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The Power of Naming

Posted on February 22, 2018February 11, 2026 by Psychotherapy.net Team

Although there are hundreds of different psychotherapies, certain fundamental ideas are common to them all. Among these are the concepts of naming and renaming. I can illustrate these tactics with a literary example.

In Shakespeare’s Hamlet, a ghost claiming to be his dead father tells Hamlet he was murdered by his brother, the current King, and orders Hamlet to avenge his death. Hamlet delays, seeking more proof. The King sends Hamlet away to be secretly murdered. Hamlet foils the plot, decides the King is a villain, returns, and—after three hours dithering on stage—kills him. Scholars have long debated the reasons for Hamlet’s hesitancy and failure to act.

Some years ago, I took part in a trip to England guided by a Shakespeare scholar. After we had attended a performance of Hamlet, our tour group had a spirited discussion about whether Hamlet’s indecision could be explained by a diagnosis of clinical depression. Many of those present believed that it could. Didn’t he, in his famous to-be-or-not-to-be speech, contemplate suicide? The inhibition and helplessness of his dysthymia, they argued, would explain his inability to act on his ghost-father’s demand for revenge. I contended he was not depressed and here’s why…

1. In 1600, depression was called melancholia. Where we would say, “I’m depressed,” someone of that era would say, “I am melancholy.” So: was Hamlet melancholy?

Shakespeare’s Hamlet dates from around 1600 and his protagonist appears in Act I with all the trappings of melancholy: black clothing, sighing, tears, “the dejected haviour [behavior] of the visage.” The photo shows an actor in his Hamlet costume, with all the melancholic signs. The photo below shows an actor in his Hamlet costume, with all the melancholic signs.

But wait: the height of fashion among aristocratic men of that time period was to adopt a melancholic dress and demeanor. They wore dark clothing with open collars and unbuttoned robes or doublets, affecting a disheveled appearance and world-weary poses with sad expressions. (Perhaps in our own time those who dress in the Goth tradition make a similar fashion statement.) This “melancholic style” was considered a sign of great poetic feeling and intellectual depth, a stereotype with which Shakespeare’s audience would be very familiar. In short, Hamlet strikes a melancholic pose but his fashionable outfit doesn’t mean he’s depressed.

2. Hamlet is mourning his father’s recent death. In his 1917 paper, Mourning and Melancholia, Freud differentiates the two states: “In mourning, it is the world which has become poor and empty; in melancholia it is the ego itself.”

Hamlet is unequivocal about which state he experiences. For example:

In Act I, he observes, “How weary, stale, flat and unprofitable/ Seem to me all the uses of this world.”
And later (Act II), he says: "… it goes so heavily with my disposition that this goodly frame, the earth, seems to me a sterile promontory…”

Clearly, it is his world that is, as Freud said, “poor and empty,” and not Hamlet himself. He is contending with grief, not depression.

3. And then there is the seemingly suicidal rumination of the “to be or not to be” speech.
Here again, Hamlet’s thoughts are not those of someone struggling with the mental pain of true depression. Rather the soliloquy reflects his wish to be relieved of a heavy burden: what to do about the ghost’s demand for revenge.

He doesn’t speak directly about this dilemma. Instead, he generalizes about the many frustrations and indignities of life.:

“the slings and arrows of outrageous fortune” and
“the thousand natural shocks/ that flesh is heir to.”

Again, his focus is the world, not his inner mood. He rejects suicide as a solution to these afflictions because death is “The undiscovered country from whose bourn/ No traveler returns,” and the possibility of more dreadful troubles in the afterlife “makes cowards of us all.” No thanks, Hamlet concludes, I’ll stick with the problems I’ve got. A wise choice, not a melancholic decision.

But Hamlet is only a play, so whether the Prince is depressed or not really doesn’t matter. In psychotherapy, however, the incorrect identification of an affective state can create unnecessary problems. We sometimes encounter patients who confuse “depression” with a variety of other emotions. They may tell us:

“I’ve been depressed since my grandmother died.” (No, like in Hamlet, that’s grief.)
“My team lost in the playoffs. I’m really depressed!” (No, that’s unhappiness.)
“That tearjerker movie left me so depressed!” (No, that’s sadness.)
“I’m depressed because I didn’t get a raise.” (No, that’s disappointment.)
“I can’t afford a new cellphone. It’s really depressing.” (No, that’s frustration.)

Confronted with these misapprehensions, our first task is to help the patient accurately identify the dysphoric state. This correction not only allows us to focus our therapeutic effort on the appropriate target, it also helps the patient to better understand his or her own reactions. In the worst case, it avoids the temptation to consider an “antidepressant” as a helpful intervention. None of these mischaracterized emotional states would respond to a drug.

So, back to the idea of naming and renaming…

Merely naming a set of symptoms provides clarity and a focus of exploration. As above, naming Hamlet’s emotional distress as “grief” not only explains his mood; it allows us to better understand his later behavior. If he were in therapy with us, we might examine his ambivalence about his ghost-king father as a basis for his indecision or challenge his negative overgeneralization about the world’s “emptiness.”

Renaming is an intervention that helps define a therapeutic problem in a more accessible manner. If we renamed Hamlet’s “indecision” as his sense of justice—being right about his uncle’s crime must precede any possible revenge—we could help him resolve his dilemma with much less vacillation. The play would no longer be a masterpiece, but it would save years of unnecessary therapy.

Reflections on Evolution of Psychotherapy 2017

Posted on February 2, 2018February 11, 2026 by Psychotherapy.net Team

Hard to believe, but it's been 22 years since I set up a small booth at The Evolution of Psychotherapy Conference in 1995 in Las Vegas, peddling my first videotape (yes, VHS) Existential-Humanistic Psychotherapy in Action featuring James Bugental, a teacher of mine who happened to be one of the presenters. At that time the Evolution folks (namely Jeff Zeig, director of the Milton H. Erickson Foundation, which puts on the conferences) was kind enough to contact the other faculty members, and ask them if they had any videotapes to sell, so I ended up having a small collection at my booth. Plus I managed to obtain some copies of my father’s video series on group psychotherapy. I ran an ad in the program, plain text, nothing fancy, which I recall started with this headline: “Yalom. Bugental. You’ve seen them here; now take them home.”

Honestly, I had no plans to start a business at all, I just wanted to sell some of the Bugental videos I had produced to make back my production costs. But we had an overwhelmingly positive response to our videos, and as is often the case, a business was inadvertently born.

Flash forward 22 years, and the Evolution of Psychotherapy Conference is still the event in our field. December’s conference had over 7000 attendees from over 50 countries. Initially every 5 years, then 4, and now the next one will be 3 years from now in 2020, it has been referred to as the Woodstock of Psychotherapy Conference, if you’re old enough to get that reference. Most of the presenters are….in fact sadly many of the granddaddies of the field (and a few of the grand dames) that presented at prior conferences are no longer with us (Rogers, Satir, Whitaker, Bowen, May, Haley, Ellis, Bugental, Lowen, Gendlin, and most recently Minuchin, just to name a few).

Still, many of the same faces and names were presenting, although some are really getting up there in years; Otto Kernberg, Erving Polster, Irvin Yalom and Aaron Beck are some that we hope will be back next time—but based on actuarial tables, we just can’t count on it. Plus there are some representatives from the relatively newer generation of therapists: Sue Johnson, Steven Hayes, Judith Beck and others.

A couple of thoughts: The title of conference, The Evolution of Psychotherapy implies we are evolving as a field. Sometimes I wonder. Given the total lack of family therapists from the current crop (a striking contrast from the early Evolution conferences), this would add evidence to what we all know, which is that family therapy is in serious decline. Suddenly it’s all about the brain…but we wouldn’t have a brain without families, just for starters. And as the attachment folks like Sue Johnson point out, without close connections the brain surely wouldn’t do too well at all (think Harlow’s monkeys). Are we really evolving as a field, or are we just coming up with acronyms for new branded therapies?

There was a greater number of female speakers in this year’s conference than the first conference in 1985, although they were still the minority—although the attendees were overwhelmingly female—eyeballing it I’d say well over 80%. I’m not sure that’s an entirely positive development, and unfortunately I think partly reflects the economic challenges in our field—and now another example of women being overrepresented in lower paying professions (at least compared to other professions requiring comparable education and training). Although women are typically the nurturers in our society, we need men who are compassionate and empathic as healers as well. And as for minorities…I count two in the roster: Derald Wing Sue, and Patricia Arredondo, both of whom were there to speak on multicultural issues in therapy. It will be nice when one day therapists of color are there to speak on issues other than how to do therapy with people of color. I think this says much more about our field and society than this particular conference.

Jeff Zeig and his crew know how to put on a show like no one else in our field. The energy and excitement at Evolution conferences is contagious, and one leaves with feelings comparable to ending a stimulating voyage, or theater festival, or 17 course dinner (not that I’ve partaken): filled, stimulated, tired and rejuvenated at the same time. Looking forward to 2020. If you haven’t been to a previous Evolution conference, mark this on your calendars. Based on actuarial tables, I should be there again.

Teaching Clients to Meditate

Posted on February 1, 2018February 11, 2026 by Psychotherapy.net Team

A family sent their abrasive son to a monastery to learn a better path. When he came home to visit them after having been there his first year, they asked him what he learned. The son replied frustratingly, “All I learned to do was breathe.”

He returned to the monastery, and five years later, when his family asked him what he learned, he looked disheartened as he shrugged his shoulders and said, “All I learned to do was breathe.” He went away and returned again after ten years, and this time he seemed defeated as the same question was posed and he gave the same answer.

Then, many years had passed, and the young man now became a much older man, and at last, he reached enlightenment. When he was asked what he learned to become enlightened, he replied, “Finally, I learned to breathe.”

Our egos like to assure us that we “know.” “I know, I know,” we say, “I should meditate. I know it’s good for me….” But then we don’t. Talking about knowledge makes for interesting conversation, but practicing knowledge is wisdom. In 2018, we have enough evidence from the field of neuroscience to know that even five minutes of meditation a day for six weeks can create physiological changes in the brain. Meditation decreases activity in the default mode network (our constant inner chatter), it lowers blood pressure, and it helps our amygdalas send fewer false signals of danger that lead to anxiety, fear, and ultimately all-too-often, anger. In short, you know that daily meditation can significantly help you, so what’s stopping you from practicing it?

