rezendevknowfully.com, Author at Psychotherapy.net

Molyn Leszcz on Group Psychotherapy

Posted on March 15, 2011March 13, 2026 by rezendevknowfully.com

Core principles of Group Therapy

Victor Yalom: To get started, Molyn, can you give a general definition of what group therapy is, and what are some of the core principles of the way group therapy works? I know those are broad questions.

Molyn Lesczc: I think that the first statement to make is that group therapy is not a monolith; it is a range of different approaches that utilize the group. Some groups tend to be more skill-building and psycho-educational, for example, and use factors of peer presence support, camaraderie, and economy of scale to deliver an intervention. Then there are therapists who use the group as an agent for change, in which we aim to make better use of the processes of interaction, feedback, and learning from one another that occur within the group.

VY: That, in and of itself, is quite a different idea in terms of how we tend to think about therapy. Most of us are trained initially as individual therapists, so we think of the therapist and the therapeutic relationship as the agent of change. Here, we’re suddenly thinking the whole group is part of the change process.

ML: Absolutely. The group is an entity of its own shaped by the multiple relationships that occur between people in the group. The complexity is so much greater in groups like this, but the power comes from that as well. The bread-and-butter group therapy is the kind of work that we describe in The Theory and Practice of Group Psychotherapy, where

The group becomes a social microcosm: an opportunity for people to learn about the interpersonal underpinnings of their psychological distress.

the group becomes a social microcosm; an opportunity for people to learn about the interpersonal underpinnings of their psychological distress; an opportunity for interpersonal learning—insight, feedback—and behavioral skill acquisition.

I see group therapy, really, as the ultimate integrative model, because it’s a treatment that provides an opportunity for people to gain insight, self-awareness, and behavioral skill and practice. It integrates cognitive, emotional and behavioral elements.

I think we’re always aspiring to do that in our work, but group therapy really delivers on that as effectively as any treatment.

VY: Right. Of course, you’re referring to the text originally written by my father, Irvin Yalom. And you came aboard as co-author for the latest, the Fifth Edition, of that book.

ML: That’s correct.

VY: He primarily espouses an interpersonal model of group psychotherapy. Could you say a few words to summarize the core concepts of this approach?

ML:

Sure. First, let me say that the interpersonal approach has become more popular of late, and it’s important to distinguish the interpersonal approach to group therapy and other versions that have more to do with IPT—the Myrna Weissman approach to interpersonal therapy—which is non-here-and-now, but rather more skill-building and educational. I’m going to focus on the interpersonal model of group that that was really pioneered by your father. I had the great privilege of working with him, and then contributing to the Fifth Edition of this text.

In essence, what that work does is build upon a long tradition that focuses on our need, as relationally determined people, to engage, and how our engagement in our contemporary world is shaped by early life experiences.

Harry Stack Sullivan, through his influence on other people in Baltimore at Johns Hopkins, had a big role, as you know, in your dad’s view. He impacted Frieda Fromm-Reichmann and Jerome Frank. And your father took it to a remarkably accessible level. In essence, how I understand it is like this: every person operates in this world with a certain kind of roadmap, which consists of our beliefs about ourselves and the world that emerge from early life experience, and the interpersonal behaviors that follow from those beliefs.

If we are healthy and resilient with good self-esteem, then our behaviors reinforce adaptive beliefs about ourselves, and we engage a healthy, productive loop in our relational world.

VY: Right. And speaking of self-esteem, I recall some statement by Sullivan that our own sense of esteem is really, in some sense, a collective mirroring of the feedback we perceive from others.

ML: That’s right, the reflective self-appraisals.

VY: Do you agree with that, or do you think that’s overstated?

ML: Absolutely.

VY: Isn’t there also something we bring to our personhood that we’re born with?

ML:

Certainly there are constitutional and temperamental factors. How our early life environment reacts to that and reinforces that, I think, is pivotal.

You can take a highly energetic child—temperamentally a bit reckless, aggressive, assertive—and in a family that is able to corral that and harness it and see it as self-determination and strength of will, that person will grow up with a stronger sense of self and self-esteem than a child that grows up in a family where that is viewed as being burdensome, a nuisance, and something that a depressed parent doesn’t have time for.

So the pathogenic beliefs, which are the starting point of the roadmap, are shaped by early life events, the environment, culture, personal psychology, family psychology, temperament, constitution—all these things together.

But they have powerful influence, because they then shape the interpersonal behavior that follows:we seek what is familiar, not necessarily what nourishes our growth. Group therapy becomes a very powerful way to illuminate that link between pathogenic beliefs and interpersonal behaviors. And many contemporary models of psychotherapy echo that.

VY:

So an energetic, maybe excitable child in an optimal environment would be supported, maybe gradually shaped, so that he can succeed in the world; and in another set of circumstances, his development might go awry.

So, group therapy, of course—or any form of therapy—tries to deal with the situations where something goes awry, so they’re not functioning fully effectively, and also having some internal problems—distress—about what’s happening in their life.

ML: Right.

VY: If you start with this interpersonal model that asserts that we’re basically social animals, how does group address the situations when things go awry?

ML: I think the group therapy addresses that by creating an environment in which people are able to bring themselves as they genuinely are in the world at large. That’s the social microcosm. The group would not be useful if what happened in the group didn’t reflect what happens in people’s lives at large.

VY: The social microcosm refers to the idea that however people are in the world, including their behaviors that cause them problems, will get played out or enacted in the group.

ML:

And the more you’re able to get people to look at interpersonal processes and communication in the here-and-now, the more the microcosm comes to life.

If you had a highly structured group where people were given specific tasks, you’d have much less opportunity for people’s interpersonal style and interpersonal processes to emerge. I’m sure you’re familiar with the background at National Training Laboratories, the original work by Kurt Lewin in the late ‘40s.

VY: It was a bit before my time, but I’ve heard of NTL. Weren’t they referred to as T-groups, or training groups?

ML: Yes, they were training groups for executives. In essence, they were being taught how to be better leaders. At the end of the day, all of the facilitators would meet and talk about the group dynamics, and how hard it was to get this guy to see things from other people’s perspective and the like. What emerged then is that executives found out that they were being discussed in the evenings. They said, “Give us access to that information.” So that really became the start of the encounter group mentality, where people were given feedback in the moment, rather than a focus on the transmission of content material alone.

VY: And I assume they found that feedback useful.

ML: Well, they found it useful and challenging.

Working in the Here-and-Now

VY: Getting back to the social microcosm, say I have a client who’s aggressive, has difficulty maintaining relationships, or another client who is a people-pleaser, never gets his or her needs met. A naïve reaction might be, “Well, we don’t want them to repeat that behavior in the group. We want them to change it.” But this model is saying, “First, we want to see what that behavior looks like.”

ML: That’s right. It begins by manifesting itself. We obviously don’t want it to persist, and we’re looking for every opportunity for change. But people are more likely to make changes when they have hard evidence for what the problem is.A classic example is the man who reports in the group how his wife is always hard on him, critical, and he doesn’t feel he gets a break. In fact, it’s illuminated even in the Schopenhaeur Cure video to a certain degree, with Gil and Pam. If you’re not careful, the group may sympathize with him and give him advice such as, “You’re married to a miserable woman. Get away from her.”

Whereas if you look at what’s happening in the here-and-now and ask this very powerful here-and-now question—if you asked the women in the group, “Based upon on what you know of this man, in his time in the group, what would you think it would be like to be married to him?”—then you get the feedback about what it would be like being married to an inanimate object:”He seems like a decent guy, but if I was married to him, I’d be withering on the vine because he’s so unresponsive and gives so little of himself.” It’s an intervention that your dad has used, and I’ve used many times.

VY: You’re referring, of course, to this video demonstration that we’re just releasing, which was an enactment of the characters in my father’s book, The Schopenhaeur Cure, which occurs largely in the context of a therapy group.

ML: Exactly. So

making things come alive in the here-and-now is, I think, the most important skill a group leader can develop.

making things come alive in the here-and-now is, I think, the most important skill a group leader can develop. It’s the most challenging aspect of the work, but I think once you’re able to do that, I think you really are able to move things to a very effective level in which, I think, people really make meaningful change.

VY: You’re describing one of the core skills of group therapists—according to this model, at least—which is how to bring the group into what’s called the here-and-now. Now, that’s a term that’s been bandied around a lot from Fritz Perls onwards. But in this model of group therapy, it has a very specific meaning.

ML: Yes, it does. What is meant by that is moving away from people telling their stories into talking about the experience of telling their stories—getting the group to reflect on itself, and the members’ experience with one another.So, for example, instead of you and I doing this interview in this way—you asking questions, me making comments, you making comments, me responding—a here-and-now approach would be, “What do you really think about my answers? How am relating to you?”

In a chapter I recently wrote I used the example of walking down the street and asking someone for directions. That’s a simple transaction at the level of content. But if we were working at that at the level of a here-and-now, what we’d be looking at is the following:How do I feel asking for directions? Am I concerned that my wife, kids, girlfriend will have a negative reaction to me for needing to ask for directions? When I ask somebody for directions, of all the people passing by, what am I using to determine who I will ask? What is it about their demeanor, about how they carry themselves that leads me to ask them the question?

VY: So if you take that lens of looking at group interactions, you’re thinking of how people engage in the group. Do they monopolize? Are they quiet? Are they assertive? Who are they drawn to? Who are they distant from, or afraid of?

ML: Exactly. What is the meaning of their behavior? What is driving them? And when I talked earlier about the roadmap, I believe that a group therapist needs to have a very good sense of each person’s roadmap in the group. I aspire to operate in this way:that,

in a moment-to-moment fashion, I’m thinking that whatever is happening in the group is either part of the solution or part of the problem. It is either creating opportunities for growth or it is reinforcing pathological behavior.

VY: Can you give an example of that?

ML: A woman came into a group, and the important elements of her story were that when she was a youngster, her older sister was diagnosed with leukemia. And the family was concerned, understandably, that this daughter would die. So, they threw all of their resources into caring for this daughter.My patient grew up with the sense that no one had interest in her; no one was invested in her; that her job was just to make things better for others, and not to ask for anything for herself.

So she comes into treatment with a history of disappointing relationships; failure to advance at work; chronic depression and self-harm. And at the heart of it is her belief that she is to be seen and not heard. In the group, that becomes the important focus of her work.

VY: How is that visible, then, in the here-and-now of the group interactions?

ML: Because she’s always helpful to other people. She rarely asks for time for herself. When somebody is crying, she is crying. When somebody is laughing, she is laughing. So she becomes like a Greek chorus rather than a person there in her own right, with her own entitlement.

VY: Now, I imagine that this is a likeable trait in some way, at least initially. People like someone who’s attentive to them.

ML: There’s a lot of positive reinforcement for her. But ultimately, you have to ask the question, “What is it like for you to be in this group, always giving support and not asking for much back? How do you think others in the group feel about you doing this? What’s it like for you coming to the group knowing that that’s what’s going to happen? What would it be like for you to actually ask for some time? Compare and contrast meetings where you’ve asked for things from us, and how you felt in the evening afterwards with those meetings where you come and just look after others.”

VY: So all of those are ways of getting her to focus on process—her experience of being in the group.

ML: That’s correct.

VY: And you do this with other people to give her feedback. Although they may like her attentiveness at first, I imagine they grow tired of it. They don’t feel like they ever get to know her.

ML: Exactly. And ultimately, it begins to feel inauthentic.Another incident occurred recently in a group—a man who had been badly sexually abused as a child came into a meeting feeling very annoyed, angry at how upbeat everyone was about the idea that the group leader presented. This was an early-stage meeting of a group that I supervised. The group leaders proposed that one task of the work in the group therapy was to emancipate themselves from the past. And everyone had been excited about that. But this man was then plagued that whole week with a resurgence of flashbacks and re-experiencing phenomena of the sexual abuse.

He came into the meeting saying, “I have to tell you how angry I am at you that you think it’s so easy to escape from the past. I’ve been reliving my past every day for the last 30 years.”

First, that was important because that was the opening for him to talk about the sexual abuse. It was also important because what he went on to say was that he was terrified that expressing his disagreement with us, disagreement with those in the group, would lead to attack. That was his experience, always. Whenever he protested the abuse, it resulted in more abuse.

So that was the first part. And this leads us to the next issue, which is the corrective emotional experience. Once you bring people into the social microcosm—once you illuminate their interpersonal processes, once people begin to push against their roadmap—it’s important then to reinforce that, and create an experience that this confirms their pathogenic beliefs, by virtue of insight and a relational experience.

Though with this man, we dived into what was it like for him coming to the group today, knowing that he was going to tell us he was angry with the way the meeting had gone the week before? Who did he think was going to be supportive? Who did he think might be challenging? What does he feel about the job that he’s done in protesting his opinion in the meeting today? And so on and so forth.

VY: These are, again, all process-oriented questions.

ML: All process-oriented questions.

VY: And this is done by the leader.

ML: It’s done by the leader, and ultimately, as the group matures, it’s done also by members of the group.

VY: So you’re shaping the group to start doing that work on their own.

ML: That is correct. The mature groups are able to do that on their own.

VY: And the corrective emotional experience you referred to is what? How does this help him?

ML: It helps by virtue of reinforcing the risk-taking, helping him to actually see that although making a protest in his youth led to a crushing attack, the group welcomes it now, and we do not want to silence him or marginalize his experience; we’re very interested in the meaning of things for him. And that taking this risk, in fact, makes him better known and closer to us, rather than the opposite—which is his fear that it’s going to lead to further abuse.

Training Group Therapists

VY: Let’s back up a sec. You’ve been training group therapists for how many years now?

ML: Thirty years.

VY: And I think you probably run, at the University of Toronto, perhaps the largest group therapy training program anywhere in the world?

ML: I don’t know about that. I’d be reluctant to say that because I can’t measure it against others, but we have the largest psychiatric residency program in North America, the second-largest in the world. We train about 25 to 30 residents in each of five years of training.

VY: And in your program, how many groups are going on at any one point in time?

ML: I think residents are doing groups of different sorts all over. It would be hard for me to estimate, but I would probably say residents are involved with maybe 30 groups a week.

VY: Let’s start with the skill of helping groups get into the here-and-now and talk about their experiences in the group with other members and their feelings about each other. This is a challenging skill to learn—both for beginning therapists and even experienced therapists who aren’t group therapists.

ML: It sure is, yeah.

VY: What does it look like actually getting the group to work that way? You’ve given a lot of examples of the types of questions you ask, but how does that happen, and what’s hardest thing for group therapists to learn in terms of doing that?

ML: I think that it’s difficult work. And one of the projects that I worked on in the last several years—through AGPA [American Group Psychotherapy Association]—was the creation of a document of clinical practice guidelines for the practice of group psychotherapy. What we’ve tried to compile in that are all of the elements that I think go into proper running of groups, and hence, proper training of group leaders.To run effective groups, you have to plan for them wisely, and you have to have support—of the system, of the administration. You have to be aware of how to use the therapeutic factors in group therapy—the importance of cohesion, and the principles that help to achieve and sustain cohesion. You need to be able to select wisely and prepare people properly. You need to be aware of the developmental stages that groups go through. You need to work well with group process. And you need to know how to use yourself effectively as a group therapist, and be mindful of the ethical demands of doing the work.

VY: I just read through this document and it’s quite comprehensive. And it does address initially a lot of the institutional challenges of getting groups going—administrative challenges. Just getting enough referrals, if you’re in a private practice setting, to start a group—that’s a real challenge. What are some of the key considerations and challenges to actually forming groups?

ML: People’s resistance to group therapy.

VY: Both patients and systems?

ML: Yeah. I think that there’s a general undervaluing of the effectiveness of group therapy. And group therapists suffer because their work is efficient; and people assume if it’s efficient and economical, then it’s going to be of lesser quality.

The research shows pretty convincingly that for most people, group therapy and individual therapy are equivalent, in terms of their effectiveness.

VY: And in terms of that, patients think, well, if there are eight people in the group or nine people in the group, I’m only going to get to talk an eighth of the time, so I can’t possibly get as much out of it as if I had the undivided time of the therapist.

ML: Right. They don’t have an appreciation yet—and that’s where preparation comes in—about how the group works, and how the synergies in the group can make that 90 minutes relevant. Each minute can be relevant to each person.Also, many of the people who really need group therapy don’t have positive experiences in their social groups. They haven’t been the most popular kid in high school. They’ve often felt, earlier in their life, that relationships were hard; or, because of depression, relationships have become hard. So the group is daunting for them.

Take a look at how groups are portrayed in the media and TV and movies. There’s a lot of the theme that we throw people out of groups. All the reality shows have to do with people getting extruded. It really feeds into people’s apprehension about being the weakest link, or being the first one thrown off the island.

VY: So those are patients’ fears. Then there are challenges of getting patients referred your way. Now, if you’re working in an institution or a setting where there are lots of patients, it’s easier. But if you’re in private practice, if you’re just relying on your own referrals—unless you have an extremely healthy practice—it’s quite challenging to get enough suitable people to get a group going.

ML: For sure. So you weigh it. You think, “Well, I can see these people individually and get paid for each of them by the hour rather than put them together into a group.” Groups are not necessarily more lucrative for practitioners in private practice. There’s great interest in their applicability in institutional settings, where there’s a high volume of patient flow. But it’s challenging to get started.

VY: So what advice would you have for a therapist who is, say, in private practice and really excited about doing groups, but doesn’t know how to get them off the ground?

ML: I would say get as connected as possible with other providers who will see you as an ally and a resource—whether it’s family physicians, primary care providers, or other mental health professionals. And think of a group that has something useful, both as a stand-alone, and also as something to be applied conjointly with other interventions. But you have to be deeply connected.Something else that I tell all of my trainees is, whenever somebody asks you to see somebody, whenever you have a consultation, make sure you send a note back to the referring professional. Those things really cement the relationship, and increase the likelihood of that person remembering to send people your way.

VY: I’ve always done one or two groups in my private practice, and always with a co-leader, for a couple of reasons. I enjoy the process of co-leading. So much of our work as therapists is solo, it’s been a richly rewarding experience to be able to share and learn from another therapist. But also, just logistically, if we’re both drawing on our own referrals, it’s been a lot easier to maintain the group over the years.

ML: That makes great sense.

VY: Let me just add one more point. As you well know, in major metropolitan areas, there’s a lot of competition among therapists. I’ve found that doing group therapy is one way to distinguish yourself, since not that many therapists in private practice are offering that.

ML: I think that’s a great point. At the University of Toronto, at my hospital, we get a real flow of referrals, because people recognize this is the place where people will be seen and get a good group therapy experience. In our hospital, I typically get 10 or 12 referrals a month for group therapy. So we’re able to start each year probably five or six time-limited groups, with eight or nine or ten people in them.

VY: I would guess if you’re doing that many groups, you have some different types of groups, or groups that are for people who are at different levels of functioning, so you’re able to assess people and place them into appropriate groups.

ML: Right, we do about five or six groups a year, time-limited, interpersonal group therapy. In addition, we run groups for trauma, groups in our day hospital program, groups in the inpatient setting, groups in our geriatric program, women with post-partum depression in our perinatal mental health program. We have a whole range of groups.And one of the things about groups is that they’re very malleable, that you can change your focus and emphasize homogeneous concerns. So I’ve done lots of groups with seniors with depression; with medically ill patients, women with metastatic breast cancer. We just published an article about using interpersonal group therapy to help people with alcohol abuse to maintain sobriety, and we showed that by dealing with these psychological interpersonal vulnerabilities effectively, we’re able to reduce heavy drinking and substance abuse.

VY: So even though many of these are what you called homogeneous groups—in that they revolve around a topic, a symptom, a life challenge—you still put a heavy focus on interpersonal here-and-now relations in the group.

ML: That’s right, absolutely.

Group Selection and Preparation

VY: Can you say a little about the selection and preparation of group members, because that’s so important to developing healthy, sustainable groups?

ML: I think a shorthand answer is to funnel everything that you do through the therapeutic alliance. The therapeutic alliance is the best predictor of outcomes, across all kinds of psychiatric treatment and psychotherapy. What we look for is the degree of agreement, between the treater and the patient, about the goals of treatment, the tasks of treatment, and the nature of the relationship.

VY: You’re doing that in the first assessment meeting?

ML: Yes, that’s something we’re doing right from the start. If their goals are not in sync with our goals, then the group’s not going to be an effective experience for them. They may need to be in another kind of group.Now, what do people need to be able to do to engage in the tasks of treatment? They need to be able to come reliably. They need to be able to sit in the group. They need to be able to speak. We’re talking about having the logistical, intellectual, and psychological ability to actually make use of what the group provides.

So I find it very helpful to be able to ask and answer the question, “Do we have convergence on the goals of treatment? Do you have convergence about the tasks of treatment?” Then I talk a little bit about what they can expect from me in terms of the therapeutic relationship and from the relationships in the group.

VY: But if someone is coming to you or your clinic because they’re depressed, for example, and you’re suggesting, “Gee, rather than go into individual therapy, I think you might really benefit from a group,” you need to explain to them how a group works, and how it might be helpful.

ML: Exactly.

VY: What are some ways you do that?

ML: Well, I think virtually everything that we’ve talked about in the interview so far, Victor, I would share with them:the research that shows it’s an effective modality of treatment; how it would work; how I think it would work for them specifically, with regard to understanding how their difficulties—with passivity, assertiveness, anger, self-esteem—contribute interpersonally to the difficulties that they’re having in their life at large; and that the lens that we’re going to look through is what’s happening at the level of interpersonal relationships.Then I’ll talk about the microcosm of the here-and-now, interpersonal learning, the corrective emotional experience.

VY: So you really lay it out for them—how the group works, how it might benefit them.

ML: Absolutely. There is an appendix in the Fifth Edition, of a preparation document that therapists can give to their clients. You can personalize it, but it really covers and nuts and bolts of what we feel needs to be communicated to people.And

there’s robust research evidence that well-prepared clients do much better in group therapy. They stay longer, they work better, they understand the tasks, they’re more popular group members and much less likely to drop out.

VY: Right. And dropouts can be a big problem in groups—not only for the clients who drop out, but it can be demoralizing, or threaten the very existence of the group.

ML: Yeah. It’s very hard, in particular when people are beginning to do group therapy, to have dropouts. The residents that I supervise are heartened by two comments. One is that dropouts are inevitable, and that no one in the literature, even in the most experienced hands, is able to eliminate dropouts, and the range is anywhere from 10 to 40 percent.The other point is that if you never have any dropouts, then it means you’re setting the bar for entry into your group too high, and you’re like a surgeon who only operates on people without any risk factors. And it means that you’re missing the opportunity to be helpful to a lot of people who would otherwise benefit from treatment.

VY: But if the bar is too low, and you let a lot of people into the group who don’t stay very long, it can be disruptive and demoralizing to the group.

ML: No question.

VY: You talked about preparation and the research showing how important that is. One thing I’ve heard about in some institutional settings people are doing intake over the phone and are sent to a group without much screening or meeting with the therapist. That seems like it can cause a lot of problems.

ML: I have to say, I understand the pressures that some organizations are under; but to me, it’s being penny-wise and pound-foolish. If you want preparation to really take hold, it should be provided by the person who is actually going to be doing the group. Part of the rationale for preparation is to begin to establish the therapeutic relationship, and you want to screen people in a more meaningful fashion. So I think if you cut the front-end short, you end up paying at the back-end.

Co-Leading Groups

VY: Another problem that I’ve heard about is interns in agencies being matched up with a staff member, a more experienced therapist—which is great, in theory. I mean, most of the time in our training we’re thrown in the room alone with the client, and we don’t have the chance to learn directly from working with experienced practitioners—which is how professionals generally are trained, whether in fields of law or surgery or accounting.But it often seems that interns are thrown into co-leading a group, and there isn’t sufficient time allotted to meet with the senior therapist for several sessions prior to starting a group to make sure they’re on the same wavelength. Or they may not have time to meet after the group to debrief. And there can be tensions between the group leaders that aren’t worked through.

ML: All those things happen, but I think they are by and large avoidable if people, number one, are working in good faith, and if there’s a commitment on the part of the more experienced group leader to promote the growth and development of the trainee. And the only way to enact that good faith is to actually have time to meet before the group and after the group. If you’re not doing that, then you’re not giving yourself a chance to be successful.

VY: In your training program, is there a lot of co-leading that goes on? Do you pair residents with staff or with each other?

ML: Mostly with each other. But for 30 years, I’ve led at least one or two groups a year with the residents. I often tell them that my first real experience leading a group involved, I think, the greatest gradient imaginable between my experience level and the experience level of the person I was co-leading with, which, of course, was your dad.When I began to do groups with your father, at the beginning of my fellowship at Stanford, I had had very little experience in groups. And I remember vividly—and I tell this story often—that one of the groups I co-led with your dad that he brought me into was a group he was leading for mental health professionals, all of whom had done group work. Some of them were even teaching group therapy.

I remember one group session when somebody came into the group with The Theory and Practice of Group Psychotherapy that they were using in a class that they were teaching. And I felt really de-skilled, small and marginalized, which was a very uncomfortable feeling.

But I talked about it with your dad, and he responded, in essence, “This group is too dependent on me, and that’s why they’re not making any room for you. It’s not good for you, it’s not good for them, it’s not good for me. So look for an opportunity.”

Ultimately, after several weeks, I identified that I felt no one in the group was paying any attention to what I had to say. And this goes to show you that there is an unconscious—I meant to say that people were just waiting and deferring for this “wise old therapist,” in reference to Irv.

But I didn’t say wise, I said wizened, and I didn’t realize it! Irv, afterwards, when we rehashed it, had a great laugh

But I didn’t say wise, I said wizened, and I didn’t realize it! Irv, afterwards, when we rehashed it, had a great laugh and teased me about the Oedipal strivings that were evident in that slip of the tongue.

I think in co-therapy you have to anticipate competition, rivalry, tension. But hopefully, as I say, if people are working in good faith, these don’t become insurmountable problems, but, in fact, become learning points.

I often tell residents, if you are a passive co-leader with a more active co-leader, what message does that give the quiet members of the group? It models for them that it’s okay to take a backseat. And that often has a powerful impact.

I think most people are also heartened to hear that I was able to address the gradient of my limited experience working with your father at Stanford in 1980. If I can do that, they can do what they have to do here.

VY: I hadn’t heard that story before from you, but we share that experience, because I led a group with him very early in my training, and certainly had similar experiences—that I knew very little and felt I had little to offer. It was a challenge for me to speak up and feel that I did have something to contribute.

ML: Absolutely. It’s part of the consequence of the very large shadow that your dad has cast.

VY: Indeed.You’ve trained many, many therapists over the years, group therapists. What are some of the things that are most challenging for them to learn about being effective group therapists?

ML: I would say the most difficult thing has to do with learning how to use oneself effectively as a therapist, and how to use language effectively—how to be able to communicate meaningfully with our patients; the risks that we need to take sometimes; how to be appropriately transparent, including the limits of transparency.

VY: What kind of risks?

ML: The risk of giving feedback to a patient. Oftentimes, especially young therapists are very reluctant to do that, because they feel that it’s going to fudge the boundaries.

VY: Do you think there are still some vestiges of the blank slate?

ML: Still some—and now with the added overlay of, “If I’m too personally present in the group, is that a slippery slope that’s going to lead to some boundary issues later?” Still dealing with the aftermath of the ’90s and all the focus on boundary crossings and boundary violations.

VY: What’s your take on that?

ML: I think that it’s impossible for a person to be in a room with another person and not to disclose. So I would rather be proactive and mindful about it rather than think it’s not happening.

VY: Rather than think that the way to avoid the possibility of some kind of inappropriate behavior is just to set a hard-and-fast rule that we’re neutral and we’re impartial bystanders.

ML: Exactly—to be stilted, distanced. I think fundamentally group therapy is a human experience, and we have to be humans in it.I think that probably the best line that a patient ever articulated in a group—this was a senior person who was close to leaving the group, who was welcoming somebody new into the group—she said, “You know, you’re beginning now. Likely, you’re going to be skeptical about this, the way I was skeptical for the longest time. My first impression was that the group was a very natural place for unnatural things to happen. And then,” she said, “with a little bit more time, I realized that, in fact, the group is an unnatural place—it’s constructed for this purpose—but that what happens here is very natural.”

A real endorsement of the meaning and the value of the relatedness.

VY: Yeah, because it is a contrived situation. People are paying money to be there. And yet the nature of the relationships, and the events that occur in the group, become extremely meaningful to people in a successful group.

ML: Incredibly so.

I’ve had many, many patients say to me that the group is what anchors them, and that they carry the group with them. They think about the group all the time.

In fact, one woman in a group that I run commented that she holds onto images of people in the group during the week to help her deal with adversity. And when that woman graduated from the group—a very successful ending; she was leaving to get married, having previously—a woman in her thirties—having never had any sexual contact—one of the other members of the group, who is an accomplished artist, gave her, as a going-away gift, these beautifully crafted popsicle-stick figures of each of the group members, made out of material and wood and painted. Just a beautiful embodiment of the internalization of the members of the group. Touching.

