Group practices are taking the field of outpatient psychotherapy by storm. In just the last five years, thousands of group practices have started in all corners of North America. The dream of passive income, coupled with the somber realization that a full solo practice does not yield enough money to pay for college, retirement and the lifestyle that most practitioners desire, has fueled this rise.

As someone who has run a group practice for 20 years and has coached over 200 psychotherapists in starting and growing one, I see both the promise and pitfalls in this trend.

At the first naive glance, group practice seems almost too easy. If you have a successful solo practice, you know how the therapy game works. So you hire a good therapist, give them an office and a few referrals, sit back and rake in the money. Hire a few more, and more money rolls in while you bask in the sun or stroll along the beach.

Not so fast. The reality is that group practice is a complex, dynamic beast that challenges you in ways that a solo practice never will. It requires the owner to simultaneously juggle numerous plates, while still performing therapy during the early stages of growth, sapping your time and energy. Group practice also demands that you learn a bevy of new skills. For example, you need to learn how to hire, manage and evaluate clinical and admin staff (and fire them when necessary), manage the irrational projections staff throw at you as the resident authority figure, expand your marketing, track much more complex metrics, develop a profitable compensation model, stay current with the latest ethical issues and clinical strategies and, finally, develop a work culture that people enjoy working in.

I know many group practice owners like myself who have mastered these skills and currently employ staffs of twenty or more clinicians, generating revenue over $2 million per year. But these tend to be group practices that have been around for at least five years.

As a group practice owner, I am always balancing three things: referrals, office space and clinical staff. The dirty little secret of group practice these days is that with its exponential growth, finding and keeping good clinicians is MUCH more difficult than ever before. The best clinicians already work in other group practices or have their own solo practices. One measure of the competition for good clinicians is this: the number of ads for therapists for group practices on job sites such as Indeed.com has increased tenfold in the past four years.

The new kids on the block may find themselves competing with practices that offer a host of benefits such as healthcare, retirement accounts, paid vacation and paid trainings for an increasingly limited pool of qualified clinicians.

So what can you, as a newer or existing group practice owner, do if you want to expand? Here are five specific strategies that can help:

1. Develop an internship program – there are still many pre-licensed clinicians who need hours and are hungry to learn from an experienced, successful therapist. You can pay them less than a licensed clinician, and if they like working for you, they will often stay on after they are fully licensed.
2. Stress the benefits of joining a newer group practice – it’s exciting to be part of something new, to be able to have an immediate impact on policies and procedures. If you join a larger group with 20+ clinicians, all of that will have been established years ago, and you will have very little say in what happens.
3. Use your personal network of colleagues to find therapists – don’t forget your friends and colleagues who know many other therapists in your community. Personal introductions that build on your experience in the field can be an invaluable way to attract new staff members.
4. Develop a unique specialization that is not commonly served in your community. Many group practices are one-stop shops that serve a general range of clients. Practices that specialize in one or two niches can attract clinicians who already are — or want to become — experts in a particular clinical specialty.
5. Promote your practice to people who are working in low-pay agencies that have endless paperwork and hours of boring meetings. These people are often seasoned clinicians who are thrilled to make more money and work with higher-functioning clientele.

Group practice is here to stay, and when done correctly, can fulfill the dream of an affluent lifestyle, meaningful work, and providing help for thousands of people in your community. But without solving the staffing problem, this dream will remain a distant fantasy.
 

Michael is a first-generation Chinese immigrant who requested to see me for counseling. When I met with him, I could sense dejection, fear and abject shame as he shared his wife’s desire to divorce him. By all accounts, Michael is an upstanding citizen. By Asian standards, he is a success, having immigrated to this country to start a successful business. He has provided financially for his family. He expressed bewilderment as to why his wife would want to divorce him, as he felt he had done everything possible to sacrifice for the greater good of his family.

While his therapy involved exploring some of the relational patterns that might have led his wife to feel like she was unappreciated, much of our work centered around reflecting the pain and grief he was or might be experiencing.

In one of his early sessions, Michael described having panic attacks while sleeping, waking up sweating and having a hard time breathing. He would also rhetorically ask, “What am I to do next (if she divorces me)?” and “I can’t accept this!” He described his mental state prior to seeing me, saying, “Two weeks ago I was in a dark place, depressed and felt empty.”

I immediately inquired about suicidal thoughts, and he acknowledged passive thoughts of suicide (i.e. thoughts without any concrete plans). I brought up the concept of a safety plan which would include calling 911, calling me and/or going to an emergency room. He said he could contract for safety by calling 911, but I was not convinced he would do it and felt he was just saying that to appease me.

Beyond the main current precipitating factor for suicide (upcoming divorce), I also asked him about protective factors by directly saying, “What’s keeping your alive today?” He shared about wanting to be here for his youngest son, who’s 10 years old.