Many people tell me that they “don’t have the time,” and I certainly understand living a fast-paced life with a seemingly perpetually busy schedule; so I often tell people this: You might not have ten minutes a day, and maybe right now you’re convinced that you don’t even have five minutes to do it, but you cannot rationally come up with an reasonable excuse for not having two minutes to meditate a day. And people usually agree. I start people with two minutes a day, because 20,000 hours of clinical experience has taught me that when people start off with two minutes a day, two things happen: 1. They find that they can make the time, and 2. They eventually sit longer until it’s worth it to make five or ten minutes a priority in their everyday lives.

There are many different ways to meditate, but the most basic is to focus on your breath. I recommend people sit up, because I have seen evidence that sitting with a straight spine activates the reticular formation, which is the center of our brain’s ability to pay attention. Like the monk from the story above (and like mastering anything), learning to breathe takes effort, until it doesn’t. I teach people to sit up straight and to focus on their breath. I also recommend not trying to stop your thoughts, as trying to do so often becomes discouraging, since it’s not very realistic. Instead, I encourage people to become an observer of their thoughts—to watch their thoughts move by like watching a boat pass on a river. As the “boat carrying your thoughts” goes by, come back to your breath. A two-minute timer will likely go off sooner than you think. Eventually, so will with the five or ten minute one.

My experience has taught me that it’s foolish to wait until we’re anxious or angry to try to begin handling those tough emotions. Instead, if we can breathe with intentionality as often as possible throughout our day, as well as engage in actively having realistic self-talk, then our ability to handle things like anxiety and anger when they arise will become significantly better. You have all the tools you need to start meditating daily and practicing and role modeling the type of self-control and healthy habits for your clients that will help them see that you are living the example that you are presenting to them. After all, you already know how to breathe… or do you?

Janina Fisher on Innovations in Treating Trauma

Posted on January 31, 2018February 11, 2026 by Psychotherapy.net Team

Enduring Conditions and Animal Defenses

Ruth Wetherford: Dr. Janina Fisher, you’re a clinical psychologist and expert in the treatment of trauma, author of the book, Healing the Fragmented Selves of Trauma Survivors, and have worked with many of the giants in our field—Judith Herman, Bessel van der Kolk and Pat Ogden and are currently an instructor at the Trauma Center, an outpatient clinic and research center founded by Bessel van der Kolk. Since trauma is such a overused, broad term these days, can you describe how you understand trauma?

Janina Fisher: There was a time when we defined trauma as an event outside the realm of normal human experience. Remember that?

RW: I do, yes. It had to be life threatening.

JF: Boy, were we wrong. We believed it was a rare occurrence. And we now know that 70 percent of the human race will be traumatized in their lifetimes, and probably about 40 percent will develop post-traumatic issues. So it is certainly far from outside of the norm. But over the years, the term started to lose its meaning in terms of its magnitude—now people talk about having critical and rejecting parents as traumatic, so I’m a little concerned that we have found the meaning of trauma and then lost it again, but I’ll tell you the definition I use:

Trauma can be a single event, it can be a series of events, or it can be a set of enduring conditions. Slavery was a set of enduring conditions, child abuse is a set of enduring conditions, domestic violence, war, the Holocaust.

It’s actually more common for people to be traumatized in the context of enduring conditions than to have a single event and have the rest of life be easy and smooth.

It’s actually more common for people to be traumatized in the context of enduring conditions than to have a single event and have the rest of life be easy and smooth. Then, that single event, series of events or enduring conditions have to overwhelm the individual’s capacity to cope and to activate a sense of threat to life.

It doesn’t have to literally be life threatening, like a bus barreling towards you as you cross the street. The key is that we feel a sense of threat to life whether we are capable of verbalizing it or not. Small children can’t say, “I’m afraid I’m going to be killed,” but their bodies can feel it.

RW: You’re talking about the subjective experience of threat to life. Your work focuses extensively on the brain’s reaction to it and the activation of the sympathetic nervous system. It seems like many more psychotherapists are trained in this area these days, don’t you think?

JF: Unfortunately what I hear from graduate students and from young therapists who’ve just been through training is that trauma wasn’t even mentioned in their graduate programs.

RW: That’s shocking. Well perhaps you could talk a bit about this aspect of your work for our readers who may be new to it.

JF: Well, when I first became interested in trauma in 1989-90, we still thought of trauma as being something that war veterans had exposure to and victims of sexual assault. We were still putting the pieces together and hadn’t incorporated more enduring traumas like child abuse and domestic violence.

RW: Neglect.

JF: Yes. Then 9/11 brought credibility to the concept of trauma and changed the whole world’s attitude toward trauma. Pioneers in the trauma field began to make sense of why patients could recover from depression, anxiety disorders, they could manage hallucinations and delusions, but they couldn’t manage post-traumatic reactions.

Bessel van der Kolk had this insight that “t he body keeps the score,” that what was different about trauma was how it encoded in the body and activated the animal defense responses that we share with all mammals. People thought he was nuts. I remember people coming up to me and saying, “Stay away from that guy. He’s a nut case.” But over the years, research has proven him to be accurate.

RW: So what are those animal defenses that we share?

JF: There are 5 animal defenses: fight, flight, freeze, feign death, or submit and cry for help. Fight is basically anger. Interestingly, animals are much better at fighting than humans—that’s why we’ve taken up weapons. Then there’s flight, and again, animals are faster at fleeing. Animals play possum and human beings say things like, “I pretended to be asleep,” which is the human equivalent of playing dead. We freeze like a deer in the headlights and we cry for help. Humans are better at crying for help than mammals because we have language, but all animals make sounds to communicate to their fellow animals that they’re in trouble.

RW: How do those get manifested in the effects of trauma?

JF:

Clients who have chronic submission responses tend to present as chronically depressed, hopeless and helpless, ashamed, feeling less than, and because we call it depression, we don’t treat it as a trauma symptom.

The average therapist sees the animal defenses every day in the office. For example, clients who have chronic submission responses tend to present as chronically depressed, hopeless and helpless, ashamed, feeling less than, and because we call it depression, we don’t treat it as a trauma symptom. People who chronically have the freeze, deer-in-the-headlights response get an anxiety disorder diagnosis. They’ll report, “I’ve been having panic attacks, I can’t leave the house, I can’t drive the car more than a few blocks.” Those who have chronic fight responses can’t stop fighting, can’t stop being angry, engage in aggressive behavior including aggression toward their own bodies. Some people with chronic fight responses tend to be violent toward others, some toward themselves, and an even smaller percentage have both. They have aggressive responses toward others and they harm themselves.

RW: So these patterns of behavior in adult life correlate with the animal responses that we have as children in response to various kinds of trauma.

JF: Right. We have come to understand—and this is the essence of the body keeps the score—that when something bad happens to us, not just our minds, but our bodies become sensitive to related cues. This is why when people have a car accident they avoid the place where the accident occurred for months or years afterwards. Or sexual abuse survivors who can’t tolerate being in the company of men of a certain age. The body gets sensitized to anything that vaguely resembles the original event.

Body Memories

RW: Can you talk about how traumatic experiences are encoded in the brain differently than normal day-to-day events?

JF: In the first brain scan studies, which were conducted in the mid-90s, a small group of trauma survivors were asked to write a script describing a traumatic experience and then hear someone reading the script back to them while undergoing a brain scan. I think that’s pretty brave in and of itself.

RW: It sure is.

JF: What the researchers found, which astounded them, is that the part of the brain that remembers normal narrative memories shut down when they were being read the traumatic event—even though they themselves had written the script. The part of the brain that became active was a part of the brain that we’ve come to understand holds emotional nonverbal memories.

RW: The amygdala?

JF: Yes, the amygdala. For some reason, the amygdala on the right hemisphere side seems to be the center for traumatic memories. What this meant was that we couldn’t work with the narrative memory of the event because post-traumatic memories are held as non-verbal feeling and physical reaction memories—what I call body memories.

RW: Body memories.

JF: Yes. It literally changed everything about our thinking on trauma.

RW: It was revolutionary. Why isn’t it being widely taught in psychotherapy training programs?

JF: I wish that that research, which has been replicated many, many, times, was taught in graduate school and training institutes, hospitals and clinics, because most therapists still practice the type of trauma treatment that we were practicing in the late ‘80s and early ‘90s, which consists of asking people to remember what happened.

RW: Without a sense of what to do with it.

JF: Exactly.

The “talking cure” belief that if it’s talked about, it will resolve, unfortunately does not work with trauma.

The “talking cure” belief that if it’s talked about, it will resolve, unfortunately does not work with trauma. As patients talk about the trauma, their amygdalas and their limbic systems start to go crazy, they feel overwhelmed, and they don’t want to talk about it anymore.

RW: So they leave the session feeling very undone, and they don’t want to come back. You’ve said that you learned that the hard way, as many other trauma therapists did. So, if it’s not enough to just talk about it, what is enough?

JF: What seems to be enough is a variety of activities that help us to restructure our relationship to the memories—techniques, interventions, and experiences that help to slowly recalibrate the traumatized nervous system and animal defenses that are triggered by everyday kinds of stimuli. It’s two pieces: one is the body piece and the other is the feeling-memory piece.

RW: This gives a lot of creativity and flexibility to what the therapist does in the moment.

JF: True, but one of the difficulties, and the reason why I wrote the book, Healing the Fragmented Selves of Trauma Survivors, is that there’s a relatively large subset of traumatized clients who have what we call complex trauma related disorders—some of which are reflected in DSM, but many of which are not. Complex post-traumatic stress is not in the DSM. Dissociative disorders are in the DSM, but not in a very clear, usable way. And there’s a huge amount of literature that attests to the relationship between self-harm, suicidality, addiction and trauma. There’s huge correlations between them.

I happen to be a therapist who likes complexity—I like challenging cases—so I kept seeing people who, despite their best efforts, could not get sober, could not manage their suicidality, could not manage their anxiety, had treatment-resistant depression no matter what medication or what kind of therapy. I became intrigued by how to help these clients.

I had the opportunity to hear a theory proposed by Onno Van der Hart and Ellert Nijenhuis in the Netherlands called the “Structural Dissociation Theory,” which is a very well-accepted model in Europe. As soon as I heard them describe this model, the lights came on, the orchestra started playing, and I thought, this explains so much, including what we now call personality disorders, which are beautifully described by this model. It explains them as neurobiologically based, and that we all have a part of our brains, and therefore part of our personality, that keeps on going no matter what. No matter what disaster is befalling us, the left brain part of the personality just keeps on keeping on.

