minds, and the rest of the world is sort of dead and has no inherent meaning. From a historical perspective, you can certainly make the argument that modernization has operated like that; a rejection of being in relationship with the world.

LR: You’ve used the word spiritism, so is the experience of hearing voices and sitting with someone who is hearing voices, a spiritual experience?

CH: The older understanding in anthropology is that a spirit is a non-empirical entity that people believe has causal powers. That would be the old understanding of animism. The new animism in anthropology says that a spirit is a personified relationship with some aspect of the world, a relationship with something other than another human. So, when humans enter into relationships with a particular tree that may be important to them, this tree is personified by being related to in a social way. There’s an investment of subjectivity. The relationship becomes a hub of subjectivity in itself. That is what a spirit is.

LR: So, you might work with a client in relationship to the voice?

CH: Yeah, but mostly with the voices I’ve met. It’s not trees that they have problems with. It’s usually some aspect of existence. It can be aspects of our culture, for example, certain social norms that act in a personified way, and very often it’s a kind of helper. It’s like a companion entity of some kind that is trying to help people deal with something in their lives.

Often they turn out to be quite right about what people need, but because people have been rejecting this voice and been afraid of it, the relationship has gone sour. Sometimes it turns into a war. Sadly, sometimes psychiatry contributes to creating this state of war because they encourage people to reject their voices and in telling them that this voice is a sign that there’s something wrong with your brain. That’s a very scary thing to come to understand. This element of fear and rejection tends to lead to a conflict with the voice, and then the constructive aspects of what a voice may be trying to tell people is completely lost in this war. What I’ve often done is try to be on a diplomatic mission to create a peace and to try to understand what the voice wants. Often the voices are able to communicate when you interact with them in a respectful way. Very often, they want something. When the person comes to understand this and finds a way to satisfy the voice in an acceptable way for the person, the war ends.

LR: Have you found any commonalities in the origins of patients’ relationship with the voice(s)?

CH: There’s often trauma. The first appearance of voices is often in the context of a traumatic event, but not always since some of the people I’ve collaborated with have been able to hear voices for as long as they can remember. Just seems to be an ability, something that they’ve just always had.

LR: It made me think of an interview I did a while back with an ecopsychologist, who talked about the proliferation of ecological anxiety and dread as the planet is attacked from so many different sectors. Our planet is experiencing trauma which makes me wonder if some people who hear voices are afraid of the annihilation of our world.

CH: I have collaborated with one among other voices that was extremely angry about how the world was being treated by humans and wanted the person hearing the voice to try to annihilate humanity. I wasn’t able to, to work with that person in a very consistent way. A certain reason I haven’t collaborated with this person was due to the circumstances in their life, and of course, wanting to annihilate all of humanity is not a desirable or constructive thing to do.

It was not sensible to agree with this voice about that but to appreciate the anger of this voice was certainly relevant. Of course, I would see that as the fury of this voice. You know, wanting extreme things. And we need to channel that into something that’s acceptable for a human being to actually do, and killing people wasn’t it.

LR: Can you bring to mind a client with whom you’ve worked where there was this negotiation?
CH: There is my collaboration with Alice that has been published. She heard a multiplicity of voices operating in a unified way that she called “the others.” They were very aggressive and wanted her to harm herself and other people. They enjoyed gore, suffering, pain, and things like that and wanted her to do them.

Of course, she didn’t want to do anything of the kind. Then they would torture her in various ways when she would not comply with them, and try to convince her to kill herself. Once she started talking to the others, she discovered that they had all this aggressive energy that they wanted to express through her.

Alice resisted that, but because of this, they felt trapped. They could not exercise their own being in any way. They were just trapped inside her. That caused suffering for them. They were in pain from not being able to express themselves in the way that they wanted, and therefore they didn’t want to exist anymore. The voices were trying to get Alice to kill herself, hoping that that would also put an end to their painful existence.

We found out by coincidence that they enjoyed having smoking breaks. One day, we were talking about something that they didn’t appreciate, and it seemed like an attack was coming on from them. To avert that, I said, “sure, you get it your way. We’ll talk about something else for now. You just take a break for a smoke or something.” And that was just a joke. I was trying to lighten the mood and as it turned out, that averted the attack. Alice then told me they liked that. They liked being offered a smoking break, this was after having made this discovery with Max that I mentioned earlier. After that, I brought cigarettes for them and we put them out on my desk.

