Psychotherapy.net Team, Author at Psychotherapy.net

PhDs in Therapy

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

Academics and Mental Health

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

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

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

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

Opening Doors with Online Therapy

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

This vignette illustrates such a case.

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

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

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

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

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

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

“Zdravstvuite.”

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

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

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

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

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

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

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

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

The First Session

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

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

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

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

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

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

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

Alienated, confused… little.

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

Have you ever felt like this before?

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

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

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

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

Shame in Academia

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

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

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

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

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

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

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

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

The Work Continues

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

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

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

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

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

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

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

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

Jane was close to cancelling but she did not.

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

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

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

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

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

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

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

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

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

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

References

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

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

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

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

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

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

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

The Death of Privacy

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

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

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

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

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

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

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

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

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

Becoming Myself: A Psychiatrist’s Memoir

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

Chapter One, The Birth of Empathy

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

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

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

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

I am too terrified to answer.

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

I tremble. I am speechless with fear.

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

All I can do is mumble, “I dunno.”

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

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

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

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

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

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

***

Chapter Three, I want Her Gone

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Grief is a Strange Land

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

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

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

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

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

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

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

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

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

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

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

Ah…It was my grief.

You see, I loved her madly. Still do.

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

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

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

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

Alcoholics Anonymous Founder Bill Wilson’s Long-Lost Treatment Paradigm

Posted on July 13, 2017February 11, 2026 by Psychotherapy.net Team

When I gear up to read a blog I invariably have the same thought: Tell me something I don’t know. In this blog I am going to fulfill that promise for my readers since I have never encountered a psychotherapist or addiction counselor who knows what I am about to share. (If you are the one in a million exception, please accept my apology.) So make yourself comfortable and let’s get this party started. Let’s begin with something you do know. In the summer of 1935 Bill W (aka Bill Wilson) and Dr. Bob (actually Dr. Bob Smith, birth name Robert Holbrook) conducted the first Alcoholics Anonymous or AA group. Since this initial meeting AA has helped more individuals than any group on record. Make no mistake about it. Bill Wilson loved AA and he believed in it with every fiber in his body. But two key factors prohibited this from being the end of the story. First, although AA helped Bill W deal with his alcoholism, it did nothing to curb his anxiety and depression. Second, as powerful as AA was it didn’t work for everybody. Now fast forward from 1935 to the year 1960. Bill Wilson decided to attend a parapsychology conference in New York City. It was there that the famed British Writer and AA supporter, Aldous Huxley, introduced Wilson to two esteemed psychiatrists, Abram Hoffer and Humphrey Osmond. These psychiatrists shared with Wilson a promising new treatment for alcoholics and schizophrenics dubbed vitamin B3 or niacin therapy. He was fascinated by their research. Wilson began ingesting a bomber’s load of the nutrient, 3 grams daily, only to report that his lifelong battle with depression and anxiety lifted in just 14 days! Is that amazing or what? I mean, seriously, it sounds like something right out of an infomercial airing at 2 AM after the one for Tony Robbins’ self-improvement materials. Here was an ordinary over-the -counter vitamin that when ingested in the proper dosage was a fast acting remedy for alcoholism, depression, anxiety, and schizophrenia. And, as a side effect it helped lower the so-called bad cholesterol. Wilson took immediate action and prescribed his miracle like intervention to AA friends who were described as educated. Others were said to be celebrities. According to Wilson, the results were nothing short of amazing. Wilson was brimming with enthusiasm and forged on to share his knowledge with the doctors of AA. These were physicians who were alcoholics and therefore attending AA groups. But here is where the gauntlet began to fall and nothing was ever quite powerful enough to reverse the pattern. The International Organization of AA, despite the fact that the members were appointed by Bill W, and he considered them friends, were not happy campers. Wilson, as they pointed out, was not a licensed physician and thus had no business extolling the virtues of vitamin therapy. Bill Wilson spent the last eleven years of his life spreading the word about vitamin B3 therapy as a treatment option or supplement to AA groups. Wilson tried to rally the troops by creating three powerful booklets over the years to AA physicians, but it fell on deaf ears. So who killed vitamin B3 or niacin therapy? Why was AA embraced by millions, while B3 niacin therapy never made it out of the starting blocks? Certainly, I don’t pretend to have the answer. Scores of reasons could be cited, but here are a few that just seem to make sense. Also keep in mind that nearly everybody is a great Monday morning quarterback. Had I been in Bill W’s shoes at the time I might have done exactly what he did.

Who killed vitamin B 3 niacin therapy?