The “Going on With Normal Life” Self and the Traumatized Self

RW: You call this the “normal life part” or the “going on with normal life” part.

JF: Right. The authors call it the “apparently normal” part, but I didn’t like that language because it fed into my clients’ sense of having a false self. So I renamed it the “going on with normal life” self.

Repeated trauma can cause splitting in the personality such that we start to develop subparts representing the animal defenses.

And then the model says we all have a right-brain side of the personality that’s emotional, reactive, and nonverbal, which I call the traumatized part. They describe the way in which repeated trauma can cause splitting in the personality such that we start to develop subparts representing the animal defenses: a part that fights, a part that flees, a part that submits, a part that freezes, a part that cries for help.

For me, this theory makes sense of the most confusing of our clients. It makes sense of borderline personality where you see a very big cry-for-help response, but an equally big fight response. And in high-functioning individuals, a very strong going on with normal life self who’s actually quite ashamed of these big fluctuations between neediness and anger, and doesn’t understand them any more than the therapists do.

As you know, the problem often with psychotherapy is that clients want help but feel shame or defensiveness as we delve deeper into issues that they need to work on. What I found was that this language of parts helped my clients look at very difficult issues without feeling shame and defensiveness.

RW: Well there is so much pathologizing of this symptomology in our field and so much pejorative language around it. To have a language that frames the symptom as a creative solution to an early problem or trauma can be very relieving.

JF: Absolutely. It opens a door. I can talk to clients about how their fight part takes prisoners, right?

RW: Or stands up for a cause.

JF: Right. And then they’re free to say, “Yes, but it’s embarrassing because that angers drives people away.” Or I can say, “The cry for help part of you is just a little kid, and of course a little kid would cry for help.” It gives them a way to be in a relationship to these reactions rather than either being mortified and ashamed or saying, “What anger? I wasn’t angry.”

RW: It’s a form of psycho-education it seems to me. Can you talk about why that is so helpful?

JF: Well, I was trained in a traditional psychodynamic way.

RW: Me too.

JF: Most therapists from our time were, and psychoeducation didn’t have any place in psychodynamic psychotherapy. But when I went Judith Herman’s clinic in 1990 as a post-doctoral fellow, it was one of the major things she was recommending for trauma. She said that we had to educate clients, that it didn’t work for trauma survivors to have an imbalance of power. Aside from all the usual ways therapy can create an imbalance of power, there’s the imbalance of the therapist knowing everything and the client knowing nothing. She said, “Your job is to educate the client to make meaning of the trauma symptoms so that the playing field is more even.”

RW: In addition to balancing the power in the interpersonal dynamic that kind of learning activates the pre-frontal left brain. You begin to have a model and words for understanding what happens to you when you are triggered.

JF: Exactly. I learned that you can activate the prefrontal cortex when it automatically shuts down in the presence of a threat by getting people to be interested and curious.

My psychodynamic training was all about asking very complicated, beautiful questions, but I realize now my poor clients didn’t have the brain power to answer these very abstract questions.

My psychodynamic training was all about asking very complicated, beautiful questions, but I realize now my poor clients didn’t have the brain power to answer these very abstract questions. But when we just help people to be interested and curious, then things start to hum in the prefrontal cortex.

RW: Can you give some examples of how you might talk with the client that would encourage their curiosity about parts of themselves that they previously were too ashamed of or too frightened of?

JF: I start in the very first interview with someone. Most clients come in saying, “I’m here because I am depressed,” “I’m here because I’m having panic attacks,” “I’m here because I hate myself,” “I’m here because my relationships aren’t working.”

RW: They’re not coming to therapy to learn about the amygdala.

JF: Right. So in that initial conversation, I ask them, “When did these issues begin? When did you start to feel depressed? When did you start to have the panic attacks? When did it become difficult to leave the house?” And I say, “My guess is that something triggered that depression.”

Triggers

RW: You start looking for the triggers right away.

JF: I do that to help them be curious. They come in saying, “There’s something wrong with me because I can’t leave the house.” And usually within the first 20 minutes I say, “Wow, you must have been really, really triggered,” and they kind of go, “Huh?” That “huh” is what I want because it means that their fixed belief that there’s something wrong with them has just been disturbed.

RW: The idea that your difficult feelings are actually in response to something rather than just in your head without connection to the real world. That’s so reassuring.

JF: Yes, it is. At the same time, I want to be careful not to do a one-to-one correspondence to a specific event because most clients are suffering as a result of enduring conditions, and if they think they have to have a single event connected to every symptom, it becomes more difficult to work with them. I try very hard to connect the current trigger—like the death of the cat, or the fight with the husband—to the enduring conditions.

“The effect of living in a world where only the cat loved you is still with you, still in your body.”

So for the client whose cat died, I asked, “What did your cat mean to you when you were growing up?” And she responded, “The cat was the only person in the family who loved me.” “Well, no wonder it was triggering to lose your cat six months ago. The effect of living in a world where only the cat loved you is still with you, still in your body.” We connect the triggers to the enduring conditions, not to single events.

The Role of Empathy

RW: So your motive is to understand the experience from his or her point of view and you call that empathy. What is the role of empathy in your work?

JF: Well, there’s empathy as most of us have learned it in school where we say, “That must have been very hard for you.” The purpose there is to connect to the client’s pain and to say, “I get that these are not just bad events, they also caused you pain.” But I find that many traumatized clients have trouble with that kind of empathy because they’re afraid of the pain that we’re trying to evoke more of.

So I tend to express empathy more in terms of why it makes sense that they have a particular symptom. I say many times a day, “Well, of course, it makes so much sense. If you’re depressed, it’s easier to be seen and not heard, isn’t it?”

I have a long-term client who I’ll call Annie—not her real name, of course—who said to me once,

“Why are therapists so interested in every gory detail of what happened to us? Why don’t they ever ask us how we survived?”

RW: That’s such a great question.

JF: What she was saying was, “If you empathize with how I survived, that’s going to be more validating than empathizing with how victimized I was.”

RW: That appears to many to be paradoxical.

JF: If the purpose of empathy is to resonate to our clients’ feeling states, resonating to their strengths can feel very empowering, especially if you’re someone who has felt unempowered, ashamed, hopeless, weak, and your therapist says, “Wow, you were a pretty ingenious little kid to have survived that.” There’s a feeling of empowerment there as opposed to when we say, “Oh, that must have been so hard.” That pulls for the feelings of vulnerability which are connected to feeling weak, helpless, hopeless.

The Contagion of Confidence and Calm

RW: This touches on what you’ve referred to as the contagion of the confidence and the calm of the therapist. It’s related to what we think of as the placebo effect in medicine. We know that when doctors have absolute belief that their methods are going to help us get well, and they’re focusing on the self-correcting immune responses and the strengths of our bodies, it has a strong positive effect on patients.

It’s so important to think of empathy not just as for the painful negative aspects of the self, but for the positive surviving parts.

JF: Absolutely. Certainly we want therapy to be a safe place for people to share their pain, but why shouldn’t it also be a safe place to share their pride, pleasure, excitement, curiosity? Trauma survivors can get deeply mired in the trauma the more they go for the grief and anger.

RW: And many trauma survivors don’t have a lot of sources of recognition and appreciation. They’re not coming in with stories of little triumphs through the day, so when the therapist does point it out and they see that it’s not just window dressing, that it was substantive, that’s so affirming.

JF: Exactly.

RW: Would you talk about the role of the person of the therapist?

JF: As you know, it’s a topic near and dear to my heart because what I’ve come to realize over my 37 years in this field is that we are really the instrument of psychotherapy.

Research shows that the relationship with the therapist is still the strongest variable affecting therapy outcome, regardless of the model being used.

RW: I believe it.

JF: We have so many models now which are wonderful, and I like most of them, but we have a tendency to assume it’s the model helping rather than us helping. But who and how we are makes a huge difference. You and I are probably both old enough to remember the blank screen approach.

RW: I hated people who were blank screens.

JF: Me, too. And now we understand that if the therapist is a blank screen and the client has suffered abuse or neglect, it is immensely triggering and even threatening. It’s not going to feel neutral. Freud’s idea was to be neutral so as not to be threatening, but that’s just not how it works, particularly with clients who’ve experienced trauma.

RW: Carl Rogers pointed out that there is no neutrality because a blank screen or silence or non-responsiveness is itself a response usually perceived by the right brain as rejecting, or at least disconnecting.

JF: It’s funny, I didn’t love Carl Rogers when I studied him in graduate school, but I’ve really come to appreciate his work because he got this idea that the therapist is the instrument, and how you play your instrument makes such a difference in the client’s receptivity.

RW: How do you think therapists can be more personally connected with clients?

JF:

We are both triggers of hope and triggers of fear

. First and foremost a willingness to be curious rather than to assume from the diagnosis or from the presenting symptoms that someone is in a certain category. The willingness to assume that every symptom represents what was once an adaptive way of coping with and surviving their circumstances, because we become who we become in a habitat, in a context. Lastly, and this is hard for therapists, but remembering that we are both triggers of hope and triggers of fear.

RW: Can you say more?

JF: If we get caught up in seeing ourselves as triggers of hope or safety only, we’re going to pathologize the client when the client gets afraid. I’ve had very few clients in 37 years who’ve actually said, “I’m afraid,” but I’ve had lots of clients who’ve been reactive and angry, defensive, resistant, suspicious—all of which are expressions of fear.

It’s very important to know that even as we are building a relationship and creating safety, we’re also triggering fear. So we do our best to notice those moments that we can hear or decipher the fear and then do what securely attached parents do, or what dog owners do: Change your body language and your voice to help change the child’s state, the dog’s state. We do it without thinking.

I watch how the client responds to what I just said, and then I vary my next remark based on the data I just got. So I say something and I see the client looking a little uncomfortable, then I’ll smile and say something light and see if the client’s body relaxes. Or I might say something that really underscores how bad they feel—“Wow, I get that this is really awful”—and see if the body relaxes. Or is this a client who feels defensive when I say, “Wow, this is really tough.”

They feel safer not because I have good boundaries and a therapeutic frame and all those good things, but because I’m scaring them less and less.

