Author: Psychotherapy.net Team

In the Therapist’s Chair and at the Kitchen Table: Juggling Personal and Professional Struggles

Posted on by Psychotherapy.net Team

Imagine a therapist, trained to help others navigate the darkest moments of their lives, who, despite years of expertise, finds herself unable to ease her family’s suffering regarding the mental health challenges of one family member.

Most of us know someone whose family is touched by mental illness or addiction; it’s a sad reality of modern life. When a therapist has a family member with mental illness, people might find it interesting, but most understand that no one is immune. But when a seasoned psychotherapist—armed with knowledge and resources—cannot help their child, that’s an eyebrow raiser.

That therapist is me!   

Therapists are expected to have answers, engage in stable relationships, make good decisions, and be overall healthy people. With all the education, training, supervision, and consultation, others often assume that we are equipped to pinpoint problems when they arise and have solutions. I remember how shocked I was to see my gynecologist, who delivered each of my children, walk out of a convenience store with beer and cigarettes. It’s normal to hold healthcare workers to a higher standard.

Nobody cautions us that training and education do not prepare us for the jerky rollercoaster ride of living with a child with mental health challenges. We do not get a map to navigate the bumpy roads of fear, anxiety, worry, and sometimes, shame. And we cannot be therapists to our children—emotion, protectiveness, and maternal instinct muddy the waters.

Being a therapist while also having significant personal problems at home is an isolating experience. A decade ago, shortly after achieving my goal of private-practice ownership, conflict drastically arose at home; I did not understand the severity of one of my children’s mental health challenges. I had difficulty responding to her behaviors, identifying effective resources, and taking care of myself. My self-talk was bleak. Am I hearty enough to handle all this?   

Anxiety invaded my family exponentially throughout this unpredictable period. It inflicted headaches, stomachaches, heart palpitations, and insomnia. I was dominated by fear and agony about how my problems affected my work with clients, even though the feedback I received from clients was positive, and they were unaware of my problems. I considered exiting the profession completely. I daydreamed about a far simpler job to make work life easier.

I was unaware of any other therapists going through the same thing. I kept my despair to myself. During consultation groups or supervision, I politely discussed cases with colleagues, and occasionally mentioned something trivial from my personal life, but nothing that risked judgment from other professionals. I felt alone.   

Shame was present in both roles: as a mother who failed to help her child, and as a therapist whose guidance for others did not work for herself. My heart ached with sadness. Intellectually, I made sense of my shame, but social stigma around mental health and self-imposed pressure to live up to a parenting and professional standard kept me quiet.

On one occasion, I was around other mothers of peers in my child’s grade who were celebrating their children’s college acceptances and decisions. Shame and sadness flooded my body when they talked about their child’s exciting plans. Was my child’s inability to achieve these milestones a reflection on me? Was her condition an indicator that I had failed as a parent and therefore could not possibly be successful as a therapist?  

Sometimes on social media, I saw posts by therapists who showcased pictures of their happy families and children with smiles on their faces. Sadly, I thought, Not my family. You might be wondering, What did you do?

Perhaps it was the years of effort to establish my dream-come-true therapy practice, recalling the original reasons for choosing this work, or the long-standing student loan debt—I decided to learn to cope, for my sake and that of my family, and to continue delivering quality care to clients. You ask, How did you do that?  

My answer: Focusing on three core areas—my relationship with myself, others, and work—helped me cope most effectively. Little by little, prioritizing these foundations built my confidence, strengthened my judgment as both a mother and a therapist, and guided me through difficult times. This is how I made it. 

Relationship with Myself

Finding a Therapist, or Two or Three

Therapy became my cornerstone for coping. I have engaged in psychotherapy throughout adulthood—not only in crisis but as steady support for daily life. For therapists, therapy isn’t just wise; it’s essential, especially when personal struggles feel overwhelming. I relied on my therapist’s insight, warmth, and the comfort of her office. She helped pull me out of the trap of relentless self-blame and anger. What did I do wrong? I’ve done everything I can to help my child; why isn’t she better?  

My therapist, a seasoned clinician of many years, has told me more than a handful of times that she has not known a mother to seek out and identify as many resources as I have. She helped smooth my tumultuous feelings and showed me that my efforts as a mother matter. The therapy process served as a continual resource for me. Over time, it helped me cultivate a belief that I was capable and resilient.

Throughout this journey, I addressed traumatic experiences during family conflict, so I started seeing an Eye Movement Desensitization and Reprocessing (EMDR)-trained therapist. Those sessions freed me from negative patterns and boosted my confidence as a mother. I sought out an EMDR certified therapist who identified as a parent in her profile on her website. It was important to me to work with someone who I thought might understand that aspect of my turmoil.

I consulted a Bowenian family systems coach and immersed myself in seminars to understand my role in family dynamics. The work helped me focus on my influence—how changing my actions or words impacted my entire family system. Studying my family diagram deepened my understanding of generational patterns. Learning about triangles in my family made me more focused on my behaviors and thoughts.

I began to see the role of chronic anxiety and started to change the way I contributed to it. As an added benefit, my new understanding of Bowen theory directly informed my clinical work, allowing me to help clients break free from unwanted patterns. Sharing aspects of my Bowenian family systems journey with clients created a sense of common humanity and made me a more relational therapist.

Getting a Hold of Myself

At the peak of my anxiety, I joined a 10-month fellowship cohort to learn a specialized bottom-up modality, called Acceptance and Integration Training (AAIT), developed by Melanie McGhee. At first, the learning was personal. The experience was transformative—using sequenced protocols that addressed thoughts, images, emotions, and body sensations brought real relief. Taking responsibility for my inner state became the priority, with becoming a skilled therapist as a welcome side effect. The cohort and the program restored my confidence. I practiced daily: on my walk to the office, between clients, and before bed. When self-doubt or fear hit, I had tools to find relief. Calming my body cleared my mind, leading to better decisions for myself, my family, and my work. Once proficient, my clinical skills were sharper, and I utilized the approach with clients.

Seek Purpose, Find Perspective

Tunnel vision blinded me. Worries crowded my head, leaving little room for anything else. I lost a sense of purpose. Is this what my life amounts to? There were infinite ways to engage with life beyond the problems in front of me. I gave time to volunteering through my church to missions that reminded me of what existed beyond my small orbit of issues and privilege. I chaperoned a service trip with my youngest child. These experiences were doses of humility that filled me with a refreshing view of all the things that are important in this world. Perspective helped ease the self-imposed urgency to be a good mother and a successful therapist. 

Relationship with Others

Boundaries and Discernment

Personal, family, and professional boundaries begged my attention. They needed a reset. Stress often caused me to mask my feelings or censor content, leaving me uneasy with my dishonesty. When I did speak up—commonly out of anxiety—I’d instantly regret it. The unpredictability of others’ reactions left me powerless. Many people think they have a solution for you, even though they have not experienced the same thing, and the consequence for me was believing I was a bad parent.  

I learned how to discern between what I felt comfortable sharing and what to keep to myself. My usual discernment process did not apply. For example, I would typically tell my closest friends everything. Yet, I found that I needed to be more conservative about what I shared for two reasons. First, some friends lacked the capacity or interest to listen to chronic problems. As much as they cared about me, some could not tolerate the negativity. Second, nobody wanted to talk about the same conflict over and over. My “fixer” friends and protective friends seemed to find this difficult. To mitigate frustration, I said less.

I also needed to be cautious about what I told family members. I learned that some family members did not keep private information to themselves. Some family members spewed “you should just” while not understanding that those solutions had been tried and failed. Sometimes, telling family members reinforced the reality that while many people understand the difficulty of having a family member with mental health issues, most do not.

The boundary work of Julianne Taylor-Shore revamped my relationships so that I wasn’t as reactive or affected by others’ opinions. Taylor-Shore wrote about different types of boundaries. Her concept of the psychological boundary is the one that helped me the most. It is an invisible boundary that separates your thoughts and feelings from others. It’s a process by which I respect and allow others to have their thoughts and opinions while I have mine. The psychological boundary says that it’s okay for us to think differently about something, and when we do this, we reduce the risk of feeling offended or hurt by others’ words. We also develop more compassion for ourselves and others when we practice this boundary.   
  
When I communicated with a professional or teacher about my child, I tried to be factual and general. If I made mistakes in oversharing, the result was feeling ashamed and guilty for not protecting my child’s dignity and privacy. Learning how to be more discerning eliminated this risk.

After a few discouraging family trips, I realized things needed to change. One solution was to stop traveling as a family of five. My family and friends were confused. They said, “That’s sad that you are not all going together.” It’s sometimes hard for others to understand how setting personal boundaries, protecting my time and space for the sake of sanity, is non-negotiable. Once I practiced my psychological boundary, I understood that they had their opinion based on their own experiences, and I had mine. And that is okay. Instead of ending the conversation annoyed, I could say, “It’s complicated, but what works best for us.” The “it’s complicated” remark validated their question or confusion about not vacationing as a whole family, and the latter declared that my family values were not up for scrutiny.   

Support Groups

Parent support groups were trying for me. I was ashamed as a therapist who couldn’t “fix” my life, and I was frustrated by weak group facilitation, whether it was a professional or a volunteer. The solution came unexpectedly: I reached out to three colleagues who had mentioned having family struggles. I proposed we started a private, self-led support group to share our challenges. They all agreed without reservation. Now, we meet monthly, deepening our connection and trust with one another.

I joined a second support group with some hesitation—this one led by Judith Smith, author of Difficult: Mothering Challenging Adult Children through Conflict and Change. Dr. Smith’s serious, supportive style fostered a safe space. For the first time, I was among mothers who understood the pain of struggling with an adult child’s challenges, and I was moved to tears in our first session. After the formal group ended, a small group of us continued meeting every other week. We remain the only women in each other’s lives who truly get what it means to face these struggles.

Being in support groups eliminated frightening feelings of isolation. With two groups of compassionate and understanding women, the crazy-making thoughts of wondering if what I said or did was right or wrong do not exist. I talk about it with my understanding group members, who give honest and caring feedback.

Focusing on Other Relationships

Parenting stress strained my marriage, so my husband and I started therapy to improve our communication and work better together as parents. When I met my husband, I was ecstatic to be a mother. I wanted my kids to feel important, so I prioritized them over everything else. Our child’s mental health and the way it affected our family system often became a divisive topic, and our marriage needed attention. Having a therapist guide us through those rough conversations made all the difference.

Attuning to my other two children was also an intentional tactic to focus on the joy that was right there in front of me. I celebrated their milestones and made space for enjoyment with them. It was difficult at times when my head was fuzzy with fret and tension. Making myself available to them despite the family problems laid the foundation to open communication as they got older.

After my father passed away, I responded to my longing for connection with my cousins and relatives on his side of the family and initiated spending more time with them. Our visits filled me with love and laughter. Even though they only knew small portions of the challenges in my personal life, and despite differences in lifestyles, connecting with my family roots was grounding and important to me.   

Relationship with Work

Spotlighting Blind Spots

With so much stress related to my problems at home, my skills as a therapist dulled. Some days, I sat in my therapist chair, mind foggy from overthinking, and an undercurrent of anxiety coursing through me. I was listening, but not with curiosity. I was compassionate, but my capacity was too weak. Under those circumstances, I did not realize how susceptible I was to countertransference and vicarious trauma.

Countertransference is the therapist’s unconscious reactions, feelings, and attitudes that stem from personal experiences and unresolved issues. It is ubiquitous in therapy and might erode our well-being if ignored. It is a common topic in clinical training, supervision, and consultation groups. Certain clients evoked strong responses in me, such as disgust, anger, or anxiety. Raising my awareness of this dynamic and addressing it was crucial to the integrity of my work as a therapist. I processed countertransference in individual therapy, supervision, peer consultation, and in my small therapist support group.   

Vicarious trauma is the negative impact on us when we are exposed to other people’s suffering. For several months, I worked with a client who had a trauma history. I began experiencing bad dreams, difficulty falling and staying asleep, and intrusive images in my mind. I dreaded sessions with this client. I discovered that my empathy and imagination were overloaded, and I was absorbing too much of the client’s story.

A colleague referred me to an experienced psychologist who works with therapists. The therapist created a supportive space and listened to all of my symptoms. He helped me tune into my reactions and develop a plan to have more psychological boundaries in sessions with clients. My work with the psychologist liberated my mental and emotional space, so I was more available for my family instead of being consumed by someone else’s trauma.

Taylor-Shore’s boundary work also strengthened my ability to separate from clients’ stories. Taylor-Shore suggests creating an imaginary boundary (she calls hers a Jell-O wall) between yourself and the other person to filter what comes in and what stays out. The visual image of a slightly porous wall helped slow the intake of information, both content and emotion.

Somatic work from Acceptance and Integration training helped me identify my bodily responses to various feelings. Practicing mindfulness and breathwork signaled my nervous system to stay calm.

Reworking Work

I adjusted my work schedule—specific days and hours—to accommodate my family’s needs, prioritize my family, and continue working. Scheduling consistent days and hours for business-oriented tasks helped minimize anxiety about the business. I moved my office to be closer to home so I could get there quicker if a crisis arose.

Deciding who I want to work with and whom to refer out was a practice I developed over time. I eventually proved to myself that I had a choice. I learned to say no to some referrals. All therapists probably have a list of issues or populations that they would rather not work with. I clarified my list and stuck with it. Having a long list of reputable therapists to refer to was key to my confidence in saying, “No, I believe I am not the best fit for you, but I have trusted referrals for you, and I will be happy to connect you.”   

At last, I needed a major change. After reflection and discussion with trusted colleagues and family, I closed my private practice. Freed from business ownership, I sought employment with an established group practice. It was hard to say goodbye after fulfilling my dream of running my practice. That decision ultimately alleviated stress, added financial predictability, and brought greater stability to my life. I found that I thrive in a group among other clinicians. It is comforting to know others are around to consult with or say a friendly hello to. Being in a group practice affords me more time to take care of myself and my family.