They really liked that. Otherwise, they would want her to kill herself. The voices didn’t like me talking to Alice and trying to help her get better because they wanted her to die, but now they had to admit that I offered the cigarettes. No one else in the world had ever offered them anything, but I did, so they couldn’t thoroughly hate me. We also gave them coffee. We could avert attacks like that, and begin to teach them to behave more kindly and in a friendly kind of relationship instead of an aggressive one based on power, which was all they knew. They started becoming familiar with being friendly and what that meant, so we tried to accommodate them.

They also wanted all this blood and gore and aggression. They liked that but of course, Alice didn’t. I suggested putting on gory movies for them. I didn’t want to look at it. Alice certainly didn’t. So, I put them on my computer and turned the monitor away from us, up where the voices were receiving their cigarettes and coffee.

I chose something comical, something funny like Peter Jackson’s old gory comedy movies he made before the Lord of the Rings. Later on, Alice decided to start practicing martial arts and they really liked that too. She was doing something that had something aggressive in it, but which was socially acceptable and acceptable to Alice. The voices calmed down more and more. And in the end they became quite friendly and liked me and wanted to be friends with me. They eventually stopped bothering Alice, and she stopped being afraid of them. So that was this kind of negotiation, you know? Can we give you something that you’ll appreciate, but which is also acceptable for Alice?

Narrative Therapy and Working with Voices

LR: Christoffer, what is it about Narrative Therapy that’s helped you in your work with clients and their voices?

CH: I think externalizing conversations already has some similarity with working with voices where there’s a practice of personifying problems. It has this animistic element to it. The leap isn’t that big. And then there’s the element of Narrative Therapy that’s called co-research. David Epston calls it co-research when you’re in a situation where you don’t know what to do, or how to deal with a problem. You relinquish your professional identity as the one who’s supposed to know stuff and invite the patient to explore. You work from the premise of “let’s explore this together.”

Narrative Therapy has roots in anthropology and ethnography, so this idea of collaboratively exploring the world without knowing in advance is essential. That is certainly what we did because we were in a situation where the usual stuff wasn’t working and we had to recognize the fact that we didn’t know what to do. It was a matter of just going with it to see what we could find and try it out and see what works. What we found with voices was that they responded well to this, so we did this consistently with one patient after another.

LR: Are the written elements of narrative practice like letter writing and journaling particularly useful here?

CH: Yes. When I spoke with Max’s voices that first time, he had a positive experience because the voices responded and calmed down immediately. Max then asked me to write down for him what I had said to the voices. That became a letter that he would then use whenever the voices got worked up about something in his life. He would simply read this letter to them, and they would stop attacking him. I have also used letter writing with some of my other patients when we were trying to figure things out, and as a way of documenting our discoveries. In those instances, I would write to them and some of them would also write to me to explain to me what they had discovered, or what the history of the voices was like.

Lately, I’ve been writing letters, not to my patient, but to the problem, a personified version of that problem. In one case, I wrote a letter to a dream entity of a patient with PTSD who had reoccurring nightmares. In one of those nightmares, he saw a dead man who had committed suicide. The patient had been the first person on the scene.

In the nightmare, they had a conversation where the patient was extremely angry with the dead man for the impact the suicide had on his life. The dead man told him that the suicide was his decision to make and that it didn’t concern other people. That made the patient even more furious. This conversation would happen every week in a nightmare. I decided to treat this as if it were a voice and appealed to the dead man in the nightmares as a person. This person was a personification of the trauma the patient was living.

I wrote a letter for the dead man from me said to the patient, “please read this letter right before going to bed.” As with Max, the patient thought this was a crazy idea which was not going to work. But since he had been having the nightmare for two years, he was willing to go along with the plan. He liked me enough to try. The nightmare with the dead man stopped as did the other trauma-related dreams. He later told me that when I suggested this plan, he didn’t think it was going to work. But it did.
LR: He was willing to try. A long shot at hope!
CH: I’ve had quite a few patients when I read these letters. I’ve been writing it while they were there, and just wanted to read it to them to make sure that I had all the facts right. And they would cry, because it just hit something apart from their own sense of themselves or their own minds. But something else, seemed to just appreciate it.

LR: The way you describe it is very consistent with Narrative Therapy’s focus on freeing people from systems of oppression.