RW: In my consultation with trainees where we’re going over audio or videotapes, it’s usually apparent that when the therapist says something that sounds pejorative or a little bit pathologizing, there’s a loss of empathy because of some perceived threat, and it’s often unconscious. An angry client, particularly a smart, articulate angry client, can be a trigger for the therapist. What are some things that you do to help yourself stay non-defensive? Not triggered?

JF: I sort of have a split screen. I’m very attentive to the client and to resonating to the client&rsq

What is Mental Illness? Donald Trump and the Psychiatrists Who Would Diagnose Him

Posted on January 18, 2018February 11, 2026 by Psychotherapy.net Team

Recently, the American electorate has been treated to the awkward spectacle of mental health professionals proclaiming that President Donald Trump is mentally ill. These pundits have ignored the ethical standard against diagnosing someone you’ve never met, based only on public scrutiny, and have exhibited both grandiosity (they believe themselves saviors of the Republic) and lack of insight (they fail to recognize how their personal politics taint their judgment). They show an evident contempt for our democracy and the 60 million voters who chose Trump over his rivals. (Full disclosure: I didn’t vote for any of the listed candidates; instead, I wrote in my choice: George Washington.)

In a New York Times OpEd (1/12/18), Jeffrey A. Lieberman, Chairman of Psychiatry, Columbia University College of Physicians and Surgeons, said:

… when psychiatrists engage in clinical name calling about the president’s mental status without adequate evidence and proper evaluation, they are damaging the credibility of the entire field. Psychiatry has had a checkered past: Witness its collusion in Nazi eugenics policies, Soviet political repression and the involuntary confinement in mental hospitals of dissidents and religious groups in the People’s Republic of China. More than any other medical specialty, psychiatry is vulnerable to being exploited for partisan political purposes.

A recent book, The Dangerous Case of Donald Trump: 27 Psychiatrists and Mental Health Experts Assess a President (St. Martin’s Press, 2017), accuses the President of such things as “impulsivity,” “pathological narcissism,” “paranoia,” and “sociopathy.” But what about other Presidents and Presidential candidates who these same diagnosticians would no doubt admire?

Barack Obama may have impulsively criticized as racist a white police officer responding to a possible burglary at a black professor’s home but had to publicly apologize through the “beer at the White House” photo op. Although a minor episode, it raised the issue of racial animus with the first President of color.

Lyndon Johnson refused to end the Vietnam war because, he said, “I will not be the first U.S. President to lose a war.” Tens of thousands of Americans and perhaps hundreds of thousands of Vietnamese were subsequently injured or killed because of Johnson’s apparent pathological narcissism.

Hillary Clinton may have revealed her paranoia when she defended her husband, Bill, as the target of a “vast right-wing conspiracy.” Perhaps this earlier instance of a secretive, suspicious nature presaged her later use of the infamous private email server.

And speaking of Bill Clinton, does any President more clearly show sociopathy than him? Consider a few of many possible examples: his purported history as a sexual predator, his questionable connections to the Chinese People’s Liberation Army, and even his apparent theft of White House property at the end of his term.

All of these alleged signs of mental illness fall under the category of character traits, an even more ambiguous area of diagnosis. After all, everyone has a personality, and it is only a matter of degree whether any of our mannerisms interfere with daily function enough to be considered problematic. Successful people often have strong character traits that may help or hinder them. All of the politicians above, including Donald Trump, have lifelong histories of functioning at very high and effective levels. To call any of them mentally ill begs the question: what is mental illness?

Leaving aside the political contretemps, we must recognize how difficult it is to define mental illness. The DSM5 attempts to categorize various observations and behaviors into a useful taxonomy. These categories are described as “disorders” rather than illnesses and they are constantly reshuffled with additions and subtractions in each revised edition. For example, before 1974 homosexuality was a disorder and afterwards it was not. The current edition includes gender identity disorder (or “transsexualism”) for the first time. So, in this sense, mental illness is whatever a large committee says it is. This approach is useful for research and to facilitate communication among providers, but it isn’t science.

Adding to the difficulty is the observation that a behavior considered abnormal in one part of the world is accepted as normal elsewhere. In the United States, taking one’s own life is almost always considered a sign of mental illness. Yet the Hindu practice of sati in which a wife throws herself onto her husband’s funeral pyre still occurs today, and Islamic fundamentalists blow themselves up like the Japanese kamikaze pilots of World War II. These acts are considered, within their own cultures, as honorable, not “sick.” Suicidal behavior, then, can sometimes be an illness and other times not, depending on the cultural context. I could give many other examples, but the point is that human societies vary and there is no universal standard for mental illness. The only definition that covers all of it is: mental illness is a marked deviation from cultural expectation. Although accurate, this definition is so broad as to be almost meaningless, and it has little practical utility.

In everyday practice, we rely on those who seek our help to define their own mental disability. Behaviors others might consider abnormal can be acceptable to an individual. Some live with phobias by restructuring their lives to avoid anxiety triggers. Others may accept low-level chronic depression as normal, as in the old blues song, “been down so long it looks like up to me.” Narcissistic, dependent and even antisocial personality traits may be tolerable unless they lead to significant interpersonal or societal dysfunction. People who come to a psychotherapist usually can tell us what they consider “abnormal,” and maybe that’s all the definition we need.

PhDs in Therapy

Posted on December 5, 2017February 11, 2026 by Psychotherapy.net Team

Academics and Mental Health

My online psychotherapy practice attracts PhD candidates from around the world. Young academics are passionate people—articulate, often self-aware, intelligent, and eager to learn. But one would not guess how much this population suffers from poor mental health, how exposed and fragile they can actually be.

Research on occupational stress amongst academics indicates that it is widespread, with younger academics experiencing more mental health issues than their older counterparts. A recent Belgian study suggests that PhD students are 2.4 times more likely to develop a psychiatric disorder than the highly educated general population.

Other studies show that as much as 50 percent of doctoral students leave graduate school without finishing; it is reasonable to imagine that mental health issues play a major role in such an attrition rate.

“Young academics are often reluctant to disclose mental health problems to their universities out of fear of stigmatization and punishment in the highly competitive academic world.” PhD candidates who do their fieldwork abroad are particularly vulnerable. Not only do they feel a high pressure to achieve their fieldwork, but they also lose their social support system and have to adapt to a different culture.

Opening Doors with Online Therapy

Online therapy can be a unique opportunity for postgraduates to get support and resolve some developmental issues.

This vignette illustrates such a case.

When Jane engaged in online therapy with me, she was in the third year of her PhD program from a top American University. She was studying literary theory, and her fieldwork had just brought her to St. Petersburg, on the trail of the Russian thinker Michail Bakhtin and his main object of fascination—Dostoevsky. This city, affectionately called “Piter” by the locals, happens to be the one where I grew up before leaving Russia in my late teens. A bit of nostalgia was triggered inside me.

Jane had arrived in St. Petersburg in November. It had greeted her with gale-force winds and freezing weather, even worse than what she had imagined after reading the novels of Pushkin, Gogol, and Dostoevsky. At first she had been excited to discover its canals and lightless courtyards (kolodzi or “well-yards” in Russian) hidden in the middle of buildings, but after the first months, her fascination with the place was replaced by a lingering anxiety that she was not yet able to understand.

For our first session, Jane connected from the room that she was subletting in a big kommunalka, or shared apartment. The room was dark except for a surprisingly green wall gleaming behind her back, where she sat barely illuminated by the Russian winter’s scant natural light. Jane was slowly plunging into depression, which was draining all joy out of her research and her life. The faculty members she had met at the local university had first seemed friendly enough, but now she was avoiding any contact with anybody who could ask her questions about her research progress or about anything else for that matter.

The only window in her room was facing the plain yellowish wall of another building. If at first this grim view on the bare well-yard had reminded her of Dostoyevsky, it now felt like a metaphor for her current life prospects—long, dark Russian winter, loneliness in this foreign place, and a very uncertain outlook for a career in academia.

The day before she reached out for therapy, Jane had found herself sitting on the windowsill, looking down upon the dirty snow, and imagining her body lying in the middle of the well-yard, covered with her quickly freezing blood.

Now we were starting our first session, and she greeted me in Russian:

“Zdravstvuite.”

After a few minutes, I could sense that she was struggling, looking for words to describe the way she felt. As is often the case with bilingual individuals, we spent some time in this first session exploring Jane’s relationship with her two languages. Her Russian had developed through academic work, becoming her language of organized thought; when she wanted to describe her feelings, we had to switch to English. This going back and forth between the two languages allowed us to make better sense of her experience.

Soon we settled into our linguistic routine, using either language according to the subject. As with many emigrants, this arrangement suited us both, letting our multiple selves into the encounter.

Jane spoke Russian the way linguists often do—with unnatural care and respect for its intricate grammar. Strictly speaking, Russian was her mother tongue, but her mother had always been emotionally disconnected from her, and preferred to speak to her daughter in a limited English, without nuances but enough to give orders or rebukes. In high school, Jane then learned proper Russian, a language that she had until then perceived as unsophisticated.

Her father was a Texan estate developer. He had met his wife during one of his visits to Kazakhstan, where he had high-risk-high-reward investments. Jane’s mother was at that time young and beautiful; her secretary job was just a step towards her glorious future, where she knew she would have a shiny red car and a penthouse with views on skyscrapers gleaming in the night.

When Jane was born, her mother had already experienced deep disillusionment with life in general and her husband in particular. Texas was nothing like she had imagined, except for the consolation of owning her shiny red car; she used to drive on the endless dusty roads with fury.

As Jane grew up, she only added to her mother’s disappointments: she was neither beautiful nor particularly gifted for any girlish activities. Her academic achievements did little to change her mother’s opinion that she had been thwarted by fate in her motherly aspirations.

By the time Jane turned twelve, her father had lost most of his estate investments. She could remember him drinking whisky and grumbling about taxes and politics, only to rouse when his wife would come back home and scold him, provoking a fight. They both seemed to enjoy fighting, often loudly and in front of their daughter or other unwilling witnesses.

When Jane was accepted into a top university, her parents seemed relieved at the idea that she would finally be “out of the way.”

The First Session

In our first session Jane seemed withdrawn and extremely vulnerable. I wondered whether it was best for her to meet a therapist online. It probably was not, but she felt unable to get out of her flat and make it through the snow to the practice of one of the few English-speaking therapists available locally.