Summing Up

Years of stress from raising a child with mental health challenges permeated every area of my life, including my professional work. Missteps and a lack of self-awareness about how this conflict affected me became a turning point, prompting me to seek change. When self-doubt and exhaustion overwhelmed me, I reached out for support, accessed helpful resources, and leaned on trusted individuals until balance was restored. This process enabled me to approach my clients with clarity and my family with openness. By strengthening my skills and understanding within each relationship, I became better equipped to continue practicing as a therapist and to be a more relaxed, present, and supportive mother for my family.  

On the Therapeutic Power of Presence

Posted on by Psychotherapy.net Team

I’ve been a psychologist for almost 40 years, and I am constantly amazed at just how much neuroscience research is enhancing my clinical understanding of what psychotherapy clients may really need most. What I would like to talk about here is how the concept of presence—a state of grounded awareness of the present moment—can inform clinical practice and enhance the everyday lives of our clients.

Why Presence Is Important

Presence is a state of mind of selective and sustained attention where one is intentionally and nonjudgmentally receptive to one’s own senses, is active in reflecting on them, and is consciously directing their awareness to the present moment (1, 2). Presence first requires an awareness that we have, a capacity to experience it, and second, it requires the skills to make it happen. All clients—and clinicians—are on a continuum of both, so each client requires interventions tailored to their individual level of awareness and skills. But I am discovering more and more just how crucial it is to help clients learn how to be present with both difficult and life-affirming emotions. That is, how to sit with, better tolerate, and more fully embody those moments without reactively fighting them, distancing themselves from them, or becoming frozen by them.

Psychotherapy interventions are almost always chosen in the moment, because the timing of them is believed to be most helpful to the client. Cognitive-behavioral therapists may highlight a cognitive distortion, like all-or-none thinking; psychodynamic therapists may bring attention to a protective defense, like projection; Gestalt therapists may suggest the use of an I-statement to replace impersonal or blaming language. Even though the clinician’s application of their theoretical approach may be executed with textbook precision, the intervention can fall short.

For example, if a client repeatedly returns to a conditioned or protective response to difficult situations by jumping to unwarranted conclusions, by blaming themselves or others, or by characteristically pushing away or distancing themselves from their feelings, the best interventions of the clinician may not be enough. This is particularly true if developmental trauma or significant episodic injuries have occurred. When a client has difficulty taking in, processing, or applying the clinician’s intervention, or when emotional underpinnings of their symptoms may be so severe that access to the resources needed to make use of the clinician’s interventions are not available, building skills of presence may be needed.

The concept of presence is foundational to all psychotherapies but especially to somatic psychotherapies. From the early developers like Wilhelm Reich’s Orgone Therapy, Thomas Hanna’s Hanna Somatics, Alexander Lowen’s Bioenergetic Analysis, Moshé Feldenkrais’s Feldenkrais Method, and Ron Kurtz’s Hakomi Method to more modern approaches like Lisbeth Marcher’s Bodynamic Analysis, Pat Ogden’s Sensorymotor Psychotherapy, Peter Levine’s Somatic Experiencing, Raja Selvam’s Integral Somatic Psychology, and from the diverse work of Bessel van der Kolk, clinical practitioners have learned that using mind-body practices opens up new ways to strengthen their effectiveness—particularly for clients with chronic, unresponsive, recurrent, or refractory symptoms.

The Physiology of Presence

Modern neuroscience has provided a wealth of understanding of how presence operates and how it can be fostered. Being present in the moment causes neural and biochemical changes in the visual and prefrontal regions, causing increases in alpha and theta brainwave activity, reductions in autonomic nervous system activation, and changes in how information is processed and monitored. Research has shown that presence causes a cascading series of interactions between several identifiable regions of the brain, which sets in motion the activation of neurological and neurochemical changes that induce felt states of well-being.

More specifically, by setting our intention to be present, we activate a top-down process beginning in the dorsolateral pre-frontal cortex, which causes changes in two organizing cortical and subcortical superstructures known as the Default Mode Network (3) and the Salience Network (4). These superstructures coordinate distinct regions of the brain that are responsible for decreasing emotional arousal, reducing unpleasant self-referential thinking, and more effectively tolerating painful affect.

Merely intending to be present facilitates greater calm. When we begin to exercise greater presence, the Default Mode Network slows response reactivity. Additionally, substructures within the Salience Network (the anterior insular cortex and the anterior cingulate cortex) work synergistically with the Default Mode Network to a) detect mind-wandering to distressing thoughts and b) bring us back to a greater felt sense of calm and physiological homeostasis.

If our focus wavers, the Salience Network helps sustain our attention; it filters distractions; it slows our heart rate and breathing and decreases blood pressure and muscle tension; it increases heart rate variability; it downregulates the activation of our amygdala; and quite critically, it enhances our ability to monitor affective body states relative to actual occurrences in our external world. Stated somewhat differently, the neural circuit between the Salience Network and the amygdala allows us to accurately monitor the functional and dysfunctional interpretations we make about our outer world. For example, if we become frightened for no rational reason, presence triggers the Salience and Default Mode Networks that help bring us back to center.

Inducing Presence

There are literally hundreds of ways to induce presence in ourselves and in our clients. There may be several techniques that stand out and really work well for a particular client, and other clients may prefer using a wider variety of methods. Here are a few examples of ways clinicians have helped clients manage their physio-affective arousal by helping them make more consistent contact with the present moment.

Geller and Greenberg (5) believe that therapeutic presence is foundational to the therapeutic relationship, where the therapist’s whole self invites the client to become their whole self. The authors suggest the acronym P-R-E-S-E-N-C-E to organize a series of methods, where the client is asked to:

PAUSE (P)—stopping and creating a moment of stillness

RELAX/REST (R)

EMPTY (E) their mind of thoughts and judgements

SENSE (E) their physical and emotional state

EXPAND (E) their awareness of their external environment

NOTICE (N) the relationship or the connection between their inner and outer worlds

CENTER (C)—reconnecting with their core self and bodily groundedness,

ENTER (E) back into their immediate space or resume their actions or intentions prior to inducing the state of presence.

A method like this can be especially useful as an introduction to the notion of presence, as some clients may be quite unfamiliar with self-reflective and interoceptive processes.

In Somatic Experiencing (6), presence is induced when the clinician encourages the client to notice, observe, and become a witness to attendant body sensations, images, actions, impulses, emotions, or movements. If a calming or relaxing state is needed to temporarily offset the client’s overwhelming level of arousal, SE practitioners are encouraged to invite their client to slowly vocalize the sound “voooo,” which is reported to vibrate the vagus nerve, activating the parasympathetic (rest and digest) nervous system, and deactivating the dorsal vagal freeze response (7).

In addition to activating parasympathetic activity, the practitioner is also instructed to induce presence by prompting their client to notice their belly vibrating, to feel it do so, and to observe their overall physical reaction to making the sound. Levine also describes the use of Jin Shin Jyutsu, a Japanese mind-body system of self-regulation, where stronger states of presence and relaxation occur from better “energy flow” after performing a sequence of three body holds—placing one hand under the opposite armpit and placing the other hand over the opposite outer arm below the shoulder, placing one hand on the forehead and the other on the chest, and finally placing one hand on the chest and the other on the stomach.

For clinicians and clients who may be more familiar with interoception, Raja Selvam (8) highlights eight techniques for tolerating unpleasant emotions that also can enhance the experience of pleasant emotions. Each technique fosters greater presence with oneself and with one’s emotions:

a) breathing into and with the emotion

b) resonating with the emotion

c) heightening awareness of the emotion

d) visualizing the emotion dissipating, spreading more evenly in the body

e) vocalizing sounds that are congruent or resonant with the emotion

f) using self-touch to both support and make deeper contact with the emotion

g) enhancing one’s intention to make contact with, expand, or support the emotion

h) making very small body movements to release felt stuckness of the emotion

Applying these methods of presence to address an unpleasant emotion softens it and helps to better tolerate it. For clients with low tolerance for unpleasant emotions, the method is used in very shorts durations. At some point in the process, the client becomes aware they are tolerating the targeted emotion, when, at that point, they are prompted to notice the relief of having achieved it. Through the continued use of focused awareness and presence, the client is then guided to expand and make deeper contact with their relief. This typically results in a greater openness to and eventually a welcoming acceptance of the difficult emotion.

Other commonly employed presence inducing methods include inviting clients to:

a) name several things in their environment they can see, hear, smell, taste, and physically feel

b) scan and bring awareness to different parts of their body

c) take a long and audible sigh

d) gently stretch any part of their body

e) to look at something pleasurable in their environment and then to soften their eyes—relaxing their eyelids and facial muscles—while looking at it

f) simultaneously observe objects in their peripheral vision while focusing on a fixed point

g) toggle back and forth between looking at an object at a far distance—becoming curious about its nature, its history, its function—and then to notice how they are feeling about observing the object

Presence can also be fostered using the many forms of pranayama—a yogic breath control technique—an example of which is the mantra meditation So’ham, where on each in-breath one visualizes taking in all the positive energy of the universe and on each out-breath imagining expanding that positive energy to every part of the body. The very act of observing and reflecting on one’s internal states without judgement quiets the mind. Eastern philosophies and practices that emphasize living in the present moment are central to the many forms of meditation practiced throughout the world, which neuroscientific studies have shown similarly affect the brain superstructures discussed earlier (9).

As clinicians monitor their clients’ presence in sessions, they may already be well acquainted with when and how it fluctuates, and they may already be creatively using effective but less structured methods than those I have suggested. For example, I recently observed one of my client’s arousal level waxing and waning throughout a session, influenced by small things that were said by either them or me. By tracking these remarks along with correlated changes in their breathing, movements, and muscle tension, I was able to get subtle clues about what may be fostering or inhibiting presence. Monitoring my client’s real-time physio-emotional arousal, I was able to determine when the client was sufficiently present or needed support to do so—that is, whether they needed to build tolerance for a difficult emotion, rest from the unpleasant emotion, better regulate their arousal level, or expand their resources to address the emotion.

Lin: A Case Study

Lin had been my long-time client, who experienced significant developmental trauma from his father. At one point in our work together, he went through an extended period of unemployment in a vapid job market. Despite his considerable insight about his father’s impact on him and the substantial progress he had made with this issue, the stress of his unemployment was producing exacerbated and pronounced anxiety, which had brought him to the point of helplessness, exhaustion, and withdrawal. Lin’s precipitous overwhelm was also making it extremely difficult to calm him in the sessions, as he became more prone to unending ruminations about his difficulties, almost as if I were invisible to him. He was intellectually aware that his pondering was crippling him, but he could not relent from compulsively engaging in it while shaming himself for doing so. Despite my best efforts and those of his psychiatrist, something more was needed.

I decided to better employ the methods I have been discussing here to enhance Lin’s self-attunement. Although some aspects of what I was witnessing in Lin were related to his childhood, he was not in a resourced enough state of mind at that time to process interpretations about it. He was also not resourced enough to process feedback about cognitive distortions he was caught in, so I proceeded to address his immediate moment-to-moment, physio-emotional dynamic. He needed to become better present with how he was fanning his own flames, shutting me out as a support, and cutting himself off from his own psychic resources.

Because Lin seemed to need the simplest, most easily understood and tolerated intervention, I decided to begin the next session by encouraging him to take his time and look around the room, letting his eyes move the way they wanted to. . . and name five things he could see, then asking him to name two things he could hear, then one thing he could smell. Then I asked him how it felt to do so, to which he responded, “a little better.” I said, “That’s good, Lin.” He then quickly changed the focus and began characteristically ruminating on his troubles.

After empathizing with how tough a time he was having, I asked him how it felt at that moment in the session, and he responded, “Upset.” I then asked him if he noticed the shift he made, which he was able to acknowledge. I replied to him, “It’s excellent that you observed that, Lin.” Then I asked him to take a long, slow, audible sigh, where I could see him begin to settle. I could also feel myself settle a bit, which, in the resonance, helped me confirm I was on a good path in that moment with him. Although he soon began to agitate himself again with self-shaming accusations, it took him a little longer to start doing so. I’ve seen these delays occur with other clients, so it confirmed my intuition that his resilience for, and tolerance of, his troublesome emotions were growing.

I try to continuously monitor in real time my clients’ presence and their tolerance for unpleasant feelings. I think it helps me make better decisions about whether I should help them better tolerate their arousal or help them become better aware that they are tolerating it on their own. Sometimes clients need us to be their resource when they are having trouble maintaining access to their own inner resources. Sometimes it’s more important for them to see and feel our pride in them when they are handling their arousal just fine without us.

Gale: My Experience with Therapeutic Presence

This essay would not be complete without discussing the variety of ways clinicians wax and wane in maintaining their own steady presence with clients. Every day I work on learning how to be with my clients—to be awake, to how I repeatedly lose and regain attunement to them, to vacillations in my own internal emotional and physiological states, and to the subtle effects my degree of presence has on them. Being present is relationally essential: it facilitates empathic resonance, it prevents interpretive and empathic errors, and it makes my work and my life more enjoyable.

Like many, I grew up without being taught about emotions. It wasn’t until my late thirties that I realized I had feelings that I could identify and discuss. Through the study of academic psychology, through my clinical practice, and through my personal psychoanalysis, I have met many emotional mentors, some of whom, paradoxically, have been my clients.

Gale was a middle-aged, divorced client of mine, who regularly attended his sessions but who was highly reactive and talked incessantly without reflecting on his words or actions. Managing my own unpleasant internal reactions to him took some time. Although I recognized my countertransference reaction was stemming from my relationship with my father, this insight alone didn’t provide enough real and lasting emotional relief.

