rezendevknowfully.com, Author at Psychotherapy.net

Francine Shapiro on the Evolution of EMDR Therapy

Posted on November 14, 2014February 11, 2026 by rezendevknowfully.com

When a Cup Isn't Just a Cup

Ruth Wetherford: Francine Shapiro, you are the originator of EMDR therapy, the founder and executive director of the EMDR Institute, and author of numerous books, articles, and other interviews about this process. I want to begin by asking you a basic question: What is EMDR therapy?

Francine Shapiro: Eye Movement Desensitization and Reprocessing, or EMDR, is a form of therapy that focuses on memory and the brain. Every different form of therapy has a different model, a different way of conceptualizing cases and different procedures. For instance, in cognitive behavior therapy (CBT), pathology is based on inappropriate beliefs and behaviors. In psychodynamic therapy, it’s intra-psychic conflicts. In EMDR therapy, pathology is based on unprocessed memories that are stored intact—so if someone has some irrational beliefs or negative behavior, that’s not the cause but rather the symptom.

For example, let’s say we’re humiliated or bullied in grade school, and instead of the brain digesting it and making sense of it and letting it go, it actually gets stored in the brain with the emotions and the physical sensations and the beliefs that were there at the time. One of the functions of the information processing system of the brain is to make sense of the world, so if something happens 30 years later as an adult that is similar in any way, it has to link up with the memory networks to be made of sense of. In other words, if I’ve never seen a cup before, I don’t know what it is or what to do with it. The perceptions that we have about something in the present link up with the memory networks, and if it connects with that unprocessed memory, it gets triggered, and the emotions, physical sensations, and beliefs—“I’m terrible, I’m not good enough, I can’t succeed”—get triggered as well.

People may have no idea why they continually feel anxiety in social situations or when they talk to somebody at work, because the situation is linking them to an unprocessed memory, and those feelings are coming up automatically. We really are at the mercy of our memory networks, and if an experience hasn’t been processed, we’re just buffeted hither and yon by all of these negative emotions and feelings. With EMDR therapy, we identify what those earlier experiences are and we process them. We bring that information processing system back online. And what happens during an EMDR therapy session is that very rapid associations and connections or insights are made, and the emotions, physical sensations, beliefs—all of those shift to a level of learning and resilience, so we simply aren’t triggered that way any longer.

RW: You’re making the point that the mind and body connection cannot be separated. The cognitions, feelings, and other thought activities of our minds are so integrated with our bodies. This is not new, of course, but it does seem to be getting a lot more attention lately. In a recent interview with Bessel van der Kolk on Psychotherapy.net, he describes having done the only NIMH funded study on EMDR, and as of 2014, the results were more positive than any published study of those who developed PTSD in reaction to a traumatic event as adults. He goes on to talk about the impact of trauma on the somatosensory self, that it changes the insula, the self-awareness systems—which is exactly what you’re saying.

But EMDR therapy is also very easily integrated into other kinds of therapies. In fact, I saw that you won the Sigmund Freud award from the City of Vienna.

FS: People who have been trained as psychodynamic therapists say that EMDR lets them use what they know. They use EMDR therapy to help identify the earlier memories that cause maladaptive defenses and intra-psychic conflicts, and it helps people process those memories and experiences. It’s the same with those who practice cognitive behavioral therapy. EMDR therapy is used to process the memories that are causing dysfunctional behavior and irrational cognitions.

It’s a remarkably efficient treatment. There are three studies that have indicated that for single trauma victims there’s an 84 to 100% remission of PTSD within about five hours of treatment.

RW: That’s great.

FS: A study with EMDR therapy in combat veterans found that after only 12 sessions, 78% no longer had PTSD. Of course, the amount of treatment time it takes depends upon the number of memories that have to be processed, but you don’t have to process each and every event because memory is connected. Instead, you choose one that represents a whole group, and then you have a generalization effect. It rapidly shifts.

RW: This is the phase that has so much in common with all approaches to trauma. Learning self-soothing skills is consistent with all mindfulness meditation and stress reduction methods. It gives people a sense of confidence that they’re not going to be lost when they leave the session. It’s remarkable how fast the dysfunctional beliefs can shift from “it was my fault that I was abused” to “I didn’t deserve that.” It doesn’t happen all in one session, but—

FS: Well, it can.

The 8 Stages of EMDR

RW: Perhaps you could tell us a bit more about the stages of EMDR therapy?

FS: EMDR therapy is an eight-phase approach. During the first phase, the clinician takes an appropriate history of the client, finding out what the current problems and symptoms are, how long they’ve been going on, what the systems issues and the relationship issues are, etc. Then we begin to identify what earlier memories are causing many of these problems.

If you’re coming in with relationship issues like, “I always overreact to criticism,” we try to see what’s causing the overreaction. What earlier memories might there be that are pushing it? Does the sound of your husband’s voice remind you of your father’s voice before he hit you? We have specific techniques to identify these problematic memories.

The second phase involves preparation. We teach a variety of self-control techniques so that people learn to shift from negative feelings to positive ones.

You don’t have to process each and every event because memory is connected. Instead, you choose one that represents a whole group, and then you have a generalization effect.

These techniques can be very useful for everyone, but ultimately we’re trying to lessen the need for them. That is, if I’m always buffeted by these unprocessed memories, and I’m constantly needing to shift out of negative feelings into positive feelings, what I really want to do is process these memories so I’m not getting triggered by them any longer. A preparation technique will allow the person to feel in control so that when we start the processing, if a disturbance comes up, and they feel like they want to stop, we just stop. We use the technique to shift back into feeling good, and then when they’re ready, we go back and continue the processing.

The amount of preparation depends on how debilitated the client is to be begin with. Some people have never had good experiences—they had a terrible childhood, were beaten, ignored, neglected; they didn’t have anyone in their life that they could turn to or count on. These folks can be extremely debilitated emotionally, so we may need to spend more time preparing them. For most people it doesn’t take very long at all, maybe a session or so.

RW: That’s true, it can.

FS: For an individual trauma, it might take two or three sessions. And you simply want the client to be in the best possible state, not only during the processing but also in between sessions.

RW: So they can shift into and out of the self-paced imagery?

FS: Exactly. It’s not homework, as you would get with cognitive behavioral therapies for trauma. But let’s say it’s going to take three sessions to finish an individual trauma—you can do that morning and afternoon, or you can do it three consecutive days. In other words, the treatment can be done in days or weeks, rather than months or years.

The treatment can be done in days or weeks, rather than months or years.

And because all of the therapy is done with the clinician, they don’t have to go out and confront negative feelings and experiences on their own in order to try to make things change.

RW: So the history, identifying the memories, and preparation are the first phases. What happens next?

FS: Then we move into processing. We identify a memory that has been causing the symptoms and then we identify different aspects of it—the image, the negative thoughts associated with it, where they’re feeling it in their body, what the emotion is, etc. And once we access the memory in a certain way, we start the processing, which involves stimulating the brain’s own information processing system that allows the different connections to be made.

One of the procedures in the processing involves a form of dual attention stimulation—meaning the client follows the clinician’s fingers with their eyes as they move rapidly back or forth, or it can be tones or taps. It seems to stimulate the brain’s information processing system, and the client then has different, rapidly moving associations. They may have new thoughts about the memory, or other memories may emerge, or new insights can come up. It allows the brain to do the digesting by making all of the appropriate links that it hadn’t been able to make before.

Eye Movement

RW: After the preparation phase, I usually introduce the eye movement component. First I do the protocol, the target image. Many people don’t want it to be a memory—they’re coming in with some anxiety that they’re dealing with right now, and they don’t necessarily make the connection to memories. So I might start with a target image like, “when my husband’s face gets angry and frowny, I go into a panic.” Then I write down the negative self-beliefs after and rate their anxiety on a scale of intensity from zero to ten. I see where that anxiety is felt in the body. While they’re doing this protocol, they’re identifying what they’re feeling, what their beliefs are—“I’m a bad person. I’ll be a failure. I’ll be humiliated. I’ll be punished.”

And then I draw a line across the tablet and say, “What beliefs would you like to have?” This is straight out of your protocol. It’s often surprising to people, but once they get it, they can really elaborate. “I’d like to feel confident that I can handle this moment.” “I’d like to feel certain that I can stay calm and reasonable”—that sort of thing.

It’s a powerful moment when I move my ottoman over in front of the person and hold my hand up after customizing it for them. The rapidity of the motion back and forth, how wide the sweep is—these are custom tailored for each person, and then they go into that image—they’re seeing the husband’s face, angry and escalating, and they can actually feel their beliefs: “I’m getting ready to be demolished.” It is phenomenal. It’s very different.

FS:

It’s been demonstrated in about 16 randomized controlled trials now that the eye movement also rapidly causes the vividness to shift and emotion to decrease.