The Best Kind of Work to Do

VY: And, needless to say, as this has been the focus of your professional life, it can be a deeply rewarding experience for a group therapist.

ML: Absolutely. I think it’s the best kind of work to do.

VY: How has it been rewarding for you?

ML:

I think that we grow as our patients grow. You can’t do this work and be static.

I think that we grow as our patients grow. You can’t do this work and be static. All of the things that I’ve learned about people, about the world, have shaped me in very constructive fashions. Even dealing with people who are facing death—our metastatic breast cancer research—has made me more existentially aware; the meaning of their experience, I think, has added meaning to my experience.

Your father has written extensively, of course, about existential approaches to psychotherapy, and I think there is enormous value in that. Life is short. Make use of it. Author your life in a way that is meaningful to you; you’re personally responsible for authorship.

I often tell the story of the woman that I first encountered in the metastatic breast cancer group who subsequently graduated from that group. She is one of the long-term survivors from that group. Most of those women died within a year or two. This woman was diagnosed with metastatic breast cancer when she was 26, if you can believe it, and she’s still alive and thriving twenty years later.

I saw her September 12, 2001, right after 9/11—and she comments to me what a terrible tragedy the World Trade Center attacks were. But it crystallized for her that if she had been in the World Trade Center on 9/11 and had died, she took heart from the fact that she would not have had one moment’s regret of how she lived her life on September 10.

I think that’s something that I aspire to, and I think, if we’re able to help our patients aspire to that, then we’re going to help them a great deal.

VY: Well, I think that’s an inspiring and encouraging note to end on. I want to thank you so much for taking the time to share your wisdom and passion about group therapy.

ML: If we speak for a moment, too, Victor, about our here-and now, it’s a remarkable sequence. I’ve benefited so much from my relationship with your father, and to be able to talk about that work with you in your career, in this way, feels like another good loop.

VY: It feels absolutely that way for me. And that’s an example I can’t help noticing from a process lens:when you shifted the conversation away from the content—group therapy—to making it a personal connection between you and me, I found myself moved in an emotional way that I hadn’t previously in this conversation.

ML: I feel that, Victor, and I’m glad that it touched you in the same way. I would have not wanted our conversation to end without making the comment.

VY: Thank you very much.

Stan Tatkin on a Psychobiological Approach to Couples Therapy

Posted on February 8, 2011February 11, 2026 by rezendevknowfully.com

A Psychobiological Approach to Couple Therapy

Ruth Wetherford: So, Stan, let's talk about psychobiological couples therapy.

Stan Tatkin: Right. It’s actually a psychobiological approach to couples therapy.

RW: What is that approach all about?

ST: When we're talking about psychobiology, we're talking, really, about the brain and the body. And we're looking at five domains—the first being attachment. And by attachment I mean infant attachment as well as adult attachment.

The second domain is arousal regulation. We focus on preparatory, or anticipatory, systems that work alongside the attachment system, and that are embedded in procedural memory. These anticipatory systems prepare us for moving toward and away from others, based on history and experience. And this is read through the body —through the face, the eyes, the pupils, the voice or prosody of the voice, skin color, temperature, movement, posture, and so on.

The third domain is neurobiological development. We take a deficit-based approach, not a conflict-based approach, meaning that we don't really focus on conflict. We don't focus on what most people —couples, at least —bring into therapy as a presenting problem: money, sex, mess, kids, and time. That is what most everybody complains about.

Rather, we look at the couple's ability to be a co-regulatory team–to be able to manage each other, particularly during distress.

Rather, we look at the couple's ability to be a co-regulatory team–to be able to manage each other, particularly during distress. How good are they during stress? Everybody has conflicts, as John Gottman says. Every couple has conflict. We're looking to see how a couple handles conflict and whether they handle it in a secure functioning manner or in an insecure functioning manner.

The fourth domain is therapeutic enactment. We work with procedural memory. We work with the body, with a bottom-up approach. In other words, rather than use interpretation, we stage experiences so that couples have an enactment, or certain state of mind, state of body, online to work with. So it's really experience before interpretation.

RW: What are some examples of these?

ST: It's using a lot of psychodrama —going back to Moreno, but also Gestalt, pulling from Satir. By basically moving people into experience, using a bottom-up approach rather than a top-down approach, we avoid tapping into higher cortical areas first, which are really good at error correcting, really good at processing, but can also mislead the therapist.

In other words, higher level cognitive processing is not as reliable as the body. So we want to get at the body first.

And then the fifth domain is therapeutic narrative. This is the therapist's own stance about why couples should be together. It has to be a coherent narrative that, along with theory, explains where the couple has been, what their trajectory is, why they are where they are, and where they're going. The narrative is grounded in secure functioning relationship, as opposed to an insecure functioning relationship. So it's very much as it is when you're working with personality disorders: the therapeutic stance is very important.

RW: This is an integrative approach.

ST: Yeah, very.

RW: Let’s dive in and talk about how we can use this. Where would you start, with a therapist who is reading the article on Psychotherapy.net, and is very intrigued and wants to know more about how to apply it?

ST: It depends on which domain we’re focusing on. With the people in my training, we focus on all five domains, each having its own set of principles and goals. But I would say one of the first ideas for therapists to grasp is: what is a secure functioning relationship, and what is insecure functioning relationship? I would say probably the easiest way to parse this is that an insecure functioning relationship is fundamentally based in a system that is unjust, insensitive, and unfair.

RW: Relational injustice.

ST: Yes.

RW: How important do you feel it is for therapists to focus on their own levels of security of attachment in their general approach to clients?

ST: Well, that's a big question, and that's more about therapy for themselves. We're talking here about theory. There are therapists who might have an insecure attachment if they were tested, say, in a proper AAI [Adult Attachment Inventory] with a reliable coder. But they could still be effective therapists and understand what a secure functioning relationship is, and follow those principles.

Here's the difference between therapist self-awareness and education, adherence, and understanding of theory. I think the very first thing is, talking professionally —and again, this is also true for couples —it is entirely possible for two individuals to be insecure but to form a secure functioning relationship. That is, their model of relationship, the principles they follow, would be considered secure functioning. What we're comparing is a two-person psychological system based on true mutuality (good for me and good for you), versus a one-person psychological system with too much emphasis on self-values or -interests, rather than on relational interest.

But there are other factors —not just a two-person psychological system —that add up to secure function. The other, in terms of a primary attachment relationship, is a mutual protection of the safety and security system for the couple.

This means that both partners agree that the relationship comes first, and that the safety and security of the relationship come first. And the reason it comes first is because, without that agreement, neither can really thrive.

Looking at the mother/infant attachment system and what we know about that system, in terms of security, a secure relationship is based on attraction, not fear or threat. Insecure models base their relational glue around fear or threat. So protection of that safety and security system is a key feature of a secure functioning relationship.

Yet another factor is a lot of mutually positive, amplified moments between the two, which are usually face to face, eye to eye, sometimes skin to skin. That is actually called primary intersubjectivity —when two people are in close physical proximity and using each other's eyes and communication to amplify positive moments, which, by the way, have neurochemical parallels to them.

And then, secondarily to that, is joint attention, wherein partners focus on a third thing to amplify the relationship. That's another quality of secure functioning. Namely, first, a lot of mutually positive amplified moments between the two people, and then —this is really important —second, that the negative experiences that partners encounter individually and collectively are mutually attenuated and foreshortened by the couples' skill at metabolizing and managing distress.

So I would say those two are extremely important for secure functioning relationships: high positives that are mutually amplified, and negatives that are quickly repaired and corrected. Distress is relieved quickly, not dismissed. When you asked the question, "How does a therapist apply this or understand this," I think we first must understand what it is, and then adhere to that idea when looking at couples. And then, of course, it's very hard, if you're working in this way, not to grow yourself, and look for it yourself in relationship.

RW: It’s everywhere.

ST: Well, it becomes everywhere, because that’s where your focus is.

Avoidant and Angry-Resistant Styles

RW: Regarding the importance of the soothing being a mutual skill, it’s a very common complaint in couples work that one partner complains that, when there is a breach of empathy, or something that moves the interaction toward an insecure feeling, one person is usually more in the role of the one who bridges that distance. And that person complains. They want the other to be less avoidant, more engaging. And typically two people are differently skilled about the extent to which, in the moments of conflict, they can self-regulate and reach out to the other.

ST: That’s right.

RW: Any thoughts about that?

ST: We're looking for couples to be able to rely more on interactive regulation, coregulation. People who are insecurely attached —that is, basically the avoidant and what I call the angry-resistant on the other side —have different styles that are wired in from childhood, in terms of how they regulate. For example, the avoidant, who comes from dismissive and derogating parenting, relies on autoregulation, which is a form of self-stimulation, self-soothing. It's not just simply a defense: it is an adaptation from very, very early, and it's wired in. So this is a default position.

RW: Things like saying a prayer, singing a song, taking deep breaths, meditation.

ST: Or masturbating, or reading. Or singing, like you said, or performing, writing. Anything that doesn't involve another person —although there are things that involve another person, with which the avoidant person could autoregulate. In Kohutian terms, that would be using that person as a self-object.

So autoregulation is normal–everyone does it–but the avoidant over-relies on autoregulation.

So autoregulation is normal–everyone does it–but the avoidant over-relies on autoregulation. And that's a sign of a one-person psychological system. The thing with autoregulation is that it's a very energy-conserved state, almost dissociative. And the problem with the avoidant is his or her inability to shift from being alone to interacting. Avoidants can shift from interacting to being alone, but not in the other direction very easily.

The angry-resistant, by contrast, focuses and over-relies on external regulation. Angry-resistants require another person to help calm them down or stimulate them. They, in contrast, have a hard time shifting from interaction to being alone, not from being alone to interacting. So you have two one-person systems that avoid relying on interactive or mutual regulation, which is what we're trying to move couples toward.

The angry-resistant will feel some fear about separations and reunions, particularly about being dropped. But both partners have a responsibility to repair these reflexes with each other, regardless of whether they are avoidant or angry-resistant. So we have a lot of emphasis on getting the couple, especially during distress, to coregulate —eye to eye, face to face —and to make quick repair, make things right as soon as injuries or distress arises. This way there's no memory of the event.

RW: What are some ways you have found that help people to engage in face-to-face, mutual soothing activities? Do you talk to people about the theory?

ST: Sometimes I do. But, basically, I suggest to my students that we push the therapeutic narrative forward by expecting a secure functioning relationship, not just teaching it. We expect one. So when people are not operating in this way, we wonder why. Don’t forget, it’s not simply the avoidant who can create a tone that is threatening, and who starts a fight. Let me just say this: “the reason most couples enter into conflicts that are problematic is because of their inability to know how to manage one another. They don’t know how the other person really works.”

Getting Couples to Manage Each Other

RW: Do you teach them skills to help them overcome their deficits?

ST: Yes. Much of the therapy is really active and experiential. I do very long sessions —two to four hours, sometimes six hours, and they're all videotaped. And the reason for this is to be able to move the couple through a variety of states, which are very much like real life.

Instead of talking about events, we try to enact them and try to make the corrections in real time

Instead of talking about events, we try to enact them and try to make the corrections in real time, while they're in that state of mind. So this becomes a part of procedural memory, which is actually why they get in trouble in the first place.

RW: I’m inferring a lot of coaching.

ST: There’s a lot of coaching, yes.

RW: Like when you've asked them to have an interaction, you read the facial expression and tone of voice a certain way, empathically. The spouse you're teaching doesn't. They're not empathic. They break right there. You'll stop the interaction there or you may note that and use it in some way to help them read the other face. I can imagine how helpful that would be if I'm reading my partner's eyes as angry when it's interest or when it's confused. If I see criticism, based on my deficit —if everything is critical, you can teach me nuance. That would be great.

ST: The idea here is that each partner is in the other’s care. They’re not in the therapist’s care. So we want to point to each partner: “Did you see that on her face? Did you notice that?” I don’t want to be the only person noticing things. I want them to be able to see things. I should say that the room is set up in a particular way, like a staging area. Everyone is on chairs with wheels. So I can see body movement. I can turn to them. They can turn to each other, and I can see them turning away, as well. “So the emphasis is to get them to read each other. They have to be experts on each other.”

RW: You identified the domains of your focus. What are some of the goals of these different domains?

ST: On the attachment level, we want to educate both partners in terms of their attachment orientation. This isn’t to say that we’re going to give them jargon, but we want them to understand from where they came and how that has wired psychobiologically into their nervous system and every cell of their body, to normalize it. This is not a pathological view of human nature. This is a very natural view of human nature in terms of attachment, adaptation. We all adapt. And the nice thing about looking at developmental theory is we can get a picture, a sense, of how someone has to adapt to certain situations. And that gives us a sense of what the person is going to do in the future.

We want people to understand who they are, really, and to take responsibility for that. For example, if the avoidant is dismissive or derogating or gets angry when his or her partner approaches, then he or she must quickly fix that and make it right. But also, we want each partner to understand the other and to know how to manage the other in the best way. When we look at attachment, we know that it isn’t so much about personality; rather, it’s about the sense of competence and agency that two people in a dyad feel they have over the other. In other words, I know that I can manage you. I can shift your state if I need to. I can move you around if I want to, without the use of threat. I can do this in the best way.

And that’s what we want. We want couples to learn who they are. They didn’t get married to be different people. They got married to be just who they are. But they want to feel that they know how to manage the other person. So the emphasis here is very different. We’re not teaching people how to manage themselves. We’re teaching the proper way, which is how to manage each other. And this, again, is borrowed from developmental theory.

RW: Don’t you think it’s both/and?

ST: It’s both/and, but too many therapies focus on self-regulation.

RW: Exclusively.

ST: Right. The way that this works is that, in a primary attached relationship, it is much more efficient for me to manage your state than it is for me to manage my own. And one of the reasons it's more effective is that, the way we're wired, at close distances you can see what's going on in my internal state, my nervous system, before I know. I can see what's going on in yours before you know. This gives us an advantage. There's a reason this is built in at close distances. At far distances, we're interested in whether we're attracted or we're dangerous. But in close distances, we're able to see into each other's nervous system and to be able to respond in this dance of mutual regulation.

So that's what we want to encourage, on the attachment level. On the arousal level, we want to make sure that couples can talk about anything, do anything, without fear of dysregulation. One of the reasons therapy sessions are very long is

I like to set fires and put them out, or make messes and clean them up

I like to set fires and put them out, or make messes and clean them up —however you want to look at it. But we want to get into areas of difficulty so that partners are not afraid, so that they know how to co-manage these situations by tensing and letting go, and never getting into a situation in which they dysregulate one another. They must know how to stay in a play zone, even when they're fighting. This is a very, very important part.

RW: That's powerful —the role of play.

ST: It is. Couples should not be afraid of anything when it comes to each other, and they certainly should not be afraid of the relationship breaking simply because they’re in conflict. So we take off the table any fear having to do with the relationship breaking or falling apart on either side of the partnership.

The Elephants in the Room

RW: So if there is doubt that the person wants to stay, and they say, "Yes, I am thinking about divorce, and I can stop saying that in the middle of a fight but it's there. I don't know if I want to stay" —how would you take that off the table?

ST: Well, in the very beginning, if that is really a very strong message and one partner, at least, is drifting or pushing in that direction, this is where it gets kind of tricky.

I will go in that direction and push it all out. In other words, I call it "bending metal" —going in one direction or the other fully. I'm not in the business of breaking people up. But if there is resistance and there's one person saying, "I don't know if I want to do this," then I will go full bore into breaking them up, for the purpose of getting pushback or blowback. In other words, I want to find out what they're really made of, and I think one of the jobs for all therapists is to clarify what's going on.

RW: That’s very important because that’s the elephant in the room that the other spouse knows is there. And if the therapist is too afraid to push on it and bend the metal, then you really can’t get to building the security.

ST: Right. One of the reasons this approach goes fast is the therapist is very active and evocative, and even a bit of a clown-at-the-bullfight kind of person. I was trained psychoanalytically; this is very different because we want to push the boundaries and see what people are made of. So if somebody thinks he or she wants out of the relationship, then we have a session on “Let’s divorce,” and we’ll go all out. And then I will look for pushback. Now, much of the time, people are using this as a way to threaten the partner to get him or her to comply. But once it’s exposed that they really aren’t going to leave, they don’t want to leave, they can’t leave, then it gets taken off the table. Because we’ve already proven that the person is not being truthful. They’re using this as a maneuver to threaten the partner. So we want to get that off the table as soon as possible, and we do that by getting them to throw down, basically.

You can see this is taking a little bit from strategic family systems, too, in that we’re being a little tricky, but always in the interest of clarification. So that’s how that’s handled.

RW: And that would apply when a person is having an affair?

ST: Oh, that’s our bread and butter.

RW: How so?

ST: A lot of people end up coming in because either they are having an affair or they're hiding one. And in this model,

we think of affairs not as attraction to a third, but an aversion toward the primary.

we think of affairs not as attraction to a third, but an aversion toward the primary. So when two people assume the office —and I think of it as an office —of primary attachment figure, it's almost like the office of Presidency. The office of Presidency has a certain valence to it. Forget who's sitting in it. And then there's the person with his or her personality, which either adds to, amplifies, or whatever, the office.

So when two people assume the office of primary, this is a very intense relationship that resembles no current relationship, only past relationships. And, as such, people become deep family when in these positions. That is why a lot of problems arise. I call it the marriage monster. As soon as people get married or they enter into the relationship with a sense of permanence, all these attachment fears coming from procedural memory and experience begin to arise. So movements away and toward each partner we see as part of the predictable trajectory, and not just as happenstance or an accident.

So, most affairs, depending on who's having them, reflect the insecurity of the primary attachment relationship, not so much the attraction to the outside third person. Ironically, many people pick, as their affair, somebody who's almost identical to themselves. And one of the common things I'll hear, and I'm sure you hear too, is "Why aren't I like this with that person? Why do I feel this way with my sister or my brother and not with you? Why my friends don't do this to me?" My thought about that is, "Well, marry your friend and then see what happens." Because it is a phenomenon of marriage or commitment that this material starts to come up.

RW: Going back to the goals, you were naming the goal of the attachment domain is to move towards security.

ST: Move towards security and to understand who each person is and how to manage him or her.

RW: And then, in the arousal domain, the goal is to promote mutual regulation.

ST: Yes, we're promoting interactive regulation, which is a close monitoring of each other's face, voice, eyes, and body. And by the way, interactive regulation in this close proximity, and mutual gaze, are how we fall in love, most of us. So it's simply going back to the way we originally began anyway. But also, the goal is to learn how to do this so that you and I, as partners, can talk about anything. We can enter into any area of importance without fear of threat or dysregulation. And that's a major, major goal.

On the developmental level, the therapist really has to discover what deficits do arise —and we all have deficits, and especially they come up in relationship —to clarify those and to hopefully help move them along developmentally. Partners need each other to do that.

If I am with you, and I discover that you've never been able to read my face, you've never been able to read anybody's face, that is going to be one of the reasons we have trouble. And I may have thought you were doing this purposely, when actually you weren't. This is a deficit. This is something you've never been able to do. That changes the game in a lot of ways. And sometimes people will never get very good at something. Other times they can get better with the help of the partner.

RW: Okay, any other goals in the other domains?

ST: In general, we're moving people towards a secure functioning relationship. And that includes, like I said, true mutuality. In other words, everything we do is based on a social contract, borrowing a bit from attachment theory and John Rawls here —a social contract that's based in fairness and justice and sensitivity. So, if the relationship comes first —not us as people, but the relationship —and it becomes the air we breathe, the water we drink, our basic fundamental engine of energy to go through the day and to brave the world, then there are things that we have to do with each other to keep each other feeling attractive and attracted to the relationship. And one of those is making sure that every decision we make is one you're good with and one I'm good with. There is no dragging you along because it's good for me, but it doesn't have to be good for you.

So we're changing really from a monarchy, or dictatorship, to a system that is fair between these two generals, who are both in charge and they have to please other.

RW: If we’re not both happy, neither one of us is happy.

ST: Neither one of us is happy. And everyone who lives below us and around us will be unhappy, too. I kind of think of this as king and queen. If the king and queen are in disorder, everyone in the land is in disorder.

So that goes with kids and that goes with everybody we interact with socially.

There’s one more part here: the management of thirds. By this I mean third things, third people, third objects, third tasks. This could be drugs, alcohol, work, in-laws, friends, children, dogs, pets, and so on.

RW: Famous triangulation.

ST: A secure functioning couple has a kind of couple bubble around it, wherein the dyad comes first, and thirds are secondary. What this means is that the couple is aware that in public and in private they protect each other at all times. They don’t allow either of them to be the third wheel for very long, at least not without repair. In this way, everybody actually fares much better. So the management of thirds is a huge deal. As therapists, we can find out right away if a couple is mishandling this by the way they address us.

One of the reasons I have them on chairs with wheels is that I can see how they’re moving and who they’re talking to and who they’re addressing. If I notice the partner is talking to me, ignoring the other, or saying something about the other without checking with him or her, then I know both of them handle thirds poorly. And not just in the therapy session, but everywhere. So, another big goal is the management of thirds, in public and in private.

It’s great fun.

RW: It sounds like fun. What are some things that therapists can take from this to translate it into tactical tips, tools, and techniques?

ST: First of all, I would recommend that someone who wants to get into being a couple therapist do it wholeheartedly, because it is very different than working with individuals and families. It's a specialty. And I think, as such, it deserves a lot of attention and a lot of focus. Having said that, I think that it is next to impossible to see a couple, particularly in the beginning, for an hour. I think the therapy sessions must be long, to give therapists enough time to relax and not be pressured. Otherwise, the therapist, him- or herself, can become dysregulated, and pressured. More mistakes are made that way.

So longer sessions to watch the couple cycle through different states, to give therapists time to think and formulate. Begin to play very, very close attention, not to content, but to micro-expressions, micro-movements. I think therapists today should be trained —whether it's Paul Ekman's material or other places to get this training —to work with the body and be able to pick up very subtle but very significant cues on the face and the voice that reveal shifting states and emotions. This is very key to working with the body. I think it's important to try to avoid getting caught up in the content of what a couple's talking about and start watching, basically, these two nervous system interacting.

One thing I do want to say before ending here is that this is a maxim that I always use and say: people do not know what they're doing. This goes for us therapists, as well.

We do not know what we're doing most of the time, and we don't know why we do what we do

We do not know what we're doing most of the time, and we don't know why we do what we do most of the time. And there's a reason for this. When we are interacting with another person, we're using very fast-acting subcortical processes that never see the light of day in terms of higher cortical areas. We're simply acting and reacting very quickly, as we should. And then, when asked why we did what we did, we really don't know. But because we're human beings and because we don't like to not know, we make it up.

I could say that this is a function of the left hemisphere that confabulates, because it doesn't know what the right hemisphere and subcortical areas are doing. But this is the flow of data through the body and the brain. We act and react much faster than our cognition, and certainly our words.

So the therapist would do well to understand neurobiology and how the brain actually works and what people are really doing. A lot of things that are happening between two individuals —and this includes individual therapy —are sub-psychological. In other words, it's biological. It doesn't even get to the higher levels that we consider psychological or theory of mind. This is our most basic nature. Our number one imperative as human beings is to not get killed. It comes before love. It comes before everything else. And we have some very, very well developed —in terms of evolution —primitive areas of our brain that are very good at looking out for our survival. They don't give a damn about relationships or anything else. If it comes down to feeling threatened, we do war instead of love. That's what I'd say.

RW: And from there is the title of your new book with Marian Solomon.

ST: That's right. Love and War in Intimate Relationships: Connection, Disconnection, and Mutual Regulation in Couple Therapy. It is available through Norton in the Interpersonal Neuroscience Division. The official publishing date is February of this year.

RW: Congratulations on that book.

ST: Thank you.

RW: What kind of training are you planning to do in the future, so that you can disseminate and spread the word and help people learn this?

ST: We do trainings in Los Angeles; San Francisco; Seattle; Austin, Texas; Boulder, Colorado. Maybe soon to be in New Jersey. We also have an international group that we do training with, as well. So it’s spreading like wildfire right now. And if people want to get involved in the training, which is a great deal of fun, they’d have to go to this web address: www.ahealthymind.org, and the click on the city that’s nearest to them.

RW: Is there anything that that I haven’t asked you or that you haven’t had a chance to say yet?

ST:

Applications for Individual Therapy

We didn't really get a chance to talk about how this translates into individual work, but it does, because we're dyadic creatures. Individual therapy is a dyad. I will say that, as a cautionary note, being an individual therapist for so many years, I now view primary attachment relationships as sacrosanct. And if an individual does come to me and is in a primary attachment relationship, I will work my darnedest to get that partner in, to turn it into couple therapy. And the reason I do that is because when we're working with the primary attachment relationship currently, we're dealing with proxies: people who represent the past. And there's no more powerful system than that system. The therapeutic relationship tries to approximate that, but really can never do that for a variety of reasons. For one, the therapeutic relationship is asymmetric. So, when we have that capacity and that exists, I think we should shift to couples therapy. If the couple or the individual is unwilling to do that, I think it's incumbent upon the individual therapist to act as an adjunct —to move that relationship forward rather than try to compete with it.

So I think there are mistakes being made now with individual therapists who are competing with primary attachment relationships. And that would be a nice thing, I think, for people to start to learn not to do.

RW: It sounds like you’re suggesting that therapists not only promote secure attachment with themselves, but also with the primary attachment spouse.

ST: Right. Instead of trying to compete with it, we try to promote the one that already exists. Unfortunately, when we see one individual who’s in a relationship, we will never, ever know the truth. One person is not a reliable reporter of the relationship.

RW: Well, there are different truths. There’s my truth and then there’s your truth.

ST: After a while doing this, you understand again the principle that people don’t know what they’re doing. That’s true for everybody. So, in this work, working psychobiologically, we want proof. We want to see it. We don’t want to hear about it. We want to see it.

RW: I know that you’re familiar with the notion that in many situations we don’t know if people should divorce or stay together.

ST: That’s right.

RW: Particularly if they are at the long line of a series of many, many injuries and don’t have any capacity for repair and a very entrenched avoidant or resistant pattern of attachment. And let’s say one is growing and is seriously wanting to think about leaving. How do you deal with that? How do you deal with those moments when you are promoting the divorce rather than the increased security attachment?

ST: I only promote divorce as a trick. I only promote divorce to test the mettle of at least one person who is drifting in that direction.

RW: And if the metal yields?

ST: Well, if the metal yields, then no harm, no foul, because clarity is the most important thing. People aren’t going to do anything because you tell them to, not really.

I have stopped being the arbiter of who should be together and who shouldn’t.

I have stopped being the arbiter of who should be together and who shouldn’t. I assume that partners will no longer be together when they are no longer together. Until that time, they’re a couple, and I’m their couple therapist. And I continue to assume that my job is not to decide whether they’re right or wrong for each other, but to move them toward a secure functioning relationship. That’s my job. If they do not make it, they’ll be better the next time for therapy. But I don’t decide anymore. Now, when I have strong feelings about the couple not being together, it’s always countertransference that passes momentarily. There are a lot of therapists who’ve tried to break up couples, and I think this is actually morally wrong.

I think nature has its own path. Primary attached relationships are very complex and very strong. We don’t understand them fully. I think people are quite capable of ending things when they’re really, really done. And they’ll prove it. Otherwise, you’re the couple therapist until that time. That’s my belief.

RW: Thank you for this interview. It was very enjoyable.

ST: Thank you.

Alan Marlatt on Harm Reduction Therapy

Posted on January 11, 2011February 11, 2026 by rezendevknowfully.com

Harm Reduction Defined

Victor Yalom: We're here to interview you today about your work with addictions, and specifically your contributions to the field of harm reduction. Just to get started, the name harm reduction gives a hint of what your approach is about, but maybe you could say a few words to introduce the concept.

G. Alan Marlatt: We are basically trying to support people that have addiction problems. If they want to quit, we'll help them do that. That's our relapse prevention program. If they would like to be able to reduce their drinking or drug use-harm reduction—we want to support them there too.

Many people with alcohol and drug problems are not getting any help, and I think part of the problem is they don't want to identify as drug users, or if they're using illegal drugs, they're afraid they're going to be arrested and put in jail or something like that. They're holding out. But if you talk about moderation, many people say that's an enabling strategy.

VY: Many professionals.

GM: And others. So it’s a very controversial topic, but basically my position is, “We’ll help you, whatever your goal is. You want to quit, we’ll help you. You want to cut back, we’ll help you. We’re not going to shut you out.”

A lot of the traditional treatment programs are saying, “Unless you’re totally committed to abstinence, we’re not going to work with you.”

Rebecca Aponte: If somebody wants help cutting back, is that something that they can work on with a harm reduction therapist for life?

G. Alan Marlatt: With some people it's for life. Let me give you an example of a case. This is a woman that was being treated by a psychiatrist for depression at the University of Washington. The therapist called me up and said, "I've been seeing her for about three months, and today I found out that she has this drinking problem. So, I said to her, 'I can't really help you or continue to treat you unless you go into alcoholism treatment, and I don't know how to do that.'"