Looking through the dark window in front of her, Jane told me that she felt lonely and homesick. The homesickness felt even worse because she did not have a proper home back in the States any more. “This feeling of homesickness paradoxically associated with the experience of homelessness resonated with me.”

Her college friends were spread all around the country, busy with their own research or jobs. During her first months in Russia, she had managed to maintain the illusion of contact with some of them through Skype or WhatsApp, but now the calls were becoming rare. Maybe they had lost interest in her; maybe they never had any genuine interest at all. She had started doubting everybody and everything. Her parents had not paid her a visit.

And for several months, her academic advisor had not even been responding to her emails. Jane felt hurt and humiliated by this lack of interest from someone who had initially seemed so supportive and enthusiastic about her research. Her advisor was a middle-aged woman known for her feminist views and a difficult character.

Jane complained that her advisor’s silent ghost seemed settled at the end of her desk, at the other end of the room. Jane had been unable to sit there for days, and preferred to connect for our sessions from her sofa bed, crumbling under books and printed papers that she was unable to read or remove, even though sleeping in the middle of this improvised library—“the den,” as she called it—was becoming tricky.

As Jane was lying low in her den, the ghost was comfortably occupying her desk—an ever disapproving and punitive presence. Each time she tried to formulate a thought and write it down, she could sense, almost physically, the imaginary advisor winking in distaste at her poor efforts; simply knowing that the results would never be good enough. This room that Jane seemed to share with her imaginary advisor was suffocating, but the anxiety she felt at the thought of getting out was even worse.

As Jane described her advisor’s malefic ghost, I asked how its presence made her feel.

Alienated, confused… little.

As we explored these feelings, Jane’s usually calm face changed. She looked like a young and very upset child.

Have you ever felt like this before?

She had; it was a strangely familiar feeling when she curled up in her den, sucking her thumb at times she confessed. This is how she used to sooth herself, alone in her childhood room, when her mother was annoyed with her for some reason, or busy exercising.

As a child Jane often secretly thought that she had been born to these particular parents by mistake: she had little or no affinity with either of them. Roald Dahl’s character Matilda resonated deeply with her.

Jane had had as little choice when an academic advisor had been allocated to her, as she had had in choosing her own mother. She actually resented both of them. “The awareness of her dependence on her advisor was producing a deep anxiety—the same she used to feel when she was dependent on her mother.” This time the advisor seemed to be failing her in the same way her mother had done before, and this resonance made Jane’s anger even more overwhelming.

I knew first hand how the supervisory relationship, not unlike the therapeutic one, has the potential to repeat earlier traumatic experiences.

Shame in Academia

This incident opened a door into what would become the most important part of Jane’s therapy: working with and through her shame, towards a better sense of self and higher self-esteem.

During her first steps in academia, Jane had quickly learnt that she had to justify her every word or thought. Entry into the academic environment can trigger a feeling of shame in newcomers. It is easy to feel small and under-developed when entering a community of seasoned academics that you look up to: a dwarf in the presence of giants.

Jane would spend hours imagining how her advisor and other committee members would “laugh in her face” as she presented before them. At night, she would stay awake picturing the most humiliating scenes of her academic fall made public.

As Jane was describing how little, insignificant and defective she often felt, despite her obvious academic success, it became clear that this was a familiar emotional experience for her. She had felt this way many times before. As a little girl, she idealized her mother—a beautiful, tall, elegant, and snobbish woman. She remembered how proud she had felt of her mother as her primary school mates were admiring her beauty and expensive clothes. But as she grew up, her mother lost interest in her; Jane’s awe was replaced by disappointment. Why didn’t her adored mom like her? Did it mean that something was wrong with her? A feeling of not being good enough, not likable, had put roots in her very nature. This shame was later exacerbated by the tough rules of the academic world.

A few months into our work, Jane’s mother announced that she would be visiting her in Russia. Jane felt disorientated and anxious. She thought that her mother must have been bored with her Texan life. But I could also sense how the little girl in her craved her mom’s attention; Jane was still hoping that her mother might end up appreciating her.

She went to pick her up at the airport. The first comment her mother made brought back the past: the airport hall looked provincial and rather under-equipped for a city praised by all touristic guides for its “emperor glory.” When they reached the luxurious hotel her mother had booked and sat together in the bar, facing the straight line of the Nevsky Prospect, Jane was already dreading the days to come. Looking at the middle-aged heavily made up woman, Jane realized that, however familiar she appeared, she did not really know her. In her bright yellow jacket, her mother looked strangely foreign. When Jane tentatively switched to Russian, she did not seem to notice, and carried on talking in her consistently poor English: Jane’s hope for acknowledgement of her efforts and progress in her mother’s tongue were vanishing. A young waiter came to take their order and smiled at Jane; she could not avoid noticing how her mother’s face froze.

When Jane finally heard her mother talking in Russian to people in shops and restaurants, she was shocked by the poverty of her vocabulary and the unpleasant notes of a foreign accent—maybe consciously produced by her Americanized mother.

Later on, reflecting on our use of Russian in therapy, Jane acknowledged that communicating in her mother tongue within a warm and genuine relationship was a meaningful experience to her. For a long time she had been reading about literary characters’ feelings in Russian; to speak about her own feelings in Russian to somebody genuinely interested was new to her. “Putting her childhood experiences of loneliness and hurt into words in Russian moved something deeper inside her: she was now able to express anger towards her academic supervisor, but also acknowledge the anger she felt towards her mother.”

The Work Continues

We eventually survived the winter together. As the days got longer and the first rays of a shy April sun illuminated Jane’s room, her shame seemed to lift. She washed her sole window for the first time since she had moved in, and realized that she did not feel any desire to fall. The snow underneath was starting to melt, and she noticed a neighbor looking at her from a window on the opposite side of the yard. She had never noticed any signs of life in that window before. As their eyes briefly met, she felt strangely alive.

Spring brought its own anxieties. Jane’s academic clock was ticking, and she had only a few months left to complete her fieldwork. Even if she now saw her adviser in a much less grim light, the support she was getting from her was scarce and inconsistent. The White Nights kicked in, and Jane lost sleep again over her work. Researching contemporary Bakhtinian thought, she was trying to contact the academics who saw themselves as his followers. The risk she was taking in reaching out to this closed circle triggered familiar shame: Jane was convinced that these seasoned academics would never take her seriously, and her Russian was certainly not good enough.

We had a session just before she was due to present her research project to this group, hoping to convince them to participate. Jane kept picturing how they would look bored or even leave the room before she could finish. She was particularly intimidated by one of them. This older professor looked like Bakhtin himself—the same high forehead and the white beard. Jane was not sure whether this resemblance was a cultivated forgery or unconscious mimicry. When they first met, he had spoken so quickly and pretentiously that he made little sense to her.

Her mother’s constant absence, combined with the little interest she had shown in her daughter, had never allowed Jane to confront her.

It took us a while to reach a point where Jane felt ready to have a direct and honest conversation with her advisor. She learned that she had been grieving her husband’s recent death and was being treated for depression. After this conversation, her advisor’s ghost dwindled and eventually left her desk, making space for her own thoughts. Her research journal came back to life and Jane’s eyes sparkled again when she spoke about her work.

One day Jane did not switch her camera on as we began our session. She wanted audio-only. When I asked her why, she said she did not feel well enough to shower or brush her hair. Or in essence, she felt too ugly and too unfit to be looked at. As she shared this with me, she cried. What Jane was painfully experiencing at that moment was a deep sense of inadequacy resulting in feelings of shame. To let me witness her shame felt unbearable to her; she was terrified to recognize in my eyes the same disgust that she used to see in her mother’s gaze.

Eventually we agreed that she had to take this risk to dispel her shame. After a few minutes, she was able to switch the camera on: her face looked puffy from crying and very young.

My natural response was to give Jane a hug, but the limitations of the online therapy added to the natural ethical concerns around touching a client. This time I was painfully aware about the physical distance between us.

Jane was close to cancelling but she did not.

The meetings of their little group were informal and usually held in the apartment of one member or another. She was kindly asked to bring a cake to go along with the tea. As she rang the doorbell, she was close to fainting. Once inside, she was greeted by a giant St. Bernard dog, which managed to lick her on the nose. The laughter reaching her from the sitting room and the familiar smell of the books lining the walls of the corridor reassured her. Bakhtin’s twin brother’s wife—a tiny woman with sparkly blue eyes (also a former ballerina as she would learn later)—accepted the expensive cake with an evident pleasure and led her into the sitting room. The place was warm and the academics looked like old friends enjoying a tea together.

After an hour, she felt an almost painful sense of belonging; for the first time she was part of a welcoming family. They listened to her presentation with genuine interest, asked questions, and ended up having a heated and mostly inspiring argument in which Jane was able to take part. She forgot about the imperfections of her Russian and was able to enjoy this simple warm connection with her senior colleagues.

The inclusion and warmth Jane experienced at that meeting gave her a new boost. On her way home, Jane bumped into the blond neighbour. He was walking his scruffy dog beneath her windows. She spontaneously invited him in for tea. In bewilderment, she found out that he was a PhD candidate too, but in physics. It was a long night; his dog turned out to be a real cuddler and accepted her as a new friend.

I continued meeting with Jane for another year or so. She moved back to the US and started writing up her dissertation. Bakhtin’s twin brother died suddenly a few months after their encounter, and she returned to St. Petersburg to attend his funeral. His ballerina widow gave Jane some of her late husband’s books, insisting that such had been his wish. Jane cried and felt like an orphan. Grieving for the friend and mentor she had found in this old Russian philosopher made her question her relationship with her father.

In the meantime, his drinking had got worse. Jane went to visit. She needed only one dinner in his company to realize that he did not seem able to listen to anything she attempted to say and was clearly craving another drink. Once she returned from this disappointing trip back home, we had to mourn her hope of having at least one “good enough” parent.

In the process she finished her thesis and started teaching. This activity brought back the familiar feelings of shame, but her genuine interest in her students and her revived passion for Russian literature helped Jane to eventually enjoy her work.

The therapeutic relationship we developed helped Jane survive the definitive separation from her parents; their absence in her life was not plunging her in despair any more. She has finally been able to thrive in other close relationships—with her friends, colleagues and, finally, with her first supervisees. In our ending session she talked a lot about how much our relationship meant to her, but also about her desire to be there for her students. This filled me with warmth and gratitude—towards her, but also towards my own supervisors who were genuinely and consistently there for me. Their presence has been a real game changer for my own academic journey.