It’s been demonstrated in about 16 randomized controlled trials now that the eye movement also rapidly causes the vividness to shift and emotion to decrease. So they may start out with a disturbance, but it very rapidly decreases and shifts to that new understanding—from “that’s how my father used to look at me” to “that was wrong of him” to “It wasn’t my fault” to “it was his fault.” It’s getting liberated from how they felt as a child so that they can see the present more clearly.

RW: It’s so true.

FS: Of course there might be a need for couples counseling, but in many instances, these overreactions are caused by early childhood events stored as unprocessed memories.

RW: We all know that when our sympathetic nervous system gets aroused, clear thinking goes out the window.

FS: Right, exactly.

RW: The point here is that when you’re doing the eye movement part of it, after having prepared the self-soothing and the cognitive component of the beliefs and the desired beliefs, the shift is so remarkable.

The person may have four or five associations: “I see my parents fighting. I see myself hiding behind the door. I feel terrified. I feel like I should stop their fighting. It’s my fault.” The therapist picks out one of those, which I think is an area of the art of the therapist, knowing which one to pick that will lead to the next set of associations. But when it’s very, very accepting, no judgment, no anxiety on the part of the therapist, that calmness is often rewarded. After the next set of repetitions, the person says, “I do not have to rescue. It’s not my fault.” They’ll say it. You never have to say it. They get to it themselves.

FS: Very often the therapist can stay completely out of the way and foster and support the client nonverbally. We’re conveying acceptance because we do accept it. We are conveying unconditional regard because that’s part of the therapy process, so the clients don’t have to be afraid of their own emotions. They don’t have to be afraid, and they can reveal as much as they want.

With other forms of therapy, you have to describe the memories in detail. With EMDR therapy, that’s not necessary. The client says as much or as little as they want to.

With other forms of therapy, you have to describe the memories in detail. With EMDR therapy, that’s not necessary. The client says as much or as little as they want to. As a matter of fact, in many instances, you can do it content free, and the client just gives you enough information to know that it’s changed. So rape victims, molestation victims, who may feel so much shame and guilt that they don’t want to talk about it initially—they don’t have to. You don’t have to force the client to do or say anything that they don’t want to.

RW: Your point about the calm, accepting, unconditional regard is a component you’ve emphasized in the trainings, but I don’t know that it comes across to some people who think EMDR is technique-y.

FS: There are specific procedures about when you continue the associations and when you return to the target, but the beauty of it is to allow that internal, intrinsic healing mechanism to take over and to make the appropriate associations and not take a clinical stance that you know more than the client, that you are the one that has to give the answers. In most instances, the connections are all there for the client and when they’re not, we have specific EMDR therapy procedures to kick start it again. It’s not about clinicians imposing themselves on the client, but rather allowing the appropriate healing to take place.

RW: So what is the next stage?

FS: Assessment is the third phase, where you’re identifying the memory and the different components of it, and then you move into a phase that we call Desensitization, which is allowing the insights and connections to be made until they’re a zero on the Subjective Units of Disturbance Scale (SUDS). It could start off at an eight or nine, but it’s down to a zero.

Then we move to a phase we call Installation, which has to do with concentrating on that desired positive belief the client wants and seeing if we can strengthen it so that it feels completely true to the client.

Then we move to the Body Scan phase, where we have the person think of that memory, think of the positive belief, and scan to see if there’s any disturbance in the body; and if there is, we process it.

We process the memory, evaluate, reevaluate, reassess, and see what else needs to be done until we've basically addressed all of the issues, and the client is feeling empowered.

For instance, a molestation victim who is feeling good and powerful scans her body and notices that there is a strange sensation in her back, and we focus on that. It turns out that’s where she was held down when she was raped. So we process that.

At the end of the session, the Closure phase brings the clients back to the full state of equilibrium. We remind them of their self-control techniques and the in-between-session processing they can continue to do. We also suggest that if a disturbance comes up, to just write down what happened very briefly—“I walked into X situation and I got triggered”—so that they can be targets for next time.

Then the eighth phase at the next session is Reevaluation, where we bring back the memory and see how it feels. See if there’s anything else that needs to be addressed. For instance, I worked with a girl who had been molested by her grandfather, and by the end of the session she was saying, “He was really weak. I ran into the bathroom and he tried to get in, and I just kept telling him to go away, and he went away.”

At the next session when I saw her, she felt fine. She didn’t feel dirty. She didn’t feel shameful. She didn’t feel powerless. She had a good grip on it. But in asking her what else might be coming up, she said, “Well, I was thinking of my grandmother, that she didn’t believe me when I told her I was molested.” So that’s the new target. We identify what else needs to be processed, and that’s how the therapy continues.

We process the memory, evaluate, reevaluate, reassess, and see what else needs to be done until we've basically addressed all of the issues, and the client is feeling empowered. It’s not only that the major symptoms are gone, but they feel like a positive, healthy, resourceful human being and are now able to establish and maintain positive relationships in their life.

Death by a Thousand Cuts

RW: In my own practice, the vast majority of my clients don’t come in to do EMDR therapy. They are coming in with other problems in living—anxiety, depression, relationship problems, etc.—and then I introduce it to them. It’s looking at the current target image, the current source of the anxiety, that then leads to association with past memories of actual trauma. But another source of trauma is the reaction of the social environment to the trauma. Like in the example you just gave, the woman’s grandmother, in her disbelief, was another source of trauma in addition to the molestation.

This is a common consideration in most trauma therapies—that it’s not just the trauma, it’s everybody’s reaction to the trauma that makes it worse, so I think that’s such an important component. It’s all interconnected.

FS: PTSD has commonly been thought of as a response to major traumas—earthquakes, rape, molestation, combat, etc. But the research now is very clear that general life experiences can cause even more PTSD symptoms than major trauma. Childhood experiences, humiliations, divorce, conflicts in the home—these things can be a source of chronic PTSD.

RW: Death by a thousand cuts. All the micro traumas that get accumulated.

FS: It doesn’t even need to be accumulated. You can have individual childhood events, like an individual being pushed away, being left behind, being humiliated in grade school, having people laughing at them. Any of these things can get stored in the brain with terrible feelings and thoughts of, “I’m not good enough. I can’t succeed. I’m not powerful.”

PTSD has commonly been thought of as a response to major traumas—earthquakes, rape, molestation, combat, etc. But the research now is very clear that general life experiences can cause even more PTSD symptoms than major trauma.

They get locked in and run the person for the next 30 years. So it’s important for people to have some compassion for themselves and not just dismiss their anxiety or their depression or their insecurity just because they don’t know where it came from. Many of us simply don’t remember because it’s a long past childhood event, and we don’t recognize that the problems we’re having in relationships or at work are influenced by these earlier events.

Also there’s a lot of research now showing the negative impact parents can have on the lifelong health of their children. There was a study done at Kaiser Permanente that clearly showed that adverse childhood experiences were the leading causes not only of mental health problems in adults, but of physical health problems as well—cancer, lung problems, etc. So I think we need to be more aware of how these experiences are being stored in our brain and constantly pummeling us with negative feelings that impact not only our minds but our bodies. These problems are transferred easily to children because research has clearly shown that mothers who have posttraumatic stress disorder are more likely to mistreat their children—not purposely, but they simply react more harshly.

Research has also shown that highly disturbing experiences within two years before childbirth can prevent the mom from bonding with her child, which has extremely negative effects. Maternal depression is one of those factors that Kaiser Permanente identified as causing these lifelong negative effects for adults because depressed mothers may not be able to bond with their children. It’s not only major traumas that are the problem—all kinds of experiences can have long-lasting detrimental effect on individuals.

RW: That is certainly corroborated by all the new imagery and radiology advances that have been made in which various autonomic processes—not only the body but the brain—are shown to react during negative interactions with people. There is this whole cascade of activity—everything from cortisol to high blood pressure to galvanic skin response to a change of blood flow to the frontal cortex and the amygdala. We all have this sympathetic arousal over traumatic interactions.

What is the latest research on how neurological reprocessing of trauma actually works?

FS:

EMDR processing seems to link in to the same processes that occur during rapid eye movement sleep.

EMDR processing seems to link in to the same processes that occur during rapid eye movement sleep. REM sleep processes the events of the day in order to make sense of them, and it moves them from episodic memory to semantic memory, where you can remember what happened, but you no longer have those emotions and physical sensations locked into memory. Until that happens it’s stored in episodic memory, which seems to get triggered with PTSD.

People who have posttraumatic stress disorder often wake up in the middle of a nightmare. That’s the brain attempting to process the event, but it’s too disturbing, so they wake up in the middle of it. What EMDR therapy appears to do is to take the brain further than it’s able to go in its natural state. The eye movements tax working memory and stimulate REM processes, which allows the rapid shift in imagery, emotion, cognition and sensation.

