rezendevknowfully.com, Author at Psychotherapy.net

Shaped by Experience: What a Brain Bleed Taught Me About Therapy, Grief, and Presence

Posted on November 18, 2025February 25, 2026 by rezendevknowfully.com

From the Ashes of Crisis

Alone in the ICU, tethered to machines and unable to see my family due to COVID protocols, I realized I was about to learn lessons no textbook could teach. I never imagined that a single medical crisis could teach me more about therapy than years of clinical training––surviving a brain bleed during my final semester of internship turned the ICU into the most intense classroom of my life.

Some nurses became my anchors; others showed me what I never wanted to become. I learned lessons about presence, compassion, and patience that no textbook could offer. My neurosurgeon was like a balm for my fears. Some nurses offered calm steadiness when everything felt terrifying. Others were brusque or cold, teaching me just as powerfully what I want to avoid in my work.

Even months into recovery, lingering symptoms—burning headaches, balance issues, heightened sensitivity—forced me to slow down. I had to set limits. As my internist said bluntly, “Focus on yourself.” This is advice we all need to hear sometimes—especially when life feels overwhelming. That process of slowing became a gift: I learned how to sit fully in stillness, tolerate uncertainty, and meet suffering without rushing to fix it. And humor? It can diffuse suffering. I realized it can be a quiet lifeline, reminding us of our shared humanity even in the darkest moments. The following lessons about presence and patience became especially relevant in my work with clients navigating profound loss.

Sitting with Grief: Aaron’s Story

Aaron came to therapy shortly after losing his partner in a sudden and tragic accident. The shock and anguish he carried were crushing. In the early months, he found ways to honor his partner’s memory through personal rituals that gave him small moments of connection, purpose, and meaning.

I drew on my own experience with vulnerability and life-altering uncertainty to simply sit with him, without judgment or pressure to “fix” his grief. Sometimes, just being present felt like the only thing that mattered. Over time, we explored the idea of growing around grief, which lifted some of the pressure to “get over it” within a certain timeframe—pressure that Aaron sometimes felt from his family, who were anxious for him to move on. Healing, we discovered, doesn’t erase loss—it expands around it, letting life continue alongside the grief.

Slowly, Aaron began to imagine a future where his partner’s memory stayed with him, while leaving room for new relationships, moments of joy, and perhaps one day having children—a future shaped by both love and remembrance.

Shared Vulnerability: Duncan’s Story

Another client, a young adult in their twenties, came to therapy struggling to access emotions after a loved one had died about a year and a half earlier. At first, they couldn’t cry and often felt numb, as if the grief had shut down their ability to feel. Over time, they learned to open to vulnerability, explore deep questions about life, and celebrate meaningful milestones.

Later, a sudden and tragic medical crisis, similar in intensity to my own brain bleed, involving a close family member shook them to the core. Sitting with their grief stirred my own memories of helplessness and survivor guilt. In the past, I might have redirected those feelings in the name of “professionalism,” but now I could simply bear witness—being fully present alongside their suffering.

Silence became a space where emotions could surface. Through that silence, Duncan was able to access feelings that had previously felt blocked. For me, as the therapist, the long bouts of silence were challenging, yet holding that discomfort became part of supporting him. For this client, it allowed grief to breathe, tested trust, and revealed the quiet power of shared human vulnerability. My steady presence, sometimes wordless, reinforced that being truly present can matter more than saying the “right” thing.

Takeaways for Readers

Presence is powerful: Sometimes simply being there matters more than advice or solutions.
Grief has no timeline: Healing is nonlinear, and growth can happen around, not just after, loss.
Shared vulnerability fosters connection: Authentic empathy strengthens bonds, both in therapy and everyday life.
Humor can coexist with hardship: A gentle laugh can remind us of resilience and shared humanity.

Just as I learned to sit in the stillness of an ICU room, tethered to machines yet alive, I now witness grief and healing unfold—messy, nonlinear, and profoundly human. In therapy, and in life, the greatest gift we can offer one another is simply to be present.

Therapy, for me, is about ensuring no one feels alone in their suffering. My ICU experience didn’t just shape my approach—it deepened it. I show up with attunement, patience, and care rooted in lived experience, creating space where clients can meet their own pain with courage, curiosity, and even a little laughter.

Rebuilding Connection after Grieving the Loss of a Desired Relationship

Posted on November 13, 2025February 25, 2026 by rezendevknowfully.com

The other day, one of my clients asked me, “Isn’t it unfair to know that they [people around me] still can’t figure out that I am going through something and that I have to spell it out every single time, even after all these years?”

Unmet Expectations

I sat there in quiet surprise as I remembered asking the same question to myself a few days before. I thought, this is going to be interesting!

Lately, many of my clients have been dealing with the feeling of disappointment in their close relationships when they’ve come to realize that these bonds may not be as they once believed them to be, even after years together. It can be a parent, spouse, or close friends—it doesn’t matter. As their therapist, I have found myself sailing in the same boat, and I am at a crossroad when I am with them in that room trying to hold space for their disappointment—while allowing for my own. I am realizing there is another person who creeps into that space; my own outside-of-therapy-self who is learning to deal with the weight of similar disappointment with those in my life. It’s uncanny how these clients came into my life at the same time. I don’t think this is just a coincidence.

Sometimes, I treat the people in my life in ways similar to how I secretly want them to treat me. I extend my heart in kindness, my eyes to truly witness them, my ears to listen, and my words to comfort them—hoping silently that they will do the same for me.

A client might be sitting in front of me, saying all this as the realization suddenly hits them that their disappointment and anger may be coming from an unmet personal need to be cared for or about. Eventually, the other person falls short of these unspoken expectations, and they sit there enraged, but mostly feeling hopeless and disappointed with the inevitable reality of unmet expectations.

They, like I, build a certain image of a person and our relationship with them in our minds which keeps us from seeing them as they are—humans with flaws. And this can come with a sense of grief of having to let go of a version of a relationship they—and I—hoped for, but that simply was never there or that doesn’t exist outside of the mind’s eye.

From Disappointment to Acceptance

The period of transition from disappointment with and acceptance of people as they are knows no age bounds. The realization can come at any stage of life. And when the realization does come, it is important for the person to accept that the origin of the disappointment is not in the other person, but the result of their own unmet, and likely longstanding inner need for validation. These versions of relationships aren’t lies; they were (and are still) survival tools. In difficult times, they were needed to support the idea that the bond existed. That belief, even if idealized, was sufficient.

As both a therapist and citizen of the world, I believe the mask also comes off only at the time when my clients are ready to see reality as it is. The reality in itself is not bleak; it’s just different. The challenge lies in the decision to take the next step—to fully embrace the reality of a changed relationship with the imagined person who disappoints, rather than continued anger and disappointment. It’s about considering the new, altered relationship rather than expecting it to change. That decision can be made well when it comes from a clear mind and not while in the throes of grief.

Inside the therapy sessions, I see my clients face this disappointment and ask the important questions. Initially, it used to make me feel as helpless as my clients felt. Once we are able to talk about the helplessness, and acknowledge the disappointment that comes with it, we reach a point where I can address their unmet needs that led them to hold on to those versions of relationships that never existed. This, then, opens space for addressing how together, we can fulfill these needs outside of the existing relationships. Only then is there hope that my clients can open their hearts to reconnect and renew older connections with a new perspective.

The message I try to communicate is to be open to the grief and to sit with the disappointment. I ask my clients to open a space for grief related not to the relationship per se, but to expectations that the relationship will or might change. As a therapist, I invite clients to make space for that hopelessness, while as a person, I feel privileged to have clients whose lived experiences I get to learn from and seek support. I thank them for giving me that space, too, unknowingly. This is what happens when a therapist and a client walk through the same storm together. I have not known a greater community support than this!

The fluidity of relationships is beautiful. They shift, stretch, and evolve. They permit me and my client(s) to come out of fantasies in our own time. It allows for a new light and a fresh definition of connection with them. Disappointment is not the end of a relationship but the beginning of a truer one. When my clients—or I—make a space for grief, there is the possibility of re-connection.

Case in Point

I once worked with a client who came to me with the complaint of feeling angry most of the time. “Kunal” was a well settled person in his 30s who had been married for a long time. At the time he was coming in, he had been feeling frustrated in every conversation he was having with people close to him. In our sessions, he would ask questions like, ‘They understand when I am happy, why do the bad moods need to be spelled out?’ Every time, I could see the disappointment and sadness spread across his face.

It took us some time to reach the point where he could acknowledge that relationships often come with disappointment and to digest the ever-changing nature of relationships. As he described these situations, he attempted to soothe himself as he processed the years of disappointment that came with this realization. My goal was to be fully present, mirroring his feelings. This understanding paved our way for communication with a fresh base and a new outlook to look at his existing relationships. An important lesson learned!

Christoffer Haugaard on Collaborating with Clients Who Hear Voices

Posted on November 12, 2025February 24, 2026 by rezendevknowfully.com

Lawrence Rubin: I’m here today with Christoffer Haugaard, a Danish Narrative clinician who has a particular and fascinating interest in working with clients who hear voices. Welcome, Christoffer.

Christoffer Haugaard: Thank you, Lawrence!

The Multiplicity of the Mind

LR: I know there are a lot of clinicians who will be reading this and want to know simply, how do I work with clients who hear voices? But I don’t want to start there. Instead, I’d like to start in a somewhat different place by asking what you’ve learned or are learning about the human experience by working with clients and their voices?

CH: I think what I’ve learned is that, based on the phenomenology of what voices appear to be and how they behave when you interact with them, the mind doesn’t seem to be unified. There seems to be multiple agencies, multiple perspectives that at least can be present and seem to have their own existence and are in some way tied to a particular person.

You can interact with these agencies or entities or whatever you want to call it. And, from my experience in working with people who hear voices, they respond favorably. The voices respond favorably to being treated as some kind of person, to being respected as having a perspective and their own agency, their own opinions, rather than being dismissed or rejected or taken to be not real, or only a symptom or a representation of something. They tend to appreciate being treated as if they are people too.

LR: Have you had to shed any preconceived notions along the way or divorced yourself from any common ideas about voices in order to reach that place where you recognize the multiplicity of the mind.

CH: That’s complicated. In a way it wasn’t a stretch for me because personally, I was already quite familiar with other ideas about reality of the mind, other ontologies. I’ve always been interested in indigenous societies, shamanism, animism, that sort of thing, where people experience entities or agencies outside themselves or related to the world and interact with them.

So, that way of thinking was actually quite familiar to me, but I didn’t connect it to my work as a therapist at all. I thought of psychopathology as being something distinct from that. Or at least I didn’t have any particular interest in connecting those two things. So, I regarded voices as being dissociated thinking patterns that were on repeat in peoples’ heads.

My change in view happened because we made a discovery about it by coincidence. I was working with one of my patients, named Max, whose story has been published. He considered that maybe his voices had good intentions to begin with, and I just took that idea at face value. I suggested that I try to address these voices and tell them that we had these ideas about them, that maybe they had good intentions, and tried to explain to them that Max needed them to behave in a different way so they could assist him in life.

Max thought that was a crazy idea because you can’t talk to a mental illness, but he was kind enough to not tell me that. He just said, “yeah, sure, go ahead.” So, I spoke to the voices, and they responded very favorably to that. They enjoyed being respected and acknowledged for their good intentions, and they actually changed their behavior.

From that point onwards, Max was able to appeal to them using my words in the form of a letter. In five minutes, he could quiet them down. They had terrorized him for years but responded to this immediately. That required me to change my thinking. This certainly didn’t seem to be some thinking that was dissociated and stuck in his head on repeat like a broken record.

This was something living that was responding with an opinion, and had feelings that were different from Max’s feelings. I brought that idea with me to other patients where we were stuck and we found that treating voices in this way, acknowledging them as having their own perspective, their own opinions, being persons of some kind was very effective. We then collaborated with more and more people where we were able to confirm this.

And of course, that required me to dissociate myself from normal psychological and psychiatric thinking. I was working in a psychiatric hospital where the general idea was (and still is) that voices are false. They are hallucinations, and people should not involve themselves with them. They should reject them and not listen to them, and they should be medicated to go away. I had to dare to step completely outside of that idea. I think maybe I was willing to do that because I was familiar with that way of perceiving the world already. I just never connected it to my work as a clinician before. I had a predisposition, you might say, to think that way.

So, it wasn’t a big leap for me personally, but it was something I had to dare to do in a psychiatric context, where that was not how you thought about things. I had to deal with the possibility that other clinicians would think that I was indulging people’s insanity or entertaining their delusions. But to think that that helped me to not be persuaded by such doubts or such ideas was the fact that it was just very effective.

There was just a very immediate response from these voices and nothing else had worked. I was sitting with patients who had been medicated, sometimes heavily, and who had tried many different kinds of psychotic medication for years and years; and tried psychotherapy for years and years, and it hadn’t worked. It hadn’t made any difference to these voices. And now these voices were responding in ways that were entirely novel to these patients.

They were immediately surprised that the voices were responding like this. It was useful. They could suddenly find ways to deal with these voices so that they stopped being a menace to them. Their need for hospitalization decreased, and some of them even stopped needing it. The voices ceased to be a threat to them, something they could live with. Even in some cases, they came to appreciate the input of these voices. They changed their behavior, became more reasonable, more kind, stopped going on and on about people killing themselves and stuff like that, and becoming more constructive when they were engaged in a dialog. And that was very persuasive for me and for my patients that this happened.

And when I saw that happen and the difference it made to my patients, it was it was a no-brainer really. I did have concerns about how honest I should be about what we were doing. Should I tell my patient’s psychiatrist what we were doing? But that became easier along the way because it was working.

LR: I need to dissociate myself from the popular conception that voices are equivalent to psychopathology, just as you had to. I’ll go so far as to channel Travis Heath here by suggesting that for you, accepting the reality of, and working with, voices was an act of rebellion.

CH: Yeah, and I already had a rebellious mindset. That’s why I became interested in Narrative Therapy to begin with. I was dissatisfied with how these peoples’ experiences were pathologized and just rejected as being just wrong and not worth listening to, not worth understanding, and just something that should be medicated until it stops. I was dissatisfied with how these people were not engaged in a more equal dialog about meaning and what might be helpful for them.

I had already been creating a group therapy format and participating in psychoeducation, where you tell people about diagnosis and treatments and all that. I’d become dissatisfied with being a clinician telling these people what to think about their experiences and describing it as something that was wrong with them. In the group format I developed, I invited patients to participate and interviewed them about their experiences and then together, reflect on what might this mean.

It was important to not privilege a psychiatric understanding. I wanted these people to participate in understanding their own lives and their problems instead of having to listen to yet another psychologist tell them stuff out of a textbook. I’d already done that before making these discoveries about voices. So, yeah, I definitely had that kind of rebellious mindset about it.
LR: Have you found colleagues who have attempted to adopt your philosophy about working with these clients, and have failed because they’re not you?
CH: As far as I’m aware, none of my colleagues had tried it out. It’s sort of just became a thing I did. Sometimes they would bring along a patient and ask if I could “talk to this guy or can you talk to this woman and see if you can do your thing?” So, it was more a thing I did after having published some of these accounts, circulating this knowledge, and making it available to people who hear voices. I have been contacted by people who have tried it out and found it to be effective. Not a lot. I hope there are more people out there using it that I’m not yet aware of.

A Relational Framework for Understanding Voices

LR: My guess is that because of Western culture’s hyper-emphasis on pathology and our dependance on insurance companies for greenlighting treatment, this might not find as welcome a home here as it does in Europe, or outside of Narrative Therapy circles. How does the traditional notion that voices are simply split-off and projected unpleasant or unwanted parts of ourselves fit your model?
CH: Mostly I’ve been dealing with this in a very pragmatic fashion and haven’t worried too much about that, really. Treating the voices as people was just very effective. Trying to work out what voices mean in terms of ontology or psychology has not been a concern. My patients didn’t care about that, and it wasn’t necessary to figure that out in order to do the work with them. To my mind, people are free to make sense of their voices in whatever way works for them, you know? Some people will think “this is probably a part of myself in some way,” even though that’s actually not how the voices appear.

They actually appear and behave like something of their own. But, you know, a patient who prefers to interpret that as being parts of themselves, of course, is free to do so, and it doesn’t seem to actually be important what people think of it. Voices respond to it, no matter what the host human might think of it. Right? But it doesn’t seem to depend on what the patient believes, and we don’t have to figure out what to believe about it. We have to pragmatically make the assumption that voices are people — they have their own perspective, their own desires and intentions, and we treat them that way. As soon as people have the experience that voices respond to this, they really stop caring about how crazy it might seem. It just doesn’t matter when it works. I, of course, have been interested in trying to get some idea of how we can make sense of that

I think the more traditional psychological idea that these voices must be “split-off” parts of the self presumes that the self is supposed to be unified and that this splitting is not how it’s supposed to be. Thinking that way doesn’t lend itself to acting the way we did .

You know, it becomes sort of pretending. The therapist is pretending that the voices are persons, but they really think they’re not. So, if we want to develop an idea about what voices are that actually supports literally treating them as persons, we might need a different idea about voices. It seems to me that psychology, and certainly psychiatry, is not a very good place to look for that, because these ideas are very tied to a Cartesian way of thinking about the mind and very tied to particular notions of what’s normal that are really based on industrial Western societies in the last t couple of centuries.

Basically, much of psychology doesn’t take other societies into account, or how Europeans thought just 300 years ago, which was in many ways radically different. This idea of a self-contained subjectivity is quite recent, and historically not very normal, actually. Psychology and psychiatry are very tied to such a notion of what a mind is supposed to look like. But when you start looking at the history of religions as well as anthropology and ethnography, very different ways of how the mind operates begin showing up. And a concept that has become more popular and recently redefined in anthropology is animism, which seems to be a way of understanding the world and the mind, which is pretty much universal.

All societies that have been studied either are or used to be animistic.Animism used to be considered an erroneous attribution of mind to things that actually don’t have minds. Like the “so-called” primitive belief, for example, that trees are alive or that a stone is alive. That was the original notion of animism in anthropology. And it was used rhetorically to demonstrate that religiosity in general is a primitive, irrational thing that should basically be rejected, and that the religions of civilized societies are just refined versions of this primitive animism. that was the idea back at the beginning of anthropology.

But animism has since been redefined as being an epistemology that takes the subject to be the starting point for knowledge of the world. To interact with the world socially is a way to know the world, which is different from the rationalist scientific idea of taking the object to be fundamental. In scientific, rational thinking, we want to divorce subject and object from each other, such as in Cartesian mind-body dualism. And in this vein, we then want to remove subjectivity as much as possible from the object of study, because real knowledge is supposed to be objective, independent of perspective, independent of context. It seems that many societies, indigenous societies, assert just the opposite; to know something is to invest subjectivity in it, to interact with it, to be socially engaged with it.

To know the forest then, the forest must become a person. It must become a subject. We must see through the eyes of the forest to know the forest. . As such, a spirit is not an irrational belief in a non-empirical entity. A spirit, then, would be the subjectivity of a relationship with something in the world. And in that sense, it’s a way of knowing. Instead of regarding the world as consisting of a bunch of particles in causal relationships with each other, the world can be understood to be a set of social relationships, and that the world is fundamentally social, not just between humans, but between humans and trees and animals and so on and so forth.

In this sense, animism, may be an ontology and an epistemology, a way of engaging the world that makes a different bet to rationalism and modernity. I think these notions of subjectivity, where the mind is not closed but porous, relational, and elastic, seems to be actually a very universal way of operating for our species.

And in that light, hearing voices isn’t that difficult to understand. You can look at voices as a way of understanding your life. When something in your life begins to speak to you, it’s a personification and investment of subjectivity in some aspect of your life that is problematic that you need to deal with. That’s why it begins to talk to you, so developing the right relationship with it is the road to healing. These voices mustn’t be rejected. They must be listened to because they’re trying to tell you something, and you must establish good relations with them instead of rejecting them or ignoring them or battling them.

In Relationship with Voices

LR: It almost sounds like people who don’t hear voices are at a disadvantage in some way, or that they’re not living fully in the world, as are those who are open to the experience of voices.

CH: I guess you could say that the process of modernization has been closing human beings off from the world. In making the distinction between subject and object and presuming that humans are exceptional and separate from the natural world, from our bodies, from other beings—we are asserting that we’re somehow entirely different and that only we possess minds, and the rest of the world is sort of dead and has no inherent meaning. From a historical perspective, you can certainly make the argument that modernization has operated like that; a rejection of being in relationship with the world.

LR: You’ve used the word spiritism, so is the experience of hearing voices and sitting with someone who is hearing voices, a spiritual experience?

CH: The older understanding in anthropology is that a spirit is a non-empirical entity that people believe has causal powers. That would be the old understanding of animism. The new animism in anthropology says that a spirit is a personified relationship with some aspect of the world, a relationship with something other than another human. So, when humans enter into relationships with a particular tree that may be important to them, this tree is personified by being related to in a social way. There’s an investment of subjectivity. The relationship becomes a hub of subjectivity in itself. That is what a spirit is.

LR: So, you might work with a client in relationship to the voice?

CH: Yeah, but mostly with the voices I’ve met. It’s not trees that they have problems with. It’s usually some aspect of existence. It can be aspects of our culture, for example, certain social norms that act in a personified way, and very often it’s a kind of helper. It’s like a companion entity of some kind that is trying to help people deal with something in their lives.

Often they turn out to be quite right about what people need, but because people have been rejecting this voice and been afraid of it, the relationship has gone sour. Sometimes it turns into a war. Sadly, sometimes psychiatry contributes to creating this state of war because they encourage people to reject their voices and in telling them that this voice is a sign that there’s something wrong with your brain. That’s a very scary thing to come to understand. This element of fear and rejection tends to lead to a conflict with the voice, and then the constructive aspects of what a voice may be trying to tell people is completely lost in this war. What I’ve often done is try to be on a diplomatic mission to create a peace and to try to understand what the voice wants. Often the voices are able to communicate when you interact with them in a respectful way. Very often, they want something. When the person comes to understand this and finds a way to satisfy the voice in an acceptable way for the person, the war ends.

LR: Have you found any commonalities in the origins of patients’ relationship with the voice(s)?

CH: There’s often trauma. The first appearance of voices is often in the context of a traumatic event, but not always since some of the people I’ve collaborated with have been able to hear voices for as long as they can remember. Just seems to be an ability, something that they’ve just always had.

LR: It made me think of an interview I did a while back with an ecopsychologist, who talked about the proliferation of ecological anxiety and dread as the planet is attacked from so many different sectors. Our planet is experiencing trauma which makes me wonder if some people who hear voices are afraid of the annihilation of our world.

CH: I have collaborated with one among other voices that was extremely angry about how the world was being treated by humans and wanted the person hearing the voice to try to annihilate humanity. I wasn’t able to, to work with that person in a very consistent way. A certain reason I haven’t collaborated with this person was due to the circumstances in their life, and of course, wanting to annihilate all of humanity is not a desirable or constructive thing to do.

It was not sensible to agree with this voice about that but to appreciate the anger of this voice was certainly relevant. Of course, I would see that as the fury of this voice. You know, wanting extreme things. And we need to channel that into something that’s acceptable for a human being to actually do, and killing people wasn’t it.

LR: Can you bring to mind a client with whom you’ve worked where there was this negotiation?
CH: There is my collaboration with Alice that has been published. She heard a multiplicity of voices operating in a unified way that she called “the others.” They were very aggressive and wanted her to harm herself and other people. They enjoyed gore, suffering, pain, and things like that and wanted her to do them.

Of course, she didn’t want to do anything of the kind. Then they would torture her in various ways when she would not comply with them, and try to convince her to kill herself. Once she started talking to the others, she discovered that they had all this aggressive energy that they wanted to express through her.

Alice resisted that, but because of this, they felt trapped. They could not exercise their own being in any way. They were just trapped inside her. That caused suffering for them. They were in pain from not being able to express themselves in the way that they wanted, and therefore they didn’t want to exist anymore. The voices were trying to get Alice to kill herself, hoping that that would also put an end to their painful existence.

We found out by coincidence that they enjoyed having smoking breaks. One day, we were talking about something that they didn’t appreciate, and it seemed like an attack was coming on from them. To avert that, I said, “sure, you get it your way. We’ll talk about something else for now. You just take a break for a smoke or something.” And that was just a joke. I was trying to lighten the mood and as it turned out, that averted the attack. Alice then told me they liked that. They liked being offered a smoking break, this was after having made this discovery with Max that I mentioned earlier. After that, I brought cigarettes for them and we put them out on my desk.