VY: He doesn't know how to do alcohol addiction treatment.

GM: Right. Most psychiatrists don’t know how to do that; it’s not part of their training. So he wanted me to do an evaluation of her. When she came in to see me, she’d already been to the alcohol treatment center that the psychiatrist referred her to. I said, “How it’s going?” She said, “Everybody’s telling me something different. The psychiatrist said I was probably drinking a lot to kind of self-medicate my depression.” And that was partly true.

Then, when she went to the alcohol treatment center in Seattle, they said, “No, your alcoholism is causing your depression. Unless you are into our abstinence-based program, it’s just going to continue. Are you ready?” She said, “No, I’m not ready. This is the only thing that works for me and I know it’s causing other problems, but I’m not ready to give it up.”

So she was stuck in the middle. For a lot of these kinds of people, harm reduction therapy is the best alternative. So I said, “Let’s do harm reduction therapy. I can help you keep track of your drinking, and see what’s going on.” So she agreed to do that. A lot of people at that point will drop out. If all they have are abstinence-based alternatives, they’re not going to do it.

But she agreed to do it. She worked with me for three months and we kept track of her drinking. She reduced her drinking significantly.

VY: What was her goal?

GM: Her goal was to drink more moderately and to figure out what was going on in her marriage about drinking, because her husband said, "You're a chronic alcoholic and unless you stop drinking altogether, I'm going to leave you." That made her more angry and depressed. She tried to stop drinking, and then when he would go out of town, she would get loaded—this kind of thing.

We finally figured out there was a lot going on in terms of the marriage and her anger. Then I taught her meditation, which was the most helpful strategy for her. Then, one day she was going shopping and she saw her husband in a car embracing another woman and it just made her start drinking again. She said, "I can't do this anymore."

She went to a meditation retreat center in France—Plum village, the Thich Nhat Hanh Center. You go there, you take these precepts. One of them is no use of intoxicants while you're here. She said, "I took that and I thought, 'That's it. I'm never going to drink again.'" She's been now abstinent for five years.

So harm reduction was the bridge to get her there. If you say, "You've got to stop now," a lot of people go, "I can't stop now." But if you start getting them into a harm reduction program and they realize they can reduce their drinking and begin to figure out what their triggers are, they feel a lot more confident that if they want, they could quit. That's what happens a lot of the time.

VY: Getting back to the basics of it, what do you mean by harm reduction and how did it originate?

GM: I did a sabbatical at Amsterdam in the early '80s. That's where harm reduction originally developed, because they were the first country to realize that injecting drugs can increase HIV and AIDS—so why doesn't the government provide needle exchange instead of [the addicts] sharing needles, which spreads HIV much more readily? This was when HIV and AIDS really broke out and a huge number of people died. So they said, "If people are going to use, we want to help them stay alive. We want to reduce the harm." The needle exchange program was really the first type of that.

In Vancouver, Canada, where I grew up, there are many homeless people living in the lower east side that are injection drug users, and a lot of them are overdosing and dying.

What did the mayor's office do? After some persuasion from harm reduction specialists, they opened a safe injection center. This is where, instead of shooting up in the alley and not knowing what you're getting, you can go to this site. They'll give you clean needles. They'll allow you to shoot up there. There are nurses and doctors available if they need help. Since they opened that, the fatality rate has dropped. Of course, many people say, "Why is this happening? You're just enabling them to continue using."

VY: Right. "This is illegal and the government is helping them do something illegal."

GM: Exactly. The second program in Vancouver that just started and is also having good results is basically prescription heroin from doctors. Of course, that started in England years ago. Physicians there called it the medicalization approach. If they were dealing with a heroin addict, they could say, "Look, we'll prescribe you heroin while you're doing treatment because we don't want you to overdose from buying it on the street where you don't know how potent it is." These are harm-reduction kinds of approaches.

Another example is methadone treatment; that's harm reduction because you're reducing the rate of potential for overdose fatalities.

The Bar Lab

I was interested in applying it to alcohol problems, which means moderate drinking. Mainly we’ve been working with college students who are binge drinkers, because the NIH report has been showing about 1,400 to 1,500 college students die every year from alcohol-related problems—overdose drinking, car crashes.

At the University of Washington, there was a recent case of a student who died. A 19-year-old freshman was living in a dormitory, and a woman that was his friend just turned 21. What do you do when you turn 21? You want to have a party because you can drink legally—even though her friends were 19 or underage. So they go, “Where can we go and not be caught by the dormitory advisors and things like that?” If you catch you drinking and you’re under 21, you could lose your room. So one guy said, “Hey, there’s a balcony on the seventh floor. Let’s bring all our alcohol up here.”

So they took their vodka and rum and everything else up. There were six of them. They said, “We’ve got to drink quickly just in case—otherwise we’ll get caught.” They all got loaded pretty fast, and the guy who died was sitting on the edge of the balcony telling a funny story, lost his balance—head-first down in the cement, killed on impact. His blood alcohol level was 0.26. In Washington state, 0.08 is the legal limit. He was triple that.

We found out from his family and friends that he wasn’t a big drinker in high school. Once he got to college and all of his friends were drinking, he just went overboard.

So harm reduction for college students means we’ve got to train you how to drink more safely, even if you’re underage—that’s when the highest risk occurs. We developed a program called BASICS—Brief Alcohol Screening and Intervention for College Students.

We’re teaching them, “Just like safe driving, this is safe drinking.”

We’re teaching them, “Just like safe driving, this is safe drinking.” Your blood alcohol levels, what’s going on, how alcohol affects you—we teach them all that. We bring them into our bar. We have an experimental bar on campus called Bar Lab. We give them drinks.

VY: This is like John Gottman's Love Lab.

GM: Yeah. This is the Bar Lab. It's a cocktail lounge on the second floor of the psych building. What we do there is bring students in and give them drinks. They can drink anything they want for an hour—usually about 12 to 15 students. They're usually getting pretty loose and playing drinking games. Then we tell them, "Guess what? None of the drinks that you had had any alcohol in them whatsoever. They're just placebos." They go, "What?"

We tell them, "Look, when you go drinking, three things are happening: what your actual drink is, number one; what the setting is, like a bar, there's music or whatever; and most importantly, what your set is—your expectancy about how alcohol's going to affect you. Those things make for big placebo."

So, people who go through this—we call it the "drinking challenge"—end up drinking about 30% less after they go through that particular program.

VY: How do you get them to agree to do the program?

GM: They get paid for follow-ups and assessments over a four-year period—only about $200, but still. We had an abstinence-based alcohol awareness program on our campus, and they would show car crashes and things like that—people who get killed. And they were trying to say to people, "You can't drink legally until you're 21." Who showed up for that program? Hardly anybody—maybe 2% of the students.

But if we go into the fraternities and the sororities and the dormitories and others and say, "Would you be interested in a program that would help reduce your hangovers and your driving, sexual problems and things like that?" They all go, "Yeah." So you bring them in.

So harm reduction is typically user-friendly. It's not saying, "You've got to stop or we won't talk to you." People with addictive behaviors—there's so much shame and blame and stigma. They don't want to show up. Instead, we're saying, "We're going to meet you where you are. We're not asking you to quit right away. We're just saying let's talk about what your drinking or drug use is like and see what you might want to do. We'll try and help you, whatever your goal is"—rather than confronting them and saying, "you've got to quit."

Moral Objections

VY: Why do you think there's such vociferous objection to the harm reduction approach?

GM: Many people buy into the moral model of drug abuse, the war on drugs—it's called a black-and-white model. Either you're abstinent or you're using. You're an addict. There's nothing in between. So the door is pretty tight. Kurt Olkowski, the new drug czar that we just got under Obama, said that the war on drugs has failed. Thank God, because the previous administrations under Bush and Nixon said, "Lock them up. If they're using illegal drugs, punish them." We now have 2.3 million people locked up in this country, which is more per capita than any country in the history of the world. Sixty percent of them are there either directly or indirectly incarcerated because of drug or alcohol problems.

VY: It's clear you take issue with the moralistic approach.

GM: Yeah.

VY: Is harm reduction a countervailing philosophy?

GM: It’s a public health approach.

VY: Is it a more scientific, research-based approach?

GM: Yes, it is based on research, and there are more and more studies coming out that show that it is really helpful. It's working. Our BASICS program for college students is now listed on the national registry for evidence-based practices. We've got about 2,000 universities that are now using it. That's really working. People don't like to call it harm reduction. They would call it an alcohol skills training program or something.

Alan Leshner, who's the director of the National Institute on Drug Abuse, published an article last year saying, "Drop the term 'harm reduction' because it creates so much controversy. Let's call it something else"—sort of like the word "communism" or something. Up until recently, if you were presenting a paper at the APA or any other conference where there was sponsorship from NIH, if you used harm reduction in the title, it was eliminated. They said, "No, we won't let you talk about it."

I've run into this a lot. I've given talks about harm reduction where half the people walk out of the room while I'm talking. Huge resistance.

VY: Why do you think that is?

GM: They're from the moral perspective and they think all the harm reduction technique is doing is enabling people. I received an award yesterday, and one of the people that gave me the award told me he remembered when I was first talking about harm reduction and people claimed I was murdering alcoholics and allowing them to die.

…when I was first talking about harm reduction…people claimed I was murdering alcoholics and allowing them to die.

What we’re doing, like in Housing First, is trying to keep these people alive. That’s what the research has shown. So I think harm reduction is going to take off under the new administration. Ninety percent of the people who have alcohol and drug problems aren’t getting any treatment unless they’re busted for something. How are we going to bring them in? We’ve got to allow harm reduction to be a middle way.

VY: You're not against abstinence as a goal.

GM: No. We’re for both. We’re just trying to get more people in the door.

VY: You're for both abstinence and moderation.

GM: We’re for whatever your goals are. We’re going to help you do that.

VY: If someone has a goal of moderation, but is unable—some people apparently can't control their drinking—

GM: You’ve got to put them through a program, and then they finally get to realize that they can’t do it even though they’ve had the best program. If it’s not working, they’re much more willing to consider abstinence. You’ve got to try something.

VY: Do you agree with this idea that there is a subset of addicts that just can't do moderation?

GM: It depends on the moderation program. Now there are more pharmacology treatments coming in to help people moderate drinking, and many more cognitive behavioral skills training programs. A lot of people can't achieve moderation if they just try and do it on their own. If they get into a good program that teaches them the skills, like how to use a blood alcohol level chart—if you're a male or a female, how many drinks over how many hours, what your blood alcohol level is going to be—what are you going to do instead of drinking? You want to keep your BAL lower. A lot of the young people that we work with that do binge drinking—they drink two beers in 15 minutes. They don't feel anything so they drink two more, and things like that. We tell them to slow down. Drink two beers and wait half an hour. Then they can actually feel the effects of these two beers. "I don't really need any more," this kind of thing.

We're not telling them that it's all bad. We're just telling them it can be harmful.

Alcohol is biphasic. The initial effects are euphoric, but if you keep drinking, it gets dysphoric.

Alcohol is biphasic. The initial effects are euphoric, but if you keep drinking, it gets dysphoric.You start losing your coordination. You have blackouts and other kinds of problems. What is your limit here, where one more drink is not going to make you feel any better? You learn that. You stick with it. That's been working very well.

RA: Do you see a lot of parallels between the opposition to the harm reduction approach and the opposition to anything other than abstinence-only sex education?

GM: Totally, yes. It's the same issue because they're saying, "If you teach people about safe sex and condoms and things like that, that will enable higher amounts of sexual activity, so we should promote abstinence." But those programs are not working.

It's just like the DARE program—the drug abuse resistance education—totally abstinence-oriented. Now they're finding that kids who went through the DARE program in school are doing worse in terms of alcohol and drug use. Harm reduction applies, I would think, to what we call the 3 Ds of adolescence-the three dangerous drives—drinking/drug use, dating (sexual behaviors), and driving. So if you teach people how to do those things more safely, whether it's sex, driving or drugs, you're going to reduce harm. There's plenty of research to show that it's true, but the political resistance has been amazing.

For example, one of the big harm reduction programs we have done in Seattle is for homeless alcoholics, people living on the streets who are drinking. We worked with the Downtown Emergency Services Center, which provides housing for homeless people. There was a program in Canada called Housing First where they give people housing and let them drink in their housing if they want. Compare that to what they tried in New York, in which people had to quit drinking or they wouldn't get the housing, so almost everybody got expelled or kicked out because they couldn't give up drinking.

So the Seattle program, which we received a big grant on, basically asked, "What's going on?" We wanted to compare people who got housing right away with the people who were under waitlist control. The people we looked at were selected by the King County and Seattle government; they were people that had the highest health costs over the last year. These were very sick people; the average life expectancy for them is about 42 years. So the government referred these people, who either got the housing right away or were on the waitlist. In our program, they were allowed to drink in the public housing and the opposition in the media was huge. "What? We're using taxpayers' money and letting them drink? What is that all about? You're just enabling them."

One year later, we found that the people who got the housing had reduced their drinking. For many of them, having housing gave them more reason to live. As we published in the Journal of the American Medical Association, the most important thing was the health cost savings of four million dollars over the first year. All of a sudden, people said, "Maybe harm reduction saves money compared to what we were doing before." We keep getting these flips in terms of reactions to harm reduction.

RA: I've heard you mention before that therapists can unwittingly enable their clients' addictive behaviors by ignoring the addictions that are going on: treating the emotional issues that they bring into their sessions, but not talking about their alcohol or cocaine use.

GM: Yeah. A lot of people do have both kinds of problems, and they’re using alcohol or cocaine or whatever it is to self-medicate when they’re depressed or when they’re anxious. That’s still a big split between the mental health and the addictions fields, even though many people have both kinds of problems. How are we going to approach them and teach more mental health folks to think, “Hey, there are alternatives here”?

Harm reduction is one of them, and brief interventions have become very popular now. For example, Tom McLellan, who is the associate drug czar/psychologist that everybody knows, was saying we should train primary health care physicians at general hospitals, so that when people come in with whatever their medical problem is, if they have an alcohol, smoking or drug problem, do a brief intervention. It doesn’t mean confront them, but just say, “Hey, have you thought about doing something about this? I have some information for you. Try it out. See if it works.”

They include harm reduction programs to cut back as well as programs to stop. That is very radical, but it has been happening in trauma centers around the country. In the Seattle trauma center, if people are brought in from a car crash that involved drinking or something, Larry Gentilello, a physician there, would do a brief intervention, meet with the person once their medical care is handled. “Hey, there are some programs that could help you cut back or quit drinking. Are you interested?” A lot of them said, “Yeah.” The trauma center would give them the information, and provide the referral. That turned out so well that now all trauma centers around the country have to show that they utilize brief interventions in order to get their license. That includes harm reduction.

I think we’re going to see more of it because, first of all, it works.

The research is very strong. It saves lives. It saves money.

The research is very strong. It saves lives. It saves money.It gets more people on board.

Right now, most people with these problems are just staying out. They go, “All there is is Alcoholics Anonymous. I went one time. I don’t like it, and there’s nothing else that I know about.”

Harm Reduction in Psychotherapy

VY: Let's get into the nitty-gritty of how a typical psychotherapist, who doesn't specialize in drug and alcohol use, may deal with a patient struggling with an addiction. How do you start applying these principles in the course of counseling and therapy?

GM: First of all, you’re going to ask the person what’s going on in terms of their alcohol or drug use. What are the risk factors? We adopt a bio-psycho-social model. Biologically, you want to know maybe the family history and alcohol or drug problems. You want to know about whether that’s going to increase their risk. Then you would go on to psychological issues, what we call psychological dependency on alcohol or drugs. Why do they think it’s helpful, and what are their outcome expectancies about drinking or drug use?

VY: So you ask why they think it's helpful.

GM: Or harmful. We want to look at both sides. We want to meet them where they’re at, enter their world. We use a lot of motivational interviewing.

VY: Yes, it seems very similar to motivational interviewing.

GM: So we're trying to figure out whether this person is in pre-contemplation stages of change or contemplation, or looking at possible plans of action—and matching our intervention with that. You can determine that pretty easily. Have they thought of doing anything about this? What do they think of the pros and the cons [of their drug or alcohol use]?

VY: Can you give an example of how you match an intervention to where they are?

GM: If they're in pre-contemplation, we're just going to try to talk about, "Did you know that the amount of smoking that you're doing is going to increase your risk of lung cancer and emphysema? Are you aware of this?" We try and enhance awareness of the risks. And then if they're in contemplation—

VY: Which would mean they're contemplating quitting?

GM: Or they don't know quite what to do. They're going between the pros and the cons: "Maybe I could quit, but I don't know what's the best way to quit. Maybe this isn't the right thing to do." That's when we meet them and help them look at the reasons why they like drinking and what some of their concerns are about it, and then try and move them on to the preparation and action stage.

In the BASICS program with college students, we just meet with them twice, one on one. In the first session, we give them feedback about their risks. They've filled out all these questionnaires so we know about family history and expectancies. We know about their cultural factors. We give them feedback in a friendly way. We could say, "Hey, you said that 80% of the students at this university drink more than you—actually, you drink more than 75% of the students."

VY: You're giving them some data.

GM: Giving them feedback, but in a friendly way. So they're getting a lot of feedback and awareness. And in the second session, it's the action plan. "What are we going to do about this?" We don't tell them what to do. We collaborate with them. What have you thought about doing? One young woman said, "In my sorority we usually drink and get drunk Thursday, Friday and Saturday nights. I was thinking of maybe not doing it Thursday night." We would support that—something that they come up with.

RA: Although it's not something that's necessarily spoken to directly, it sounds like this approach has a high sensitivity to the shame around addiction.

GM: Oh, yeah—shame, blame, guilt, stigma, moral issues. We're trying to let people know what their level is, how many other people have this kind of problem, and what kinds of things could help them. If they would like to quit, we'll say, "Great, we can put you in an abstinence-based program." Most of them are saying they just want to cut back. They're very positive about these kinds of skills we teach them. After we bring them in a bar lab and give them placebo drinks, then we teach them about blood alcohol levels and give them charts. We have them keep track of their drinking for two weeks so that we can see which days and what situations, whether they drink by themselves—which is more dangerous than social drinking—things like that.

We just give them a lot of feedback, but not in a punitive moralistic way: "What can you do to change? We'll try and help you."

VY: You're not coming at it from a moralistic way, but you do have some stance. You have an idea that if people are drinking in a way that you define or you think is destructive, you would like them to change that.

GM: Sure, yeah. It’s pragmatic. That’s where we’re coming from. It’s not moralistic.

VY: One thing I noticed in the video I saw of you with this black male, you got into really nitty-gritty details. He said he wanted to quit, but you really drilled down into, "What does that mean, to quit? What's your first step?" He said, "I'd go to the program." "What do you have to do to go to the program?"

GM: Right—break it all down into different steps. Also, we found that what triggered his relapses was, whenever he had cash, he'd go down to "buy a pack of cigarettes," and, "There's my beer"—these kinds of things. We're trying to teach people cognitive behavioral strategies around things that can set you up for relapse. Whether you're doing harm reduction or abstinence, there can be occasions where you just do way too much. What are the steps that lead up to that? We're using a lot of mindfulness and meditation to get people more aware of their choices.

Victor Frankl wrote this saying: "Between every stimulus and response, there's a space. In that space is our power to choose our response."So we use this idea in our work, and it's turning out to be very helpful, especially for people trying to stay on the wagon.

VY: How have you integrated mindfulness? It seems like a hot topic that's integrated into many approaches these days.

GM: Yes, mindfulness-based stress reduction—Jon Kabat-Zinn's work inspired us. I'm a good friend of his. Zindel Segal's mindfulness-based cognitive therapy for depression is very effective. Ours is mindfulness-based relapse prevention. All these programs are group-based, outpatient weekly programs for eight weeks.

We've gotten funding from the National Institute of Drug Abuse to evaluate the program, and we're finding that it's working pretty well for people with chronic alcohol and mental health problems. Of course, it's voluntary, so if people don't want to do it, that's fine, but a lot of people, once they talk to their friends who have gone through it, they go, "Hey, I'd like to do that." It's relaxing. It's stress reduction. It also gives you a different perspective on craving.

In the last study, we found that people in the control group, the more depressed they were, the more their craving went up—this was in an abstinence-based program—but if they went through mindfulness when they were more depressed, craving did not go up. The depression and craving was kind of disassociated. We're very enthusiastic about that.

VY: How do you explain that?

GM: Because mindfulness gives you a little bit of a different perspective, so you don't over-identify with situations like when you're depressed or feeling like you have to self-medicate to feel better. It gives people more of a choice. It doesn't mean they always do it, but a lot of times they do.

If you think of addiction treatment, the 12-step program, which is very popular, is basically Christian-based. The word God shows up in six of the steps, although they say the higher power could be anything. But a lot of people don't connect with that. The mindfulness program is more based on Buddhist psychology. It's a whole different approach. It's also very consistent with harm reduction—the middle way and things like that. It basically tells people there is another way. Instead of the 12-step program, you could do the eightfold path in Buddhism—right mindfulness, right activity, all that kind of stuff. So I think it's an alternative.

Carl Jung originally said that a lot of people with addiction problems are kind of like frustrated mystics. They're looking for an altered state.

Carl Jung originally said that a lot of people with addiction problems are kind of like frustrated mystics. They're looking for an altered state. Many of them are hooked in the spirits in the bottle, where they're really looking for another spiritual approach. I think mindfulness is another pathway. A lot of people relate to that pretty well.

The Disease Model of Addiction

RA: Do you have a problem with the disease model, from the standpoint that it classifies a person as an addict in a way that integrates into their self-identity?

GM: Yes. Phillip Brickman identified four models: the moral model, the disease model, the spiritual model and the cognitive behavioral model.

The disease model says, "You have a disease and it's due to factors beyond your control: your genetics and your physiology and it's all the same disease for everybody, so we're not going to give you any individualized treatment. We're going to put you in a 12-step program"—which also buys into the disease model. The theory is that there is no cure whatsoever. All you can do is arrest the development of the disease by maintaining abstinence. If you have one drink, it's a relapse. In AA, you have to go back to the beginning again.

In harm reduction, we take the attitude, "Hey, lots of people have slips. Let's look at what happened. You made a mistake. How can you learn from it?" We're not saying, "You've got to go back to the beginning."

RA: That's very shaming.

GM: It's very shaming, yeah. I asked a lot of the disease model people, "Why do you say that there's no cure?" They said, "If there was a cure, people could go back to drinking. We don't want them to do that."

Even though the research at NIAAA—the National Institute in Alcohol Abuse—shows that quite a large percentage of people who have what we would call alcohol dependence, alcoholism, later moderate their drinking and do fine.

… a large percentage of people who have what we would call alcohol dependence, alcoholism, later moderate their drinking and do fine.

They don't want to say that. The disease model says that's enabling. I'm much more in the cognitive behavioral model.

VY: So you don't buy into the disease model at all.

GM: I don't want to put people in jail and say that they're moral failures. Sure, they have a problem—but for me, the disease model is: if you're a heavy smoker or a heavy drinker, there are potential disease consequences. You could develop cancer. You could develop cirrhosis. Is what you're doing a disease?

VY: Is the act of reaching your hand out and picking up a drink caused by a disease?

GM: It's a habit with potential disease consequences. In one of my most recent books, The Complete Idiot's Guide to Changing Old Habits for Good, we talk about changing old habits for good. Habits are what's driving this. It has disease consequences, totally. We're talking a huge health problem. But just to say the whole thing is a disease—what's the point?

VY: You haven't convinced everyone, obviously.

GM: No, of course not. But we’re out there. There are more and more people coming over to the cognitive behavioral model because, treatment-wise, that’s what is most effective.

VY: So you consider your approach consistent with the cognitive behavioral model?

GM: Oh, yeah. Many people call mindfulness a meta-cognitive coping skill, so it’s consistent with the cognitive behavioral approach. Plus lots of research shows that it’s stress reducing.

The biggest trigger of relapse is negative emotional states. People are upset. They’re angry. They’re depressed. They’re anxious. They want help from the drug. So meditation is an alternative way of giving them stress reduction. That’s what a lot of the patients that we’re working with are saying: “Wow, this is really helping. I’m meditating and giving myself a choice instead of giving into my cravings.” We’re showing a big reduction, as I mentioned before, between negative emotions and craving for relapse risk.

Consumer Choices

VY: I know back in the days, they tried to study and come up with an alcoholic personality or an addictive personality, and it seemed like there wasn't too much success with that.

GM: The main kinds of personality factors that keep coming up are sensation seeking—people that crave the high, altered state—and self-medicating—what they call coping. Those are the two main personality traits. Some people have both. That does increase the risk.

There are personality models. Right now, NIDA and other people are saying, "Addiction is a brain disease. It doesn't matter what drug you're using—it's all releasing dopamine in the brain. The pleasure centers are lighting up. We need pharmacotherapies that can reduce the effects of these different drugs or replace them, whether we're talking about methadone or any of these other kinds of things."

VY: What do you think of that?

GM: It may be helpful. Some of the medications do reduce craving on the short run. I think if we combine that with mindfulness, maybe the two of them would work together.

My position is, if you think something is going to work for you, try it.

My position is, if you think something is going to work for you, try it.It could be a pharmacotherapy. It could be psychotherapy.

In the addiction treatment field, there was Project Match that came up a few years ago. They were saying therapists should match patients with a particular type of therapy that the therapist thinks would work. In Project Match, they assigned hundreds of alcoholics to get Alcoholics Anonymous, cognitive behavioral therapy, or motivational enhancement interviewing. Those were the three groups. They followed everybody up for two years. They found—guess what?—there was no difference. All three groups did equally well.

What really worked the best was therapeutic alliance: if there was a good relationship between the therapist and the client, it worked.

VY: This has been the finding in all of psychotherapy research.

GM: Yeah. So I think instead of doing treatment matching, we should switch to consumer choice. People come in: “Hey, I’m interested in getting some help. What have you got?” There are some programs that are saying, “We’ve got a lot of different programs here. I’ll show you some videos. Here’s what’s happening with 12-step programs. Here’s a cognitive behavioral program. Here’s something on moderation management. Take a look and see what you think might work for you and have a backup.” Give people a choice of pathways.

VY: Back to being pragmatic.

GM: Back to being pragmatic. "If the thing you're trying doesn't work, there are other things you can try. Don't give up." The average number of serious attempts that smokers make to quit before they are successful is twelve. Twelve attempts! So people that have tried to quit smoking and say, "I can't do it. I've tried it three times"—I tell them, "You're not even there yet. Each time you learn something."

Therapeutic Mistakes

VY: What do you think are some of the typical mistakes that therapists make if they don't specialize in working with addicts?

GM: Like the psychiatrist I was telling you about earlier, a lot of them say, “I can’t handle this so I’m going to refer you to alcohol treatment. Until you get that under control, I’m not going to see you anymore.” That happens so much. It’s the wrong thing to do. People just get stranded. They get caught. They don’t know where to go.

VY: What would you tell the therapist to do?

GM: Integrative approach: look at addictive behaviors like any other behavior issue. Read about it, get some training, take some courses and things like that; don’t leave these people stranded.

VY: If someone's having problems with anxiety, you don't say, "I don't treat anxiety. You've got to go to an anxiety program." You integrate that into the treatment

GM: Not being able to see how the addictive behavior and the mental health problem relate to each other—thinking they're separate diseases. In reality, they're often extremely interactive. One is relating to the other—like the person with depression is trying to self-medicate and he gets caught in between. I think that is the main thing.

Sometime after that psychiatrist called me, I asked him, "How much training in alcohol and drug problems did you get when you were in medical school?" He said, "One half day." Christ. Of course they don't know anything about it.

VY: That's amazing.

GM: Yeah. That's the biggest issue—even in psychology. When I was a graduate student in the late '60s, I said to my professor at Indiana University, "People are studying behavioral therapy and they're doing all this kind of work with different behavioral problems. What about drinking as a behavior problem?' He said, "You don't want to get into that field." I said, "Why not?" He said, "The addictions field is very low prestige. Why don't you get yourself a real problem like snake phobias?" That's what was going on then.

VY: As a social policy health problem, there are a lot more people with problem drinking than with snake phobias, let alone snake bites.

GM: I said to my professor, “I don’t know anybody with a snake phobia, but I’ve got a lot of people in my family with heavy drinking problems. Why can’t we do something about that?”

The disease model didn’t really look at drinking as a behavior or as a habit. The big shift was to try to move it from strictly genetic into habits. “Smoking is a habit. It’s not a disease in itself, but it causes diseases.”

VY: That is changing, that field.

GM: It’s gradually changing. When I got into the field, people were saying, “Stay out.”

I Like to Drink

RA: There are some addictions that are considered controversial, like sex addiction. From your perspective, is it the object of the person's desire that is addictive, or is it the relationship between the person and what they're going after that's addictive?