Michael was mild-mannered and not openly emotionally expressive of his pain in session, although he acknowledged bouts of crying spells at home. He also described a life that appeared isolated and lonely. Playing golf for hours at a time by himself is what he described as his means of coping. It made me worry as he lacked an emotional support system.

While he denied suicidal thoughts in the following weeks, his physical symptoms increased in intensity (i.e. panic attacks and feeling like the “sky is going to fall”). Since Asians are much more comfortable talking about somatic issues than emotional ones, I recognized that he might still be trying to assess the extent to which he could trust me. I gently probed and educated him that his thoughts of “not sure if he could go on” were indeed considered passive thoughts of suicide. He was unaware of this and expressed the belief that feeling suicidal was simply when one had concrete plans.

During this time, I continued to press Michael to determine if he had friends, colleagues or others in whom he could confide about his upcoming divorce. Because of shame, it took a long time before he could even share this with his own parents. He eventually opened up to one friend, which I believed was a courageous first step towards openly expressing vulnerability. He told me that if he felt suicidal, he could and would likely be able to reach out to this friend. I remember feeling relieved that there was at least one person in his life whom he trusted.

***
 

This case example demonstrates the delicate balance that therapists must tread when working with cultural shame and suicide. Over the years, I have learned that despite the shame Asian clients may feel about their lives and related suicidal thoughts, we must be bold enough to directly engage in these conversations.

In the general suicide literature, precipitating and stressful life events include divorce, death of a loved one, job loss and physical health problems. For Michael, it is no different. While divorce is mainstream in America and Caucasians may see this as simply another loss from which to recover, Asian clients may view this quite differently. As Asian identities revolve around familial ties and their place in the family, divorce can propel an Asian into a painful and shame-filled world where he/she may feel ostracized not only from their family, but from the greater Asian community, including friends, colleagues, churches and extended family relatives.

Michael is somewhat atypical in the sense that his thoughts of suicide occurred in mid-life, compared to those aged 20-24 years old, when suicide is the leading cause of death among Asians. However, what links Michael with other Asians is their centuries-old viewpoint on mental health and cultural shame. Shame is what Asians learn to avoid in any form throughout life, so going through a divorce is considered highly shameful. The belief that they have shamed their family and ancestors leads some to feel they have so disgraced their kin that they must hide oneself (physically and/or emotionally) or atone for their actions by ridding themselves from society by suicide.

In the context of younger Asian Americans, shame can emanate from perceived failure in academics (not getting high enough grades), poor career choices (pursuing a less financially secure occupation), or relational mistakes (dating or marrying someone the parents object to).
The fear is far more than one of disappointment, and is instead the concern over outright abandonment. There are innumerable stories of Asian parents disowning their children for not abiding by their parent’s dictate. Even if this were not a reality, the very fear or perception that this threat exists could lead one to suicide, depression, addiction, isolation and a host of other maladaptive coping behaviors.

In addition, mental health is viewed as a weakness, and talking openly about anything emotional such as sadness, disappointment and the stress of various life events is discouraged and rarely emulated in traditional Asian families. Stoicism is desired and the notion of physical touch and verbal affirmation can be seen as coddling.

Even suicide is viewed very differently among traditional Asian cultures. Some view suicide as an opportunity to atone for their misdeeds in this life and return honor to their families. In this regard, there are even extra incentives to die by suicide, including restoring the family’s reputation as well as those of the ancestors. It also can be seen as spiritually elevating oneself, since those who die by suicide become free of criticism.

All this is to say there is much work to be done in the field of mental health and outreach as it pertains to Asian Americans. If you’re working with Asian Americans in any capacity, be aware of their nature to minimize negativity and emotions that are regarded as shameful.
Clinicians should be mindful of life events that Asian clients deem so shameful that suicide becomes an option (job loss, divorce, bankruptcy). Because Asian shame is endemic to the culture, you also have to be wary of the client’s support system (or lack thereof). Is your client isolating from friends, peers, or relatives? Does your client struggle with emotional intimacy and fear that if someone else (besides the therapist) knew of their struggle, they would be abandoned?

Regardless of your therapeutic modality, when working with Asian American clients it’s imperative to find ways to reframe therapy from a shameful, stigma-inducing event to one where the client is working towards health, wellness and growth.  

Bibliotherapy, as an adjunct to psychotherapy, can be helpful to clients struggling with mental health problems ranging from alcohol abuse, anxiety and depression to cancer patients hoping to increase their coping skills in the face of the disease. Although there has been little to no research conducted on the beneficial impact of bibliotherapy for couples in counseling, I’ve worked with many couples who attest to the benefits of reading counseling books as a supplement to therapy — John Gottman’s The Seven Principles for Making Marriage Work, Harville Hendrix’s Getting the Love You Want and Gary Chapman’s The 5 Love Languages, to name a few. Yet, as people are busier now than ever, especially the couples I work with who are managing two work schedules, daycare, parenting, school functions and activities, travel and all the other activities and obligations that dominate their day-to-day lives, couples simply don't have the time to sit down and read a book, let alone read a book together.