They really liked that. Otherwise, they would want her to kill herself. The voices didn’t like me talking to Alice and trying to help her get better because they wanted her to die, but now they had to admit that I offered the cigarettes. No one else in the world had ever offered them anything, but I did, so they couldn’t thoroughly hate me. We also gave them coffee. We could avert attacks like that, and begin to teach them to behave more kindly and in a friendly kind of relationship instead of an aggressive one based on power, which was all they knew. They started becoming familiar with being friendly and what that meant, so we tried to accommodate them.

They also wanted all this blood and gore and aggression. They liked that but of course, Alice didn’t. I suggested putting on gory movies for them. I didn’t want to look at it. Alice certainly didn’t. So, I put them on my computer and turned the monitor away from us, up where the voices were receiving their cigarettes and coffee.

I chose something comical, something funny like Peter Jackson’s old gory comedy movies he made before the Lord of the Rings. Later on, Alice decided to start practicing martial arts and they really liked that too. She was doing something that had something aggressive in it, but which was socially acceptable and acceptable to Alice. The voices calmed down more and more. And in the end they became quite friendly and liked me and wanted to be friends with me. They eventually stopped bothering Alice, and she stopped being afraid of them. So that was this kind of negotiation, you know? Can we give you something that you’ll appreciate, but which is also acceptable for Alice?

Narrative Therapy and Working with Voices

LR: Christoffer, what is it about Narrative Therapy that’s helped you in your work with clients and their voices?

CH: I think externalizing conversations already has some similarity with working with voices where there’s a practice of personifying problems. It has this animistic element to it. The leap isn’t that big. And then there’s the element of Narrative Therapy that’s called co-research. David Epston calls it co-research when you’re in a situation where you don’t know what to do, or how to deal with a problem. You relinquish your professional identity as the one who’s supposed to know stuff and invite the patient to explore. You work from the premise of “let’s explore this together.”

Narrative Therapy has roots in anthropology and ethnography, so this idea of collaboratively exploring the world without knowing in advance is essential. That is certainly what we did because we were in a situation where the usual stuff wasn’t working and we had to recognize the fact that we didn’t know what to do. It was a matter of just going with it to see what we could find and try it out and see what works. What we found with voices was that they responded well to this, so we did this consistently with one patient after another.

LR: Are the written elements of narrative practice like letter writing and journaling particularly useful here?

CH: Yes. When I spoke with Max’s voices that first time, he had a positive experience because the voices responded and calmed down immediately. Max then asked me to write down for him what I had said to the voices. That became a letter that he would then use whenever the voices got worked up about something in his life. He would simply read this letter to them, and they would stop attacking him. I have also used letter writing with some of my other patients when we were trying to figure things out, and as a way of documenting our discoveries. In those instances, I would write to them and some of them would also write to me to explain to me what they had discovered, or what the history of the voices was like.

Lately, I’ve been writing letters, not to my patient, but to the problem, a personified version of that problem. In one case, I wrote a letter to a dream entity of a patient with PTSD who had reoccurring nightmares. In one of those nightmares, he saw a dead man who had committed suicide. The patient had been the first person on the scene.

In the nightmare, they had a conversation where the patient was extremely angry with the dead man for the impact the suicide had on his life. The dead man told him that the suicide was his decision to make and that it didn’t concern other people. That made the patient even more furious. This conversation would happen every week in a nightmare. I decided to treat this as if it were a voice and appealed to the dead man in the nightmares as a person. This person was a personification of the trauma the patient was living.

I wrote a letter for the dead man from me said to the patient, “please read this letter right before going to bed.” As with Max, the patient thought this was a crazy idea which was not going to work. But since he had been having the nightmare for two years, he was willing to go along with the plan. He liked me enough to try. The nightmare with the dead man stopped as did the other trauma-related dreams. He later told me that when I suggested this plan, he didn’t think it was going to work. But it did.
LR: He was willing to try. A long shot at hope!
CH: I’ve had quite a few patients when I read these letters. I’ve been writing it while they were there, and just wanted to read it to them to make sure that I had all the facts right. And they would cry, because it just hit something apart from their own sense of themselves or their own minds. But something else, seemed to just appreciate it.

LR: The way you describe it is very consistent with Narrative Therapy’s focus on freeing people from systems of oppression.

CH: Yes, but with the twist that what seems to accomplish this work is the assumption that the problem is a person with good intentions. So it’s important not trying to resist the problem or undermining the problem, but to actually listen to what the problem is saying. I’m trying to acknowledge the good intentions of the problem, and then explain to the problem the effects of how it is going about its work of helping the person. I ask the problem to consider that the way it’s been behaving is having all of these negative effects. And then I just ask people to read this letter on my behalf to the problem every day. I say to the person that all they have to do is read the letter to the problem. And that’s been very effective.

LR: Do you ever introduce voices into your work with clients?

CH: In what sense?

LR: Such as with a client who has no history of hearing voices other than their own, where you might invite them or invite a voice into the conversation. Or is that a crazy question?

CH: No, no, no, I get what you’re saying. Yes, I do sometimes try to relate to the problem as a person when people are not hearing voices, and that that’s often very effective. I don’t usually explicitly introduce that or explain that. I allowed the person to wonder, like I might say, “I wonder if this depression might be trying to tell you something.”

I might also wonder aloud if “the depression has come at the time that it did in your life for some reason”. And then, based on what people have told me, I consider “well, maybe this depression has been looking at you and has been looking at how your life has been unfolding and how you’ve been dealing with your life. And perhaps this depression is aware of the things that are important to you, and therefore this depression is dissatisfied. It has been dissatisfied with what you have been doing, how you have been compromising with the things that are important to you, the things that matter to you, that you have been sacrificing yourself for the boss at work or whatever.” I might add, “maybe this depression has decided to make an intervention to stop you from living your life the wrong way.” The thing is with depression, at least in my experience, they tend to be like a sawn-off shotgun. When they fire, they fire all over the place.

I might continue, “Maybe this depression is, in fact, trying to dissuade you from living in a way that isn’t right for you, but in interfering with your life, it’s just hitting everything, putting you completely at a halt with lots of negative consequences. But maybe this depression wants something for you. And maybe we need to try to hear that message. Maybe you need to try to satisfy the depression with what it actually wants, its intention, not all the negative effects it’s also having, but it’s intention for you; what’s actually important to you, how you’re supposed to live. Maybe you’ve been compromising with something essential in the way that you’ve been living up to the point where this depression stepped in and interfered with your life.”

Often I worry that people think I’m crazy when I say these things, but I’m surprised that they don’t. They tend to be on board with that quite immediately, actually.

LR: So, in a sense, and regardless of the emotional valence of the voice(s), you consider them always on the side of the patient.

CH: Yeah, I make that assumption or at least try out that idea very carefully that the voices have good intentions before assuming that the problem has only bad intentions. Voices tend to respond quite well to the assumption that they have good intentions

LR: Even when a patient’s voices are instructing them to kill their parent? In cases like this, is it a safe assumption that the client has rageful feelings, or that there are rageful feelings toward the parents?

CH: They may or may not have those feelings, but I would try to invite the patient to explore the voice’s intention with me and also directly with the voice. The voice may have different reasons for wanting that. To become a teacher here in Denmark, you have to learn how to how to teach, how to communicate in a way that’s conducive to learning. I have the impression that voices have not had this course. Sometimes they’re very angry at their host human because they think the person hasn’t been taking care of themself, such as “Back when you were raped, you should have killed that rapist. I’m so angry with you because you didn’t and because you didn’t, I think you’re useless. You should die.” When what you’re hearing is just, “you should kill yourself, you’re useless,” It’s very difficult to see the good intention, but it is often possible to actually unravel it.

What the voice wants is for this person to stand up for themself, but that communication needs to be translated into something that’s acceptable for an actual human being to do. We don’t want to kill anyone, but that may be the voice’s way of expressing a desire for protecting the person, or demanding they defend themselves. In Alice’s case, the “others” would say, “kill him,” whenever they were angry with me because they thought I overstepped my bounds or talked about something they weren’t comfortable with. There, I would say something like, “I’m sorry that I have offended you. Please take another sip of coffee or let me give you another cigarette, and I’ll be more careful to not offend you in the future. That certainly wasn’t my intention.” And then they’d calm down.

Sometimes voices can have these very violent and graphic ways of expressing themselves, and that language may need translation. It shouldn’t necessarily be taken at face value. It may be an expression of extreme frustration and desperation on the voices part. And that’s what we need to understand so that we can respond to it in the right way; saying something like,“We don’t want to kill anyone, but there’s someone you want to blame. There’s someone you’re angry at, and you want something else for this person you’re talking to. Okay, let’s see if we can solve that, because I certainly get that. I get being angry at that. Right? I get wanting to defend yourself.

But, you know, voices, this person wasn’t able to do that back then. She was a child. She was powerless against this person. We have to find other solutions here. And I invite you voices to participate in that because I appreciate your good intentions. I wish she was able to defend herself back then, but she couldn’t. I understand why you want the rapist dead, I get that. But we can’t do that. We have to find another solution. But I want to collaborate with you to find that something that this person needs , something that they can do.”

Expanding the Subjectivity of Voice Hearers

LR: Christoffer, we’re nearing the end of the hour, but may I ask a question about cultural healing practices?
CH: That’s a very big issue. We talked about spirits and animism and all that, but my point is not to say that voice hearing and spirit encounters in various cultures are necessarily the same thing, and that people in other cultures are all hearing voices and or that people in our society who hear voices would be shamans in other societies. That’s not necessarily the case. The point is more that animism provides a different way of understanding subjectivity and a way of handling subjectivity that fits quite nicely with what works for voice hearers. So, I can be agnostic about how voice hearing relates to spirits. It’s more about the commonality in the subjectivity.

You know, we might learn something from the spiritual practices in other cultures without it necessarily meaning that what we call mental illness is the same as the experiences that shamans deal with. I think that would be a conflation and an oversimplification.

But there’s a common structure of subjectivity around voice hearing and the practices and understandings in other cultures. It’s a better fit if we don’t view what I do through the lense of traditional, Western theories and practices. These don’t lend themselves very well to doing what I have done with voice hearers, because it would be very difficult to go from a traditional psychological model to offering cigarettes to a disembodied voice.

From an animistic perspective; however, it makes a lot of sense. These are offerings. We’re making an offering of tobacco that’s found in many indigenous groups in the Americas. To make an offering is to appease spirits by making a gift. And when you receive a gift, you enter a moral community of mutual obligation. That’s the logic of an offering. Alice’s others responded to that.

LR: Lastly, and speaking of community, can you say a word about the Hearing Voices Network. Is their work and philosophy consistent with what we’ve been talking about?

CH: There’s a lot of similarities. When we set out to do this co-research, David Epston and I along with these patients decided to not engage with the literature of the Hearing Voices Movement to just start from scratch and make discoveries. But a lot of what we found is very similar to some of the discoveries of the Hearing Voices Movement. And of course, the Hearing Voices Movement doesn’t have one unified idea or one unified practice. They have this idea that people should be allowed to find their own way, but certainly some of the discoveries that they have made are very similar, like for example voice dialog. So, we have arrived at practices that are like what they have arrived at. I find that very encouraging, that without trying to do the same thing, we have arrived at similar practices, working from scratch. And that expands that notion of subjectivity across continents, across borders—not just ideological borders, but geographic borders.

LR: without trying to do the same thing, we have arrived at similar practices…and that expands that notion of subjectivityI think that will be a good place to stop. Thanks so much for this fascinating conversation, Christoffer.

CH: This has been a very interesting conversation. Thank you very much. I’ve enjoyed it.

Links to Christoffer Haugaard’s JCNT (Journal of Contemporary Narrative Therapy) articles

Respecting Voices: A Report on a Co-research Project Concerning Voice Hearing

The Ring in the Well: Psychosis as a Crisis of Identity

Rose and the Whispering Voices

Sitting through it with the Voices: Victoria’s story by Christoffer Haugaard & Victoria

Is it Ethical to Use ChatGPT for Diagnosis and Treatment Planning?

Posted on November 5, 2025February 25, 2026 by rezendevknowfully.com

When questioning your work with a client, ever consider consulting Artificial Intelligence (AI)? Have you considered the ethical and legal implications?

A supervisee of mine recently introduced AI into our supervision sessions. My supervisee explained how they came to see the treatment plan development in relation to the feedback received through consultation with AI. In examining a specific client case my supervisee felt they were stuck with, we delved into exploration of AI professional relevance. Below is an excerpt reflective of one of our sessions:

Bringing AI into the Supervisory Conversation

Supervisee (SE): I am really struggling to understand why my approaches with the client do not seem to be resulting in the client’s therapeutic progression. Supervisor (SP): Tell me about some of the interventions you have used and how you came to establish their appropriateness for this client.

SE: I have tried cognitive restructuring first. AI suggested the intervention.

SP: Let’s start here. Help me understand how AI prompted the recommendation for cognitive restructuring.

SE: I asked AI, “what counseling interventions would help an adolescent female overcome social anxiety?” AI stated cognitive restructuring has been found to be helpful.

SP: What evidence did AI offer concerning the interventions’ effectiveness?

SE: No specific study was shared, just general feedback.

SP: When you say general feedback, do you mean reports from clinicians or clients?

SE: I don’t know.

SP: Did AI offer any scholarly sources?

SE: I did ask for resources to help me implement the intervention and some websites were shared. I read a few of them to see how cognitive restructuring has been used in sessions. Some of them had scholarly sources. I feel some of the resources were helpful for this client.

SP: I see that in your last session’s progress note for this client, you mentioned in the assessment that your client meets criteria for the diagnosis of social anxiety disorder and cited AI.

SE: Yeah, according to AI, my client meets the criteria.

SP: Are the criteria reflective of the DSM-5-TR?

SE: They should be.

SP: For billing purposes, you will be required to provide the appropriate DSM diagnosis. You will need to ensure the client’s symptoms meet the DSM criteria. Share with me how you found AI to account for your whole client. For instance, some of the information you gathered from the intake, and you learned through your sessions thus far.

SE: Well, I couldn’t share some of that information due to the client’s right for privacy and confidentiality, so I had to just generalize to populations like her being an adolescent female.

SP: Knowing these limitations, the need to research AI for sources and then research the sources’ relevance, why not just search for scholarly sources first?

SE: Open AI is easy and accessible with my phone so I can complete my notes on site between clients.

SP: Do you have your phone with you now?

SE: Yes, why?

SP: Would you be open to trying something using your phone?

SE: Yeah

SP: Please type in Google scholar in your browser and click on the link to open it.

SE: Okay, got it.

SP: Complete the same search here in Google scholar that you did previously with AI.

SE: Got it.

SP: How are these results compared to what you received in AI?

SE: Some of the relevant sources shared by Open AI came up. A lot of research-based articles came up in Google scholar.

SP: I want to take a moment to pause and offer some reflection on your experiences thus far with AI, progress notes, diagnosis, scholarly sources, and search for appropriate client interventions in general. Imagine going to court based on your work with a client and they claim you engaged in malpractice and unethical business practices based on your diagnosis, would you feel confident in sharing with the judge your current process in working with your clients?

SE: Not really to be honest. I feel like I am a bit overwhelmed, and AI has been a great tool to help me not stay at the office for hours after working with clients to complete documentation, but I am not always confident in what I am doing.

SP: Remember that confidence comes with time and this is why you have built in parameters right now to support… required supervision, open consultation hours with numerous senior clinicians, required team meetings for case conceptualization.

SE: I am a bit fearful people will not think I am good at my job and will no longer send me clients.

SP: What are your thoughts about a few clients that you feel confident in working with versus many you are unsure how to effectively support?

SE: I would rather feel confident, but I do not want to loose my job.

SP: First and foremost, thank you for your honesty. My role is to also support you to grow as a clinician and aid you with your development. Let’s agree for the next month, we will keep your caseload where it is at and revisit later to grow again.

SE: Thank you; I just don’t want my colleagues to think I can’t do my share.

SP: We all have seasons of life where we may need to provide best practices with our clients.

SE: I know.

SP: Remember, your ethical obligation, as well as mine, is to the welfare of theclients first and foremost. What would you rather tell the judge you used to guide your work and decisions with the client, AI or Scholarly resources?

SE: Scholarly resources.

SP: So why use AI? You shared the ease of access. Something to consider is also how you use it. I am not going to say all AI is bad, because there is also a great deal of research highlighting the benefits of AI. However, engaging with AI considering your compliance with HIPAA as well as your professional standards of practice is essential.

I proposed to you earlier about the client consideration and the credibility of the responses. There is a free training course I would suggest you complete that examines AI implementation for mental health providers. Here are the objectives for the course [shares screen]… how do you feel about this course being able to support your confidence with client work with use of AI?

SE: The course seems to cover many areas I am struggling with and supports the use of AI, which I like, so it may be a good fit for me.

SP: Instead of completing the three additional intakes assigned for you this week, would you be open to completing the three-hour training by our next supervision session next week?

SE: I think that is doable.

Final, but not Last Considerations

Lesson here, as a professional counselor navigating ethical best practices, you are encouraged to seek guidance from scholarly sources. If you don’t feel comfortable bringing your documentation in front of a judge, it is probably not the most ethical decision you can make. Applying ACA’s step 6 of the Practitioner’s Guide to Ethical Decision-Making model, application of the test of publicity, can further highlight if the choices you are making in the work with your client are choices you would be proud to stand by.

With AI specifically, we understand our world is consistently increasing its embrace. In healthcare alone, numerous AI platforms have been developed with the intention of supporting clinicians with their work with clients from advertising, intakes, platform capabilities, and even documentation. However, understanding how to distinguish between tools that align with your professional standards of practice is essential to not only protect the clinicians but also the clients. Furthermore, understanding how to implement the tools appropriately for your role with compliance to your profession’s ethical and legal parameters is critical.

Toward a Critical Realist Understanding of Psychoanalytic Interpretation

Posted on October 29, 2025February 25, 2026 by rezendevknowfully.com

Reflections on Psychoanalytic Interpretation

Psychoanalytic interpretation, though subject to the analyst’s own biases and limitations, should not be dismissed as merely subjective or arbitrary. While interpretations inevitably arise within the context of specific psychoanalytic traditions—such as Freudian, Kleinian, or relational theories—they are not devoid of epistemic value. Rather, these interpretations can be understood as provisional efforts to track psychological truths, albeit imperfectly and always open to revision. This view aligns with the philosophical stance of critical realism, which holds that reality exists independently of our perceptions, and as Margaret Archer and Roy Bhaskur suggest, our understanding of it is mediated through theory, language, and social context.

Applied to psychoanalysis, this implies that while interpretations are never final or infallible, they can be evaluated and refined over time in light of clinical experience, internal coherence, and therapeutic efficacy. Interpretations thus occupy a middle ground: neither purely objective “discoveries” nor wholly constructed “narratives,” but tentative approximations of deeper truths about the patient’s mind and its workings.

This perspective on psychoanalytic interpretation contrasts starkly with the views of many relational and intersubjective theorists who rely heavily on a postmodern worldview that is inherently skeptical of science and truth as found in the writings of Robert Stolorow and his colleagues. For these theorists, meaning is co-constructed in the analytic dyad without appeal to any deeper, mind-independent reality, thereby shifting the focus from discovering psychological truth to negotiating intersubjective experience. While this view underscores the ethical importance of mutual recognition and co-authorship, it risks eroding the epistemic ambition of psychoanalysis as a discipline committed to understanding the unconscious processes that shape thought, feeling, and behavior.

Previously, Nassir Ghaemi and Jon Mills have leveled critiques of contemporary mental health practices on this basis. Ghaemi, a psychiatrist, has argued that postmodernism has led to a gross expansion of the psychiatric diagnostic system, which since the 1980s has prioritized reliability of diagnosis over validity. To Ghaemi, psychiatry—and, by extension, psychoanalysis—have been infiltrated by a postmodern belief system that is largely unconscious but widespread. He contends that this epistemic shift has undermined psychiatry’s capacity to seek truth, replacing it with a relativism that favors consensus and utility over ontological clarity.

Mills, a formally trained philosopher, psychologist, and psychoanalyst, has offered his own views on postmodern influences on psychoanalysis, concluding that much of modern relational and intersubjective theory is philosophically unsound and scientifically illiterate.

He writes, for instance, that “postmodernism has become very fashionable with some relationalists because it may be used selectively to advocate for certain contemporary positions, such as the co-construction of meaning and the disenfranchisement of epistemic analytic authority, but it does so at the expense of introducing anti-metaphysical propositions into psychoanalytic theory that are replete with massive contradictions and inconsistencies.” Mills’ comments on relational theory’s rejection of the individual self are particularly relevant to discussions about psychopathology.

I wish here to add some thoughts on these trends, arguing for a critical realist orientation that neither retreats into the naive objectivism of classical positivism, nor succumbs to the epistemic nihilism of postmodernism. Such a position allows psychoanalysis to retain its interpretive depth while preserving a commitment to truth-seeking as a core value. It acknowledges the hermeneutic and contextual nature of all knowledge while affirming that some interpretations, through sustained clinical engagement and theoretical refinement, bring us closer to understanding the enduring structures of the human mind.

Critical Realism and Psychopathology

Critical realism provides a robust philosophical foundation for the psychoanalytic understanding and treatment of psychopathology. Take, for instance, borderline personality disorder (BPD), which object relations theory frames as a disturbance partly rooted in early relational trauma and developmental arrest. From this standpoint, BPD is not merely a discursive construct or a social convention, but a genuine, structured pattern of affective dysregulation, identity diffusion, and interpersonal turbulence. Simultaneously, critical realism recognizes that our knowledge of BPD is mediated by theoretical lenses and clinical judgment—rendering psychoanalytic interpretation both necessary and fallible.

Consider a case example: a woman in her late twenties, diagnosed with BPD, seeks treatment after a cycle of stormy relationships characterized by rapid idealization and devaluation. She vacillates between clingy dependency and explosive withdrawal whenever the therapist enforces limits or plans time away. For instance, in one session, her reaction to the therapist’s upcoming vacation erupts into accusations of abandonment and betrayal. Rather than dismissing this response as merely capricious, the analyst, drawing on object relations theory, interprets it as the activation of split internal objects—“good” nurturing figures versus “bad” persecutory ones—echoing an early maternal rejection schema.

This interpretive move does not claim to unearth an immutable historical fact, but offers a provisional hypothesis: that the patient’s intense rage and despair stem from reactivated internal dynamics forged in childhood. In critical realist terms, the clinician’s account approximates the underlying mechanisms sustaining her borderline pathology. Over successive sessions, such interpretations can be tested against emerging clinical evidence—shifts in the patient’s capacity for affect regulation, moments of self-reflection, or changes in relational patterns—and refined accordingly.

By affirming BPD as a real psychological phenomenon while treating interpretations as revisable approximations, critical realism steers a path between naïve positivism and radical constructivism. It validates diagnostic categories as pointers to enduring disturbances in mental organization yet insists that every analytic formulation remains open to revision in light of new data, theoretical scrutiny, and therapeutic outcomes. In contrast to postmodern and constructivist approaches that reduce diagnoses to social artifacts or co-created narratives, this stance upholds both the ontological reality of BPD and the epistemic value of psychoanalytic interpretation in illuminating—and gradually transforming—the structures of the mind.

A Path Forward for Psychoanalysis

While postmodern approaches have rightly emphasized the importance of subjectivity and the therapeutic relationship, they risk, according to Mills, collapsing interpretation into narrative relativism, thereby undermining psychoanalysis’s commitment to exploring unconscious processes and enduring mental structures. Without a regulative ideal of truth, interpretation can devolve into rhetorical improvisation rather than a disciplined inquiry into the patient’s internal world. A critical realist stance retains the epistemological humility of relational theory—acknowledging that all knowledge is mediated and provisional—without relinquishing the pursuit of deeper understanding. It provides a framework in which psychoanalytic interpretations can still aim to track truths about the patient’s inner life, even if those truths are partial, revisable, and influenced by context. This philosophical grounding affirms the possibility of shared understanding and therapeutic change, grounded in the recognition of the patient’s psychic reality.

Moreover, critical realism may serve as a vital philosophical bridge between psychoanalysis and the broader domains of psychiatry and scientific psychology.

A longstanding critique of psychoanalysis is its epistemic isolation from empirical science, particularly its perceived resistance to diagnostic standardization or outcome-based measures. While this critique often oversimplifies psychodynamic epistemology, it underscores real tensions between hermeneutic and positivist models of mind. Critical realism offers a reframing of these tensions by supporting a layered ontology, where psychological phenomena can be real and causally efficacious even if not directly measurable.