RW: A possible physiological analogy would be how insulin produced by carbohydrates causes the pores of fat cells to open and take in fat, and it’s only when we have proteins that the cells open and the fat comes back out so that we can lose weight. Similarly, there’s some unlocking of synapses where the memories of the trauma are stored. The anxiety has to go down, but there’s something about the bilateral movement that not only allows the memory to be stored, but also then connect with current, more rational, more safe feelings that give people a sense of identity and agency. It connects together and desensitizes the memory, which loses its power, while the current situation gains power. The current sense of self gains power.

FS: What we say is that it arrives at an adaptive resolution. What’s useful from the event is incorporated and the learning takes place. What’s useless is let go, so the negative emotions and physical sensations and beliefs are basically all gone. But it’s different than the concept of “extinction” employed in cognitive behavioral therapies, where the person is asked to describe the memory in detail as if they’re reliving it, making sure they don’t think of anything else but just stay there with that memory. It allows desensitization to occur, but the original memory that’s being targeted doesn’t change; rather a new one is created. The theory is that the person has been disturbed because of avoidance behavior—they haven’t allowed themselves to stay with it because they believe they’ll go crazy, they’ll die. And as their therapist causes them to tell the story over and over again, they realize they won’t die, and that creates a new memory that competes with the old one—but the old one is still there.

With EMDR therapy, there’s a short exposure where you ask the person to think about it, have the eye movement for about 30 seconds or so, and then you specifically elicit associations. They often move right to another memory.

It appears that the original memory is transformed as these connections are made, and the new learning and the new insight is made, and then it’s stored in this changed form.

It appears that the original memory is transformed as these connections are made, and the new learning and the new insight is made, and then it’s stored in this changed form. They no longer feel terrible about themselves. The transformed memory is stored and the original form it began with no longer exists. We call that “reconsolidation,” not extinction. So with exposure therapy, the original memory is still there, but in EMDR therapy the original memory is no longer there in its old form. This may be responsible for certain differences that we’ve seen in treatment.

For instance, there was a study comparing exposure therapy and EMDR therapy for those who had complicated mourning—intense grief that wasn’t changing. When somebody dies suddenly, very often the person who is bereaved continues to have negative imagery, negative thoughts of the person dying, seeing them in pain, guilt about what they should’ve done, could’ve done, etc. When individuals were treated with EMDR therapy and with exposure therapy, the EMDR was more rapid with better outcomes. Interestingly, there was twice the positive recall of the deceased than after treatment with exposure therapy. The fact that the original memory was still intact might be the reason for that.

Another example is the EMDR therapy treatment of phantom limb pain, where accident victims and combat veterans, who lost limbs in a traumatic experience continue to feel pain in a limb that’s no longer there. What we’ve found from the articles that have been published so far is that by identifying the trauma in which the leg was damaged, for instance, and processing it with EMDR, at the end of the treatment, 80% of people either no longer had any pain or it was substantially reduced.

No other form of therapy has reported elimination of chronic phantom limb pain.

No other form of therapy has reported elimination of chronic phantom limb pain.

One last example. In a treatment of psychotic people who had suffered trauma, when treated with EMDR therapy that targeted the trauma, not only were the PTSD symptoms eliminated, but a majority of those who had started out with auditory hallucinations reported that they were completely gone at the end of treatment, which was only about six sessions. That had never been reported with CBT. So there’s a lot more to explore over the next decade or so.

Neurons That Fire Together…

RW: Particularly as we learn more about specifics of the neurophysiological underpinnings of each mind function, like the functions you were talking about just now—extinction and consolidation. This reminds me of the work of Norman Doidge, the Columbia psychiatrist and psychoanalyst who wrote the book about neuroplasticity, The Brain That Changes Itself. He believes that EMDR therapy is one of the greatest breakthroughs in psychology in his lifetime. He would say that there’s probably a neuroplastic underpinning to each one of these very dramatic changes. He talks about how when we are really listening to something, the auditory cortex will make acetylcholine. And when we have a sensation of pleasure or decreased anxiety, there’s a little bit of dopamine secreted, and it’s that combination of acetylcholine and dopamine that creates the brain’s dendritic growth factor, which causes the dendrites to grow a few microns per hour.

Over time these dendrites find each other, which is why a dog will salivate at the sound of a bell once he learns that he’ll be fed after the bell rings. The auditory cortex has absolutely nothing to do with saliva, but the bell creates salivation because those dendrites have found each other. In other words, neurons that fire together, wire together. During EMDR therapy, there must be a lot of firing going on—self-soothing and the reduction of anxiety is getting wired together with the old memories and the new sensations of agency and safety and new cognitions. They somehow get wired together, and that really does replace the old wiring. I believe at some point we’ll be able to confirm this on the molecular level.

FS: I think ultimately that’s where the field is going, but the field of neurophysiology is still in its infancy, so as of yet no one has ever seen a memory network. But there are more than a dozen studies showing how the brain functions both before and after EMDR therapy, and you can see many differences including growth of the hippocampus as well as changes in cortical and limbic activation after EMDR therapy. Why and how that happens will probably take another decade or so to discover, since imaging will need to become much more sensitive.

RW: I just read, I think in Wired magazine, that the new MRI machines can measure 10,000 times greater detail than the current ones, so they can actually see the electrochemical impulse go down the neurons. Isn’t that wild?

FS: Yes. We have a very exciting decade to look forward to.

RW: What about critics who believe that the research is weak because the dependent variables are all self-report? It makes me think about how innovations are accepted in any field, but particularly scientific fields. There are the early adopters, who are just a few, then the middle adopters as more people hear about it, and then there’s a tipping point where everybody jumps on and incorporates the new learning or the new innovation. It seems to me like you’ve been working on this now for 25-plus years. Where do you think we are in that curve of adoption?

FS: I think we’re in the latter stage now. Those critics you’re talking about were responding to research from 15 years ago. At this point, there are more than 25 randomized controlled trials that have demonstrated the positive effects of eye movements, and a recent meta-analysis has shown there’s a significant effect. In fact, one of EMDR’s original vehement critics has completely turned around and stated that it’s clear that the eye movements have been demonstrated to be effective. Critics who make derogatory statements are very much out of date.

The same is true about the research on EMDR’s effectiveness. There are now more than two dozen randomized controlled trials that have demonstrated the positive effects of EMDR therapy with all of the bells and whistles of good research, including standardized measures, interviews, etc. The World Health Organization (WHO) has even stated that trauma focused cognitive behavior therapy and EMDR therapy are the only psychotherapies recommended for the treatment of PTSD across the lifespan. That is for children, adolescents, and adults.

The Trauma of Everyday Life

RW: I want to return to this idea that is so prevalent in our society that if you didn’t have any major traumas, then you should be all right. In fact, that’s not the case at all, as you pointed out. There are so many life events that become traumatic based on cultural influences. There are so many traumatic and worsening aspects of our culture—the increase in poverty and unemployment as wealth is sequestered in smaller and smaller groups; the emphasis on extroversion and positive feelings over fear, anger and grief; the pathologizing of normal problems in living. All of these things are enormously traumatizing, but we don’t think of it as something that our culture needs to look at.

FS: That’s one of the reasons I wrote the self-help book, Getting Past Your Past—to bring attention to the many things that can be causing our negative reactions and symptoms in the present and explain what to do about it. There are so many events in life and so many things about our relationships that can cause anxiety, depression, insecurity and PTSD. It is explainable and it’s treatable.

We have a nonprofit organization that came into being after the Oklahoma City bombing in 1995. We got a call from a FBI agent, who said, “Can you please do something because the mental health professionals are dropping like flies.” There were no empirically validated treatments for trauma back then. We sent out clinicians to do free treatment for the frontline providers and victims, and the program evaluation showed that it had the same positive effects—about an 85% success rate within three sessions—as a randomized controlled study that was published that year. Since that time our Trauma Recovery/EMDR Humanitarian Assistance Programs, has been providing free treatment for victims of natural and manmade disasters throughout the world and low cost programs for inner city areas in the U.S.

RW: How many people do you have volunteering or doing low cost treatment?

FS: There are hundreds. We have responded to all the major disasters in the US such as Katrina, Sandy, the Boston Marathon Bombing and Newtown shootings. Trauma Recovery Networks have been established in about 30 cities throughout the country. And we’ve also sent teams out after the tsunamis and earthquakes around the world. EMDR Asia came into being a couple of years ago, so now they’re able to do the humanitarian work on the continent themselves.

But there are so many more that need help. People who have been hurt can hurt others. Child molesters, for instance, are often viewed as intractable. Many people don’t want to have anything to do with them. We basically keep them ostracized from society.

RW: Further traumatizing.

FS: But a director of a program incorporated six sessions of EMDR therapy for those molesters who seemed the most incorrigible. They themselves had been molested in childhood—which is often the case with those who molest children—and when their own molest was targeted and processed, they came in contact with how they felt at the time.

We can take people that seem intractable and transform them into positive human beings so they’re no longer hurting others.

They recognized that they hadn’t wanted it and empathy emerged for their own victims. They no longer felt sexually attracted to children. It was measured by something called a penile plethysmograph, which measured their arousal, and 90% no longer exhibited deviant arousal towards children. So we’re attempting to conduct more research in this area.