To regroup, I decided to take my own advice—that is, to apply to me and my own process with Gale, the recommendations I was making to my clients. In fact, this essay is a reaffirmation of what I continue to learn—how to authentically embody a better moment-by-moment attunement to “me” when being with my clients;how to give myself flashes of time to breathe, a moment to be with myself, to attend to me, to care for me, and to have an instant where I can honor and affirm my own existence.

As I permitted myself to focus on my needs while with Gale, a variety of methods to be more fully present spontaneously emerged. My next thought with Gale was to experiment with my own movement, so I consciously authorized myself to change my posture. Because I was so intent on focusing my attention on Gale, I realized that I wasn’t aware enough of my muscle tension and joint discomfort. As I crossed my legs, stretched my back, shifted my weight, I found myself quietly sighing. At first, it felt like a release, but it soon evolved into a wondrous return to a safe and grounded place—a place where I could give myself room to be with Gale’s loquacious tangentiality, without judging it or reacting to it.

From this place of peaceful inner calm, I started feeling more genuinely grateful for the relational space Gale and I were co-creating, and with it arose a greater sense of compassion and appreciation of his struggle. As I described in the earlier section on the physiology of presence, I could experience my arousal level diminishing, my dysfunctional interpretations of my outer world with Gale quieting, my capacity to accurately monitor my own body states increasing, and my tolerance for enduring my illusion that I was being ignored strengthening.

As if divinely inspired, my brain’s higher-order functions suddenly kicked in, and I realized at a visceral level that, not unlike myself growing up, Gale had no one in his childhood he could talk to about the things he wanted, for as long as he wanted. He never had anyone who wanted to be with him in the way he needed, to play with him on his terms, who conveyed to him that he was important, that he mattered. So, I sat with Gale, sometimes for whole sessions at a time, intently listening, staying present, breathing with intention, unobtrusively sighing, shifting my posture. . . until one day he began to slow and settle and finally voice, “I’ve had a lot to say,” to which I simply smiled and nodded.

At that moment, I could feel the resonance of his attunement with me and mine with his. Paradoxically, I became aware of what I believed I really wanted with Gale all along—not only for him to be aware of himself, but for me to be truly present with him, to connect with him, and to feel his connection with me.

References

(1) Kabat-Zinn, J. (2003). Mindfulness-based interventions in context: Past, present, and future. Clinical Psychology: Science and Practice, 10, 144–156. https://doi.org/10.1093/clipsy/bpg016

(2) Koch, C., & Tsuchiya, N. (2007). Attention and consciousness: Two distinct brain processes. Trends in Cognitive Sciences, 11, 16–22. https://doi.org/10.1016/j.tics.2006.10.012

(3) Malinowski, P. (2013). Neural mechanisms of attentional control in mindfulness meditation. Frontiers in Neuroscience, 7, Article 8. https://doi.org/10.3389/fnins.2013.00008

(4) Philip, N. S., Barredo, J., van ‘t Wout-Frank, M., Tyrka, A. R., Price, L. H., & Carpenter, L. L. (2017). Network mechanisms of clinical response to transcranial magnetic stimulation in posttraumatic stress disorder and major depressive disorder. Biological Psychiatry, 83, 263-272. https://doi.org/10.1016/j.biopsych.2017.07.021

(5) Geller, S. M., & Greenberg, L. S. (2012). Therapeutic presence: a mindful approach to effective therapy. American Psychological Association. https://doi.org/10.1037/13088-000

(6) Levine, P. A. (2010). In an unspoken voice: how the body releases trauma and restores goodness. Berkeley, CA: North Atlantic Books. https://www.northatlanticbooks.com/shop/inanunspoken-voice

(7) Porges, S. W. (2011). The polyvagal theory: neurophysiological foundations of emotions, attachment, communication, and self-regulation. New York: W. W. Norton & Company. https://wwnorton.com/books/9780393707007

(8) Selvam, R. (2022). The practice of embodying emotions: a guide for improving cognitive, emotional, and behavioral outcomes. Berkeley, CA: North Atlantic Books. https://www.penguinrandomhouse.com/books/673734/the-practice-of-embodying-emotions-by-raja-selvam-phd

(9) Bauer, C. C. C., Cabral, J., Stevner, A. B. A., Kirchhoff, D., Sousa, T., Violante, I. R., … & Kringelbach, M. L. (2022). Mindfulness meditation increases default mode, salience, and central executive network connectivity. Scientific Reports, 12, 13219. https://doi.org/10.1038/s41598-022-17325-6

Why Trauma Recovery Isn’t a Straight Line

Posted on by Psychotherapy.net Team

When clients begin trauma therapy many hold onto the hope that healing will follow a clear path. They picture a beginning, a middle, and an end. A moment where the past stops hurting, their relationships feel easier, and their bodies finally release the tension they’ve carried for years. But as therapists, we know it rarely unfolds that way. Healing is not linear. It comes in waves. Progress can be followed by regression. A moment of insight might be lost in a fog of overwhelm. A good week can lead to a hard month. It’s not a step-by-step climb. It’s a spiral. Clients return to the same emotional terrain again and again, but each time, hopefully, with a little more clarity, a little more stability, and a little more strength.

Clients Might Not Recognize Themselves at First

One of the earliest shifts I’ve witnessed in my trauma work is a client beginning to question long-held coping strategies, survival instincts, and automatic responses. These were the very tools that kept them safe in environments where safety was uncertain. They may start setting boundaries and feel a wave of guilt they can’t quite name. They may say no and spiral into fears of abandonment. They may feel anger surface for the first time in years and have no framework for how to manage it.

This stage can be disorienting. Clients often wonder if they’re regressing or doing it wrong. In truth, they are beginning to do something radically new. The nervous system often perceives unfamiliar experiences as potential threats, even when those changes are healthy. That is why growth frequently shows up as discomfort.

As a therapist, I have found it to be essential to help normalize this phase and support clients in tracking these shifts as evidence of progress. What once felt unsafe begins to register as tolerable. And over time, it begins to feel like safety. This is not failure. This is the nervous system recalibrating.

For clinicians interested in exploring the neurobiological foundations of this process, resources like Bessel van der Kolk’s work, and that of the National Child Traumatic Stress Network offer helpful frameworks for understanding how neuroplasticity supports recovery. I keep reminding my clients and myself that discomfort is often a sign of meaningful change. With time, what feels unfamiliar now can become a source of strength and stability.

The Nervous System Has a Story to Tell

Trauma doesn’t just live in your client’s memories. It lives in their bodies. It often shows up in the form of chronic tension, unexplained exhaustion, or a racing heart in situations that seem calm on the surface. I have noticed how a client becomes anxious in safe environments, withdrawn when connection is offered, or goes numb during moments that would typically bring joy. These aren’t signs of resistance or dysfunction. They are adaptive nervous system responses developed to survive past experiences.

The body carries what the mind may no longer recall. My client’s nervous system often reacts before their conscious awareness catches up. These responses made sense in the context of trauma, even if they seem confusing or disproportionate now. As a therapist, I can help clients begin to recognize these embodied patterns with curiosity and compassion. The healing process often starts with noticing—subtle shifts like shallow breathing, clenched jaws, or emotional distance in the room. These cues are the nervous system’s way of communicating safety or threat.

Rather than encouraging clients to override these sensations, I guide them toward listening to their bodies with gentleness. When I help create space between sensation and reaction, I offer a new way forward. That space is often where integration and healing begin. In learning about how the nervous system holds trauma and how regulation begins with awareness, I have found the Polyvagal Institute to be a particularly useful resource.

In one session, I have found that a client may speak with clarity and confidence. The next, they might come in feeling discouraged after falling into old patterns. Maybe they people-pleased, avoided conflict, or ignored their own needs. They begin to question whether any of their progress was real. It was!

Healing is not linear. The strategies that once helped a client survive can resurface, especially when they are tired, anxious, or uncertain. These moments are not evidence of failure. They are part of the natural rhythm of recovery. What begins to shift is their awareness. They notice the pattern more quickly. They pause before reacting. They ask themselves what they truly need in that moment. These subtle changes are meaningful. They mark the growth of resilience.

I have also found it important to help clients see these moments for what they are. Not as regressions, but as opportunities. This is where change begins to deepen. When someone catches themselves repeating an old behavior and chooses even a slightly different response, they are practicing something new. There is also something powerful that happens in these harder moments. Pain and struggle often reveal where care is still needed. They slow things down. They invite both the client and therapist to listen more closely to what is underneath the reaction.

This is where the deeper benefits of pain and suffering begin to emerge. These experiences have the potential to strengthen emotional awareness, deepen empathy, and reconnect a person with their values. Suffering, while never sought out, can become a guide that point to unmet needs, long-held beliefs, or unresolved grief that is asking to be seen. These moments help build presence, not perfection. Setbacks are not the end of healing. They are woven into the work. I have supported my clients in seeing these experiences not as detours, but as part of the path forward.

Healing Can Disrupt Your Relationships—And That’s Okay

As clients begin to heal, their relationships often start to shift. They may stop over-functioning. They may begin setting firmer boundaries or expressing their needs more clearly. Behaviors they once tolerated may no longer feel sustainable. These shifts, while healthy, can create waves. Not everyone in the client’s life will welcome or understand the changes. And that can bring grief, confusion, or even guilt.

Clients may feel lonely even as they move toward what’s best for them. They may grieve connections that once felt familiar, even if those dynamics were rooted in dysfunction or emotional distance. Letting go of old patterns often feels like loss, even when it is progress.

At junctions such as these, it’s important to normalize these growing pains. Healing doesn’t always feel good at the moment. It can challenge long-standing relational roles and bring uncertainty to familiar bonds.

These disruptions also signal movement toward something more grounded, more honest, and more self-respecting. Support clients in recognizing that discomfort in relationships is not a sign of regression and can be a sign of emerging authenticity. Healing doesn’t always preserve the old. Sometimes, it clears space for relationships that are built on emotional safety, mutual care, and respect.

It’s Normal to Feel Tired and Take Breaks of Healing

There have been moments in my clients’ journeys when the work feels like too much. They may grow tired of telling their story, tired of tracking every trigger, tired of examining old wounds. The weight of self-reflection can feel heavy. They might withdraw for a while. Maybe they spend more time scrolling, bury themselves in work, or cancel a session or two. These behaviors are not necessarily resistance. More often, they are signs of fatigue.

It is particularly important to name and normalize this part of the process. Healing is demanding. It takes emotional energy, and it does not always move at a steady pace. Help your clients understand that needing rest is not failure. Taking a break is not giving up. Slowing down does not erase progress. Sometimes the most meaningful work happens when clients step away and give themselves time to integrate what they’ve already uncovered. Growth needs room to breathe. It needs softness and space. When clients return, whether next week or next month, I acknowledge that return. Remind them that showing up, even imperfectly, is still showing up. That, too, is healing.

Clients often come into therapy carrying unspoken pressure. They want to get better quickly, move on from the past, and prove they’re strong by needing less. Some may feel shame for still struggling or frustration that their healing is taking “too long.”

There’s No Deadline for Healing

Therapeutically, it’s important to gently challenge this mindset. There is no prize for speed. No gold star for needing the least amount of help. Healing is not a race, and there is no finish line.

What matters is consistency, not perfection. It’s the willingness to return to work again and again, even after a setback. It’s the slow rebuilding of trust within themselves. I invite my clients to move at a pace that honors their body and nervous system. I help them see that slow progress is still progress. I let them know that taking the time they need is not only acceptable but it is wise. Therapy is not about rushing toward resolution. It is about creating a space where healing can unfold naturally, with patience, care, and room to breathe.

Postscript

If your clients’ healing journeys feel slow, confusing, or filled with setbacks, that doesn’t mean they’re getting it wrong. In fact, it often means they’re doing the hard, necessary work of integrating change. Recovery from trauma is rarely a linear process. It moves in spirals, detours, and pauses because that’s part of what makes it real.

As therapists, we can support this process by holding space for grief, for uncertainty, and for the parts of healing that take time. We can remind our clients that it’s okay to move at their own pace. That healing isn’t measured by speed but by presence, consistency, and the courage to keep showing up.

Nancy Haug on Psychedelic-Assisted Psychotherapy

Posted on by Psychotherapy.net Team
Lawrence Rubin: Hi Nancy, thanks so much for joining us today. You are a professor in the department of psychology at Palo Alto University, and an adjunct clinical professor in the department of psychiatry and behavioral sciences at Stanford University School of Medicine. You have ongoing collaborations with and a teaching role in the Stanford Psychiatry Addiction Medicine Program, where your current research interests include implementation of evidence-based practices in addiction treatment, harm reduction for substance use, cannabis vaping, and psychedelic-assisted psychotherapy. Welcome!
Nancy A. Haug: I would add to that that I do have a small private practice where I treat clients, some for addictive disorders, but I am mostly a generalist.
LR: I didn’t know that you also have a private practice. Do you practice psychedelic assisted psychotherapy?
NH: I do a little bit of that work, but it’s a very small percentage of my clients, and it’s mostly limited to the preparation and integration phases of psychedelic therapy. I’m not doing any kind of administration of psychedelics in my office or in my practice. My clients will get that elsewhere. And then I’ll help them integrate the experience into therapy. We can get more into that later.I’d like to start by acknowledging the indigenous peoples and practices, because many psychedelics are derived from sacred plant medicines that have been used for millennia by many cultures. This isn’t something new, because much of the work we’re doing with psychedelics comes from thousands of years of cultural shamanic traditions.