GM: The new DSM-IV revisions have been including other kinds of addictive behaviors, like gambling, sexual addictions, shopaholism, things like that. From a cognitive behavioral perspective, there are a lot of similarities. There’s a lot of craving, whether it’s sex or gambling. There are differences in terms of the effects, of course, but I see there being lots of common issues.

One of the biggest things is the problem of immediate gratification. We call it the pig problem. “I want to hit the jackpot. I want to have a sexual experience. I want to get drunk.” All these kinds of things are very similar in terms of the neuroscience of what’s going on.

So I’m totally open to talking about addictive behaviors as including ones that don’t involve drug or alcohol use.

VY: You've been doing this for a few decades now, and addictions has been a career-long interest for you. What are some things you've learned that have made you a better therapist?

GM: I think having these experiences myself. I like to drink. I have drinking problems in my family. I wouldn’t consider myself an alcoholic. Many people in the addiction treatment field are in recovery so they’re saying, “Don’t use at all.” I’m much more user-friendly to these people because I do it myself. I’m helping to teach them that there are better ways to do this.

Since I’ve been more of a Buddhist psychologist, I took the bodhisattva vow, which is to reduce suffering in people that have these kinds of problems. If I can relate to them and identify with them rather than saying, “I am abstinent and you’re using,” it works a lot better.

VY: Thanks for taking the time to meet with us.

GM: You’re welcome. It’s been a pleasure.

It’s Over Now: Termination and Countertransference

Posted on December 6, 2010February 11, 2026 by rezendevknowfully.com

The Dreaded Phone Call

Recently, a client of mine left the following message on my voicemail: “Hi Melissa, I just wanted to let you know I won’t be coming to my appointment tomorrow. I’m feeling fine now. I’m not coming back, but thank you for all your help. I’ll call you again if I need you.”

Of course, I called her back. It’s the age of caller ID, though, and not surprisingly, she did not pick up. Nor did she return my call, despite my delightfully supportive message wondering if we might at least have a wrap-up session.

Clients cancel appointments and leave therapy prematurely for all kinds of reasons. It’s not the first time I’ve been left by a client and it won’t be the last, but, admittedly, it had been a long time since I’d given much thought to endings.

The world of modern psychoanalysis does not put termination near the top of the training agenda. Most everything is looked at as a resistance to treatment. I like this a lot, actually—first because it puts the focus on studying the client’s unconscious, and second because it then puts the focus squarely back on mine. And it encourages studying emotional communications and unconscious obstacles to treatment with curiosity and interest, which is profoundly soothing to the part of me that tends toward self-attack and self-doubt. Looking more deeply at the challenges that get in the way of the work continuing is a good way to help the work continue.

Frankly, termination is not really at the top of anyone’s list in terms of training. In fact, much of the information out there focuses mostly on professional ethics, process, and client rights. There’s not a whole lot about what we therapists are left with when clients leave after a planned termination process, let alone when they drop out of sight without so much as a good old-fashioned goodbye.

“When clients leave suddenly, we have little recourse, but big feelings.” We pull out all of our training nuggets to help us try to understand what happened. We can figure that maybe they got what they needed; we can look back to the last session to see if we may have hit the wrong note; we can wonder if perhaps they are protecting themselves from something, or protecting us by leaving abruptly or without discussion. Perhaps they are protecting us from their rage, their hopelessness, or their discontent.

And we can think about our patients’ characters, history, patterns of functioning. Our clients might be letting us know finally how they have felt, being left in their lives—frustrated, discounted, ignored, worthless, abandoned or powerless, perhaps—which is often how therapists feel when clients leave without warning or discussion. They give it to us good over the psychic airwaves. Abrupt exits from treatment can be jarring, aggressive or even mean. The emotional communication is powerful, and while it can give us valuable information about the client, it also can be a window into our own psyches.

Therapists Have Feelings, Too

For good reasons, we therapists don’t often like to admit that we have feelings towards clients, let alone strong ones. We may be ashamed or embarrassed of our reactions, or even afraid—especially when we feel injured, abandoned, angry or stung.

Yes, of course we study the countertransference: we know we can go far enough, at least, to notice a feeling and give it a nod, to guess at where it comes from and maybe how to use it in session, for the benefit of the client. But beyond that, we hedge. Though we feel, deep down we think that we should not actually feel anything—not unless we are sure it’s in the best interest of the treatment. Not unless we have our professional head on—our dignified, composed, contained persona.

After all, we are trained to focus on the client, even when studying such ideas as subjective countertransference, when the emotional communications of the client trigger unconscious, unresolved conflicts in the therapist. For instance, when a client says that the therapy is not helpful, if the therapist has the impulse to be self-attacking or self-doubting, she may personalize the feelings, feeling anything from anger to hurt to worthless. And she may collude with the client’s desire to leave to avoid having to feel all those bad feelings.

Strangely enough, the fear that a client may leave, is, in some instances, really an unconscious wish—especially if that client brings us too many hard-to-bear feelings, or if we are burnt out or frustrated, or fear we are doing a bad job. And it’s possible that sometimes clients are onto something in us. Clients are often sensitive to emotional communication from us as well. Sometimes we may be sending the message that they are not wanted in some way. They may need much assurance that we are trained to welcome all their feelings, and help them do the same.

One client I work with wanted to stop coming because he imagined he was inconveniencing me with his weekend appointment. Another wanted to stop because she was fearful of how big her anger was. She believed I was frightened of her. Good discussions with these clients not only headed off ending the treatment, but led to all kinds of insights into their character, wishes, life experiences and patterns. And while it may be tricky to study the transferences, when it comes to endings everyone fares better when we do.

In the phone supervision groups I run, we talk a lot about termination. We debate all the ways to prevent abrupt exits, and avoid being stuck holding the bag of bad feelings. We talk about ways to help clients stay, to deal with difficult feelings differently. We discuss the merits and drawbacks of ongoing evaluation tools, professional protocol, policies, and termination letters. We wonder about preparing for discharge right from the start, checking in at each session to see how things are going in the therapy, having billing policies or not having them. But I think it’s also defensive driving. We do need to act ethically and we do want what’s best for our clients, but we do not want to be hurt. We do not want to be left. “Many of us do not think we are supposed, or allowed, to feel anything genuinely and deeply when it comes to our clients, and we most certainly don’t want to feel all the feelings that being left drudges up.” Some of us will do whatever we can to prevent bumping into abandonment, and its steadfast companion, inadequacy.

We can’t always attribute these feelings to the transference alone. Many desires are shared among therapists: to do good work, to sustain a solid income, to feel effective and accomplished, and, when possible, appreciated.

Therapists do lose sleep over these things. Our fears may get triggered when clients leave under any circumstance, but all the more so when they ditch us without so much as a “see ya.” Even planned and successful terminations can leave a therapist with a host of feelings, from loss to fear to doubt—especially if the therapist is not convinced it’s best to terminate, or does not feel that he has a real say in the decision, or if the client is leaving for external reasons like moving away or scheduling conflicts (and even these could potentially be worked out).

And if our practice is less than full at the time, or our personal finances are not what we’d like them to be, we may bump into financial fear. The fact of our business is that our livelihood is very much tied into getting and keeping clients. Many therapists fear their own financial hunger and, in an effort to prove they are not acting on their own desires, may join clients’ treatment-destructive resistance, and help them to go. I’ve seen therapists do this in a variety of ways, such as sending termination letters, bills, not returning calls when clients cancel or quit via voice message or email, or agreeing to termination without asking if the client would like the therapist’s thoughts on the decision or if the therapist has a say.

“In fact, in letting clients leave without attempting to discuss things, we may be rejecting them, or colluding with a pattern of rejection in their lives.” For some clients it may be therapeutic to help them stay; they may be relieved that they are wanted and not so readily let go of.

That’s not to say that we can’t ignore the unconscious if we’d like to, or that we don’t have and enjoy good endings, or feelings of satisfaction over good sessions and good therapeutic relationships. But let’s face it: in the volleying back and forth between occasional grandiosity and occasional inadequacy, clients who go AWOL can tip the slide downward for us fast.

"Am I Losing It?"

It’s hard to know when our feelings are safe and when they are on the edge. A friend of mine was recently angsting over some terribly good erotic feelings she was having for a client. She took it to supervision where her supervisor said lightly to her, “If they are not interfering with the therapy, enjoy them.” This permission to feel freed my pal up considerably. The erotic feelings faded and the work continues to be successful.

One therapist friend of mine says, “I feel like an emotional prostitute sometimes. I get to roll around in the all the intense feelings and then I get left alone in the chair.”

“That’s what we get paid for,” says another friend of mine. But we are so dedicated to staying contained, to reining in our feelings and our fears, that we may be cheating ourselves, not just protecting ourselves, the client or the work. What do we think will happen if we let ourselves go haywire? Not, of course with a client, but by ourselves or amongst our peers, in our supervision or personal analysis?

One colleague of mine did actually have his analyst go berserk on him. Upon my colleague saying that he would be leaving therapy soon (after 15 years and much good work) the analyst seemed to blow a gasket. He yelled, he screamed; he said that my colleague was in denial, was sick, did not even know how sick he still was. He told him to get out of his office immediately. Ungrateful lout!

When I first heard this story I hardly believed it. Perhaps my colleague friend was making it up. Perhaps he heard wrong or exaggerated, or even dreamt it? After all, this seems to be every client’s nightmare—and maybe every therapist’s. Would we really go crazy and let loose on a patient? Most likely not, but to that end, if we don’t allow ourselves to feel what we feel toward our clients, we may be missing out on a lot of good information that would benefit everyone.

But since many of us nurturers are not at all immune to self-attack, accessing our feelings may be easier said than done. Especially when clients leave us, we can be quick to accuse ourselves of all kinds of evil (especially if we ourselves are going through something difficult in our personal lives). Perhaps we really are (only and always) money-hungry, self-seeking, self-gratifying, selfish, poorly trained do-gooders? Or the opposite. What about our gift?! We most certainly could help them if they would just cooperate and let us! Why don’t they want this help? “It must be me” is the quiet tugging somewhere in our brains.

Maybe we are burnt out? Maybe we are losing our touch? Or losing touch? Maybe we are not actually helping anyone at all anymore. Maybe everyone is going to leave us. Maybe we need more training, a different approach, another certification. Were we not paying attention? Should we have been more confrontational, or less?

There may be some use in asking these questions, but it seems to me that we healers and helpers will go after ourselves in a schizophrenic loyalty to our trade before we will let ourselves have all our feelings about our clients.

Sometimes therapists tell me that they want to get rid of clients, especially the ones that are mean or demanding or frustrating, or boring, or are not making the progress they’d like them to make. On some level it’s hard for us to accept (and help clients accept) that talking itself is progressive and that we must be vigilant about not being too demanding of our clients or devaluing of our good ears.

After unpacking feelings with a therapist I work with who gives homework and advice frequently to clients, we came to understand how frustrated she feels in certain sessions—hence her urge to be more directive. While she continues to pride herself on giving resources, she is paying more attention to the words of one her patients who recently yelled at her (in itself a testament to their good relationship), “Would you stop trying to help me so much!”

Speaking Up, Pushing Back

A favorite story of mine is about an analyst I know whose patient called to cancel and “take a break” from therapy because she had to have surgery on the day of their appointment and would need a while to recover. The analyst asked if the surgery could be rescheduled for another day. At first take, this sounds ridiculous. Most of us would most likely offer up oohs and ahhs and “let me know how it goes.” But not this analyst: she works on the assumption that nothing is more important than the therapy and she does not want to give anyone’s unconscious the idea that being sick and needing surgery is ideal. She says by valuing the therapy above all else she is messaging the unconscious that it’s not okay take out difficult feelings on the body. Better to talk about them, learn to tolerate them, and live well.

The patient got angry at first. All kinds of aggression came out toward the therapist, albeit tentatively, about how the therapist was insensitive, mean, ridiculous, and odd. Funnily enough, though, the patient called back a few days later to say that the surgery was no longer necessary and she could keep her appointment.

Of course, we don’t attack someone’s defenses straight out, and sometimes a duck’s a duck, but it is interesting to consider how tightly or not we hold onto to the importance of valuing our sessions. Though we don’t always know how they will be received, our responses do send emotional messages. And since we therapists have to swim every day in the sea of a hundred feelings, we sometimes, unconsciously, may seek to avoid them by going along too readily with people’s disappearing acts.

Sometimes people really are not interested, ready, motivated enough, or are just too frightened to be in therapy. Do we forget that we have to go so very lightly sometimes, even for a while, to help people become real clients? In an informal survey among my clients who have had prior therapy, most tell me that they left without actually discussing their exit with the therapist. Some felt pushed. Many felt misunderstood and not helped, or they disliked the therapist’s style or something the therapist said. Very few recall discussing their concerns and feelings with the therapist before leaving.

A friend of mine, however, came to me for advice after doing just that. She felt her therapy was no longer helping her grow in the direction she wanted to go. She discussed it with her therapist and they agreed she should make a change. She changed, but felt that her new therapist was somewhat mean in his demeanor. She was thinking of canceling and not going back, but, reluctant to make yet another switch, she asked for my thoughts. I suggested she tell the new guy that she thought he was mean, which, bravely, she did. And in response, he told her she was right—he was mean sometimes.

My friend felt enormously relieved. It turns out her father was quite mean, but whenever she had tried to tell him so as a child, he denied it. In overcoming her fear of saying what she felt directly, and having her response validated and not denied, she believes she has made significant progress. She has decided that it’s okay to have a faulty therapist. She now takes great joy in pointing out each time she feels the therapist is being mean, and helping him to address it. And, she tells me, he is getting better. She is curing him.

The Failure Complex

When I supervise new professionals, I often find them to be blunt about their feelings, and I find myself encouraging them to say everything in supervision, and to become interested in their words and actions in sessions. When new therapists tell me, “He was so rude! I can’t stand him!” or “I’m furious with her,” I am delighted and respond by steering them toward curiosity about why they feel this way and what they may learn about the client and themselves. Seasoned professionals who I work with seem to hold back more, and are relieved to be reminded that they can have all their feelings, that clients are difficult (we ourselves may be difficult as clients), and that experience and expertise don’t negate our own need to feel our feelings and talk about our work.

And few outside the profession really understand this, I think: the constant meteor shower of feelings we encounter in our offices, this psychic holding we have to do of everyone’s feelings. Some of us fear that perhaps, even if a feeling is an inducement, we may act on it. Unfortunately, some of our colleagues do act on inducements–sometimes little ones, sometimes big ones. The number one complaint before ethics boards is for sex offenses, boundary violations. Acting on feelings. Most of us guard these borders vigilantly. “We know that erotic transferences in the treatment room are normal, and can be dealt with gently, with words and care and no action.” We may fear them, but we know they occur.

But murderous feelings? Rage? And abandonment and inadequacy? One analyst I know calls it her “Failure Complex.” Over her many years of experience she has learned that she will not be able to help everyone, that some clients will leave or punish her even when she has not made a mistake, because that’s what they do to survive. She knows that when clients leave and don’t say goodbye, it feels just like when she was a kid and her father would stop talking to her for days on end, blaming her for his reactions. She had no control over this feeling then, and felt for years that anything that happened in the treatment was her doing, her mistake. The psychic umbilical cord tying her to her father was like a straight shot back to her feeling like a lonely, misunderstood ten-year-old. Even with all her advanced training, she still wound up back there in the pit of that despair and rage. She berated herself for that, too.

After some time though, she says she has come to feel better. Her dad was just being her dad, she tells me now. And her clients are just being her clients. And she is just doing what she knows how to do. She wears it all a little lighter now.

I like the modern analysts’ idea of helping clients to say everything—at their own pace, of course—and I especially enjoy it when it translates into therapists being able to say everything in our own supervision and therapy. As another therapist I work with says, “I like to let my fear flag fly! Talking about my own stuff builds my resiliency, and then I can stay the course.”

From the Heart

Many seasoned therapists agree that part of staying the course means checking in with the client now and again, to see how the therapy is going, either with evaluation tools, or by helping clients to say everything to us about the therapy itself, and that doing so goes a long way toward preventing abrupt exits. But we have to be willing to bear our own discomfort, and keep our support systems active. When we do this, we are better able to negotiate the blurry line between discharging our own feelings in session and making good clinical interventions.

A few years ago I sat before a panel of professionals who run a regional referral service. I was hoping to be added to their referral network. I came in with my CV and my suit and took my seat. They asked a bit about my background, and then asked me what modalities I use. When one of the interviewers spoke up and asked, “What do you do with difficult clients?” I was quiet for a minute.

“I listen and I love them,” I said finally. “And I help them to talk.”

I do get referrals from them now, but I recall at the time feeling terrified. Who says that? I really was poised to talk about my training and about interventions and skills, and the things that we do that bring recovery and healing, but that’s what came out. Love. (I suppose I could have said that I get frustrated and I tolerate it. Either might be true at one time or another.)

“Here’s what I think keeps us up at night: the idea that we are not supposed to speak from the heart, the soul, or the depths of our psyches.” We may be so tied to what we think we are supposed to be, to know, to feel and to do, that we are afraid of what we really feel. And while most of the time we don’t have intense feelings for or about clients, certain clients and situations fire us up more than others (a nod to transference), like being left without a chance to know why, to heal something, or to at least say goodbye.

On top of this, many therapists imagine a domino effect: first a bad session, then one client leaves, then another, and then the unemployment line. Much as we might like to be, we are not at all immune to worry, doubt and insecurity. Even the most experienced clinicians have moods that are directly tied in to the state of their practice.

An old friend of mine who lives her life by her 12-step program likes to tell me that finding serenity, pleasure and contentment means practicing the ability to bear discomfort—that it’s ten ways to Tuesday. Whatever your discipline, training, experience or knowledge, success and satisfaction are about feeling what you feel (good and bad) without doing harm. We do get emotionally walloped once in a while in this business. Chalk it up to transference, to regression (ours and our patients’), or call it a bit of temporary psychosis when feelings get too intense.

One analyst I know continues to call her dropout patients every now and then. She leaves messages just saying hello or asking how they are. She told me that many years ago she used to worry that they would think she was just after their money or out to build up her practice. And maybe so. (“Why shouldn’t everyone make money and prosper?”) But now, she says, she thinks it’s just good practice to let clients know we are still interested, available, and open to a connection. She has a thick skin when it comes to rejection: it’s all grist for the mill. Pointedly, she tells me that some of her dropouts do return to treatment, happy that she had continued to hold open the door and hold onto the idea that they and the work were worthwhile.

Our work is fluid, frightening, fantastic, and filled with blind spots all at the same time. But I think that therapists sleep better when we allow ourselves to feel everything, to talk about everything in the company of good peers, and to find comfort in the idea that we really are not alone, no matter how crazy we sometimes feel. We can be interested, curious, and confident that we’ll be okay—and we can pass that freedom on to our clients, enriching the experience for everyone.

I am not suggesting that we never agree that it’s time for therapy to end or to pause. Certainly, there is a season for all things. But more often than not, if we are really honest, most attempts to leave treatment have some deeper meaning. And if we go along with the surface material, especially if we are only mildly in touch with what we ourselves feel, we may be helping our clients to miss out on the benefits of a meaningful therapeutic experience.

Nancy McWilliams on Psychoanalytic Psychotherapy and Psychoanalysis

Posted on December 6, 2010February 11, 2026 by rezendevknowfully.com

Making Psychoanalytic Theory Accessible

Louis Roussel: In all of your books—Psychoanalytic Diagnosis, Psychoanalytic Case Formulation, and Psychoanalytic Psychotherapy—you're able to bring the essential features of psychoanalytic thinking into a language that is both accessible and practically useful, particularly for clinicians who are just beginning to familiarize themselves with these concepts. This is a vital project, in my opinion, particularly given the many misunderstandings and prejudices against psychoanalysis in contemporary Western culture. I wonder if you could say something about why this is so personally meaningful for you.

Nancy McWilliams: I come from a whole family of teachers, and I have had a teaching component to my career since the early 1960s if you count my years as a camp counselor, and at the college level since about 1970 in one form or another. So for a very long time, if I wanted to get people interested in the stuff that fascinated me I had to make it accessible to them.

I taught an undergraduate course in theories in psychotherapy for several years with people who had really no background in psychoanalytic thinking, and I slowly developed a kind of skill, I guess, in making it relevant to people's ordinary lives, as opposed to talking to other scholars or theorists in the field.

LR: Speaking to other colleagues and scholars in the field, I was quite struck with one comment that you made in your most recent book, Psychoanalytic Psychotherapy, that the contemporary psychotherapy field is one that is incredibly pluralistic, with many competing theories of clinical work. And there was a point where you spoke of how each of these theoretical perspectives really represents a unique understanding of very complex, multifaceted human problems and dilemmas.

And you spoke about suggesting a style of listening to alternative theories that is analogous to how a clinician might actually listen to a client in psychotherapy. I was particularly moved by that, especially given that it seems like that's not an easy listening stance to achieve, particularly with colleagues.

NM: I learned that there are a lot of identity issues involved in people becoming therapists and they tend to get organized around one theory or sensibility when becoming being a therapist. But all of us are looking at the suffering human animal and trying to be helpful, and eventually we're all going to learn similar things and have different language for talking about it.

I have tried to fight the tendencies in me that presume a position of knowing more than other people or making them the devalued other.

I have tried to fight the tendencies in me that presume a position of knowing more than other people or making them the devalued other. It's a natural human thing to do, but a lot of grief comes from it.

I've learned enormous amounts from people of very different paradigms than my own. You not only find a lot of common ground, but you find the areas where your own particular point of view has blind spots.

LR: Absolutely. As I was looking through some of your writings, there were a number of points where it seemed that you linked psychoanalysis with larger social political issues. You quoted one of the local analysts here in San Francisco, Michael Guy Thompson, when he spoke about psychoanalysis as an unremittingly subversive practice which gives voice to that which is most denied by the larger prevailing culture.

I was struck by that, because I think psychoanalysis is characterized in some ways as more conformist than I think its true essential nature is.

NM: I came to psychoanalysis not through psychology but through political science. My first experience reading Freud was as a junior in college, when my political science professor suggested I had a kind of psychological sensibility, so perhaps for my honor's thesis in political theory I'd like to read Civilization and its Discontents and talk about Freud's political theory. That's what sort of started me down this path.

I really found in the psychoanalytic movement a very subversive kind of orientation toward the world, and there were only a couple of decades where, for various interacting reasons, psychoanalysis was highly prestigious in American culture. During those decades of roughly the 1950s and 1960s, it was a quick way to prestige in the medical establishment if you were a psychiatrist. The way to get moving ahead in your discipline was to get psychoanalytic training, and that pretty much guaranteed you eventually a leadership position in the department of psychiatry. But that was sort of a fluke of the times, and it's behind us now.

I'm actually kind of happy it's behind us, because during those years a lot of people were attracted to psychoanalysis not because they loved it or they were really curious about the unconscious. They were attracted to it for narcissistic reasons, and they didn't tend to make very good therapists because they liked being right. They didn't like being surprised. They took a superior position toward their patients and talked down to them.

Many of the current troubles in psychoanalysis come from an era where people spoke rather arrogantly. They felt they were in the chosen profession.

Many of the current troubles in psychoanalysis come from an era where people spoke rather arrogantly. They felt they were in the chosen profession. I don't think psychoanalysis does very well when it's culturally at the center; it does much better from a point of view of marginality in describing things that the culture doesn't necessarily see so easily.

Therapy on the Margins

LR: That’s an excellent point. It almost seems as if the loss of prestige and the marginalization of psychoanalysis in some ways is connecting us with the beginnings of the movement. In the early days, it was quite a risk to become an analyst, and involved sacrificing more established, secure careers. Today, psychoanalytic practice is not the most popular road to go down.

NM: I do think it's very hard on contemporary students who fall in love with psychoanalysis and want to work in depth with people. Corporate agendas tend to have an awful lot of power in this culture, and it's in the interest of both insurance companies and drug companies to describe human suffering in a fairly superficial way and to apply either a drug or a short-term treatment to it.

These are hard times economically. People who want to really get to know their patients in all their complexity have to fight against some of the pressures to oversimplify things and do some quick-fix intervention. I think we've seen a paradigm shift from a cultural understanding that psychotherapy is a healing relationship in which you might use several different kinds of techniques, but the healing relationship is the definitional part of it. It's been redefined as a set of techniques that are applied to discrete disorder categories. It's moved therapists from being healers to being technicians—and often technicians at the behest of the larger culture, which has an interest in putting people in the cogs that exist in the great commercial machine, and not necessarily increasing the meaningfulness of life or the satisfactions of life.

LR: In your most recent book, Psychoanalytic Psychotherapy, you spoke of how psychotherapists in general tend to devalue what we do—activities that we view as passive and receptive, like listening, for example—and overvalue those based on doing, producing, manufacturing, achieving.

This speaks a little bit to what you were just touching on in terms of what is most valued in our Zeitgeist, and yet, what may not be in the best interest of our psychic health.

NM: Yes. I seem to be seeing more and more people lately that are coming to me for anxiety or depression or an eating disorder or something Axis I-ish, who, when I actually listen to their story, they aren't living a livable life. They're commuting one and a half hours to work. They're staying at work from 8:00 in the morning until 7:00 at night. They barely see their children.

They're trying to take care of a house, a summer house, a couple of kids, a boat—if they're people of reasonable means—elderly parents, a dog. And they're just driven. The culture seems to tell them that they should be happy this way. And of course, that's not a livable life. It's just crazy.

LR: Exactly. It’s quite an alienated existence you just described.

NM: Yes.

Psychoanalytic Love

LR: I was also very interested in something that I don't think analysts necessarily speak enough about. You spoke about psychoanalytic love, and this tension that I think clinicians face: How is it that we can basically accept someone in a very deep way in terms of who they are as a person, but still be on the side of growth and change?

NM: I don't think that being a therapist is like being a parent in most respects. But in terms of the affects involved, it's not too different. You deeply love your kids, but you also have hopes that they'll be their best self—not be satisfied with living a kind of minimal existence.

So I don't think that deeply loving people means that you have no hopes for their doing better.

So I don't think that deeply loving people means that you have no hopes for their doing better.

I think all the empirical literature on what's effective in psychotherapy, not just psychoanalytic therapy, ends up emphasizing relationship and personality. And when you talk about relationship or about the working alliance, you're talking about the two parties making an attachment to each other, which is just a fancy word for love. It certainly includes hatred and all the other affects, but it's a commitment. There's a kind of devotion that characterizes a therapeutic relationship in which somebody can grow. And we haven't talked too much about that.

We have some theories of it that are sentimentalized. You can't decide you're going to love somebody into health, but if you make a genuine authentic relationship with somebody and try to be honest with them, be honest with yourself, and help them increase their honesty with themselves, you're talking about a relationship characterized by love. You're accepting who they are, including all their darker parts. They're tolerating who you are, including all your mistakes and failures. And that sounds like love to me.

On Failure

LR: There have been some analysts who have talked about how we can't accept a patient into analysis, especially given the nature of the deep intimacy and the depth of emotional involvement unless, we have a deep sense that we like them. And yet I can think of many examples from my own experience where that feeling wasn't there at the beginning but it emerged later.

NM: Yes. On the subject of experiences where I felt like somehow I couldn’t get a therapeutic relationship really going, that’s happened many times to me, where I have failed with somebody. Sometimes I thought I failed, and many years later I find out that the patient really felt that they got something important. And other times I thought I’ve done a pretty good job, and I later find out that I missed something important.

You can’t be in this business for too many years without getting humbled about how little you really know.

LR: Yes, definitely.

NM: One person recently came back to me after 30 years, and I thought I had bombed with her. I was surprised that she came back to me, and, I reminded her that we kind of fizzled out. We both decided at a certain point that the therapy didn't seem to be moving. I asked her to just think out loud about what had happened.

What came out was a story about how, when she was little, her mother wanted her to be a musician, and she had no musical ear at all. Her mother's agenda was that she was going to be a great performer. She practiced and practiced, and went through excruciating performances, and tried to be good–and just didn't quite succeed.

I realized as she was talking about this that when I first worked with her, I was so excited that I had somebody that I thought was a good candidate to put on the couch and do real psychoanalysis with, that what I had enacted was, I was like her mother in wanting to fit her to a technique that I wanted to do, that really didn't suit her.

When we talked about that 30 years later, we decided that we would work face to face, and I would be more disclosing. I think we worked much better the second time around. You don't usually get the chance to undo your original mistakes.

In that case, I think that was a narcissistic thing. I wanted to see myself as an analyst, and here was a person that I thought I could put on the couch and ask to free associate. And I ended up replicating a childhood scene where the agenda of the authority didn't fit the particular inclinations of the kid—or the patient, in this case.

LR: This is so interesting in terms of having a particular valued notion in mind of what we would like to see happen, and how that can compete with how the analysis is actually meant to unfold.

I wonder if that also comes up in teaching, particularly teaching psychoanalysis. I have discovered that teaching psychoanalysis today requires a much greater level of flexibility and attunement to how students are, including some of the resistances that they sometimes come in with, related to stereotypical notions about psychoanalysis.