The bottom line is that we’re looking at the potential that no one needs to be left behind. We can take people that seem intractable and transform them into positive human beings so they’re no longer hurting others. We want to make sure that we’re able to get the treatment to all who need it, so that we stop the pain for future generations.

RW: For any clinicians who are reading this and are interested in getting EMDR training, what’s the best way for them to do so?

FS: It’s extremely important that clinicians who are interested in being trained go to a program certified by the EMDR International Association in the U.S or the EMDR Europe Association in Europe. There are people out there offering programs that are not up to snuff. Certified trainings are six days plus consultation. There are international standards that have been developed to make sure that clinicians know what they’re doing before they treat any clients. Non-profit agencies can arrange for low cost trainings from the Trauma Recovery/EMDR Humanitarian Assistance Programs.

RW: Any final comment you’d like to make before we sign off?

FS: I’m hoping that interviews such as this will really allow people to get a better understanding of EMDR therapy and its potential for healing. The unimaginable amount of suffering that’s going on out there does not have to continue. People can truly heal in a comparatively short period of time and move to a state of happiness, strength and resilience, with healthy relationships.

RW: Thank you so much, Francine, for a very good interview.

FS: Thank you.

Brad Strawn on Integrating Religion and Psychotherapy

Posted on August 26, 2014February 11, 2026 by rezendevknowfully.com

The New Conversation

Greg Arnold: You're a professor of integration of theology and psychology at Fuller Theological in Pasadena. You’ve written extensively on the integration of psychology and theology and just co-edited the book, Christianity & Psychoanalysis: A New Conversation. From the perspective of religion on the one hand and psychology on the other, tell me about this new conversation. What was the old conversation, and how does this new conversation set itself apart?

Brad Strawn: Well, there are a lot of conversations going on in this area, and one of the points of this book is to try to be particular and specific. So we're not talking about all of clinical psychology, but about psychoanalytic psychology or psychotherapy, and we asked each of the contributors to be specific about their own Christianity because there are Christianities. There is Catholicism, Anglicanism, Anabaptism, there's Reform, Wesleyan, and the list goes on and on.

GA: Yes, of course.

BS: Part of what we mean by new, however, is that in the history of the relationship between psychoanalysis and Christianity, beginning with Freud, religion has been considered a way that we protected ourselves from the anxiety of fate and those things that we can’t control.

In the history of the relationship between psychoanalysis and Christianity, beginning with Freud, religion has been considered a way that we protected ourselves from the anxiety of fate and those things that we can’t control.

He ultimately captured all of this in his understanding of the Oedipal Complex—the God in the sky is the great patriarch that we project things into. As we grow up, just as a child grows up and eventually doesn't need the father, we also as a society and as a culture would grow out of our need for religion. Science for Freud becomes the new religion, the new way of knowing.

What we argue in the book is that changes in philosophy, in theology and in psychology have allowed for a much more relational understanding of all of those areas. So now we don't have to pathologize religion, but we can recognize that religion serves important functions in culture and there is actually room for it to be considered a viable way of knowing. This allows new conversations to emerge; it’s no longer about psychopathology, but about human flourishing, human knowing, human relatedness, and health. So religion can be a healthy way of interacting with the world.

GA: When you say it like that, it illustrates the common ground between the ostensible purpose of psychotherapy and psychology at large, and what we traditionally consider the goals of religion: Human flourishing.

BS: Right.

GA: It’s good to hear that modern philosophy has shifted to facilitate that. But you did hit on one important criterion for the new conversation, and that’s Christianities. When Freud was saying we're going to grow out of this, how did that contrast with what you're aiming for, which is integration?

BS: Freud had this image of religion as fairly primitive. There were a lot of complex intersecting realities going on at the time, and he was reacting to a number of them. It wasn't a great time to be a Jew, obviously. He ended up fleeing to England to save his own life, which many of his colleagues also had to do, and saw Christianity as part of the problem, which it was.

GA: Sure, but he characterized it as this singular monolithic Christianity with a capital C. How does that get challenged in this new conversation?

BS: It would have been difficult for him to conceive of religion that had a mature component to it. What’s helpful about Christianities is that it opens up the conversation to many other ways of seeing things. There are immature forms of religious experience and mature forms. Erich Fromm was a disciple of Freud, but he went in a very different direction, allowing for the idea of mature religions. D.W. Winnicott is another psychoanalytic thinker who conceives of the maturation of religion. He himself grew up in a Wesleyan tradition and held to it throughout his life to some degree, even though he doesn't espouse much particularity in terms of faith per se.

I think that’s what we get when philosophy, theology, and psychology begin to open up this idea that there are different ways of knowing. We can borrow from the ways that people talk about culture these days. We no longer see certain cultures as being “primitive,” but instead talk about the particularities of a culture. What are the indigenous psychologies within a particular culture or ethnicity or race that cause people to see the world in particular ways? We wouldn't want to talk about them as being immature or primitive. We would want to say, "What do they add to the conversation?"

When I talk to people who aren't religious I say,

"Think about religion as a form of culture that brings particular ways of seeing the world and conceptualizing things."

"Think about religion as a form of culture that brings particular ways of seeing the world and conceptualizing things." It's not true or false. It's just what it is. I think that's been helpful for people, particularly those outside of the religious dialogue.

Therapy is a Moral Discourse

GA: I love the idea of borrowing from our evolving vocabulary about culture, especially in our profession of psychotherapy. We've got a huge vernacular for talking about culture in the therapy room and we can think of religion as a culture and treat it the same way. Intersectionalities, all these blossoming identities, and there's no one integration of psychology and faith because there's no one faith. They're all situated. Let’s take it a step further. Can we, as therapists, view our handling of our own religion and our clients' religion as one more facet of multi-cultural competence, or is there any reason we want to treat it differently than the other trainings we have about multicultural competence?

BS:

I tend not to use the word “competent.” I don't think we can become competent because there are too many cultures and too many religions.

I tend not to use the word “competent.” I don't think we can become competent because there are too many cultures and too many religions. I think we sometimes fool ourselves that we can know enough. When my African-American client who is Muslim is talking, what I know is that this person has a particular way of seeing the world, and my job is to try to understand to the best of my ability how they see the world and where they’re experiencing problems. Where they’re getting caught up in ways of seeing the world that are in conflict with their culture—for example being religious in a secular culture—and helping them figure out how to navigate that conflict.

I believe that psychotherapy is essentially a kind of a moral discourse between two people. The therapist has a particular way of understanding the oughts and shoulds of the world, and the client does as well. We don't do ourselves any good pretending that we can bracket that and leave that out of the room. We have to be honest about that, and at times bring it into the room so we can have open and honest conversations. Not that we as therapists impose that on our clients, but if we don't own where we're coming from, we may in fact be more likely to unconsciously or covertly impose our views on our clients. That's what colonialism was, right? A “white” and “right” way of seeing the world that we now know isn’t the truth.

GA: So it’s important to identify where you're coming from in your own faith tradition, no matter where it is.

BS: Exactly.

GA: Where does the non-religious practitioner fit into this? Can they contribute to the effort to integrate psychology and faith? What does the interfaith dialogue need to be?

BS: A former colleague of mine who is now passed, Randy Sorensen, did some research where he found that good therapy impacted religious clients positively based not on whether the therapist was religious or not, but how open the therapist was to the client's religious experience.

It's the way they approach their clients' religion rather than whether they are religious or not. It's the respect they show for it, the same way they would show respect for a client's culture.

If they didn't pathologize the client's religious experience like you wouldn't pathologize someone's cultural experience, but welcomed it hospitably and made it a place where the client could then explore that in a non-judgmental way, people came out feeling more positive and open about their religious experience than with those practitioners who didn't allow it to be an open and non-judgmental kind of dialogue. I think that's very helpful for non-religious therapists to keep in mind—it's the way they approach their clients' religion rather than whether they are religious or not. It's the respect they show for it, the same way they would show respect for a client's culture.

Religion can, of course, be used in pathological ways, and good therapy ought to help people disconnect from that. But that's not going to be possible if the therapist doesn't want to talk about it or comes in with too many a priori assumptions about religion. So that's where a secular or non-religious therapist can actually contribute to this dialogue, and particularly contribute to good psychotherapeutic work by welcoming a client's religion the same way they would welcome the client's culture or gender or sexual orientation.

GA: So multicultural awareness and sensitivity is going to put us in good stead there. There are lots of ways we can mess therapy up by being closed, rigid, biased, not having identified our own location. Can you talk more about what you see being the positive outcomes for the client when the therapist is aware and open?