In this view, constructs such as internal objects, splitting, and projective identification are understood as real mechanisms operating at the psychological level of analysis, even if they are not reducible to biological correlates or behavioral metrics. This allows psychoanalysis to retain its interpretive richness and depth while remaining engaged with scientific standards of explanation, coherence, and progress. It supports a pluralistic science in which meaning-based and empirically grounded approaches work in tandem to illuminate the complexity of human suffering.

In sum, a critical realist framework offers a productive middle path. Psychoanalytic interpretations, including those applied to complex psychiatric disorders like BPD, are shaped by theoretical models and clinical subjectivity, but they are not arbitrary constructions. They represent serious, good-faith efforts to make sense of unconscious dynamics and to promote psychological transformation. In this light, critical realism not only supports the epistemological integrity of psychoanalysis but also repositions it within the larger landscape of scientific psychology and psychiatry. It allows psychoanalysis to reclaim its rightful place as a discipline committed both to meaning and to truth.

Emigration: Hidden Suffering, Complex Grief, and Identity Transformation

Posted on October 15, 2025February 25, 2026 by rezendevknowfully.com

The war in Ukraine has persisted for more than three and a half years. In that time, I have supported many Ukrainians navigating the psychological effects of displacement, both internal and external. Much of what is publicly visible focuses on logistics: relocation, safety, and survival. But behind these surface realities lie long-term emotional wounds—complicated grief, loss of identity, and fractured belonging—that are less discussed but deeply consequential

As a psychotherapist with extensive experience supporting clients affected by war through Soul Space, I have seen firsthand how displacement reshapes people from the inside out. The process is never linear. This article shares what I’ve observed, heard, and worked through with clients, offering insights into emigration as a deeply human psychological journey.

Displacement and Identity: A Shifting Foundation

When the war began, many clients were uprooted from their stable lives. In sessions, I hear stories of teachers who no longer teach, parents unsure how to guide their children in a new culture, and professionals who feel invisible. Their roles disappeared almost overnight.

This loss of social function creates emotional detachment and disorientation. People speak of feeling like they are “watching someone else live their life.” This state often resembles a suspended existence, not due to passivity, but because the ground under their feet has shifted too fast to keep pace.

What’s more, it’s not just individual identity that suffers. Whole communities lose their frameworks. The culture, rituals, and structures that support meaning and selfhood are interrupted. Even internal displacement within Ukraine has a similar psychological impact. The place may differ, but the rupture is felt all the same.

Grief That Doesn’t End—Complication, Confusion, and Collective Loss

Clients grieving in displacement are not grieving in the usual sense. There are no funerals for lost routines or roles, and no formal goodbyes to old homes. Instead, grief emerges in the form of disorientation, guilt, exhaustion, and self-doubt.

Many of my clients meet criteria for what is clinically called complicated grief: the kind that stays unresolved, not because people are unwilling to heal, but because they never had the chance to mourn properly in the first place.

As therapist and scholar Thomas Attig has emphasized, people grieve differently. In my work, I’ve seen how displaced clients carry layered grief for:

their homes and what they represented.
their community and place in it.
the future they had imagined.

It’s also common to encounter survivor’s guilt, especially among those who left their families behind. These emotions can complicate both healing and the capacity to feel joy again.

Therapy Themes—What I See in the Room

Functioning Outside, Fractured Inside
Clients may appear well-adjusted. They hold jobs, attend language courses, and care for their families. But inside, many describe emptiness or persistent numbness. Therapy offers space to pause and feel what has been hidden under duty and resilience.

Children and Parents Swapping Roles
Teenagers translating legal documents for their parents, children mediating with landlords—this kind of role shift is emotionally confusing and exhausting. Therapy helps clarify expectations, validate struggles, and restore balance.

The Strain of Chronic Uncertainty
People live in limbo, waiting for visa extensions, worrying about family, or feeling unable to settle or return. This uncertainty is not just logistical but deeply psychological. It erodes agency.

Disrupted Belonging
Even in communities that are welcoming, many clients say they feel “othered.” And often, they feel disconnected from who they were before the war. Helping them reconnect with lost parts of the self becomes a critical focus in therapy.

Host Communities Also Struggle
It’s important to acknowledge that migration affects those receiving displaced people as well. Many local residents have never been exposed to war trauma or large-scale migration.

They may experience:

fatigue from trying to help and not knowing how.
fear of change in cultural identity.
guilt over their own comfort in comparison.

If these reactions go unsupported, they can lead to distance or judgment, making displaced people feel even more alienated. Integration is not only about paperwork; it’s about mutual adaptation, patience, and shared emotional learning.

One Family’s Story

I worked with a Ukrainian family of four who relocated to Western Europe. The parents were in their late 30s. The mother experienced frequent panic attacks. The father became silent and irritable. Their daughter became withdrawn at school. Their son, only 6, began wetting the bed and refused to sleep alone.

We began with structure. We worked together to restore family rituals like shared meals and bedtime routines. The parents practiced grounding exercises such as short breathing pauses and body scans between sessions.

We gave space to grief. Each family member created a “memory journal,” not just for losses but for moments they still carried with them––songs, smells, images. Over time, the children began to sleep better, the father became more involved, and the mother’s panic attacks reduced significantly.

How to Truly Support

Many people want to help but don’t know how. Here’s what displaced people have told me helps:

show up consistently. Small gestures matter.
ask how someone is – but be ready to listen to the real answer.
don’t minimize loss. Being safe doesn’t erase grief.
stay open to discomfort. Growth happens in dialogue, not in perfection.

Communities must learn to adapt, just as the displaced do. Without this dual process, there is no true integration. More than three years into the war, the psychological work is still only beginning. For many of my clients, healing does not mean going back to who they were, but learning how to live meaningfully as who they are now. Therapy plays a crucial role, but so does community, policy, and the spaces in between where people rebuild themselves. Emigration is not just a change in geography. It’s a transformation of the self. If we’re willing to witness this transformation fully with honesty, patience, and humility it becomes not just a story of loss, but one of resilience and renewal.

Understanding Sexual Reenactments and How to Eliminate Them

Posted on August 13, 2025February 11, 2026 by rezendevknowfully.com

In general, reenactments are an unconscious attempt to reconcile, reframe, or repair a trauma that occurred in childhood. Sexual reenactments are no different. Most sexual reenactments originate due to childhood sexual abuse or sexual assault in adolescence or adulthood. Although not every former victim of sexual violence will have a need to reenact their trauma, many do. This is because most sexual trauma goes unprocessed. Most sexual abuse victims don’t talk about it due to feelings of shame and the fear that they will not be believed. Many try to put it in the past the way friends and family encourage them to do. Unfortunately, this doesn’t work, and they end up reenacting the abuse in some way. As it is with other forms of abuse, typically, former victims tend to either reenact their trauma by continuing to be victimized or by becoming abusive.

It is common knowledge that victims of child sexual abuse have a tendency to reenact their trauma by being re-victimized throughout their lives, by repeating what was done to them and thus becoming an abuser, or by becoming promiscuous or sexually addicted. In this article I will discuss all of these types of sexual reenactment.

Patterns of Re-Victimization

Research over the past decade has consistently shown that women who were sexually victimized as a child or adolescent are far more likely to be sexually assaulted as an adult than other women. One study found that former victims of CSA are 35 times more likely to be sexually assaulted than non-victims. (1)

In addition, reenactments often lead to re-victimization and with it, related feelings of shame, helplessness, and hopelessness. For example, it has been found that women who were sexually abused as children are more likely to be sexually or physically abused in their marriages. Therefore, helping clients gain an understanding and control of reenactments is a primary way to help them avoid further victimization and shaming.

Why are victims of child sexual abuse more at risk of being re-victimized?

Most former victims of child sexual abuse experience a lot of shame and self-blame. These two factors are by far the most damaging effects of CSA and increase the likelihood of re-victimization more than any other effect. This is partly true because victims of sexual abuse develop certain behavioral problems, such as alcohol abuse, that make re-victimization more likely. Victimized women, in particular, believe that they have brought any abuse they’ve experienced on themselves and that they do not deserve to be treated with respect or loved unconditionally. (2) Furthermore, shame is related to an avoidant coping style, as the person who is shame-prone will be motivated to avoid thoughts and situations that elicit this painful emotional state. A victim who is experiencing avoidant symptoms may be prone to making inaccurate or uninformed decisions regarding potential danger because of the fact that the trauma has been denied, minimized, or otherwise not fully integrated. (3)
They tend to have alcohol and drug problems. Former victims often numb their re-experiencing symptoms with alcohol and drug use, which can serve to impair judgment and defensive strategies. According to research, former victims of child sexual abuse are about 4 times more likely to develop symptoms of drug abuse, and adolescents who have been sexually abused were 2 to 3 times more likely to have alcohol use/dependence problems than non-victims CSA has also been identified as a significant precursor to alcohol abuse. (4)
Certain factors increase the likelihood of re-victimization. Factors such as the severity of the abuse, the use of force and threats, whether there was penetration, the duration of the abuse, and closeness of the relationship between victim and offender are associated with higher risk of re-victimization. (5)
Certain kinds of abusive men target women whom they perceive as vulnerable. These men can easily spot a vulnerable woman just by observing their posture, the way they walk, and the way they speak.
Former victims tend to have sexual behavior problems and oversexualized behavior. Children who have been sexually abused have over 3 times as many sexual behavior problems as children who have not been abused.
They tend to have low self-esteem and poor body image. Obesity and eating disorders are more common in women who have a history of child sexual abuse. Girls and women who have a poor body image are more likely to feel complimented by male attention and are more vulnerable to men taking advantage of their need for attention.
They may feel powerless because the abuser has repeatedly violated their body and acted against their will through coercion and manipulation. When someone attempts to sexually violate them as an adult, they may feel helpless and powerless to defend themselves.
They don’t tend to respect their bodies. They may feel stigmatized, suffer from a great deal of shame and feel like they are already “damaged goods,” and there is no point in protecting their reputation or their body.
They don’t tend to be attuned to warning signs that a person may be a sexual perpetrator.
They don’t tend to have good boundaries. Former victims often allow other people to have too much access to their body, to take direction and advice too readily, to have difficulties saying “no.”

My client Ellen was re-victimized many times, by several different men and for many of the reasons stated above, specifically, shame and self-blame, being targeted by abusive men, feelings of powerlessness, a lack of respect for her own body, and poor boundaries.

“Starting when I was seven years old, my uncle began grooming me. My parents had just divorced, and my uncle started taking me places—supposedly to make up for the fact that my dad stopped coming to see me. He’d take me to the zoo, the park, and to the movies. He bought me candy and popcorn and sodas. And he bought me comics—I was really into comics. He was always very affectionate towards me, and I welcomed it because I missed my father so much.

“His affection gradually turned into sexual touches. It felt good so I didn’t resist. He progressed from touching my vagina to inserting his finger and then inserting other objects. At that point I didn’t like it. I didn’t get any pleasure—in fact when the objects got bigger it began to hurt. But I couldn’t say anything. He’d done so much for me, and I loved him so much that I just took it. Sometimes it hurt so much that it made me cry. He just ignored my crying and kept on doing it.

“I realize now that I have been reenacting the horrible abuse I experienced at the hands of my uncle for quite some time now. I’m so embarrassed to even tell you what I’ve allowed men to do to me. I was involved with one guy who was deep into BDSM (Bondage, Discipline, Sado-masochism) and I ended up letting him tie me up, drop hot candle wax on my vagina, insert objects into my anus. You’d be shocked if I showed you the number of scars I have because of that relationship. At the time I convinced myself that I loved him and because of that, I wanted to please him. But in actuality, I was just blindly repeating what my uncle did to me.”

Abuser Patterns

Just as not every former victim of CSA develops a victim pattern, not every former victim becomes an abuser. But unfortunately, many do. There is quite a lot of controversy about the extent to which males victims, in particular, repeat the abuse they suffered. Collecting reliable data has been difficult since subjects are not always willing to reveal their earlier childhood experiences, nor their own perpetrator behavior.

It appears that the type of sexual abuse one experiences can be a factor in the likelihood of becoming an abuser. For example, the evidence shows that only 21% of incest victims become sexual predators, whereas being a reported victim of pedophilia is strongly linked with being subsequently a perpetrator of pedophilia, alone or jointly with incest, with the combined rate being 43%. (6)

Several studies were conducted assessing the rate of child sexual abuse reported by 1717 male perpetrators of sexual assault who had admitted their crimes. The researchers were able to determine that, overall, 23% of the perpetrators had experienced sexual abuse with physical contact in childhood. (7) More recently, other studies have indicated that child sexual abusers are much more likely to have been sexually victimized as children compared not only to people who sexually assault adults, but also to non-sexual criminals and the general population.

Several studies have examined the factors that may increase the risk that male victims of child sexual abuse will go on to commit sexual assault. The key factors are:

In childhood:

Severity of the sexual abuse (more than one perpetrator, use of violence, greater frequency, longer duration, significant relationship with the perpetrator, etc.)
Sexual abuse committed by a woman
Positive perception of the sexual abuse experienced (positive affection for the perpetrator, perceived pleasure, poor understanding of the negative effects of the abuse, etc.)
Limited emotional support from family and friends during childhood
Intimidation and few meaningful social contacts during childhood and adolescence
Maltreatment
Lack of parental supervision
Adjustment difficulties and mental health problems in childhood and adolescence

In adulthood:

Limited awareness of the difficulties associated with having experienced sexual abuse in childhood
Low self-esteem
Antisocial behavior (8)

What Do These Findings Tell Us?

Experts maintain that, in the case of males, being sexually abused in childhood is an important risk factor for committing sexual assault later on in life, but that it is not the only risk factor that plays a role in the perpetuation of sexual assault.
Most victims of child sexual abuse will not become perpetrators of sexual assault, and a history of sexual victimization is neither a necessary nor a sufficient condition to sexually offend.
Personal and family factors in childhood that have been identified as increasing the risk that a sexually abused child will go on to commit sexual assault suggest that children who obtain specialized treatment, sufficient support from family and friends, and grow up in an environment where they do not experience maltreatment are less likely to develop a number of problems, including sexually aggressive behavior.
Individuals who do offend had, among other things, more problems in childhood and were unaware of the negative effects of the sexual abuse they suffered.

The bottom line is, if someone was sexually abused in childhood or adolescence, they need to:

Admit the abuse to themselves.
Learn about the possible effects it can have on someone, especially in terms of their sexual attractions, their sexual relationships, the amount of anger they still have toward their perpetrator and how they act out this anger sexually.
Learn what their specific triggers are—those reactions that can cause them to not only remember the abuse but to act out in a negative or even dangerous way.
Focus on what their unfinished business might be so that they are not motivated to reenact the trauma.

What’s at the Core of Sexual Reenactments?

Reenactments are always an attempt to manage unprocessed trauma. But in addition, sexual reenactments can be the following:

An unconscious attempt to come out of denial and face the truth about what happened to you
A cry for help
An attempt to take back a sense of power and control
A reaction to being triggered
An attempt to understand what happened to you

Let’s discuss each of these reasons one by one.

An Unconscious Attempt to Come Out of Denial

As I’ve have been discussing, reenactments are caused in part by powerful unconscious forces that must be eventually verbalized and understood. These patterns of behavior are often unconscious attempts to reconcile, reframe, or repair the abuse that occurred in childhood. Unfortunately, they do not always accomplish this task and can result in perpetual psychological and emotional damage. The primary reason why it is important for former victims to acknowledge the sexual abuse is that those who are in denial are particularly vulnerable to sexual reenactments.

One of the main reasons why victims of CSA continue to be re-victimized is that they are either in denial about the fact that they were sexually abused, they have minimized the damage caused by such abuse, or they convince themselves that they are not at risk. Let’s return to Ellen, the woman who was frequently sexually mistreated by men and who allowed a boyfriend to repeat what her uncle had done to her. In Ellen’s case, she had never denied that her uncle had molested her. But she did struggle to believe that he never cared about her, that he was just using her. “Even though he did terrible things to me sexually, he had originally been so good to me that I tried to excuse the other stuff. I continued to believe that if I let him do the bad stuff, he’d become the “good Uncle” again. I must have had the same thinking process with all those men who did horrible things to me. By reenacting the abuse by my uncle, in a weird way I was actually forcing myself to admit that he never really loved me, something I needed to face.”

It’s critical to help clients acknowledge whether they were sexually abused as a child or not. Child sexual abuse includes any contact between an adult and a child, or an older child and a younger child, for the purposes of sexual stimulation of either the child or the adult or older child and that results in sexual gratification for the older person. This can range from non-touching offenses, such as exhibitionism and child pornography, to fondling, penetration, incest and child prostitution. A child does not have to be touched to be molested.

Many people think of childhood sexual abuse as being an adult molesting a child. But childhood sexual abuse also includes an older child molesting a younger child. By definition, an older child is usually two years or older than the younger child but even an age difference of one year can have tremendous power implications. For example, an older brother is almost always seen as an authority figure, especially if he is left “in charge” when their parents are away. The younger sibling tends to go along with what the older sibling wants to do out of fear or out of a need to please. There are also cases where the older sister is the aggressor, although this does not happen as often. In cases of sibling incest, the greater the age difference, the greater the betrayal of trust, and the more violent the incest tends to be.

Many former victims do not realize that what happened to them as a child or adolescent was considered abuse because their image of child sexual abuse is limited to an older man abusing a child of the opposite sex. But this does not take into account males who are victimized by another male, those who were abused by a female, victims of sibling abuse, and victims of clergy abuse.

Also, in addition to the actions that we normally consider to be childhood sexual abuse, there are many other behaviors that fall into this category. You may wish to provide your clients with the following questionnaire, following questionnaire, from Put Your Past in the Past: Why You May Be Reenacting Your Trauma and How to Stop.

Questionnaire: Were You Sexually Abused?

Did a family member, a caretaker, a sibling or other older child, an authority figure or any other adult or older child:

1. Lie or sit around nude in a sexually provocative way?
2. Walk around the house in a sexually provocative way (nude, half dressed)?
3. Frequently walk in on you while you were getting dressed, while taking a bath or while using the toilet?
4. Flirt with you or engage in provocative behavior such as making comments about the way your body was developing?
5. Show you pornographic pictures or movies?
6. Kiss, hold, or touch you inappropriately?
7. Touch, bite, or fondle your sexual parts?
8. Make you engage in forced or mutual masturbation?
9. Give you enemas or douches for no medical reason?
10. Wash or scrub your genitals well after you were capable of doing so on your own?
11. Become preoccupied with the cleanliness of your genitals, scrub your genitals until they were raw, tell you that your genitals were dirty, shameful or evil?
12. Force you to observe or participate in adult bathing, undressing, toilet, or sexual activities?
13. Force you to be nude in front of others? Force you to attend parties where adults were nude?
14. Peek at you when you were in the shower or on the toilet, insist on an “open door” policy so they could walk in on you at any time in the bathroom or in your bedroom?
15. Make you share your parents’ bed when you were old enough to have your own bed (assuming other beds were available)?
16. Have sex in front of you after you were old enough to be upset, confused, or aroused by it?
17. Tell you details about their sexual behavior or about their sexual parts?
18. Take photographs of you nude or engaged in sexual activities (once again, after you were old enough to be embarrassed by it)?
19. After you reached adolescence or older, ask you to tell them about inappropriate details about your sexual life.
20. Allow you to be sexually molested without trying to stop it?
21. Deliver you to other people so that they could molest or rape you, or bring people over to the house who would molest or rape you?
22. Make you into a child prostitute?
23. Continue to make sexually inappropriate comments, or to touch you in sexually provocative ways even after you reached adulthood?

A Cry for Help

Often, without realizing it, former victims of CSA put themselves in dangerous situations as a way of letting others know they need help. They behave recklessly, get in trouble with the law, drink too much, take drugs, and/or associate with dangerous people. Coming back to Ellen, another reason for her reenactment was that she was crying out for help—not on a conscious level of course, but on an unconscious one. Although she was ashamed of all her “battle scars,” they too were cries for help. In fact, she later admitted that she often wore short sleeves so people would see her scars and ask her about them.

In most situations, if you were to confront former victims about the risks they take, they will deny it, but there is no doubt about it, in spite of their protests to the contrary, they are desperately crying out for help. This was the case with my client, Caitlin:

“When I was a teenager I got into all kinds of trouble, from shoplifting to overdosing on drugs. My parents were exasperated—trying to control me, trying to make me understand the danger I was putting myself in. But frankly, I just didn’t care. I didn’t care what happened to me.

“Now I understand that I was calling out for help. I wanted my parents to know how much I was hurt and why. I was being molested by my grandfather, a man my parents adored, and because they adored him, I couldn’t say anything. I didn’t want to break their hearts if they realized what a monster he actually was, and I didn’t think they would believe me anyway. It was like I was waving a giant red flag saying, ‘Hey, look at me. See how much I’m hurting. Try to figure out why.’ But they never did, and I just got worse and worse.

“Eventually, I got involved with a guy who was basically a gangster. He and his friends robbed liquor stores, but he pretended to be a nice guy. He’d come to my house to pick me up and be all nice and polite to my parents. He had them fooled completely, just like my grandfather had them fooled. Talk about a reenactment.”

An Attempt to Take Back Power and Control
Another common reaction to child sexual abuse is to attempt to regain a sense of power and control over one’s sexuality. Perhaps the best example of this is when former victims of CSA become prostitutes or strippers. There have been numerous studies showing that a majority of prostitutes were sexually abused as children or adolescents (8, 9). One of these studies (McClanahan) interviewed 1,142 female detainees at the Cook County Department of Corrections found that childhood sexual victimization nearly doubled the odds of entry into prostitution throughout the lives of women. The other (McIntyre) noted that 82% of the sample had been “sexually violated” prior to their involvement in the sex trade, while three-quarters had a history of physical abuse.

Many researchers have interviewed prostitutes who freely talk about the fact that they feel empowered selling sex to men because they feel like they are turning the table on them. They feel that they are now the ones in power. Of course, the sad truth is that they are no more in power than they were when they were being sexually molested. Please note: these studies primarily studied and interviewed prostitutes in the United States, Canada and Europe. Those that studied prostitution in third world countries such as in Asia and Africa found that other factors, such as poverty, were primary motivators for prostitution.

In addition to becoming involved with prostitution and stripping, former victims of CSA or sexual assault in adolescence or adulthood get involved with other activities, such as BDSM in an attempt to gain power and control. Ellen always took the passive role in her sexual reenactments but others take the aggressive or active role. This was the case with my client Tanya.

“I got involved with BDSM because it gave me a chance to be the one in power. I got to call the shots—I had all the control and it felt great. I got so good at it that I actually became a dominitrix for a while. Men paid me to humiliate them and make them feel powerless—like how I felt when I was being sexually abused. For a long time, this felt really good. But that was before therapy, before I figured out what I was actually doing, before I processed my feelings about being abused. Once I did that it turned my stomach to treat men the way I had been treated. It took all the pleasure out of it for me. I began to see them as helpless victims like I had been because who knows what had happened to them, you know? They were pathetic really and I no longer wanted to participate in their need to be punished.”

Another common way that former victims attempt to take back power and control is by becoming abusive themselves. By becoming an abuser, former victims can play the role of the more powerful person in the relationship in an attempt to overcome the powerlessness they felt as a child. My client Jake is a good example of this. This is what he shared with me when we first started working together.

“I guess the average guy can watch porn and not get triggered like I do. But what happens to me is I start feeling agitated. I feel like a caged animal—trapped in my own home, in my own skin. I immediately find some excuse to tell my wife I have to go out. Then I just drive. I drive until I see an opportunity. I might see a woman walking alone on a road, or I might see a Strip Club or bar that looks interesting. My goal is to have access to a woman, any woman, as quickly as I can. It doesn’t matter how old she is or what she looks like. She just needs to be available.

“I find a way to get the woman alone and then I try to convince her to have sex with me. I’m like a hungry animal; I have to satisfy my hunger. If the woman doesn’t cooperate, I become more and more aggressive. I do whatever I have to do to get her to give in to me—I lie, I manipulate, whatever I have to do. Sometimes I just need to coerce her to go with me to a secluded place. But if she ends up fighting me off, I get physical. I slap her, punch her—whatever I need to do to make her stop resisting.”

As Jake and I continued to work together we discovered the reason pornography was a trigger for him. When he was 12 years old, he was sexually abused by a neighbor who used pornography as part of his grooming process. The neighbor had groomed Jake by playing video games with him, providing him with sodas and later on alcohol, and by showing him pornographic films. Most of the films were about gay sex and afterwards he would molest Jake.