Psychedelics as Medicine

LR: Thank you for that acknowledgment. I think it’s important that clinicians appreciate the broader cultural and historical context of psychedelic use.So, there are practitioners of psychedelic medicine, and there are practitioners of psychedelic assisted psychotherapy—two distinct but overlapping applications.
NH: Sure. I think the medicine piece would be more in the context of something like Ketamine treatment and/or the administration of psychedelics in a more medicalized setting. Clinical trials are being conducted right now that are looking specifically at psychedelics as medications. But as a psychologist, I’m more focused on the therapy piece which I really believe is an important component. It is about the way that psychedelics can be therapeutic for psychological healing.
LR: much of the work we’re doing with psychedelics comes from thousands of years of cultural shamanic traditionsSo, you might have a client presenting with symptoms of depression or anxiety or trauma going exclusively to a medical professional and receiving one of the psychedelics, but not necessarily being referred to a mental health professional for integration into therapy?
NH: Exactly.
LR: Is there a turf battle between medical and mental health practitioners in the realm of psychedelics over who gets ownership over their use? A battle in which psychotherapy is considered a diminutive form, and the integration of psychedelics into therapy as an encroachment of sorts?
NH: I believe that a lot of the providers of Ketamine treatment would support integration into psychotherapy as part of that workIt depends on who you talk to. We can certainly get into the differences between the various psychedelics, but at this point, there are many clinics where people can receive Ketamine infusions for various conditions that don’t involve psychotherapy. But I believe that a lot of the providers of Ketamine treatment would support integration into psychotherapy as part of that work. I actually work with a psychiatrist who runs a ketamine clinic, and he is always asking me if I’m taking referrals or if I can give him referrals to other therapists. He does have some therapists built into his clinic, but there’s not enough of them to meet the patient needs. So, I think there is recognition that the therapy component is helpful and that it can improve outcomes.
LR: Which chemicals are most often used in this line of research and intervention?
NH: Ketamine was used as an anesthetic in veterinary clinics and given to soldiers in Vietnam in the 1970s as a field anesthetic. It’s also been used off-label for the treatment of refractory depression and suicidality.The classic psychedelics are LSD, psilocybin, DMT, which is dimethyltryptamine, ayahuasca, and mescaline, which comes from the peyote cactus. Of the hallucinogens that have been studied and are in current trials, I would say psilocybin has probably been looked at the most. And then we have MDMA––ecstasy or Molly, methylenedioxymethamphetamine, which is a serotonin, dopamine, or epinephrine agonist, It’s sometimes called empathogen or enactogen, which produces a heightened sense of connectedness or openness. It’s characterized by the person becoming very empathetic and compassionate. MDMA has stimulant properties, but it’s different from classic psychedelics, which affect more perception, cognition, mood, and sense of self.
LR: if someone is going to do this work, it’s very important to be familiar with the different compounds, their effects, and what conditions they’ve been applied toI would think that mental health professionals would really need to know their way around pharmacology to venture into this realm of practice.
NH: I really agree that if someone is going to do this work, it’s very important to be familiar with the different compounds, their effects, and what conditions they’ve been applied to—just knowing the research. Most training programs for therapists who are interested in integrating psychedelics into their work will include the history of psychedelics, and then there’s always a psychopharmacology piece that is addressed. I don’t really endorse one or the other training programs, but I think most of the established ones are pretty good. Psychedelics are classified as Schedule I drugs by the FDA, meaning they do not have an accepted medical use.Some states, including Oregon and Colorado, have initiatives supporting psilocybin use in therapy, but they do require therapists to go through training programs. I think they get certified or licensed somehow as being psychedelic providers, which I think is a good thing—just to put some controls around it. And this isn’t just limited to psychologists. Anyone who’s a licensed therapist can do this work and can get training. That includes licensed marriage and family therapists, and clinical counselors.
LR: Is there a national certification that is available, or is it currently a state-by-state affair?
NH: Not that I’m aware of. I think a lot of the training programs developed in the context of clinical trials, and now pharmaceutical companies that are doing drug development, like Compass Therapeutics, have developed their own kind of training protocols for doing this work, and there are a few manuals, like Deliberate Practice in Psychedelic Assisted Therapy, which is one of the volumes in APA’s Essentials of Deliberate Practice series.

Integrating Psychedelics into Psychotherapy

LR: Is there a standard definition of psychedelic assisted psychotherapy?
NH: psychedelic medicine may or may not involve therapy as it’s more focused on the administration of the psychedelic. I do have a definition of psychedelic assisted psychotherapy that I like to use which I pulled together for a presentation with one of my colleagues. Psychedelic assisted psychotherapy is a clinical intervention that combines preparation, psychedelic administration, and integration of experiences to facilitate psychological healing in the context of a therapeutic environment.All of these pieces are important components of psychedelic assisted psychotherapy. There’s also an umbrella term called psychedelic medicine, which you’ll also hear a lot, and that I simply define as applications of psychedelics or hallucinogenic drugs to the treatment of psychological conditions or psychiatric disorders. Psychedelic medicine may or may not involve therapy as it’s more focused on the administration of the psychedelic drugs. But I know you wanted to talk about the therapy piece.
LR: Am I correct in assuming that there are randomized controlled trial studies comparing psychological treatment with Ketamine alone and psychotherapy with a psychedelic?
NH: We’re still in the early stages of this work. There was a review paper that came out recently looking at the different types of therapy that have been implemented, but there’s not a gold standard at this point.
LR: if I’m going to do this work, I’m working closely with a physician or a psychiatrist who’s administering the medication in a controlled settingWould a psychologist need prescription privileges if they wanted to use psychedelics independent of a licensed physician?
NH: I don’t think that would really be part of our domain as psychologists. Our role is to provide the therapy! It’s important to work with other providers, so if I’m going to do this work, I’m working closely with a physician or a psychiatrist who’s administering the medication in a controlled setting. There is a treatment model where the patient will be prescribed sublingual Ketamine lozenges that they can take at home and then work with a psychologist or licensed clinician to do the therapy.
LR: I don’t know anything about half-lives of the various psychedelics, but must the client be in an active substance-induced state, and how do you know if they are?
NH: I think again it depends on which psychedelic medicine and on the particular model of treatment. With the IV Ketamine infusion, the person typically isn’t conscious, so you couldn’t really be doing the therapy while they’re under the influence. But you could afterwards, because there’s research suggesting that because of the brain’s plasticity after psychedelics, the patient may be more receptive to therapy within 24 to 48 hours after they’ve ingested the medication.Like I said, we really don’t have a gold standard. And I think there’s been some challenges in disentangling the effects of the psychedelic drugs from the therapy itself. Some trials have tried to incorporate evidence-based treatments like Cognitive Behavioral Therapy or Acceptance and Commitment Therapy. There is some evidence that this might promote better clinical outcomes. I think ACT specifically, and mindfulness therapies lend themselves really well as interventions because of the psychic or psychological flexibility that they target. So, combining that with the psychedelic might create synergistic effects. But again, we haven’t standardized it, so it’s really hard to even compare across studies. You asked earlier what I thought the mechanism of action was, so I did want to say that we really think that it’s a result of the interaction between the medicine, the therapeutic setting, and the mindset of the participant. People might take psychedelics like ecstasy at a rave, or mushrooms at a festival; but that doesn’t necessarily lead to them being cured of their trauma or depression. Because it’s a different setting that is not necessarily a therapeutic context, they don’t have a guide with them really exploring underlying processes. We really want to help the patient become clear about their intention, such as addressing their fixed beliefs or getting more in touch with certain emotions. The therapy can help loosen some of that up, which will allow for greater flexibility.
LR: there’s been some challenges in disentangling the effects of the psychedelic drugs from the therapy itselfWhat do you hope to tap into or capitalize on when applying psychedelic assisted psychotherapy?
NH: I think it’s different for each patient and depends on what they are coming in with. Are they coming in with an unresolved trauma? Are they coming in with existential depression? I try to determine where they’re stuck and what it is that they’re trying to get insight about. And if they have cognitive expectancies, which refers to what they expect might happen during the psychedelic experience, or their mindset. And that does require some preparation work.One of the things I would want to be clear about with my patients is what they are looking for and not overselling this therapy as a magic bullet or that they’re going to be cured of their depression. That’s not how it works, and so I would actually be hesitant to do this work with someone who came with the notion that psychedelic therapy is the end all, be all, and that they’re going to be fixed. That’s probably not going to be helpful for them. I might even want to temper those expectations by providing a more realistic picture of what could happen, which starts to get into some of the ethical issues around this, particularly with informed consent, because we don’t know what’s going to happen. How do we obtain informed consent when we can’t even explain the psychedelic experience? I can’t tell what’s going to come up, and sometimes there are even personality changes where the person becomes more open or has altered metaphysical beliefs. So, it’s important to provide a lot of education and information about what could happen, including some of the subjective effects. There are just so many possible outcomes.
LR: one of the things I would want to be clear about with my patients is what they are looking for and not overselling this therapy as a magic bulletIs there any solid research about how the brain actually changes under the influence of psychedelics that make it easier for the clinician to access conflicts, or to get through resistance, or for the clinician to more directly intervene on a particular issue? In other words, is there anything proven about what happens in the brain that allows for that?
NH: Absolutely. Psychedelics enhance neural plasticity. One model that’s been put forth is the REBUS model by Robin Carhart-Harris, which is about relaxed beliefs under psychedelics. The idea is that the psychedelics relax what they call priors, or prior beliefs, or assumptions to allow bottom-up processing in which information flows more freely, where the mind can really open. Psychedelics have also been referred to as “disruptive psychopharmacology” because they disrupt boundaries among brain networks, allowing for greater communication across the whole brain.Psychedelics are also considered nonspecific amplifiers of human experience. In other words, whatever the person is going into the experience with – their particular mindset and setting – is going to be amplified during the psychedelic-induced state of consciousness.
LR: one model that’s been put forth is the REBUS model by Robin Carhart-Harris, which is about relaxed beliefs under psychedelicsHave there been any randomized controlled trial studies involving the use of placebos?
NH: It’s really hard to come up with a placebo that is comparable to psychedelics because people usually know when they’ve been given a placebo. That’s actually been one of the most difficult pieces of doing this research is that we can’t actually blind people. I know with some of the Ketamine studies they’ve tried to use Midazolam, which is a benzodiazepine. Usually, people know the difference.
LR: Circling back a bit; you mentioned that ACT lends itself particularly well to psychedelic integration.
NH: I think that because ACT emphasizes mindfulness, anything–psychedelics in this instance– that allows for fuller contact in the present moment, can help the client more fully and deeply navigate the therapeutic experience including any states that may arise. As another example, I believe they’ve used Internal Family Systems model in the MAPS (Multidisciplinary Association for Psychedelic Studies) trainings; and while I’m not trained in IFS, some people report that it’s useful because it helps the person look at different parts of themselves that they might not otherwise.In general, I would say that the therapy that occurs while the person is under the influence of the psychedelic tends to be more nondirective. In this context, the clinician and the client can respond in the moment to what is coming up. If the clinician is using a somatic tool or some other type of cognitive reprocessing, you don’t want to try to direct them in a particular way. It is important that the client’s inner wisdom, rather than the clinician or any particular technique, be the guide.
LR: it is important that the client’s inner wisdom, rather than the clinician or any particular technique, be the guideYou describe the presence of the psychedelic drug or experience as a co-therapist; a therapeutic ally or resource. The disinhibiting or loosening helps the person to get more in touch with their somatic experience. Whatever intervention you use may be enhanced, accelerated, or deepened. So, the therapist is a facilitator or guide.
NH: Exactly! You’re a facilitator or guide. In the MDMA trials through the MAPS program, they actually have two therapists, male and female. They have various reasons for doing it that way, one of which is perhaps to facilitate projection that could take place as the client reflects on their relational experiences. But it gets very expensive to have two therapists in the room for eight hours doing this work. I’m not sure how they could scale that.
LR: we have a lot of evidence that MDMA really does work with veterans who have been in combat; but also with survivors of sexual abuse and traumaYou mentioned that Ketamine has been successfully used for clients with depression. Do you have a sense of what the mechanism of action is in this case as well as with PTSD?
NH: Typically, MDMA is going to be the psychedelic of choice for PTSD. My understanding is that it promotes emotional processing, and reprocessing of the memories in a way that the person feels safe, less threatened by the memories or the images which allows to experience a deeper contact with those emotions or memories so can work through them.We have a lot of evidence that MDMA really does work with veterans who have been in combat; but also with survivors of sexual abuse and trauma. MDMA was recently reviewed for approval by the FDA but was rejected for various reasons including lack of supportive research. It’s hard to quantify and standardize psychedelic therapy, and since the FDA is not in the business of approving therapies, more research will have to be done. I do know that this outcome was very disappointing to the psychedelic community because we’ve been working hard at this for a long time and thought there was sufficient evidence, especially with PTSD, where clients with PTSD improve more with MDMA than with other behavioral therapies.
LR: I’ve seen an acceleration in progress for those clients who try psychedelic therapiesSince you spoke earlier about the role of client expectancy in treatment outcome, I’m wondering if you’ve noticed a difference in your own therapeutic presence or expectancy when doing psychedelic assisted therapy?
NH: I think I am more optimistic because I’ve seen clients who’ve really benefited from this work. I am hopeful that they will have breakthroughs because I’ve seen an acceleration in progress for those clients who try psychedelic therapies. They kind of get to the heart of their issues and dig into the meat of where they’re stuck a lot faster than they would with regular psychotherapy. I try to go in without any expectations and just let it unfold like I have no idea what’s going to happen.
LR: There’s so much research these days comparing the efficacy of various therapies, but I wonder how much emphasis you place on the role of the relationship in therapy outcome, especially when psychedelics enter the frame? Are you a technique-oriented person or relationship-oriented person, if such a simple binary even makes sense?
NH: I think I would call myself both, but it’s a really interesting question. I recently had an expert speaker come into my class to talk about CBT for addiction. He was talking about how we have all of these branded therapies, but that all good therapy really comes down to common factors and the therapeutic alliance. We need to foster a sense of safety and trust with clients, irrespective of intervention. In using psychedelics, a lot of fear can emerge, so they really need that safe space, which is where the therapeutic relationship becomes all the more important.