BS: What some of the research seems to indicate is that clients are able to examine not only their religious tradition in the way that impacts their psychology and vice versa, but their image of God can also be transformed over the course of therapy. Religious people, like everyone else, often come to therapy because something has happened in their life, or life isn’t working out the way they expected it would. Well, for a religious person, that raises issues of, "Who is God then and where is God and how does God function in the world?" It may be that they've come in with some ideas about God and religion that were functional and helpful for a while, but now are not helpful and functional anymore. That doesn't mean that their earlier thoughts are bad or pathological, but it means that they've got to expand and develop and grow like anything in our lives. It doesn't mean they have to jettison their faith—I think some people feel like they have to leave their faith or say that there is no God anymore—but they can evolve their understanding of God and religion. It's not throwing the baby out with the bathwater, but sifting through the dirty bathwater. A good therapist, whether he or she is secular or religious or of a different religion than their client, can create the space that allows that to happen in ways that are therapeutic.

So Many People Believe in God

GA: So we can get over feeling guilty about religion being on the table, or this idea that it’s not valid to bring religion into the therapy process. It's appropriate for psychotherapy to really work with that.

BS: I think so. We have data that suggests so many people believe in some kind of God—in the United States at least. People are religious. We could get into a whole debate about religion versus spirituality, but in general many people have these religious-spiritual inclinations. So to feel guilty that we're talking about religion seems to be a major mistake. It's part of people's identity, so it needs to be on the table. To leave it out is like leaving out talking about sexuality. How can we do that? That's a whole part of what makes people who they are.

GA: Would you agree that it’s kind of taboo, though, to bring religion into psychotherapy? From the secular side religion is often seen as a kind of pathology, but even on the religious side, people may feel like those issues are better dealt with in a church or a synagogue or a mosque. What has your experience been?

BS: I think sometimes for the religious and even maybe the non-religious, we don't always know what to do with the APA ethic codes. We're so afraid of imposing our views, of taking away the client's autonomy, but we’re beginning to learn how we can hold a client's autonomy in mind even as we're helping them think about the variety of issues they are dealing with. I don't think we do them a favor by not bringing things into the room. I had a professor who would say, "We can expose things without imposing." Of course, that's an art form. There's always a danger that we're going to impose. But I think there is plenty of evidence that therapists impose without even saying things at times, or their very theories have implicit ethics within them that we never think about—for example, the ethic of individualism or autonomy. Those are ethics. Those say things about how people ought to live their lives. So all of our underlying points of view need to come under this more post-modern lens. We need to own what we’re doing.

It’s true that some religious practitioners think that these issues should be left for the church, but I also think that some religious practitioners don't want to bring up religion because it becomes personally challenging to them. It challenges their own countertransference. So if their client is questioning, say, the existence of God or how God works in the world and it's uncomfortable to the religious practitioner, he or she may unconsciously avoid it because it's anxiety provoking. That's something that they need to work out in their own therapy and supervision.

GA: Because they're getting in the way of what's best for the client. I'm glad you admit it's really hard and it's a danger to impose. It's an art. You've got to really do a lot of work. How are we doing as a field at including this in the therapy room, at not imposing, and what can a practicing clinician out there do if they're not in training anymore to advance this effort to integrate faith and psychology and to be more culturally sensitive?

BS: The good news is there are a lot of good resources out there—everything from various models of integrating faith and psychology to how people actually work clinically from various modalities. You can find cognitive behaviorists and how they work with religion, or psychoanalytic or family systems practitioners. Even the American Psychiatric Association is publishing resources about the language of spirituality. I think that's a good way to start and it helps clinicians listen in different ways for issues of spirituality, but the larger issue is still this fear of imposing.

How do we manage the issue that morality and ethics are a part of every psychotherapy?

How do we manage the issue that morality and ethics are a part of every psychotherapy? The most responsible thing we can do is own that and figure out how we use it in appropriate ways that doesn't become coercive, what one of my colleagues would say violent to the therapy.

GA: Absolutely.

BS: But that doesn't mean falling back into this kind of Freudian myth that we can be objective blank screens. I think this is true even with cognitive behavioral people. They pretend that they are not bringing themselves to the work, but they are. So how do we most effectively bring ourselves to the work? That would be the question I'd like to spend more time thinking about.

Talking Out of Both Sides of Your Mouth

GA: This idea of an objective blank slate is a liability. It's made us at risk for this kind of violent idea that we're mechanics operating on machines and we've just got to get out the owner's manual and look up in the appendix of how to fix this machine. Morally, we have to own what we're bringing to the room. But how do you integrate your whole individual philosophy of embodiedness and embeddedness with the DSM and empirically supported treatments and evidence-based practice? How has that balancing act gone for you personally and professionally?

BS: That’s a great question. I hedge my bets by rarely using insurance as a clinician, which means I rarely have to provide a diagnosis. I think that's how a lot of people work these days because they're so disillusioned. Unfortunately there are a lot of people working in settings where that's not possible for them, and I always wonder if they are just talking out of both sides of their mouths as a necessity. They use the language they need for the reimbursement but they continue to think a different way. I think that's probably how a lot of clinicians tend to operate.

I think there's a whole subset of people who want to keep thinking about therapy as art and to do that we have to be creative in other ways. So maybe we don't take insurance, but maybe we have sliding scales that are ridiculously low at times. I see people at times working for well under the going rate for Pasadena. I work a lot with students from other clinical programs who are in training who I hope are going to go out and do the same kind of thing because they've experienced that with me. Here at Fuller we think a lot about how our students can use the best clinical training they can with underserved populations.

It's almost a Trojan horse model—they do the work that they have to do, but they're still bringing their deeper vision to the work.

It's almost a Trojan horse model—they do the work that they have to do, but they're still bringing their deeper vision to the work.

Good therapies always have this core of humanism in them. They're real-life people here that we're trying to help and we're creative and we're flexible, but maybe there are some things that some people just can't do. They won't do. I can't see myself ever working in a setting where I had to use an empirically validated treatment manual. But that's me. That's not everyone's story. I'm not trying to be dogmatic about this.

GA: The medical model has brought about a real identity crisis in the field. A lot of people are talking out of both sides of their mouth.

BS:

Morality is not just a concern of religious people. There is secular morality.

Morality is not just a concern of religious people. There is secular morality.

I came to psychology because my experience in the church, the Christian church, was that there was a lot of good information about what one shouldn't do, but its models for transformation were a bit thin. You might argue that’s because my particular Christian tradition had disconnected itself from some of the ancient wisdom of Christianity.

What I discovered studying psychology in college was that it was offering models for how people transform and change. I thought, if I could bring that together with my Christian faith, what a powerful model that would be. So that's one of the ways I've understood what psychology could bring to religion.

GA: So what could a church pastor learn from studying psychology?

BS: Well, think of group therapy and all of the wonderful tools it has brought to church communities. Most churches now have therapeutic support groups for people struggling in various ways, and the psychological issues get pretty tricky in groups, really fast. Yalom’s theories on interpersonal processes in group therapy have been tremendously helpful for both lay people and professionals in helping to guide group work. We think about group dynamics, about transference, about procedural learning, about behavior.

Sometimes the church can be just as prejudiced and afraid of psychology as psychologists can be of religion, so we’ve needed translators who could bridge the gap and show that these secular theories are not dangerous or bad or a threat their faith.

GA: Do you think it’s useful for pastors to get psychotherapy training?

BS: Well, I think one of the things you have to dig down into is their presuppositions about truth. At Fuller, where I teach, we say all truth is God's truth. So it doesn't matter if Freud or Ellis or Skinner discovered it. Or a contemporary neuroscientist discovered it. If it's true, then it's useful. Of course this can be used in improper ways as well, so again we're back to ethics.

Some Christian groups dichotomize between nature and grace—God is involved in grace, but nature is something entirely different; psychology is nature and therefore not useful. All we need is in the Bible. That’s one example.

Other Christianities—and this is why Christianities is a really important concept—would say there is no dichotomy between God and nature. The person who discovered penicillin may or may not have been a Christian, but who cares? Penicillin cures and heals people, and curing and healing and restoring humans is part of the religious impetus some groups would argue.

If I were working with a pastoral care group, I would try to assess how they think about nature and how they think about how God works in the world and would try to tease out whether they think that all truth is God's truth or only the truth that comes from scripture.

Community and Interconnectedness

GA: But this inclination to dichotomize is not just a religious inclination. There's this sort of militaristic atheism that states: "We're science. They're not." And that's just as damaging and unproductive.

But I think also where I'm seeing it from my non-religious side of the fence is this call to morality or this idea that Christianities, many of them modern, mature, intelligent, contemporary Christianities, have a great authority and ability to speak to the call to humanism and bringing morality back into our endeavor.

BS: One of the things that modern Christianity can also help with is a call back to community and interconnectedness. Ethics can become very individualistic. The great philosopher Alasdair MacIntyre says our ethic is primarily what he would call emotivism, which is “whatever feels good to me is right.” I think a lot of psychological theories have that ethos embedded within them, whereas many religions posit that your individual rights end at your communal responsibility. Victor Frankl said this years ago in one of his books.