We then needed to understand the connection between his sexual abuse and his aggressive behavior toward women. Jake was finally able to make the connections we were looking for—the explanation for his abusive behavior after watching pornography. As it turned out, Jake felt compelled to watch pornography, even though he didn’t like how it made him feel. The reason he felt compelled to go searching for a woman after watching porn was that he unconsciously needed to prove to himself that he wasn’t gay. Another motivation: he needed to assert the power and control he had lost to the molester. And the rage he felt toward the women he forced to have sex with him was actually the rage he felt toward his perpetrator—the neighbor man.

A Reaction to Being Triggered
Often a reenactment is caused by being triggered. If you noticed, Jake mentioned being triggered by the pornography he felt compelled to watch. The most common triggers for those who experienced child sexual abuse are:

Sounds, smells or tastes that remind you of the abuser or the environment where the abuse took place
The smell of alcohol, someone being drunk
Being in the dark
Someone reminding you of your abuser
Someone coming too close to you physically
Someone wanting to be emotionally close to you before you are ready
Being alone with someone
Being alone with a stranger in a small room
Being around pornography or someone who is watching pornography
Family get-togethers (especially for those who were abused by a family member)
Being touched
Someone flirting with you or making sexual comments
Being seduced
Being manipulated (if you do this, I’ll do that)
Being pressured (Oh come on, I know you’ll like it if you just try)
Secrets/clandestine activities
Feelings of betrayal
Lies and cover-ups
Blackmail, threats
Being “bought”
Cameras and video cameras

An Attempt to Understand What Happened

Ongoing reenactments often indicate that a survivor is emotionally stuck. Some are attempting to work through an aspect of the trauma by repeating it with another person hoping that this time the result will be different. Others refuse to believe that someone they loved and/or respected could harm them in such a selfish way. Still others blame themselves for the abuse or have identified with the aggressor, and cannot admit to themselves what really happened. In this case, their reenactments are often unconscious ways to try to understand what happened to them, or their unconscious trying to force them out of denial. This was the situation with my client Monica who explained her situation this way:

“I love my fiancé very much but whenever I am at an event or party without him, I almost always get into trouble. If a man comes on to me, I just can’t seem to push him away, especially if he comes on strong. I mean, I want to get away from him, but it is like my feet are in cement. I’m ashamed to say that I let these men touch me in places they should never have access to. Even worse, on several occasions I have let men pull me into a bathroom to have sex with me. I even have haunting memories of being slammed against a wall in a dark hallway. I’m so ashamed of my behavior. I just don’t understand myself.”

I explained to Monica that it is very common for survivors of sexual abuse or sexual assault to respond in the way she does when men approach them. There is a trauma response called “freezing” in which a person cannot defend themselves or even move when they are being attacked. Many describe it as a feeling like their feet are in cement. This explanation opened the door to Monica talking about the fact that she was attacked by a much older boy after choir practice at church when she was 13 years old.

“He started talking to me after choir. At first, I was flattered to have a boy so much older than me take interest in me. But then he tried to kiss me several times and I pulled away and told him to stop. No matter how often I pushed him away he just kept trying. I ran away and tried to avoid him from that time on.

“I thought I’d dealt with the problem, but I guess it made him angry that I pushed him away because one evening he waited for me and pulled me into an empty room and raped me. I tried to call out but there was no one around to save me. I’ve blocked out the details, but it was a horrible experience for me.”

“Did you tell anyone about it?” I asked.

“No, I was too embarrassed. I knew I shouldn’t have been talking to him in the first place. My mother has always warned me about talking to strangers, but I was flattered that an older boy took an interest in me, and I ignored her warning. I thought she’d get mad at me for being so careless. And I didn’t think anyone would believe me. After all, why would a boy so much older than me, a good-looking boy for that matter, bother with such a young and unattractive girl like me?”

As you can probably imagine, there was a lot going on with Monica and it explained why she was acting the way she did with men who approached her. She was so traumatized by the rape that she froze when men came onto her. She was unconsciously reenacting the trauma of being raped. Monica needed to acknowledge and process the feelings she had experienced when she was raped at 13, feelings she had tried to push away and forget. By doing so, and by realizing that the rape was not her fault, she was able to stop her reenactments entirely.

Passive and Active Reenactments

I’ve divided sexual reenactments into two major categories: passive and active (or aggressive). While those involved in reenactments are typically unaware of what they are doing, those who are involved with passive reenactments (men as well as women) are particularly unconscious when it comes to realizing they are reenacting previous trauma. They go about their lives, putting themselves in risky, if not dangerous situations, completely oblivious to their motive—replaying the trauma of child sexual abuse hoping for a different outcome.

Passive Reenactments

Passive behavior is continuing to view sex from a victim’s perspective and therefore can become a reenactment of the abuse. Behaving in any of these ways causes clients to feel ashamed and to continue to lose respect for themselves. Even more troubling, behaving in these passive ways is often re-traumatizing.

Examples of passive reenactments can include:

Not being able to say no to someone who comes on to you or to getting involved with sexual activities that you are not interested in or are even repulsed by.
Allowing someone to pressure you into sex or demand sex of you.
Being involved with domineering/abusive partners.
Being involved with shame-inducing behaviors—sexual activities that cause you to feel deep shame during or after sex. Examples: someone humiliating you sexually or saying derogatory things to you during or after sex.
Practicing risky behaviors such as drinking too much or taking drugs at bars or parties, especially when out alone or where you don’t know anyone. This includes not watching your drink or leaving your drink to go to the restroom and not insisting that a man where a condom.

Aggressive Reenactments

Those who identified with the aggressor or hid their shame behind a wall of arrogance or bravado often recreate the abuse by being aggressive sexually. This can include:

Being sexually inappropriate (standing too close to a stranger, touching a stranger in an intimate way [hand on their leg, hip, back, behind]).
Being sexually coercive or demanding.
Humiliating and degrading your sexual partners.
Being emotionally, physically or sexually abusive toward your partner.

Identifying Shame-Inducing Sexual Compulsions

Shame is by far the most damaging aspect of CSA. Former victims carry a great deal of shame, causing them to have low self-esteem, self-hatred, a tendency to blame themselves when things go wrong, and a general feeling of being “less than” other people. If things weren’t bad enough for former victims, some find themselves locked into compulsive sexual behavior that can perpetuate feelings of helplessness, a sense of being bad, or out of control, resulting in further shaming. These sexual compulsions happen outside of conscious awareness and are often characterized by dissociation of thoughts, emotions and sensations related to the traumatic event.

The list below are some of the most common shame-inducing sexual compulsions––

sexual activities that can cause you to repeatedly reenact the pain, fear, or humiliation of the sexual trauma you suffered (either as the one in power or as the victim).

Engaging in humiliating sexual practices (sadomasochism, sex with animals)
Combining sex with physical or emotional abuse or pain
Frequent use of abusive sexual fantasies (either seeing oneself as the abuser or the abused)
Engaging in promiscuous sex (many sexual relationships at the same time or in a row)
Charging money for sex
Having anonymous sex (in rest rooms, adult bookstores, telephone sex services)
Acting out sexually in ways that are harmful to others (forcing someone to have sex)
Acting out in ways that are harmful to yourself (allow yourself to be humiliated during sex)
Manipulating others into having sex with you
Demanding sex from others
Using rape or other types of fantasies to gain sexual arousal or increase sexual arousal
Committing sexual offenses (voyeurism, exhibitionism, molestation, sex with minors, incest, rape)
Feeling addictively drawn to certain unhealthy sexual behaviors (sadomasochism)
Continually using sexual slurs or degrading sexual comments to humiliate your partner or allowing your partner to do this to you
Engaging in secretive or illicit sexual activities
Relying on abusive pornography in order to become aroused

Other sexual compulsions can be less obvious reenactments of the trauma of child sexual abuse and are more likely to be ways to cope with stress or self-punishing behaviors such as:

Engaging in compulsive masturbation
Engaging in risky sexual behavior (not using protection against disease or pregnancy)
Being dishonest about sexual relationships (has more than one partner but professing to be monogamous)
Engaging in sexual behavior that has caused problems in your primary relationship, at work, or with your health

Eliminating Shame Inducing Behavior

If a client wishes to reduce or eliminate the amount of shame they feel they typically need to remove the above behaviors from their sexual repertoire. The same holds true if they wish to eliminate the likelihood that they will become involved in sexual reenactments. The most extreme, and therefore the most shaming of these behaviors include: talking to or treating your partner in degrading ways or asking to be talked to or treated in these ways; demanding sex or forcing someone to have sex; watching violent pornography; engaging in sadomasochism; and engaging in other dangerous sexual activities. These activities are all examples of extreme shame-inducing behaviors and are often reenactments of the abuse. Therefore, it is vitally important that your clients make a special effort to first identify and then to eliminate these particular behaviors from their sexual repertoire.

I’ve outlined some of the specific changes your clients can begin to make in order to eliminate these shame-producing behaviors and attitudes that may have dictated their sexual life.

Remedies for Passive Reenactors

Learning to Say No

While it may seem obvious that saying no is important and necessary, the truth is that many women and men don’t know they have the right to do so. It is also true that even more people don’t know how to say it. Practicing how to say “No!” teaches someone how to literally say “No!” in a strong, assertive manner—but perhaps even more important, it will give them permission to say it, not just with their words, but also with their actions and attitude. It will show them that they don’t have to just put up with unwanted sexual remarks or touches, and that by keeping silent, they may be giving people permission to go further than they should. It will help them to understand, on a deep emotional level, that they have a right to expect that their body is off-limits to anyone they don’t want touching them. The following exercise will help your clients become stronger in their resolve to stop allowing people to pressure them sexually.

Exercise #1 Saying No!

Think of a fairly current situation in which someone recently disrespected, invaded or abused your body.
Imagine that you are saying “No!” to this person.
Now say it out loud. Say “No!” as many times as you feel like it. Notice how good it feels to say it.
If you’d like, in addition to saying “No!” add any other words you feel like saying. For example, “No! You can’t do those things to me.” “No! I don’t want you to touch me like that!”

Practicing saying “No!” will help your clients gain the needed courage to say it when they need to—whenever someone is trying to coerce them into sex when they don’t want it.

Know what is Healthy for You and What is Off-limits

This step is an especially crucial one. In many cases this goes beyond sexual “preferences” to sexual needs. For example, if the person who molested your client fondled their breasts as a part of the molestation, they may have an aversion to having their breasts touched. This is a common scenario and is completely understandable. On the other hand, if the perpetrator did everything else but touch their breasts, that may be a “safe zone” for them, a place on their body where they are not re-traumatized and from which they can actually derive some pleasure. If the perpetrator did not penetrate their vagina with his finger, his penis, or another object, having vaginal intercourse may be their “safe zone,” and may be quite pleasurable. A fairly common scenario is for former victims of CSA to be able to enjoy having their partner touch those parts of their body that were not touched by the abuser, as well as enjoying engaging in sexual activities that the abuser did not impose on them.

Exercise: What’s Off-Limits

Make a list of the parts of your body you find uncomfortable to have touched. Don’t worry if you end up listing many parts of your body. This is common for former victims and is a reminder of just how traumatic the abuse was.
Try to find the reason as to why someone touching a particular part of your body is uncomfortable for you. It probably is due to the fact that this part of your body was involved in the sexual abuse in some way.
Now make a list of sexual activities that are uncomfortable, shaming, or triggering for you. Try to be as honest as you can, even if it means listing activities you believe you “should” like to do or have been doing.
Write about the reasons why you think these sexual activities are uncomfortable, shaming or triggering for you. The more connections you can make the more in charge of your sexuality you will become.
Finally, list the parts of other people’s body that you find uncomfortable to touch.
Think of the possible reasons why these body parts are uncomfortable for you to touch.
Now complete the following sentences:

Some parts of my body are just off-limits. These are: ___________________________________________________________________________________________________________

I am triggered by (have a post-traumatic response to) certain sex acts. These are: ___________________________________________________________________.

I am not comfortable looking at, touching, or feeling some parts of another person’s body. These are: _________________________________________________________________________.

Feel free to share these exercises with your clients but please cite the source (Put Your Past in the Past).

Remedies for Aggressive Reenactors

In the same way that many former victims reenact the abuse they experienced by being passive, many react to past abuse by being aggressive. As we have discussed, these people attempt to avoid further shaming by building a wall of protection to insulate themselves from the criticism of others. These same people often become bullies—attacking others before they have a chance to be attacked. But behind that aggression, behind that need to dominate or humiliate others, is a little child who is still shaking in his boots. Pretending to be tough and strong isn’t really solving the problem, and shaming and humiliating others before they have a chance to do it doesn’t help either. What will help is for your client to take off their mask, tear down that wall, and face the truth. They are just as vulnerable, just as hurt as any other victim of child abuse and they need to address their pain, humiliation, and fear instead of hiding it from themselves. Suggest they start by doing the following:

Instead of demanding sex or compulsively masturbating, or watching pornography, ask yourself if sex is really what you need? Young children who were sexually abused often discover, perhaps for the first time, that their sexual organs can provide good feelings. This can be the start of compulsive masturbation or a sexual addiction. The child, and later the adult, grows to rely on sexual pleasure and sexual release in order to cope with feelings of shame, anxiety, fear, and anger. When you begin to obsess about sex it may be a signal that you are feeling shame or that you are feeling anxious, afraid, or angry. Or you may have been triggered. In addition, you may use sex as a way of avoiding your feelings and staying dissociated. For many former victims, sex becomes one of the only ways they can feel worthy, or they can interact with another person. In other words, your client may be having sex to fill needs that are not necessarily sexual, such as needs for physical contact, intimacy, and self-worth. They may be seeking sex because they need to be held. Many former victims don’t feel loved unless they are engaging in sex with someone.
Ask yourself what sexual activity or sexual compulsion does for you. For example: What needs are you trying to fill when you have sex? Is sex the only way you can connect with other people? Is it the only way you think you can be loved? What painful emotions does the compulsion help you avoid? One of my clients answered the question in this way: Having a lot of sex makes me feel powerful. It keeps me from feeling how helpless and powerless I felt when I was being abused by my father.
If you discover that you are using sex, or fantasies of sex, to cope with shame, anxiety, fear or anger, find other, healthier ways of coping. This is also where self-soothing strategies come in. Instead of using sex or sexual fantasies to soothe yourself, find soothing strategies that work for you (taking a warm bath, gently touching your arm and saying something like, “You’re okay,” or “You’re safe now”).
Learn what your triggers are—what emotions or circumstances catapult you back in the past to memories of the abuse. If you haven’t made a trigger list, do so now.
Check to see if you have been triggered by shame. Shame is an especially powerful yet common trigger. For example, if you have been triggered by shame (your partner complains about the fact that you don’t make more money) offer yourself some self-compassion. Compassion is the antidote to shame so tell yourself something like, “It is understandable that I would feel shame about not making more money. But I am doing the best I can under the circumstances. I don’t feel good enough about myself to go out and try to find a better paying job but eventually I will.”
If you tend to be sexually controlling or demanding, practice taking a more passive-receptive role. At first this will likely feel uncomfortable or even scary. You took on an aggressive stance in order to avoid feeling small or vulnerable. But if you can practice being more passive a little at a time (i.e., adjusting so that you are on the bottom and your partner is on top) you will likely discover that it actually feels good to relax and let your partner, take over.
Allow yourself to be more vulnerable with your sexual partners. If a partner has opened up to you and shared information about their childhood, see if you can do the same. You don’t have to tell the person that you were sexually abused, but test out how it feels to share other information about your childhood that you don’t normally share with others. Opening up and becoming vulnerable will feel risky at first but if you choose wisely who you reveal yourself to, you will likely discover that it feels good to be more open.
Avoid exposure to things that reinforce or replicate the sexual abuse mindset. This includes television programs, movies, books, magazines, websites, and other influences that portray sex as manipulation, coercion, domination, or violence.
Avoid pornography or work toward weaning yourself off of pornography if you use it regularly or feel you might be addicted. For former victims of CSA watching pornography can be especially problematic because you are reenacting an abusive dynamic that disengages you from yourself, and opportunities for respectful sexual relationships. Pornography has aspects of sexual abuse such as secrecy, shame, and dominance—all tied up with sexual arousal. Pornography is especially harmful to sexual healing because it is often a depiction of sex as one person dominating another (usually a male dominating a female) which is a reenactment of CSA. Specific problems caused by watching pornography include:
- Those who were sexually abused are often inundated with feelings of shame and try to distract themselves from these feelings by watching porn. But ironically, after viewing pornography and masturbating to it, it is common for former victims to feel shame, disgust and failure—the very feelings they have been trying to get relief from in the first place.
- Former victims tend to keep their pornography watching a secret from their partners. This can mirror the way sexual abuse was kept a secret, and in that sense can be a reenactment. When their partner finds out their sense of betrayal can be overwhelming and can cause as much harm to the relationship as pornography itself. More than one-quarter of women viewed pornography watching as a kind of affair. (10)
- Viewing pornography is, generally speaking, not about connection, intimacy, and affection. Instead, there is a blurring of boundaries around acceptable sexual behaviors, especially where there are overtly humiliating or degrading practices. Researchers have found that over 80% of pornography includes acts of physical aggression towards women, while almost 50% includes verbal aggression. Only 10% of scenes contained positive caring behaviors such as kissing, embracing or laughter.
- Research also shows that viewing pornography can influence the viewer’s sexual interests and practices. A 2011 study found that people who watched violent pornographic material were more likely to report that they had done something sexually violent or aggressive. Another study found that men who watch violent pornography or are frequent viewers of pornography, are more likely to say they would rape a woman if they could get away with it.
Use new language when referring to sex. The way a person talks about sex influences how he or she thinks about it. Avoid slang terms such as screwing, banging, getting a piece, etc. Instead, use terms such as making love, being physically intimate. Stop using words for sex parts such as prick, dick, boobs, tits, cunt, and asshole. Instead, use anatomically correct and accurate terms such as penis, breasts, vagina, and anus.
Learn more about healthy sex. Read books and articles that can help you educate yourself more about healthy sex. Attend classes, lectures, or workshops at which healthy models for sex are being presented.
Tell someone about the abuse. The most important benefit of disclosing is that you will be allowing yourself to be vulnerable and to admitting how much you were hurt. This will help you lower your defenses and not always have to be the one in charge.
Enter psychotherapy or join a survivor’s group. This can be especially difficult for males. Research has found that male survivors are less likely to report or discuss their trauma, and more likely to externalize their responses to CSA by engaging in compulsive sexual behavior.

***

It is vitally important that clients stop blaming themselves for the ways they have attempted to cope with the sexual abuse they experienced. I’ve never met a sexual abuse victim who didn’t have sexual issues—whether it is the two extremes of avoiding sex, or being sexually promiscuous; having feelings of fear or repulsion about certain sexual behaviors, or parts of the body; or inappropriate or even dangerous sexual fantasies or compulsions. But this doesn’t mean it isn’t possible to confront and heal these unhealthy ideas and practices.

References

(1) Natalie, Tapia. (2014). Survivors of child sex abuse and predictors of adult re-victimization in the United States. International Journal of Clinical Justice Sciences. 9(1),64-73.

(2) Filipas, H., & Ullman, S. (2006). Child sexual abuse, coping responses, self-blame, post-traumatic stress, and adult sexual revictimization. Journal of Interpersonal Violence, 21(5), 652-672.

(3) Noll, J. G. (2003). Re-victimization and self-harm in females who experienced childhood sexual abuse: Results from a prospective s. Journal of Interpersonal Violence 12(18), 1452-71.

(4) Oshri, A, et. Al. (2012). Childhood maltreatment histories, alcohol and other drug use symptoms, and sexual risk in a treatment sample of adolescents. American Journal of Public Health. 102(82), S250-S257.

(5). Classen, C. C., et.al. (2005). Sexual re-victimization: A review of empirical literature. Treating Violence and Abuse.4(6), 103-129.

(6) Hanson, R. K., & Slater, S. (1988). Sexual victimization in the history of child sexual abusers: A review. Annals of Sex Research, 1:485-499.

(7) Baril, K. (n.d.). Sexual abuse in the childhood of perpetrators: INSPQ. Institut national de santé publique du Québec. https://www.inspq.qc.ca/en/sexual-assault/fact-sheets/sexual-abuse-childhood-perpetrators

(8) McClanahan, S., etal. (1999). Pathways into prostitution among female jail detainees and the implications for mental health services. Psychiatric Services, December, 50 (12), 1606-1613.

(9) McIntyre, J. K., & Spatz Widom, C. (2011). Childhood victimization and crime victimization. Journal of Interpersonal Violence, 26(4), 640–663.

(10) Lumby, C., Albury, K., & McKee, A. (2019, February 12). Problematic use of pornography – living well. Living Well – A resource for men who have been sexually abused or sexually assaulted, for partners, family and friends and for professionals. https://livingwell.org.au/managing-difficulties/problematic-use-pornography/

Deciding How to Die: Narrative Therapy in Palliative Care with Someone Considering Stopping Dialysis

Posted on October 10, 2023February 11, 2026 by rezendevknowfully.com

Acknowledgements

Thank you Larry Zucker, Aileen Cheshire, Timothy Pilkington, and Catherine Cook for your valuable comments and questions when reading earlier drafts of this story, and David Epston for your encouragement and insights throughout the many iterations.

An Introduction

Living with a life-ending illness can raise questions where there is no clear “right” answer. The following illustration of Narrative Therapy focuses on conversations with a man who was tortured by indecision as he considered whether to stop dialysis. Stopping dialysis would lead to his death. This story of our work together illustrates narrative therapy practices that can help to restore dignity, witness suffering, enhance meaning-making, and offer a person a sense of agency as they approach death. Accompanying the illustration of therapy are footnotes. The footnotes [Ed. Note: To be found in the original article] explain more about my thinking and the ideas behind some of the questions that I asked. They also describe how I have applied ideas drawn from philosophy and Narrative Therapy to practice in palliative care. You can choose to read the story of the therapeutic conversations and the footnotes either together or separately.

Deciding How to Die

“Please would you see Mr. Fionn Williams as soon as possible? He has end-stage kidney disease and is having dialysis three times a week. Fionn is being cared for at home by his son Liam, and Liam’s partner Pete. Every week, Fionn decides to stop dialysis only to change his mind at the last minute. This has been going on for months and he and his family are very distressed. Fionn describes himself as “tortured” by his indecision. Dr. White has discussed stopping dialysis with Fionn and his family a number of times. Fionn knows he doesn’t have long to live, and his quality of life is very poor, however, his indecision continues. Fionn has refused counselling support every time it has been offered, but yesterday, he changed his mind. His family are relieved he has accepted counselling and are waiting for your call.”

I rang Fionn immediately.

Reviving Dignity and Meaning

Fionn’s son Liam greeted me at the front door. Liam was a tall, lean man, in his thirties I guessed, with a welcoming manner. He invited me into a tidy living room to sit down and then excused himself to let Fionn know I had arrived.

Fionn hobbled into the room leaning on Liam. I stood up to greet him and, as he caught my eye, we exchanged a brief acknowledgement. As Fionn came closer, I could hear him breathing heavily. He was dressed in winter pyjamas and a heavy cardigan despite the warmth of the day. The grey hue of his skin and the care with which he nursed his body through each step made him look older than his 74 years. Unlike Liam, who had a deep red beard, Fionn was clean-shaven, but it was easy to see that they were father and son due to their similar statures and light blue eyes.

Liam supported his father into the comfortable looking chair beside me that I had carefully avoided sitting in. Fionn gingerly settled back into the chair and looked at me.

“Are you the one who’s come to analyse me? I’m quite curious to hear what you make of me,” he rasped crisply.

I smiled warmly as I leant forward to shake his hand, choosing to respond to the possibility of humour in his comment and to my hopes for the relationship rather than the crispness of his tone. “My name’s Sasha, I’m one of the counsellors from the hospice. I’m looking forward to talking with you, though I’m more interested to hear what you make of you and your experience.” I was aware that being a 58-year-old woman with a soft voice and a big smile might have added to this introduction some of the care I wished to convey. I was generally just what people expected when they agreed to see a counsellor working for hospice and that could ease our first moments of getting to know each other.

Fionn chuckled. Liam turned to his Dad with his eyebrows raised and a slight smile on his face. In a tone of pleasant surprise he said, “I’ll leave you to it Dad, so you can have some privacy.”

Fionn immediately replied, his voice wobbling as it betrayed the toll even speaking had on him, “No, no, you stay. I haven’t got any secrets from you.”