CH: Yes, but with the twist that what seems to accomplish this work is the assumption that the problem is a person with good intentions. So it’s important not trying to resist the problem or undermining the problem, but to actually listen to what the problem is saying. I’m trying to acknowledge the good intentions of the problem, and then explain to the problem the effects of how it is going about its work of helping the person. I ask the problem to consider that the way it’s been behaving is having all of these negative effects. And then I just ask people to read this letter on my behalf to the problem every day. I say to the person that all they have to do is read the letter to the problem. And that’s been very effective.

LR: Do you ever introduce voices into your work with clients?

CH: In what sense?

LR: Such as with a client who has no history of hearing voices other than their own, where you might invite them or invite a voice into the conversation. Or is that a crazy question?

CH: No, no, no, I get what you’re saying. Yes, I do sometimes try to relate to the problem as a person when people are not hearing voices, and that that’s often very effective. I don’t usually explicitly introduce that or explain that. I allowed the person to wonder, like I might say, “I wonder if this depression might be trying to tell you something.”

I might also wonder aloud if “the depression has come at the time that it did in your life for some reason”. And then, based on what people have told me, I consider “well, maybe this depression has been looking at you and has been looking at how your life has been unfolding and how you’ve been dealing with your life. And perhaps this depression is aware of the things that are important to you, and therefore this depression is dissatisfied. It has been dissatisfied with what you have been doing, how you have been compromising with the things that are important to you, the things that matter to you, that you have been sacrificing yourself for the boss at work or whatever.” I might add, “maybe this depression has decided to make an intervention to stop you from living your life the wrong way.” The thing is with depression, at least in my experience, they tend to be like a sawn-off shotgun. When they fire, they fire all over the place.

I might continue, “Maybe this depression is, in fact, trying to dissuade you from living in a way that isn’t right for you, but in interfering with your life, it’s just hitting everything, putting you completely at a halt with lots of negative consequences. But maybe this depression wants something for you. And maybe we need to try to hear that message. Maybe you need to try to satisfy the depression with what it actually wants, its intention, not all the negative effects it’s also having, but it’s intention for you; what’s actually important to you, how you’re supposed to live. Maybe you’ve been compromising with something essential in the way that you’ve been living up to the point where this depression stepped in and interfered with your life.”

Often I worry that people think I’m crazy when I say these things, but I’m surprised that they don’t. They tend to be on board with that quite immediately, actually.

LR: So, in a sense, and regardless of the emotional valence of the voice(s), you consider them always on the side of the patient.

CH: Yeah, I make that assumption or at least try out that idea very carefully that the voices have good intentions before assuming that the problem has only bad intentions. Voices tend to respond quite well to the assumption that they have good intentions

LR: Even when a patient’s voices are instructing them to kill their parent? In cases like this, is it a safe assumption that the client has rageful feelings, or that there are rageful feelings toward the parents?

CH: They may or may not have those feelings, but I would try to invite the patient to explore the voice’s intention with me and also directly with the voice. The voice may have different reasons for wanting that. To become a teacher here in Denmark, you have to learn how to how to teach, how to communicate in a way that’s conducive to learning. I have the impression that voices have not had this course. Sometimes they’re very angry at their host human because they think the person hasn’t been taking care of themself, such as “Back when you were raped, you should have killed that rapist. I’m so angry with you because you didn’t and because you didn’t, I think you’re useless. You should die.” When what you’re hearing is just, “you should kill yourself, you’re useless,” It’s very difficult to see the good intention, but it is often possible to actually unravel it.

What the voice wants is for this person to stand up for themself, but that communication needs to be translated into something that’s acceptable for an actual human being to do. We don’t want to kill anyone, but that may be the voice’s way of expressing a desire for protecting the person, or demanding they defend themselves. In Alice’s case, the “others” would say, “kill him,” whenever they were angry with me because they thought I overstepped my bounds or talked about something they weren’t comfortable with. There, I would say something like, “I’m sorry that I have offended you. Please take another sip of coffee or let me give you another cigarette, and I’ll be more careful to not offend you in the future. That certainly wasn’t my intention.” And then they’d calm down.

Sometimes voices can have these very violent and graphic ways of expressing themselves, and that language may need translation. It shouldn’t necessarily be taken at face value. It may be an expression of extreme frustration and desperation on the voices part. And that’s what we need to understand so that we can respond to it in the right way; saying something like,“We don’t want to kill anyone, but there’s someone you want to blame. There’s someone you’re angry at, and you want something else for this person you’re talking to. Okay, let’s see if we can solve that, because I certainly get that. I get being angry at that. Right? I get wanting to defend yourself.