A Few Challenging Issues

LR: I’d like to circle back to the beginning of our conversation where you mentioned the importance of psychedelics with indigenous cultures. I don’t know the extent to which indigenous people reach out to traditional [white] therapists, but is there research on the use of psychedelic assisted psychotherapy within specific cultures?
NH: I don’t know that we’ve done enough of this. There’s a movement to try to be more inclusive, particularly in developing our approaches by consulting with indigenous communities. MAPS was doing some training to be more inclusive of therapists and clients of color. There was a paper published suggesting there are very few therapists of color or researchers in the field who are doing this work, so there’s definitely a need for more of this. We do know that MDMA and other psychedelics can be helpful for racialized trauma. Monnica Williams has done some of this important work.I have a student who did a dissertation on this topic where she interviewed clinicians in the community who were administering psychedelic assisted therapy. She asked them about motivations and workplace values in serving diverse communities. She had therapists of color and from marginalized groups, including one indigenous therapist. It was a qualitative study, and she had some interesting findings around the values that were being incorporated into their training, their identities, and then in their work with clients, and how countertransference reactions came into play. We definitely need to do more of this kind of research and perhaps even studies that look at therapy performed by clinicians who are given the option to use psychedelics like Ketamine so they can understand what the experience is like, although there would be challenging legal parameters there, especially around some of the Schedule I psychedelics.
LR: we do know that MDMA and other psychedelics can be helpful for racialized traumaAre there any counter indications for the use of psychedelics in psychotherapy?
NH: Absolutely! I would say clients who experience depersonalization, derealization, and intense existential struggles. There can be personality changes and long-term negative effects. I think it’s a small percentage, but there’s always a risk. I would say the same risks you would have with other medications and with therapy, right? There’s a percentage of people that can be harmed in some way, or for whom it can make their symptoms worse. It’s not going to be a positive experience for everyone.I think particularly along the lines of existential struggles. Some people might even encounter a higher consciousness or spiritual or mystical experiences that they weren’t expecting which can be disturbing. A person’s outlook on the world can change or they can wind up with a totally different perspective. For some people, that can be helpful, especially around end of life anxiety, where they can begin to feel more connected and safer around their own death. But sometimes, people can feel like they’ve died when using psychedelics, and that can be very unsettling. It can take a long time to integrate these kinds of experiences and to process things they didn’t necessarily want to see.
LR: some people might even encounter a higher consciousness or spiritual or mystical experiences that they weren’t expecting which can be disturbingSort of seeing someone for good old cognitive behavioral therapy and ending up at some existential cliff, looking at an abyss that they didn’t anticipate.
NH: Exactly! There’s another model I wanted to mention called the FIBUS model, or the False Insights and Beliefs Under Psychedelics. We know that psychedelics can promote therapeutic insights, but a person may experience misleading beliefs and insights that feel like they’re profound and true but might actually not be. So, one role of a therapist would be to help guide them in distinguishing what’s helpful, what’s harmful, what’s real, and what’s not.
LR: In that vein, I can see that psychedelics might not be useful with clients experiencing dissociative disorders, delusions, or cognitive impairment where they can’t rely on their own cognitive processing.
NH: Right, right! So, this isn’t for everybody. I think the clinical trials have done a really good job screening people by using strict inclusion and exclusion criteria. But in clinical practice, we could do a better job at looking at who might and who might not benefit from this, such as a person with a history of serious mental illness like schizophrenia or bipolar disorder.
LR: Are there any particular resources that you would direct readers to if they wanted to learn more about psychedelic assisted psychotherapy.
NH: There are some professional practice guidelines for psychedelic assisted therapy, like the American Psychedelic Practitioners Association and the Ketamine Research Foundation. There was also a paper published on ethical guidelines for Ketamine clinicians. I know the VA provides Ketamine therapy for treatment resistant depression in some of the Ketamine clinics they’ve set up where they have established protocols. Yale University has a program for psychedelic science and published an article on the use of ACT with psychedelics. But, I would say the training piece is always of critical importance.
LR: many of my students come into the program really clear that they want to be psyche

Insight into the Clinical Challenges of Adoption

Posted on by Psychotherapy.net Team

What does it mean to truly embrace the journey of families made by adoption? This question has both intense personal and professional significance for me. I am both an adoptive parent of BIPOC children and a play therapist who has taken the journey with many adoptive families as my practice has moved into the worlds of complex trauma and attachment issues. Adoption has long been seen as a solution—the miracle, that solves the problem of child abuse, neglect, and abandonment. During the era in which my husband and I were building a family, it was our solution to pregnancy loss and challenges to fertility. The miracle version of the story has inspirational, even profoundly spiritual overtones in many families. The idea of bringing together caring adults who want to be parents with children who have lost the care of their first parents through some version of tragedy and harm is an inspirational narrative. To the degree that it replaced the secrecy and shame of earlier decades’ approach to child placement and adoption, or overtaxed, harmful group institutional care, it represents a significant step forward in the lives of children and families.

Beyond Happily Ever After

Despite being a child mental health professional, I was not well prepared as a parent for the “what’s next” part of the adoption journey. However, neither was I alone. Many of the families that I have come to work with over the years have struggled to balance their own “miracle” language with the realities of the trauma and attachment loss for the child, even when placement and adoption occur early in life, before the so-called “age of memory.”

Thanks to Bessel van der Kolk and others, we are increasingly aware of the importance of somatic memories built implicitly in the earliest months of life, even in utero. When the preverbal or early in life trauma experiences compound with attachment loss and disruption, it make the realities of emotional and behavioral regulation deeply challenging. Parents, like myself, struggle to respond adequately to a day-to-day reality quite different from “the happily ever” after version of the adoption miracle story.

In this space, a trauma and attachment-focused play therapist who enters the family system can have such a profound impact. We have to be ready to challenge the miracle narrative and, in its place, use the best clinical tools we have to help the child feel supported in the unfolding of their own true and three-dimensional story. This story includes a recognition of the emotional, and often cultural, dislocation and disruption that is at the core of this adopted child’s life journey.

It also must address an understanding of the messages from the most fragmented parts of the self that are communicated through the body. Attempts to deny, dress up, or over-soothe these losses and disruptions can land badly. When loss and adversity are left unprocessed and unresolved, this can lead to the intense emotional dysregulation some children display, and for others, can lead to a ticking time bomb for a crisis of worthiness, belonging, and the capacity to form deeply satisfying attachments over the life span.

For children with multiple disruptions as they moved through the foster care system, the complicated wounds to their attachment exact a painful and complex cost, as there are so many missed opportunities for adults to keep their part of the attachment bargain—that every little human born into the world deserves to have their basic needs met, to be enjoyed and nurtured. By the time the adoption happens, these forever caregivers may have a lot to prove and the negative energy they get from the child is the cumulative effect of others’ failures.

Many of my clients’ parents with whom I’ve worked have despaired that their efforts to connect with, and shape, the behavior of their dysregulated and insecurely attached adoptive child(ren) are met with rage and rejection, instead of responsiveness. Often, I have felt those impulses as well, during struggles to make the child’s response make sense in a cause-and-effect, logical consequence version of the parent-child relationship. For a child who missed out on the basic building blocks of the serve and return part of secure attachment, consequences are perceived as threats, and may work to grow the most defensive and rageful parts of the child’ personality.

A Layer Cake Metaphor for Adoption-Based Therapy

One of the attachment concepts I find so useful in these moments is based on the notion of mentalization, and the ability of caregivers to create and sustain an attuned mental map of what is going on inside the child. Peter Fonagy and others have been writing for many years about mentalization and the impact on reflective functioning in the attachment between parents and children. In my own experiences, I have come to realize that clinging to the “miracle” narrative can sabotage mentalization.

Why does this happen? So often the impulse to spare children the hard parts of their own story or soothe away uncomfortable information leads to a real phobia of their own child’s distress and the resulting failure of mentalization. The answer to this challenge is for therapist—and the adoptive parent—to help the child make sense of their story, including the hard parts; expand the family system’s capacity to hold the distress without minimizing it, and do this work with the parent as an active participant, with support from the therapist.

In attempting to teach a group of clinicians about weaving together of all the things that seem important in therapy with families, I came up with the metaphor of the layer cake. Play therapy, trauma/attachment work, dissociation theory/parts work and family therapy are all a part of this multi-layered work, even as we try to help our clients eat the “whole thing,” bite by bite.

I think of my work with a child who was adopted from an orphanage in the developing world as a preschooler, and the complicated, but beautiful layers of how the therapy unfolded for him a few years after his adoption in the US.

Play Therapy Layers

Like many children, offering open and child-centered play in the playroom, led to the emergence of post traumatic play narratives, giving clues or hints to the preverbal experiences. One example was many narratives around characters fighting over scarce resources, as well as abandonment stories played out with dinosaurs, video game characters, and superheroes.

Dissociation/Parts-Work Layer

Dissociation is the infant/child’s solution to the unbearable threat of betrayal by the original caregiver whether through overt abuse, neglect, sexual exploitation, or attachment loss. To fragment and isolate that chain of painful associations and emotional/somatic stress is a very adaptive way to cope. By the time this child entered therapy, these dissociative patterns had resulted in some fragmentation, including rageful episodes and “baby” parts who were almost incapable of receiving soothing from the parent. The parent admitted to a lot of dysregulation herself in the early months after placement and compounded the effect with threats, yelling, spanking. It was clear that we needed to playfully befriend these dissociated parts through some expressive work. Using a lot of drawing and flexible sand tray creations, we involved the parent experientially in play scenarios apologizing to the hurt parts of the child that she had frightened.

The EMDR/Trauma Protocols Layers
Bridging from trauma content held implicitly in play into first person narrative work, while staying grounded in the present is a tricky business. I used a flexible and playful approach to adding EMDR processing in the playroom for short periods, especially when the adoptive parent was able to support and bear witness to that work. This often served an additional purpose of shifting angry and embittered caregivers into empowered and compassionate ones.

As they come to see their child’s story through their eyes, it increased their reflective capacity and attunement. This parent struggled at times with her own impulse to soothe—she and I talked of her desire to “put a bow on it” and keep the child from feeling the intensity of his losses and rejection as he grew older, and became more aware by following my lead in the playful EMDR sessions.

Anti-Racist, Anti-Bias Icing on the Cake

This is an area of great challenge for adoptive parents who may have limited experience with the day-to-day realities of being Black or Brown, especially in the White majority spaces where many adoptive kids are growing up. In this case, the parent had really minimized the impact of cultural dislocation for her child, but as I insisted on broaching the subject directly, we discovered a lot of distress for him around looking different from her, navigating racial/cultural groups of peers, and as we began to work through the hard parts of his own story, anger at the birth country for “throwing away children” arose.

Permission to feel big feelings was needed throughout that work, and collateral work with the parent on her own biases and perceived need to soothe and minimize these experiences of microaggressions was crucial. Given the polarization and negative narratives in the wider culture, this work will likely be ongoing throughout his development, but the work so far has helped them both to have a framework in which to stick together, and build the parent’s capacity to move past the “miracle” of coming together into the power of growing together through adversity.

***

As my own children have moved from adolescence into young adulthood, I continue to marvel at how unfolding layers and the expanding capacity hold the hardest parts of their stories. I never cease to be humbled by my own invitation to that process, in my own family, as well as in my psychotherapy work, and even the potential to act in a wider culture that needs that capacity now more than ever.

Redefining Strength: A Black Woman’s Journey to Healing

Posted on by Psychotherapy.net Team

Redefining Strength: A Black Woman’s Journey to Healing

Kayla sat in my office with her arms crossed against her chest—a familiar shield against the world. At 23, she had grown accustomed to protecting herself, whether necessary or not. She avoided eye contact with me like the plague, guarding herself as hard as possible. “I don’t even know what I’m doing here,” she said, her eyes fixed on the floor. “This is so awkward.”

“That’s normal,” I said.

As a therapist, I have heard many clients share that they are unsure of what has led them to therapy. What was always different for me was tonality. I have heard people voice uncertainty about therapy with anger and even sadness. Kayla’s voice was filled with exhaustion.

“I feel so out of control as of late. I feel like I’m in a loop of the worst days of my life. I go to sleep thinking about my mistakes. I always wake up feeling worse than I did the day before. I’m eating and spending like crazy. I’m so tired.”

Kayla’s specific wording and my clinical judgment led me to believe there was more behind what she shared. So, I asked her, “What is weighing on you?”

Kayla burst into tears, and for the first time, she looked into my eyes, hers filled with anger and sorrow. “My mom died! I finally tell her how much I hate her, and she dies!” Kayla sobbed as her words lingered in the air. It had been a year since her mother passed, but as we know, there is no time limit on grief. Grief moves at its own pace and intensity. For Kayla, grief was feeding off her deep-rooted trauma.

“I keep replaying that argument with her over and over. Maybe what I said caused her too much heartbreak. Maybe she’d still be here if I had kept things unspoken.”

I leaned forward slightly.

“Kayla, your mother’s passing is not your fault.”

Kayla shook her head as tears continued to roll.

“Then why does it feel like it is?”

A Childhood Built on Survival

Kayla’s childhood was a lesson in what love wasn’t. She realized early on that her mother was not like the mothers she saw on television who supported their children and told them they loved them at the very least.

“My mom wasn’t like Clair Huxtable or anything. I didn’t get hugs or life lessons. She just wasn’t that kind of woman,” Kayla said. “I can’t recall her ever saying she was proud of me. When I would make good grades or clean my room, she would say,‘That’s what you supposed to do.’”

For Kayla, affection was nonexistent, validation was rare, and she never felt safe displaying anything other than strength. Kayla felt sympathy for her mother as she knew her mother faced hardships as a child herself. Kayla’s grandmother shaped her mother into the woman who raised her—distant and emotionally unavailable.

Over time, Kayla began to convince herself that she was the one who needed to change.

“I just stopped asking for things that she couldn’t give me. I consoled myself. I taught myself. I protected myself. I didn’t want to rock the boat with her because she was always extremely irritable. It annoyed her whenever I was in need, so I stopped needing her.”