Liam responded by pulling up a chair so that the three of us sat around the coffee table. “Alright then but I’ll have to leave shortly Dad. I’ve got a few things to do.”

They both then turned and looked at me.

“Would it be OK to begin maybe, with me asking you a bit about yourselves?” I offered tentatively. Liam nodded and, looking at Fionn, I explained further, “… so that I might know a little of who and what matters to you. I find people are so much more than their current situation.”

Fionn’s tone was abrupt. “Sure,” he croaked. Before I could respond, Fionn heaved his body forwards gasping at the air as if unable to get enough of its vital oxygen.

I waited, watching until his breathing eased.

Once Fionn could speak again, he explained, “It’s like this a lot… very hard to breathe… If I start to cough, it’s going to interrupt us. Did they tell you it takes a while to settle it down?”

I wondered if the struggle to breathe was behind the severity with which Fionn expressed himself and reflected that he might be anxious or even afraid. Feeling so sick could be overwhelming and here he was risking meeting a stranger on top of everything else.

I spoke with sincerity looking into Fionn’s faded blue eyes, “I’m sorry I didn’t know that. Thank you for seeing me. If you start to cough, is it OK if I sit with you or is there something else you’d like me to do? I’d like to do whatever is most comfortable for you.”

Fionn’s voice softened. “Just wait for me to stop. I do eventually.”

“I’m happy to wait. I’m in no hurry. Please take all the time you need to be comfortable without worrying about me,” I said warmly, trying to reassure Fionn that he didn’t need to consider me.

I reflected that people often have to cope with the responses of others on top of the symptoms they are managing, and briefly wondered what Fionn’s experience had been.

Liam chipped in with, “Dad has some medication for it but basically nothing can be done. He puts up with a lot.”

Nodding at Fionn in acknowledgement, I considered pursuing what he was putting up with but then thought it might be more useful to come back to it later in the conversation. We didn’t know each other, and I wanted to create with Fionn an entryway into a space where his experience of illness and treatment could be spoken about without compromising his dignity.

Fionn helped me out by indicating where his interest lay.

“Yeah…so we were doing some introductions. What do you want to know?”

Guided by Fionn’s question, I reiterated, “Would you mind telling me a little about yourself to start with perhaps?”

Speaking to the floor, he answered, “Not much to tell… haven’t thought about anything much other than trying to get through each day for ages. Let’s see now…well, for a start you can call me Finn. It’s what my friends call me”.

I smiled appreciatively, thinking of his generosity in extending me his friendship. “Thank you, Finn. Is that Irish?”

“Yeah. My grandparents came out from Ireland.” He lifted his eyes from the floor and focused on a nearby corner.

The Sustaining Power of Music

I turned my head to look with interest.

Finn leant forward, and in spite of his weakness, managed to convey a flicker of enthusiasm. “Played it for years. It had a beautiful mellow sound until last year when I went downhill and couldn’t play it anymore.” Finn hung his head with his body seeming to follow as he collapsed back in his chair.

“What a beautiful instrument. How did you come to learn the cello?”

What could have been a hint of pride entered Finn’s voice as he raised his eyes to meet mine. “My Dad taught me and then I’ve practiced over the years.”

“How old were you when your father began to teach you?” I asked.

“Just a young nipper. Must have been about seven I s’pose”.

“Gee, that’s young. What did your father see in you that made him think he could teach you the cello when you were only seven years old?” I exclaimed.

Finn furrowed his brow thoughtfully. “I s’pose he knew I’d work at it. I’m not one to take something lightly, if you know what I mean. You have to start out young with strings ideally.”

I leant forward to better hear Finn as I asked, “When you say he knew you’d work at it and not take it lightly, would you mind explaining a little more of what you mean?”

“Well….”, Finn hesitated, “Dad knew I’d practice, and you’ve got to do that if you want to learn to play… especially with a stringed instrument. You have to make the notes you see. Even when I was a boy if I set my mind to something, I’d keep going with it.” Again, I noted a glimmer of what could have been pride in Finn’s demeanour. My keen interest must have been evident on my face. When Finn caught my eye, he explained further.

“When I was 4 years old, I decided I wanted to ride an old two-wheeler bike and there was just no way anyone was going to stop me trying. Did it too in the end. Just kept going till I did it.” Finn glanced at me again with a small smile transforming his lined face for an instant.

I responded immediately caught up in the picture he had drawn of himself. “What do you call this ability to keep going with something you want to do?”

“Grit, I guess. I’m a hell of a determined kind of fellow.”

“You sure are, Dad,” Liam echoed.

“What have you come to respect about your Dad’s grit and determination, Liam?” Finn peered at Liam while Liam told a story of Finn never leaving a job unfinished even if it became frustrating and difficult. Liam glanced at Finn as he spoke, seeming to check he was listening.

“Finn, has this ability to apply grit and determination shown up in other areas of your life?”

“Yeah, pretty much everywhere. I would have been dead by now if I hadn’t had it. It’s important to do your best at things and not cop out.” Finn’s certainty suggested to me that this was a quality he valued.

“Would it be too much to ask for another story of you giving of your best with grit and determination?” I enquired, aware Finn had little energy and might want to save it for other matters.

Finn began to give me other examples with Liam chiming in and sharing with me his father’s persistence in living with his disease. When we had gathered a collection of stories of Finn’s grit and determination, I returned to another piece of information he had shared.

“You also mentioned your father taught you the cello as he thought you would enjoy music. Do you think your father had some hopes for you in teaching and encouraging you further into a musical world?”

For a moment, light danced in Finn’s eyes softening the lines of weariness that marked his face. “Music always gave my Dad joy. He loved it and he wanted to pass that on to me. He did too.”

“Like your father, do you get joy from music?” I asked. Finn nodded in agreement. “Is this something you are still able to experience even now when you have so much to contend with?”

“Well, yeah,” Finn said, sounding surprised by himself. “…Especially if I’m listening to the Bach cello suites… beautiful.”

“What does this ability to appreciate music and to feel joy from listening to it give you day to day, especially at this time when you are living with some serious health issues?” I chose to narrow our focus to day-today living to reduce the size of my question.

“There isn’t much that I can do anymore. I used to be a landscape gardener. That’s gone! Liam and Pete keep my garden up for me now. I do appreciate what they do. But every month there’s another thing I can’t do. Listening to music is something that keeps me going I guess.” Resignation was thick in Finn’s tone.

I tried to imagine Finn’s world. “What is it about the experience of listening to music that keeps you going?”

Finn hesitated as he considered. “It takes me to another place.”

I was fascinated. “Would it be OK to ask where it takes you?”

Finn dropped his shoulders and his face relaxed. “Ah…it takes me back to happier times.”

I asked Finn about these happy times, and he responded readily, sharing some treasured memories. I then returned to an earlier thread of the conversation.

“When did you first notice that you could take yourself to another place while listening to music, even when you were unwell and perhaps had the pain and sickness to draw you back?” I framed my question in such a way that Finn might notice this as an ability and something he was doing. I was aware that a person’s experience of illness could rob them of a sense of having influence over their life.

“In the last year or two at dialysis… I couldn’t read… or concentrate… so I listened to music and it made the time better. I got sicker but it was a habit by then and, well, I’d done it every time. I was kind of used to it.”

“Used to it?” I queried, half to myself as I reflected, searching for a link to Finn’s increasing skill as he got less well.

“I’d kind of practiced it I s’pose…,” Finn explained.

My ears pricked up. “You practiced it? How did you go about that?”

“It’s just what I’ve always done. I started doing it more and more. Certain pieces are better than others. The 1812 Overture doesn’t help pain but if I’m feeling like I need a boost, it’s just the trick,” he shared with a small smile.

I furrowed my eyebrows as I reflected on what Finn had just explained. It seemed like he might have developed a number of skills to manage the symptoms he was experiencing and, hoping to draw these possible skills to Finn’s attention, I offered a brief summary for him to consider. “Can I just check that I’ve understood you right?”

I waited for Finn to indicate if it was alright with him for me to proceed. When he nodded with attention, I continued, “Have you worked out which music helps you live with this and have even discovered particular pieces of music are helpful to you at different times depending on how the illness is affecting you?”

“Well, yeah,” Finn exclaimed, looking pleased and surprised at the same time. He glanced at Liam who gave a firm nod and smiled with encouragement.

“And you said you’d practiced. Could you help me understand a bit more about this practice you’ve been doing?”

Liam and I both turned to Finn who looked as if he was enjoying himself. “I found if I knew the piece… well, I was more relaxed, I guess. It was easier to forget the bad stuff and relax… So… I listened to music I liked till I knew every note. It used to help. Not so much now. I’m too far gone now. Listening to music is one thing I can do though. That counts for something. There isn’t much… Liam and Pete sometimes come and sit with me, and we listen together.”

“It’s a nice time together, Dad. We enjoy spending it with you,” Liam added, as if trying to convince his father. Finn raised his eyebrows and gave Liam a tired smile as if he didn’t quite believe what Liam was saying.

I turned to Liam. “What is it that you enjoy about spending time with your Dad?”

“It’s nice to be together as a family…” he replied with a sidelong glance at Finn.

“Liam have you learnt anything from your Dad’s grit and determination or his ability to appreciate music and be taken to another place that has been useful to you in your life?”

Liam let out a big breath as if gathering some resolve. “It’s been enormously important to me. I had a tough time at school. I was bullied a lot. Mum was always supportive, which meant the world to me, but it was Dad who taught me how to keep going and not give in to it.” Finn looked down and shook his head slightly. Liam turned to his father trying to catch his eye and said, “You taught me how to survive, Dad.”

Finn muttered, “Wish I could have done more…I didn’t realise how tough it was for you.”

“Attitudes were different then. You’ve been wonderful since Mum died, having me and Pete here and all. Dad, I survived because of you and Mum. Both of you.”

Finn’s eyes glinted with tears as he reached out to Liam. They clasped hands for a moment. A small smile emerged on Finn’s face and his forehead relaxed. Liam lowered his shoulders and released a breath as he looked again at his father.

“Finn, what is it that you wish you could have done for Liam?”

Finn looked steadily at me but his words were for Liam. “Been there for him… understood more…protected him, I guess. Beth was better at it than me.” He turned awkwardly towards his son, moving his chest carefully around until his eyes eventually found Liam’s.

Liam choked up. He managed to croak, “Oh, Dad. That means a lot,” before emotion silenced him.

We sat together not speaking as we quietly honoured what had passed between Finn and Liam.

After a few minutes Finn began to cough. Liam touched his back lightly waiting patiently for Finn to settle. When they both looked at me indicating their readiness to continue, I asked Finn, “Is there anything in particular you would have liked to have understood, or maybe protected Liam from, that you would like to speak about today?” I was aware that Finn might die at any time and such a question could lead to further acknowledgement and connection that might be helpful for both Finn and Liam.

We continued talking together in this manner. Bit by bit I researched, listening out for what was important to them in their lives, their good intentions, skills, beliefs, and hopes. When we encountered acts of kindness, loyalty, love, and any virtue they might value, I asked more questions. Finn talked about his wife Beth, fatherhood, the important relationships in his life, and his work.

Twenty minutes later, Finn signaled a wish to change the direction of our conversation. “It’s all been taken away, Sasha. Bit by bit. I was an active person with a full life. Now all I’m left with is this terrible sickness.”

Exploring the Impact of Finn’s Illness

Finn seemed to welcome the opportunity to talk. “I’m fainting every day, and this pain…” Without seeming to know what he did, Finn held his ribs. He was clearly uncomfortable but carried on speaking though hopelessness seemed to hover nearby as he spoke. “I never have any energy and I feel so sick I don’t feel like doing anything anyway. I’m so nauseated I can’t eat, or not much. Nothing tastes good. I can’t even sleep and I’m not nice to be with. Irritable. I want to die. I’ve had enough. I want to die.”

He sighed but the reflective pause was denied him as the next moment he coughed and choked, gasping as his face became greyer with every minute. Liam immediately bustled away to get some medication while I stayed providing companionship as Finn struggled to breathe. It took 10 minutes for the medication to settle Finn’s breathing, and longer for him to relax.

Once Finn was comfortable again and his breathing had eased, Liam reluctantly explained that he needed to go. There was medication to pick up and other jobs to do. I thought about the extra work and expense that often came along when someone is very sick.

The front door shut noisily a few minutes later. Finn and I were alone in the quietness of the house.

“You were speaking of how each part of your life is being taken away bit by bit from you and you said you’d had enough and want to die. Would you mind if I asked you a few questions about that?”

“Go ahead,” Finn replied, and I noted the warmth that had become increasingly present in his voice.

“Is there anything in particular that has been taken away that leads to this sense of having enough and wanting to die?”

Finn spoke with energy as he confided, “It’s all of it but mainly that I feel so awful. I wish I’d hurry up and die but I keep waking up every morning and another day starts.”

I tried to convey care in my tone as I responded, “Would you mind explaining a bit more of what you mean when you speak of wishing you would ‘hurry up and die?’”

Finn sighed. “I want to go to bed and not wake up in the morning. Tonight preferably. Every day is a struggle.”

“Could you help me understand what your day-to-day life is like, Finn? Would you be kind enough to walk me through a typical day for you perhaps… so that I can better understand a little of what this struggle is like for you to live with?” I tried to shrink my question about the struggle Finn was experiencing into a more manageable size by offering a time frame, so it wasn’t overwhelming.

Finn shared with me his daily routines. As I listened, I could easily empathise with why he might be feeling like he’d had enough. The effects of being unwell sounded exhausting. Hearing about Finn’s day-to-day life allowed me to gather some detail, and as he talked, I asked him how he responded to each difficulty or symptom he encountered. I noted how eagerly he spoke to me in spite of the fatigue he was managing and the topic of conversation and wondered if he’d had the chance to speak of his efforts in response to the difficulties.

When a pause occurred in the conversation, I checked with him, “How are we going with this conversation, Finn? Are we talking about what you hoped we might, or have I taken us off track?”

Finn relaxed back in his chair. “It’s actually a relief to talk about it, Sasha. I don’t want to worry Liam and it’s different saying it out loud somehow.” I wasn’t surprised by Finn saying that he didn’t want to worry Liam. People I meet often want to protect those they love from the worst of their experience.

“Finn, how would you describe the changes you’ve had to make to your life as a result of this sickness?”

Finn picked at his cardigan meditatively as he considered my question. “It happened gradually. When I first got sick, the dialysis really helped. I felt good and I could enjoy being outside and in the garden. I was able to keep working for quite a few years. But now, I feel terrible all the time. It’s been all downhill. I can’t work of course. I can’t do anything. Liam cooks for me and I have help showering. Last week I started falling. That’s on top of the fainting. And of course, I have to go out to dialysis three times a week. That’s always a huge effort.”

“Could you teach me about your experience of dialysis?” I asked, wondering what it was like for him.

“A taxi comes and picks me up ‘cause Liam and Pete are at work. It takes me to the hospital. All the people having dialysis are in a special room hooked up.” Finn sighed.

A picture formed in my mind. “Do you get to know the other people there?”

“We don’t talk to each other. We just all stay on our beds there. There was one man who would talk to everyone in the room and got people chatting a little but then one day he didn’t come back. I don’t know what happened to him. People do gradually stop coming back but I don’t know exactly why. I wonder about them you know…. have they died or did they decide to stop?

“In the end it’s a bit of the same thing I suppose…” Finn sighed and his shoulders sagged. I had imagined the people all sharing their experience and learning about each other’s lives, maybe finding some support in being together. Finn’s description was a surprise and it contrasted with the stories I had heard from other people. I briefly considered what Finn had told me and thought of asking about the effects of not connecting to the other people receiving dialysis. However, I decided to take another tack which I hoped would be more useful to him.

“May I ask, what were your hopes and intentions when you decided on this routine of attending dialysis three times a week?

“I wanted to live! And I wanted to have a good quality of life…I was pretty sick then. I’d been in and out of hospital, had three operations and endless tests. Beth was alive and we wanted to be able to do things together that we’d planned….and support Liam. It seemed a really good solution at the time. I didn’t hesitate. I wanted to feel well again. The dialysis saved my life… and if I stop, I’ll die.”

I nodded solemnly to acknowledge the magnitude of what he was facing and we both paused for a moment. “…Were your hopes met by the dialysis treatment?”

Finn explained, “Yes, they were at first. I was able to do things with Beth and I felt good”.

“As the years went by, did these hopes and intentions you held for the dialysis shift or change in any way?”

Finn answered me thoughtfully. “They changed without me knowing, if you know what I mean. I got sicker as my disease progressed. I s’pose I’ve just kept on going to dialysis as I don’t want to feel so sick. But then there are side effects as well, not as bad as the disease of course, but bad enough, and the visits to the clinic take a lot of time.” He paused a moment and frowned. “It’s different now. I don’t know what to think. I want to die. Every morning I wake up and I think I’ve had enough. I can’t live like this anymore. I’d rather just not wake up one morning.”

Exploring Finn’s Wish to Die

Finn hung his head. “Well…yeah…that’s right. I know I should stop dialysis, but I can’t seem to make the decision. Yesterday I thought I was going to stop but then I couldn’t go through with it again. I’ve been doing it for months. It’s awful, not just for me. I’m putting Liam and Pete through it too. I’m letting everyone down. I’m such a coward.”

Tears filled his eyes.

I reached out, moved that he would judge himself a coward when such a decision would try most of us deeply. “Would you like to try and figure this out together?”

Finn took out a large handkerchief from a pocket in his cardigan. He dabbed his eyes with the folded hanky before slipping it back into his cardigan. “Yes, yes, that would be good,” he responded looking at me with what might have been a glimmer of hope.

I considered what might be a helpful direction to go in. I was tempted to inquire about Finn’s idea that he was a coward but reflected we might first need to carefully research his experience of decision-making. Perhaps we could unravel some of the ideas that were leading Finn to feel he was letting people down and “should stop dialysis.” He might then be able to arrive at some different ideas about himself. “Would it be OK if I asked you about your thoughts about dialysis and what you want?”

Finn nodded.

“I notice that you said you were thinking that you should stop dialysis. Could you help me understand how you came to think stopping dialysis was something you were supposed to do?”

“Lots of ways. Dr. White said he couldn’t do any more for me than what he’s doing. He said there comes a time when dialysis just doesn’t work so well anymore, and the disease has progressed too far. I know he’s worried about me.

“Last time that I was in hospital some of the ward staff talked to Liam and Pete and said I was so bad that they should try and help me stop. It’s expensive too, and I could be taking someone else’s spot. I feel so terrible, but I just can’t seem to do it.” Finn’s voice tailed off into a whisper. At the same time a pink flush appeared on his neck and began spreading up towards his face.

“It sounds like people are worried about what you are putting up with and there is quite a tide of thought towards thinking it would be a good idea to stop…May I ask you though, Finn, do you have any thoughts about how you would like to go about this last part of your life?”

“I don’t want to be like this, worrying all the time and feeling such a chicken… I don’t know…” Finn rested his head in his hands and looked down at the floor. I waited as he considered what he might want. Eventually he murmured, “I want to be enjoying my life… spend time with Liam and Pete… Quality of life I suppose. The dialysis gave me that for so long. I wanted it then, but it started to change.”

“Can you remember how it began to change?”

“Yeah. It was a few years back and I was admitted to hospital. I started to have a few doubts about it then.”

“Do you remember any experiences or thoughts that led you to having these doubts and perhaps consider that dialysis might not be completely what you wanted?” I asked, wanting to acknowledge the mixture of possibly conflicting feelings as we researched the movement in Finn’s thoughts.

“I guess as I started to have some problems and was less well. After Beth died, I had a few doubts. I started to think I might not want to prolong my life but then I had some projects on, and time kept passing. As the dialysis worked less well, I thought about it more. When I started to feel awful, even though I was having it, I wondered, ‘what was the point?’ Then I got more side effects after each dialysis session. I had to have another operation too and that made me think I might want to stop. But there was stuff to do, and it just stayed in the back of my mind.”

“Would it be OK to ask what happened to the idea that it wasn’t completely what you wanted? Did it stay with you unchanged or did it begin to change over time?”

“As I got sicker, I thought about it more and more, I suppose…now that I think about it. I didn’t know if I could keep going. I got really irritable with everyone…wasn’t nice to live with. I guess I started to think about how bad I was feeling and whether I should keep going all the time.” Mournfully he added, “I want to be able to decide to stop and I can’t.”

I didn’t make any attempt to hide my compassion for Finn from my face or my voice.

“What a terrible position to be in. If you were to describe to someone else this weighing up you have been doing of whether to continue with your life, how big of a decision would they think this was?”

“Huge. It’s the only one I’ve got!” Finn smiled wryly in spite of himself. I nodded in acknowledgement.

“As you both want to die, and at the same time, consider whether you can go on with your life, what do you take into account?”

“I guess it depends how I’m feeling. Most of the time I feel like I can’t even make it through another day I feel so bad…I decide I can’t take it anymore and won’t go to dialysis but then I change my mind again like I did yesterday.”

As I listened to Finn, I noticed that the thought of stopping dialysis seemed to be specifically linked to the feeling he couldn’t bear the symptoms he was experiencing. I decided it might be helpful to gather more information. I also wondered if introducing the idea of possible agency in Finn both “deciding” and “not deciding” to go to dialysis might be useful to him. His description of himself as a coward loomed large in my mind.

“Hmmm…Finn, would you mind walking me through how you came to decide yesterday to stop dialysis and then re-considered and decided to continue?”

“Well…I couldn’t eat yesterday the nausea was so bad. I’d been awake a lot in the night, and I was feeling so terrible. All I could do was sit in my chair. I’d had enough… It felt like I couldn’t go on. So, I decided I wouldn’t go. But then I changed my mind at the last minute again. Made me late…”

Concentrating hard I asked him, “Could you walk me through sitting in your chair to you deciding to go to dialysis?”

“I was sitting in my chair feeling so terrible I wanted to die… and then Sue, the wife of an old friend, came to the house with a cake. I couldn’t eat any of course. Then I sat in my chair. And…half an hour later I thought maybe I’d go.”

“What sort of cake did Sue bring?”

Finn raised his eyebrows. “It was a chocolate cake she’d made.”

I reflected on Sue’s kindness. “Did she make it especially for you?”

The pace of Finn’s speech quickened, “Yeah, she did. Nice person. She often pops in with my mate or sometimes on her own with some cooking and we have a chat. She’s a sympathetic woman.”

“May I ask what difference it made to you to have Sue pop in with a cake she had baked especially for you and have her stay for a bit of a chat?”

“I dunno. I guess it felt like life wasn’t so bad maybe.” Finn sat up a little straighter in his chair.

“What was it about your life in that moment that made it seem ‘not so bad?’” I asked, collecting more details.

Finn spoke with gratitude, “There are good people around. Kind people who are interested in me I s’pose. Makes me think life isn’t so bad after all.”

“How would you say feeling ‘life wasn’t so bad after all’ influenced the way you felt about going to dialysis?”

“Well…I do wish I didn’t wake up this morning but yesterday, well, I felt I could go on, that things weren’t so bad…and… so I went to dialysis,” Finn replied meditatively.

“Do you both want to die and value some of what your life gives you?”, I persisted.

Energy penetrated Finn’s voice, “Well…yeah! I never thought about it like that.”

“Would it be OK if you gave me another example of you re-deciding to continue on with your life?” I asked, intending to examine this idea further.

Finn began to give me examples of him deciding to stop dialysis and die because he felt he could no longer go on, and then finding some reason to continue on with his life. Sometimes it was a gift from someone, a kind act, a moment of respite from the symptoms he was living with, or even a phone call. I discovered that he was skilled at finding things to appreciate and reasons to continue with his life.

“Finn, do you both want to die and value some of your life?” I repeated with a smile.

He responded, “Well, yeah. It doesn’t sound like it makes sense but yeah!”

“When you start to feel overwhelmed by the symptoms of the illness or the side effects of dialysis, what happens to this valuing of your life?”

“I don’t know. I lose it… I feel overwhelmed. Then someone does something nice and I remember it again.” Finn looked up with a small smile on his face. I noticed with admiration his gratitude for the people in his life.

I was tempted to research more about this value Finn held for his life, but time was running out and he was starting to look fatigued. I made a mental note to return to it if we met again and instead decided to pursue the way he described himself.

“Finn, you described yourself earlier as a coward. Would it be OK to ask you what your understanding of a coward is?”

“Someone who runs away…is chicken and doesn’t face things,” he muttered, a bit shamefaced.