GA: The counterpart is this kind of just reification of the individual, a kind of inward, isolating journey to health. That mental health is achieved inwardly. So your work is saturated with this sensitivity to how healing relationships are and can be. It has to happen between persons, not within persons.

BS:

One of my frustrations with contemporary spirituality is that it tends to be, at least in the United States, so individualistic and inward—"Well, as long as I'm not hurting anyone else it's okay."

One of my frustrations with contemporary spirituality is that it tends to be, at least in the United States, so individualistic and inward—"Well, as long as I'm not hurting anyone else it's okay." But what counts as hurting people? It may not seem like you’re hurting people by consuming all these resources, but in truth you really are hurting people. We've got to come back to this communal ethos. One of the things that's essential to me as a psychologist and a Christian is this idea that we are always inextricably linked to others, and that's both how problems come about and how healing comes about. There's just no isolated self. We are always selving and always contextualized and always embedded and always embodied.

I suppose some would call me radical in that sense. I have colleagues who really cling to an individualistic psychology and spirituality. I think you can make the argument that much of contemporary evangelicalism in the US is quite individual and that the worship experiences they have are in fact quite consumeristic. They're just consuming Jesus—it's sort of the person and God or the person and Christ—which I don't really think is what the gospel is all about.

Folks who think more like me tend to be theologians and hopefully more will come into the integration-of-psychology conversation. In the book I wrote with Warren Brown, The Physical Nature of Christian Life, we talk about how there really is no isolated Christian, no isolated person, and that religion is always going to be experienced and needs to be experienced in these communal sorts of ways.

GA: Before reading your work I'd never encountered a fully Christian thinker espousing this deeply relational embodied philosophy. I'm finding I'm confronting my own prejudices about Christianity as I do more investigating. I think that my former critiques of Christianity have been toward this more immature Christianity, the more consumerist Christianity, not having been aware of the more mature Christianities, as you call them.

BS: I think that Christianity, like anything else, is also a sort of developmental process. James Fowler, who taught at Emory University, compared his work with Kohlberg's work on stages of moral reasoning and suggested that there are stages that religious people go through. So maybe thinking about faith as individual and private is a developmental phase. Maybe as people grow and develop and have more life experience, they will come to recognize that life is more interconnected, relational, communal. However, Fowler would say, and I'd agree, that not everybody moves to the same level.

I think those Christians who embrace this relational theology may be better at being hospitable to people who are not of their faith tradition than those who don't. I think there's a more protective defensive way of viewing others when you see religion as kind of ethereal, as spiritual, as otherworldly, as “what I do now to get to another place.” If bodies don’t matter and we’re just waiting for the afterlife, then I don’t really care about my body or your body; I don’t care if you’re hungry or poor or living in an oppressive regime. In other words, the here and now is not my focus. But if I think of religion as experienced in the here and now, as embodied not just in the soul but in the body, in the senses, then the call of God is more of an action, a call to love all people, whatever they believe, or whatever they come from, or whatever they look like.

Seeing Beyond the Soul

GA: So it’s seeing beyond the soul?

BS: Right. If bodies are important, if souls aren't saved but humans are saved, then humans need to be fed and clothed and protected and not raped and not abused as children and not under the oppression of a dictator. The implications of the two ways of thinking can be profound. I have some friends who ruin my theory, however. They cling to an individualistic soul concept with fervor, and yet they're the ones visiting people in prison, bringing food to the hungry. So there are no absolutes here.

GA: Do you have any closing thoughts you want to leave our readers with about why this is important, what they can do, what you've learned in your efforts?

BS: I think just that there is a lot of room for both religious and non-religious clinicians and researcher to help each other. At the end of the day we're trying to help people live more productive, healthy, flourishing lives. But we need to ask what we mean by healthy and flourishing, and where did we get those ideas? There are all of these underlying belief systems that we’re not owning.

A lot of therapists who say they care about relationships might not realize that some of the theories they're practicing are highly individualistic.

A lot of therapists who say they care about relationships might not realize that some of the theories they're practicing are highly individualistic. But if they could take a look at that, I think they could then begin to make some adjustments and think about it differently.

Erich Fromm, in his book on psychoanalysis and religion, made a distinction between cure of the soul and social adjustment therapy. For him, social adjustment therapy was just helping a person function better in the crazy society they already live in. His question was: Is that really what psychotherapy is supposed to be about, or is it about creating people who flourish and can become thinkers and can transcend some of the disease that might be in the culture around them? So one of the things I'd like to end with is this idea that psychologists are in a particularly interesting position to think about ourselves in the area of social justice as people who work for social equality. But to do that we're going to have to step back and critique our own discipline.

GA: Beautiful. I for one welcome the inclusive conversation, the new conversation. I'm happy to be a part of it. Thank you so much for sharing your time.

BS: Thank you. It's been a pleasure to chat with you.

Psychotherapy with Transgender and Gender Nonconforming Clients

Posted on June 24, 2014February 11, 2026 by rezendevknowfully.com

The Unbearable Otherness of Being

Imagine making your way in a world where your physical appearance makes others uncomfortable, anxious, confused, or uncertain about themselves. Your very presence may be perceived as a threat to another individual’s sense of self or sexual orientation. Everywhere you go, people stare at you—sometimes discreetly, often blatantly—leaving you very little room to walk unselfconsciously through life. The reactions you experience from others, while the result of ignorance and sometimes mere “curiosity,” do nonetheless harm you, for you are perceived as “Other.” At times, people’s reactions are more hostile, the result of conscious and unconscious fears about what it means to deviate from gender norms, and you may be verbally or physically assaulted just for being you.

This is what it’s like to be a gender nonconforming or transgender individual in today’s world. Though there is increasing awareness and tolerance around gender issues in certain small segments of American culture, the truth is, the level of misunderstanding, ignorance and prejudice that surrounds gender nonconforming people as they go about their lives has created a mental health crisis in our society. To illustrate the epidemic nature of this crisis, here are a few statistics from the American Foundation for Suicide Prevention’s 2014 Report, “Suicide Attempts among Transgender and Gender Non-Conforming Adults.”

In a pool of 6,000 self-identified transgender respondents:

41% had attempted suicide
60% were denied health care and/or refused treatment by their doctors.
57% had been rejected by their families and were not in contact with them.
69% had experienced homelessness.
60-70% had experienced physical or sexual harassment by law enforcement officers.
65% had experienced physical or sexual harassment at work.
78% had experienced physical or sexual harassment in school.

For gender nonconforming individuals, the very nature of their sense of “self” lies in marked conflict to society’s gender identity “ideals” and social scripts. The resulting prejudice (transphobia and homophobia), whether explicit or covert, often manifests in forms of denial, invisibility, harassment, bullying or, in more extreme cases, assault and murder. As if this weren't enough, gender nonconforming and transgender persons may be further marginalized by their ethnic and racial identity, economic status, physical abilities, and age.

More subtle forms of discrimination exist, many occurring within the helping professions, including mental and medical health, nonprofit support services, legal and government institutions and public schools. Overpathologizing, misdiagnosing, maltreatment (including refusal of services), neglect and demonization are just some of the ways transgender individuals are routinely discriminated against within systems whose mission is to support and serve. These discriminatory practices are carried out by providers who fail to become educated and respect, protect, or provide treatment that is appropriate, impartial, and equal to the care given to other clients. Following, I will attempt to provide the nuts and bolts necessary for aspiring clinicians who wish to work in a culturally competent manner with their gender nonconforming and transgender clients.

Gender and Language

I often remind my colleagues, students and clients that we all have a gender identity and diverse manners in which we choose to engage in self-expression. As a cisgender female (i.e., I identify with the gender I was assigned at birth—female), I am conscious of the great extent to which I can embrace the everyday conveniences of being privileged. I am not ostracized for my gendered self, and no one questions my choice in using a public restroom. For gender nonconforming and transgender clients, this problem is known as the “bathroom issue.”

We practitioners need to become fluent and speak the same language as our gender nonconforming and transgender clients. In doing so, we demonstrate the intention of promoting respectful communication that expresses an intricate set of thoughts, ideas, and feelings associated with sex, gender, sexuality and identity. The language used among this diverse community is multifaceted because finding words to articulate complex notions of identity is arduous. In fact, the youth in my office frequently inform me, a gender specialist, how some of the language and concepts I use are now outdated. Nonetheless, staying current with the language being used within the gender nonconforming community is an important part of being not only a culturally competent therapist, but an empathically attuned therapist. Such language literacy also enables mental health professionals to understand concepts, organize thoughts, foster discussion, exchange ideas, and support the community in the least confusing, shameful, and harmful way. Familiarity with the community’s positive expressions of self and identity not only helps clients feel understood, but ensures that therapists don’t rely on clients to educate them—an all-too-familiar experience for cultural minorities.