The niacin flush. Unlike the tiny amount of B3 included in a typical multiple vitamin supplement, in order to import a clinical impact, the dose of niacin (also known as nicotinic acid) generally has to be high enough to induce a flush replete with itching and profound warmth. The effect is so pronounced that individuals taking niacin often mistake these symptoms for a heart attack or stroke and end up in the ER or an acute care facility. In all fairness, a very small percentage of the population finds the experience pleasurable. AA traditions. Tradition six suggests AA won’t endorse, finance, or lend the AA name to any outside enterprise or facility. Tradition ten suggests that AA has no opinions on outside issues, hence AA cannot become involved in a public controversy. The American Psychiatric Association. In 1973 the organization revealed they could not duplicate Dr. Hoffer’s data and therefore could not promote niacin therapy. Rumors surfaced that large doses of niacin caused liver problems. Hoffer, who boasted he took more B3 than anybody on the planet, remained healthy until he passed away at age 91. He denied all claims that niacin was responsible for liver difficulties and went as far as to say it promoted longevity. Before he passed away he discovered a Canadian woman named Mary MacIsaac who took massive doses of B3 for 42 years. She practiced cross country skiing at age 110 and lived until age 112! Okay, I think I’ll have what she was taking. Yes, it’s clearly N=1 data, but I think it’s safe to say that most supercentenarians don’t spend the better part of the day on a ski slope. Morbid fears related to the practice of orthomolecular psychiatry. Orthomolecular psychiatry (I’ll pause while you Google it), a term coined by two time Nobel Prize recipient, Dr. Linus Pauling in 1968, is basically individualized mega-vitamin/nutrient therapy. B3 or niacin therapy fit neatly into this treatment category. The idea that patients might be diagnosing themselves and then heading for the nearest pharmacy or health food store to buy niacin on a BOGO sale just didn’t sit well with mainstream psychiatrists. To be sure, the pharmaceutical companies marketing psychiatric medicinals were not overly thrilled either. Forget the doctors of AA, Bill Wilson should have taken his message to the masses. I am thoroughly convinced that Bill W pitched his ideas to the wrong population. In my humble opinion if he had penned a self-help book on the topic B3 niacin therapy might well have become a household word. This was the 1960s and early 1970s for gosh sakes and titles like I’m O.K.—You’re O.K., How to be Your Own Best Friend, and Born to Win were shaping American culture, not to mention the landscape of mental health. Today, vestiges of niacin treatment live on in the minds of longevity seekers, the alternative health movement, and nutritionally minded cardiologists hell bent on shaving another silly little point off your LDL cholesterol score using straight niacin or a modern slow release version which may or may not eliminate flushing. Had Bill W been successful in his mission to incorporate vitamin B3 niacin therapy into AA the entire face of addiction and mental health treatment might have looked very different today. The story goes that before Bill Wilson passed away he was asked what he would like to be remembered for in the history books. Much to the chagrin of experts and those who have benefited from 12-step groups he chose niacin therapy over AA. Who knew?

Psychotherapy “Terminations” and Beyond

Posted on June 29, 2017February 11, 2026 by Psychotherapy.net Team

Often when I “terminate” with a client (what a horrendous term for the conclusion of a meaningful human encounter) I let them know that I don’t see therapy as some kind of permanent cure to the concerns that brought them in to see me. At best it offers some meaningful relief, and some expanded awareness and resources that they may draw on when they inevitably face future challenges.

I usually tell them I’d be happy to be of help in the future, whether seeing them again, or referring them to a colleague, often adding that I’d be delighted to hear from them with any update on how things are going for them. 95% of the time I never hear back, but of course certain clients run through my mind at various time. I may walk by a building that a client had done the architectural plans for. Or I am riding my bike, and I remember their joy in a bike tour they once took in New Mexico. Or a client springs into my mind for no apparent reason at all, and I wonder whether their marriage—that I had some role shepherding them into—gave them the love and sense of safety they craved.

And then there are those clients that I mark down on my inner scorecard as failures. Yes, I might have given them some support, maybe I helped marginally change the trajectory of their lives, but I felt that somehow I just couldn’t help them break through to achieve the types of changes that they desired—or I desired for them. How were they doing? Were they still as depressed as when we parted ways? Or worse…had they given up entirely? Committed suicide?

I notice that I hesitate before I type the word “suicide” as if somehow that reflects poorly on me that I’d even have this worry. Why the hesitation? Is it that I should be omnipotent, and never have clients, or even former clients that might commit suicide? Or is it that I shouldn’t admit that clients occupy my thoughts even years after I stop seeing them? Has the pernicious concept of therapeutic “neutrality”—one that we thought started and ended with psychoanalysis—become so rooted in our profession that we carry it with us without awareness? As if it’s wrong to care about our clients as actual human beings, as individuals!

There is one specific client that I do worry about from time to time—yes, worry whether he did decide to put an end to his tormented life—but I was somewhat reassured recently when I ran into a colleague at a conference whom I had entirely forgotten was the original referral source. She knew the client personally, and related to me that he was still alive, although still very much struggling day to day, but that she was grateful for the help I provided her friend. Given my feeling of failure with him, I was pleasantly surprised that my efforts were appreciated.

Just a few days ago I got an email out of the blue from a client I’ll call Penelope whom I saw several years ago. She said she just wanted to say hi, thank me for the help I had provided, and let me know that things were going well for her. She was a classical musician who was starting to achieve some success in her highly competitive field, and for the first time in a stable relationship.

I recall that the course of therapy was not an easy one—for the client, as well as for me. We all have our own tricks of the trade, some we like to think of as our own, or at least ones we’ve customized to fit our own personality. I like to work in the “here-and-now” when I can, drawing attention to how the two of us are engaging, with the idea that this will shed light on the client’s interpersonal relationships. Of course this is not a proprietary technique—I learned a great deal about this from my father—but I like to think that I have achieved some mastery in this.

In this case it failed repeatedly: Every time I asked Penelope how she was feeling towards me, she bristled, got angry, and didn’t see how this was relevant to her issues. I recall various responses on my part. One time I made an impassioned plea, relating her difficulty in trusting me to problems she was experiencing with a friend or co-worker. Or I would try to push back, again in the here-and-now, saying something like “I really sense that when I ask you how you feel towards me, it hits some sort of nerve for you. Can you tell me what is triggered?” Again, this got nowhere fast. Finally, I took this prized technique and stuffed it back in my toolbox where it belonged. Was that a failure? Or a brilliant realization that there is no one-size-fits-all in this work?