But, you know, voices, this person wasn’t able to do that back then. She was a child. She was powerless against this person. We have to find other solutions here. And I invite you voices to participate in that because I appreciate your good intentions. I wish she was able to defend herself back then, but she couldn’t. I understand why you want the rapist dead, I get that. But we can’t do that. We have to find another solution. But I want to collaborate with you to find that something that this person needs , something that they can do.”

Expanding the Subjectivity of Voice Hearers

LR: Christoffer, we’re nearing the end of the hour, but may I ask a question about cultural healing practices?
CH: That’s a very big issue. We talked about spirits and animism and all that, but my point is not to say that voice hearing and spirit encounters in various cultures are necessarily the same thing, and that people in other cultures are all hearing voices and or that people in our society who hear voices would be shamans in other societies. That’s not necessarily the case. The point is more that animism provides a different way of understanding subjectivity and a way of handling subjectivity that fits quite nicely with what works for voice hearers. So, I can be agnostic about how voice hearing relates to spirits. It’s more about the commonality in the subjectivity.

You know, we might learn something from the spiritual practices in other cultures without it necessarily meaning that what we call mental illness is the same as the experiences that shamans deal with. I think that would be a conflation and an oversimplification.

But there’s a common structure of subjectivity around voice hearing and the practices and understandings in other cultures. It’s a better fit if we don’t view what I do through the lense of traditional, Western theories and practices. These don’t lend themselves very well to doing what I have done with voice hearers, because it would be very difficult to go from a traditional psychological model to offering cigarettes to a disembodied voice.

From an animistic perspective; however, it makes a lot of sense. These are offerings. We’re making an offering of tobacco that’s found in many indigenous groups in the Americas. To make an offering is to appease spirits by making a gift. And when you receive a gift, you enter a moral community of mutual obligation. That’s the logic of an offering. Alice’s others responded to that.

LR: Lastly, and speaking of community, can you say a word about the Hearing Voices Network. Is their work and philosophy consistent with what we’ve been talking about?

CH: There’s a lot of similarities. When we set out to do this co-research, David Epston and I along with these patients decided to not engage with the literature of the Hearing Voices Movement to just start from scratch and make discoveries. But a lot of what we found is very similar to some of the discoveries of the Hearing Voices Movement. And of course, the Hearing Voices Movement doesn’t have one unified idea or one unified practice. They have this idea that people should be allowed to find their own way, but certainly some of the discoveries that they have made are very similar, like for example voice dialog. So, we have arrived at practices that are like what they have arrived at. I find that very encouraging, that without trying to do the same thing, we have arrived at similar practices, working from scratch. And that expands that notion of subjectivity across continents, across borders—not just ideological borders, but geographic borders.

LR: without trying to do the same thing, we have arrived at similar practices…and that expands that notion of subjectivityI think that will be a good place to stop. Thanks so much for this fascinating conversation, Christoffer.

CH: This has been a very interesting conversation. Thank you very much. I’ve enjoyed it.

©2025, Psychotherapy.net

Links to Christoffer Haugaard’s JCNT (Journal of Contemporary Narrative Therapy) articles

Respecting Voices: A Report on a Co-research Project Concerning Voice Hearing

The Ring in the Well: Psychosis as a Crisis of Identity

Rose and the Whispering Voices

Sitting through it with the Voices: Victoria’s story by Christoffer Haugaard & Victoria

Is it Ethical to Use ChatGPT for Diagnosis and Treatment Planning?

When questioning your work with a client, ever consider consulting Artificial Intelligence (AI)? Have you considered the ethical and legal implications?

A supervisee of mine recently introduced AI into our supervision sessions. My supervisee explained how they came to see the treatment plan development in relation to the feedback received through consultation with AI. In examining a specific client case my supervisee felt they were stuck with, we delved into exploration of AI professional relevance. Below is an excerpt reflective of one of our sessions:

Bringing AI into the Supervisory Conversation

Supervisee (SE): I am really struggling to understand why my approaches with the client do not seem to be resulting in the client’s therapeutic progression. Supervisor (SP): Tell me about some of the interventions you have used and how you came to establish their appropriateness for this client.

SE: I have tried cognitive restructuring first. AI suggested the intervention.