NM:

Teaching Psychoanalysis

I'm finding that students know a lot less about psychoanalytic ideas. Some of them have been very explicitly told that psychoanalysis has been empirically discredited, which is patently untrue. But there are a lot of academics that believe that.

Part of the reason for that is that there is an increased schism between academics and therapists at this point, for numerous sociological reasons. It used to be common that people who taught abnormal psychology might have a small private practice and know what it's like to be in the trenches trying to help suffering people. Now, it's so much harder to get promotion and tenure that they'd be crazy to do that. They have to chase grants. They have to turn out short-term studies and get a publications list.

So academics' image of therapists is often wildly off base from the therapeutic community as it actually exists. They tend to think that therapists apply their theory uncritically rather than try to adapt to every patient flexibly. So students are taught all that old psychoanalytic stuff, especially drive theory.

I haven't heard an analyst talk in terms of drive theory for at least 30 years. But the academics tend to think that psychoanalysis stopped in 1923.

I haven't heard an analyst talk in terms of drive theory for at least 30 years. But the academics tend to think that psychoanalysis stopped in 1923.

So students come in not knowing that there has been a whole scholarly evolution of psychoanalytic theory. One of the reasons they don't know this is that analysts pretty much pursue their interests in freestanding institutes and not in the academy, so there hasn't been cross-fertilization there. Analysts, I think, are to a great extent responsible for some of the estrangement with academic psychologists, because they wanted to develop in communities of their own.

So students now come to us with very little exposure to what's central to the psychoanalytic community. And we have to adapt to that. I've been asked in recent years, “What is the meaning of the term ‘transference’?” — something that any graduate student would have known 10 years ago. One student not long ago asked me what the term “ambivalent” meant.

On the other hand, as they get taught various cognitive behavioral techniques and so forth, they are often learning stuff that's very parallel to psychoanalytic learning. Some of what Marcia Linehan does is not too different from what Peter Fonagy or Otto Kernberg does. She just speaks a very different language. Jeffrey Young’s schema therapy is not too different from psychoanalytic ideas about organizing motifs in people. But students tend not to know that.

On Political Involvement

LR: Going back to something we talked about a before regarding the political and social dimension of psychoanalysis, it seems like in some ways the analyst is in a position where she or he could potentially make a valuable contribution in terms of speaking on the larger societal level, and yet it seems to rarely occur.

NM: Yes. It's an interesting thing. It used to occur. Certainly, Erich Fromm spoke a lot at that level. Robert Lifton and Karen Horney certainly did. There were a lot of social commentaries from analysts a few decades back—not so much now. Eric Erikson would be another good example, or Robert Coles addressing the problems of the poor and the marginal. But I think that was part of that European sensibility.

We're a little bit more narrow in the United States. We're a little bit more pragmatic. We're more optimistic—"let's figure out what this is and fix it."

A big part of the psychoanalytic sensibility is trying to help people accept what can't be changed. But that goes contrary to an American conceit that you can be anything you want to be, which, to me, is a pretty psychotic belief. I might want to be a giraffe; I'm not going to get there. But we actually raise our kids saying, "You can be anything you want to be."

And that's the kind of language of a young country that has enormous resources and not too many limits. I don't think it's the best language for us anymore, but we're kind of stuck with it. The sensibility of people who've lived with more limitation than Americans have is, I think, good for us to take in.

But I have to say that an awful lot of what psychoanalysis contributed to the United States had to do with people coming over before or during the Holocaust and having a kind of broad European learning that's not that common in the United States. And that whole generation has pretty much died off now. But they enriched not just psychology—they enriched the social sciences, the natural sciences, mathematics. We had an awful lot of very, very bright people who had a more wide-ranging set of interests than is typical for the pragmatic American sensibility.

The Future of Psychoanalysis

LR: Yes, that's so true. I wonder if you could say something about your sense of the future of psychoanalysis. Since its inception, since Freud's early days, psychoanalysis has been declared dead many times, and the decade within which we live is no exception.

There are certainly many who speak about psychoanalysis disparagingly as something antiquated, as no longer relevant. And there are those who even go so far as to say that psychoanalysis has reached a tipping point and we're on the decline and facing extinction. I don't share those views, but I wonder what about your sense of what psychoanalysis's future might hold.

NM: I'm not sure. I have my optimistic days and my pessimistic days. I think psychoanalysis will endure because we help people. They know it. They tell their friends. I see many people who've tried many other things, and they eventually come for analytic therapy and they get a lot out of it. But I don't think we're going to survive in the mainstream healthcare system.

I don't see any sign of that—at least not the more intensive, long-term, open-ended work that most of us like to do in the psychoanalytic community. I think it's hard to imagine, under the current circumstances, that the culture at large is going to support that being available for anybody but people who can afford it out-of-pocket. In the Scandinavian countries it's a little different, but they have a single-payer system.

Sweden, a few years ago, decided not to offer psychoanalysis—meaning several-times-a-week psychoanalytic work—on the national health plan, and there was a kind of grassroots objection to it and they put it back in. But I can't imagine that happening in this country. And in a few years, I think it's going to be unlikely in Sweden, because although it used to be a wealthy country, it's been stressed a little bit more in recent years. And as countries struggle, they try to cut down what they offer. So I just can't imagine that intensive long-term work is going to be supported in general.

Susan Lazar's recent book, Psychotherapy Is Worth It, really documents how cost-saving it is to get a lot of psychotherapy, even intensive psychotherapy. It saves on jail time, on sick days from work, on addictions. But most of the ways we measure the cost of healthcare is very long-term.

Insurance companies ask their benefits' managers, "How much money did you save us this year?" And people change their jobs, so they change their insurance. So they don't really have a 50-year view, or even a 10-year view, of putting out money now to do prevention in the long run.

I'm quite convinced—and there's plenty of empirical data to support this—that psychotherapy and intensive psychotherapy and psychoanalysis are very cost effective for the culture, but I don't see politically that we can make that argument effectively. So I think we'll become a kind of therapy that people will get privately.

Advice to Aspiring Therapists

LR: Yes, that’s true. If you had to give one piece of advice, maybe something you only discovered through a lot of personal struggle and pain, what do you think it would be? What advice would you give to somebody thinking about entering the field today?

NM: I don't know that I can honestly say that I have had to go through a lot of personal struggle and pain. I have loved my work. As soon as I discovered you could actually make a living by listening to people and getting close to them and trying to help them, I was thrilled. I feel very fortunate to have been able to have the kind of career that I've had. And I don't feel it's been Sturm und Drang at all. I've had very good teachers myself. I had a very good analyst. As I'm older, I realize more than I did when I was younger how lucky I was about that, because if I had a person who was a bad match—it's a powerful kind of relationship, and it can do harm as well as good. But I had good supervisors, good teachers, good colleagues, a good analyst, and I've been just constantly fascinated by the work. I guess I would tell students to follow their passion: if this is what they want to do, they can make a living doing it.

LR: Well, that’s great. Yes, that’s certainly been my experience. It seems like we’ve covered a lot of ground here. Is there anything else that you’d like to speak to?

NM:

Take to the Streets

The sermon I've been giving to psychoanalytic audiences lately is get out of your offices and talk to people outside the psychoanalytic community.

We have something very precious and valuable, and we can talk to each other about it until the cows come home, but

I think we have some responsibility to be socially useful and apply some of the knowledge to social problems and to making people's lives better—not just in the consultation room, but in the culture as a whole.

We should be talking about things like why the teenage suicide rate has gone up so high, and what our ideas are about the obesity epidemic, and what are the strains of contemporary life. When you were asked before about people who have commented more on the social level, and I was naming people like Erich Fromm, there are a few people now.

Christopher Lasch is dead, but he was trying to talk about that in recent decades. Jonathan Lear tries to talk about it. There are people that are trying to talk to the larger public about some of the knowledge that we've accrued over 100 years of listening carefully to people and their struggles, and I'd like to see us take to the streets more than we typically do.

LR: Do you have a sense of why we don’t?

NM: Part of it, I think, is that it involves being quite visible, including to our patients, and some of our patients are terribly upset when they see us out of role. I think analysts get very conservative about what they do because we’ve all had experiences of a patient being devastated when they find out when we have a different political belief from them, or that they disagree with something, or they’re ashamed of us. I think it’s very inhibiting being a therapist.

LR: I really appreciate your talking with me. This has been very enjoyable, and I've learned a lot.

NM: Thank you. I loved your questions and it was fun to have this conversation.

How Therapists Fail: Why Too Many Clients Drop Out of Therapy Prematurely

Posted on November 3, 2010March 13, 2026 by rezendevknowfully.com

Depending on which study you read, between 20 and 57 percent of therapy clients do not return after their initial session. Another 37 to 45 percent only attend therapy a total of two times. Although many factors contribute to premature client termination, the number one cited reason by clients is dissatisfaction with the therapist. The problem of the “disappearing client” is what Arnold Lazarus has called “the slippery underbelly to the successful practice of psychotherapy that is almost never discussed in graduate programs or medical schools.”

As clinical supervisors of interns at a university community clinic, we are painfully aware of the high rate of client dropout, and thus the idea for our book How to Fail as a Therapist was born. What we found in doing the research for the book is that high dropout rates are not just common amongst interns, but are equally prevalent among experienced therapists regardless of training and clinical orientation.

When clients drop out early, everyone loses. We clinicians lose a chance to help someone in need and our wallets and reputation suffer as well. The consequences for clients are even more dire. Those clients who drop out early display poor treatment outcomes, over-utilize mental health services, and demoralize clinicians.

Now the good news (after all, therapists should be optimistic): there are a number of well-researched strategies which have been proven to reduce dropout rates and increase positive treatment outcomes. For example, in one study a simple phone call to confirm a client’s first appointment resulted in a two-thirds reduction in dropouts. Unfortunately, it is often labor intensive to seek out and review much of the relevant research because it is scattered throughout the literature–a journal article here, a chapter in a book there. And, unfortunately, most mental health clinicians, with and without a PhD, rate reading research as a very low clinical priority.

Thus, a major task in writing the book How to Fail as a Therapist was to assemble, organize and condense the vast body of research addressing therapeutic effectiveness. Of the 50 therapeutic errors described in the book, here we present five of the most common ones made by clinicians–both beginners and “master” therapists.

The “Infallibility Error”

One of the most distinguishing characteristics of therapists who have low dropout rates is that they actively seek feedback–both positive and negative–regarding the effectiveness of their clinical work. On the other hand are those therapists who believe that after years and years of study, comprehensive exams, postgraduate supervision, and licensing exams, they do or should have all of the answers to clinical matters. So when their clients voice concerns about their progress, or worse yet, when they drop out or deteriorate under the therapists’ care, there is a tendency to avoid accepting responsibility for committing a possible therapeutic error. It is easier to point the finger elsewhere: “maybe the problems were too severe”; “the patient was not ready or willing to change”; there was too much transference operating.” The possibility for rationalization and denial is endless. These explanations, even when partially valid, may soothe the ego, but they protect clinicians from engaging in an honest and comprehensive exploration of what might have gone wrong in a particular case.

A group of interns were asked to describe a case in which a client of theirs terminated early in therapy. One intern described the case of a 10-year-old male client, who had been referred by his teacher because he seemed disconsolate over his parents’ divorce. When, in the first session, the intern probed about the effect of the parents’ separation, the client became emotional and wanted to change the subject. The intern persisted, however. The client stood up, tears falling, and refused thereafter to return to therapy. The supervisor responded to the case presentation by emphasizing the need for therapists to be very cautious during early sessions, particularly when eliciting difficult material from clients. Before the supervisor could get very far, the intern interrupted by stating: “I am already discussing this case with my other supervisor, so I probably shouldn’t get input from both of you.”

Clearly, this intern was desperate to avoid facing the possibility that he did not handle the case as delicately as perhaps he should have. None of us really relishes the idea that we may have blundered, but if we deny this possibility, we deny ourselves the chance to grow as clinicians.

One way to avoid the infallibility error is to seek feedback from clients who have dropped out prematurely. Arnold Lazarus describes in his book, Multimodal Behavior Therapy, how he has gained great insights by writing “early terminators” and suggesting that they come in for a “feedback session” for which he doesn’t charge. In one such case, a client reported that she felt the therapist had not been sympathetic when she was recounting the loss of a beloved pet. The therapist apologized for the insensitivity and the client decided to continue in therapy.

One crucial statistic to keep is mind is that the majority of clients who drop out do so after the first or second session. Thus, we must elicit client feedback, positive and negative, early on to head off any misunderstandings or negative feelings about the therapist, the therapeutic process or the therapists. Clients can be asked directly at the end of the first session if they feel therapy is on track and if they feel liked, understood and respected. “Asking for direct feedback may feel a little awkward; however, a little awkwardness is better than losing a client before he or she can be helped.”

The “Pathology Orientation” Error

In the field of psychotherapy, the term “The Bible” has become synonymous with the publication known as Diagnostic and Statistical Manual. This definitive compendium of emotional disorders was first published in 1952. Since that time, the Manual has gone through a number of revisions (four major and several minor ones) and has continued to add new diagnostic categories. In addition, it has really bulked up over the decades, growing from a mere 138 pages at the outset to over 800 pages in its most recent incarnation.

Currently every student entering the field of psychiatry, psychology, social work or counseling is required to virtually memorize the DSM-IV-TR, and thus professionals in our field have greatly increased their knowledge base of diagnostic criteria, demographics and prognoses of emotional disorders. Alas, these advances have a downside as well: it has created an overemphasis on pathology to the near exclusion of what is healthy, resilient, and capable in the clients that we treat.

At the same time that the fields of diagnosis and assessment were becoming more sophisticated, an alternative view of human potential was also advancing. Theorists such as Carl Rogers, Abraham Maslow and Victor Frankl were among the forerunners of those who tended to take a broader view of the client, looking beyond pathology toward human capability. Milton Erickson’s work, which emphasized client resources, was in the vanguard of this new perspective.

Following Erickson’s lead, a number of other clinicians and researchers have explored the idea of utilizing client strengths as a resource in the treatment of emotional problems. Narrative Therapy avoids the exclusive focus on problems and pathology by instead exploring clients’ alternative stories–occasions in which healthy, productive behaviors were enacted instead of the usual counter-productive responses.

Ryan was described as “incorrigible” by his teachers. He spent as much time in the principal’s office as he did in the classroom. His main transgressions revolved around aggressive and bullying behavior. Ryan’s counselor applied a narrative approach by first asking Ryan about his “problem story”–the things that get him in trouble. They then gave a name to his problem story–“Mr. Trouble.” In addition to gathering the nasty details of his misbehavior, the counselor also inquired about occasions when a different Ryan, a kinder Ryan, surfaced. The question itself seemed to shock the 10-year-old. However, after reflection he confessed that on occasion he had shown care to his younger brother when he was ill, or was lonely and needed a playmate. The counselor then asked follow-up questions to explore the way “Kind Ryan” felt after demonstrating care to his brother.

“What did you think of yourself for being helpful to your brother?”
“How did your brother respond to your help?”
“What did your parents think of you?”
“What does it say about you that you show care to your brother?”

Unfortunately, despite the advent of “positive psychological” approaches to therapy, we have been programmed to look more at what clients are lacking and less at client strengths. Most intake forms have a space in which the client’s clinical diagnosis is supposed to be entered. To avoid the pathology orientation, we need to expand the initial interview to include a thorough assessment of clients’ skills, talents and resources. We need to know what challenges they have surmounted, what kinds of accomplishments they have attained, what special abilities they have developed. When therapists and clients shift their focus from the pathologized victim to the heroic victor, therapy becomes a much more creative and productive process.

Emphasizing Therapeutic Techniques Over Relationship Building

One of the best things about attending continuing education seminars is learning about the latest therapeutic interventions. And every year or so, such new “breakthroughs” arrive—EMDR, DBT, ACT—you name it. We rush home from the seminars, and can hardly wait for the first patient that we can try out our newfound knowledge on. Many of these innovations do have credibility, but there is one glitch in all of the focus on techniques. Decades of research have consistently demonstrated that the most powerful predictor of positive therapeutic outcome depends less on what type of therapeutic interventions you employ, and more on what kind of therapist-client bond you develop.

An intern related to her ever-patient supervisor that she had been learning about the use of “paradoxical intentions” in her advanced counseling class. She was hoping to try out this new dramatic technique with one of her clients, and did so with a patient during their very first session. The patient had returned to school after a recent divorce, and complained of being totally overwhelmed. She couldn’t get herself to do any homework and was no longer the organized housewife she used to be–failing to do even the simplest of chores like laundry or dishes. The intervention the intern tried was to “ join the symptom” and prescribe the homework assignment to do “absolutely no work at all this week,” then report back at the next session about how this went.

Unfortunately, there was no next session–the client was never heard from again. The lesson here is one that is all too commonly missed: the therapeutic relationship trumps technique. To be more precise, no other single factor affects therapy outcomes more than the quality of the client-therapist relationship. Although exact percentages of therapeutic effect are difficult to ascertain, one study did attempt to do just that. After reviewing over a hundred outcome studies, Lambert and Barley¹ derived an estimate of the relative contribution of the myriad factors which have been studied in outcome research. Surprisingly, the specific techniques employed by therapists (cognitive, psychodynamic, etc.), accounted for only 30 percent of therapeutic outcome. However, the quality of the client-therapist relationship predicted results 40 percent of the time.

In the case discussed above, the paradoxical intervention might have proven effective in the long run, if the therapist and client had developed enough rapport and a trusting relationship before implementing the approach. The tendency to rush into the therapist tool kit and resolve the problem quickly is of course exacerbated by the current emphasis on brief or time-limited therapy. Suffice it to say, this bottom-line, time-is-money orientation is not always in the patient’s best interests. Relationship building begins with the first hello and handshake. In fact, in one study of medical doctors, the handshake was cited by patients on an exit questionnaire as the most positive factor in the office visit.

One of the best (and least utilized) methods to ensure that the therapist and client are on the same page is to employ a relationship assessment tool such as the Working Alliance Inventory developed by Horvath and Greenberg. This user-friendly tool predicts with a high degree of accuracy whether or not a client is at risk of dropping out of therapy. It also points to the areas of disconnect which can be addressed sympathetically with the client.

The Homework Assignment Trap

Providing clients with opportunities to apply what they have learned in therapy is one of the keys to therapeutic effectiveness. This makes good sense, given that clients spend only an hour or two per week in therapy and 165+ hours in the real world. So it would stand to reason that the majority of therapists would regularly utilize out-of-session activities as part of their therapeutic arsenal. However, the sad truth is that the majority of therapists report never using such assignments. Why would there be this disconnection between what the research shows and what most therapists do?

What the research doesn’t show is that creating homework assignments that clients actually comply with is a tricky business–and there are a multitude of therapeutic errors that can interfere with the process.

A case history will help illustrate:

Dr. Doom was working with Sabrina, whom he diagnosed as socially phobic. Sabrina had particular difficulty in her college classes, worrying excessively about bringing attention to herself. To avoid the possibility of embarrassment, she always arrived early to class, sat in the last row, and never raised her hand. After several weeks of therapy in which he gave her no assignments, Dr. Doom decided it was time for action and suggested that Sabrina arrive five minutes late to her next class meeting. At her next session, Sabrina at first told her therapist that she forgot to do the assignment but later admitted that she was able to comply with the first part of the assignment–being late–but could not muster the courage to actually enter the classroom, so she ended up cutting class.

Was Sabrina’s case just another example of client resistance, lack of commitment, or lack of readiness to change? In fact, a careful analysis of the approach the therapist used reveals several therapeutic errors that greatly decrease the likelihood of compliance.

Unilateral Assignments (“Here’s what you need to do…”)
For starters, Dr. Doom “decided” on his own, without input from his client, that it was time for action, and then he chose what that action should be. This one-sided approach helped guarantee noncompliance. Just as the entire therapeutic process should be collaborative, each assignment needs to be arrived at by a joint meeting of the minds. Thus, the term “assignment” is not really appropriate at all because it connotes one person doing the assigning and the other person complying. Far better are concepts such as “experiments,” “activities,” or “tasks.” Therapists certainly can take the lead in developing possible strategies, but clients must be encouraged to provide their input and feedback as the tasks are developed. Clients who feel they have participated in the process of generating the activity are more likely to attempt it, complete it, and maintain whatever they have learned from it. Leaving the client out of the decision-making process increases the likelihood that the task may be beyond the reach of the client’s capabilities. In this case, suggesting the client arrive late to class was an attempt to hit a home run with one pitch instead of moving gradually toward the ultimate goal.

Failing to Prepare Clients for the Assignment
All too often, clinicians employ a “take two aspirin and stay out of drafts” approach to therapy. That is, they act as if mental health work is identical to the medical model in which clients ask the all-knowing physician for a diagnosis, prognosis, and treatment recommendations. In reality, most therapy clients need information about the efficacy of specific interventions. In the course of Dr. Doom’s assignment-giving, he neither sought Sabrina’s input nor gave her even a clue what this fear-inducing activity was supposed to accomplish. What might have seemed obvious to the therapist was probably not at all clear to the client. For those with phobias such as Sabrina’s, education about the efficacy of gradual exposure should have preceded any specific homework recommendations.

Failing to Provide Backup Support to Increase Compliance
As any therapist quickly learns, just because clients say they will perform an activity outside of session, this does not mean they will actually follow through with the commitment. Getting clients to comply with homework (even those assignments they have helped design) is about as difficult as getting students to complete school assignments on time. Understanding this, successful therapists utilize a wide array of approaches designed to overcome the numerous obstacles to completing out-of-session activities.

1. Use Post-it notes. At the conclusion of a session, suggest that the client write down the assignment and then post it at home in a convenient location. The therapist should also make a note of the assignment so it can be reviewed at the next session.

2. Encourage the client to tell a trusted individual about the task, asking the friend to check back and see how the assignment is going. This person should not be a guilt inducer or have any vested interest in the activity other than the welfare of the client. Typically spouses, children, and parents are not useful choices.

3. Determine whether the client has a buddy who is also willing to engage in the desired activity. This can be especially helpful with assignments such as increased exercise or attending classes or support groups.

4. Frame the assignments as a way to learn about oneself while trying new things. Emphasize the possibility of enjoying the opportunity to develop new skills that could be beneficial for a lifetime.

5. Leave little or nothing to chance by carefully clarifying the how, when, and where components of the assignment.

6. Do a thorough assessment of any an all obstacles which might prevent the client from following through with the assignment. Make no assumptions. For example, one client committed to doing an online search for employment during the week. However, an inspection of barriers revealed that the client had never used the internet and in fact did not even have an internet connection for his computer!

Underutilizing Clinical Assessment Instruments

Assessment tools, used early in therapy to measure the type and intensity of the initial problem and occasionally during the course of treatment, can aid in treatment effectiveness, client morale and reduction of termination by resistant clients.

Despite this, clinicians by and large are often skeptical about the value of utilizing assessment tools. For example, one clinical supervisor described a case where a postdoctoral intern was not following agency policy to administer a well-known and highly validated instrument. The trainee stated that she did not “believe in” the assessment because it was not particularly useful and took a lot of time to score–despite the fact that the specific instrument had proven its validity and utility in dozens of studies.

There are a number of factors that contribute to the effectiveness of utilizing assessment instruments:

1. The therapist gains information from a source that allows comparisons to other clients regarding the severity of the problem.

2. Repeating the test at periodic intervals can help demonstrate to the therapist and client whether treatment is being effective.

3. If the results indicate improvement, positive expectations are reinforced. If there is no improvement, the client and therapist can adjust the treatment approach appropriately.

4. Clients tend to see assessment utilization by the therapists as an act of caring, and it enhances client regard for a clinician’s expertise.

All of this and more–and yet clinicians often ignore assessment tools like the plague. Two common reasons for the underutilization of these instruments involve the perception that they require a lot of time to take and score, and that they cost an arm and a leg. To counter this problem we have compiled a list of short, easy-to-score tests which are in the public domain–meaning they are free for the taking. (These are listed at the end of this article.)

While utilizing assessment tools is a good starting point for improving therapeutic outcome, there are two other factors which can enhance their use. First it is crucial to explain to clients that just like medical doctors, therapists utilize assessments in order to pinpoint possible problem areas. Lastly, results of assessments should not be kept secret from the client. It would seem quite odd if your medical doctor did not provide any feedback after a patient had a series of tests such as blood work or X-rays. Similarly, several studies have shown that an open discussion of the results of psychological tests enhances therapeutic outcome by increasing client engagement in the therapeutic process.

A Final Note

All clinicians have no doubt experienced something like the following scenario: You provide your client with some helpful information–“for all the reasons we have discussed, maybe now is not the time to start a new romantic relationship”; your client nods his head in agreement; and at the following session the client announces that he has fallen head over heels in love. The helpful information somehow went in one ear and out the other. Our hope in writing this article and the book upon which it is based is that it will actually impact clinician behavior, that readers will not just nod their heads in agreement, but also put one or two concepts into practice.

To help clinicians move beyond the conceptual to the behavioral involves some self-assessment. This assessment involves taking a few minutes to answer the following questions: What is your clinical batting average?—or conversely, what percentage of your clients are dropping out prematurely? What type of clients are the dropouts? What is it about those clients that makes them more difficult to work with? What type of clients do you tend to do well with?

Addressing questions such as these enables us to take stock of our clinical strengths and weakness and can help us locate the therapeutic errors we may be making with clients – errors such as the ones discussed in this article. This in turn can lead to the implementation of new therapeutic practices and better outcomes for clients and ourselves.

Public Domain Assessment Tools

Following is a list of just a few of the many public domain assessment tools available:
Depression: Center for Epidemiologic Studies. Depression Scale (CES_D)

Eating Disorders (Anorexia Nervosa): Eating Attitudes Test (EAT)
Social Anxiety: Fear of Negative Evaluation (FNE)
Post-Traumatic Stress Disorder: Impact of Event Scale – Revised (IES – R)
Substance Abuse (Alcohol): Michigan Alcoholism Screening Test (MAST)

¹Lambert, M., J. & Barley, D., E. (2001). Research Summary on the therapeutic relationship and psychotherapy outcome. Psychotherapy, 38, 4, 357-361.

Mark Epstein on Mindfulness and Psychotherapy

Posted on October 31, 2010February 25, 2026 by rezendevknowfully.com

Buddhism and Psychotherapy

David Bullard: Mark, I am very grateful and thankful that you found the time for this interview in the midst of a wonderful three-day workshop on Buddhism and Psychotherapy, which you are presenting in tandem with Tenzin Robert Thurman at Menla Mountain Institute. I’ve probably done this interview 40 times in the last couple of weeks, but this will be different because you are actually here this time! In preparation, I’ve considered a series of questions which led into more questions, and have already gotten a huge gift from the anticipation of having this time together. On the other hand, this interview should probably be organic and free-form, and grow from our being in the present rather than from a pre-selected list of questions.

Mark Epstein: Well, it’s great that you’ve been thinking about it so much, and to have really thoughtful questions formed could be very helpful.

DB: It could be, and that’s my desire. You’ve written a lot about the nature of desire and disappointment—we’ll have to see which this will be!

ME: Trust in your desire. We’ll get into that.

DB: Let’s begin with a brief review of your extensive writings on the integration of Buddhism and psychotherapy from psychoanalytic and psychodynamic perspectives, which include wonderful examples of your own process and journey. You have published five very influential books, as well as many articles and chapters; you have taught at NYU and have participated in many workshops, and, of course, continue your private practice. In Open to Desire: The Truth About What the Buddha Taught, your acknowledgement section lists 60 people, so you are certainly well connected in your professional and personal lives. I personally have also enjoyed your chapter “From Eros to Enlightenment” in Brilliant Sanity: Buddhist Approaches to Psychotherapy. So shall we begin the interview with your first exposure to Buddhist teachers and how they were helpful to you?

Buddhist and Psychotherapy Teachers

ME: I came to my first Buddhist teachers after a very short experience with psychotherapy; so those first encounters were framed with a beginning attempt to seek therapeutic help for myself at the student health services at Harvard, where I was given a practitioner of short-term psychodynamic psychotherapy. This therapist met me three times and told me not to worry—my anxieties were just a result of my Oedipal complex and once I understood that, I would be fine.I went from there to a Buddhist summer camp in Boulder, Colorado where I met my first Buddhist teachers: Joseph Goldstein and Jack Kornfield. They taught me mindfulness meditation, in which I learned how to actually be physically with my emotional experience. They refused to name it or to encourage me to name it, but really taught me how to dig down into it and know it, with less fear. So that was the first great gift that I got from Buddhism.

DB: Can you contrast that with any particular gifts received from your psychotherapy teachers and mentors?

ME: The insights from my psychotherapy teachers were many but came later, after, to my dismay, I realized that what I was learning from Buddhism still left me sometimes struggling, especially in my relational life. So I went back to psychotherapy informed by Buddhism, and then was touched by how deftly certain of my therapists worked with my relational self in the actual interactions with them in the moment. It seemed very Buddhist to me, only active and engaged. I have examples I have written about in my books, that crystallize for me what I think I learned from these interactions.In one, a therapist suddenly interrupted me as I was clumsily trying to explain what I wanted to get out of therapy, and asked me if I was aware of how I was sitting. I found this annoying. What was wrong with the way I was sitting? But he pointed out that I was sitting on the edge of my seat. “You give yourself no support,” he said.