My memory is a bit hazy, but I recall we worked on and off for a year or so. I don't remember exactly how things ended, but it certainly wasn't one of those Hollywood therapy endings where her neurotic puzzle was solved, and I was left with a warm glow that I had performed my craft with precision. So thank you Penelope for being one of the 5% who let me know what has happened in your life. I go on faith that most of those I work with have some lasting benefits from our work, but it’s sure nice to hear it from you.

* * * * *

That was going to be the end of my musings, so I sent this piece to Penelope to make sure she felt comfortable with me publishing this (even though identifying details are changed). She wrote the following:

“I think that even though it made me pretty mad when you asked me how I was feeling towards you, I realize now that I was mad because that’s what I needed to work on. It took me a few more years to not get mad when people asked me stuff like that, but once I got more comfortable having conversations like that it was a lot easier for me to have close relationships.”

Wow! If I had known at the time that my apparent misfires would ultimately yield results, it would certainly have reduced my anxiety during the therapy. Would that have made me a better therapist? Perhaps not. Uncertainty is inherent to the process, and something we need to learn to live with. But how heartwarming it is to know now that my efforts with Penelope planted some seeds that are now blooming.

Are High-Risk Clients Suitable for Online Psychotherapy?

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

Into the Virtual Unknown

When we first began practicing online via the Skype interface, each of us felt a similar trepidation. Four or five years ago when we started, online psychotherapy was in its infancy and there were no supervisors or established authorities to guide us, so there was an understandable fear of the unknown.

We also worried about mastering the technology, as neither of us is particularly skilled in computer matters more complicated than word processing and email composition. Should we use built-in or external cameras? Should we use headsets with boom microphones? How fast of an Internet connection did we and our clients need? And perhaps unnoticed at the time but inspiring a subtle anxiety: “Would we be less skillful as therapists, less confident in our abilities, when we no longer met with a client within the authoritative confines of our own offices?”

Another source of anxiety was deciding which clients to accept for online treatment. Uncertain of our ability to work in this new format, we originally believed that we ought to confine our online practice to high-functioning clients—people who’d be able to sustain the supposedly less intimate form of contact and, with only a screen image for bonding, wouldn’t feel detached or abandoned. High-risk clients such as those who self-injured or posed a risk of suicide were definitely off limits. Today, when we discuss the subject of online therapy with some of our colleagues, we encounter similar questioning, and sometimes profound skepticism.

Over the ensuing years, we’ve both become entirely comfortable with the technical interface offered by Skype and confident in our abilities to provide quality online psychotherapy. With experience, we’ve also come to feel that the population of clients who might benefit is much larger than we first believed. There are still limits, of course, especially when there is a serious risk to life or when a client is psychotic; but based on the past five years, we’ve found that nearly all prospective clients can benefit from online psychotherapy.

Joseph first began to envision a larger scope to his potential online practice during his early work with a client who had concealed the extent of her involvement with self-injury at the beginning of treatment.

Anastasia pushed the scope of her work when an ongoing client she had started treating face-to-face in Spain for acute panic attacks had to return to Russia: Transitioning to online therapy was the only way to continue working with her.

Danielle and Olga are two clients who didn’t at first appear to be good candidates for online psychotherapy as they both displayed ongoing instability in moods and behaviors.

Danielle (Joseph’s client)

Danielle had followed my blog for a couple of years before she contacted me for treatment, not long after I began working by Skype. On her client questionnaire, she disclosed a history of self-injury but described it as minor, under control, and not life threatening. She insisted that she wasn’t suicidal. In our email exchanges prior to scheduling a first session, I told her that I couldn’t see her less than twice a week; otherwise, I didn’t feel we’d have the conditions to manage her issues. If I’d been seeing her in person, I would have required the same twice-weekly sessions.

During our first exploratory session, before we committed to working together, I made sure that she had an adequate local support system in case of emergency. Danielle assured me that, if she did at some point feel suicidal or if self-injury became a much larger issue, she had resources to contact: her pastor as well as a local therapy practice to which her prior therapist had belonged before he moved to another city. Danielle was familiar with emergency medical services and knew whom to call. Although I felt a little apprehensive about her history of self-injury, I felt that we’d established the conditions necessary to begin treatment.

From the beginning, Danielle and I developed a strong working relationship. Because she’d read every one of my blog posts, many of which are quite revealing, it didn’t feel to her as if I were a complete stranger. I found her endearing, engaging, and a pleasure to work with. In her line of work, Danielle managed a team remotely and held daily meetings by Skype, so she was even more comfortable with the medium than I was. We met twice a week on Tuesdays and Fridays. It soon began to feel to me no different from meeting a client in person, as difficult as that is for professionals who haven’t worked by Skype to understand.

Although she didn’t disclose the full details of her past until much later, Danielle let me know early on that she’d been sexually molested by more than one of her stepfathers beginning when she was 7 years old. She also told me that her mother had looked the other way when a family friend began abusing Danielle later on; the mother needed the man’s help and essentially gave away her daughter in exchange for it. This arrangement went on for several years.