The path towards a PhD is never easy. It takes a lot of work but also a lot of daring. As any transitional stage of life, it abounds with demons that we must tame.

Jane is actually a fictional character inspired from many stories of PhD candidates whom I work with in my online psychotherapy practice, or during the course of my own PhD. I admire their courage, hard work, and passion for knowledge. These qualities are a great asset in therapy, which is a natural and inspiring companion for such a journey.

Reaching out for therapy online can help young academics to get the much-needed support, even when they are far away from home.

References

Bozeman, B. and Gaughan, M. (2011) "Job Satisfaction among University Faculty: Individual, Work, and Institutional Determinants," The Journal of Higher Education, 82(2), pp. 154-186.

Kinman, G. (2001) "Pressure Points: A review of research on stressors and strains in UK academics," Educational Psychology, 21(4), pp. 473-492.

Kinman, G. and Jones, F. (2003) ''Running Up the Down Escalator: Stressors and strains in UK academics," Quality in Higher Education, 9(1), pp. 21-38.

Levecque, K., Anseel, F., De Beuckelaer, A., Van der Heyden, J. and Gisle, L. (2017) 'Work organization and mental health problems in PhD students," Research Policy, 46(4), pp. 868.

Lovitts, B.E. (2001) Leaving the Ivory Tower. The causes and Consequences of Departure From Doctoral Study. Rowman & Littlefield.

Shaw, C. (2015) http: //www.th eguardian.com/education /2015/ feb/13/un iversitystaff-scared- to-disclose-mental-health-problems (Accessed on 23/9/2017).

Walsh, J.P. and Lee, Y. (2015) "The bureaucratization of science," Research Policy, 44(8), pp. 1584-1600.

The Death of Privacy

Posted on November 21, 2017February 11, 2026 by Psychotherapy.net Team

Nowhere is privacy more important than in the mental health field. We psychotherapists have always insisted on the highest standard of confidentiality for our patients. We want to be more protective than HIPPA and outdo the CIA in insisting on need-to-know. Even without the absolute protection the law gives attorney-client relationships, we resist whenever possible any intrusions from courts and from government investigators.

This effort has become even more important as privacy has disappeared from our society. People seem increasingly willing, even eager, to open their lives to public scrutiny through social media and other manifestations of the digital revolution. Texting, sexting, tweeting, personal blogging, online forums, and other displays of private, personal information are all too common, even when the consequences are employment problems, public shaming and legal jeopardy. Whether it’s loss of a job or a promotion, or revenge porn, or evidence in a criminal trial, the lesson never seems to be learned. If people want to be foolish in their personal lives, however, it’s their right to do so.

But nowadays many of us lose our privacy even when we want to protect it. Involuntary loss of privacy is increasingly prevalent as massive examples of hacking and the theft of personal information and identities destroys the attempt to keep private data private. Already, tens of millions of online medical records have fallen prey to malicious hackings. In our field, patients are routinely forced by third party payers to surrender their personal health data or lose their insurance coverage.

And now, a new and growing threat to the privacy of mental health information is the Electronic Health Record (EHR). With the government making the EHR a legal requirement, imposing fines for non-compliance and threatening to withhold reimbursement, the EHR is no longer a choice for many and soon might be universal. Even apparently benign uses of this data can lead to unauthorized disclosure when the EHR is shared with other providers, whether they be for medical, legal or justifiable mental health purposes. Once the information is out of our hands, we can no longer apply our standards to its release. The EHR represents a clear and present danger, but, unfortunately, it is also a legal document and cannot be entirely avoided.

The only remedy to this growing menace is to limit what we put into the EHR to the absolute necessary minimum. Examples are legally required data, such as the date of service, the next scheduled meeting, and any specific advice or prescribed treatment. We should also include any perceived risks, such as suicidal intent, and, most important, what steps we plan to take to mitigate them. Add perhaps any communications from other providers or significant sources of external information. In short, we are legally required to preserve any data that forms the basis for patient care.

We may also need to include the diagnosis, although that piece of data is the most problematic. Psychiatric diagnoses are simply observations that have been codified to facilitate communication and allow research comparisons. Nothing, however, embodies the stigma attached to mental illness more than a diagnostic label. In the EHR, available to all providers within the system and, through third party records, to anyone who ever provides care to that individual, it is likely to prejudice others against our patients and clients. Because it can bias the attitude of other caretakers, it may result in skewed, limited or even injurious treatment in the future. Where possible, we might use a brief description rather than a formal diagnosis. If that’s not feasible, then at least we can choose the least negative label available.

All the rest of what we’d like to memorialize—process notes, observations, plans, speculations and other insights—should be kept in a separate, non-digital record. Here is where paper is the best option. Paper can’t be hacked, won’t leave our control unless we want it to, and can be thoroughly and completely destroyed. No computer technician can retrieve the data from paper the way deleted material can be retrieved from a digital source. Paper can’t be squirreled away forever in a “cloud” server.

In our paper-based patient file—that only we ourselves will ever see—we can record anything that does not directly relate to patient care and that we would never want to release. After treatment ends, we can shred (or burn) the patient’s paper file and be confident we have protected both the patient’s privacy and our own standard of care.

Becoming Myself: A Psychiatrist’s Memoir

Posted on October 17, 2017February 11, 2026 by Psychotherapy.net Team

Chapter One, The Birth of Empathy

I awake from my dream at 3 a.m., weeping into my pillow. Moving quietly, so as not to disturb Marilyn, I slip out of bed and into the bathroom, dry my eyes, and follow the directions I have given to my patients for fifty years: close your eyes, replay your dream in your mind, and write down what you have seen.

I am about ten, perhaps eleven. I am biking down a long hill only a short distance from home. I see a girl named Alice sitting on her front porch. She seems a bit older than me and is attractive even though her face is covered with red spots. I call out to her as I bike by, “Hello, Measles.”

Suddenly a man, exceedingly large and frightening, stands in front of my bicycle and brings me to a stop by grabbing my handlebars. Somehow I know that this is Alice’s father.

He calls out to me: “Hey, you, whatever your name is. Think for a minute—if you can think—and answer this question. Think about what you just said to my daughter and tell me one thing: How did that make Alice feel?”

I am too terrified to answer.

“Cummon, answer me. You’re Bloomingdale’s kid [My father’s grocery store was named Bloomingdale Market and many customers thought our name was Bloomingdale] and I bet you’re a smart Jew. So go ahead, guess what Alice feels when you say that.”

I tremble. I am speechless with fear.

“All right, all right. Calm down. I’ll make it simple. Just tell me this: Do your words to Alice make her feel good about herself or bad about herself?”

All I can do is mumble, “I dunno.”

“Can’t think straight, eh? Well, I’m gonna help you think. Suppose I looked at you and picked some bad feature about you and comment on it every time I see you?” He peers at me very closely. “A little snot in your nose, eh? How about ‘snotty’? Your left ear is bigger than your right. Supposed I say, ‘Hey, “fat ear”’ every time I see you? Or how about ‘Jew Boy’? Yeah, how about that? How would you like that?”

I realize in the dream that this is not the first time I have biked by this house, that I’ve been doing this same thing day after day, riding by and calling out to Alice with the same words, trying to initiate a conversation, trying to make friends. And each time I shouted, “Hey, Measles,” I was hurting her, insulting her. I am horrified—at the harm I’ve done, all these times, and at the fact that I could’ve been so blind to it.

When her father finishes with me, Alice walks down the porch stairs and says in a soft voice, “Do you want to come up and play?” She glances at her father. He nods.

“I feel so awful,” I answer. “I feel ashamed, so ashamed. I can’t, I can’t, I can’t . . . ”

Since early adolescence, I’ve always read myself to sleep, and for the past two weeks I have been reading a book called Our Better Angels by Steven Pinker. Tonight, before the dream, I had read a chapter on the rise of empathy during the Enlightenment, and how the rise of the novel, particularly British epistolary novels like Clarissa and Pamela, may have played a role in decreasing violence and cruelty by helping us to experience the world from another’s viewpoint. I turned out the lights about midnight, and a few hours later I awoke from my nightmare about Alice.

After calming myself, I return to bed, but lie awake for a long time thinking how remarkable it was that this primeval abscess, this sealed pocket of guilt now seventy-three years old, has suddenly burst. In my waking life, I recall now, I had indeed bicycled past Alice’s house as a twelve-year-old, calling out “Hey, Measles,” in some brutish, painfully unempathic effort to get her attention. Her father had never confronted me, but as I lie here in bed at age eighty-five, recovering from this nightmare, I can imagine how it must have felt to her, and the damage I might have done. Forgive me, Alice.

***

Chapter Three, I want Her Gone

I have a patient, Rose, who lately had been talking mostly about her relationship with her adolescent daughter, her only child. Rose was close to giving up on her daughter, who had enthusiasm only for alcohol, sex, and the company of other dissipated teenagers.

In the past Rose had explored her own failings as a mother and wife, her many infidelities, her abandoning the family several years ago for another man and then returning a couple of years later when the affair had run its course. Rose had been a heavy smoker and had developed crippling advanced emphysema, but, even so, she had for the past several years tried hard to atone for her behavior and devoted herself anew to her daughter. Yet nothing worked. I strongly advocated family therapy, but the daughter refused, and now Rose had reached her breaking point: every coughing fit and every visit to her pulmonary doctor reminded her that her days were limited. She wanted only relief: “I want her gone,” she told me. She was counting the days until her daughter would graduate from high school and leave home—for college, a job, anything. She no longer cared which path her daughter would take. Over and again she whispered to herself and to me: “I want her gone.”

I do all I can in my practice to bring families together, to heal rifts between siblings and between children and parents. But I had grown fatigued in my work with Rose and lost all hope for this family. In past sessions I had tried to anticipate her future if she cut her daughter off. Would she not feel guilty and lonely? But that was all to no avail, and now time was running out: I knew that Rose did not have long to live. After referring her daughter to an excellent therapist, I now attended only to Rose and felt entirely on her side. More than once she said, “Three more months till she graduates from high school. And then she is out. I want her gone. I want her gone.” I began to hope she would get her wish.