Problem, meet solution! Podcasts can fill the bibliotherapy gap created by busy schedules. Podcasts, if you have a smartphone (and everyone has a smartphone) are available at the touch of a finger. You merely need to download a podcast app, subscribe and listen away. A client can listen while riding a bike, mowing the lawn, on their commute, sitting with their partner, watching the kids play in the front yard, going to the bathroom (we all look at our phone while on the toilet) or while preparing school lunches.

The convenience and accessibility that smartphones provide are really mind-blowing, and to boot, there are a number of excellent podcasts available that address not only relationship issues but issues related to depression, addiction, anxiety and much more. Here are a few standouts your clients can subscribe to for free:

• The Hilarious World of Depression with John Moe – Each episode features a conversation with someone about depression.
• Where Should We Begin? with Esther Perel – Podcast from a world-renowned couple’s therapist. Each episode features a couples counseling session.
• Meditation Minis with Chel Hamilton – Episodes offer guided meditations to help listeners develop mindfulness skills and reduce stress and anxiety.
• Hidden Brain with Shankar Vedantam – Excellent resource about psychology and, more specifically, the hidden motivations which derive from the unconscious mind.
• Invisibilia with Alix Spiegel and Hanna Rosin – Episodes offer powerful narratives which explicate latest findings from the field of psychology.
• Speaking of Psychology with Kaitlin Luna – The APA’s podcast about current trends in the field of psychology and latest research findings.
• The Hardcore Self Help Podcast with Robert Duff – A weekly podcast about various mental health issues that cuts through the fluff and gets to authentic advice.
• Not Another Anxiety Show with Kelli Walker – A deep dive into all things anxiety. Experts are interviewed who offer advice on how to cope and treat anxiety.
• The Dark Place with Joel Kutz – Honest interviews with real people about mental health illness who speak about depression, anxiety, trauma and a number of other mental health issues.
• The Mental Illness Happy Hour with Paul Gilmartin – Famous and everyday people are interviewed about mental health struggles like depression, anxiety and trauma.

Accessing supplemental therapy content outside of a session can be useful for a client. A client has only one hour with you per week (really only 50 minutes). Even if you have a great rapport with your clients and they absorb every thought you have to offer, 50 minutes isn’t much time. Therapy workbooks and self-help books can make up ground where traditional, weekly, one-hour therapy may not be enough. This is especially true in couples work where an hour session can fly by. So, why not arm couples with additional psychotherapy material that they can noodle on between sessions?

You may be wondering, podcasts sound great, but how do they actually function relative to actual live couples therapy? The therapy office, in a sense, is a laboratory where couples perform a number of relational experiments. They then try those same experiments out in the real world and come back to session to analyze the results. From this outcome data, we can observe what worked and what didn’t. A couple could easily cycle through 15 ideas and find that only four work for them. It is only by the process of experimentation that the four become evident. So why not increase the range of ideas a couple can experiment with? Let’s imagine if we increased the number to 30 ideas. If the trend holds true, then the couple will discover eight ideas that really work. Bibliotherapeutic works, in this case podcasts, are an inexpensive and efficient way of increasing the number of ideas a couple can interact and experiment with. Below is an example where a couple in counseling utilized podcasts to increase their therapeutic gains.

I worked with a couple who needed longer sessions, yet because of my schedule, I could only see them for the typical 50-minute hour. This left a number of important topics without the necessary elaboration. As a way to compensate, I recommended the couple listen to a podcast on an issue they struggled with as therapy homework. The couple followed the advice and took the assignment beyond the original intent. They were able to use the podcast content to spark meaningful conversations. And, as one partner shared with me, she was deeply touched by the fact that her partner spent time, unrequested, on researching podcasts and listening to them. For her, it demonstrated engagement and investment in their relationship. Additionally, the content of the podcast contained communication skills and tools they were able to apply to addressing their destructive relational pattern. This learning segued nicely into the work done in session. They discussed insights gained from a podcast, further reinforcing the value of the ideas. Moreover, they discussed ideas difficult to understand, which I was able to clarify and through which enhance their understanding. All in all, the couple and I found podcasts to be immensely beneficial to their counseling goals.

Some therapists may have ethical or clinical concerns related to the use of podcasts in therapy, and for good reason. Podcasts are not to be a replacement for therapy. Additionally, the therapist may sacrifice some influence or control to podcasts. And not every podcast will express sound, evidence-based, therapeutic advice. Or the advice given in a podcast may contrast with your counseling. Certainly there are some liabilities that come with podcasts, which you can wisely mitigate. I suggest only recommending podcasts you have vetted and that specifically target the client’s issue. The podcasts recommended in this article give disclaimers that they are not replacements for therapy and are static, in that they can’t respond to crises or provide personalized advice. That level of care can only be provided by a therapist. With these potential liabilities considered, the research supporting the use of bibliotherapy and my own clinical experience supports the adjunctive use of podcasts in couples counseling. 