A month or so into treatment, it became clear that Danielle’s involvement with self-injury was far from “minor”; she admitted that she’d misrepresented how serious it was out of fear that I wouldn’t accept her as a client if she’d told the truth. In fact, “I probably would not have taken her into my practice had I known.” Relatively inexperienced in working by Skype at that point, I would have assumed that a client who self-injures needed the more immediate contact afforded by in-person therapy.

Minor hair pulling, pinching, and scratching helped Danielle to manage her emotions most of the time—she’d explained this to me at the very beginning. But as I later learned, when conflict arose with her ex-husband or work became especially difficult, she’d cut herself with razor blades to find release from emotions that threatened to overwhelm her. During that stressful period, a month or so into therapy, cutting had become a daily practice.

By that point, I’d already developed a strong connection with Danielle and didn’t feel I could simply stop working with her, although I did feel more anxious about her welfare. At the same time, I wasn’t frightened and didn’t make Danielle sign a contract binding her not to cut as a condition of treatment. I’ve worked with other women who self-injure and understand the dynamics of emotional self-regulation involved in cutting. I felt that together, given our strong working bond, we could help her find healthier ways to self-soothe.

A complicated transference relationship soon developed. While on one level, Danielle idealized me and developed some sexual fantasies about the two of us together, on an unconscious level, she also struggled with a great deal of rage toward me, displaced from all those “fathers” who should have looked after her but instead exploited her as a sexual object. The cutting also had more than one meaning. It provided emotional relief, as I’d seen with other clients, but it also gave Danielle an outlet for the rage she felt. As I put it to her during our sessions, she couldn’t hurt me directly but she could get to me by hurting my client.

To confront these emotional dynamics, along with one’s own anxieties about clients who self-injure, often makes professionals unwilling to take such people into their practice. It can be quite scary, especially when these clients often want to scare you. Sometimes it’s because they want you to come to their rescue; sometimes they want to “prove” they can be more powerfully destructive than you are creative; sometimes they need to express the rage they feel for having been helpless and exploited. Bearing with these emotions without becoming terrified or enraged yourself is a major challenge for the therapist. Most professionals understandably worry about a malpractice suit if a client actually were to kill herself. Nobody wants the guilt and regret for having “failed” a client who committed suicide.

But in my experience, the emotional dynamics and therapeutic methods for understanding and coping with those who self-injure are the same with both in-person and Skype clients. I made the same sort of interventions with Danielle as I’ve done with clients I’ve met in my consulting room. By remaining calm and engaged with her, and not retreating in fear or anxiety, I helped her over several years to find better ways to cope with her emotions.

“We survived a period of intense cutting, when severe blood loss brought on heart palpitations, and she began reaching out to me by email between sessions.” Although I don’t normally encourage email contact, I welcomed Danielle’s communications, just as I would have welcomed emails from a self-injuring client I was meeting with in person. Sometimes that extra contact during breaks is needed to support clients in their struggles to take better care of themselves. By the end of our treatment, self-injury truly had become a minor issue.

Early on in my practice by Skype, this experience with Danielle taught me that distance therapy is suitable for many more potential clients than I would have imagined. If she hadn’t concealed the extent of her self-injury at the beginning, I might never have learned this valuable lesson.

Olga (Anastasia’s Client)

When Olga reached out by email, I’d already had experience working online with complex cases. Olga had fled the war in her country and now lived in Prague as a refugee. Her existence was precarious in every possible way; she did not speak Czech and, feeling isolated, was barely able to navigate her new environment. She complained about panic attacks, depression and an “acute desire to die.” For several days previous to her “cry for help” (these were the exact words she chose for the “subject” of her first email), Olga was unable to leave her room and the only “food” she was able to consume was coffee and cigarettes.

I agreed to meet for an introductory session to see whether I would be able to help her. “While I felt an obvious sense of urgency and a natural desire to rescue her, I also secretly planned that after this first conversation, I would refer her to a local English-speaking therapist.” I usually try to avoid any rigid diagnosis, but I suspected that Olga might be labeled as “borderline” and could probably benefit from medication.

Only later, several sessions into our work, did I realize the full extent of Olga’s issues: She experienced social phobia and agoraphobia, was mildly self-harming, and felt suicidal most of the time. The level of isolation and despair she was experiencing at that point made it impossible for her to get out of her room, to struggle with an unfamiliar language or navigate foreign streets, and to engage with a local in-person therapist in her wobbly English.

There were several occasions in the early stages when I questioned my decision to welcome Olga as an online client. We were in the middle of our third session when she suddenly announced: “I need a break, just for a minute,” and she abruptly disconnected. “I sat there, in front of my painfully empty screen and thought to myself that I had lost her.” The intensity of the emotional response that she had read on my face must have made her panic. To see her own unexpressed pain reflected on somebody else’s face was too much for her.

In the chat box, I let her know that I would prefer to remain online whenever she felt overwhelmed by emotions. I was able to keep calm and stay connected without the sort of unpredictable outburst she would typically have received from her mother. Was it ok if I called back? A few minutes later, when we resumed our conversation, she was ready to reflect on what had happened.

The idiosyncrasies of an online setting allowed Olga to regulate her own risk-taking behavior and vulnerability. Temporarily logging off when she felt overwhelmed and then reconnecting once she had recovered was an empowering experience for someone who had been feeling hopeless and depressed for a long time. Such experiences, if used mindfully in the session, often provide great grist for the psychotherapy mill.