SP: Let’s start here. Help me understand how AI prompted the recommendation for cognitive restructuring.

SE: I asked AI, “what counseling interventions would help an adolescent female overcome social anxiety?” AI stated cognitive restructuring has been found to be helpful.

SP: What evidence did AI offer concerning the interventions’ effectiveness?

SE: No specific study was shared, just general feedback.

SP: When you say general feedback, do you mean reports from clinicians or clients?

SE: I don’t know.

SP: Did AI offer any scholarly sources?

SE: I did ask for resources to help me implement the intervention and some websites were shared. I read a few of them to see how cognitive restructuring has been used in sessions. Some of them had scholarly sources. I feel some of the resources were helpful for this client.

SP: I see that in your last session’s progress note for this client, you mentioned in the assessment that your client meets criteria for the diagnosis of social anxiety disorder and cited AI.

SE: Yeah, according to AI, my client meets the criteria.

SP: Are the criteria reflective of the DSM-5-TR?

SE: They should be.

SP: For billing purposes, you will be required to provide the appropriate DSM diagnosis. You will need to ensure the client’s symptoms meet the DSM criteria. Share with me how you found AI to account for your whole client. For instance, some of the information you gathered from the intake, and you learned through your sessions thus far.

SE: Well, I couldn’t share some of that information due to the client’s right for privacy and confidentiality, so I had to just generalize to populations like her being an adolescent female.

SP: Knowing these limitations, the need to research AI for sources and then research the sources’ relevance, why not just search for scholarly sources first?

SE: Open AI is easy and accessible with my phone so I can complete my notes on site between clients.

SP: Do you have your phone with you now?

SE: Yes, why?

SP: Would you be open to trying something using your phone?

SE: Yeah

SP: Please type in Google scholar in your browser and click on the link to open it.

SE: Okay, got it.

SP: Complete the same search here in Google scholar that you did previously with AI.

SE: Got it.

SP: How are these results compared to what you received in AI?

SE: Some of the relevant sources shared by Open AI came up. A lot of research-based articles came up in Google scholar.

SP: I want to take a moment to pause and offer some reflection on your experiences thus far with AI, progress notes, diagnosis, scholarly sources, and search for appropriate client interventions in general. Imagine going to court based on your work with a client and they claim you engaged in malpractice and unethical business practices based on your diagnosis, would you feel confident in sharing with the judge your current process in working with your clients?

SE: Not really to be honest. I feel like I am a bit overwhelmed, and AI has been a great tool to help me not stay at the office for hours after working with clients to complete documentation, but I am not always confident in what I am doing.

SP: Remember that confidence comes with time and this is why you have built in parameters right now to support… required supervision, open consultation hours with numerous senior clinicians, required team meetings for case conceptualization.

SE: I am a bit fearful people will not think I am good at my job and will no longer send me clients.

SP: What are your thoughts about a few clients that you feel confident in working with versus many you are unsure how to effectively support?

SE: I would rather feel confident, but I do not want to loose my job.

SP: First and foremost, thank you for your honesty. My role is to also support you to grow as a clinician and aid you with your development. Let’s agree for the next month, we will keep your caseload where it is at and revisit later to grow again.

SE: Thank you; I just don’t want my colleagues to think I can’t do my share.

SP: We all have seasons of life where we may need to provide best practices with our clients.

SE: I know.

SP: Remember, your ethical obligation, as well as mine, is to the welfare of theclients first and foremost. What would you rather tell the judge you used to guide your work and decisions with the client, AI or Scholarly resources?

SE: Scholarly resources.

SP: So why use AI? You shared the ease of access. Something to consider is also how you use it. I am not going to say all AI is bad, because there is also a great deal of research highlighting the benefits of AI. However, engaging with AI considering your compliance with HIPAA as well as your professional standards of practice is essential.

I proposed to you earlier about the client consideration and the credibility of the responses. There is a free training course I would suggest you complete that examines AI implementation for mental health providers. Here are the objectives for the course [shares screen]… how do you feel about this course being able to support your confidence with client work with use of AI?

SE: The course seems to cover many areas I am struggling with and supports the use of AI, which I like, so it may be a good fit for me.

SP: Instead of completing the three additional intakes assigned for you this week, would you be open to completing the three-hour training by our next supervision session next week?

SE: I think that is doable.