The following list presents a very general overview of how we come to understand the meaning of sex, gender/gender identity, gender roles, and sexuality for our gender diverse clients and ourselves. It’s important to remember that these terms are constantly evolving within the gender nonconforming, transgender, queer or transsexual communities, as well as by the practitioners who intend to help them. Gender nonconforming and transgender identities include but are not limited to: Transgender (TG), female-to-male (FTM), male-to-female (MTF), transgirl or transboy, girl/woman (natal boy), boy/man (natal girl), they/them, bigender, gender fluid, agender, drag king or queen, gender queer, transqueer, queer, two-spirit, cross-dresser, androgynous. The terms FTM (female-to-male) and MTF (male-to-female) encompass a spectrum or continuum from those who identify as primarily female or male, to those who identify somewhere in the middle or both (e.g., queer). Between these two posts or “extremes” (female and male) lie most gender nonconforming individuals.

The sexual orientation of gender nonconforming and transgender clients is a separate identity and should never be presumed or assumed. It refers to the gender one is typically romantically and sexuality attracted to (e.g., homosexual, heterosexual, bisexual/pansexual, polysexual, asexual etc).

Becoming Gendered

It’s important to think about how we become “gendered.” In part we do this by the way we organize and construct language. Most of the English language is “gendered,” constructed in a way that makes it difficult to deviate from strictly binary conceptions of male and female. We tend to acknowledge and refer to one another through pronouns, and consequently become gendered in our relational experiences. For example, when we frequent our local coffee shop, “Excuse me, Sir…Mam…May I have a large coffee?” Here is a simple example of how we have already ascribed gender to a complete stranger.

As clinicians, we need to learn to ask and address our clients appropriately. More importantly, we need to develop the capacity to become conscious of our own gendered ways. Specifically, we need to ask all our clients about their gender identity and development as well as their gender pronoun preferences. The youth that show up in my office often challenge this binary model most of us are so accustomed to, and request to be referred to as: ze, hir, one, or the plural “they” “their,” “them.” Interestingly, I often find myself arguing with my cisgender colleagues, who get caught up in grammar policing, about the importance of honoring the self-identification of these clients. The English language is constantly evolving, after all, and human and civil rights struggles play an important part in its evolution. At the same time, it’s important to not make any assumptions about people’s identification preferences. Plenty of gender nonconforming or transgender clients prefer to be referenced by conventional pronouns such as “him” or “her” because it feels congruent with their internal identity.

People tend to be preoccupied with gender long before a child is born. “Do you know your baby’s sex?” is a constant question for pregnant parents. Sex, in this case, refers strictly to the external genitalia of the child rather than their potential internal gendered self. “Gender is assigned prenatally and from that moment it determines—and severely limits—acceptable gender expressions and desires.” Our early training begins with our parents’ color selection for our nurseries, the names we are given, and the activities we are encouraged to enjoy, and because we want their love and approval, we emulate what is desired of us. We internalize the societal roles, behaviors and beliefs ascribed to us by the culture around us (including that of our family) and may not know that any other way of being is possible. Boys get blue items, are given toy trucks and guns, and are prompted to be assertive and confident. Girls wear pink, are given dolls to play with, and are encouraged to be empathic and compromising. These behaviors, beliefs and customs are socially constructed—situated in the context of historical time, social class, ethnicity, culture, power, politics, physiology, and psychology—but they are deeply entrenched in our psyches and ways of being.

Clinical Practice

As the presence and experience of transgender people has entered both public consciousness and mental health facilities, clinicians are now beginning to think about transgender/gender issues. However most clinicians are not trained to identify clinical themes prevalent for transgender and gender nonconforming individuals, and consequently misunderstand their mental health and their global treatment needs. Our traditional training fails to address gender and sexuality development for transgender persons from a nonpathological perspective. In addition, negative countertransference from providers and institutions is common and lends itself to discriminatory practices or, worse yet, thoughtless analysis of clients’ needs that may lead to irreversible medical interventions. Common feelings and attitudes for inexperienced clinicians toward these clients may include anxiety, fear, disgust, anger, confusion, morbid curiosity, and rejection, all of which can severely compromise the therapeutic relationship, our ability to help, and an individual’s identity development and transition process.

The journey of self-discovery for gender nonconforming and transgender individuals is laborious and often lonely because, simply put, the desire to become more congruent with their “True-Self” in body and mind may require a shift in physical identity. Children tend to be the most disadvantaged in this phase of life as they may be required to repress their desires to play with “cross” gendered toys and are left feeling ashamed to admit their favorite colors and activities (e.g., the boy who is prohibited from playing with dolls and having a pink bedroom).

As gender nonconforming individuals become more psychologically distressed they often feel the need to have a more congruent experience of their internal and external selves. They may need to first embrace a social transition—choosing an alternative name that reinforces their internal identified gender, dressing in a stereotypical fashion that supports their gender identification and engaging in “cross” gendered behaviors. In my clinical experience, when given the permission and support, gender nonconforming children and adults tend to become less anxious, depressed and gender dysphoric as a result.

However, some gender nonconforming and transgender individuals have a persistent need to modify or transition the physical attributes of their body to the opposite of their ascribed birth gender. This process is often too confusing for most people to comprehend, and is especially difficult because one’s gender expression and behaviors are typically the initial identifying marker for organizing one’s relational experiences among others. The clients with whom I work often desire bodily change not only to feel more congruent with their internal self, but with the hope of being experienced relationally as they truly are. For example, my transgender FTM clients use heavy-duty binders to flatten and contain their breasts so that they will not be mis-recognized as tomboys or lesbians. This experience of congruence tends to reduce gender dysphoric intrapersonal and interpersonal experiences. Our transgender clients need additional support around the use of physical and medical interventions, so it’s all the more important that we be well-educated and sensitive to these issues.

Gender Dysphoria

The new addition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), released in May of 2013, has removed the diagnosis of Gender Identity Disorder and has re-classified Gender Dysphoria as a clinical condition that gender nonconforming, transgender and transsexual clients may experience. Gender dysphoric symptoms arise when one’s self-concept and expressed gender in relation to their ascribed gender is “incongruent.” The psychological distress that results from these internal and external conflicts can lead to dysphoria, depression and a host of other conditions commonly experienced by transgender or gender nonconforming individuals. This turmoil is often created by internalizing the “gaze” of the world around them, i.e., they experience a great deal of psychological discomfort due to being publicly misgendered. Yet, it is also important to note that many gender nonconforming and transgender clients do not experience Gender Dsyphoria. They tend not to make it to our consulting rooms.

What of the clients who do end up in our offices? If a gender nonconforming or a transgender client and his or her family seek our support, are we available to console them, educate and advocate on their behalf, and offer culturally informed and sensitive treatment to the client and the family without getting caught up in our own agendas? How do we determine whether a child is an appropriate candidate for social transition, hormone blockers or even cross-hormone interventions? How do we determine whether the child is an appropriate candidate for genital reassignment surgery, which is often irreversible? How do we think about their fertility options and future family plans? How do we help a transgender child assigned female at birth who is in distress after his first menstrual period? Some of these interventions may seem radical, but if we fail to educate and train ourselves adequately around these issues, we can actively cause harm to our clients. Self-harm (body mutilation), substance abuse, homelessness, suicidal ideation or even suicide attempts can result.

A number of other conditions emerge in gender nonconforming children, particularly when their families aren’t able to provide the support and unconditional love that is necessary for them to thrive. These include adjustment issues, depression and anxiety disorders, trauma, substance dependency, and characterological pathology. Clinicians must be aware that families, too, must be educated about transgender issues, learn skills for coping with the child’s gender change, and be able to mourn and seek social and emotional support for themselves. And, of course, many clients may have co-occurring conditions, such as Autism spectrum disorders, that are beyond the scope of this article.

When treating a client with a gender nonconforming or transgender identity, clinicians may find themselves involved in a few situations unique to these clients. They may be asked to assess and substantiate a client’s preparedness for various biomedical interventions—usually involving the Real-Life Test/ Real Life Experience or a Gender Readiness Assessment—which involves encouraging a gender nonconforming client to begin living in their self-determined gender role and then assessing the impact of that experience. For example, some clients might experience a reduction in gender dysphoric distress, while others—say those whose family or community context is hostile to their nonconformity—may experience an increase in symptoms. Though this assessment is no longer required by the Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People published by The World Professional Association for Transgender Health, many medical providers and insurance agencies require it for coverage.

Bridging the Gap

A transgender or gender nonconforming individual’s psyche and the issues they face are very complex—and at times, convoluted—with complications in the psychological, medical, legal, and social realms. Because of this complexity, and the severity of their suffering, it should not be left solely in the hands of clients to educate their clinicians, nor should these clients be put in the vulnerable position of relying on their clinician’s empathy to determine whether they will receive the care they require. An ignorant clinician who responds negatively to such clients—even if only at an unconscious level—can cause untold harm and make it that much more difficult for clients to seek the help they so desperately need. We need to take responsibility for becoming educated and seek guidance from gender specialists—trained providers who can inform clinicians about transgender history and integrate traditional psychoanalytic and psychodynamic perspectives with queer theory.