At first when we were connecting, Olga would be sitting on the floor: She felt too weak and too ashamed to hold herself upright. In a more traditional setting, the client is forced to adapt to the therapist’s environment. With clients who carry some deep psychological wounds, this can be simply impossible at the beginning of treatment. “The fact that we meet the client in his or her own environment opens a window into the client’s experience: Seeing Olga curled up on the floor of her untidy room, I could sense her shame and fragility.”

Later in treatment, on the day I saw her sitting upright in a chair, with her laptop on the desk in front of her, I knew we’d made some serious progress.

Several months later, when she had more fully recovered and was resolving her current life situation, I asked Olga to share her experience of working with a therapist online. I also informed her that I would use her account in an article. This invitation offered a therapeutic boost to her broken self-esteem: It let her know that not only was her opinion valuable for me, but it could also be of use to others who might also feel isolated and in desperate need. This is what she wrote:

“I remember that day when in the half fog, in the total despair, I plucked up the courage to write you an e-mail. After several attempts to commit suicide, after repeated uncontrollable impulses to harm myself, after feeling myself to be absolutely unfit to live, after realizing I not only can't carry on living like this but don't want to, and it would be better to die right now, what could I do? I could write an email. I didn't have anyone, anything, I wasn't even myself—that in short is how you could have described my condition. My Internet had been paid for. I talked a lot during our first conversation; you gave me this opportunity. I talked and you listened to me until I could get my breath back. I sat on the floor, leaning my back against the wall. Via Skype I could see on my familiar iPad, the calm, compassionate expression of an unknown face on the screen. I knew that at any moment I could press the button and ‘hide.’”

Olga took a huge risk, reaching out when her trust in herself and the world was broken. Now it was my turn to take the risk and be there for her, even if my support would be limited to the screen during our twice-weekly sessions.

Such limitations may at first seem like an obstacle to working with more challenging cases, but they often end up playing an important role in containing people who feel torn and fragmented: They allow these clients to regulate the intensity of the contact, and empower them to make choices about the physical conditions of the session. In the case of Olga, the choice about where and how to sit, and how long to stay connected, helped her to become more aware of the process and of her connection to me. This awareness gave us both insight into our quickly evolving relationship.

Working online with clients who are deeply distressed makes therapists keenly aware of the absence of touch. We cannot shake our client’s hand when we greet them at the door, we cannot offer the same warm gesture at the end of each session. Any online therapist is familiar with this frustration. But with Olga, this physical distance helped her to trust me enough so that she could engage in the process. Olga’s mother had touched her daughter in many abusive ways, asking to join her in bed and to give her endless back rubs. At the initial stage of our work, Olga knew she was safe and out of reach.

Like many online therapists, I often work with clients who are experiencing some form of displacement. Olga’s case may seem extreme, but what she was experiencing in an acute form (due to her precarious refugee status, her traumatic history, and a very particular sensitivity) is familiar to many emigrants as an unavoidable part of their lives. The benefits of online therapy for such individuals cannot be over-estimated. In the case of Olga, before we could get anywhere close to her borderline mother and the abuse she had experienced throughout childhood, we had to deal with the harsh realities of her current living situation: her fear of going out to buy groceries, her inability to engage with others, her disrupted sleep patterns and her struggle to feed herself. At this initial stage, the fact that she was able to connect with me from her own room—the only “safe space” she knew—became crucial. This is Olga’s account:

“… [A]t the very beginning, I deliberately focused my attention on ‘my familiar iPad.’ It has a small screen. For the first few sessions I didn't expand the window to full screen, after several sessions, I tried it for the first time, then forced myself and then I wanted to… Skype therapy was the only therapy possible… I am located within my ‘familiar space.’ I look at your face on the ‘familiar screen.’ I can sit there in whatever clothes suit me and with my hair unbrushed, with my legs pulled up under me, and thus I learn what I am and I don't have to pretend. I am not ‘attacked’ by the details of your room, my consciousness ‘does not float away,’ it doesn't get distracted… and when we finish the session, this screen, this room remains with me. Several sessions ago I was unbearably frightened after each session—do you remember the cries for help in my messages: ‘How can I live each minute?’ Then it became a little bit easier to finish a session and leave myself at least a small drop of the sense that I exist, when we aren't talking any more, I am in a familiar place, as before everything threatened me including myself and I was ‘on the lookout,’ but I can stay at home and immediately crawl under my blanket or continue to sit in the same place, giving myself time to get up and go and do something, however small.”

It took us a few sessions before she was able to follow my advice and reach out to a psychiatrist I had located for her in Prague. She agreed to take medication, which quickly improved her sleep and her concentration. The risk she took in leaving her room and meeting the psychiatrist was our first victory, a testament to our growing therapeutic alliance.

As is often the case with deeply troubled clients, Olga’s childhood had been catastrophic: She grew up in a dark, cold and neglectful environment. Her mother was unpredictable, volatile, and emotionally and physically abusive. She had never been diagnosed, or sought treatment, but her behavior indicated some severe personality disorder (probably BPD). Olga’s father was drunk every evening, and later in life discussed his suicidal urges with no regard to his children’s feelings. Her parents divorced when she was seven, and after that, her eight-year-old brother was supposed to take care of her. Both children cooked, earned money as they could, cleaned the apartment and protected their mother from distress. They knew far too well how violent and terrifying she could become when upset.