Final, but not Last Considerations

Lesson here, as a professional counselor navigating ethical best practices, you are encouraged to seek guidance from scholarly sources. If you don’t feel comfortable bringing your documentation in front of a judge, it is probably not the most ethical decision you can make. Applying ACA’s step 6 of the Practitioner’s Guide to Ethical Decision-Making model, application of the test of publicity, can further highlight if the choices you are making in the work with your client are choices you would be proud to stand by.

With AI specifically, we understand our world is consistently increasing its embrace. In healthcare alone, numerous AI platforms have been developed with the intention of supporting clinicians with their work with clients from advertising, intakes, platform capabilities, and even documentation. However, understanding how to distinguish between tools that align with your professional standards of practice is essential to not only protect the clinicians but also the clients. Furthermore, understanding how to implement the tools appropriately for your role with compliance to your profession’s ethical and legal parameters is critical.

Toward a Critical Realist Understanding of Psychoanalytic Interpretation

Reflections on Psychoanalytic Interpretation

Psychoanalytic interpretation, though subject to the analyst’s own biases and limitations, should not be dismissed as merely subjective or arbitrary. While interpretations inevitably arise within the context of specific psychoanalytic traditions—such as Freudian, Kleinian, or relational theories—they are not devoid of epistemic value. Rather, these interpretations can be understood as provisional efforts to track psychological truths, albeit imperfectly and always open to revision. This view aligns with the philosophical stance of critical realism, which holds that reality exists independently of our perceptions, and as Margaret Archer and Roy Bhaskur suggest, our understanding of it is mediated through theory, language, and social context.

Applied to psychoanalysis, this implies that while interpretations are never final or infallible, they can be evaluated and refined over time in light of clinical experience, internal coherence, and therapeutic efficacy. Interpretations thus occupy a middle ground: neither purely objective “discoveries” nor wholly constructed “narratives,” but tentative approximations of deeper truths about the patient’s mind and its workings.

This perspective on psychoanalytic interpretation contrasts starkly with the views of many relational and intersubjective theorists who rely heavily on a postmodern worldview that is inherently skeptical of science and truth as found in the writings of Robert Stolorow and his colleagues. For these theorists, meaning is co-constructed in the analytic dyad without appeal to any deeper, mind-independent reality, thereby shifting the focus from discovering psychological truth to negotiating intersubjective experience. While this view underscores the ethical importance of mutual recognition and co-authorship, it risks eroding the epistemic ambition of psychoanalysis as a discipline committed to understanding the unconscious processes that shape thought, feeling, and behavior.

Previously, Nassir Ghaemi and Jon Mills have leveled critiques of contemporary mental health practices on this basis. Ghaemi, a psychiatrist, has argued that postmodernism has led to a gross expansion of the psychiatric diagnostic system, which since the 1980s has prioritized reliability of diagnosis over validity. To Ghaemi, psychiatry—and, by extension, psychoanalysis—have been infiltrated by a postmodern belief system that is largely unconscious but widespread. He contends that this epistemic shift has undermined psychiatry’s capacity to seek truth, replacing it with a relativism that favors consensus and utility over ontological clarity.

Mills, a formally trained philosopher, psychologist, and psychoanalyst, has offered his own views on postmodern influences on psychoanalysis, concluding that much of modern relational and intersubjective theory is philosophically unsound and scientifically illiterate.

He writes, for instance, that “postmodernism has become very fashionable with some relationalists because it may be used selectively to advocate for certain contemporary positions, such as the co-construction of meaning and the disenfranchisement of epistemic analytic authority, but it does so at the expense of introducing anti-metaphysical propositions into psychoanalytic theory that are replete with massive contradictions and inconsistencies.” Mills’ comments on relational theory’s rejection of the individual self are particularly relevant to discussions about psychopathology.

I wish here to add some thoughts on these trends, arguing for a critical realist orientation that neither retreats into the naive objectivism of classical positivism, nor succumbs to the epistemic nihilism of postmodernism. Such a position allows psychoanalysis to retain its interpretive depth while preserving a commitment to truth-seeking as a core value. It acknowledges the hermeneutic and contextual nature of all knowledge while affirming that some interpretations, through sustained clinical engagement and theoretical refinement, bring us closer to understanding the enduring structures of the human mind.