A friend of mine once told me that when psychology encounters great literature, literature comes out the loser. I took her point. And yet, every Christmas I find myself thinking that Dickens’ A Christmas Carol is, among other things, a singularly brilliant psychological treatise. The transformation of the story’s main character, Ebenezer Scrooge, is, of course, legendary. But the actions of the spirits who guide him are not just supernatural; some of them are surprisingly psychotherapeutic. And seasoned therapists may even find them—if I may say so—hauntingly familiar. The Scrooge we meet at the beginning of the story is not the kind of guy who typically comes to us for help. He is rigid, compulsive and defensive—far more likely to resist than to seek out a therapeutic process. He scorns human kindness, and he callously says the poor should die “and decrease the surplus population.” To be fair, though, Scrooge is also quick and spunky, and he is not without occasional flashes of wit. He attempts to disarm Marley’s ghost as a “disorder of the stomach,” quipping “There’s more of gravy than of grave about you!” And who among us has never wanted to see some exceedingly cheerful person boiled in his own pudding? Ah, but Scrooge is a hard case! As Dickens says, he is “a squeezing, wrenching, grasping, scraping, clutching, covetous old sinner.” Yet on the seventh anniversary of Marley’s death, something else is at work. As Scrooge enters his cold, dark, empty house, eerie things begin to happen: he sees Marley’s face on his door knocker. And before long, Marley himself appears in ghostly form, terrifying Scrooge and warning him that three more spirits will follow—his only chance to avoid a fate worse than Marley’s. Where is all this coming from? Seemingly from the spirit world. But might it not also be coming from within Scrooge himself? For hasn’t the old man buried parts of his own fractured self—his hopes, his humanity, his guilt about bad acts? And, once buried—undead—in Scrooge’s personal underworld, might not these fragments be struggling now to return in uncanny and ghostly form? The three spirits do come to Scrooge, and they come, periodically, through the night like dreams. At times, it seems as though they might actually be dreams. The first spirit, gentle and kindly, conducts Scrooge back through his childhood, and we start to see him in a more sympathetic light: a motherless child banished from his family by a resentful father, living in books, and finally turning to a pursuit of wealth so obsessive that it leaves him unable to love even his sweetheart. Immersed in this past with his spirit companion, Scrooge is unexpectedly wrenched by human emotions—laughing at happy memories and sobbing about the love he lost. Surely, there is real therapy happening here! But insight without change is empty, and, as stated before, Scrooge is a hard case. His rediscovered emotions have begun to chip away at his character armor, but this armor is formidable, and it requires something equally formidable to break it apart. The second spirit, therefore, is a “jolly giant,” impressive to behold, commanding in nature and more than a little intimidating. Flying with this spirit through the city of London and places unknown, Scrooge sees rich and poor alike, including those he knows, celebrating Christmas, warming the bitter cold of the night with their cheer. In the homes of his clerk and his nephew, he shares the glow of the season—only to be mortified when the mere mention of his name casts a pall on the merriment. Worse, the spirit informs him that “if these shadows remain unaltered,” his clerk’s sickly child, Tiny Tim, will soon die. Scrooge’s distress at hearing this turns to shame when the spirit cuts him to the core with his own previous callous words: “If he be like to die, he’d better do it and decrease the surplus population.” For the first time, Scrooge is confronted with the reality of the human suffering he has so lightly dismissed. A shaken Scrooge now encounters the third spirit. Frightening, faceless, and shrouded in a black garment, this spirit points silently at future events that seem to have existential significance for Scrooge. Most of these events involve a wealthy man who has recently died, leaving no one to mourn or care about his passing except a few seedy characters who are busy stealing bits and pieces of his estate. Although the answer is obvious, Scrooge repeatedly entreats the spirit to name the man who has died. The spirit says nothing but takes him to the cemetery, where it points to a neglected gravestone bearing Scrooge’s own name. Begging to know if change is still possible, Scrooge tries to seize hold of the spirit—who shrinks down into his bedpost! Was it a dream? Does it matter? Christmas morning, it turns out, is just starting. The shadows can still be altered, and Scrooge is a changed man. He is elated—feeling like “a baby,” “light as a feather,” simultaneously laughing and crying. In some versions of the story, his maid runs from the house, hysterically proclaiming that the old miser has gone mad. But if this is madness, it is a madness touched by divinity—for Scrooge is transformed, and he begins a new life of goodness, kindness and generosity. How though, has this transformation been accomplished? Certainly, one element was revisiting the past with a nonjudgmental guide to unearth his childhood wounds and to initiate a process of healing. Another element was the second spirit’s unsparing confrontation of Scrooge with the real-life ramifications of his previous behavior. Finally, the third spirit brings Scrooge face to face with the ultimate and timely fact of his own mortality. And yet, my friend’s warning about psychology and literature still weighs heavily on my mind. Can we really reduce Scrooge’s transformation to an “intervention” by a trio of psychodynamic, confrontational and existential spirit therapists? That seems a bit too easy, and even vapid. Scrooge’s transformation is not just a psychological change. It is a matter of the soul, a full-fledged spiritual rebirth. He has shed some kind of unspeakable hubris that deeply infects, in varying degrees, all of humanity. The full depth of the actions that have reanimated Scrooge, therefore, will not be found in psychotherapy manuals or textbooks, or in lists of best practices. Insurance will not cover them. Perhaps we’d best leave them to the spirits.