Throughout her life, Olga had felt completely responsible for her mother. She continued sending her money (often the only money she had) and supported her mother’s myth about her sacrificial parenting. This came at a high cost; her dysfunctional mother had taken up residence deep within her own bowels. Olga’s behavior toward herself and in her relationships with others mirrored her mother’s shaming, persecutory, and abusive manner.

In the course of our work together, Olga began to experience some intense kidney pain and vomiting, which did not seem to have any purely physiological reasons. On a psychological level, it marked the beginning of a separation and liberation process and an important stage in the therapy. As Olga struggled to separate from her mother, I stayed as “close” to her as I could. We met twice a week, sometimes more, when she was feeling particularly fragile. Through my screen, I bore witness as she relived many painful moments from her childhood; as a new narrative of her life emerged, she began to feel more alive.

As is often the case with online therapy, boundaries were easily challenged. Olga would reach out frequently, sending me distressed messages via the Skype chat box. Initially I felt stressed by these intrusions, but once I addressed the issue openly with her, we agreed on some simple rules: I wouldn’t always respond straight away, or would sometimes just confirm that I was there and thinking about her. This reassured her as to healthy nature of our relationship, strikingly different from what she had experienced with her mother who had constantly pushed, violated, and dismantled boundaries with her violent emotional storms.

The fact that I was located at a safe distance, in a different country, permitted her to experience separateness and create a safe space around her. Soon, she was able to fill it with her own thoughts and desires. Our relationship was by definition at a physical distance, so different from what she had experienced with her mother: They had lived together in the same small apartment for more than twenty years. At crucial moments, this distance and our limited physical access to one another kept us both safe.

Olga went on to experience powerful emotions of hatred and anger, which she could never have expressed to her mother. As for me, the “safe distance” offered by the online setting helped me to be “there for her” at those difficult moments without letting these emotions sweep me (and our relationship) away.

Towards the end of our work Olga regained the ability to deal with her every-day reality. She slowly resumed her daily activities and began engaging with others in healthier ways. For the first time, her life felt like it was actually her life, separate and apart from her mother.

Taking the Risk

In the process of dealing with such difficult cases, we’ve developed some useful strategies. At the outset, we always discuss the limitations of online therapy with new clients, stressing the fact that it doesn’t allow us to be physically present when we might like to be. Addressing this reality openly allows us to model ways of dealing with the frustrations and the limitations of a distance relationship. This modeling is extremely beneficial, particularly for those clients who have little healthy experience with appropriate emotional bonds or are confused about their own personal boundaries.

While we typically meet with our online clients weekly, we tend to offer a more intense rhythm in more challenging cases. In the two cases described above, we met with our clients twice a week, and sometimes more frequently when major shifts or breakthroughs were occurring.

We also found that online clients reached out to us between sessions more often than usual, and responding to their emails turned out to be a very important part of the therapeutic process. While we usually expect in-person clients to cope with the inevitable lack of contact between the sessions, this is sometimes too much to ask of online clients, giving the physical distance. Responding, briefly but mindfully to their emails, helps these individuals to maintain the sometimes-fragile connection. While this places an additional demand upon the therapist’s time, it can be crucial at some stages of the client’s recovery. Once the client starts to feel stronger, the email flow usually diminishes naturally.

In cases involving some serious disturbance, we can also insist that the client meet a psychiatrist in person. We typically raise this subject several sessions into therapy, once a good therapeutic alliance has been established. Even with the most resistant clients, this strategy eventually works out well once they’ve developed enough ego strength and trust in our support to take this challenging step of consulting with a psychiatrist and eventually taking a prescribed medication.

“Expanding one’s practice to the online realm can feel risky, and to accept clients with major disturbances can feel even riskier.” As with any venture into the unknown, however, the effort may widen our perspective: What we had felt to be out of reach suddenly becomes possible, at least with some of the people who approach us for treatment.

And in taking such a risk, are we not modeling something important for our clients?

Straight Life Cycle/Queer Life

Posted on May 9, 2017February 11, 2026 by Psychotherapy.net Team

It's Time

“It’s time,” my husband emailed me, along with details for an adoption orientation. We were thirty-seven. We both had careers we loved—he a lawyer, me a therapist. We had achieved some creative goals–writing, acting, cake decorating–and let go of many more. We had each lost parents way too soon. And we were not getting any younger. This was obviously the right time to have a kid, I said to myself, right?

And then I met Miles, a client whose life would collide with mine, rousing us both to rethink the concept of time.

He contacted me just as I reached the finish line of promoting a book—a period of time I have heard others describe as “the calm after the calm,” i.e., when the book release is less life-changing than the author anticipates. My book was about modern weddings, including reflections on my own wedding, and so I found myself talking a great deal in interviews about my very “normal”-sounding stages of development, along the lines of those created by psychoanalyst, Erik Erikson—e.g., First comes love, Then comes marriage…. As my husband and I had begun the adoption process, people wondered if my next book would naturally be about modern adoption. And while my exterior may have shone with a normative veneer, on the inside I felt entirely queer: off the track of social expectations.

For one thing, I missed my parental figures. I missed my father and mother-in-law, who died when I was twenty-two and thirty-one. I missed my mother who had just moved to a senior facility, halfway across the country (Erikson didn’t warn me about any of that). And while I was passionate about raising a child, gone were the illusions of moving through time as a normal-looking family with a normal set of parents (now grandparents) sagely guiding my spouse and me to the next normal milestone.