Slowly, I summarised a little of our conversation. Finn nodded as I recapped, “You’ve talked about wanting to die and deciding to stop dialysis…but then being reminded of the value you hold for your life by appreciating someone or something, and then re-deciding to continue with your life by going to dialysis. Would you describe this as running away from death — as cowardly — or is it perhaps closer to moving towards living, appreciating it, and being connected to what you hold dear?”

Finn stared at me wide eyed. He managed to stutter, “Well…yeah, my life…yeah, I’m doing that…not running away…no, not running…”

I repeated my question, offering a little more for him to consider. “Are you valuing and respecting your life even as you wish to die?” Finn nodded. “Does that valuing perhaps connect you to living and make ‘having a hand’ in the timing of your own death more difficult to contemplate than most of us could possibly imagine?”

Finn nodded again. Tears flowed down his face as he stared at me unblinking. He reached into his pocket for his handkerchief.

“I’m not a coward,” he croaked.

We sat together with Finn mopping his face with his handkerchief. He sat, no longer hunched or downcast, but upright, making eye contact with me from time to time as he continued to pat his skin dry. Every now and then his face lightened, and a small smile emerged.

In a whisper he repeated to himself as he patted the tears away, “No…I’m not a coward…”

We were coming to the end of our time together and I noticed Finn was beginning to look weary. After a few more minutes of conversation I finally checked, “Is this a good place to stop?”

“Yeah. It probably is.”

Tentatively I asked, “Would you like to meet again?”

“Oh, yes. Can you come back soon? In a few days?”

I was aware that Finn could die at any time or in the next few weeks. Time has a different meaning when someone is approaching death and that meaning has a role in shaping the gap between counselling meetings as well as the length of them. I looked up from my diary and smiled at Finn, “I’ll be back at work on Wednesday. That’s five days. How does that suit you?”

“Yeah, yeah. Come back then,” he answered hastily returning my smile.

Getting Curious About Fear

“I’m still here,” Finn stated ruefully. His voice scratched over the words as he explained, “I knew I’d go for treatment this week. I nearly couldn’t get out the door. I was vomiting and it was almost too much, but somehow I managed…your hospice doctor visited afterwards and it’s better now…”

My speech slowed to match his. “How did you know you’d go for treatment?”

Finn’s eyes twinkled. “I pretty much decided after you left last time. I figured I needed a bit more time to work things out.”

I gave a small smile in return. “What made you think that it might be helpful to give yourself a bit more time to work things out?”

Finn immediately looked serious. “I’ve been wondering…You must have seen people like me. I feel so bad now…how much worse is it going to get? I’m kind of wondering about what it might be like…you know, dying…” Finn’s voice trailed off. His face was drawn and tense. I could see a pulse at his temple moving his papery skin rapidly in and out.

I wondered if fear could be playing a role in making it difficult for Finn to know what he wanted. “Would it be helpful to talk about your wonderings about dying?”

Finn raised his chin though his voice had a tremor, “Yeah…might be.”

“Is it OK to ask which part of dying you have been wondering about?” Some people I meet with are more worried about the process of dying while for others their biggest concern may be about how family will cope or what it might mean to be no longer alive. I didn’t know where Finn’s attention was focused.

Finn drew his eyebrows together and shifted in his chair. “The dying part. It’ll all be over when I’m dead. I guess I’m wondering what it’s going to be like…might not be too good…might be painful.” He looked up at me with wide eyes.

I was aware from the hospice doctors that Finn might feel very sick when he stopped dialysis but the medical staff had also spoken of what could be done to help Finn. Dr. MacDonald had also told me that this information had been explained to Finn many times. With this in mind, I wondered if it might be helpful to draw out the narrative of what could be done to support Finn.

“What did the doctor say they could do to help you should you start to feel sick coming off dialysis?”

“She talked about one of those pumps…that make you relaxed and give you pain relief all the time…” He glanced at me as if checking this was true. I nodded in response.

Finn and I continued to talk. As we spoke, it became apparent that he was now voicing fears and considering the end of his life in a way that until now he had not been able to. Finn repeated to me the information he had been given by the doctor. As we revisited what Finn remembered it seemed to reassure him. It was as if Finn had been unable to consider and absorb the information until that moment, he uttered the information himself.

Finn rounded our discussion off with, “I’ve just got to decide and follow through with it… whichever way.”

“Would it be OK if I asked you about this desire of yours to make a decision and to follow through with it? Have I got that right?”

Finn nodded. “Yeah, that’s right. Sure.”

“What makes it important to you to decide and then follow through?” We both knew he didn’t have long to live regardless of whether he stopped dialysis or not.

I looked over at Finn who was shifting stiffly in his chair. Noticing he had more to manage than just my question, I elaborated a little, conveying in my tone as much care as possible. “If you were to die, say in your sleep having decided not to decide one way or another about going to dialysis, how would that sit with you for example?”

Mournfully, Finn intoned, “My soul would know. I’d die feeling like I’d copped out and I hadn’t looked after Liam and Pete. It’s hurting them. I have to decide one way or the other. I feel like I can’t live properly while I can’t decide. It’s with me all the time.”

“Mmm…” I empathised, my complete attention on every word. “What do you imagine it might feel like to have made a decision about what you want to do?”

Finn sighed. “Peaceful…”

“If you were to decide, how would you know if it was a decision that you would want to follow through on? That it was a decision to be acted on?”

“I guess I would know if it was my decision and I thought it was the right thing to do. Not what someone else thought was right but what I thought. I’ve been thinking about what I told you last time.”

“How would you recognise a decision that was yours and right for you?”

“I would feel it in here,” he replied, putting his hand over his heart, “…not in my head. I wouldn’t worry all the time.”

I considered asking Finn if he could envisage any steps that might take him in the direction of deciding but wondered if it might be too hard of a question, which would not be helpful. As I was pondering, Finn repositioned himself again in his chair groaning quietly with each movement. “I just feel so bad, Sasha. I’m so tired from all this. It’s gone on and on. Everything’s a struggle.” He sighed heavily.

“Which parts of the struggle are you noticing as we talk, Finn?”

“It’s the pain. I can’t seem to get away from it today,” he groaned. Rather than ask him about the pain which had already been canvased in depth by the two of us earlier, I enquired, “Finn, what keeps you going day to day when you are living with pain that you can’t get away from as well as many other challenges caused by this illness?”

“It doesn’t feel like I’ve got a choice, Sasha. I just keep on keeping on like I’ve always done.” I waited as he seemed to contemplate. A small smile crept onto Finn’s face. “There’s one thing though. See those buds there?” he said, pointing to some bulbs outside the window. “I’m waiting for them to flower.”

“What is it about waiting for the buds to flower that has you keeping on with your life?” I wondered, curious.

“You just never know exactly how they are going to flower and that moment when the petals unfold…so beautiful.” Light crept into Finn’s eyes and his brow relaxed as he talked about the plants he had delighted in nurturing most of his life. I was fascinated by his ability to appreciate beauty and asked him about it. When he had concluded I decided to research further.

“What else supports you to keep going as you manage this disease?”

Apologetically, Finn explained, “I’ve never watched much TV, but Pete and I have been watching Downton Abbey together. We both like it. I keep wondering if Edith’s going to be alright.”

I grinned. I wanted to know too!

As we talked, I reflected that there were many aspects of Finn’s life he had found a way to enjoy. As the list grew longer, I marvelled at his ability to adapt to his circumstances. If I had guessed at that moment, I would have imagined Finn would decide to continue with dialysis for as long as possible.

I finally asked him, “You have spoken of finding ways of enjoying parts of your life in spite of all that you are managing, of things you are looking forward to and times of companionship. Is there anything you’d like to add that’s important to you in the keeping on going?”

Finn screwed up his face concentrating. After a pause he said with generosity, “Well…Liam is important… and Pete his partner. I want them to be happy.”

I could see Finn was tiring. He had begun to cough, and his speech had slowed. I carefully summarised what we had covered, checking with him as I spoke. We then arranged another time to meet the following week.

As I picked up my bag and got ready to leave, I turned at the door to say a final goodbye. Finn smiled at me. In what could have been a mischievous tone, he sent me on my way with, “You know, Sasha….I have hope for my life!” His smile became a grin and I left, uplifted by the manner of his goodbye.

Deciding To Die

Five days later I sat in the morning meeting unable to focus. I heard conversations around me but they passed me by. All I could think of was the news that had greeted me when I walked in the door. Finn was in the hospice inpatient unit. He had decided to stop dialysis. Finn was dying. As the news reverberated through me, some of the staff offered their praise. They understood Finn’s decision as the right one given his poor quality of life.

“That’s good work you’ve done, Sasha. That poor man was suffering so much,” a colleague said.

The kind words didn’t ease my mind though. Dominating my thoughts was the question, “Was this what Finn truly wanted? Was it right for him?” My internal agitation made its way to the surface, and I moved restlessly in my chair. I could hardly believe Finn’s swift change of heart. “What had happened? How had he come to decide?”

I had met with many people who were considering treatment options they had been offered by their doctors. I often created spaces in which a person could discuss how they wanted to approach the end of their life. What was it that had me quite so unsure this time? Was it the rapid time over which this had all occurred? I thought about Finn saying to me, “I have hope for my life” as I had left his house only the week before. I knew I had held no preference as to what Finn should do, but what effect, if any, had our conversations had on his decision-making? I resolved to make sure Finn was doing what he truly wanted.

I almost ran downstairs to my office, checking my diary as I went. As I made my way through the hospice inpatient unit, I asked one of the nurses to enquire if Finn would like to see me. When I arrived in my office the answer was already waiting for me on the answerphone. Finn and Liam were keen to meet with me.

I knocked on the door to Finn’s room in the late morning. Finn was lying in bed in his pyjamas. His head peeped out of the bedclothes, the white of the sheets drawing my attention to his pallor.

“Hi, Finn.”

“You found me alright, then. Thought you might go to the house…” he rasped. Finn’s mouth turned up as he attempted a smile. He seemed to have forgotten that I had arranged this meeting with them only hours ago.

Liam’s eyes shone with tears as he explained, “We arrived yesterday morning. Dad’s been getting worse every day. He’s a bit confused at times. They say he’s only got a day or two maybe…”

Tentatively I asked, “Finn, do you have the energy to catch me up on events since we last met? Or would it be easier if Liam helped me out here? It seems like a lot has happened…”

Each word was an effort as Finn explained, “After I saw you, I went to dialysis and decided I’d had enough.”

My speaking seemed to slow to the pace of his. “How did you know you’d had enough?”

“It was just too difficult.” The gaps between each exchange lengthened as we responded to the limits of illness.

“May I ask what it was that became too difficult?”

“Living…when I decided to stop treatment it was like a great relief… as though a weight had been lifted off my shoulders…I was in pain all the time. I’m in the final stages…and I’d had enough. I wanted some peace.”

“What were you hoping for that some peace could give you?”

“For the last few months, I was always in pain, tired, and felt sick. I was falling over and I couldn’t breathe properly. I never got a day’s relief…” Finn paused gathering his breath. I remained silent, allowing him the time he needed to go on.

“The doctor told me it was harder to stop than to start dialysis…and I started to think about that. It’s easy to start because you think it’ll do you some good. And it does to start with. Then it gets harder and harder…to get some peace you have to feel worse first.” Finn began to cough. I waited quietly, conveying in my stillness and relaxation that I was in no hurry for him to resume the conversation. When Finn had settled, I picked up the thread again, “You’ve spoken to me of the struggle to decide. How did you move towards thinking that some peace might be more important to you than continuing on with your life?”

“I realised I couldn’t do what I wanted, I don’t have quality of life and I thought a lot about what I wanted…what was important to me…you asked me that…and I thought, ‘I want some peace.’” Finn shut his eyes underlining what he had said.

“You had some worries about this time and what it might be like. Are those worries still there, or have they changed in some way?”

“They’re different now, not so bad. The staff are helping me.” Finn looked out the door in the direction of the nurse's station. “I’ve been thinking about it for a long time, and I just thought, ‘this is enough’”

Finn tried to move up the bed but couldn’t. Indicating with his hands to Liam he didn’t want help, he settled for moving his body onto his side.

Liam answered as he watched Finn struggle but respected Finn’s request to be independent. “It was a shock. It took me a while but I understand. And it was a relief especially when we found out Dad could come into the hospice for care. Suddenly he was the person he used to be. Laughing and joking and poking fun. He was himself.”

Turning to Finn I asked, “Do you feel more yourself?”

Finn answered as if each word was weighted down by the effort it took to utter. “Yes. I was using all my energy in the fight…with the illness. It was a struggle every day. There was nothing left…Just to go to dialysis was so exhausting. It’s a relief… A total relief and now I want peace. I won’t go back to dialysis again…”

I turned to Liam to give Finn some respite from speaking. “Liam, what do you think your Dad is prioritising when he chooses peace?”

“Control over himself again. He wanted to take it back. He’s spent so long being sick, going to dialysis, taking so many pills, trying to sleep and dealing with the pain. It’s a relief for him now. And drugs have side effects. He’s more himself now.”

Finn added, “Yeah…it kind of enslaves you….” His eyes closed.

“Liam, you said that your Dad stopping dialysis was taking back control and being the person he is. Could you tell me about this person you understand your Dad to be?”

“Organised. He always liked to be in the driving seat. He is a bright, active man who always managed everything on his own. He got himself to treatment every week through all these years, did things on his own terms.”

Finn opened his eyes again and echoed, “Yeah, and I’m going out on my terms now.”

“Finn, you mentioned that ‘it kind of enslaves you,’ earlier. Could you help me to understand more of what you mean by that?”

Finn sighed. “My catheter leaked last night…everywhere. The nurses had to come and we did a big clean up. It’s not just the dialysis. It’s everything. All the problems, the treatment, the side effects. It’s all the time.”

“So much to deal with….” I murmured.

Finn responded with a long speech for someone so unwell. “I feel free now…A man came to the dialysis unit for his first treatment when I was having my dialysis the day after I saw you — what ended up being the last one. I watched him come in and I thought, ‘if it was me doing it again, I would never start.’ I was kind of shocked by myself thinking that, but I realised it’s true. I wanted to go over and tell him not to do it… but I didn’t of course. And then I thought, “What am I doing here?” and suddenly I knew I didn’t want to be. I thought it would feel like giving up, but it doesn’t…it feels right in here…” Finn moved his hand to his heart. “I am me again…and soon I will have some peace”.

As Finn spoke, I reflected that I might not ever fully understand what had allowed him to decide. I wondered if reconnecting him to a sense of his own worth or to some of his knowledge and abilities had had a role, but I would never know for sure. A slight smile emerged on Finn’s relaxed face. In that moment I could see what looked like the peace he had been describing.

I left the room after thanking Finn for sharing so much of himself and his life with me and teaching me about decision-making.

It wasn’t the last time I saw Finn though.

Two days later, I walked past Finn’s room knowing he was now close to death. Finn was alone, lying in his bed and I thought I could hear Liam’s voice in the hallway talking to a nurse. Finn invited me in with a look. Speech seemed beyond him. When I sat down by his bedside, Finn reached over to hold my hand. Willingly, I offered it to him, and he clutched it tightly. We remained silent, although I could feel what I thought of as companionship and warmth between us.

Finn lay sprawled on his back with his eyes closed. His breathing was moist, and I thought he was possibly close to death. After a time, I felt a slight pressure on my hand. “Is this it?” he whispered, seeking my confirmation he was dying.

Steadily, gently, and with all the kindness I could fold in, I slowly confirmed, “Yes…This is it.” He seemed to relax then, sinking back into his bed as if soothed. Though his hand still held mine, it had lost its tight grip.

* This article, with full references and the author’s notes, first appeared in the Journal of Contemporary Narrative Therapy, 2022, Release 2, 27-61, and is reprinted with permission of the author.

Is Private Equity Coming for Your Therapy Practice? An Interview with Joe Bavonese

Posted on February 16, 2023February 11, 2026 by rezendevknowfully.com

In Search of Golden Geese

Lawrence Rubin: You are a practicing psychotherapist, owner of a large group practice, and consultant to other practitioners around practice development — including selling those practices. You have also mentioned to me that you twice went through the full process of selling your own practice to private equity firms but changed your mind in each instance. What exactly is a private equity firm, and why the seeming current high level of interest in psychotherapy practices?

Joe Bavonese:

private equity firms tend to be these rather large companies whose sole purpose is to buy other businesses as an investment and then flip them in a couple years

Private equity firms tend to be these rather large companies whose sole purpose is to buy other businesses as an investment and then flip them in a couple years, hopefully making a profit. In the last five years, they’ve figured out that mental health practices can be a very profitable company to purchase in lieu of trying to make a profit. So, we’ve seen this influx of these large national companies that are heavily funded who have either started their own practice — like BetterHelp — or are simply purchasing practices with the goal that “We’re going to buy maybe 5 or 10 practices and then in 3 years we’ll sell them all to a bigger fish and we’ll make 50 percent profit.”

LR: If the sole purpose behind private equity firms buying practices is flipping and profiting from the sale, does it really benefit the owner of the practice beyond whatever remuneration they receive? Or perhaps what I’m asking is if there is any fidelity to the practice of psychotherapy involved in these purchases.

JB: Well, that’s been the big controversy, Lawrence, because in the last few years, it seems like the larger the private equity firm and the more money they have, the less concerned they seem to be about patient care and/or how the staff is treated. So, that’s one of the ethical issues that I think a lot of practice owners are experiencing. You know, “Do I want to sell my practice to a company where the care of the clients may deteriorate, the staff may be unhappy, and I’ve nurtured this baby from day one as my legacy, and it’s all going to get trashed?” So, that’s definitely one of the big problems.

LR: They say that you never really lose money buying real estate or gold, but why do these equity firms think that psychotherapy practices are golden geese, so to speak?

JB:

what’s attractive about psychotherapy practices is that they are relatively inexpensive to run — you don’t need any fancy, expensive equipment

What’s attractive about psychotherapy practices is that they are relatively inexpensive to run — you don’t need any fancy, expensive equipment. The demand for mental health, especially since COVID, is through the roof. Then what they typically do is buy a practice that only has psychotherapists and immediately hire several psychiatrists which adds tremendously to the revenue and the profit margin. They’ll do things like this just to eke out as much profit as they can, but it’s really a volume game. In other words, they are really looking for large practices where there are 30, 40, or 50 therapists and then they can really show a higher profit margin on volume.

LR: Is that common? Are there that many group practices of that size in this country to be bought?

JB: Oh, yes. There are. I can talk in terms of revenue over size of the practice, but there are quite a few group practices that have revenue of at least $2 million. I know quite a few that are between $4 and $6 million gross revenue, and then the profit of that ranges from 15 to 25 percent. So, if you have a $5 million practice and you make a 20 percent profit, that’s a $1 million profit a year. That’s not chump change.

LR: No. That’s not chump change at all. Is there a difference between a venture capital organization and a private equity firm when it comes to buying and selling psychotherapy practices?

JB: I’ve not heard of a venture capital company wanting to buy a psychotherapy practice. You hear about how they seem to go after tech start-ups and things that really have a chance to scale tremendously. Psychotherapy doesn’t scale tremendously like a Facebook or Amazon.

LR: What does scalability mean when it comes to selling and buying a private practice?

JB:

over the last two years hiring has been very difficult

Scalability means you can grow exponentially. So, a typical experience would be that of a practice owner who has three therapists who says, “Wow, this is great. I’m making $1,000 profit a month for doing nothing.” Then suddenly, they have 6, 9, 12, 15, and 20 therapists, and they’re making $200,000/year profit, and it just grows rapidly exponentially. Almost everybody I know who has a large group practice never thought they’d get as big as they are. They’re always like, “Well, I thought I might get 5 or 10 therapists and have a nice little cushy cash flow on the side.” But once it takes off it’s almost like it just gathers momentum and more people hear about it. Now, having said that, over the last two years hiring has been very difficult. I think the pace of scalability and growth exponentially has slowed down for many practices.

Winds of Change

LR: What factors contributed to the financial attractiveness and scalability of psychotherapy practices?

JB: I started my group practice in 2000 and there was very little competition. So, it was relatively easy to find competent therapists who didn’t want to deal with their own office, didn’t want to deal with billing if they used insurance, didn’t want to deal with marketing or advertising. They just wanted to show up, do their work, and go home and not worry about anything else. That model worked for a lot of people, so I began coaching group practice owners.

I designed a course called “Creating Group Practice” in 2009. Back then, almost everybody did very well. The harder thing was getting clients. Getting therapists seemed easier. During COVID, there were two things that kind of juxtaposed. There was COVID, and then there was the influx of private equity. So, we now have companies like BetterHelp that are — you’ve probably got these things in the mail — you know, a $500 signing bonus to do teletherapy.

There are more and more group practices. On Facebook, there’s a page called “The Group Practice Exchange.” It has like 3,000 members. There are more people who have realized that just having a solo practice may not provide enough money to live the lifestyle that they desire. That was certainly my motivation. I thought when I got out of grad school, “Oh, I just need to fill out my practice, my wife’s a therapist and there’s two of us, and we’ll be fine.” Well, life is expensive when you have kids, a retirement, college savings, and all that, and a lot of us realized it’s not enough money.

LR: So, there was an exponential increase in group practices. Did COVID impact the scalability of practices and their value?

JB:

as the interest rates have gone up along with fears of a recession the valuations that private equity firms have given group practice owners have gone down significantly

The peak valuations group practice owners were getting was around 2020. However, as the interest rates have gone up along with fears of a recession, the valuations that private equity firms have given group practice owners have gone down significantly. But in terms of your question, during COVID I think the virtual therapy businesses like Talkspace and BetterHelp, who had massive backup funding from Wall Street, just poured millions of dollars into hiring and advertising. So, that created a real problem. The other thing I’ve been hearing in the last six months from several group practice owners is that some of these companies are poaching their therapists. So, yes. It’s just created a whole different climate. Now, referrals are plentiful, although that seems to be slowing down a little lately. But finding therapists is much more difficult.

LR: So, these trends are making private practices less attractive to equity firms right now, or more attractive?

JB: Less. They’re willing to pay a lot less than they were just two years ago. The other trend I should mention, Lawrence, is that it’s never been easier for a therapist to go out on their own. I’ve heard so many cases over the last two years during COVID of good therapists leaving group practices saying, “I’m going to sit at home and do what we’re doing right now on Zoom or on some other platform, and I’m going to make 100 percent of the money, and I don’t need to pay for an office.”

LR: So, there was a massive increase in interest in group practices, followed by decreased valuation related to COVID?

JB: Yes, because the people that were able to hire during COVID did very well. I have several colleagues and friends who put a massive amount of money into hiring and retention. They hired recruiters and did all sorts of things. Many of them expanded tremendously during COVID because the referrals were plentiful, and it was just a matter of finding bodies and you could fill them up instantly with referrals.

LR: Then that slowed down?

JB: Yes. Group practice owners' ability to hire has been a problem. I was just talking to someone yesterday in Oregon. He has a large group practice and said, “The problem is that therapists are leaving to go on their own just to do teletherapy. No office payment. Plenty of referrals if they’re just on Psychology Today. And they’ve been able to keep 100 percent of the money.”

LR:

but with COVID and the exodus into teletherapy these same therapists figured I don’t need to pay overhead anymore I can work in my pajamas out of my basement

So, the group therapy practices were a haven for therapists who didn’t want to run their own practices, but with COVID and the exodus into teletherapy, these same therapists figured, “I don’t need to pay overhead anymore. I can work in my pajamas out of my basement.” So, there’s been a retreat from group practices and the group practices became less profitable, scalable, and thus less interesting to private equity firms?

JB: Yes. They’re still interested. It just seems like they are willing to pay less. There’s a concept when you value a practice called EBITDA, which stands for “earnings before interest, taxes, depreciation, and amortization.” But what it really means, to simplify it for our discussion today, is the profit of your business plus whatever you pay yourself that a buyer wouldn’t have to pay. So, for example, let’s say your practice value is $200,000 a year, but you pay yourself $50,000 a year for salary and you pay yourself $50,000 a year for healthcare and other miscellaneous personal expenses. Well, the new owner isn’t going to have to pay for either of those, so you add that to the $200,000 and now your valuation is suddenly $300,000. Then they give you a multiple of that as the ultimate value they’re willing to pay for the practice. Two years ago, people were getting multiples of 10 or 12 times their EBITDA. So, again, if it was $300,000, that could translate into a $3 million value. Now, in the last few months, I’m hearing 4 to 6 is typical, with occasionally an 8. So, the value you could get two years ago could be double what you get today.