Symbols fascinate me, and working with adolescents has given me plenty of material to think about. Halloween costumes, for example, often feature intensely conflicted themes, like those of a blood-phobic boy I treated who went to a party as Dracula, and a self-demeaning girl whose costume mimicked a toilet. Music, too, provides numerous hints about struggles with identity. One boy I worked with had become obsessed with determining the truth of accusations about past infidelity and neglect that his divorcing parents had hurled at each other. This boy had tattooed himself with the name of a rock star who played with reality by keeping his fans guessing whether his behavior was actually as outrageous as it was rumored to be. Another boy showed up for therapy in a T-shirt picturing a heart and an EKG line under the song title “Heartbeat Like a Drum.” After a number of individual and family sessions, it became clear that he deeply feared that his past rebellious behavior might have contributed to his father’s heart attack.

The symbols I find most fascinating, though, are those that hint not only at sources of pain but also at sources of strength and possible transformation. Such was the case with Marie, a 15-year-old girl who had a great fondness for rainbows. For several years she had been collecting trinkets decorated with rainbows, and in the hospital, she had continued to exhibit this rainbow motif in occupational therapy projects and occasional comments. The rainbow motif was consistent with Marie’s past temperament, which had been described by her parents as happy and “twinkly.” But her parents had become increasingly baffled, and then frightened, as Marie’s behavior gradually became angry, defiant, withdrawn and suicidal. In the hospital, Marie alternated between a cheerful demeanor and expressions of intense hatred for her parents, especially her mother, whom she described as hypocritical, judgmental and verbally abusive. Adopted as an infant, Marie characterized herself as “bought and paid for” but unable to meet her mother’s perfectionistic standards no matter how hard she had tried.

In therapy, Marie began to reveal a complicated and troubled decline that had preceded her hospitalization. During the past two years, she had escaped into her room at home and what she called her “Little World”—where she ruled a fantasy land, like Oz, full of rainbows that she materialized by rearranging colored objects in her room. The colors had reminded her of happier times, especially family trips to a brightly colored theme park, where Marie and her parents used to go on annual vacations and where they experienced rare periods of untroubled closeness. But in the past year, as the problems at home had grown worse, her Little World had become colorless, and then malignant. She had started hearing voices—that of a little girl who cried while other voices would say “mean things,” swear and argue with each other. These voices had been very frightening to her.

We had glimpsed this darker side early in Marie’s hospitalization when she had been tested psychologically. She had not appeared psychotic, but she had reacted strongly to the Rorschach inkblots, which she had characterized as dark, scary and depressing. Later in the test, she had described a colored inkblot as looking like “a rainbow destroyed.” It seemed significant, however, that her response to the next inkblot, which was also colored, seemed more hopeful: “a rainbow with the colors coming together . . . kind of circular.”

Family sessions with Marie and her parents were tumultuous. Initially, she raged at both parents. She accused her mother of judging and verbally abusing her when she did not live up to her mother’s standards of perfection, and then acting lovingly afterward. Her father, she said, had never stood up for her or shown her the love he did her brother (also adopted). At first, her parents denied her accusations, but as more was said they began to acknowledge that some of them were true. Marie was particularly relieved when they agreed that they had made a mistake by not seeking help for her after a previous overdose, and her father admitted, “We were just hoping the problems would go away.” In subsequent sessions, the family built on this new openness, and near the end of her hospitalization Marie raised, for the first time, questions about her adoptive status and her birth mother—a topic of great difficulty for her adoptive mother.

In individual therapy, I interpreted Marie’s Little World as an attempt not only to escape but also to discover who she really was—to put parts of herself together, as she had tried to harmonize the colors in her room. She acknowledged that some of the perfectionism she had seen in her mother was also coming from within herself, and she recognized that she would have to continue to sort out both her anger and her love for her parents. By the end of her time in the hospital, the voices were gone, and she said “I can still see my Little World. It’s deserted now. I like it that way.” Marie may not have intended it, but she had invoked symbolism with exceptionally broad and deep cultural roots.