By age ten, Kayla had perfected the art of being invisible. She didn’t ask her mom for love. She didn’t ask for affection. She didn’t ask for help. In turn, she saved herself from disappointment.

The “Strong Black Woman”

Kayla’s experience growing up was a complex one due to the emotional neglect and also the unwritten rules of what it takes to be a Black woman (1). She grew up being told to be strong and keep going no matter what. There was not enough room for anything else. Kayla comes from a family of Black women who embodied these qualities as armor against the world. Growing up in a space that offered little empathy to Black women, Kayla’s mother taught her how to survive, and that was her act of love.

“She used to tell me that if I think anyone cares about me crying, then I have a lot to learn,” Kayla stated angrily. “Like crying made you weak or something. In a way, she was right. I had to make sure people knew I was nothing to mess with!”Even after Kayla’s mother died, she felt like she had no space to grieve. “My aunt told me everything happens for a reason, and we can’t spend time crying. So, you mean to tell me I can’t have time to be sad about my mom’s passing? Even in death, do I have to push on? That’s a lot for anyone. If my family knew I was here, they would wonder why. After everything I have endured, they would still wonder why. Because we don’t do this.”

In addition to her trauma and grief, Kayla was struggling with knowing that she needed help but feeling uncomfortable while seeking it. There has been an undeniable stigma in the Black community when it comes to mental health. As a Black woman myself, I resonated deeply with her.

“My aunt would probably be like girl, you need to talk to God, and not no therapist! Talk to God, and you will be all right. Like I haven’t been talking to God. Talking to you is my last hope at this point.”

Kayla was plagued by wondering if she should even be here as a Black woman and also hoping that therapy would “work” for her.

“You know you can do both, right?” I asked. “You can talk to God and spend time in therapy.” Kayla arched her eyebrows as if she were in deep thought. I continued, “James 2:14 says, ‘Faith without works is dead.’ Kayla, you are doing the work right now.”

“Wow, I’ve never thought about it like that,” she smirked. “I like that!”

Naming the Wounds and Breaking the Cycle

Kayala learned to survive from an early age, and her defensive tactics served her well. Now, it was time for her to thrive. I discussed clinical diagnoses with her, and her mood instantly changed. I could tell she was not fond of labels.

“What is Post Traumatic Stress Disorder and Borderline Personality Disorder? Are you saying I’m crazy?” she asked, irritated.

“Absolutely not!” I said sternly. I swiftly disputed Kayla’s thoughts so she didn’t disengage with me. “A diagnosis is not about calling you crazy; it’s about creating a roadmap. Knowing your diagnosis helps us understand what’s wrong and how we can fix it.” I continued while I still had her attention, “Right now, your mind still seems to think that you are in danger, and it is responding accordingly. Kayla, you are safe now, but your experiences in life have wired your brain into a constant state of fear. When this happens to us, it is hard to regulate our emotions or trust new people because that is not a priority; safety is. That is why we are looking at Post Traumatic Stress Disorder or PTSD. We need to look at the research for what has been proven to work with your symptoms.” (2)

Kayla’s jaw tightened, but I saw a flicker of understanding.

I continued. “Now, some traits of Borderline Personality Disorder or BPD concern me. Again, this does not mean that there is something wrong with you. It simply means that something happened to you that is causing patterns similar to BPD to arise in your personality.”

Kayla previously reported mood swings, fear of abandonment, and impulsive choices that she wished to cease. I wanted her to understand that these symptoms made sense when one has endured the trauma that she has. Giving it a name only serves as a guide to addressing her symptoms.

“But here is the most important thing,” I said. “None of these things mean you’re crazy. They mean your brain did what it had to do to survive. And now, we’ll teach it a new way of looking at life.”

She nodded slowly. This time, she was really hearing me.

The Work: Using DBT to Rebuild Control

Kayla discussed feeling out of control when she first sat on my couch. She said she was tired and had exhausted all options. She wanted to feel different. Therefore, we had to try something different. Kayla was stuck in a cycle of emotional dysregulation, intrusive thoughts, and impulsive behaviors—trying to numb a pain that never seemed to dull. As a result of her trauma and grief, she had become avoidant. She had cut off her family in an attempt to forget her past and her unfavorable memories of her mother. She had also distanced herself from friends, convincing herself that being alone was the safest way to be. However, the isolation only compounded her sadness.

“I like to be alone. I don’t have to worry about anything…or anyone,” she said.

It was clear that avoidance had become a comforting survival mechanism for her, blocking her pathway to healing by dismissing the very things she needed to address. That is why Dialectical Behavior Therapy (DBT) was the chosen approach for Kayla—she didn’t just need to talk about her pain; she required structure. She was new to managing her emotions and grasping concepts of healthy communication. As someone who always “just dealt with it,” Kayla needed practical tools to help her regulate her emotions, tolerate distress, and rebuild her broken relationships with family and friends (3). DBT would allow Kayla to accept her past and present circumstances while learning tangible ways to help her approach her overwhelming emotions less detrimentally.

Kayla’s case and the use of DBT demonstrate its flexibility beyond its original purpose for borderline personality disorder for managing trauma and grief as well. Unlike traditional talk therapy, DBT provides tangible solutions to change. It was designed for people like Kayla—individuals who felt emotions so intensely that they often became destructive. With some culturally adapted tweaks, I knew DBT would be life-changing for her.

DBT Treatment Sessions: A Step-by-Step Process

Reframing Emotional Regulation Through Radical Acceptance

“So, what? I just breathe through my feelings? That’s not gonna do anything,” she snapped when I introduced emotional regulation techniques. Kayla came to therapy with the belief that any emotions outside of anger made her weak. She had been taught to be a strong Black woman. For her, that, unfortunately, meant suppressing pain and keeping her composure no matter what she faced—crying, asking for help, or expressing vulnerability felt like weakness. Regulating emotions meant giving in and giving up. We needed to reframe that thinking. I knew I had to introduce something concrete that would challenge this belief in a way that made sense to her lived experience.

That’s when I introduced Radical Acceptance.

“To radically accept something means acknowledging our reality no matter how much it hurts. It doesn’t mean you like it. It doesn’t mean it was fair. It simply means it happened and is out of our control.”

She narrowed her eyes.

“So, I just roll over and accept what happened to me? That sounds like letting people run over me.”

“It’s the opposite,” I assured her. “It means you stop wasting energy on what has happened and can’t be changed, then you can focus on healing and moving forward.”

We practiced this with a powerful exercise. I asked Kayla to create two different lists. On the first, I asked her to list everything she wished had been different. On the second, I asked her to write down the reality of what happened. Kayla hesitated, as if putting the truth into words would finally make things real for her. But eventually, she did it.

When she finished, I asked, “Which one is true?” She looked at them for a long time before responding.

“The second one.”

“And which one are you living in?”

She tearfully stated, “the first one.”

“That’s why it hurts so much.”

There was silence. I saw Kayla arch her brows again, as she always does when thinking.

“I guess I can’t change the past, huh? Being angry about it isn’t going to change it for me, either. I need to focus on what I want to be different now and make a plan to change my now.”

Managing Impulsivity Through Distress Tolerance

In our next session. I wanted to focus on Kayla’s binge eating and spending. These weren’t random actions. They were her mind’s way of coping with her trauma and grief. These behaviors were a quick way for Kayla to feel something other than discomfort, if only for a brief time.

“I don’t think—I just do it,” she admitted when we explored her excessive spending and binge eating.

I introduced distress tolerance skills to teach Kayla to sit with her uncomfortable feelings. One of the most valuable techniques for this was the STOP Method:

  • Stop – Pause before you react.
  • Take a step back – Create space to think before deciding.
  • Observe – Notice your emotions without judgment.
  • Proceed mindfully – Act with awareness.

At first, she was skeptical about being able to control her urges. But then, one evening, I received a text from her: “I almost spent $500 online on something silly, but I stepped away from my phone and did that STOP thing instead. So… yay, I guess.”

It was a small victory for Kayla but a critically important one. Over time, she began to master interrupting her impulsive urges. We were replacing her self-destructive behaviors with healthy coping skills.

Processing Trauma Through Mindfulness & Exposure Our next session was challenging as we addressed Kayla’s most potent and longest-held form of self-protection; we addressed her avoidance. I felt that Kayla had enough coping skills at this point to start to touch on some of her trauma that impacts her today. She shut down and cut off anyone who was a reminder of her trauma, further isolating herself and feeding her negative behaviors.

“I just don’t have time to think about any of that stuff. It feels bad,” she told me once.

But avoidance doesn’t erase trauma—it only buries it deeper.

I introduced mindfulness-based exposure therapy, where she slowly confronted the memories she had been running from. We spent half of one session just looking at a picture of her mother and addressing the emotions that rose from that. Eventually, we reached a point where Kayla was listening to an old voicemail her mother had left her shortly before her passing. Her mother called to check on her as she had not seen her since their argument. Kayla’s hands began to tremble; her breathing became shallow.

“This hurts me so much,” she whispered.

I nodded.

“I know. Just go with it.”

As she let the tears roll, she didn’t dissociate. She sat in how she felt. That was a breakthrough!

Breakthrough Session: Onward to Healing

Months into therapy, Kayla no longer felt like she was spinning out of control.

“I still have my bad days,” she sighed. “But I don’t feel like I can’t do anything about it anymore.”

Her progress was never about curing her pain. It was about living with it more healthily. She was still grieving, still processing, only this time around, she had the tools to cope. As she stood up to leave our session today, she paused. “You know,” she said, “I think my mom would’ve liked you.”

I smiled, and said, “I think she would’ve liked you too.”

Kayla walked out of my office that day, not healed, but healing. For now, that was enough.

Reflections from the Therapist’s Perspective

My experience with Kayla has grown me in ways no training or manual could. After some time sitting across from her, I realized that I was doing much more than simply applying interventions to an issue. What I was providing Kayla was a safe space. As big as the world is, many people do not have the space to be truly vulnerable and seen in their pain. In that space, it was not about how much I knew academically, but how deeply I could listen, be present, and make it safe for her to unravel.

Therapy is often misunderstood as something people do to “fix” an issue. However, healing does not come from quick fixes. Healing comes from connection when I can help carry the weight someone shouldered alone for far too long. Kayla reminded me that everything I do matters. My patience, validation, and commitment to her healing mattered so much. These small and consistent actions are the most powerful tools a therapist can implement during therapy. Most importantly, I learned I cannot validate what I do not acknowledge.

Kayla’s life experiences, beliefs, and values all stemmed from her upbringing. They stemmed from her identity as a Black woman in her home and the world. As a Black woman myself, I resonated deeply with the themes around mental health that Kayla had come to know as truth. As a Black therapist, I am even more grounded in my belief that therapy must make space for cultural humility and the intersectionality of the people we sit across from. Their identity, history, and experiences make them unique. That said, we must see our clients for all that they are.

References

(1) Carter, L., & Rossi, A. (2021). Embodying strength: The origin, representations, and socialization of the strong Black woman ideal and its effect on Black women’s mental health. In WE matter! (pp. 43–54). Routledge.

(2) Bremner, J. D., & Wittbrodt, M. T. (2020). Stress, the brain, and trauma spectrum disorders. International review of neurobiology, 152, 1-22.

(3) Prillinger, K., Goreis, A., Macura, S., Hajek Gross, C., Lozar, A., Fanninger, S., … Kothgassner, O. D. (2024). A systematic review and meta-analysis on the efficacy of dialectical behavior therapy variants for the treatment of post-traumatic stress disorder. European Journal of Psychotraumatology, 15(1), 2406662.

A Therapist’s Guide to Breaking Free from Impostor Syndrome

Posted on by Psychotherapy.net Team

Two years ago, I released a song called Imposters, which explored my feeling of not belonging, especially in relationships. Fast forward to today, and I find myself still wrestling with the same theme. However, my perspective has evolved. I am no longer speaking just as a musician, but also as a therapist, a writer, and a human being actively living through this experience.

The Evolution of an Imposter

What exactly is imposter syndrome? The dictionary defines it as “the persistent feeling of not deserving one’s success and of being a fraud despite a history of accomplishments.” With that definition in mind, it is important to ask: why is this experience so seemingly common? Is it because we live in a world where personal successes are only validated when they align with rigid societal standards? Or is it because we are so emotionally, mentally, and spiritually undernourished that we struggle to affirm ourselves, making it almost impossible to acknowledge our growth, even when it is right in front of us? Over the past year and a half, these questions have become personal; I turned 30, became a business owner, assumed the role of lead psychotherapist in my mental health practice, and launched a podcast called Do We Have Your Attention? (shameless plug—go listen). On paper, it appears that I am thriving. In reality, much of this growth has felt out of my control. It was during this significant transitional phase that imposter syndrome resurfaced more intensely than ever before. Despite having extensive training from one of the top clinical training programs in the country, a license to practice, and a growing business, I found myself doubting my competence. The number of accomplishments did not seem to matter; when the feeling of unworthiness sets in, it can easily overshadow everything. This brought me to a deeper and more critical question: how do we measure worthiness? To truly understand imposter syndrome, I feel compelled to examine the standards against which we compare ourselves. Isaac Prilleltensky describes worthiness as the feeling of being valued and the ability to give value to oneself and others. Based on that definition, I should undoubtedly feel worthy. After all, I have dedicated my life to helping others heal and thrive. Yet, despite these tangible contributions, the voice of self-doubt has persisted, highlighting the disconnect between external achievements and internal validation. Why, after reaching these professional milestones, was the voice of my imposter syndrome louder than ever? Tracing this back led me to my childhood. I was the student who struggled academically, often hovering between average and below average. At one point, my parents even considered having me repeat a grade. Reading and comprehension were significant challenges. I could study an entire chemistry textbook and retain almost nothing. Instead of encouragement, I frequently received criticism, particularly from teachers, reinforcing the belief that I was incapable. Slowly, a damaging internal narrative formed: I am incompetent. While not everyone’s experience with imposter syndrome originates this way, identifying the root belief system has been an essential road stop on my healing journey. Given my academic struggles, and the subtle, but consistent, feelings of disappointment from important figures in my life, it makes sense that success now feels undeserved. Early narratives, once embedded, have clearly shaped my self-perception long after I have outgrown the environments that created them. Understanding this, it has become clear that addressing my imposter syndrome is not solely about recounting achievements; it is about confronting the reflection I meet in the mirror each day. It is about understanding why I so often meet my reflection with shame, criticism, and doubt, instead of acceptance and worthiness. Could healing imposter syndrome be as simple as identifying its roots? The answer, unfortunately, is no. Recognizing where it started has certainly been essential, but it is only part of the work. We must also contend with external reinforcements—failed relationships, rejected opportunities, academic struggles, and the perpetual comparisons fostered by social media, where others’ curated successes are constantly on display. These external triggers have continuously reinforced my feelings of inadequacy.