As I took my bicycle ride later that day, I silently repeated Rose’s words—“I want her gone. I want her gone”—and before long I was thinking of my mother, seeing the world through her eyes, perhaps for the very first time. I imagined her thinking and saying similar words about me. And now that I thought about it, I recalled no maternal dirges when I finally and permanently left home for medical school in Boston. I recalled the farewell scene: my mother on the front step of the house waving goodbye as I drove away in my fully packed Chevrolet, and then, when I vanished from view, stepping inside. I imagine her closing the front door and exhaling deeply. Then, two or three minutes later, she stands erect, smiles broadly, and invites my father to join her in a jubilant “Hava Nagila” dance.

Yes, my mother had good reason to feel relieved when I, at twenty-two, left home for good. I was a disturber of the peace. She never had a positive word for me, and I returned the favor. As I coast down a long hill on my bicycle, my mind drifts back to the night when I was fourteen and my father, then age forty-six, awoke in the night with severe chest pain. In those days, doctors made home visits, and my mother quickly called our family doctor, Dr. Manchester. In the quiet of the night, we three—my father, my mother, and I—waited anxiously for the doctor to arrive. (My sister, Jean, seven years older, had already left home for college.)

Whenever my mother was distraught, she reverted to primitive thinking: if something bad happened, there must be someone to blame. And that someone was me. More than once that evening, as my father writhed with pain, she screamed at me, “You—you killed him!” She let me know that my unruliness, my disrespect, my disruption of the household—all of this—had done him in.

Years later, when on the analytic couch, my description of this event resulted in a rare, momentary outburst of tenderness from Olive Smith, my ultraorthodox psychoanalyst. She clucked her tongue, tsk, tsk, leaned toward me, and said, “How awful. How terrible that must have been for you.” She was a rigid training analyst in a rigid institute that valued interpretation as the singular effective action of the analyst. Of her thoughtful, dense, and carefully worded interpretations, I remember not a one. But her reaching out to me at that time, in that warm manner—that I cherish even now, almost sixty years later.

“You killed him, you killed him.” I can still hear my mother’s shrill voice. I remember cowering, paralyzed with fear and with fury. I wanted to scream back, “He’s not dead! Shut up, you idiot.” She kept wiping my father’s brow and kissing his head as I sat on the floor curled up in a corner until, finally, finally, about 3 a.m., I heard Dr. Manchester’s big Buick crunching the autumn leaves in the street and I flew downstairs, three steps at a time, to open the door. I liked Dr. Manchester very much, and the familiar sight of his large round smiling face dissolved my panic. He put his hand on my head, tousled my hair, reassured my mother, gave my father an injection (probably morphine), held his stethoscope to my father’s chest, and then let me listen as he said, “See, Sonny, it’s ticking away, strong and regular as a clock. Not to worry. He’s going to be all right.”

That night I witnessed my father drawing close to death, felt, as never before, my mother’s volcanic rage, and made a self-protective decision to shut the door on her. I had to get out of this family. For the next two to three years I barely spoke to her—we lived like strangers in the same house. And, most of all, I recall my deep, expansive relief at Dr. Manchester’s entrance into our home. No one had ever given me such a gift. Then and there I decided to be like him. I would be a doctor and pass on to others the comfort he had offered me.

My father gradually recovered, and though he had chest pain thereafter with almost any exertion, even walking a single block, and immediately reached for his nitroglycerin and swallowed a tablet, he lived another twenty-three years. My father was a gentle, generous man whose only fault, I believed, was his lack of courage in standing up to my mother. My relationship with my mother was an open sore all my life, and yet, paradoxically, it is her image that passes through my mind almost every day. I see her face: she is never at peace, never smiling, never happy. She was an intelligent woman, and though she worked hard every day of her life, she was entirely unfulfilled and rarely uttered a pleasant, positive thought. But today, on my bicycle rides, I think about her in a different way: I think of how little pleasure I must have given her while we lived together. I am grateful I became a kinder son in later years.

12 Things You Didn’t Know About Milton H. Erickson and His Daughter Betty Alice Erickson

Posted on September 7, 2017February 11, 2026 by Psychotherapy.net Team

The impetus for this blog originated many years ago when I stopped at an all-night book store late one evening and walked away with a copy of Jay Haley's book, Uncommon Therapy: The Psychiatric Techniques of Milton H. Erickson, MD. That night I could hardly sleep as I read well into the wee hours of the morning. I knew that Dr. Erickson was doing something new, exciting, and creatively different than the rest of us. I couldn't wait until the next morning to ask one of my graduate professors about this master of psychotherapeutic intervention.

As I shared my reading experience with my professor, he laughed and shook his head from left to right. He then cut me off as I was speaking. "Howard stop, listen, those eight psychosocial stages he talks about are totally useless when performing psychotherapy. Trust me, I've been doing counseling for years. Please don't waste another minute of your time on that useless stuff."

I came away with two important conclusions. One, my professor clearly had no clue who Milton H. Erickson was, and wrongly believed I was talking about Erik Erikson. And two, for the sake of my GPA, I sure as hell wasn't going to point out his ignorance, nor would I share his thoughts with my Human Growth and Development course professor who thought the sun rises and sets around Erik Erikson's stages!

In this brief blog, I am going to do a reality check and attempt to separate fact from fiction regarding this larger-than-life figure in the history of our field. Using 12 key questions I am going to touch base with one of the people who knew Milton H. Erickson best—his daughter, Betty Alice Erickson. And, yes, she's a card-carrying published therapist who has conducted workshops around the world on Ericksonian therapy. She also served as co-editor with Bradford Keeney, Ph.D., for the book, Milton H. Erickson, M.D.: An American Healer, and she co-authored the text Hope and Resiliency: Psychotherapeutic Techniques of Milton H. Erickson, M.D. with Dan Short, Ph.D., and Roxanna Erickson Klein, RN, Ph.D., as well as contributing chapters and forewords for numerous books.

Howard Rosenthal: Think back to when you were ten years old or so. If you had to describe your father in a few sentences what was he like as a parent? Was he strict, permissive, or supportive?

Betty Alice Erickson: He was a typical father. He was too strict and not strict enough. We were allowed quite some freedom if we had demonstrated we could manage it. He stressed and valued hard work greatly. We always knew we were loved and he was interested in us and was proud of us.

HR: So when you were having a problem or down in the dumps how would your father generally respond?

BAE: This sort of goes back to the last question. Daddy was very clear that we were responsible for what was rightfully ours. If we had a problem, for instance, we would go to the home office door and stand. He was always working on something. He would finish his thought, and motion us to come in. Then we would shut the door, if we wanted, and sit down. He would then set his pencil down and from that moment he was totally attentive and helpful. When we had what we had come in for, he would pick up his pencil and say, "Anything else?" And that was it. I think this was a very valuable teaching. If you want something, you must ask or at least seek it. Then you get help or needed information or better understanding. But it is your job to ask for what you want.

HR: Were you aware that he was a master therapist at a very young age and did that influence your decision to become a helper yourself?

BAE: I am not sure any kid is really interested in their parent's work—unless they're participating in it. We used to read whatever he wrote, especially for the American Society of Clinical Hypnosis Journal, but only to see if he mentioned our names. As for me, I was a high-school teacher and gradually shifted into troubled adolescents—I even ran a self-contained school for the Department of Defense overseas, long before there were special programs for this. Later, I got tired of the increasing paperwork schools were requiring, so I figured out what I really liked—teaching and seeing people change and grow. I went back to school and became a licensed therapist and then a licensed supervisor. I have been lucky to have taught countless workshops all over the world—and I have never ceased to be humbled and amazed at how important and influential and truly "genius-y" Dad was.

HR: In our field we always think of Milton H. Erickson as being a larger than life hero, but did he have any heroes growing up or when he entered into the psychotherapy field? Was there anybody who was a role model to him?

BAE: I think Daddy carved his own pathway from the very beginning, and never varied from that. But he always made it clear he admired and respected honest, productive people who were open to learn more.

HR: A lot of the textbooks imply that your father developed his keen sense of perception due to his health challenges in his childhood. Do you buy that position or do you think something else was going on?

BAE: Daddy spent a year bedfast, paralyzed with polio, and had lots of time to think. He used to practice listening to people walk up to the house, trying to figure out—male or female, how old, who it was. Then when conversation began in another room, he would figure out if it were a social visit, if someone wanted a favor, who would be the first to directly address that. He never stopped practicing those type of skills. He began to move by practicing remembering how it felt to move his thumb and fingers together . . . and practicing that memory over and over until he actually saw a movement. He took off from there, with enormous dedication and even greater hard work.

He had always keen visions of where he wanted to go in his life. With therapy, he did the same—what does the patient productively want? He was a farm boy, and would look at the "lay of the land," just as a farmer does to see if he can plant a productive crop. Then he would think about what he, and the patient, had to do to help get the best outcome. People call it speaking the other person's language; but it's more complex than that.

In other words, he figured out where he wanted to be before he tried to get there.

HR: Just like a child growing up wants to become the next Babe Ruth or Serena Williams, as therapists many of us still want to be Milton H. Erickson. Is that even possible or did he have special talents that the average helper could not ever hope to possess? For example, a therapist who saw your Dad performing therapy once told me it blew his mind. He said your father was such an adept helper it was like he possessed psychic powers or telepathy. What was the main thing that separated him from the average, everyday therapist working in a private practice or agency setting?

BAE: Daddy definitely did not have psychic powers, and it annoyed him when people asked him that. But more to the point of your question, he believed people were too infinitely varied to be classified in any theory—certainly the kind of clients we usually see. He never forgot to listen to the patient and hear what he was really saying, which is another skill which he constantly honed. The more I practice, the more I recognize clients always tell you what they want, maybe clumsily, maybe hidden, but if you're interested and really listen without thinking about you, or how it fits in the theory you're constructing (or using), you hear it. That's one thing. Another is he truly cared about his patients. He was unafraid to tell them things about him—to share certain things about himself. Today that's often seen as a "violation of boundaries." I was once chastised by a supervisor because my client, a professional astrologer, asked my birth date and I told her. My supervisor said it was inappropriate sharing of personal information. Nonsense! That's merely human beings connecting. That human connection is absolutely vital to good therapy, to a good relationship.

Last but far from least, he genuinely liked his patients. He recognized they had made the best of what they knew how to do, and they wanted to make themselves better—even if they phrased it that they wanted someone else to do something.
You can't convey these kinds of connection unless you, the therapist, can genuinely offer yourself. It's a hard skill to teach because when you connect, you become vulnerable and many people don't like to be vulnerable. They mis-define it as opening yourself to personal rejection. But it's not.