In fact, my parenting fantasies went well beyond taking home a delicious little baby to make us three. My mind flashed forward eighteen years to having a happy healthy young adult we could visit, share a meal with, hear stories about college, or simply sit on the couch and watch a good movie with. I could think of nothing more rewarding between parent and child than that. What I wouldn’t give to have such a moment with my dad today! I longed for the past and for the future.

Miles knew none of this, and only perceived what was available to him about me in the present. He had read about my book and thought I could offer guidance on his impending nuptials with his male fiancé. He was excited about his wedding but could not envision the next step, repeatedly thinking to himself, “Then comes….what?”

Miles came from an educated and accomplished family: his mother was a respected trial attorney and his father a fancy judge. Miles himself went to an Ivy League college and law school, and then he clerked for—you guessed it—a fancy judge. Meritocracy had served him well, shuttling him smoothly from one life milestone to the next. He did hit one detour along the way, though, when he came out as gay. This was challenging for him, as his parents accepted but rarely acknowledged his sexual orientation. For Miles, righting the course after this detour demanded ever higher levels of personal achievement. In addition to his robust CV as a lawyer-to-be, Miles spoke three languages, played the saxophone at jazz clubs, and showed his artwork in galleries. All of this, unbelievably, before he turned thirty.

And then Miles’ mother died unexpectedly. She had always said she couldn’t wait to sit and talk with him before his first big trial. “This was a when, not an if,” Miles said, mournfully describing this expectation.

Insult compounded injury when Miles learned that the civil rights law job of his dreams, which he had landed soon after his mother’s death and which he had worked toward for years, did not pay enough to cover his law school loans. And despite his impressive education, law firms were not interested in hiring a lawyer several years out with no private-sector experience. In order to pay the bills he had to take a non-legal job doing work that to him (and his father) seemed mediocre. Miles had lost his identity. He had been knocked to the sidelines of social expectations where for the first time in his life he was forced to watch other people, including his fiancé—a successful photographer—pass him by.

He did have one crucial milestone left, marriage, but by then even this felt uncertain. “Though he was in love with his partner and eagerly looked forward to their wedding day, he simply couldn’t picture the day after.” The day the milestone had passed. “Then comes what?” His experiences with law school, and coming out, and losing his mother—a littering of unmet expectations—had at this point left him with little hope for the future.

First Comes Marriage

Then Miles got married. The wedding was gorgeous and meaningful. I know this because he showed me pictures during one of our sessions, kneeling next to my chair and swiping his phone with a child’s glee. I absorbed each image like a proud parent. In that moment we were two peers, two married gay men in our thirties, and at the same time we were father (or mother) and son.

And therapeutically I wondered, just as Miles often asked himself, “then comes…what?”

The dark after the dawn came. Week after week Miles seemed more and more lost, stuck, and depressed in our sessions. “I just don’t know what to do,” he would say, repeating a pattern of always seeming to have the answers until he didn’t. In this state of dread he desperately hoped I would have an answer. I didn’t but desperately wished that I did.

For example, I could have taken a page from my own life and asked him if he thought about raising kids. But to bring up family planning would disguise me in the mask of Erik Erikson, the confident, arbiter of “normal”—albeit the gay version—while I squirmed in my own queer ambivalence about “stages of life” underneath.

Given Miles’ experiences of achievement and loss (as well as my own), I felt strongly that if I suggested any tangible solution existed for him at all, I would only conjure false hope. I did not want to set him up for disappointment yet again: to cross yet another finish line only to be denied another trophy.

But it was hard for me to sit with his despair. “I felt like a fraud, like I had failed to be the accomplished, gay married therapist who had it all figured out—in other words, the therapist I imagined he wanted me to be.” Were we both failures? Both lost outside of time, aimlessly floating in space?

At the beginning of one session, both of us hopeless and forlorn, I was sure he would tell me that he was done. That therapy was a waste of time.

Miles’s father had been staying with him for the previous week, and this made him feel worse than usual. “Why?” he wondered aloud. Was it because his father polished off all the leftover booze from the wedding? That he failed to show much interest in Miles or his husband during the visit? That the only question he asked was if Miles had checked in with any of the law firms that had rejected him in case they might reconsider? Was it all of the above?

As usual, I felt like I was coming up short. Miles wanted me to tell him what he should do, and I didn’t know, so I did what therapists do at such times and reflected his feelings back to him. This only made him feel worse and ask again, “What should I do?”

Caught

The feelings of failure and loss in the room were suffocating. I found my mind casting about desperately for air. I thought of the next ream of adoption papers my husband and I still had to fill out—ugh—and then I thought of something more fun. My fantasy of the future, the simple weekend visit with my grownup kid, and how nice that would be.

“What are you thinking about?” Miles asked.

Oops. He caught me. Daydreaming is not on the list of expectations for a therapist. I felt a rush of embarrassment. But I also realized there was nothing I could do but be in the moment.

As I inhaled (deeply and pensively), I began to realize how on topic my daydream actually was—which is often the case for therapists in moments like this, as it turns out. I remembered how lovely it was to sit and look at pictures with Miles, and thought how sad it was that his father had overlooked that opportunity during his visit.

“I was thinking that your father could have told you how lucky he is to be alive and to have you. How happy he is that you’ve made an interesting and loving life for yourself, and how rewarding it is just to sit and visit with you, right now.”

“Yes,” Miles said. He began to tear up. “He could have said that.”

We shared a momentary smile and sat in silence. The past and the future, the lost and the longed for, were all commingling, awake and alive in the present.