A Remedy to the Imposter Syndrome

A tool I have found incredibly helpful in managing these feelings is a mindfulness practice called RAIN, developed by Tara Brach. RAIN is an acronym that stands for: Recognize, Allow, Investigate, and Nurture. It is a framework that guides individuals in meeting difficult emotions with both compassion and clarity. Recognize, the first step. For me, it often involves recognizing the feeling of incompetence resurfacing, particularly as I step into public roles—building a business, launching a podcast, and exposing myself to real-time visibility and judgment. Vulnerability is inevitable. Allow, the second step. Allow the experience to exist just as it is. This has been difficult for me, and can be especially so for those who habitually try to control outcomes. The goal here is not to fix or suppress the emotion but simply to sit with it. Investigate, the third step. This means approaching your experience with curiosity and compassion, rather than judgment. Asking questions such as: What beliefs are fueling this feeling of fraudulence? How is this emotion manifesting in my body? This step invites gentle exploration rather than critical analysis.   Nurture, the fourth and final step. Here, you meet the pain with kindness. Ask yourself: What do I need right now? and then offer that, whether it is reassurance, forgiveness, comfort, or patience. This is the space where healing begins to take root. RAIN is not a magic fix. It is a practice that demands consistency, patience, and kindness. Each person’s process of nurturing may look different, and that is not only acceptable but necessary for true self-compassion. Today, I continue to navigate imposter syndrome. I am learning to balance building a new life while tending to the younger parts of myself that need validation and reassurance. My focus now lies in disciplined self-care: wellness routines, prayer, nervous system regulation, and practicing RAIN.

Case Application

In my clinical practice, I’ve worked with numerous individuals grappling with the weight of imposter syndrome, particularly those from marginalized communities where societal expectations often clash with personal realities. One client, a Black woman in her early thirties, offered a vivid example of how imposter syndrome can intersect with perfectionism, anxiety, and culturally constructed definitions of success. Despite being high achieving by many standards, she struggled with persistent feelings of inadequacy, often comparing her life trajectory to that of her peers. These comparisons left her questioning her worth and accomplishments, particularly because she had not followed certain conventional milestones such as pursuing a postgraduate degree, or attaining what she perceived as a “stable” professional identity. Complicating her experience was a long-standing history of Attention-Deficit/Hyperactivity Disorder (ADHD) and Generalized Anxiety Disorder (GAD), both of which amplified her self-doubt and made it difficult for her to feel grounded in her successes. As our work progressed, it became increasingly clear that her internal narratives of success were not organically her own––they were shaped by broader societal pressures and cultural messaging about what it means to be accomplished, especially as a Black woman expected to “excel” in all domains. Together, we began the process of deconstructing these inherited belief systems, and rebuilding a more authentic, internally defined understanding of success and happiness. A key part of this work involved using the RAIN framework (Recognize, Allow, Investigate, Nurture) as a tool for emotional regulation and self-inquiry. We began by Recognizing the core distress: the belief that she was “unsuccessful.” This belief stemmed from her decision not to pursue further academic credentials and from taking the bold step of starting her own business, choices that felt right to her but conflicted with societal norms. Next, we practiced Allowing, making space for the emotions that accompanied this belief, rather than trying to immediately fix, change, or suppress them. This allowed her to begin cultivating a compassionate relationship with her inner experience. As she became more comfortable with allowing these emotions to exist, we moved into Investigation, exploring questions like: What do I believe being “unsuccessful” says about me? Where did this belief come from? How does it show up in my body? This phase helped her connect with the somatic experiences of anxiety and perfectionism, allowing for deeper insight into the ways these beliefs were embedded in both mind and body. Finally, we moved into Nurture, supporting her in meeting herself with compassion and care. This included grounding practices, affirming internal dialogue, and honoring her needs for safety, validation, and emotional rest. Over time, she began to recognize that success is not a fixed or universal standard, but rather a deeply personal and evolving concept. Through this reframing, she was able to cultivate her definitions of what it means to live a meaningful, successful life free from the limiting expectations that had previously governed her self-worth.

Therapeutic Reimagining

Posted on by Psychotherapy.net Team

An Introduction to Therapeutic Reimagining

I’m very proud to have recently published my first book, Reimagine Your Life: How to Change Your Past and Transform Your Future, in which I introduce a process that I have named “therapeutic reimagining.”

There are many reasons why I am proud of this book, but the greatest achievement is to have overcome the intergenerational narrative provided by my “working class” upbringing in the United Kingdom, with its self-limiting beliefs about myself, others and the world.

I come from a family of six siblings, three of whom left school virtually unable to read or write. My father was an Irish immigrant who worked on a building site doing unskilled work, and my mother left school at the age of 14 to look after cows on a local farm. I too was educationally backward as a child, and was never given a book, or helped with reading by my parents. So, if they were alive today and I told them that I have written a book about a new way of doing psychotherapy, it would be incomprehensible to them.

It has taken me 20 years of hard study and practice to put all of the puzzle pieces together and create this process that I call therapeutic reimagining. I simply couldn’t have done it earlier in my life. That is the gift of ageing: being able, over time, to integrate a multitude of different experiences.

Although writing Reimagine Your Life was conceived as a way of helping people who either couldn’t afford therapy or couldn’t access it for other reasons, the core process of therapeutic reimagining was born in my psychotherapy practice in Cambridge, England as a way of accelerating clients’ progress in therapy. Simply put, they were able to get much further forward in their healing journey by being empowered and encouraged to continue their transformational work outside of sessions.

The book cover has a clock face and the question, “How far would you wind back time and what would you change?” This gives us a clue that it is about overcoming trauma by redoing the past.

Often in people’s lives something goes wrong or there is trauma that leads to a whole downward trajectory of events. So, I invite my clients to wind back time to a point before it happened and explore an alternate timeline or alternate history.

This might sound like time travel and science fiction. However, it is actually science fact: the psychology of counterfactual thinking. You may have never heard of it, but it is something we do with our clients all the time. Every time we ask a question like “How do you wish your childhood was different” we are inviting them to imagine an alternate history with a new narrative.

In Gestalt Therapy, we ask the client to go back in time and “Be there now.” In Transactional Analysis, it is called “early scene work;” “enactments” in Psychodynamic Therapy, and “portrayals” in some other therapies.

However, where therapeutic reimagining is different from all of the above, is that it provides a roadmap of how to do the process, so that clients can create their own portrayals at home. It has worked so well with my clients that I wanted to write a self-help book that would allow those who can’t afford or can’t access one-to-one therapy to benefit from the process. It is safe to do at home because the reader is invited to imagine a more pleasant alternative to what actually happened.

The book contains nine stories, written by the clients themselves, explaining how they used therapeutic reimagining to overcome shame, guilt, fear, anxiety, overeating, and even medically unexplained physical symptoms.

One of the stories concerns a theme that many people encounter in later life, the illness and death of their life partner. Stephanie was 73 when she came to see me, full of toxic guilt related to the circumstances of the death of her husband several years earlier. Her guilt interfered with the grieving process and caused her a great deal of emotional pain and suffering. With Stephanie’s consent I am sharing her therapeutic reimagining journey.

Stephanie’s Story: Grief Without End

I was struggling with the knowledge that I had not done everything that I could have done for my husband in his last few days of life. He was in hospital, and the doctors told me he had kidney failure which they were planning to treat with dialysis.

I had no idea that he was going to die soon. On the fourth night, they called me into the hospital because he was dying. He died the next day. All the time that he was in the hospital I believed that they were trying to help him.

All the time he was in the hospital he was asking me to take him home. Once he had died, I realized that he knew he was dying, and he wanted to die at home. I had no way of knowing that he was dying at the time, and I persuaded him to stay in the hospital where I believed that he was getting treatment that would help him, and that although he was seriously ill with lymphoma and we knew that it could not be cured, we thought we had a few years more.

For more than three years after he died, I suffered profound guilt about my behavior during these days. This feeling haunted me, and even though I knew that I wasn’t aware that he was dying during his last days, I found it hard to forgive myself for not paying attention to his requests to be taken home. My intelligent self knew that if I had known, I would have acted differently, but this knowledge had little or no effect on the extremely painful feelings that I was experiencing day after day.

Anthony encouraged me to visualize an alternative narrative. To imagine moment by moment what would happen if I had taken him home instead of persuading him to stay in the hospital. I found this extremely difficult at first, I could imagine investigating the possibilities of bringing him home, of engaging a nurse and arranging for a hospital bed to be brought to our flat. I got as far as imagining the ambulance people bringing him up the flight of stairs to the room I had prepared for him. But it was really difficult to continue the story.

At first, I found it very difficult to imagine him actually in his bedroom and actually dying there. But I persisted and over a week I was able to visualize everything from the point of deciding to bring him home and preparing a room for him and then imagining his death at home. I was able to borrow from the actual experiences. For example, there was a very compassionate nurse who had helped him in the hospital. In my imagination, she was in the bedroom at home. I remembered the night I spent stroking and talking to him whilst he was dying and unconscious, but I reimagined these experiences and saw them in the bedroom in our flat with me sitting on one of our chairs and not the hospital chair.

This new experience became very real to me. Although I knew it was a new narrative, and I knew that it hadn’t happened this way, I was able to experience the events emotionally. It made such a difference, and afterwards I didn’t dwell on the original painful experience to the same extent. Over time that pain has receded: not the pain of his death, but the pain of the guilt that I felt around the circumstances of his death.

In some ways, it feels like magic. I know how things happened. I know the real story of how John died. But I have been able to overcome the extremely painful feelings of guilt and responsibility that had troubled me so deeply and for such a long time. Something had changed, and it has helped me to recover. I’m not sure I forgive myself entirely for not being aware enough at the time to act differently, but I’m not punishing myself for my oversight anymore.

Learning Points from Stephanie’s Story

I’ve re-read Stephanie’s story many times over the last few years, but I still feel very moved by it. Her story gives us an idea of how simple, yet powerful, therapeutic reimagining can be. Although she says, “At first I found it extremely difficult to imagine,” she persists over one week and is able to add all of the details. Crucially, she is able to include the very moving emotional elements of her husband actually dying in his bedroom at home.

As a human being, I felt some resistance to suggesting she imagine this very emotionally challenging scene, especially knowing I would not be with her when she did. However, as a therapist, I knew there was a very good chance that if she did, she would be freed from endless toxic guilt. She would no longer be “haunted” by it and would get the closure that she needed.

In session, as soon as Stephanie said, “If I had known he was going to die, I would have looked after him at home,” I was immediately alerted to the possibility of using counterfactual thinking to redo the past. This was a classic “If I knew then what I know now” example of a situation in which we can use counterfactual thinking to heal a painful regret. In fact, whenever a client says, “If only” or “I wish,” it is a cue for therapeutic reimagining.

However, I don’t wait for the client to stumble across the answer. Instead, I ask questions like “What should have happened?” and “What could have happened differently?” These are the key questions that I encourage clients to ask themselves, in order to reimagine their life.

Another way in which to conceptualize what needs to happen differently is: what happened that shouldn’t have happened, for example trauma; and what didn’t happen that should have, for example being loved by one’s parents as a child, or getting to say goodbye before the death of a loved one. Although she never wrote about it in her brief story, saying all the things she had wanted to say to her husband before he died was another aspect of Stephanie’s healing in her therapeutic reimagining. It helped give her closure and is sometimes called a completion portrayal when done in the therapy room. We had never discussed doing a completion portrayal in session. However, her creative unconscious guided her in doing it on her own.

Trusting the Client’s Creative Unconscious

Although I offer lots of ideas and suggestions, it is always the client’s choice of what new narrative they will create in their therapeutic reimagining at home. Sometimes, I suggest they write a letter to their younger self or even an internalized parent, imparting important information about their future that will help their younger self. However, they often come back the following week and rather sheepishly say, I did the homework, but not as you suggested. I usually say, “Great! I bet your creative unconscious mind came up with something even better than either of us could come up with in the session.” And often, they have.

This was the case in Viktor’s story. He had come to see me about his problem of forming relationships with women. After some time, we realized that part of the problem was connected with his relationship with his mother as a child. I suggested that maybe he should write a letter to his mother from his childhood, warning her that the way she was treating him would have serious consequences for him in the future.

However, he seemed to have intuitively known that his mother from the past wouldn’t have listened to his present-day self, so he chose to do the process in a very different way. He informed me that, instead, he had talked to his present-day mother (the version of her in his head) who “instantly knew what to do,” he said. She then talked to her younger self, explaining why she must desist from her harsh treatment of him. Victor explained that it was hard work even for his present-day mother to get through to her younger self, but eventually she succeeded. This all occurred at home as a conversation in his mind between these parts of himself, which he created entirely on his own.

Now that he had found a viable solution that was believable to him, Viktor was able to imagine his mother being different in his childhood, he was able to experience a number of therapeutically reimagined scenes, where she did not treat him so harshly. Victor reported that the effect of this work on his present-day relationships with women, had been rapid and transformational.