Critical Realism and Psychopathology

Critical realism provides a robust philosophical foundation for the psychoanalytic understanding and treatment of psychopathology. Take, for instance, borderline personality disorder (BPD), which object relations theory frames as a disturbance partly rooted in early relational trauma and developmental arrest. From this standpoint, BPD is not merely a discursive construct or a social convention, but a genuine, structured pattern of affective dysregulation, identity diffusion, and interpersonal turbulence. Simultaneously, critical realism recognizes that our knowledge of BPD is mediated by theoretical lenses and clinical judgment—rendering psychoanalytic interpretation both necessary and fallible.

Consider a case example: a woman in her late twenties, diagnosed with BPD, seeks treatment after a cycle of stormy relationships characterized by rapid idealization and devaluation. She vacillates between clingy dependency and explosive withdrawal whenever the therapist enforces limits or plans time away. For instance, in one session, her reaction to the therapist’s upcoming vacation erupts into accusations of abandonment and betrayal. Rather than dismissing this response as merely capricious, the analyst, drawing on object relations theory, interprets it as the activation of split internal objects—“good” nurturing figures versus “bad” persecutory ones—echoing an early maternal rejection schema.

This interpretive move does not claim to unearth an immutable historical fact, but offers a provisional hypothesis: that the patient’s intense rage and despair stem from reactivated internal dynamics forged in childhood. In critical realist terms, the clinician’s account approximates the underlying mechanisms sustaining her borderline pathology. Over successive sessions, such interpretations can be tested against emerging clinical evidence—shifts in the patient’s capacity for affect regulation, moments of self-reflection, or changes in relational patterns—and refined accordingly.

By affirming BPD as a real psychological phenomenon while treating interpretations as revisable approximations, critical realism steers a path between naïve positivism and radical constructivism. It validates diagnostic categories as pointers to enduring disturbances in mental organization yet insists that every analytic formulation remains open to revision in light of new data, theoretical scrutiny, and therapeutic outcomes. In contrast to postmodern and constructivist approaches that reduce diagnoses to social artifacts or co-created narratives, this stance upholds both the ontological reality of BPD and the epistemic value of psychoanalytic interpretation in illuminating—and gradually transforming—the structures of the mind.

A Path Forward for Psychoanalysis

While postmodern approaches have rightly emphasized the importance of subjectivity and the therapeutic relationship, they risk, according to Mills, collapsing interpretation into narrative relativism, thereby undermining psychoanalysis’s commitment to exploring unconscious processes and enduring mental structures. Without a regulative ideal of truth, interpretation can devolve into rhetorical improvisation rather than a disciplined inquiry into the patient’s internal world. A critical realist stance retains the epistemological humility of relational theory—acknowledging that all knowledge is mediated and provisional—without relinquishing the pursuit of deeper understanding. It provides a framework in which psychoanalytic interpretations can still aim to track truths about the patient’s inner life, even if those truths are partial, revisable, and influenced by context. This philosophical grounding affirms the possibility of shared understanding and therapeutic change, grounded in the recognition of the patient’s psychic reality.

Moreover, critical realism may serve as a vital philosophical bridge between psychoanalysis and the broader domains of psychiatry and scientific psychology.

A longstanding critique of psychoanalysis is its epistemic isolation from empirical science, particularly its perceived resistance to diagnostic standardization or outcome-based measures. While this critique often oversimplifies psychodynamic epistemology, it underscores real tensions between hermeneutic and positivist models of mind. Critical realism offers a reframing of these tensions by supporting a layered ontology, where psychological phenomena can be real and causally efficacious even if not directly measurable.

In this view, constructs such as internal objects, splitting, and projective identification are understood as real mechanisms operating at the psychological level of analysis, even if they are not reducible to biological correlates or behavioral metrics. This allows psychoanalysis to retain its interpretive richness and depth while remaining engaged with scientific standards of explanation, coherence, and progress. It supports a pluralistic science in which meaning-based and empirically grounded approaches work in tandem to illuminate the complexity of human suffering.


In sum, a critical realist framework offers a productive middle path. Psychoanalytic interpretations, including those applied to complex psychiatric disorders like BPD, are shaped by theoretical models and clinical subjectivity, but they are not arbitrary constructions. They represent serious, good-faith efforts to make sense of unconscious dynamics and to promote psychological transformation. In this light, critical realism not only supports the epistemological integrity of psychoanalysis but also repositions it within the larger landscape of scientific psychology and psychiatry. It allows psychoanalysis to reclaim its rightful place as a discipline committed both to meaning and to truth.