In another, a therapist waited patiently for me to begin a session. I sat there wide-eyed, staring at him but with nothing to say. I was remembering how a spiritual teacher of mine, Ram Dass, used to begin our private sessions that way. “Blink!” my therapist broke in. He made me see how my efforts to prolong contact with him actually diminished it, that when you stare too long at someone or something, you actually lose touch with it. He was showing me something about the rhythm of intimacy and the pull of addiction.

In a third example, I was speaking to my therapist about how ‘”part of me” was angry and “part of me” understood that I didn’t need to be angry. He looked at me with barely disguised disdain and said, “Mark, you don’t have parts.” This has served as a koan for me over the years. “I don’t have parts? What am I, then?”

DB: Could you tell us what particular thoughts you like to convey both to beginning students and experienced therapists, eager to learn or deepen their understanding of the art and science of psychotherapy through Buddhist psychology?

ME: A lot of therapists come to me with an interest in how to use Buddhist psychology to enhance their work. And often they are thinking much more concretely about “should I teach my patients to meditate,” “how can I use Buddhist wisdom to help my patients feel better and help them resolve their neuroses,” etc. I always feel that the most important way Buddhism can impact psychotherapy is by helping the therapist.

What Buddhism teaches very practically is a psychotherapeutic attitude: how to deploy psychotherapeutic attention both intrapsychically within the self and as well as interpersonally. When you are training as a psychotherapist you don’t necessarily get specific help in how to deploy that kind of attention, but Buddhism is all about that. So I try to turn it back: “Here, this is for you.” If you get something from it, maybe you will be able to make it come alive for your patients.

Evidence-Based Buddhism?

DB: I’m smiling because I know that is your emphasis, in an era that is technique-oriented or theory-driven. Which brings us to the current hot topics of “evidence-based psychotherapy” and “empirically supported psychotherapy.” It is being greatly debated with some divisiveness in psychology organizations. Can you offer us your perspective on that?

ME: I think there is a huge need to increase the cost-effective delivery of health care and to make psychotherapy understandable to the general population in terms of weighing the economic costs. In terms of doing research in what is therapeutic and isn’t, I completely appreciate that way of thinking. And yet there is something to be said for the old-fashioned, psychoanalytic “not knowing” and groping around blindly in the unconscious—being able as a therapist to create an interpersonal field in which one doesn’t know what will emerge, and yet trusting that what does emerge will potentially be therapeutic. Whether that turns out to be cost-effective or not, or operationalizable or not, we don’t know yet, but is certainly worth the study.

DB: But are there other kinds of evidence, from the accumulation of thousands of years of Buddhist teachings that have survived, together with the Buddha’s injunction that each person must explore deeply the applicability of the teachings, rather than to accept them on faith? Is this a kind of empiricism, a kind of “single case study” that Buddhism encourages?

ME: I think one has to be careful with this kind of reasoning. Just because something has survived for centuries doesn’t necessarily make it right. War has survived, for example. People thought the earth was flat for longer than they’ve accepted it being round. Buddhism has cultivated an introspective method over the centuries. It could just be a sophisticated kind of brainwashing. The scientific method is certainly capable of holding it up for study. That is already starting to happen.

DB: Yes, as we see from the labs of Richard Davidson and of Dan Siegel, among others, increasing our understanding of the impact of meditation on the brain. Many exciting issues are emerging from this collaboration between Buddhist psychology and neuroscience.In another vein, therapist Michael Yapko recently said that he counted over 400 forms of psychotherapy. The vast majority of these, even if they are helpful, won’t be studied or validated by research. So what is psychotherapy?

ME: I think there is both science and method to successful psychotherapy, depending on the character structure and issues of the person needing psychotherapy. There are clearly different methodologies that are more or less effective, which a trained therapist will have some understanding of. And how these methodologies are deployed matters a lot—the fostering of a relationship that is beneficial or potentially destructive, or that could do nothing. So I think there is a lot to learn from all of the 400 schools—they probably all have something to teach. What I remember being impressed by, in terms of the research of the efficacy for a rather healthy population, is that the type of psychotherapy is less important than the relationship which ends up being fostered between the patient and therapist. And the quality of that relationship probably contains much of whatever it is that is healing in any kind of therapy. How to define that quality, other than using worlds like “love,” and so on, I think will prove difficult, but clearly people know when there is a positive or trusting relationship, and when there isn’t.

Safety in Psychotherapy

DB: You’ve expanded a lot on Winnicott’s idea of safety as a primary issue in psychotherapy.

ME: At least the possibility of safety. One finds in psychotherapy, even working with someone where there is a positive and good relationship, that there are things that people still don’t want to talk about or don’t feel safe talking about, that might emerge after many, many years into a given treatment. So even safety is a relative concept.

DB: So safety allows you to get to the edge of what they can talk about.

ME: There is always an edge to where someone feels safe, even with a therapist with whom one feels safe.

DB: No absolute safety.

ME: Yes, no absolute safety, and some fear, some trepidation, some insecurity. Pushing into that, playing with the edge of that, is something that can happen in a working psychotherapy that keeps it alive and vital and interesting.In talking about Winnicottian issues like safety, holding environment and good-enough mothering and so on, it’s easy to conceptualize the therapist’s role as being nothing but facilitating—psychotherapy as being primarily an empathic relating. But I think that that misses what the therapeutic task actually is. Therapists, in my view, have to be very clearly themselves, to be able to come from an authentically individualized place so that they are not just emoting or communing or sympathizing, not just providing a field. They have to be really there, and at the same time have to be able to not be so present that they are filling a space too much or intruding. Winnicott is excellent about talking about the middle ground or balance between impinging or intruding and abandoning. It’s easy to misinterpret the kind of presence that Winnicott encourages as being more selfless than a good therapist has to be. Therapists have to be very clear about who they are, and be able to use their own responses and opinions, their own techniques and methods.

At the same time, a therapist has to primarily be able to wait, and wait, and wait, and wait, and not be so anxious to display his or her intelligence or understanding or insights into what they think is going on, and to trust that there will be a time when it is obvious that what needs to be said can be said.

DB: In being authentic in the way I think you are speaking, the therapist doesn’t have to be perfect, and a client or patient’s reacting to the therapist’s imperfection can be a very deep part of the therapy work, providing for relational depth. For some, it can be very important to be able to challenge one’s therapist.

ME: Yes. Well, perfection is impossible, so one will always be failing one’s patients. But if you fail too much you do them no service, so there is a balance there, too. Using the word “authentic,” however, has become a cliché—the authentic therapist being too authentic becomes inauthentic. It is their image of what an authentic person should be.

DB: Maybe you are also speaking along the lines of a quote from Jung, who was asked how one learns to become a great therapist. My recollection of his comment is: “Go and read everything written about the art and science of psychotherapy, but then forget it all before you first peer into the human soul.“

ME: We should be able to have them and not have them at the same time. I’m not sure you have to learn them and forget them. I think once you learn them they are there, but you don’t have to be restricted by them. You can use them when you need them.

Should We Desire To Have Desire?

DB: I like your modification of my paraphrase! This might be a good time to segue into issues you discussed in your book, Open to Desire. Would you like to start with the story of Nasrudin eating the peppers?

ME: I wrote the book about desire because in Buddhism, desire has a bad name. One of the shortcuts in understanding the Four Noble Truths is that the First Noble Truth is the truth of suffering—that all experience, even pleasurable experience, has a hint of unsatisfactoriness or dukkha or suffering, because we are conscious of its transience. The Second Noble Truth, the cause of suffering, is sometimes given as desire. A deeper reading of the word the Buddha used translates better as thirst, craving or clinging, but we confuse our idea of desire with the Buddha’s notion of clinging. So I think that a lot of confusion has arisen about desire. Is desire okay? Is it evil? Is it bad? Is it wrong? My sense is that even within a Buddhist framework there is desire—the desire for liberation, the desire for enlightenment. That is obviously a desire. The Buddha’s solution to the predicament of suffering wasn’t to stamp out desire per se. It was to not cling to it, or to not cling to the object of it, more to the point.I remember a phrase that came from an Indian teacher: “It’s not desire that’s the problem, it’s that your desires are too small.” I use that as a jumping-off place because the problems many people have with desire are that their desires are too small. They are locked into the seeking of pleasures that once provided a huge relief but that now, over time, repeatedly provide only a shadow of the relief that they once did. To our minds, they seem to be the only sources of relief. The Buddhist teachings are all about opening up the seeking to find other kinds of pleasure.

The story that you were referring to is where Nasrudin, who is a kind of amalgam of wise man and fool, is sitting in the marketplace eating handfuls of hot, red chili peppers and tears are weeping from his eyes. His friends come to him and they ask, “What’s with you? Why are you always eating peppers that are making you sick?” And he says, “Oh, I’m looking for a sweet one!” So the small reading of the story is that desire is the source of suffering, “so why don’t you just stop eating the peppers?”—the idea that stopping acting on desire will stop suffering. The more nuanced reading of the story is that Nasrudin, in the guise of the fool, is demonstrating the potential of desire to ultimately find something sweet for his soul. I’m not sure which reading is right.

Disappointment and Relationship

DB: I came across a quote from Soren Kierkegaard you may know from the Western philosophical tradition: “Perfect love means to love the one through whom one becomes unhappy.”Can you share some thoughts about relationship and desire, the real world of living in a relationship, and disappointments?

ME: Disappointment in love relationship is often taken as the exit door, especially in our culture where it’s become more acceptable to actually exit. In many cases, that might be the right thing to do. And it’s impossible even for a therapist to be able to say for any given person. Often as therapists we are put in the position of “should I stay or should I go,” but that is a tough call, even for the individual in the relationship. But certainly from the Buddhist perspective, and I think from a psychodynamic perspective also, there is no love without disappointment. Even in what appears to be a true or perfect love, the idea that one could rest forever in that state, and that it would last unchangingly, clearly that is too much to ask of love. So then the question arises: Should we take disappointments as a defeat, or take them as an obvious shadow of love? A lot of that is in the attitude and the ability of both partners to continually reconnect without necessarily solving those aspects of a relationship that lead to frustration, disappointment or anger. I think there is something to be learned from both the Buddhist side and the psychoanalytic side. Instinctively, not too many people know how to do that easily.

DB: At last year’s workshop on Integrating Buddhism and Psychotherapy, Columbia University Professor and Buddhist scholar Dr. Robert Thurman reported that his wife once advised him: “Bob, you are going to disappoint people, so you might as well do it sooner rather than later.” I think that embodied a lot of wisdom! A week after Bob said that, a colleague of mine who is a longtime Zen priest and psychotherapist reminded me that disappointment is a major Zen teaching.

ME: In relation to this question I always read Winnicott, who talks so beautifully about both how important it is for a mother to be able to fail her child, and how normal it is for children to hate their parents and parents to hate their children. The “good-enough” mother doesn’t need to be taught, but intuitively knows her task, in relation to her child’s anger: to simply survive, not to retaliate or abandon, but simply to survive. And I think there is something in that intuitive sense that one needs to survive, without the need to abandon. To stay in that place allows an experience of both separation and union, so that it continues to unfold in an ongoing way.

The Joy of Meditation and of Psychotherapeutic Work

DB: Is there any additional question or issue you would like to address in this brief interview?

ME: It is a little hard to talk about, because I haven’t thought it through completely, but what I have been exploring a lot lately is the Buddha’s understanding of joy or happiness that is derived not from seeking after sensual pleasures but from non-sensual or non-worldly experiences. The Buddha, in that language, was talking specifically about experiences that come in meditation, when the usual seeking after pleasure or rejecting of unpleasure is suspended and one’s experience can withdraw, though that might not be the best word—that one’s experience can relax into the nature of mind. There’s an inherent joyfulness, an inherent balance, one could say loving or shining nature, to the mind that becomes available through the deliberate renunciation of the usual attempts at maximizing pleasure.So taking that seriously, I’ve been thinking about how some aspect of that is actualized in the psychotherapeutic relationship, as well. Which also involves a tremendous amount of renunciation, both on the part of the therapist and the person in therapy.

Joy, I think, is a good word to describe the feeling tones that can be opened up in the psychotherapeutic relationship, which I think therapists have been aware of since the time of Freud but have been scared of, and which people have continually tripped over because it can lead to the suspension of renunciation and the acting out of the feelings that are evoked. But one dimension that the Buddha’s world gives to us is this sense: not of the unconscious being only a whirlpool or cesspool of destructive feelings, but also a background of joyful and loving energy that is here if we are willing to look for it, or is even here if we are receptive to it.

The Courage To Create

DB: It sounds like another book is percolating: The Joy of Therapy, perhaps!Non-therapist acquaintances of mine sometimes remark: “Oh, I could never listen to people’s problems all day!” I often reply that, although I certainly hear painful, difficult and tragic life issues, I also hear of the courage in people’s struggles, and they also share their joyful moments of delight, aliveness, and triumph. It is a privilege to be able to learn deeply about the astonishing varieties of human experience. And at times, at its best, it is a form of I-Thou relationship.

I also wonder if you would feel it appropriate to describe your current personal meditation practice, if it can be so described, other than the meditation-like experience of psychotherapy?

ME: My current meditation practice? I try to sit whenever I have time for it. In the morning if I can, in the evening before bed if the time is available. After reading the New York Times. And I try to go away on retreat (for a week if I am lucky) every year or two.

DB: In ending this talk with you, I am remembering Rollo May, who was another much-admired author I was honored to talk with many years ago. Of his many books, one of my favorites was The Courage to Create. So on behalf of all of your readers and all of the people who have been touched by you and your writing, I want to thank you for being willing to put all of these compassionate, thoughtful and wise explorations out there for us to read because it really does take courage to create.

ME: Thank you.

Harry Aponte on Structural Family Therapy

Posted on September 17, 2010February 27, 2026 by rezendevknowfully.com

Putting Therapy in Context

Rebecca Aponte: First, just so our readers are not confused, we should clarify that neither of us knows of any family connection, despite our shared last name.

Harry Aponte: That’s correct.

RA: You primarily practice family therapy. It’s interesting, because family therapy seems to be in danger of disappearing–it doesn’t seem like most therapists do it at all. What’s your sense of the state of family therapy today?

HA: I think family therapy has gone through its phase of fanaticism. It’s like so many other perspectives on therapy: it went through a phase where people made a new discovery, and they got infatuated with it, and that became the answer to it all. I believe the thinking about working with families has matured so that it’s not such an exclusive focus. People are much more flexible about working with individuals and couples as well as families, and people are more flexible in terms of being prepared to work with some unit of a complex family system without necessarily seeing all the members of the family, while maintaining a broader perspective so that they understand that the individual or the couple in the context of not only family, but also of community. So I don’t think it’s dead at all. I just think it’s matured to the point that it’s been incorporated into the very large and complex field of therapy.

RA: Do you think that the perspective of keeping the broader sense of community is as integrated into most therapists’ minds as it should be?

HA: Well, to answer the last part of that question, I think it should be. I believe that we have become much more sensitive and knowledgeable and insightful about the impact of the broader social system on people’s personal functioning: the effect of people’s social economic circumstances, the effect of culture, the effect of people’s spirituality, and how all of those affect in a very intimate way how people think of themselves, how they relate to one another, how they understand their reality. Any therapist who wants to engage with another human being at any level at all–to understand that person, that couple, that family–has a lot of factors to take into consideration. And I think that’s happening. I think people are much more comfortable with looking at their clients from a variety of perspectives at the same time.

RA: Is that something you would actively reflect back to a client–that you have their broader context in your mind–although they might not be thinking about themselves in a broader context?

HA: What I reflect back to a client is what I think will be helpful to the client. I’m not there to give the client a lesson on what therapy should be. I’m there to be helpful to the client. I need to take responsibility for having all of those perspectives in mind and taking them into consideration as I explore what the issue is and the roots of the issue, and what resources are in that client’s life for that client to be able to make the necessary changes to solve the issue. I don’t need to explain that to the client, but I do need to be aware of it and work with it.

RA: I’m asking some of these from the perspective of therapists who primarily see individual clients, because that’s probably the most common today. If someone does come to you as an individual, how might you bring up getting their family more involved in the treatment? Is that something you would suggest right away, or does it happen over time?

HA: I’m a pragmatist, so what I do is I listen carefully to what the client’s issue is, and I try to understand the issue, and I try to understand the context of the issue: who’s involved, who’s touching on that issue of that particular individual, as well as what resources are available to that person in their context. And I will try to pull in whatever and whoever is necessary. Even if I need not pull them in, it doesn’t mean that I’m not going to work from a suspended ego complex or perspective. It’s rare that I not ask clients about the history of their issues. And if I ask about the history of their issues, I’m asking about them in the context of their current relationships, their past relationships, including their development within the family of origin. All of that helps me to get some deeper sense of what they’re struggling with and why they’re struggling with it the way they are.

Structural Family Therapy Defined

RA: Let’s back up a bit. What exactly is structural family therapy? Is the distinction from family systems therapy important?

HA: Structural family therapy is an aspect of systems thinking. You have to understand the origins of structural family therapy in order to appreciate its contribution to systems thinking. The work originated, of course, with Salvador Minuchin, Braulio Montalvo, and other people who were working together at the Wiltwyck School for Boys in New York. They were working primarily with all these youngsters who were black and Latino, and who were institutionalized. These therapists began to include the families of these boys in their efforts to be helpful to the boys, because they found that working with them in an institution, outside of the context of their families, they were not achieving the success that they hoped to achieve. As they included the families, they found their success rate change significantly.Well, what happened? Because they were working with boys and families that came from seriously disadvantaged circumstances, they found themselves working with families that were, more often than not, poorly organized, in that they didn’t have the kind of structure that normally helps families to cope with the challenges that life brings. A typical story for a therapist working with the families I’m describing is you find that when you begin to talk with them, they interrupt each other, they speak over each other, and very often it’s unclear who’s really in charge of the family. And if there is somebody in charge, they may be so totally in charge that other people don’t have a voice in the family. You don’t have an organization there that can identify a problem and come together in a way that can solve it.

It’s really no different from what one would be thinking of in another kind of system, such as a business, where when you see a problem in how that business is operating, you’re going to be thinking of the structure and organization of the people who are working within that business. If they’re not effectively communicating with one another, they don’t have a clear hierarchy, and they don’t have clear responsibilities, you’re going to find that things fall through the cracks and the system fails.

Well, that happens with families, and it particularly happens with families that come from disadvantaged circumstances because they also come from disadvantaged communities that are poorly organized. These families, then, suffer the effects of their community, and they’re not able to organize themselves in a way that normally enables families to meet problems and solve them. Every family has problems, but when you don’t have an effective organization, then it’s hard to talk about the problem, it’s hard to identify the problem, it’s hard to cooperate together, it’s hard to find leadership within the family so that you can work towards a particular goal and solve the problem.

That’s the first experience of therapists who worked with families from disadvantaged circumstances. The gift that Minuchin and his colleagues gave us was that they focused on that organization. They understood individual dynamics; they certainly understood the contributions of other systems therapists at the time. But they were dealing with a particular population that had a significant issue around family structure, and that is an aspect of systems thinking. When you are dealing with families that are well organized that still have problems that they can’t solve, you tend to take the structure for granted. You cannot take the structure for granted when you’re working with these families that come from disadvantaged circumstances and who themselves are not organized in a way that’s effective.

RA: It sounds like one of the things that they found was that the pathology of the boys they were working with existed within this much larger environment, far beyond what would have been within the control of the boys or even the therapists.

HA: That’s correct.

An Ecostructural Approach to Family Therapy

RA: You’re talking about major social issues that are much bigger than families as well. How do you overcome those obstacles in a family therapy situation?

HA: Early on, I wrote about an ecostructural approach to family therapy–“eco” referring to the social ecology of the family, highlighting how so many of these families’ problems had their roots in the community they lived in. You have schools that have not only poor resources, but that themselves may have gangs organized within them, that are physically dangerous places for the children there, that make it difficult for the teachers to run the classrooms and create an effective learning environment.When you are working in some of these neighborhoods, the street itself becomes a place that is dangerous. It becomes a place where children just cannot go out and mix together and play together and do the kind of social learning that is important for their development. They’re dealing with drug dealers and other kinds of factors in the community, in the street themselves, that affect how these children think about themselves and how they think about the world. They have to cope; they have to survive. They may have to be more aggressive than children under other circumstances. All of that affects their personal development. And in these neighborhoods, you have problems with getting proper healthcare as well as educational resources. So you have a lot of social factors that are impinging in very direct ways upon the ability of families to function well.

And these families cannot just put all of their energy into nourishing the family environment. They have to be thinking about how to deal with protecting themselves vis-à-vis the community, so they put energy out there that should be put more into the family itself. They’re dealing with difficult environments, and that affects the ability of the family to function successfully.

RA: It’s a lot to think about.

HA: It is a lot to think about. And when you’re thinking about the environment, and you’re thinking about the family, you really cannot offer families coming from these circumstances a service that is exclusively focused on the family unit itself. You have to take a broader perspective that says, “I’m dealing with a child that’s in the context of a family, that’s in the context of a community. So when I then conceive of the work that I’m doing with these families, I have to take all of these into consideration and organize my services so that I can mobilize various aspects of that complex ecosystem to support the goals that I have with this particular family.”My point, though, is that this work with disadvantaged families gave a gift to the whole movement of therapy. It highlighted the importance of this complex social ecosystem– its effect on individual functioning–and the need to be more sophisticated about the dynamics of these various levels, in terms of understanding how they work, and in terms of working with them so that we can achieve our goals. It opened up a whole area of thinking that had to be taken into account. I think it’s been incorporated naturally, and I think people today think in those terms much more readily than they used to.

If we go back historically to the psychoanalytic movement, that was a very intense focus on the individual and what was happening in the individual’s psyche. And that provided critical and wonderful insight. Then we realized, “Well, that’s not the whole person. We need to expand our perspective.” So we expanded it to the families. Then we worked with this particular population and said, “My goodness, we really need to be thinking about the context in which this family is developing.”

So it just broadens our perspective. And we’ve learned ways of understanding these dynamics so that we can actually work with them, not just as sociologists, but as therapists who can be quite focused on trying to obtain a particular objective.

RA: Particularly now that therapy is not just the realm of white, middle-class clients, as historically it has been, there’s a more focus on tailoring therapy to fit people from a multitude of different ethnic and economic backgrounds. Do you have specific advice for therapists who have worked primarily with middle-class individuals, on branching out and working with people who have these bigger issues? One aspect is just being cognizant of the fact that there are many aspects of someone’s development and someone’s selfhood that extends beyond them. But what do you do with that awareness?

HA: I think what we’ve seen now, as a very normal part of therapist’s training, is the therapist being more conscious of the factors of values, world views, culture, spirituality, how these affect the way they see their problems, and how they view a solution that is acceptable to them. We have a much more complex society today than we had 50 years ago or further back, where there was a generally accepted norm of what a family is, how a family should function, and what is acceptable behavior.Today, we have a society that is much more fragmented and often in conflict with itself about what is acceptable in terms of lifestyle and behavior. That changes what one may consider to be a problem, and it certainly affects what we think of as appropriate solutions to problems. That thinking–which was expanding already back in the ’60s, when The Families of the Slums was written by Minuchin and colleagues about the work at Wiltwyck–all of that has been incorporated into everyday, normal therapy.

Nowadays, I don’t know what therapist training doesn’t include some courses that say, “You need to be sensitive to race and culture, and sensitive in such a way that you understand how race and culture directly affect not only how we view the issues and how we work with them, but the very nature of our relationship with our clients, and how we join with our clients.” Therapists will have their own culture, they’ll have their own values, as well as certainly their own personalities and life experience. But how do these therapists relate and connect to clients who are always going to be different in some particular way or another, in a society that says we need to be more accepting of the differences among us? So we’re working in a more complex world today as therapists than we did in the past.

The Person of the Therapist

RA: Certainly. And it sounds like you’re saying, too, that it requires therapists to be more sensitive to themselves and to their own world views, and really have a clear idea of their own personalities and backgrounds and how they appear in the therapy.

HA: If you’re not aware of what you’re bringing to the therapeutic relationship and the therapeutic process, you can’t take responsibility for it.

RA: Is that essentially what “the person of the therapist” means?

HA: That’s exactly what “the person of the therapist” means. The therapy of today is a therapy in which therapists are certainly much more actively engaged with their clients or patients than what would have been the model in the psychoanalytic world. And certainly, if you read the writings on structural family therapy, you would see how therapists use themselves very actively to influence the dynamics within the family, and how they engage with individuals within the family. What I’ve done with the “person of the therapist” model is to try to take that a little deeper and say to therapists, “It isn’t just a matter of how you use yourself.” It starts with understanding yourself, not only from a psychological perspective, but also from a cultural and spiritual perspective. As a therapist I have to get in touch with what’s inside of me–and not only what’s inside of me, but because these are living, active dynamics, I have to get in touch with what I struggle with in my own life, what I struggle with psychologically, what I struggle with in my relationships with people, what I struggle with spiritually. I need to understand that, I need to be in touch with that, because all of those factors are active when I engage with the client. They’re going to affect how I see the client, how I hear what they have to say, how I connect with that person, how I even conceive of how we’re going to try to find some solutions.These factors are active even beyond our normal awareness as therapists. We need to get the kind of training that makes us experts on who we are and what’s happening within us, so that even as we are working with our clients, we’re conscious of what’s going on within ourselves, and we can take responsibility for what we communicate about ourselves and what we try not to communicate about ourselves and how.

RA: How do you practice that? Does that mean therapists do their own therapy, or is it more self-reflective?

HA: It’s a specific kind of training. Traditionally–certainly in the psychoanalytic world–therapists needed to undergo their own therapy. But that objective was one that said, “I need to try to solve my own personal issues so that I am freer to work more effectively with my clients. I’m not going to put on my clients my own hang-ups.” That way of approaching the work of the person of the therapist was continued and picked up by Virginia Satir and Murray Bowen, but again from the point of view of, “Let me identify my issues and try to resolve them so that I will become a more effective therapist.”What I’ve been emphasizing is that all of that is absolutely important and useful, but the simple reality is that we never resolve all of our personal issues. We struggle with ourselves the rest of our lives. We need to go through training programs where we become aware of ourselves in the context of doing therapy, not to resolve personal issues, but the primarily to understand ourselves in vivo: When I’m engaged with my clients, what’s going on inside of me? How do I get in touch with it? How do I decide how to use what’s going on within me in order to understand and empathize better with what’s going on in the client? How can I relate in a way that’s specifically useful to the client at this particular moment in time?

So it’s an approach to preparing the therapist to use this instrument that is me, in a way that is much more effective. Then I can use all of what I’ve learned technically and theoretically of other models of therapy, and I can use it through the person that I am in a way that amplifies the effectiveness of my work.

RA: So this model rejects the psychoanalytic idea of being a blank slate or completely neutral, and focuses instead on the therapist’s personhood.

HA: It certainly does. The advantage that classical psychoanalysis had was that the analyst was sitting behind the couch out of the view of the analysand, and wasn’t engaging eye-to-eye with the patient. Today, most all of our therapy is eye-to-eye, and we feel each other. We and our clients are engaged personally in the therapeutic process, and that’s a simple reality. The question is, how do I engage personally within the boundaries of my professional goals so that I can be of use to this person?

The Role of Spirituality in Therapy

RA: You’ve mentioned a couple of times the role of spirituality in therapy. How do you bring spirituality into the therapeutic relationship in a way that’s safe for clients who might have different views?

HA: It’s not a matter of bringing it into the process as much as it is of being aware that it’s there. Spirituality is just a normal aspect of who we are. We all have a morality of one sort or another. We all have a world view–a philosophical perspective on life and what’s important in life, what’s meaningful about life, what our goals should be in terms of moral principles. And that will certainly affect how we think about the issues that come up for us. A simple example that’s very relevant today is the postmodern view of reality, where reality is something that you cannot know directly, but only through what you sense–meaning that you cannot prove a truth, so truth is only in the eyes of the beholder. That’s a spiritual perspective; that affects the way we look at life.And if you do believe there is a reality that we can perceive, and that there is an objective truth that we can relate to, that’s very different from somebody who comes from a perspective that says, “It’s really what you perceive, more than it is what you think is out there.” That affects how we think of our problems; that affects how we’re going to try to solve our problems.

RA: So you’re trying to understand how clients perceive themselves and their problems, and having knowledge of yourself is primarily to keep you from being closed off from their world view when it’s different from yours?

HA: If I’m going to understand them, I need to try to understand them from an emotional perspective, but also from a cultural and spiritual perspective. So I’m listening for all of that. But I can’t listen to that and understand it unless I am aware of that within myself.You cannot see spirituality in somebody else unless you can see it within your life. How is it real for me? How does it affect me? The better I understand that, the more insight I’m going to have, and the better I’m going to be able to see how it relates to their lives. So that becomes something I normally look for as people present their issues. It also influences what kind of questions I’m asking them, so that I don’t just assume what their moral stance is on things.