Why Every Therapist Should Read Dr. Robert Firestone’s New Book “Overcoming the Destructive Inner Voice: True Stories of Therapy and Transformation”

Posted on March 16, 2017February 11, 2026 by Psychotherapy.net Team

Some people collect stamps, others baseball memorabilia. I prefer psychotherapy and treatment related books. It would be an understatement to say some select works have had a profound influence on my career.

As I type this blog, I have a vintage 1925 hard back copy of John B. Watson's Behaviorism sitting to the side of my monitor. In its day the work commanded a hefty price tag of $3.00 and tied for the most expensive tome in W.W. Norton & Company, Inc. "Lectures-in-Print" psychology series. Today, a signed copy—mine isn't, darn—will fetch $1000.00 on eBay. The book shows its relative age by sporting two small and quite primitive paper covers glued to the hardback surface of the text.

A few feet away is yet another one of my prized possessions: Andy Salter's classic Conditioned Reflex Therapy. Salter, often cited as the true father of behavior therapy and assertiveness training, could write as well as he could practice psychotherapy, and that's saying a lot.

A cursory glance to my left reveals several volumes from Lewis R. Wolberg's time-honored The Technique of Psychotherapy set. These books not only serve as a premier source of psychotherapeutic information, but weighing in at approximately 6 lb. per book, can easily substitute as a set of dumbbells for your next set of bicep curls if you happen to be away from the gym.

But the important thing is the impact that books of this ilk have on you as a helper. A case in point. When I purchased a copy of Jay Haley's Uncommon Psychiatric Techniques of Milton H. Erickson, M.D., I stayed up the entire night reading it. I thought I would never have a psychotherapeutic literary experience of this magnitude ever again. I mean history never repeats itself and they don't write psychotherapy books like they used to . . . or do they?

Frankly, after reading the Haley work, for the first time in my career my thirst for psychotherapeutic tomes was beginning to wane. I went through an extended period where nothing caught my fancy.

Then came the dawn. Enter Robert W. Firestone's 2016 book Overcoming the Destructive Inner Voice: True Stories of Therapy and Transformation. As I delved into the first chapter I unconsciously found myself giving my college class in theories a little extra time for a break so I could sneak back to my office and peruse a few more pages in Dr. Firestone's work.

Keep in mind that Firestone is no Johnny-come-lately to the psychotherapeutic arena. He began his clinical psychology practice in 1957 (not a misprint). Just to put that in perspective it was the year auto manufacturers put fins on cars making them look more like rocket planes, the Frisbee was released, and Elvis purchased a mansion in Memphis and named it Graceland. So much for the theory that experts who write psychotherapy books don't have any real-world experience.

In a sense I have both known and respected Dr. Firestone's work for an extended period of time. As a former program director of a suicide prevention center, and later a book author on the subject, I showed Dr. Firestone's award winning 1985 video The Inner Voice in Suicide to countless helpers and graduate students. It was simply a cut above everything else I could find on the topic. This book shares unique insights from the movie.

So what makes this book different and dare I say it, special? A lot of things.

First, the book is not sterile or antiseptic. Dr. Firestone is very familiar with the reader, often sharing his own innermost thoughts, feelings, reactions, and on occasion an off-color word. Most books of this genre portray the therapist as devoid of reactions, as if he or she is a blank slate or perhaps a computer performing the interventions. Not so in this case. The author comes across as a real person.
Moreover, his anecdotes go well beyond the traditional psychotherapy office with tales including friends, relatives, and colleagues.

It is difficult, if not impossible, to remain emotionless when Dr. Firestone recounts his friendship and first-hand experience (i.e., he was there) of the death of the famed psychiatrist R.D. Laing. He also shares his up-close-and-personal experience with noted psychiatrist John N. Rosen, who pioneered direct analysis which utilized psychoanalytic principles to take on the problem of schizophrenia. This creative approach contradicted the establishment's view that psychosis was a biochemical or strictly a medical problem and thus could not be treated by psychotherapy. Firestone gives us a truly unique perspective of the psychiatric facilities of yesteryear and helps us answer the question of whether Dr. Rosen was a genius or a madman.

If you are searching for another cookie cutter book that says do x,y, and z to cure your clients, this is decidedly not the book for you. And don't let the title fool you. Just because the term "inner voice" is emphasized, this is definitely not just another book on CBT. Far from it! In my estimation, the inner voice is a lot more intricate than conventional cognitive therapies. It is as if Dr. Firestone tweaked cognitive therapy, infused a healthy dose of existentialism, and added a dab of psychoanalysis in all the right places.

In a nutshell, your inner voice is composed of critical remarks from your mother or father, or significant others. These thoughts can eventually morph into your own negative thoughts. Thus, you might say to yourself: "You are so stupid. Only an idiot would do that. Who would want to date you. Nobody!"
Not that as a therapist you would have any personal problems, but just in case you know a colleague who does, Firestone rounds out the book with an appendix aptly titled "How To Incorporate Voice Therapy Into Your Life." Translation: Therapists as well as their clients can harbor some painfully destructive inner voices or parental attitudes he terms the anti-self.

I'm not going to spoil it for you by telling you everything, but I will go on record as saying that his work might just be the cure for the common psychotherapy book. It's definitely a keeper. Or to use a play on words from an advertisement released in the early years of Dr. Firestone's career: The name that's known is Firestone, where the psychotherapeutic rubber meets the road.

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