The Business of Practice Ownership

LR: It sounds like owning a group practice, or even a private practice, requires a certain degree of entrepreneurial skill. My understanding and my experience are that psychotherapists who are there to help others are not necessarily entrepreneurs. Do you find that that’s the case?

JB:

one of the biggest struggles a lot of private practice owners have is separating the need for service from the need for paying attention to the bottom line, the numbers, and the money

Yes, absolutely. I’ve been coaching therapists since 2005. One of the biggest struggles a lot of private practice owners have is separating the need for service from the need for paying attention to the bottom line, the numbers, and the money. A lot of therapists tell me they feel guilty if they promote themselves. A lot of therapists are not good at numbers and keeping track of all the metrics. What I would say is the group practice owners who have succeeded at a high level are all entrepreneurial, have all studied business in various ways, and have figured out how to be a business owner as well as a clinician.

LR: That makes sense. You certainly seem business savvy, so what was your experience like each time you went through the process of selling your practice but then pulled back?

JB: It’s interesting. The first time I went through the process was in 2018. Valuations were still pretty low back then. But the process was that you got a letter saying, “This is what we’re willing to pay for your practice,” and then you have a 60-day period of due diligence where the company that wants to buy your practice wants to look at all your metrics to make sure that what you told them was accurate, which makes sense. So, if you said your revenue was $2 million and it was really $1 million, they would want to know that. So, you had to give them a slew of things like years of tax returns, profit and loss statements, and a lot of just busy work. A lot of spreadsheets, PDFs, and things like that.

The part I found uncomfortable was that they basically try to prove that you’re lying to them. And you’re pretty much talking to a bean counter. You’re not talking to a therapist. So, their job is to prove that the numbers are valid and accurate. But my experience was they did it in a fairly demeaning way, which was uncomfortable. Like I said, “I gave you all these tax returns, all these bank statements, and you think I’m lying or hiding? What could I be hiding?” So, that was part of the process. Then what happens is that you start out with an offer and then their job is to whittle it down by saying fairly trivial things just to keep lowering the number, which can’t go up from the original number — but it can certainly go down.

LR: Like car dealers. Just it’s not a car, it’s a practice. So, it was demeaning, it was patronizing, it was nickel and diming, and that sort of took the wind out of your sails?

JB: Yes. Ultimately, we ended up with a number that I didn’t think was worth it because one of the things you think about is, well, how much profit do I make in a year? And if I could make up in two or three years what they were going to pay me in one lump sum, well, that seemed kind of stupid. I figured I could make a lot more money in 5 or 10 years than getting out now and just having this one lump sum.

LR: It seems that the group practice owner contemplating a sale must consider not only financial issues, but lifestyle issues, existential issues, family issues. It’s not just a matter of how much money, but it’s what’s left for me professionally and financially if and when I do sell.

JB: Yes, exactly. Because if I said to you, “I’m going to give you $3 million,” well, that sounds like a good chunk of money.

LR: But?

JB:

if you sell your practice and you leave, and you’ve devoted every waking second to this for the last 10 years, it’s a huge loss of meaning

But you’re going to pay taxes, you’re going to pay broker fees, you’re going to pay attorney fees. So, you usually end up with about two-thirds of that, and then is that enough money to live on for the rest of your life? In most cases, not. So, part of it is, do I have enough money to do this, or do I want to stay on and keep working like a lot of people do? I wasn’t interested in that when I was doing it, but a lot of people stay on once they sell and take an annual salary.

I’ve seen $125 to $250,000 a year, and that of course makes it easier to see if the money will last. But then you have the other issue of, “Now, I have a boss when I haven’t had a boss in years and I’m part of a large organization with politics and other things.” But you use the word existential. The meaning question I think is one of the significant ones because if you sell your practice and you leave, and you’ve devoted every waking second to this for the last 10 years, it’s a huge loss of meaning, and I don’t believe one that’s easily replaced.

LR: What types of psychotherapy practices seem most attractive to private equity firms?

JB: What they’re looking for is consistent growth over the last three years — 20 to 30 percent per year. They want to see an expansion in staff. They want to see diversification of services. They’d rather have a company that’s the one-stop-shop that deals with anxiety, depression, couples, and trauma rather than just somebody who has one specialty. They’re also interested to know if medication is prescribed by a nurse practitioner or psychiatrist, which is a huge bonus because it’s a cash cow for them. They’re also interested in geography — they want to enter a territory and start you as the hub of that territory. Or if they already have practices in your location, they may want to add you as one of the spokes around the hub. Those are some of the main factors that they’re looking for. Also, a healthy profit margin. If your profit margin is 8 percent instead of 20, well, you’re not going to get as much money because there’s an inefficiency there that they’re going to uncover.

LR: Have sellers of group practices ever been held liable by these equity firms for unmet financial promises? “

JB: This is what happens. Usually, they structure the deal where they’ll say something like, “This is the price I’m willing to pay, but it’s contingent on a certain percentage of therapists staying,” because a certain percentage of therapists will typically leave after a sale. So, for example, what they’ll often do is they’ll say, “I’m going to pay you $1 million for the practice, but only $500,000 today, and then depending on the size of the staff in 6 or 12 months, I may only pay you $200,000 more because you’ve lost 20 percent of your staff.” So, it’s incumbent on the owner to be the cheerleader to encourage all the staff to stay on. Typically, they have better benefits than they had previously, so there are some incentives to stay on. But again, if the quality of the client care and the staff care decreases significantly, a lot of people are going to leave.

LR: When a group practice owner is planning a sale, do they ask or have their therapists sign an “I will not leave” contract to protect themselves against that?

JB:

almost every mental health stock in the last 2 years has gone down 70 or 80 percent

No. The company buying the practice will have a contract everybody must sign. They typically don’t tell them until the ninth inning. It might be two weeks before they close. So, all the therapists will usually meet with the group practice owner as well as somebody representing the buying company, and they’ll present them with a contract. Then they’ll say, “You have two weeks to sign this contract,” and if a significant number don’t sign it then the deal is off. So, that’s the tense part. I have known some deals where they didn’t have a thing like that. The other thing I should mention, Lawrence, is often the companies that are buying prefer that some of the compensation be in the form of stock options instead of cash. So, I might say to you, “Okay, I’m going to pay you $2 million, but $500,000 of that is going to be in stock options.” Then they’ll tout the potential of the stock. However, almost every mental health stock in the last 2 years has gone down 70 or 80 percent, so if you were one of the ones who were banking for a big payday because of your stock options you may have lost quite a bit of what you thought you were getting.

LR: Stock options?

JB: Yes. In other words, I’m a big company that’s on the stock exchange and I have shares that I will give you. I’m going to give you so many thousands of shares. But you can’t sell them right away. You’ve got to have two or three years before you can sell them. But remember, in the last two years, almost every mental health stock has gone down like the rest of the market.

LR: So, when you’re saying mental health stock, you’re not talking mental health stock. You’re talking about the stocks and the shares in the private equity firms or the firms that own the firms?

JB: Yes.

Ethical Concerns and Red Flags

LR: You said one of the positives to the therapists who stay in the group practice are benefits. Maybe life insurance, certainly continued coverage of overhead. Are there any other benefits that the therapists who stay on reap as opposed to any disadvantages that accrue to the remaining therapists?

JB:

the therapists who stay on are at the mercy of this rather large national company

The benefits usually include health insurance and retirement. Sometimes it includes stock options for the therapist. That’s another thing. The healthcare and the retirement stuff is generally better than what they had, but in terms of a downside to staying, it's that they’re suddenly part of a huge company instead of a tiny company with 30 or 40 employees, so the policies and procedures are often quite different. They have to learn how to use a new electronic medical record program. They might have to participate in more meetings. They have less say in changing anything, which they might have had at a group practice where they were able to meet with the owner and change something. Now, the therapists who stay on are at the mercy of this rather large national company.

Sometimes what we’ve seen is that some of these large national companies really don’t have anybody who’s ever run a group practice at the higher levels. So, some of the things that they do don’t work very well. I’ll give you an example. A large national company may, for example, have five practices around Tampa and only one regional call center. A potential client can’t walk into the actual practice and make an appointment. They can’t walk into the office where their therapist works to speak with that therapist or check on their bill. They have to call this regional center that has no idea who they are. The feedback I hear is it’s been awful because people are used to getting answers right away with a friendly face in the office. There might be an office manager they can talk to. Suddenly, there’s this impersonal regional center that answers the calls and a lot of people don’t like that.

LR: Along these lines, you mentioned that you’ve had serious concerns about the ethical issues of selling. This is obviously one of them — the stakeholder, the client getting lost in a large corporate machine. What other ethical concerns have arisen from this for both practitioners and clients?

JB:

i think a lot of the ethical issues I hear are about the unknown part of the sale and how the staff will be treated

The other one is how the staff is treated. Again, when you run a group practice, you usually have a dedicated admin staff who have grown with you. It feels like your family. They’ve gone through all the tough times with you and the good times, so they’re very loyal. So, the idea of throwing these people to the wolves is part of the ethical issue. I think most group practice owners worry less about the therapists because there’s so many opportunities nowadays for them to land on their feet or go on their own. But I think a lot of the ethical issues I hear are about the unknown part of the sale and how the staff will be treated. For example, an owner may sell their practice in 2022, and the purchasing company says, “Yes, in 2025, we hope to sell out to another company and then all the policies and procedures are going to change again.” So, there’s this unknown. What am I subjecting my staff to? It’s just impossible to know.

LR: Aside from the impersonal nature of practices that are regionally managed, are there other downsides?

JB: In addition to feeling like things have gotten more impersonal and colder, there may be changes in insurance. There may be changes in therapists’ availability. There may be changes in non-competes. They may feel more locked into a schedule. Those are mostly the things that I think the clients or patients feel.

LR: Are there any red or green flags when a group practice owner is sent a letter of interest by one of these national equity firms?

JB:

in retrospect, I’m grateful I didn’t sell because I had no idea what I was doing

The group practice owner must do their own due diligence. In the last couple of years, most group practice owners of a significant size have gotten two to five letters like that in the mail. So, usually, they just want to talk to you on the phone initially and give you the sales pitch about why you should consider this. But I think the red flags would be you really need to be part of a support group of other group practice owners. I run or co-facilitate four different group practice online groups of various sizes and we share resources. Somebody said, “Oh, I’ve got a new one. I just got a letter today. Has anybody heard of this one?” So, it really helps, because when I first did this in 2018, I didn’t know anybody back then who had been approached or tried to sell so I was really shooting in the dark. In retrospect, I’m grateful I didn’t sell because I had no idea what I was doing.

LR: What about when a single therapist gets a letter about joining a group practice that has been purchased? Any red flags there? Because I get several of these a week.

JB: Again, you just have to do due diligence and see what they’re really offering and ask if it’s really any better than what you’re doing right now. You’re definitely going to lose some freedom. It may make certain aspects of your practice easier. But you really have to research. The companies are so different. Some of them seem very focused on clinical care, and with others it just seems like an afterthought, just as an example.

LR: Have there been reports to the Better Business Bureau or to the APA, or are there similar places where someone while doing their due diligence could go to see if these private equity firms have not met their promise or been abusive?

JB: As simple as this sounds, Lawrence, the best thing is often to go on Google and just type in the name of the company with the word reviews and it reveals quite a bit. Some of the companies are listed in the Better Business Bureau, though not all of them, and you can get some feedback there. But I’m just finding that the word of mouth through the community probably gives the best information. But I’m surprised by just how much you can get just from a simple Google search.

A Short List of Tips

LR: Is there a short list of tips and guidance you could offer a practitioner who is approached by or seeks out a private equity firm?

JB:

some of these equity firms not all are just ruthlessly focused on growth and all they care about is bigger bigger and bigger

Well, like I said, do your due diligence. Get as much information about the company as you can. Especially ask, “Why are you interested in my practice now? What is your goal for the next few years? What is your philosophy about how you treat the staff and the clients?” Because, like I said, some of these equity firms, not all, are just ruthlessly focused on growth and all they care about is bigger, bigger, and bigger, and it comes through clearly when you talk to them. Others will slow it down and talk about their philosophy. But you really want to zero in on how much do you really care about clinical care? How much do you care about the competence of the staff, or is it just a numbers game to you? So, those are some of the things you want to find out.

LR: So, theoretically, a private equity firm could come in and just fire the whole staff?

JB: Well, they wouldn’t do that because hiring even for them is still difficult these days. Really the only value of the whole enterprise is the staff and the client, so if you fired them, you’d lose the whole revenue.

LR: In insurance companies there’s usually a psychologist who oversees claims and answers difficult questions. In your experience, has there been a clinical point person in these equity firms?

JB: Yes. Usually, they have a clinical director, a regional clinical director, or a national one that you’ll talk to who will make everything sound sweet and rosy. But during that 60-day due diligence, that person is pretty absent and you’re mostly just talking to the accountants or the attorneys.

LR: Boy, you’ve really got to be sharp and on your game.

JB: Yes. That’s what I should mention. There’s no way as a licensed psychotherapist to do this on your own. You have to get a broker or some financial person to help you through it. It’s just too much stuff that you have no idea about. You need somebody who understands the lingo and can help you avoid the obvious traps.

LR: Have private equity firms favored white-owned, white-serving practices? Is there a racial/cultural line?

JB:

i would say the percentage of black owned group practices is lower than the percentage of Blacks in the population

That’s a good question. I would say the percentage of Black-owned group practices is lower than the percentage of Blacks in the population. Like I said, I’ve talked to probably 80 to 120 group practices in the last 5 years. It’s not an exhaustive search, but it probably gives me a fairly decent survey of who is out there. I haven’t heard of that. I think they’re more focused on the numbers and whether the location fits into their long-term strategy, but I really don’t have any data on that.

LR: Of those 80-120 practices you’ve spoken with over the last 5 years, have you found that there’s a consensus around the right time to sell, or is it more idiosyncratic?

JB: Well, it is idiosyncratic, but there are some categories I think people fall into. One category is that “I’m so burned out and sick of this, I’ve got to get out,” which unfortunately I know a fair number of people like that where they are constantly stressed out by their group practices, constantly stressed out, and physically and emotionally exhausted by the demands of dealing with the staff. For those people, I think if they can afford the deal financially, it is probably best to get out because they’re not happy. They’re really not enjoying the ride. Then the other thing is the category of people that just want to say, “I don’t want to ever have to work again if I can get a good enough deal, and if I like the philosophy of the company buying me, then that’s good and I’m happy to do it.” But again, it depends on your age, the age of your kids, all those financial things, and your lifestyle. So, I’m thinking the most common thing is that the motivation is financial, clearly. A good friend of mine recently said, “I’m looking for a new challenge. I’ve been doing this for 10 years. It works well, I know how to do it, but it’s getting kind of boring. And a lot of the private equity firms are saying, ‘I want to buy your practice and then I want you to spearhead the project of adding eight more locations around the area of your practice.’”

LR: And they don’t want to do that. They just want the hell out.

JB: Yes. But if they want to stay on to keep a salary coming, that’s basically what they’re going to be doing for a while. It’s just, “Okay, what do you think of this one?” More than likely, the parent company will fund it. One of the nice things people have told me is not having to worry about the price of furniture or computers — it’s sort of like a blank check. Whatever you need in terms of a new location, we’ll provide it.

LR: So, the group practice owner who is ambivalent or who is not quite at the stage of life where they should make the decision probably needs to be coached? And that’s where you come in with your consulting service.

JB:

i do one on one coaching. I have other colleagues who do one-on-one coaching for the same reason for those people

Yes. There are a lot of people who are interested in it, but they don’t know some of the things we’re talking about today. They don’t know the realities. Or somebody promised them something on the phone that turned out to be false in the long run. So, I do one-on-one coaching. I have other colleagues who do one-on-one coaching for the same reason for those people.

LR: Joe, to turn the tables; if you were me interviewing you, is there anything I’ve missed? Any questions I could’ve asked that would deepen our readers’ understanding of the issues?

JB: JB: I just think the existential issue gets minimalized by people. I really don’t think people realize how hard it is to replace meaning in their life because it’s not like most entrepreneurial-minded people who are successful at a group practice do not do well with free time. One of the phenomena I’ve seen which is interesting is that as people get bigger and more successful, they stop seeing clients totally and then they delegate more and more stuff, and suddenly they might only be working 10 or 20 hours a week. You would think on the surface that would be great, but what I hear is, “What do I do with my time?” So, it’s like having gaps in their schedule after working crazy hours for years to build this thing up is often difficult. It sounds funny, but it’s a real issue that I think people minimize when they go into this process.

LR: So, I would imagine you often coach these folks around the existential issue, almost like doing therapy?

JB:

one of the things that I did was to ask myself what were some of the things that I stopped doing when I had kids and when I started my group practice that I wished I could have continued

Yes. It becomes more therapy than business coaching at that point because everybody’s sense of meaning is different. But I guess it’s no different than retirement coaching other than they’re still working to some degree. But yes, it becomes more like therapy to kind of tease out, “Well, what are the most meaningful things?”

One of the things that I did was to ask myself, “What were some of the things that I stopped doing when I had kids and when I started my group practice that I wished I could have continued?” Then I made a list and that’s what I’m doing now, so it works out nicely. But I still think a lot of people have never thought about it. “Well, it’ll just be an endless vacation, or I’ll just play golf.”

LR: Or climb mountains or go to baseball games.

JB: That’s right.

LR: Thanks so much for sharing your expertise and experience with me today, Joe. This area is so new to me, and I think it’s going to be equally new and hopefully helpful to many of our readers, some of whom may be contemplating joining a group practice or building a group practice or selling their group practice.

JB: Well, good. I’m glad to hear that, thanks.

Travis Heath on Psychotherapy as an Act of Rebellion

Posted on December 8, 2022February 25, 2026 by rezendevknowfully.com

An Act of Rebellion

Lawrence Rubin: Hi Travis, thanks for joining me today. I first became aware of you and your work after reading “Reimagining Narrative Therapy” that you co-edited with Tom Carlson and David Epston. There you said that therapy is, or at least should be, an act of rebellion?

Travis Heath: I wrote that, huh? It’s always interesting to reflect on one’s own words. Should it be an act of rebellion? Maybe it shouldn’t be in every case. Yet, I think there could be therapeutic advantages to therapy being an act of rebellion. What I mean is that sometimes, usually unwittingly, therapy can become an act of reinforcing normative ways of being. What we might describe as “mentally healthy” may actually be a normative societal way of behaving. So then, an act of rebellion is when people move against the norm, right? To go against the status quo. And there could be — whether it be in therapy or elsewhere — immense therapeutic value when that rebellious act is consistent with who the person most knows themselves to be. Now, I’ll say that an act of rebellion for the sake of rebellion, like a contrarian act of rebellion around every turn, may not always useful. But one that is truly consistent with who a person is can have a positive impact on one’s mental health.

LR: And sometimes people come to therapy not sure of who they are, or which story is the one that is the healthiest for them to live by. Are you suggesting that for some people a therapeutic relationship allows them to rebel against norms that are oppressing them or holding them down?

TH: I think a therapeutic relationship can help with that, although I don’t know if that is enough alone. As someone who is informed by narrative ways of working, therapeutic questions are very important to me. Most of my questions are average at best and probably don’t lead to much change in people’s lives. But all I need is one really good question. Not one that I’ve conjured up, but one that just comes up quickly in the moment from the relationship I am having with the person that I just throw out there. A good question can open up a way of living that a person hadn’t articulated in a particular way before. Maybe they felt it somewhere or tried to imagine it, but now they’ve put words to a particular direction.

LR: This may be a tough one to pull out of your hat, but can you give me an example of a client that you recently worked with, or that stands out in memory, where you came up with the right question at the right time?

TH: Yeah, that’s a good question. I was working with a women-identified person in her 40s. In our culture, there are certain ideas about bodies — how they should look, and how bodies should and shouldn’t be shaped. I think this is especially so for women. That pressure seems to be increasing for those of us who are male-identified as well, but it’s been very tough for women for some time. She was really distressed when she came to me and was talking about eating peanut butter. Like, “I’m really distressed because I’m eating peanut butter.” And I remember saying to her, “Okay, I hear you and I want to understand what’s distressing about this?”

I remember saying to her, “Can I share something with you? I eat peanut butter too sometimes.” And she kind of smiled, but added, “No, I mean I eat too much peanut butter.” And I said, “Okay, again, I hear you. Help me understand. What’s too much peanut butter?” She said, “Well, I might eat a spoonful or two spoonfuls of peanut butter.” And I said, “Hey, I won’t want to tell you how to eat or what you should or shouldn’t be eating. I’m just really trying to understand. And I wonder, is it possible that you could eat a spoonful or two spoonfuls of peanut butter and that might in some way be okay? Now, if you told me you ate the whole jar or something and you were doing this nightly, I would understand how that would be distressing. But do you suppose it might be okay that you eat a spoonful or two of peanut butter?”

With that question, she burst into tears. It was a simple question, not something you’d see in a textbook as an exemplar. But it was really just a question that in some small way, maybe larger than I initially realized, invited her to think about how she came to understand what’s too much peanut butter and what’s not enough peanut butter. The question was asking her to consider how she came to understand that eating peanut butter might begin to define her as not a good person. How did she come to understand that process? And we really had a session just about peanut butter, which sounds sort of wild, but it wasn’t initially an act of rebellion. It became an act of rebellion for her because she was resisting some of these discourses about food and about her body.

I remember asking her, “Okay, so how often do you do this?” She said once or twice a month, so I said, “All right. Let’s just say that you stopped doing that. Do you then think your body would, over time, or maybe quickly, begin to conform to this body that you’ve been told you should have?” She really thought about that and said, “No, it probably wouldn’t.” “Well, what kind of acts of torture or anything else could you put your body through to make it look like these bodies you’re telling me would make you a good person?” In that moment, with that question and the questions and answers that followed, it was essentially about, “If I looked this way, I’d be a good person.” But she couldn’t initially articulate that. It was the question about “peanut butter” which enabled her to communicate those feelings of insecurity that she constantly experienced yet couldn’t ever explain. In that way, our conversation about eating, and even just existing in her body, became an act of rebellion against normative prescriptions of what society tells women is a good body.

LR: You know, Travis, I would imagine at one level you were very aware that you weren’t really talking about a spoonful of peanut butter. Instead, you were creating a space in which she could really question the legitimacy of her rigid thinking, and maybe even dive more deeply into a conversation about self-worth, body image, and perhaps gender with its discontents.

TH: Lawrence, I might say it just a little bit differently. Not so much her own self-talk, but the talk of the culture that she had adopted and the cultural meaning of “self-talk.”. Because when people say “self” in front of anything — self-talk, self-esteem — I get skeptical. Self-talk isn’t really her talk, although it may feel like her talk because Lord knows how long that talk has been kicking around. But she didn’t come out of the womb with that talk. That talk came from someplace, and now it’s become a part of her. So, I think that this act of rebellion you’re talking about, when it is really shining, can help people see that and say, “Oh gosh, I didn’t come out of the womb with this. Actually, these aren’t my ideas.” Then that can lead to, “And I don’t even have to subscribe to these ideas,” which can be very liberating.

Confessions of an Anti-Manualist

LR: So, you created a space in which she was given permission to rebel against certain language that has been forced on her or force-fed to her. Shifting gears a bit, has traditional therapy’s search for the grail of evidence-based techniques enhanced or diminished the craft of psychotherapy?

TH: I like the question, and I think it’s an important one. Without trying to be too long-winded, I do think that historically the idea of “evidence-based techniques” came from a good place. By that, I mean hey, there was a time when psychotherapy was viewed in a certain kind of way—the work of charlatans. Hell, there were psychologists, not clinical psychologists, but there were psychologists — I think Cattell and some of those other folks — that weren’t necessarily huge fans of psychotherapy. And so, I think there was a time when it was important to show that there was some kind of scientific evidence base, that therapy wasn’t just akin to palm-reading. Maybe I shouldn’t dismiss that out of hand, but that’s a different conversation. The point being, there was a real reason for attempting to create psychotherapeutic techniques with evidence as their primary foundation.

At some point, this idea of evidence-based practice got tangled up with late capitalist ideas, and people discovered that you could sell a hell of a lot of workbooks. You could also bring a hell of a lot of legitimacy to what you were doing, and it helped your personal brand that was tangled up with the brand of your therapy. That’s where I think it started to become problematic. So, the idea of having evidence is not necessarily bad. But when it’s done for these sorts of capitalist reasons, I become concerned about it.