All over the world, rainbows have signified a variety of related themes, including transience, hope, renewal and restoration. In some cultures, the rainbow may be a totem, or sacred object, and when coupled with circularity it may also serve as a mandala or symbolic schema for integration and transformation. For Marie, rainbow souvenirs had served as tokens of a happier time when her family had been able to recapture the closeness she had experienced as a young child. And in therapy they had given her a metaphor to encompass some of that history and a way to think about possible change.

Symbols, such as the rainbow for Marie, are not only hints at deeper meaning but richly layered and textured clues for clinicians willing to explore them with their clients. When I have followed these clues with my clients, I have often found that they point the way to important themes I might otherwise have missed. And they have given me a great appreciation for the depth and complexity of human communication.   

Like most professionals, I am required to earn continuing education credits in order to maintain my license as a psychoanalyst. I usually experience this requirement as a pain in the neck. I have to find lectures or conferences that invariably interfere with my weekends. But each time I go to a lecture or conference kicking and screaming (metaphorically), I always leave feeling that this is a really good requirement and that I've learned something valuable that is useful to my psychoanalytic work. Most recently, I have been watching videos or reading lectures on Psychotherapy.net because I can earn CCE credits at my leisure–without having to give up an entire weekend.

A few weeks ago, I read an interview with Allan Schore about the neuroscientific underpinnings of psychotherapy. He pointed out the traditional way the different functions of the left and right hemispheres of the brain have been explained: the left hemisphere is engaged in objective thought, reading, thinking and language; while the right hemisphere is the center of subjectivity–e.g. empathy, intuition and emotional processing. Shore says that the core self-system is in the right hemisphere and hence the change that goes on in therapy is in the right hemisphere. Change and/or repair occur in treatment at the most cathartic moments–e.g. when we become aware of our body-based emotions more than our thoughts, when we have an "aha" moment,when a shared metaphor is imbued with emotion or when patient and therapist share an insight through humor. All of those, Shore says, are right hemisphere functions.

That was all very interesting, but the part of his discussion that really stuck with me was about the relationship between affect dysregulation and psychopathology. Schore said that affect dysregulation is the result of insecure attachment, and the two major ways that people try to regulate themselves when they suffer from it is by over-regulating (i.e. avoidance strategy) or under-regulating (anxiety strategy) their effect.

Soon after I read the Schore interview, I was in a phone session with a patient, Jonathan, who had his secretary call me and cancel four sessions in a row. I felt angry that he did not communicate with me himself because we had discussed having his secretary communicate with me at other times. I also felt frustrated that he had cancelled so many sessions when, in the sessions before that, he had been feeling unusually connected to me. I wondered if that had frightened him and perhaps caused him to create distance. I was thinking about his fear of intimacy.

When I asked Jonathan what he thought it meant that he had cancelled so many sessions and had his secretary communicate it to me, he said he was frightened of having to give an important talk at a conference and did not want to speak to me because he felt so fragile. I immediately realized that this was not about intimacy, but about attachment. Attachment issues are more primitive than intimacy issues.

             I said, "It sounds like you felt that talking to me would make you feel upset."

             He agreed. "I didn't want to talk to anyone. I am feeling calm about the talk at this moment and didn't want to take a chance."

             "So, it sounds like when you are frightened, you don't expect that connecting with me will make you feel better."

             "No, it's funny. I know that in reality I feel better after I talk to you," Jonathan said, "but I always expect it to make me feel worse. I've been in a state of terror about the talk and I just want to be alone."

             "What do you make of that?" I asked.

             "I never felt that I could go to my parents when I was worried or afraid," Jonathan said tearfully.

           "You feel like you're drowning," I said, "and no one can help you, you just keep flailing to try to get a breath."

           "Yes, exactly," he cried.

Because I had just read the Schore interview, I immediately understood he was describing a disorganised-disoriented state of insecure attachment. The issue wasn't that he was withdrawing because of being afraid of intimacy with me. Rather, Jonathan could not generate an active coping strategy to confront subjectively perceived overwhelming, dysregulating events, and thus he quickly accessed the passive survival strategy of disengagement and dissociation.

Jonathan was incapable of maintaining intimacy because of his insecure attachment. He could not think about talking to me when he was struggling with what he perceived as an overwhelming event. This happens with women he gets involved with as well. He cannot maintain the connection to them when work or life events overwhelm him. The affect dysregulation that results from insecure attachment leaves no room for providing comfort or give-and-take or commitment. Since an intimate relationship is mutual, affect dysregulation limits or precludes intimacy.