For example, when you’re working with adolescents and their families, and their sexuality is an issue–which is almost inevitable when you’re working with adolescents–what is their moral view about sex outside of marriage? What is acceptable? What is not acceptable? That’s going to influence the work that you do; it’s certainly going to influence the goals that you determine are part of your work.

RA: I understand that you worked for some time with Sal Minuchin, and I’m sure some of our readers would like to know what he was like. How was it to work with him?

HA: Sal is a fascinating personality. The man is intellectually so bright and so original in his thinking, but he’s also very much a dynamic human being, and that influences his style of therapy. He always engaged with the clients very fully and emotionally–not only intellectually. It made his model a very dynamic approach to life, so that it could be challenging to therapists who tended to be much more reserved in how they relate to people. But Virginia Satir and Carl Whitaker were also individuals who had dynamic personalities, and used that dynamism in the way that they conducted their therapy. Sometimes people lost perspective and confused the dynamism of the individual with the theory and the technique that they were trying to teach.

RA: What’s your sense of yourself as you developed your own personal style of working in this frame of mind?

HA: Sal was more likely to be confrontive than I would be. My particular personality and style is that I tend to be very direct with people, but I also tend to be more inclined to want to join with people and relate empathically with them. You would get a very different feeling with me than you would have from Sal. Sal, as you see in his writing, talked more about unbalancing the system, and he would often unbalance that system in a more forceful way than I would. I would also unbalance it, but not in the same style.

This really emphasizes the importance of knowing one’s self personally and saying, “I’ve got to work through the person that I am, and not through the person of the guru that I admire.”

RA: Absolutely. You’ve been doing this for quite some time now; do you have a sense of your personal evolution and what’s changed? Do you feel yourself becoming more confrontive over time or less so, or just more refined?

HA: I think what has changed is that as I’ve matured, I’m more confident about myself when I’m with people, and I’m more confident about what my thinking is, so that I can risk being direct with people about what I see and what my opinions are about what’s going on, always allowing for the feedback and room for them to challenge me back. But the challenge is not so much a matter of me confronting as it is a matter of being able to state, “This is the reality that I perceive right now. Now give me your reality and react to what I’m suggesting to you.” That doesn’t work with certain clients, but I find it tends to work with people who are looking for results, and they say, “I can see what you’re saying and I can see why you’re saying it, and it does or does not make sense to me, but now I can give you back some feedback and we can work actively together to make something happen.”

RA: Do you have a sense of where you feel yourself being pulled in the future?

HA: As I look towards the future, I’m now continuing to focus on the person of the therapist and trying to develop that further, not only as an aspect of training therapists, but also as an integrating principle in the therapeutic process: we are integrating our technical and theoretical thinking around who I am and where I am in my life, so that when I do the therapy, it becomes very much my therapy. Even as I’m learning from other people, I’m moving more in that direction. But that also says to me that the common factors work being done by people like Sprenkle is an important contribution. I’m looking more at the common factors among the various models of therapy, and including these factors among the various views of the use of self. I’m thinking about how to highlight those common factors to encourage therapists to extract the essential elements of the therapeutic process, rather than having to choose between various camps of therapy, which I think is such a waste of time.

RA: We’ve definitely covered a lot of ground. Do you have any concluding thoughts you’d like to share with our readers about any of the topics we’ve discussed?

HA: We ended on the note that I hoped we would end on, which is the importance of therapists training to understand themselves more profoundly than they have in the past, not only from a psychological perspective, but also from a cultural and a spiritual perspective, so that they can use all of themselves more effectively in their therapeutic work, on the one hand; and on the other hand, the usefulness of thinking about common factors among the various therapeutic models so that people will not blind themselves to the contributions of the various models because they need to adhere to some particular school of therapy. From my perspective, there is no model of therapy that does not offer us an insight that is useful to all of us. I think it’s important that we open ourselves up to learning from the various schools and approaches to therapy, and then take that and integrate it within ourselves so we become effective therapeutic instruments.

RA: I think that’s sound advice. I appreciate you taking the time to talk with me today. I’ve very much enjoyed it.

HA: Good, I’m glad you did. It was a pleasure, Rebecca.

Walking A Tightrope: Family Therapy with Adolescents and Their Families

Posted on September 15, 2010February 11, 2026 by rezendevknowfully.com

Beyond the Comfort Zone

“Clyde is spiraling out of control,” she cried. “He’s begun to hang out with a bunch of do-no good, do-nothing hoodlums.” She was worried that failure—or worse, tragedy—was aggressively recruiting her only child. “He is a good kid,” she attempted to reassure me, “but I worry about him being in the wrong place at the wrong time.” Although he’d had no brushes with the law, she was terrified of any potential encounters he might have with the police—an encounter she intuitively knew could be a matter of life or death.

“Mrs. Gilyard, like so many other parents of color, was raising her child with the police foremost in her thinking.” While she and her husband enjoyed a solid middleclass lifestyle, both were African American and understood all too well the rules of the streets, especially regarding young black males. Mrs. Gilyard was worried because she understood that the urban streets were unforgiving for many young black males like Clyde. Unfortunately, Clyde, according to his mother, “knows everything and won’t listen to me or his father.” In fact, Clyde had, in a very short period of time, according to his mother, transformed from a “very respectful young man” to a disrespectful, self-centered, impulsive shadow of the human being he used to be. “He’s moody, often refusing to talk for days, and all he wants to do is sleep, text message, hang out with his friends, and download music. To be honest with you, Dr. Hardy,” Mrs. Gilyard said, “although he is my God-given son…” She paused. “I am quickly getting to the place where I can’t stand to be in his presence. I am not sure I even like him anymore. I can’t tolerate his nasty attitude. I have no patience with him. I’m worried that I might hurt him, or someone else will, if he doesn’t get some help.”

As our telephone conversation progressed, it seemed to have no end in sight. Mrs. Gilyard needed to vent and was oblivious to time or circumstance. I tried numerous times to gracefully end the phone conversation that was dangerously slipping into a full-blown noncontractual, nonconsensual therapy session, but Mrs. Gilyard was too consumed by her utter sense of desperation, now flirting with panic.

I commented that although she seemed to have moments where she felt disdain for Clyde’s behavior, her dominant feelings towards him seemed to be worry, fear, and a deep motherly love for him. I went on to suggest that I imagined the situation with Clyde was taking a huge toll on her, as well as the entire family, and although she was seeking treatment for Clyde, I thought it would be helpful for the entire family to attend. My comment and suggestion apparently surprised Mrs. Gilyard and immediately earned her ire. Her tone and approach to our conversation changed instantly.

“Why do we need therapy?” she demanded. “I don’t think there is anything wrong with Claude and me, and I honestly don’t know what there is for us to gain from coming into therapy. We will do whatever to help Clyde, but he has to find himself and nobody else can do that for him. As his parents, we have to provide him with love, support, and guidance, but he has to be willing to accept it. Right now, his friends and his music seem to be all he cares about! I don’t see how us coming to therapy is going to help him get what he needs.”

My interaction with Mrs. Gilyard suddenly shifted from the emotionally intense, unconditionally accepting reflective listening phase of engagement to one of the most delicate and thorny areas of family therapy: problem definition and who should attend the session. These issues are always critical dimensions of family therapy treatment. Mrs. Gilyard and I suddenly found ourselves on a major collision course. She remained convinced that Clyde was the problem and that whatever was going on with him needed to be fixed inside of him. In her world, problems were individual and the solutions were simple: you found out what was broken and you fixed it. From her perspective, Clyde was broken, like a malfunctioning carburetor in a car, and in either case the solution was a simple matter of targeting it and repairing it. She seemed to be oblivious to the fact that even the best mechanic in world could not repair a faulty carburetor without having access to the car! This was where our worldviews collided.

I believe that all problems are essentially relational and that we all are relational beings living our lives in a relational context. As a family therapist, I believe that problems are delicately and seamlessly interwoven in a nexus of relationships. “It is difficult for me, if not impossible, to envision any human interaction problem without considering the relational context in which it is embedded.” So, unlike Mrs. Gilyard, I assumed that the problems were embedded in relationships and the relationships were embedded in problems. In this regard, in cases such as the Gilyards’, it is my contention that family members contribute to the formation of a problem, the maintenance of it, or both. And if problems are embedded in relationships, so are solutions! Thus, having the entire family participate in therapy is essential.

However, from the perspective of Mrs. Gilyard, Clyde was the problem because it was his behavior that was problematic. It was he who was broken, malfunctioning, or deviating from family and societal norms. Accordingly, Mrs. Gilyard believed that the best solution to the problem was to treat the problem: Clyde! The dilemma was that if I dismissed Mrs. Gilyard’s definition in favor of mine, therapy could not occur. Yet on the other hand, if I abandoned what I believe, how could I possibly assist the family without further problematizing Clyde? Before ever meeting Clyde, it was crystal clear to me that he was considered the problem and would continue to be until his deeds, attitudes, and behaviors complied with his mother’s wishes. So in a sense, the only problem was the problem that was asserted by the family. And, if I insisted otherwise–i.e. that my definition of the problem should overshadow the family's viewpoint–then that would only result in creating yet another problem! This is the tightrope that all family therapists have to gently and delicately traverse.

Despite Mrs. Gilyard’s claim that she would do anything to assist Clyde “in getting his life back,” attending therapy with him was not on her immediate list. Because I often believe that a family’s refusal or reluctance to participate in therapy is usually a result of a tendency to think individually and not relationally, and an underlying fear of being blamed and/or exposed, I knew I had to tackle both of these issues with Mrs. Gilyard if family therapy were to ever take place.

I tried to reassure her that a family session would not be about finger pointing or keeping score about who did what to whom. “It will be a place where we can develop a deeper and better understanding regarding how the family operates and how each of you is affected by what everyone does,” I explained over the phone. “You know, families cannot function well when each member attempts to do what they think is right or best without considering how it affects others.”

At this point, although unfazed and unconvinced, she at least seemed willing to listen more carefully.

“You, along with your husband, seem to be concerned, involved, and loving parents. I imagine the two of you have an infinite reservoir of information about Clyde that you have been collecting since his birth. You, quite possibly unlike any other person on the planet, have cherished early life memories of Clyde that you have probably safely tucked away in the secure closets of your mind. I know you and your husband need my help, and I am honored that you are willing to trust Clyde in my hands. But I need you and your husband’s help as well. I need the infinite knowledge and wisdom that you and quite possibly only the two of you have about him as well. My time with him will be limited no matter how much time we have, and it would be great to have the two of you as resources. You know, I am sure you have heard that old African proverb expressed a million times that it ‘takes a village to raise a child.’ Well, if Clyde is struggling as much as you say he is—and I have no reason to believe otherwise at this point—he needs a village. And we will be Clyde’s village!”

After an impregnated pause and a chilling silence, Mrs. Gilyard, in a much softer voice, said with a slight sigh of relief and perhaps resignation, “Yes, you’re right. Clyde is a part of me. He is like my third arm or leg. I do know him. Or at least, I used to. I will talk to my husband. Doctor, I hope you—er, I guess I should say, I hope we can help my son.”

It Takes a Village

Exactly one week later following our phone conversation, Mrs. Gilyard made good on her promise. She, her husband of 30 years Claude, and their son Clyde arrived at my office for our first session. My initial interactions with the family were pleasant and polite as we engaged in light-hearted conversations about the weather and traffic. Throughout it all Clyde remained detached, appearing disinterested but respectful. There was an understandable tightness to the family. They seemed tense. Mr. Gilyard was noticeably uncomfortable and asked several times in the first few minutes about how long the session would last and how many sessions would it take before they would “see results.”

I thanked the family for coming and their dedication to finding answers to issues that were plaguing them. Then I turned to Clyde. “I’ve talked to Mrs. Gilyard on the phone and know that she is worried a great deal about you.”

He smirked slightly but refused to bite the bait and respond to me verbally. I was encouraged by the smirk because it was a sign of responsiveness to being engaged—a private mental note I made certain to record. I turned to Mr. Gilyard and asked, “Do you share your wife’s concerns?” Then, turning to Clyde again, “What do you think about all of this?” To increase the probability of participation throughout the therapeutic process, “it is imperative in family treatment to acknowledge all family members as early as possible and to invite their participation even if and when they passionately refuse.”

The room was quickly filled with a breathtaking silence and discomfort. Finally, perhaps as a function of her discomfort, Mrs. Gilyard broke the mounting minutes of silence that must have felt like hours to the family, by inexplicably saying: “You are so much smaller than I imagined you to be. I for some reason expected a bigger, older man.”

After many years of clinical practice, I am seldom surprised by the disclosures that are uttered within the private walls of therapy, but I was surprised by Mrs. Gilyard’s comment and wasn’t immediately sure what to make of it. I simply responded: ‘Oh, well… Thanks for your honesty… I always find it an interesting task to imagine what someone looks like based on their voice and telephone personality.”

It was of note to me that Mrs. Gilyard elected to make me the focal point at the precise moment that I was attempting to engage Claude and Clyde about their perceptions about the family. Maybe this was coincidental, but I wondered if I was getting a snapshot of how hard Mrs. Gilyard worked in this family. Since I had spent an appreciable amount of time with her on the phone, I really wanted to make a concerted effort to interact with Claude and Clyde. So I returned to father and son and asked, “What is going on with the family from where you sit?”

Mr. Gilyard then turned to Clyde and said: ‘The doctor’s talking to you. Tell him what you think. And sit up, please. And Clyde, take off the hat. And put that thing away,” she ordered, gesturing toward his son’s iPod. Clyde sat still and stoically, dressed in a blue-and-white NY Yankee baseball cap that he had on backwards, stylishly coordinated with an elegant blue silk tee shirt, and blue-and-white Jordan sneakers. He looked at his father and slowly removed his baseball cap, never uttering a single word.

Mr. Gilyard, after thinking for a few minutes, said he was worried about Clyde and believed it was getting harder and harder to reach him. He noted that he didn’t share his wife’s short fuse with regards to Clyde’s antics but was bothered by his son’s lack of direction. “He doesn’t take life seriously. He thinks it’s a joke, a game! He has no sense of the sacrifices that his mother and I and many who came before us have made for his benefit. He is reckless, impulsive, and irresponsible. He thinks only of today, this minute—this second! He has no goals or interest in anything. He wants to sleep his life away,” observed Mr. Gilyard, his voice rising. “I am so afraid that he is going to wake up one day and suddenly discover that life is indeed short, precious, and waits for no one—a realization that will come much too late for him to do anything about it.”

As Mr. Gilyard’s lower lip began to quiver, and his right eye began to slowly fill with a single developing tear, I asked him to turn to his son and to tell him that he loved him and that he was worried about him. The older man seemed stunned and paralyzed by my request. Obviously overcome and perhaps even slightly embarrassed by his emotions, he could only say to me in a tone slightly above a whisper, shaking his head slowly and affirmatively, that Clyde knew.

“But can you turn to him and tell him?” I asked again, to which he responded by repeating his earlier refrain: “He knows.”

A New Conversation

“Once again, Mrs. Gilyard was in her familiar role of working overtime for the family while Mr. Gilyard was working hard to emotionally retreat from the interaction.” Maybe there was something to this dynamic: maybe Mr. Gilyard’s “low pulse” for engagement heightened his wife’s anxiety, which she ameliorated by becoming more actively involved in an interaction. Her involvement in turn reinforced his low pulse, and his low pulse heightened her anxiety and so forth and so on.

Meanwhile, Clyde remained a central but peripheral figure in the family’s interaction. He was the frequent subject of his parents’ reprimands, criticism, and attempts to speak for him. While it was Mrs. Gilyard’s good intention to make sure that Clyde was reassured of the love that his dad was having difficulty expressing directly, it was nevertheless counterproductive to what I was trying to accomplish with the family at this point. So I decided to re-engage Mr. Gilyard by simply turning my body towards him and pointing to Clyde.

He started his interaction with Clyde by telling him, critically, why he needed to change. I immediately interrupted him. “I realize this is important fatherly advice you’re offering your son,” I said, “but I want you to suspend the advice giving for a moment and simply tell your son that you love him and that you’re worried about him.”

For the first time during the session, Clyde looked at me and said, “Boy, you’re a trip! Just give it up. Why keep asking the same frickin’ thing over and over again? I know he loves me. There. Are you satisfied? Now can we move onto something else?” It was striking to me that this one seemingly benign and simple request sent so many reverberations through the family while giving me a front-row seat to the family drama that had necessitated the Gilyards coming to therapy.

I commended Clyde. “I like the fact that you’re so honest and direct. You didn’t feel like you needed to sugarcoat your feedback for me. I think I like you, Clyde!” I hoped that my feedback would have some resonance with him and provide a small buffer against the barrage of negative feedback he was accustomed to getting from his parents. Clyde responded with a very faint smile, a slight shrug of his left shoulder, but for the most part he continued to sit motionlessly and without much overt expression.

The family’s process had been marvelously effective at maintaining their status quo. The climate in the room was much less intense and they seemed more relaxed, at least on the surface. Mrs. Gilyard scanned the room with a sense of anxious anticipation. She looked as if she was wondering, “What’s going to happen next?” Mr. Gilyard retreated and seemed far away, while Clyde nervously patted his right foot and stared at the ceiling. I sat quietly observing the family as my eyes occasionally connected with Mrs. Gilyard’s.

After a few minutes of silence, I commented to Mr. Gilyard, “It seemed like it was a little difficult for you to talk directly to Clyde a few minutes ago. Was it difficult?”

“You know, Doctor,” Mr. Gilyard quickly responded, “it is not difficult for me to talk to my son and I don’t really have a problem talking to him. It’s just sometimes it seems pointless because Clyde is going to do what Clyde wants to do. I feel like the things his mother and I say to him go through one ear and out the other. So sometimes my attitude is, ‘Why bother!’”

I noted how frustrating and seemingly futile such a dynamic could be, especially when there are legitimate worries and wishes that they would like to seriously convey to Clyde. Then I made an observation to Mr. Gilyard, trusting that Clyde and Mrs. Gilyard were eavesdropping.

“My early sense of Clyde so far is that he is self-reflective, contemplative, and a courageous communicator,” I said. “I have noticed the way that he has sat here very quietly but has been very attuned to what is going on here, though his words have been few. Yet as you observed a few minutes ago, when he had something to say, boy, did he say it with force, conviction, and clarity. I think a good conversation is possible between all of you if you could each attempt to have the conversation differently. Trying to have new conversations the same old way you have been attempting to have them is not working for the family. If you continue to hold onto the old ways you have been trying to engage with each other, this process will take forever and Clyde will turn to his friends for the conversations he should be having with his parents!”

Mr. Gilyard seemed intrigued, if for no other reason than my oblique reference to the timetable for treatment, which I knew was important to him. I then asked Mr. Gilyard, “So do you think taking a different approach to talking to Clyde is something that you would be willing to try?”

“I am willing to do anything that you think will help me reach my son,” he replied.

“I appreciate your willingness to give this a try,” I responded. “I would like to return to where we were earlier. When I listen to you, I feel a kind of underlying pain—almost haunt—that you have when you think about Clyde’s life. What I hear and feel from you is worry, fear, and pain, yet what gets communicated to Clyde, and probably what he hears, is criticism, rejection, and anger. I would like for us to try this differently this time around. Can you turn to your son and tell him you love him and that you’re worried about him?”

Mr. Gilyard looked at me with a slight sheepish grin and nodded. He then took a minute to collect his thoughts as he stared at something beyond the room in which we are sitting. Mrs. Gilyard fidgeted a bit and nervously rubbed her hands together. I could tell Clyde was very tuned in, although he outwardly retained his cool pose of detached disinterest.

The silence built and so did the intensity in the room. After a few more minutes, Mr. Gilyard turned to Clyde.

“I don’t know why this has been so hard for me,” he said to his son. “I don’t want you to think it had anything to do with not loving you…because I do love you very much, my firstborn son. I will always love you, and I am sorry if I have somehow ever given you the message that I don’t love you or that my love for you is conditional.”

“Can you also tell him about your worries?” I encouraged him.

Mr. Gilyard sighed. “I do worry about you.”

“Can you tell him about your worries?” I prodded. “The ones that keep you up at night.”

“I guess I worry all the time. I worry about drugs, although I don’t think you would ever be stupid enough to do drugs. I worry about you not giving your best in school and the ways that will hurt your future. I worry about…” “Mr. Gilyard’s breathing shifted; his words suddenly seem much harder to find.” His voice was beginning to break and he now seemed more hesitant to continue.

“You’re doing great,” I told him. “This is the type of conversation that you and Clyde have needed to have for awhile now. Please don’t hold back now. Tell him about all of the fatherly worries you have about him.”

“I worry… I worry…” Mr. Gilyard began to cry. “About something awful happening to you. About you dying, and there is nothing I or your mother can do to protect you. I worry about the damn trigger-happy police. I am worried that life is short and I don’t know what I would do if anything ever happened to you,” he sobbed. “The streets are vicious. People are vicious. And no one seems to GIVE A DAMN about young black boys like you.” He pounded the coffee table with his hand. “I can’t tell you, Clyde, the number of times that I have awakened in the middle of the night sweating from the same bad dream—the same nightmare that you are lying on 22^nd Street in a pool of your own blood which is OUR blood too.” He turned to his wife. “Tell him, Geraldine, how many times you have had to comfort me from the same goddamn dream. “ Mrs. Gilyard nodded in confirmation while I gestured to her to refrain from speaking at this point. Both Mrs. Gilyard and Clyde were now beginning to cry as well.

Clyde spoke. “I don’t know what’s wrong with you and Mom. All you do is accuse me of doing bad things and being a bad person. I go to school, I get decent grades, and yet I all I ever hear is, ‘You didn’t do this. You didn’t do that. This is going to happen. That is going to happen.’” Clyde was more animated than I had yet seen him, and his voice was raised; he was crying profusely .

“Clyde,” I said, “I am so glad to hear you say how all of this affects you. I would be surprised if your parents knew that you have been affected so much by their worries and criticism of you. Thank you for again being such a courageous communicator—you know, having the courage to say what needs to be said and not just whatyou think others think you should say. Your tears—who were they for? What were they for?”

“I don’t know,” Clyde said softly.

“Clyde, honey,” said Mrs. Gilyard, “I am sorry that I have been so caught up in my own worries that I have not taken a second to think about how all of this has been affecting you.” She began to cry even louder as she walked over and draped one arm around Clyde while reaching out with the other for Mr. Gilyard. As she held Clyde, sobbing, she repeated, “I am so sorry. I am so sorry.” I sat quietly, observing this pivotal and sacred moment for the family, and remained appropriately peripheral for the moment.

Mr. Gilyard broke the momentary silence. “Son, we didn’t mean to hurt you and put so much pressure on you. We don’t think you’re bad. We just worry about you.”

“I honestly don’t know why you are so worried,” said Clyde. “I feel like I can’t breathe without causing somebody—you or Mom—to worry.”

Finally I stepped in. “I want to thank each of you for all of your hard work today, and thank you, Mrs. Gilyard, for your hard work in getting everyone here today. Mr. Gilyard, I am so pleased that you were able to tell Clyde about your worries. Now he knows that there are real heartfelt worries beneath all of the criticism. My hope is that you and Mrs. Gilyard can be more diligent in expressing your worries without the criticism, and that, Clyde, you could remind yourself that somewhere beneath their criticism is an unexpressed worry. By the way, Clyde, I share part of your curiosity regarding the roots of your parents’ worries.” I turned to the parents. “I completely understand your worries about the police, school, and what happens if Clyde ends up in the company of the wrong crowd. I think it’s great that you are concerned and involved parents. But as I mentioned earlier, there seems to be a ‘haunt’ when it comes to your efforts to parent Clyde. It is particularly poignant with you, Mr. Gilyard.”

As I wrapped up our first two-hour session, I reminded the family that I am a firm believer in assigning homework between sessions. “Homework is a wonderful strategy for ensuring that families continue to work together outside of treatment and not rely solely on our weekly two-hour meetings to promote change.” The actual tasks to be completed are seldom as important as the spirit of cooperation, collaboration, and communication that is generated (or not) as a result of the assignment. The Gilyards’ first homework assignment was for each member of the family to generate a minimum list of three beliefs each of them had regarding why there was so much worry in the family. They should generate their respective lists separately and then share their beliefs in a brief family meeting that should be scheduled by Mr. Gilyard and must take place before our next session. Clyde was assigned the task of keeping track of whether all of the rules had been followed by all members of the family, including himself, of course. And finally, Mrs. Gilyard was assigned the task of taking a vacation day from all coordinating tasks associated with the homework assignment.

The Gilyards showed up for our next session on time, and not only had they completed the homework assignment but had done so by rigidly adhering to all of the specified terms. While the assignment failed to produce any revelatory moments for the family, it did lay down some important groundwork for several transformative future sessions.

A Haunted Past

“It was too much responsibility and too big of burden. How can you possibly protect your children from the perils of the world? My parents were super parents and even they could not protect Clyde and Roger,” he often reflected. “For many years of my life, the pain of losing my brothers was so painfully gut-wrenching, I couldn’t have imagined any greater pain had they been my children. And then Clyde was born. Everything changed. Suddenly I could imagine a greater pain than what I had already experienced. For a few years, especially the early ones, he actually helped to redirect some of the pain I felt about the loss of Clyde and Roger. Maybe he gave me something else to focus on that my own father never had after losing two sons. I know that both Mom and Dad never ever recovered from Clyde’s murder, and then when Roger was killed, they simply stopped living.”

Mr. Gilyard’s protracted mourning and shame never allowed him to be honest with his son about his uncle and namesake. He created the story about Viet Nam because it allowed him to recreate his brother in an image that was more positive and less burdened by the all of the familiar stereotypes of black men. This, unfortunately, was a huge piece of his son’s burden—a burden he undoubtedly carried from birth. He was not only his fallen uncle’s namesake, but he was a psychological object of possible redemption for his father. Suddenly all of Mr. Gilyard’s worries made sense to me. How could he not possibly once again find himself facing the dawning of the period of adolescence, without re-living the traumatic loss of his two younger brothers? How could he not worry about Clyde, the flesh of his flesh, possibly following the pathway of brothers Clyde and Roger? “After all, life had taught him a brutally cold and unforgettable lesson that young black boys don’t live beyond age fifteen”, and Clyde was now fourteen.

As our sessions continued, it was a bit unnerving to discover just how unkind the untimely death of young boys had been in the Gilyard’s family. Mrs. Gilyard also had a younger brother, Will, who was killed at age seventeen in a terrible car accident. Although Clyde knew of his Uncle Will, and the circumstances of his death, he did not know that his uncle was illegally intoxicated at the time of his death. According to Mrs. Gilyard, Will was a passenger in a car that was driven by his best friend who was also intoxicated at the time of the accident. As Mrs. Gilyard told the story of Will’s final moments, she wept as if it had just happened yesterday. She maintained that had Will not been in a state of an alcohol-induced stupor, he could have possibly survived the tragic accident. Clyde’s surge into adolescence had been a significant unintended catalyst for re-igniting the unresolved grief that haunted both of his parents. In a strange way, Clyde’s life was a powerful symbolic reminder of the Gilyards’ ongoing struggle to make peace with death and loss.

I continued to see the Gilyards for a total of eleven sessions, and I believe they made tremendous strides, though there was still additional work to be done. As a result of family therapy, the parents had a better understanding of how the tragic losses of their siblings were infiltrating and sabotaging their best efforts to be the type of parents that they ultimately wanted to be. They were far less critical of Clyde, but still resorted to blame and criticism when they felt anxious about their son’s life. The Gilyards had made significant progress in granting Clyde considerably more breathing room, and yet this was still a major challenge for them to completely master. Our work together had also been instrumental in helping Clyde to see and experience his parents with far more complexity. While he strongly resented their “constant nagging,” he also now understood and felt more genuinely their love for him. From our sessions together, “he had the opportunity to experience his parents as human beings with real feelings—hurt, pain, and joy”—and not just as critical, robotic and detached enforcers of the rules. He was able to develop more compassion for his parents and them for him. The family sessions afforded Clyde the opportunity to both fight with them—something that the family excelled at—as well as to cry with them—something they were not very good at. Yet, on the other hand, and in spite of it all, Clyde also continued to live up to his reputation as an adolescent. His failure to follow through with chores, spending too much time of his cell phone, and his frequent flashes of self-righteousness continued to be challenges for him and his parents.

Providing the Map

Both Mr. and Mrs. Gilyard terminated therapy with the understanding that the difficulties that brought us together were much bigger and more complicated than what rap music Clyde listened to or “his no-good, do-nothing hoodlum friends.” While Clyde expressed a number of troubling behaviors that at times appeared depression-like, “his” problems were much more complicated and intricately embedded in family dynamics and history than he or his parents realized Clyde’s symptomatic behavior was as much an indication of a family system that was not functioning properly as it was a sign of his individual pathology.