Now to your question of the art, if you will, of psychotherapy. I’ll share a quick story from a class I was teaching probably 10 years ago. It was an undergraduate intro to clinical and counseling class, and as we discussed I have never been too keen on these evidence-based models. So, I started the class by bringing in treatment manuals and handing them to everyone. “All right class let’s look these over. What do you think about them?” Most of the students, and I think this says a lot, were comforted by this. “Oh, great. I could do this. I could follow this script.”

Then one intrepid young woman who sat in the front of the class asked, “Well, what happens if you’re using this and it doesn’t work with someone?” And I said, “Well, okay, that leaves us at a bit of an impasse, doesn’t it? I personally don’t believe there are just two ways to do therapy. But let’s just look at two possibilities. So, one possibility is we use this manualized approach that we’re looking at. And it works to a certain degree for some people, maybe even most people. And you do a mediocre, good enough job, your whole career. And then, every now and again, you find someone it really doesn’t work for, and I guess you just abort mission. Or another option — it’s not the only other option — is that we learn how to do this on sort of a moment-to-moment basis. We’re really being in touch with the other person.” I said some other shit, too, but the students almost universally agreed that one sounds better, but it also sounds scarier. It sounds like a lot more work. And how do I know if I’m doing it right? They had all these questions, which were all very fair.

My worry is that somewhere, usually early on in people’s formal training, without even realizing, without even really being presented it, they’re nudged to make the choice of one manualized treatment over another. They’re nudged to go down one of these pre-determined roads — and they’re sort of nudged often. And then if you’re trained in that way, it’s hard to put the genie back in the bottle. It’s not really that one way of doing therapy is superior, but if you’ve worked with enough people, you come to understand that you aren’t going to be able to take the same damn thing and apply it to everyone who walks through the door, or even most people.

LR: So, would you say that you are an anti-manualist, or that you practice an anti-manualized form of therapy? I know Narrative Therapy is, by definition, an anti-manualized intervention.

TH: I have never heard it put that way. I like the term. I accept the term. I don’t know if I always live up to that as much as I could. I mean look, there are certainly patterns to my work. And people who know my work well and who have watched it behind mirrors or whatever they’ve done over the years, could point to patterns in my work. I don’t know if patterns are manuals because I’m not necessarily adhering to a prescriptive one, two, three, four, this is the order of how you do things. But there’s a certain soul to the way that I work. And there are patterns in how I work. I won’t deny that. At one point, however many years ago, I said, “Well, I never do the same therapy twice.” That feels a little self-aggrandizing. Like why am I saying that? Yes, there are elements that overlap. So, to be an anti-manualist, yes. I like that idea. And, I have to acknowledge that not everything I do with every single person is completely new and creative. There are some patterns that you see.

De-Colonializing Therapy

LR: There are likely many clinicians in our audience who are really into manuals. It seems that once a therapy has an acronym, a workbook, and a “seal of approval” by some credentialing body, it becomes the stuff of grail. In this vein, and based on our conversation and my reading of your work, are we speaking about detraditionalizing therapy practice?

TH: Thanks for asking these questions. To detraditionalize, for me, is something that if it doesn’t happen, then a therapy dies. But let’s get outside of therapy for a moment. I think almost anything dies. Maybe some of the folks who would frequent this interview may not be sports fans, so excuse the sports analogy, but I’m a big basketball fan — played basketball my whole life. And people will watch the modern NBA and they’ll say, “these guys shoot too many three-point shots. Back in my day, we never shot 30-foot shots.

That may be true enough, but the game has to evolve. It must evolve. It cannot stay stagnant. Now, did it have to evolve in the way it did? Maybe not. But it must evolve, or it dies. And I think it’s the same with therapy. So, to detraditionalize, it’s not that we can’t do it with intention, we can. But I think for an approach to therapy to remain viable over the years, it must change and evolve. A lot of psychoanalytic psychodynamic approaches are probably misunderstood in the modern world. But the best practitioners I know who appreciate and look through that lens, they’re not doing the same shit Freud was doing. They might have taken some of those ideas and some of those cues, but they’ve detraditionalized them. In a way, they’ve modernized them. So, that’s the first thing I want to say.

The second is, like in my work, I think traditionally there is a healer and a person to be healed. And then the person that’s the healer is somehow supposed to have the answers or write the prescription. And to me — I’ll take a line from my mentor friend and colleague David Epston — a lot of Narrative Therapy is about elevating the knowledge of the other. And so much of my practice, and a part of it that I think is maybe detraditionalized, is not to rely on psychological knowledges, or psychiatric knowledges or descriptions, but to try to elevate the knowledge of the other.

And the other doesn’t just include the person who’s in front of you. There’s a whole ancestral presence that often comes with that person who sits in front of you. Whether they realize it or not, it travels with them, it informs them with insider knowledge about how they may approach distress or problems that they’re up against in the world. And even so with therapists that would make the claim, “Well, I’m client-centered, I focus on the client.” Yes, but if you actually watch it unfold, it’s still based on a counseling prescription or a psychiatric or psychological prescription about how the session should go. It isn’t necessarily elevating the knowledge of the other.

LR: You said something earlier, and I don’t necessarily want to skip around too much, but it seems like we’re entering a cross-conversation about multiculturalism. When we talk about “elevating the other,”, are we getting at your ideas about working with “the other,” and what you have referred to as “decolonializing” psychotherapy?

TH: The phrase I’ve liked most recently is “anti-colonialize.” De-colonialize is fine, but I don’t like post-colonial, because post-colonial implies that somehow, we’ve moved past colonial logic, which we haven’t. Anti-colonial to me just seems like a little bit of a stricter stance against past, present, and future colonial logic and colonial attempts at living. So, I’ll start with that. But de-colonial is fine. I like that word, too.

You’ve heard me use the phrase “colonial logic,” but I’d like to weave in yet another term here: “multicultural.” If we look at the term “multicultural,” and a multicultural approach to therapy or counseling, often what that is saying is, “Hey, those of you from non-European descent, you can come, we welcome you. You can come and heal in these Eurocentric mediums of healing.” On the surface of it, that’s a nice offer. But it doesn’t make a ton of sense. And really what it’s doing is replicating colonial logic in that, “Hey, these European ways of being, behaving, and these European standards of living, these are the right standards. And we’re going to help you through therapy live up to these standards and these ways of being.”

To me, an anti-colonial approach would seek to first try to find the colonial logic that’s at play. And nobody bats a thousand at that, I would argue. But because it’s so embedded in the culture, we don’t think to critique it, although that has been happening more in the last couple of years. Anti-colonial, then, talks about culturally democratic approaches to therapy. A friend of mine, Makungu Akinyela in Georgia, has a type of therapy called “Testimony Therapy” which he equates to being next of kin to narrative therapy and African-centered therapy approaches. He says that a culturally democratic approach is to invite people to speak on behalf of their own healing.

And so, if we hope to practice an anti-colonial approach, which to me is like the big umbrella term, then a culturally democratic practice seems important because people are allowed to speak on behalf of their own healing. Speak in their mother tongues. Speak through the cultural knowledges that they have come up with.

One thing about psychiatry and psychology, if we’re not careful, is we can get a little too big for our britches. We can think that healing’s only taken place in the last century-and-a-half, or whatever it’s been. No, it’s like, hey, come on, you think just because we’ve now labeled these things as depression or anxiety or PTSD, people haven’t been up against these things throughout time?

LR: Like we invented these afflictions.

TH: Right. And did these people with depression and anxiety all just curl up in a ball and not live their lives? No, people have experience with healing. And they have knowledge about healing. It doesn’t have to exist in a Eurocentric way. And often what therapists are doing — almost always unwittingly — when they’re reproducing colonial logics in their practice is recolonizing people. And often the therapist doesn’t realize this is happening, nor does the client. And yet, this process is playing out. It’s assimilation. We talk about, should people assimilate when coming to a new country…Well, really that’s what therapy has often been doing, again unwittingly. I don’t think this has been done with malice.

LR: This is psychiatric assimilation.

TH: Right, exactly. And so traditional therapy reproduces this colonial logic, which then sometimes — again, completely unwittingly almost always — is reproducing internalized racism where people might already experience feelings of inferiority. It doesn’t always have to be around race, of course. It could be any number of other factors. So, I hope that there’s some justice to your question.

LR: So, traditional multicultural counseling, if I’m hearing you right, is, “Sure, come into my session, wear your native garb, let me learn a couple of buzzwords that are unique to your culture. And sure, tell me your story. But in the end, I’m going to lay some ACT on you.”

TH: Yeah. And again, almost never is this done with malice. But that’s some of the demanding work I think we have to do. And another thing is like, okay, I am of mixed racial background. I have the blood of the colonizer and the colonized that runs through me, which is a complicated place.

One of my colleagues out here in San Diego now, Vid Zamani, he was the first one I heard say that if we are reproducing traditional Eurocentric ways of doing therapy, then we are a de facto White. And I really appreciated that, because it was like, well, just because of my own background, that doesn’t make me immune from practicing colonial logic. And he said, of course, that makes total sense.

But if we’re not careful, then what happens is in the field’s attempt to diversify—sure, we might look diversified on the surface, but our practices aren’t that diversified—we’re still practicing the same colonial logics. The practice really isn’t changing, even if superficially the people doing the practice look different.

LR: So, until the psychotherapist recognizes that they are colonializing their clients, until the traditional colonializing psychotherapist rebels against their own inherited narratives of what psychotherapy is, they will continue to colonialize their clients. And colonialize the psyches of their clients.

TH: Yes. And this is, I’ve found, a largely unpopular idea. Especially among folks who have been doing this for a while. I’ll share this story that I think drives home your point. I was doing a job interview. Not for the institution I’m currently at, but for a past institution. I was doing a presentation that talked about some of this stuff that we’re talking about now. And when I got to the end of it, a dude says to me — an older white man in his 60s, “Hey, I’m going to throw you a softball question.” And right away I was like, okay, yeah, what’s this guy up to? And then he says, “Well, what am I supposed to do when you tell my students that I am practicing a therapy that’s colonizing folks?” And I thought about it for about five seconds, and then respectfully I said, “Well, if I can share something with you, I can guarantee you I’m practicing in colonizing ways. And in fact, I can guarantee you I’m doing it in ways I’m not yet aware of. So, in that sense, I wouldn’t be asking you to do anything that I am not practicing myself.” But I found that there are folks that are resistant to the fact that their work could be colonizing at all.

Communities of Care

LR: In the context of this thing called multicultural practice and colonization, what do you mean when you talk about the dignification of the client? I think that was your word.

TH: No, it’s David Epston’s word, although I might have used it. What’s interesting about that, Lawrence, is that I met David in 2015, so that’s seven or so years ago. I had been out of graduate school a good six, seven years at that point. I had been practicing in the community for the same amount of time. I had been a university professor for seven or eight years. I had been around this a minute, and I had never — and I mean literally never — heard a person use the word “dignity” regarding clients in therapy. I was taken aback by the word the first time I heard it in this context. Dignification is even a little better than dignity.

When someone’s up against something, some kind of distress — I’ve worked with a decent number of people in the criminal legal system — they are often stripped of their dignity. And so, dignification is really an effort to afford the person that dignity within the conversation. And when we engage in dignification and people can feel that they have dignity, that helps to open additional stories in their lives. And maybe those stories were already there, but if they don’t feel as though they have dignity, then those stories are inaccessible to us. Even if they’re there someplace.

I noticed this with people in the penal system—it doesn’t happen after one meeting and could actually take months — but when they really started to feel dignity, and that they were living a life with dignity, and respected as a person with dignity, we would start to see a turning point in what we were doing. Because there aren’t many systems that are practicing un-dignification more than the criminal legal system. And so, it was actually a great place for me to see that juxtaposition of when people are afforded dignity. And these probation officers would ask me, “Hey, how did you get this young man to take responsibility for his actions?” And I said, “Well, first by never mentioning the term ‘personal responsibility.’ That’s probably not a great way to go, even if that’s what you’re hoping for. And secondarily, by taking them seriously. Treating them with dignity. Listening to their ideas. Taking that insider knowledge they have and really using it as something that could move us forward in a way that would make sense in their lives.

LR: Your dislike of the notion of “personal responsibility” brings me to something you said about the difference between self-care and communities of care. What is that difference?

TH: Well, it depends. What’s the goal? If the goal is to make money and sell lots of products, then we’re not moving in the wrong direction at all. I think Ronald Purser is the dude’s name, he wrote the book “McMindfulness.” He articulates this as well as anybody I’ve heard. It’s worth the read.

Look, self-care is another one of those things I feel like came from a good place. And when I talk about my issues with self-care, I preface it by saying, if you want to take a bubble bath, that could be lovely. If you want to watch a movie or do whatever, great. I’m not against that. Where I find this to be problematic, and our field has done this as much as any that I’ve seen, is a student, for example, in a master’s or doctoral training program in our field starts struggling. And often the response by those in charge has been, “Well, are you doing your self-care? What are you doing to take care of yourself?” But then you look at a PhD student. They come here, work 18 hours a day, doing all their school stuff. We don’t pay them enough to survive, we give them a small stipend. Now they have to go work another job. But we remind them “please don’t forget to take care of yourself.”

Essentially and systemically, we outsource the responsibility for the oppressiveness of the system and then turn around and say, “It’s your responsibility.” As opposed to a community of care — and this is something I try to think about in my role as chair now of an academic department — which is, “Okay, if we have faculty that are drowning or students that are drowning, what are we doing to do to help, rather than lay the responsibility on the student to adapt to a system that is rather oppressive?” So, do we need to scale back some of what we’re requiring? Do we need to change the ways that the system operates? What can we be doing, other than once a school year bringing puppies in? “Hey, that’s lovely.” Or they’ll have a little massage chair set up. Fine.

I was talking to someone this morning, and the language that she used was so passive. We say, “I’m experiencing burnout.” And my thought about that is, no, you’re being burned out. That’s not the same thing. It’s about experiencing burnout versus being burned out. Our systems are burning us out. And so, if our systems are burning us out and we’re asking people to handle this individually while the system that’s doing this for its own gain takes no responsibility, well, then this is just going to keep repeating.

And I’ll come full circle to say that I think, not individual people, necessarily, but folks with something to sell don’t mind that. Because if the person is continually being burned out, guess what? They’re going to consume more of the product that we want. So, the system is actually set up beautifully for making money. I don’t necessarily think it’s set up good for quote-unquote “mental health.”

LR: So, in a sense, graduate trainees, like therapy clients, are typically colonized and oppressed by structures of authority. What do you mean when you say that therapy — and graduate education in the context of this conversation — should be an act of shared humanness?

TH: Yeah, I think again, the culture that we’re in is so ruggedly individualist, that often the human experience gets defined solely within the individual. And I worry about that. And to me, therapy at its best is shared humanness. I used to do this early on when I was a therapist. I came up for my first master’s class in 2002 with all these journals under my arm. I was going to save the world by going into these communities in South Los Angeles. And it didn’t take me long to figure out that shit wasn’t going to work, and I had to do something else. I learned that quickly.

The way I think about the shared humanness now is, we can’t be doing what we’re doing right now in this conversation without shared humanness. The same goes for a therapeutic conversation. When there is shared humanness and it comes together, something exponential is possible. But I would not be able to say everything I’m saying today during our time together without your questions. Your question takes me somewhere that I couldn’t have gone just by myself. Maybe I could have generally gone there, but something about your questions and the give–and-take transports us there. And the shared humanness in therapy is exactly the same. You bring these two people together. And what we could each accomplish on our own could be fine, or even good. But what we can accomplish in this shared human way is exponential.

Wholehearted Therapy

LR: Very similar to what Irvin Yalom refers to as the here–and–now—that the therapeutic relationship is lived in the moment — the fruits of psychotherapy grow from the back and forth. Is this related to what you describe as “wholehearted therapy practice?” And what does a therapist look like when they’re practicing halfhearted therapy?

TH: I think halfhearted therapy, or quarterhearted, or two-thirdshearted could happen for a lot of different reasons. But to me, wholehearted therapy is bringing all of yourself to the practice. One of our students asked a fair question just a couple of weeks ago; “How do I know how to be in therapy relative to how and who I am out in the world?” They asked it a little differently, but basically what they were asking was based on their feeling, “I don’t know how to not bring all of who I am into the room.”

And so, I think halfhearted therapy can happen when we think that there are parts of us that somehow can’t come into the room. Now, what I’m not saying is that there are certain topics we might not talk about in the room. Now, I would even question some of those and whether they are truly off limits, and I do frequently. But obviously there would be some topics that would be off-limits for us. Therapists could decide that. But I’m not so much talking about the topics of discussion. I’m talking about how much of themselves that they’re bringing. And I fear that therapists are often taught not to bring important parts of themselves.

With regard to halfhearted therapy, they could be doing therapy in a system in which they’re chronically underpaid and overworked, and their spirits are just really sucked dry. And then they just don’t have that spirit to bring. In no way would I blame the therapist for that. But if I think about the times when I’ve engaged in halfhearted or quarterhearted, or however much hearted therapy practice, it’s often been for those reasons. Now, earlier on in my career, it was because I was asking myself, well, can I be this in the room? And of course, that’s a ludicrous question, because I am this. So, one way or another, the person that I’m in conversation with starts to deduce that anyway.

LR: In the recently released “Reimagining Narrative Therapy Through Practice, Stories, and Autoethnography,” you wrote a chapter entitled, “Maybe We Are Okay: Contemporary Narrative Therapy in the Time of Trump,” in which you narrated the therapeutic interaction you had with a person whose political views, specifically, their Republican views, clashed very dramatically with your Democratic views. So much so that the conversations about who you voted for 2016 became part of the therapeutic relationship. And in that relationship, you nicely demonstrated how you can disagree with someone’s political views, but still respect them as a person. Was that an example of wholehearted practice?

TH: It was interesting how that chapter came about. You know how therapists can get together and start talking in between seeing clients. Well, I noticed a lot of my colleagues saying something like, “Well, if Trump came to therapy, would you work with him?” I didn’t say anything when my colleagues were saying, “NO, I would never do that! Who could do that?” But then, I thought about it, and I was like, yeah, I think I’d work with him. I don’t know if he’d want to work with me. Maybe he’d tell me to get lost, but I think I’d try.

I just remember how outraged they were. And when they asked the question of how I would do that, I would say, “Well, I haven’t worked with Trump, but I’ve worked with plenty of people who have views that are very different than mine.” So, that was the inspiration for this, to try to explain shit to myself. Even after writing the chapter, I’m not sure I understand how I always engage in this work. But, to go back to bringing one’s full self into the room, we didn’t get deeper into the party politics in that chapter. But if we happened to in our sessions, I wasn’t super-enthused about voting for Hillary. I felt like a lot of people — like I have to decide between two people that I’m not really enthused about. Okay, I’ll take the one that I’m a little more enthused about. I’ll engage in a minimization-of-harm vote, is kind of how I felt.

But clearly, in the chapter you’re describing, my client and I voted for different people. When that moment came up, the question was, “Do I talk about it or do I not?” And the thing about that is, okay, I could decide not to talk about it. I could decide to do the thing as, “Oh, that’s an interesting question. I wonder why you’re asking?” But she knew. She had a sense of this, of who I voted for. And I’ve heard people say this kind of thing who haven’t read the chapter, but have said, “Well, you know, you’ve got to be careful. You’re pressing your political views on them.” But I disagree. What I’m doing in therapy is I’m simply showing up as I am, and she can show up as she is. And then we have to figure out how that meshes, and how we do the work together that we’ve been charged with doing with one another.

And that doesn’t require me being neutral. And by the way, I’m not neutral. It’s just a matter of whether I admit I’m not. I’ve seen a lot of discourse around this lately about neutrality and people debating what it means and all this kind of stuff. But to me, it’s an impossibility. We are not neutral. And so rather than try and pretend as though I am — not unsolicited would I share such a thing, but when it works its way into the session — when she brings this up, it’s like okay, let’s talk about the shit that we’re not supposed to talk about. Let’s talk about religion. Let’s talk about politics. To me, therapy seems like a great place to do that. And not just in the sense of me just passively listening or looking for pathology in the patient and how they talk about this. But rather, let’s have an actual conversation with two wholehearted human beings about the thing that we’re not supposed to have a conversation.

LR: In a sense, you are co-rebelling against the mandates of traditional therapy with a client by self-disclosing and by being fully present.

TH: And neither of us has to change our political party. Although for me, I’m not that enamored with the Democratic Party, either. But I’m not sure I have a party that represents my interests, to be honest. I certainly wouldn’t say I’m an Independent. That has its own set of connotations. But I don’t feel like I have a party that represents my interests. And I didn’t say that explicitly. At least I don’t recall saying that in my work with her. But perhaps it came out. Perhaps this is more complicated than we give it credit for.

And to me, probably these last two or three years, I’ve constantly been on the lookout in my therapeutic work for people with binaries. Because our culture relies so heavily on them. And I often find that when people bring those up, that’s at the root of something that they’re really struggling with. And it’s built into our language, Lawrence. We say, “Well, I need to hear both sides of the story.” And to me I’m like, I’d like to hear all the sides of the story that I could hear. I’d like to hear many sides of the story. I found that often people are thrust into these binaries, and it almost feels like there’s not another option. So part of my job is to have these discussions and then look outside of those binaries for what could be there. And I don’t think therapists do this on purpose, or clients do it on purpose. It seems to be a real cultural thing.

LR: I used to joke with my classes — sorta — by saying, “There are two types of people in the world. Those who believe there are two types of people in the world, and those who don’t.” Does this wholeheartedness, the kind you described in your work with this particular client involve what you refer to as “radical respect?”

TH: I can tell you the story about where that term came from. I don’t know if we mentioned it in the book, but it came from Art Frank, a brilliant writer. He’s not a therapist but when he would read transcripts of sessions or watched sessions, he said, “When I see David [Epston] practicing, Tom [Stone Carlson] practicing, what I see is radical respect.” And so that term actually came from someone outside of the therapeutic community altogether, which I think is worth noting.

I think part of what he’s getting at is there is that no matter where the person moves, no matter where they might take the conversation, no matter what the stories are that they might wish to live through, or that are living through them, that narrative therapy endeavors — it isn’t always successful — but endeavors to hold this deep respect for people and why they are behaving the way they are. Why they’re living through the stories that they are. Why they’re feeling the way they are. And that radical respect then to me promotes curiosity.

So, in the chapter that you were referencing, the Trump chapter as it’s getting to be called, I hope there were some examples of radical respect in there. I’ll give you an example from the chapter of my attempt at it. When I came to realize that by completely dismissing her perspective — which I don’t think I did, but I could have because I found a lot of things Trump did objectionable — I might have been engaging in some sort of erasure of her family. And that would have been highly disrespectful. And so even when it was something that I fundamentally disagree with, there was still a way I could practice respect. This was opposed to going, “Well, but you’re on the wrong side of history.” I also think radical respect is a feeling that both the therapist and client experience, sometimes without words.

Art Bochner talks about “evocative autoethnography” which is not about the therapist simply being a fly on the wall, but instead being moved by the client’s story, their narrative. Let’s say you were reading that chapter about me and the woman, and you had never seen either of us before, and then you see us walk out of a room. You’d know it was us. But the point is, that’s what we’re endeavoring with autoethnography. We get out of the world of jargon so both partners in the therapeutic moment can feel and experience it.

LR: As we near the end of our time, Travis, I want you to know that I’ve had a lot of fun in this interview. Do you have any questions for me?

TH: No, but I will say one thing quickly, though. If therapy is really an act of rebellion, then there has to be something at stake, there has to be risk involved. It has to mean that you could be out of compliance in some way — with tradition, with certification standards, with accreditation expectations. And if we’re not doing anything, if what we’re doing is completely devoid of risk, or we’re afraid to take any of that, then we won’t move any of these things forward. And I know plenty of people who are, in their own ways, challenging these different systems. And this is not to knock the accrediting bodies. They have their role. But we have to take some of these risks. To detraditionalize, as we were talking about earlier. Risk is inevitable, right?

LR: On that note, I think I’m going to say goodbye. I thoroughly enjoyed this conversation, Travis. It reignites me.

TH: Stay in touch. Holler at me with whatever.

QUESTIONS FOR CLINICAL THOUGHT

How does Dr. Heath’s description of his work resonate with your own therapeutic approach?
Which of his concepts strikes a particular chord with you and why?
How might you have worked with the client who struggled with peanut butter consumption?
How do you engage in radical respect with your own clients? Do you have difficulty doing so with a particular type of client?
Can you think of a client with whom you have worked, or continue to work, wholeheartedly or halfheartedly?
What about Narrative Therapy interests you and challenges you to learn more about the model?

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