HR: As a therapist who used a lot of hypnosis myself I can't help asking: How does Ericksonian hypnosis differ from the garden variety practiced by nearly everybody else in the field?

BAE: Michael Yapko once told me that Dad re-defined hypnosis. It isn't what someone "does to someone else"—it is a co-created relationship between two people. Most of his students understand and teach that. However, people who don't understand his work are often not real comfortable with a non-rigid pattern of hypnosis. Daddy also relied on a conversational trance, which is so so easy to create and has most of the attributes of a formal trance even though it is far more flexible. A true Ericksonian knows his unconscious and the subject's unconscious are integral parts of all trance states. Even more structured ones, as in pain management, have to be crafted with the subject in mind.

HR: Did the textbook authors like Haley, Bandler, Grinder, Rossi and others get it right? I say that because I've have heard you hint in the past that some of the literature and workshops weren't quite accurate and might have misrepresented what Dr. Erickson was doing.

BAE: Some of the them "get it"—many, many do not. When people try to make Daddy's work a 1,2, and then a 3 and 4 . . .it is not Dad's usual type of work. First, Dad's work expands available options. Word choices are extremely important because most words carry many meanings. It can be very direct, but it is also very indirect. It looks at the whole picture as well as specifics within that bigger landscape. The problem is the client's, the solution has to be the client's.
Our skill as a therapist lies in creating the best, truthful, and most attractive options. With an expanded field of those options, most clients do the right thing for them. Most– clearly not all. Then you have to do, say, offer things differently.

HR: When you read about Milton H. Erickson you get the feeling he could treat almost anybody of any age, with virtually any problem. Today there seems to be a push for specialization . . . you know, a therapist has to be a specialist in suicide prevention to help suicidal kids, or an expert in eating disorders is required to help an adult who is bulimic etc. What would your father think about this model? Is it limited and would he think it is inaccurate?

BAE: I don't know what Daddy would think. I know he totally believed that AA was an excellent resource for alcoholics, and he referred people there regularly, as do I. But I think he would think that this mini-specialization ignores that we all have experience with some level of most problems. There are some issues which probably do require specially trained people like a protocol for dealing with severe PTSD for recent trauma. But I know he thought problems are problems. We can probably help most people –while remembering to remember our own limitations.

HR: What would your Dad say about the emphasis on big Pharma today? It is nearly impossible to watch a television show or pick up a magazine without seeing an ad for some sort of psychiatric prescription medicine.

BAE: He definitely knew sometimes people need meds for mental health. After all, he worked at the Colorado State Institution for the Criminally Insane for his medical residency—long before psychotropic drugs existed. We older children also grew up living in state mental institutions where he worked early on—even we knew there are people who genuinely need something more than talk-therapy. But Big Pharma for everything?—the only truism about medication is that they have side effects which I think is sometimes forgotten.

With that aside, how are we going to learn to deal with life, which is often not to our liking, if we only know how to medicate our discomfort, our pain away? We forget pain can be a wonderful teacher. Even little kids quickly learn that if you touch a hot stove, you'll have pain.

HR: Okay, tell us something about your Dad we don't know that might surprise us.

BAE: There has been so much written about him that I really don't know except trivial things like he loved limburger cheese which is the most terrible smelling cheese in the world and has to be kept in the refrigerator where it stinks up everything. Or, he contributed anecdotes for years to a "humor/human-interest" column in the Detroit Daily Newspaper under the name of Eric the Badger. He loved puns and, what all we kids considered, stupid jokes and riddles. And kept a little notebook so he wouldn't forget them, which I now have.

HR: Eric the Badger. Wow, I'll need to check that out. Okay, I know you carved out 10 life rules from your Daddy's teachings. 1. Life is hard work. 2. Life is unfair. 3. Life is filled with pain. 4. Everything ends. 5. Every choice costs. 6. The law of averages is usually correct—that's why it's called the law of averages. 7. Change is the only constant. 8. It is what's in our head and heart that really matters. 9. What we receive in life depends on merit—and good or bad luck—or a combination. 10. Life was made for Amateurs. If you had to single out one rule that has been the most important in your own life what would it be and why?

BAE: That is genuinely hard. The one my clients usually hate is #9—but it, like the others, is true. Dot.com millionaires worked genuinely hard, but had they been born five years earlier or later, they wouldn't have had such success. I guess the best for me is #7. Change is the only constant. This is miserable—it'll change. This is wonderful? Savor and love it because it too will change.

HR: Betty Alice, this has been great. Thanks for sharing these gems of wisdom.

BAE: Thank you! You've made me think and organize my thoughts as well as have even more appreciation for my good fortune in life.

Grief is a Strange Land

Posted on August 22, 2017February 11, 2026 by Psychotherapy.net Team

My mom died recently after struggling with dementia and severe rheumatoid arthritis for many, many years. I moved to the Bay Area from the East Coast in the year 2000 to be closer to her, as I thought she might not have much time left, and 17 years later, on a sunny spring morning shortly after my 43rd birthday, she died as I lay in a liminal half-sleep between the 3rd and 4th round of my snooze alarm. I woke to a series of texts from her very dear Armenian-American caretaker at her assisted living facility:

9:19am
Hi Deb,
Mrs Linda’s blood pressure dropped
significantly this morning, called
hospice to monitor her

9:34am
I’m sorry to let you know, Mrs Linda
Passed away 🙁

What?! While I slept? Over text?! I wandered frantically around my apartment for a minute, or ten, searching for my mother’s gone-ness, eyes open wide, unblinking.

I had waited and prepared for this moment, had even started praying, tentatively and awkwardly, that she be released from her incontinent, bed-bound, arthritic limbs and atrophied mind, and yet: How could she just die like that? I was going to go visit her in two weeks for her 78th birthday. I should have gone sooner. I should have gone sooner.

Much of that day was spent a few inches outside of my body as I negotiated with the mortuary, made calls to friends and family, and repeated the phrase “My mom died,” each time a dissociated succession of syllables. My friends knew of her long struggle, my long struggle, and said things like, “You must have mixed feelings.” I did not have mixed feelings. I was devastated.

This was Friday. I went back to seeing clients Monday, and didn’t tell anyone that my mother had died. Eleven years earlier, when my father died after a struggle with Alzheimer’s, I had also gone right back to seeing clients at my practicum in graduate school, but because I had canceled sessions for two weeks while he was dying, I told them why I had been away. This time there was no dying—just death—and not many details to attend to after. My mom’s sickness had been long, her personality alienating, her plight sad; by the time she died there were no friends left, no one with whom to gather for a funeral.

Not having skipped a day of work, I decided I would only share my loss if it arose organically with a client. It didn’t. I felt protective of them. How hard would it be to talk about themselves, whatever they were working on at the moment, once they found out my mom had just died? Plus, I was still kind of numb—would I come across like a zombie with no remorse? Would I be able to reassure them that I was in fact OK and that I was just where I wanted to be? I imagined what a drag it would be to go to my therapist, prepped to talk about the week’s pathos, only to find out her mom had died. I would feel like a self-involved jerk diving into my own preoccupations in the face of her loss, and would feel like a jerk talking about how I felt like a jerk talking about my own preoccupations. No, I didn’t want anyone to bear my burden. That’s not why they come to therapy, after all.

The opaque sense of unreality that arose in the weeks after she died—my palette of sensations muted like a blue twilight after the sun disappears—was almost comforting. “Perhaps this won’t be that hard,” I thought. After all, she’d been deteriorating, and then dying, almost forever. Losing her had been a slow and steady stream of small infirmities and indignities rather than a flash flood, the erosion of her essential being an accumulation of griefs I hoped would inoculate me against the crushing pain I had suffered after my father died.

But I didn’t know how to both bear my burden and not burden clients. I wanted to be doing therapy—I felt present and alive with my clients—but after a few weeks it felt like the vessel in my heart where I hold people’s pain, their stories, had no more room in it. I hadn’t entirely understood that place in my body until it stopped working, and it was alarming. Because I wasn’t experiencing paroxysms of grief, weeping uncontrollably at random intervals, I mistook myself for “not really grieving.” This was compounded by the fact that my mom was in many ways a “not-good-enough” mom—her mental and physical illnesses had compromised her ability to mother long ago, but I thought I had “dealt” with that grief already, damnit. So what was this parched-solar-plexus feeling?

Ah…It was my grief.

You see, I loved her madly. Still do.

I took the week off from work in an effort to bring some space and consciousness to my grieving. I slept, read, wrote in my journal, saw beloved friends, exercised, booked an extra therapy session, got a massage. It was awful. Anxious, listless, unmoored from my routines, I spent the week berating myself for not doing a better job at grieving. I felt it was up to me to figure out an appropriate ritual to mark her death, but the idea overwhelmed me. What would I say? Who would I want to bear witness? Inside or outside? What spiritual tradition to draw from? My dad was Jewish. She was a blend of everything and nothing, but a spiritual person. Where would I release her ashes? It was too much to figure out; I was tired. I stuck her ashes in the closet near, but not directly next to, my father. They hated each other. Was it OK for them to be in the same closet? I watched a video about cremation and decided it was.

The capacity to be wise and spacious around others’ pain, the sense of tenderhearted compassion that comes so readily through me in my role as a therapist, often tricks me into thinking I don’t need help with my own struggles. But I don’t have me the way that my clients do. I have my own therapist and she, in turn, doesn’t have herself the way that I have her. We cannot be our own therapists. Therapist-Me is also an orphan right now, struggling to make sense of death, of having no parents, of the freeing and terrifying reality of being on my own—generationally-speaking—for the rest of my time here on earth. No amount of “self-care,” parenting of my inner child, and guided meditations makes Therapist-Me available to myself.

Despite years of training in the mental health field and working with people as they struggle with death, I’m struck by what a strange land grief is for me. I’ve heard many therapists say that their own grief has brought a richness and depth to their work with clients, and I think that is true for me too, but not in a particularly tangible way. What I am most aware of is how nurturing working with clients is to me right now. It is the only place where I am fully present, and being present is a tender relief as I navigate the complexity of loss in my own life.

How have your experiences of grief impacted your work as a therapist? What has helped you? What has not? I would love to know. Feel free to send me an email at: Deborah@psychotherapy.net.

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