While the issues that constituted the core of Mrs. Gilyard’s early concerns about Clyde were significant issues, they paled by comparison to the complex, systemic, and intergenerational issues that made the Gilyards’ task of parenting so challenging. Through my work with the family, I was able early on to get a poignant snapshot of how the family was organized and how they interacted. I was able to rely more on what I observed than what they told me. There is something powerful and transformative about the process of witnessing—having the ability to experience and re-live the stories of another’s life with them. Had I complied with Mrs. Gilyard’s request and “treated” Clyde independently of his family, he would have probably continued to live his life in the shadow of his Uncle Clyde without him or the family acknowledging it, while the family simultaneously and unfortunately maintained that the uncle who had been murdered unceremoniously and without distinction on the streets of the inner city, was instead a Viet Nam veteran and hero. It was interesting and prophetic that Mrs. Gilyard, before our first session, noted passionately that Clyde had “become a shadow of the human being that he used to be.” I guess he had.

During this pivotal moment of therapy, Clyde was able to bear witness not only to his father’s shame, humiliation and hurt, but to his pain and humanness as well. It changed forever how he saw his father, understood him, and more importantly, experienced and related to him. Mr. Gilyard, in return, was able to give his beloved son and the namesake of his twin brother a gift of humility and a context for better understanding his father’s worries. And Mrs. Gilyard was finally able to “catch her breath” and exhale. She, for once, would not have to over-function to compensate for Mr. Gilyard’s reticence and emotional blockage. Finding the lovingness in him as a father also allowed her to add depth to the lovingness that she had for him as a spouse, which had the unplanned consequence of further strengthening their marital bond as well. “This is the beauty of family therapy: when it works well, it helps families to recalibrate and to experience reverberations throughout the system even across generations.” If Clyde someday decides to become a father, I believe that the shifts he experienced in the relationships with his father specifically, and with his parents in general, will impact how he parents. As a result of the family’s involvement in family therapy, the generational and relational arteries that connected the lives of Clyde, Uncles Clyde, Roger, and Will, as well Mr. and Mrs. Gilyard and many others, have been refreshingly and painstakingly unblocked, but will require ongoing work to remain so. This, too, is part of walking the tightrope: helping families find ways to celebrate newfound highs while simultaneously keeping them grounded enough to confront the next new challenge.

Family therapy, especially with adolescents, is often about walking on a tightrope: dangerously and delicately walking the fine line between hazard and hope. The tightrope is ultimately about encouraging and exploring that undefined, often difficult-to-measure balance between clinically taking positions and imposition, between promoting intimacy and compromising safety, and between increasing intensity and fostering comfort. Having a willingness to tiptoe along the tightrope often means that in my work with adolescents and their families, I have to stretch myself well beyond my zone of comfort and safety. As a family therapist I have to earnestly and relentlessly push myself in treatment to ask one question more than the question I am comfortable asking, and to take risks that might expose me to failure, while at the same time offering tremendous potential for the promotion of healing and transformation.

Kenneth Doka on Grief Counseling and Psychotherapy

Posted on August 20, 2010February 11, 2026 by rezendevknowfully.com

Defining Grief

Victor Yalom: Letâ€™s start with the basic building blocks. What is grief and what is its function?

Kenneth Doka: I think it’s probably important to acknowledge and recognize that grief is a reaction to loss. We often confuse it as a reaction to death. It’s really just a very natural reaction to loss and so we can experience grief obviously when someone we’re attached to dies, but we can also experience it when we lose any significant form of attachment. You can certainly experience grief in divorce, in separation, in losing an object that’s particularly meaningful or significant, in losing a job that has meaning or significance. Whenever we experience an attachment and we experience loss in that attachment, grief becomes the natural way we respond to that. We used to look at the function of grief as kind of allowing a process of detachment and a restoration of life in the absence of that person. Now we no longer really use that old sort of Freudian model. We really emphasize that people really don’t detach. They have a changed and continued bond with the person. It’s the process of adjusting to in many ways what’s going to be a new relationship and a different relationship rather than simply the abolition or detachment from a relationship.

VY: Whatâ€™s your understanding of how grief helps that? Why is it necessary?

KD: I don’t know—necessary is sort of a strange word in this context. I think it’s just a natural reaction as we respond to a significant loss.

VY: Thereâ€™s so much being written about evolutionary psychology these days. Is there anyone thinking or hypothesizing about some evolutionary or Darwinian function of grief?

KD: I think Bowlby points out that the initial response to grief arises from an evolutionary desire to reattach. We signal distress as a way of gaining attention and support and maybe rebuilding the bond—think of the child who’s lost in a store and the toddler all of a sudden starts crying and gets help and assistance and maybe even the mother hears the cries. Grief may come from that very basic sense of attachment, but even from an evolutionary standpoint, you can say, even then for an animal who loses a significant attachment, calling attention to oneself is a mixed blessing.

VY: You write that weâ€™ve moved away from universal stages, such as the Kubler-Ross stages to individual pathways of grief.

KD: We used to look for some kind of universal reactions and Kubler-Ross was one such pattern. Actually, Kubler-Ross never really spoke, until later in her work, about applying this to grief; she was talking about a particular aspect of coping with dying, but even there, we move toward more individualized reaction. There are other people who attempted to find—Colin Murray Parkes at one point in his career attempted to find these kind of universal sort of stages that everyone goes through. But now what we recognize is that grief is highly individual and individuals grieve in their own way. Certainly their responses to grief can include a number of dimensions. We can respond to grief physically, on a very visceral physical level with aches and pains and all kinds of physical reactions. We can respond with emotional reactions—sadness, loneliness, yearning, jealousy even, anger, guilt are all relatively common reactions, as well other ones—just a sense of relief sometimes, when a person’s suffering has been very, very long. We can respond cognitively. We may think about the person. We may experience a sense of depersonalization. We may find it hard to focus or concentrate. We can respond behaviorally—again, acting-out behaviors or withdrawal or lashing-out behaviors or even things like avoiding or seeking reminders of the person who died or the thing that was lost. Of course, it can affect us spiritually. Again, everybody’s pattern of grief is highly unique.

VY: You make a point about denial, that people go in and out of denial. Itâ€™s not a black or white thing. How do you think about denial?

KD: I think probably most of my writing and talking about denial has probably been in the context of illness. There, what I would say is, again, denial is a basic defense mechanism. Avery Weisman uses a very good term when he talks about life-threatening illness. He talks about middle knowledge.

True denial is very, very difficult to maintain, but people sometimes choose not to focus on their illness, so it is more of a selective inattention than actual denial.

True denial is very, very difficult to maintain, but people sometimes choose not to focus on their illness, so it is more of a selective inattention than actual denial. Again, I think you see that same pattern in grief. It’s hard to really deny a significant loss, but sometimes we choose not to focus on it.

Intuitive vs. Instrumental Grieving

VY: Let’s get back to grieving styles, as that’s been one of your major contributions. You developed these ideas of the intuitive grieving style, which is a more emotional style of processing grief, versus the instrumental style, which is more cognitive and action oriented. Tell us about these and how you came up with these concepts.

KD: That was work I did with Terry Martin from Hood College. Originally, what we were doing was exploring the issue of gender and grief—on differences between the ways men grieve and the ways women grieve. As we moved on into that work and began to do some research, we found that these “male patterns” and “female patterns” were really more widely distributed than we had perceived.

VY: It wasnâ€™t purely male or purely female.

KD: Exactly. We first moved into what we called—kind of with a Jungian perspective—masculine and feminine grief, knowing that men or women could have a more feminine pattern or vice versa. Then we realized that the gender connection was probably unhelpful and inappropriate, so we moved away from gender, although not entirely. We’re saying gender is one of the factors, certainly, that influences one’s grieving style, and certainly we would be comfortable in saying more men may have an instrumental style or lean toward the instrumental style in U.S. culture and probably in many Western cultures. So it’s influenced by gender, but not determined by it. And we look at this as a continuum, so many people are sort of in the middle or maybe an alternate visualization would be two overlapping Venn diagrams with some space separate and lots of space sort of shaped. People who are highly intuitive as grievers will often—when you ask them about their experience of grief, they’ll often talk about waves of affect and waves of emotion. When you ask them how that grief was expressed, it’ll mirror those reactions, “I just kind of felt this. I cried. I screamed. I shouted.” Their expression of grief mirrors their inner experience of grief. When you ask them what helps, how they adapted to grief, they’ll often talk about the fact that it really was helpful for them to find some place, whether in therapy, whether with a confidante, whether in a support group, whether in their own journaling or internal process, to sort of explore their feelings.

On the other end of the continuum are what we call instrumental grievers, and with them the very experience of grief is different. When you ask them how they experience grief, they often will talk about it in very physical or cognitive ways: “I just kept thinking about the person. I kept running over it in my mind. I felt I was kicked in the stomach. I felt somebody punch me.” When you ask them how grief was expressed, sometimes they’ll be curious about that question. They might respond at first “I guess I didn’t express much grief,” but then when you really talk to them about it, they’ll say, “I did talk about the person a lot” or “I was very active in setting up this scholarship fund.” They may not always recognize that as an expression of grief. They may actually be perplexed by their lack of affect. It’s not that they lack affect. Their affect is more muted. When you ask them what helps, it’s often the doing.

VY: You give a great example in your book, Grieving Beyond Gender, of a man whose daughter crashed into a neighborâ€™s fence and died, and he spent his time after the death rebuilding the neighborâ€™s fence.

KD: Right, and it’s important to recognize that was the most helpful thing he did. One of the things that sort of helped us think about this was — in my book on disenfranchised grief, Dennis Ryan does a chapter on the death of his stillborn son, which as we were thinking about this, really was a kind of enlightening moment. Dennis is a professor by vocation, but a sculptor by avocation. He talks about after his son was stillborn, this long-awaited child,

his wife would come back from work each day and go upstairs and have a good cry and he would be working, crafting the perfect memorial stone out of a piece of granite. As he’s chipping away at this granite and hearing his wife cry, he’s saying, “Why aren’t I grieving?

Bias in the Mental Health Profession

VY: You said that the mental health profession has had a strong bias toward intuitive or emotional grieving.

KD: Sue and Sue, in their book in Counseling the Culturally Diverse, describe western counseling as swallowed by affect, meaning that the quintessential counseling question is, “how do you feel?” In grief, we’d say a better question would be, “How did you react?” or “how did you respond?” By saying, "How do you feel?" you take one of the dimensions of the ways to respond to grief and make that the primary one.

VY: If this has been the dominant paradigm in counseling and therapy for grief, what kind of problems does that cause for the instrumental griever?

KD: For the instrumental griever, it may simply not validate the honesty of his response. There is one other type of griever we talk about in our book too. We certainly recognize that lots of people are blended. They’re sort of in the middle and they have characteristics of both. We also talk about dissonant grievers. Dissonant grievers are people who really experience grief one way, but find it difficult to express it that way. This might be the male who feels he has to maintain a strong image and though he’s strongly intuitive in his experience, he does in fact repress his emotions.

VY: You also mentioned disenfranchised grief. Can you define that?

KD: Sure. Disenfranchised grief refers to losses that people have that aren’t always acknowledged or validated or recognized by others. You can’t publically mourn those, receive social support or openly acknowledge these losses. This actually started with research I did on ex-spouses — what happens when your ex-spouse dies. A lot of these people really couldn’t get time off from work, because after all, ex-spouse isn’t in the grief rules, the bereavement leave, but whether it’s an ex-spouse or not, you often had a strong relationship and a continued relationship with that person. Then we expanded it. Now when we talk about disenfranchised grief, we talk about a host of relationships that aren’t recognized—teachers, mentors, coach, therapist, patients. Think about that. This would be an interesting dimension. You have a profound relationship with a patient—in some cases, on either end, and when the therapist dies, especially if nobody knows they’ve been seeking therapy, they may have had a significant loss and yet really no opportunity to openly acknowledge or mourn that loss.

VY: When itâ€™s disenfranchised, itâ€™s not noticed or valued or accepted by others that this is really a significant loss.

KD: Or you may just be ashamed to bring it up. In other cases where the loss isn’t always recognized, such as divorce or…we’re better on perinatal loss than we used to be, but for mothers, not necessarily for fathers and siblings and grandparents and others. It’s sometimes when the griever isn’t recognized as being capable of grief—somebody with intellectual disabilities or sometimes the very old or the very young. Sometimes it’s a result of the type of loss that the person experiences—suicide, AIDS, homicide. Then just the ways the person grieves—grieving styles may not be always acknowledged. We do a strange thing with grieving styles. I always say we disenfranchise instrumental grievers early in the process. “What’s wrong with this person? Why isn’t he crying?” We disenfranchise intuitive grievers later in the process. “What’s wrong with that person? He or she is still crying. Why haven’t they gotten over it yet?” Of course, sometimes it can be for cultural reasons. Again, different cultures have different rules about how one is to mourn and especially in bicultural families, others may look askance at different people’s grief.

VY: Once you start throwing in all these factorsâ€”different grieving styles, disenfranchised grief, cultural differencesâ€”if we move into the area of counseling, how do you help bereaved people? It can get fairly complicated.

KD: It can, which shouldn’t be surprising, because it is always complicated.

VY: Letâ€™s start with the grief styles. Grief is a fairly universal process, but as you pointed out, people grieve differently. How do you even know if grief counseling or a support group or some other type of intervention is necessary to begin with?

KD: I think that’s a very good question, because I think the truth is that most people—and studies vary between 80% to 90%—probably do pretty well without any formal intervention or may just need what we would call grief counseling in the sense of just some validation that says, “No, it’s understandable. No, you’re doing okay.”

VY: So, that would be normal, uncomplicated grieving in?

KD: Yes, that would be a normal, uncomplicated kind of grieving. Bibliotherapy can be so effective with these people, as it provides that basic validation. It provides some good psychoeducation. It may provide some ideas for coping and certainly says that most people get through this. That may be all that’s needed, or they may benefit from psychoeducational seminars, or support groups, or even in short-term counseling. Others may have more significant reactions. One of the things that’s kind of interesting now is there’s some movement to create a category for the next DSM, the DSM-V, called Prolonged Grief Disorder. There are some critics about that, but at this point in time it’s probably an even bet as to whether it’s going to be included or not. Certainly people who are self-destructive, certainly people who are destructive with others, certainly when grief is disabling—where a person really is having a difficult time functioning in a work role or functioning in another role—these are good examples of grief which is more problematic.

VY: Okay, so say you have someone who, for whatever reason, has sought out grief counseling or is already in therapy and then experiences a significant loss. Youâ€™ve written that itâ€™s important to first assess what their grieving style is. How do you go about doing that?

KD: First, you ask them about how they’ve tended to experience grief. You ask them about their history about how they’ve dealt with losses before, how they’ve experienced and expressed and adapted to losses before. There are a variety of ways you go about that. And then you ask them about how they have responded to the current loss. An intuitive griever might say, “I just feel sad all the time. I have this overwhelming sense of sadness.” An instrumental griever would probably answer in another domain: “I just can’t concentrate. I just can’t focus since he died. I feel like somebody punched me in the stomach.” So the key to any assessment is asking questions that don’t necessarily prompt one response or another, and then really listening to the language that they use. The book I’d really recommend for people who are starting out in this field or who just need a little bit of a refresher is Worden’s book Grief Counseling and Grief Therapy. Beyond grieving style, there are a lot of things you have to assess.

VY: And as youâ€™ve said, some people are fairly clear-cut, whereas others are blended grievers.

KD: You’ll get a sense for blended grievers as you hear them describe how their grief experience is now versus how they’ve reacted historically to losses. The tip-off would be that if somebody says, “I’ve had a very close relationship with this person and I responded this way,” but you notice that they’ve tended to respond other ways in the past. Maybe they’ve always responded in an intuitive way before and now they’re dealing in a much more instrumental way; that’s when it really becomes kind of intriguing and you really want to ask, “Why the difference now when historically you’ve coped and responded in these other ways?”

VY: I think most counselors or therapists have a pretty good sense of doing therapy with an intuitive or emotionally-based person. Thatâ€™s the paradigm weâ€™re used to. Thatâ€™s what we think of. If you have someone who is pretty clearly on the instrumental end of things, what implication does that have? How would you conduct therapy differently?

KD: You start out by respecting and validating that style and helping them draw on their historic strengths. You don’t try to push them to an emotional place that’s going to be very uncomfortable for them. You say, “You’ve mentioned that you’re dealing with a little bit of this guilt. What has helped you before?” Maybe it’s helping them construct some kind of active way to deal with that guilt or to memorialize that person or to do something else. You build on their strengths.

VY: You support them and normalize their reactions.

KD: You support them and normalize. For instance, if I had a Dennis Ryan who said, “I don’t know. I’m not grieving. My wife cries every day and I just hammer away at this stone,” then you might try to help them recognize that that is his expression of grief and it’s a legitimate expression of grief. And you might ask, “Where does that help you? Where are its limits? What else do you need to work with as you deal with this?”

VY: You said there are some more complicated cases. Someone may be an intuitive griever, but for one reason, theyâ€™re not accessing their natural response or vice versa. Why might that be?

KD: I think you try to ask what are the inhibiting factors. Maybe the person needs a safe space. For instance, one case I had was a person whose young daughter died of cancer. He tended to be very emotional with other losses, but in this case he removed all the pictures of his daughter—he didn’t want any reminders—and that caused a conflict with his wife. That’s what brought them, really. His wife basically said, I can’t deal with you this way. You need to seek help.

VY: This can create real conflict among couples.

KD: Sure. If they have a different grieving style and they don’t recognize that. This is an extreme case in which it did cause conflict. This guy was an engineer by training, and it was very, very clear that from his past history that he tended to experience things on a very emotional level, but was really repressing emotions in this case. We talked about that and he said, “I’m really fearful if I start letting go of some of these emotions, it’ll be like a dam bursting and I won’t be able to control myself.” And I responded “Don’t dams have an overflow valve?” I’m sort of well known among my friends for not being particularly mechanical or handy. The joke is that my favorite tool is my checkbook. So I was very proud that I figured out that analogy! Then we used that analogy, that he has to find safe places to release some of this emotion and we talked about the strategy of dosing. You can control it. You can dose it.

He found ways to do that. One of the things he used to do was he had a particular song that reminded him of his daughter and he played that on his way home from work and he’d weep. That would reduce some of the energy of his grief, the issue. Then, over time, he was able to begin to talk about his daughter and begin to become confident that he didn’t always have to keep things bottled up. He was able to talk about it and release some of his emotion and at times cry with his wife, and this wasn’t going to leave him fully losing control.

Grief Counseling in Action

VY: Would you say itâ€™s still the case that most therapists donâ€™t get much specific training in grief counseling?

KD: It scares me, yes.

VY: Why does it scare you?

KD: I think that there’s been a real explosion of material about grief in the last 20 years. In my mind, it’s become a specialty. I see clients who have come and say, “I’ve been working with my therapist, but I still can’t accept the loss.”

And you know they’re coming from a kind of Kubler-Rossian kind of model and you’re thinking, “My God, people haven’t been doing that stuff for 15, 20 years in the field.

And you know they’re coming from a kind of Kubler-Rossian kind of model and you’re thinking, “My God, people haven’t been doing that stuff for 15, 20 years in the field.” What we’re saying is that you continue a bond with the person, that it’s very, very normal throughout your life, that you’re going to have surges of grief maybe 30 years later. Your dad died and 30 years later, your granddaughter’s walking down the aisle and you’re thinking, “I wish my father were here to see that.” This is very normal stuff and as I said, there’s a lot of poor information about grief out there, which I think is being filtered into some therapeutic context. I think people who are going to do grief counseling need to really keep abreast of the literature in it.

VY: All therapists have to know how to deal with this. I mean, even if youâ€™re not trained as an addictions counselor, youâ€™re going to have clients who come in for one reason and then youâ€™re going to find out that they have an addiction. Similarly, youâ€™re going to have people that come in to your practice as a general practitioner that are dealing with griefâ€”either as a presenting complaint or in the course of therapy, theyâ€™re going to have losses. But I think they really donâ€™t know how they should respond to a grieving client, other than of course being empathic and supportive.

KD: I think there’s some basic information that, therapists ought to be aware of. As I said, we’ve moved away from stages to more universal pathways. We’ve moved away from detachment to a paradigm that emphasizes that we continue a bond with the person. There’s a number of ways that our understanding of grief has changed.

VY: If you had to give some bullet points or a primer to a therapist who does not have specialized training in grief counseling, what are the things you think they need to know or skills that would be good to develop?

KD: I think number one would be to recognize grief in its many manifestations, not just as a response to death, but as a response to any significant loss. I think to understand the fact that we have our own personal pathways, that we do not detach but continue a bond with the person who died, that we recognize the increasing importance of how culture frames our response to grief.

VY: You mentioned culture a couple of times. Can you think of any cases youâ€™ve dealt with or supervised where cultural aspects have been important?

KD: It’s a hard question to answer, because I think culture always has to play a role; every case I supervise has a cultural aspect. I’m half Hispanic and in Hispanic culture, godparents are very, very important. If somebody comes in, they may very well in fact be mourning a godparent and a therapist who’s not familiar with that culture may be trying to figure out why that role is so significant. They’re actually called comadres, compadres—meaning literally co-parents or parenting with.I think understanding how culture affects attachment, how it affects the expression of grief, how different cultures have different rituals—these are all critical pieces to take into mind.

VY: Any case examples jump out as youâ€™re talking about it?

KD: I remember dealing with a client who is Native-American and we used some of the expressive arts. Ultimately he did some wood carving as a way to memorialize the loss, and I think that was very culturally compatible with who he was and what he was and with his culture. It’s kind of a totem-like thing that he ended up carving as a memorial to the person who died.

VY: Was that something he did on his own or did the therapist encourage him to do this?

KD: The therapist encouraged him, by first asking, “What do you normally do?” Again, it’s a sensitivity to what interventions and what strategies work well with what types of people. I just want to go back to make one other comment on those bullet points. The last bullet point I would emphasize is that, I think one of the things we’ve moved away from, as a field, is just asking the question, how do we cope with grief to how has this loss changed us? I think there’s also been a recognition of what some theorists have called post-traumatic growth, that for some, a significant loss is sometimes a spur to significant personal growth.

VY: People that are with their partner or loved ones at the time of death often talk about this being a powerful experience, even a sacred experience, although they might not identify themselves as being religious or spiritually inclined.

KD: They may not be religious, but inevitably it’s a spiritual experience, because it has to do with issues of meaning and transcendence.

As an aftermath of death, people may experience growth in skills, they may have new insights, new priorities in their life, a renewed spirituality

As an aftermath of death, people may experience growth in skills, they may have new insights, new priorities in their life, a renewed spirituality—there’s lots of changes that can occur. Again, sometimes they can go on and use these losses to make very significant changes. I think of John Walsh, host of America’s Most Wanted, whose son Adam was kidnapped and ultimately found decapitated. When he first realized his six-year-old son was missing, the police took a very nonchalant attitude and they said, “If he’s still not here in 24 hours, we’ll go look for him.” He then went on a crusade to change the way we as a society responded to the issue of missing children. The woman who founded Mothers Against Drunk Driving again used her grief to change the way we looked at drinking and driving in the US. It’s very different now than it was 30 years ago. Even teenagers are aware of the fact that there are real complications if you do this. So sometimes grief can be a spur to significant social action as well.

VY: What are some common mistakes or countertransference issues that therapists and grief counselors deal with?

KD: Again, I think failing to recognize the personal pathways, to accept that the client’s ways of grieving, and of not being aware of whatever countertransference issues you have in terms of loss or working through loss. I think using outmoded theories, using outmoded methodologies or even having a single approach.

VY: What about burnout or compassion fatigue?

KD: I think that’s a big issue in grief counseling, because you’re working with people in the midst of suffering. The research on that has really kind of emphasized that self-care is critical in the sense that you validate your own loss, especially if you’re working with people who are dying or ill, and you look toward your own spirituality, however you define it, as to how you deal with suffering and loss and that you find significant ways to find respite.

I think it’s also emphasized that organizations have a responsibility which includes providing support for their staff, providing validation for their staff and maybe even providing opportunities for the staff to engage in their own rituals as a way of validating and supporting their loss. Years ago, I worked with a project where staff dealt with foster parents who were taking on HIV positive kids and this was right at the very beginning of the epidemic, when the standard rule of thumb was that a third of the kids died within six months, another third died within the first year and everybody was dead within three years. They found their social work nursing staff was deeply affected by these losses and so they provided a range of supportive services, including an in-house ritual whenever a child died and a staff support group, as well as and the informal support of administrators recognizing the significance of those relationships and losses and really trying to be supportive to staff in whatever ways they could be.

VY: It seems thereâ€™s also a particular problemâ€”youâ€™ve talked about the bias towards intuitive grievers in terms of clients, but it seems thereâ€™s also a problem for therapists or counselors who are more instrumental in their grieving style, because working in the mental health field, they can easily be made to feel that theyâ€™re not empathic enough or that thereâ€™s something defective about them.

KD: I think there’s a paradox there and the paradox is that very often people who get into grief counseling field do it as an instrumental way of coping—so they often can find themselves disenfranchised by the field they selected. I think that was why when I worked on styles of grieving, which we thought was so contrary to the conventional wisdom at the time—that it was so supported by grief counselors, because they acknowledged and recognized what they saw in themselves.

VY: Ron Levant has a different terminology for that, what youâ€™re referring to as instrumental grievers, he talks about as action empathy. Empathy is not just feeling another person, but you can act in ways that are empathic. You give examples of that in your book as wellâ€”that someone who takes care of their dying spouse and does a lot of things after the death, but they still feel like theyâ€™re not empathic enough because they donâ€™t feel the loss as much as other people do. I think there tends to be a confusion between feeling intensely and empathy, which are in fact two separate concepts. I mean you can feel a lot, but that doesnâ€™t mean youâ€™re actually behaving in a way thatâ€™s empathic toward someone.

KD: Right. I would agree with you.

VY: And conversely, you may not feel others so intensely, but you can care deeply about someone and act in a way that is putting their needs first.

KD: Yeah, very definitely.

VY: So, it seems that this can really be troubling to counselors or therapists that are doing good work but have this idea that if they donâ€™t feel a lotâ€”and that idea may be reinforced by their colleaguesâ€”that thereâ€™s something wrong with them.

KD: Well, a lot of the clinical training is affectively based.

VY: Any thoughts about individual counseling versus group counseling or support groups. How might you make that determination on what would be most appropriate?

KD: For uncomplicated people who are grieving, a support group can be very, very fine. When you look at the research on grief counseling it shows that you need a careful assessment and an individual targeting of intervention. As far as the question of support groups, you need to look at whether the support group is well run, and does it have an emphasis on positive coping and even potentially transformation? You know, how is this experience changing you?

Sometimes the problem with support groups is they can be just places of what we call "shared anguish" where everybody just kind of comes in and says, "Hey, if you think that story’s bad, let me top it off." And so you come out of the support group thinking, "Wow, you know, the world’s hostile." So, a good support group leader would say, "Okay, yeah, that was a pretty horrible experience, but how did you cope with that, and how have others of you coped with experiences like that and what have you learned from those?" So there’s got to be this notion of emphasizing not just the sharing of anguish, but also how we kind of deal with that anguish.

VY: I imagine support groups also can be problematic for instrumental grievers if the focus is primarily on expression of affect.

KD: Yeah, it can be. There was the Harvard bereavement study found that, for instance, single dads benefitted more from more problem-oriented support groups like "How to be a good single dad,” rather than groups that really focused on their grief experience.

VY: So, that would be, of course, important to assess that grieving style in making a referral. What are you currently working on now?

KD: Well, we’re doing a book now on spirituality in loss for the Hospice Foundation of America, and so that’s my current project right at the moment. We’re looking now at the issue of spirituality a little bit more deeply.

VY: And just to wrap up, what are some of the most meaningful things you have learned personally and professionally working in this field for several decades?

KD: Well, I’ve very much enjoyed my involvement with two professional associations, The International Work Group on Death, Dying and Bereavement, and The Association of Death, Education, and Counseling. The International Work Group is an invited group—you have to be involved in the field to be invited to join it. But the Association, anybody who’s really interested in grief counseling should join and you’ll benefit tremendously from your experience in that. I very much have found my work with the Hospice Foundation of American to be extraordinarily meaningful, because in many ways—we publish a newsletter for the bereaved called Journeys—and I think what’s really been exciting about that is getting some of the best people in the field to do some writing, really with a self-help emphasis, and really taking some of the best of current theory and practice and really translating it to a lay public. And that newsletter goes out to 60,000 people a year, so that’s a significant segment of people for a bereavement newsletter. And then, of course, I love teaching graduate students at the college in New Rochelle. That’s always a meaningful experience for me.

VY: Well, I think this has been a greatâ€”weâ€™ve packed a lot of material into one interview and I think it will be of great interest to our readers. Thank you for taking the time.

KD: Thank you for the thoughtful interview.

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