All of the nine stories in the book are very different and so the therapeutic reimagining scenes that they needed were also very different, but it is always the client who decides what they need. However, I do always encourage the client to experience the emotions of the new scenes, so that it feels real, as this is a key ingredient in making the outcome therapeutic.

Why ‘Therapeutic Reimagining’ Works

Some of the theory of why it works comes from the neuroscience of memory reconsolidation and the juxtaposition of old and new memories. Creating an imaginary alternate timeline with a new narrative may allow the brain to un-anchor from the old painful memory. However, it is more important to understand psychologically what was needed in the past and to know how to do the process of therapeutic reimagining than to understand why it works at a neuronal level. This is what the book provides, a roadmap for the process. The nine client stories offer lots of examples of what could be reimagined and how they did it.

Although I do explain some of the theory of why the technique works in the main chapters, I’ve gone a lot deeper into the theoretical underpinnings of the process for mental health professionals in “Appendix A for therapists” at the back of the book.

How Hard do Clients Find Therapeutic Reimagining?
For some clients like Stephanie, who had been dealing with chronic toxic guilt, the solution and resolution of the problem can be surprisingly rapid because they have always unconsciously known the solution. “If I had known he was going to die, I would have looked after him at home,” she said. If we stay alert, we can often notice that the client has already glimpsed an alternate timeline that will allow them to create a new narrative. All we need to do is encourage them to explore that new path.

With others, it may take longer as the client hits some blocks to doing therapeutic reimagining. We saw this in Victor’s story. Initially, he could not see his mother in his childhood treating him any differently, not even if he explained to her the consequences of her actions in a letter. However, he quickly came up with an ingenious solution of speaking to his internalized mother from the present who was able to persuade herself from the past. I’m often amazed and delighted by my client’s creative unconscious ability to find exactly what they need to set themselves free.

There have been a few clients for whom therapeutic reimagining didn’t work initially, until we figured out what the block was. For example, Fergus, who had a problem with catastrophizing events in the future. When he first tried to use the technique, instead of imagining therapeutic outcomes, he simply catastrophized the past instead of the future, and we abandoned using it for some time as it was not helpful. However, one day we did get to the bottom of what function catastrophizing was fulfilling for him, and then he was able to use the process therapeutically.

Is it Safe When the Client’s Sense of Reality is Distorted?
Some clients are already living constantly in a fantasy world, one where they are always the hero. This was beautifully depicted in the film, The Secret Life of Walter Mitty played by Ben Stiller. With such clients, it is important to first confront them with the reality of their actual life before using therapeutic reimagining otherwise they would most likely do what Fergus did above, take his defense into the reimagined past, which would have no therapeutic benefit.

The process of therapeutic reimagining was even used successfully with a client who was recovering from psychosis and hospitalization, and was still taking anti-psychotic medication. However, it was only after thoroughly assessing the client’s current grasp on reality that I considered using it with him. Additionally, I regularly checked with him to see that he was completely aware of the differences between his actual life and the therapeutically reimagined scenes that he created to resolve attachment issues with his father.

Clients who Might Struggle to do Therapeutic Reimagining

One category of clients who often find therapeutic reimagining more difficult to do at home on their own is people with ADHD. These clients, who struggle to remain focused enough to imagine scenes outside of sessions, may need the work to be done as a portrayal in the therapy room instead. Similarly, some clients might need the work to be done in session for their therapist to help them regulate their emotions. My experience, however, has shown me that our clients are often more resilient than we believe and able to reimagine scenes that are healing.

***

Although Reimagine Your Life was conceived as a book that could help a lot of people who can’t for some reason access therapy, therapeutic reimagining was born in my psychotherapy practice as a way of accelerating clients’ progress. Simply put, clients were able to get much further forward in their healing journey by empowering them and encouraging them to continue their transformational work outside of sessions.

Hide & Seek: Evoking Desires to be Seen, Heard, and Found

Posted on by Psychotherapy.net Team

Separation and Reunion

Hide-and-seek is a universal game enjoyed by children across different cultures and ages. It reflects the ongoing interaction of separation and reunion that begins in infancy. As children develop emotionally, they transition from infancy to toddlerhood and eventually to childhood, engaging in various play activities such as peekaboo, chasing, and hide-and-seek. These games help children navigate developmental challenges, allowing them to experience loss and learn how to manage the dynamics of separation and reunion while forming close relationships with others. Playing peekaboo and hide-and-seek help children transition from relying on the physical presence of their caregivers to developing mental representations of them that they can recall when the caregivers are not around.

Play allows a child to make sense of their experiences. Play Therapy provides a therapeutic environment in which children can explore the unconscious independently. Children inherently strive for growth and healing. Our role as play therapists is simply to create the right therapeutic space and setup, enabling them to express and address what needs to be transformed or resolved. This is why play therapists don’t have to actively introduce concepts; children naturally initiate hide-and-seek themes on their own in the playroom.

Attachment and Loss

The presence of repetitive hide-and-seek in play therapy suggests the child may have experienced an inability to master the developmental task of emotional constancy, had (or has) a break in attachment where the child did not feel wanted or desired, or weak attachment bonds.

A major task of childhood is achieving emotional constancy. Emotional constancy is the ability to have an inner conviction of being ‘me and no one else’ while also respecting and valuing the separateness of others. Achieving emotional constancy enhances one’s ability to manage emotions during change or in response to anger, disappointment, and frustration. Hide-and-seek is essentially the child’s attempt to overcome and work through the earlier developmental need to understand that people can disappear but then return.

Boy who wanted to be found

Jeremy is an 8-year-old boy who faced medical complications at birth and continues to live with a rare heart condition. He was separated from his mother and spent several months in the Intensive Care Unit before his parents could bring him home from the hospital.

As we entered the playroom, he looked at me with the biggest smile on his face. I looked back with glee.

“You’re excited to play today,” I said.

“Yes. Because I am going to hide now, don’t look,” he shouted! “Close your eyes,” he added as he ran toward the other end of the playroom.

With my eyes closed and my hands over them, I waited while he hid. After some time, I softly walked around looking for him.

“Oh, where are you,” I asked. “Where did you go?”

Before I could make my way around the playroom, he popped out.

“Here I am!”

“Oh, there you are. I was wondering where you went.”

He shook his head in agreement.

“Again, find me again,” he quickly directed!

Jeremy played variations of hide-and-seek with me, and also in the burying and unburying objects in the sand during our time together in the play. He often struggled to stay hidden during the process, popping out or revealing himself before I could find him (or the object) suggesting he struggled with the tensions of aloneness and deep down feared no one would notice or “find him.” Across time and throughout the sessions, he was able to spend more time hidden and eventually developed confidence in sitting with tensions of oneness and separateness. I was careful to attune to his desire to be seen, heard, and found.

***

For Jeremy, and others his age and developmental level, hide-and-seek symbolizes the universal human desire to be seen and heard. Play therapy allows children to explore, restore, and practice the concerns that occupy their inner world. Engaging in hide-and-seek with me helped him to manage anxiety, while also fostering a sense of mastery and reinforcing his self-worth.

Questions for Thought and Discussion

What childhood games have you effectively utilized in therapy?

What are your impressions of the way this author used hide-and-seek?

Given the child’s presenting issue, what might you have focused on in the playroom with him?

A Supervisor’s Guide on How to Create a Culture of Support

Posted on by Psychotherapy.net Team

My entry into the workforce began, and has remained, in 24/7, high-paced environments be it call centers or residential treatment. These fast-paced settings taught me the importance of resilience and self-care, but it was not until I transitioned into private practice that I could begin to slow the pace. However, the demands of a high-risk caseload meant that even in private practice, I maintained extended office hours. Throughout my career, I have had the privilege of supporting many mental health professionals who regularly engage with trauma survivors or those in active crisis. Understanding the toll that vicarious trauma takes, I developed strategies to support the well-being of and prevent burnout in professionals. I’d like to share three strategies that my supervisees found especially helpful in fostering their mental wellness in the workplace.

Creating a Supportive Supervision Model

As a supervisor, my role extends beyond overseeing the day-to-day tasks of my supervisees. I recognize that mental health professionals, especially those working with trauma survivors and high-risk clients, require both administrative and clinical support to manage their responsibilities effectively and maintain their well-being. I take responsibility for creating a culture where staff feel supported and equipped to handle the emotional demands put on them. To this end, I created a structure that delineated the roles of administrative and clinical supervision, providing a balanced, comprehensive support system.

In a typical supervisory relationship, the administrative supervisor is responsible for evaluating and supporting performance—ensuring that supervisees meet the operational and procedural requirements of the agency. However, the clinical supervisor focuses on developing psychotherapeutic and case conceptualization skills, providing professional development and emotional support to the supervisee as they navigate the complexities of trauma work. This division of roles ensures that each supervisor can specialize in their respective areas, offering targeted guidance that fosters professional growth and emotional resilience.

One of the most important aspects of effective supervision is fostering open communication about the emotional impact of trauma work, ensuring that staff feel safe to express their vulnerabilities without fear of judgment. I implemented a supervisory triad model, pairing each supervisee with one administrative supervisor and one clinical supervisor. This model allowed for an integrated approach to supervision: the administrative supervisor handles performance evaluations, time management, and task completion, while the clinical supervisor concentrates on therapeutic skills, case discussions, and the supervisee’s well-being. Additionally, the clinical supervisor, in keeping with the ethical standards of confidentiality in therapeutic relationships, ensures that any personal disclosures made by the supervisee regarding their emotional or psychological state remained private and were not communicated to the administrative supervisor. This clear distinction between the two supervisory roles allows supervisees to feel secure in discussing sensitive issues without fear of it affecting their professional standing.

In some cases, I oversaw a structure where six supervisors held both administrative and clinical roles, but never for the same supervisee. This arrangement provided the supervisees with consistent support from trusted individuals while preventing any potential conflict of interest. Supervisors were able to give well-rounded feedback and support while being mindful of the emotional and professional needs of their supervisees, ensuring that both aspects of supervision—administrative and clinical—worked synergistically to help the supervisees thrive in their work with trauma survivors and high-risk clients.

Peer Support Groups: A Collective Approach to Emotional Resilience

One of the most effective strategies I implemented to foster staff well-being was the creation of a volunteer peer support group. This group convened every other day, providing a dedicated space for staff members to offer one another support without the direct involvement of leadership. The peer support group primarily focused on emotional and practical support, creating a safe, informal setting for staff to share their experiences, challenges, and coping strategies. This allowed staff to connect with one another, offering solidarity and understanding in a way that was distinct from their regular work tasks.

By establishing the peer support group, I aimed to encourage a culture of mutual aid, where colleagues could provide emotional assistance without the pressure of leadership oversight. This structure empowered staff to manage stress and challenges together, without relying solely on hierarchical support structures. I made it clear that if the peer support group identified systemic concerns or common issues that could be addressed at a larger organizational level, those concerns should be brought to leadership’s attention in a collective, constructive manner. This approach prevented individual staff members from feeling burdened by problems that could be addressed more effectively at the systemic level, fostering a shared sense of responsibility for the emotional health of the workforce.

Creating this peer support network was an essential part of building a sustainable and compassionate work environment. It helped staff feel less isolated in their experiences, knowing that they had a space where they could seek support from peers who truly understood the emotional toll of trauma work. This group was not just about coping in isolation but about collectively sharing strategies, offering comfort, and validating one another’s experiences, helping to build emotional resilience across the team.

Self-Care Encouragement: Prioritizing Individual Well-Being

In addition to peer support, I strongly believe in the importance of self-care as a crucial component of maintaining long-term emotional and psychological well-being in trauma and crisis work. As a supervisor, I consistently emphasize the significance of work-life balance and self-care, especially in high-stress environments where emotional and psychological demands are prevalent. I encourage supervisees to establish clear boundaries between work and personal life to avoid burnout and preserve their mental health.

To promote self-care, I implemented several strategies. First, I set aside two hours each week for every supervisee to either engage in reflexive writing or exercise, ensuring that this time was a non-negotiable part of their workday. Reflexive writing offered a space for staff to process their emotional experiences and gain clarity on their work, while exercise provided an opportunity to release physical stress and re-energize. This initiative was intended not only to give supervisees a break from their caseloads but also to encourage habits that promote long-term resilience.

Additionally, I encouraged the cultivation of personal self-care routines, such as mindfulness practices, regular physical activity, creative outlets, and maintaining social connections. These habits allowed staff to recharge both mentally and physically, preventing exhaustion and helping them stay engaged and compassionate in their work with trauma survivors. By prioritizing these practices, I hoped to empower my supervisees to take ownership of their well-being, ultimately enabling them to maintain their capacity to care for others without compromising their own emotional health.

Conclusion

The integration of peer support groups, reflexive writing, exercise, and a culture of self-care was designed to not only prevent burnout but also promote long-term emotional health for staff. By fostering a culture where emotional support and self-care are prioritized alongside clinical work, I believe we can create a more sustainable and compassionate work environment where professionals can thrive in their roles, while maintaining their mental and emotional well-being. A supervisor’s guide to supporting well-being involves proactive interventions, such as reflective writing or exercise, that encourage staff to engage in practices that recharge both their bodies and minds. By establishing a peer support network within the team, I help cultivate a sense of shared responsibility, where colleagues support one another without the direct involvement of leadership, promoting autonomy and mutual care. As a supervisor, it has been crucial for me and my colleagues to not only offer guidance in clinical practice, but to ensure that the emotional needs of the staff are met, empowering them to maintain their compassion and professionalism in the face of difficult work.

Questions for Thought and Discussion

  • What about the author’s model of supervision do you find useful? Not useful?
  • How is self-care practiced at your facility? In your practice? In your personal life?
  • How has burnout entered into your own life and practice, and what do you find most effective in combating it?