Clearly, being introduced to Schore's ideas sensitized me to what was happening with Jonathan–I was able to empathize with the terror he felt as a result of his affect dysregulation. Using the metaphor of drowning was reparative and strengthened our alliance because it helped Jonathan feel that I understood his body-based raw emotion.

I have decided to stop complaining about mandatory CE credits. 

The title metaphor of my new novel, The Stone Boys, is of a boy who must become hard like stone to survive childhood sexual abuse. As an adult, he may function well for large chunks of time, even marrying, being intimate, raising children; but his internal resources are thin, and he rarely has any choice, if untreated, but to resort to hardening up against relationships, especially those that become close. I was one of the stone boys. At ten years old, in 1968, my psychiatrist molested me over a period of six months, first grooming me, then moving to abuse. After I escaped him, my confusion, shame and terror had no outlet except into signs of trauma that adults at the time did not recognize as abuse-trauma for two reasons: I did not disclose the abuse until I was 18, and in 1968, the signs were not public enough for people to know about them. A Case Study: Tom, 37 My client, Tom, had some of the same signs I had. In my office, he said, “I’ve never been very good at relationships, and reading your Stone Boys book, I think I finally understand why. It’s so obvious, but I missed it.” “What’s obvious?” Tom had been married and divorced twice, had difficulty holding down jobs, and had been in and out of rehab. “Well…” now, antsy, he stood up out of the chair; I asked if we should go take a walk together, to which he agreed. At a local park, we sat down on a bench. “Did the story trigger memories?” I asked. He nodded his head but didn’t speak. “You can tell me,” I said. “I’m safe, we’re confidential, and you know I will get what you’re saying. You know I’ve been there, in my own way.” “I know,” he acknowledged, standing back up again. We walked again in silence for a while, returning to my office where, once the door was closed, he told me his story. His abuse had been even more brutal than mine.

***

By now, most or all therapists are familiar with the ACEs (Adverse Childhood Experiences) survey, a very useful tool for trauma-informed counseling. I have also developed my own relationship-based checklist for my clients. Tom had eight of these “Signs of Unresolved Childhood Abuse Trauma in Adult Relationships.”

1. Alienation
2. Anger
3. Hyper-vigilance
4. Excessive Blaming
5. Imposter Syndrome
6. Addiction
7. Sexual difficulties (includes excessive porn use, promiscuity, inappropriate sexual contact or displays, and avoidance of sex without porn)
8. PTS (PTSD)
9. Gender Dysmorphia
10. Faking it (existing in the world with some success but retreating into a “stone boy” when triggered by the fear of connection and intimacy).

There are more than one hundred brain differences that apply to females, males and trauma, and many of these apply to a single thread: comparatively less developed connectivity between the male mid-brain (where memory, aggression and sensorial activity are mainly housed) and the top of the brain, where intimate decision-making and executive functioning occur. Abuse is not the same for females and males, despite the fact that we are all, indeed, human. Treating Abused Boys and Men A first step in treating males especially is Personal Storytelling. Even if a therapist has never experienced sexual abuse trauma, all of us have experienced trauma of some kind: some form of storytelling about trauma in your own life can help males to open themselves up. A second step is recognition that sexual abuse for males is indeed different than for females (in most cases), not only in the myriad ways males and females are neurobiologically different but in the specific male confusion over pleasure. Most sexual abuse of males, though not all, involves male ejaculation, something that gives pleasure. Much less often does the abused girl experience an orgasm. With Tom, talking about this helped him sort through guilt and shame at deep levels. More Best Practices for the Abuse Survivors and Their Therapists For abused males, these are best practices I have relied upon and will likely be needed as ongoing mechanisms for healing. Therapy, Medication, Brain-Direct Modalities EMDR (Eye Movement Desensitization Reprocessing), Neurofeedback, mindfulness, meditation, prayer, spiritual dialogue (talking directly with God), and ongoing talk therapy. Ongoing Support Groups Getting men involved in support groups, mentoring/counseling by and with males, and groups and counseling with people from their own milieu (racial, sexual orientation, culture, similar religious background) who have also been traumatized. Couples Therapy Because nearly everyone who has been sexually traumatized has relational difficulties of some kind, these men often need couples/relational therapy as soon as possible. Addiction Work Many abuse victims also possess addiction genetics which get triggered by the abuse. Recovery groups and addiction therapy can be crucial. Choice Theory Because an abuse survivor has felt out-of-control during the months or years of trauma, it is important to give him choices and “control” now, years later. Help Him Avoid Rumination Loops Negative rumination loops may be precursors to severe depression and actions taken (“What should I do!”), especially in a man’s islands of competence, can help. Journaling Writing or video journaling can lead to more rumination, so it can backfire, but often it is a good tool for boys and men who lean already toward reading, tech, and/or verbal processing. Organizations That Can Provide Support National Sexual Assault Helpline. 800.656.HOPE (4673). Department of Defense Helpline. (877) 995-5247. SAMHSA (Substance Abuse and Mental Health Services Administration). Additional Reading The Stone Boys, Michael Gurian, Latah Books, 2019. Saving Our Sons, Michael Gurian, GI Press, 2017 Victims No Longer, Mike Lew, HarperPerennial, 2004. Abused Boys, Mic Hunter, Ballantine, 1991 Beyond Betrayal, Richard Gartner, John Wiley, 2005.

I watched one day as Brittany, a tall, stylishly dressed young woman, came into my office and wondered (as I always do in a first session) what problem or issue would she would present.

“I saw you on Facebook, talking about “perfectly hidden depression (PHD).” I’ve never been to therapy. But I know that you’re describing me, and I’ve got to get help, because things are getting worse.”

She stopped abruptly, seeming to immediately regret telling me even that much about herself. Smiling brightly, she sat a little sheepishly on the sofa, one of her legs nervously pumping up and down. She didn’t know what to do and waited for me to respond.

“Well, if you identify with PHD, you’re not used to openly talking about yourself. So, I bet being here is hard.” She nodded, looking down at her feet. “We can take all this very slowly. I’m here to listen, but you’re in charge of how fast or slow this goes. So, is there something that’s happened recently that made you more worried about yourself?”

Brittany didn’t tell me everything about her life in that session. In fact, it was months before I would know the whole story. As trust grew, she’d blurt out hurtful secrets that she’d been keeping, all the while very closely watching to see my reaction, as she gradually took more and more risks in sharing her real life. Still, her ability to openly express the emotions connected to those secrets was very limited; self-compassion was foreign to her. I’d see only an occasional tear, quickly covered by a blank look or a change of subject.

What was that story? It began with a childhood assault by her drugged-out father, with injuries that required multiple surgeries. It continued with a passion for ballet, which was sabotaged by a teacher who was demeaning and sharply critical of her body, contributing to anorexia. That was followed by intense pressure from her mother to marry someone who was “going to do well.” But the someone she attracted, her fiancé, was abusive and highly manipulative, frequently threatening to publicly humiliate her by telling “all he knew.”

Brittany wasn’t the first client I’d seen with this kind of emotional disconnect between the pain of what she was saying and the feelings she struggled to identify. Elizabeth found herself lying naked on a beach, having been drugged and raped. "I've never thought the story was all that important, it was a long time ago," she told me, smiling hesitantly. Linda hadn’t cried in years, even after her mother's sudden death. "Crying makes me uncomfortable,” she explained. “I think it’s a sign of weakness." Jackson talked about strange, secret impulses to drive off the road, then followed his confession with, “I have a good wife and family. I'm just a little stressed."

Like Elizabeth and Linda and Jackson, Brittany didn’t look depressed in the classic sense. She was highly organized, her planner stuffed with sticky notes and extensive to-do lists. She stayed very busy with dinners with girlfriends while she and her fiancé appeared to have the perfect relationship. She was successful in her job, although highly anxious about making the right decisions for her professional future. She didn’t look sad; in fact she was often quite jolly and funny. What she allowed others to see looked pretty perfect.

The more we worked together, the more she became aware of perfectionism’s grip on almost every aspect of her life. She realized the many barriers she put up to even consider living a more vulnerable life. She tackled her anorexia, confronting and discarding old irrational beliefs that she no longer wanted to live by, one of them being that she always had to seem in control. She said, “I cry now every time I eat dinner. But I know I’m growing.” She ended her silence, one emotion at a time, confronting her tendency to remain overly analytical and “in her head.” With huge trepidation, she broke things off with her fiancé and faced the wrath of their families. Much to her amazement, her mother backed her up. She could recognize that, all along, her emotional pain had been masked by her obsessively cheerful demeanor and incredibly high expectations of herself.

It was such an old strategy—she hadn’t been conscious of it. Until she was. And the light of that awareness couldn’t be turned off.

On the last day I saw her, she looked at me very directly. “I never told you that I planned to kill myself. I couldn’t see another way out. But I heard the term perfectly hidden depression, and something clicked. I didn’t know what I was doing but I knew I wanted it to stop.”

***

In suggesting the concept of perfectly hidden depression, I’m not offering the absolute, never-has-been-considered-by-anyone-else warning signal for depression or suicide. Perfectionism has been known to be correlated with depression. Yet an awareness of the presence of perfectionism might lead to us asking different questions. Instead of, “Do you feel hopeless?” the question becomes, “If you ever felt hopeless, would you tell anyone?”

I’m challenging mental health professionals to think outside classic depression’s diagnostic box. We know that depression can present as melancholy or anger and agitation. Another potent contender should be the virtual absence of spontaneous expression of any emotion but rigid positivity.

Perfect-looking is perfect-seeming. But seeming isn’t being.