Diane Ehrensaft, PhD, director of Mental Health at the Child and Adolescent Gender Center in San Francisco, and her colleagues are doing groundbreaking work in this area, bridging the gap between developmental, biological, queer and psychoanalytic theory using what she calls a “Gender Affirmative Model.” She draws upon Winnicott’s ideas of “true gender self” and “false gender self” in formulating her notion of gender creativity to better understand gender nonconforming and transgender children and adults. Turning prevailing wisdom on its head, she argues against labeling gender nonconforming invidividuals as dysphoric and instead views their varied gender expressions as fluid, dynamically intertwined between biology, development, socialization, and cultural context in time. Gender is not binary and may change over lifespan.

Understanding the issues that gender nonconforming clients face creates the possibility of an authentic and empathically attuned treatment that can be a true corrective emotional experience. Having the competence and confidence to administer a Real-Life/Gender Readiness Assessment can make all the difference in our patients’ lives, allowing them to socially transition and integrate their gender identity with other aspects of themselves. Thinking of the client as whole is instrumental to their overall well-being.

Not until we as clinicians grapple with our own gender identity, behaviors, and attitudes can we begin to utilize our assessment skills in developing diagnostic impressions, identify and observe our countertransference feelings, and implement treatment interventions that will lead to a balanced internal and external sense of self that improves a client’s overall quality of life. I encourage all my fellow colleagues to become more cognizant of the their own identities, values, and beliefs, and particularly to confront their fears and prejudices when working with transgender individuals. We must become mindful of what we ask—and do not ask—in our clinical interviews.

We also mustn’t assume that gender nonconforming clients are coming to us because of their gender or sexual identity and be open in creating our hypthotheses about our clients’ needs and desires. Let us accurately reflect the true clinical condition with which our client’s struggle. As I noted at the beginning of this article: imagine making your way in the world where your very sense of being makes others anxious, confused, and uncertain of themselves. By becoming culturally competent, we will be better able to provide an empathic approach to treatment that considers a range of gender nonconforming expressions and behaviors as healthy, as an authentic gender identity and bodily presentation, albeit variant from societal expectations. Gender deviation is not pathological, and if you think it is, you’ve got some work to do. On the other hand, it’s important to not be reflexively “progressive” and mindlessly support a transition that is not first deeply understood clinically.

Reflections on the theory of gender development, diagnostic conditions, and clinical treatment implications must include the role of the clinician as a gatekeeper to another’s self-determined gendered body, heart, and mind. The exploration of the transference-countertransference relationship is paramount, regardless of whether you are a case manager, a medical doctor, or a psychotherapist. Let us play with gender, and in our journey, discover the kaleidoscope of possibilities for clients as well as for ourselves. As providers, it is our social responsibility to change the role of the clinician from a gatekeeper to one who can form a therapeutic relationship that offers a way for clients to integrate their sense of self in relationship to the other that can hopefully be emulated in the outside world. A solid sense of self is likely to build confidence and self-esteem that will foster healthier relationships and diminish uncertainty and fear, decreasing the risk of self-harm and—hopefully—violence toward gender nonconforming and transgendered individuals.

Recommendations for Clinical Practice

Ask your clients about their gender identity and preferred pronoun. Explore their internal experience and how it impacts them interpersonally.

Foster multiple and integrated identity development: race, ethnicity, gender, class, sexuality, profession etc.

Educate parents about the importance of not pathologizing the gender expression of their children.

Treatment interventions should include allowing children the space to explore their gender expression, family education and support, as well as parental support to mourn the loss of their fantasies about their birth child's ascribed gender.

Collaborate treatment efforts with the providers involved, e.g., social workers, endocrinologist for hormone blockers and hormone treatment, family therapist, and treatment team staff.

Remember: Gender nonconformity is a natural expression of human development and experience.

Do No Harm: Seek consultation from a gender specialist. Monitor countertransference and refer out if you are not able to act fully in the best interest of your client.

Clinical Resources

Report of the APA Task Force on Gender Identity and Gender Variance.
Standards of Care for the Health of Transsexual, Transgender and Gender Nonconforming People, Version 7.
Achieving Optimal Gender Identity Integration For Transgender Female-to-Male Adult Patients: An Unconventional Psychoanalytic Guide For Treatment (2008), Karisa Barrow.
Gender Born, Gender Made: Raising Healthy Gender-nonconforming Children (2011), Diane Ehrensaft.
The Transgender Child: A Handbook for Families and Professionals (2008), Stephanie Brill & Rachel Pepper.

Deconstructing Gender: Self-Exploration Exercise

What is your own gender identity?
How old were you when realized you were a “girl” or a “boy?”
Who and what made this clear to you?
Did you agree with your parents clothing choices for you as a child?
What activities did/do you enjoy?
Have you expressed your own gender identity differently over the course of your life?
How do you feel about your body? Your genitalia?
What messages have you received about your gender and from whom (e.g. parents, media, religion etc.)? Were you “policed” by others around your identity, gender roles and social practices or body?
How has your gender shaped your beliefs, social engagements and practices?
What have you been allowed/encouraged to do because of your gender identity and what limitations have you faced (e.g. social sanctions/promotions)?

Thomas Moore on the Soul of Psychotherapy

Posted on June 20, 2014February 11, 2026 by rezendevknowfully.com

Therapy Isn't Healing

Deb Kory: Thomas Moore, you are a writer, a theologian, a psychotherapist, a musician, a former monk, and a professor. You lecture widely on incorporating aspects of the soul into daily life, and have written many books on the subject, including the bestseller, Care of the Soul. You've just released a book called A Religion of One’s Own, which seems in part intended to bring meaning back to the word and to argue against the secularization of modern life. Since our audience is primarily psychotherapists, I'd like to first ask you about psychotherapy: How you define it and what role do you see it playing in bringing soul back into the world, and into your clients?

Thomas Moore: I go back, as I always do in my books, to etymologies. I like to think about how people first thought about the use of the word since the very beginning. The word therapy has been around for a couple of thousand years at least, and originally among the Greeks it meant to care for or attend to. I like that meaning of the word. It never meant to heal or to fix or anything like that. In fact, there's a passage in Plato where a student asked Socrates what he means by therapy, and Socrates says, "It's like someone who takes care of horses. They give them water and food and take them for some exercise and clean their stalls. That kind of thing is therapy."

So it's an interesting definition of the word. Then if you put psyche with it—psyche is the word for soul—you get psychotherapy, to care for the soul, to attend to the soul. That's how I see therapy.

I'm not interested in helping a person get along in life, and I'm not interested in helping them improve or get better as a person. That's more of an ego kind of project. I'm interested in the soul, which is deeper.

When someone comes to me for therapy, I'm always listening at a very deep level, because I want to know what their soul is hungry for. I listen to their stories and look for where they are getting in the way of their soul’s unfolding. What is trying to emerge? Where are they headed in spite of themselves?

DK: So you are against the whole idea of therapists being healers?

TM: Yes, pretty much.

DK: Can you say more about that? Is it because it’s too omnipotent a role?

TM: Yes. I think the idea of care is different from helping or healing. Healing sounds like you're really going to once and for all fix this person and resolve their problems or get rid of their pain. Sometimes, in fact most of the time, what I feel I have to do is be with the person in their suffering or their pain, and in the moment I may hope that we get to the point where they don't suffer anymore, but I don't think I can get there by being the hero and thinking that I can get rid of their pain. I can't. But together what we can do is see what's going on and, as they get to be closer to their deeper life, their attitude in life shifts and they usually make different life decisions. Those things tend to resolve the pain and the suffering.

DK: So you don’t necessarily feel responsible for what happens in therapy?

TM: I don't feel responsible, no.

I'm rather shocked when I hear from some of my clients that they've been in therapy with people who tell them what they should be doing. I can't imagine it because I don't know—who am I?

It’s tempting at times to tell people what I think they should do, but I don't think that's my place. I'm rather shocked when I hear from some of my clients that they've been in therapy with people who tell them what they should be doing. I can't imagine it because I don't know—who am I? I don't have any special insight or any kind of revelation about people's lives. So what I do is I go with them and I try to get a glimpse of who they are and what's wanting to emerge.

DK: That’s in striking opposition to all of the manualized and “evidence-based” psychotherapy that’s currently in vogue.

TM: I'm not interested in any of that.

DK: You're kind of outside of that system altogether.

TM: Totally on the outside of that system.

DK: It sounds like part of what you've been trying to do throughout the course of your career is to critique that system, because it's in every profession in one way or another. Perhaps that’s what you mean by secularization?

TM: Yes, it is.

DK: It’s almost as if science, itself, has become a religion.

TM: I think when you secularize, the ego comes to the foreground, in the sense of, “I know what's going on. I need to be in control.” My approach has been more what I would consider a religious approach, in the deepest sense—not as part of any particular religion, but rather appreciating and acknowledging that there are things going on that I don't understand and can't control, but I can help with by being an attentive listener. I respect what's happening in a person, and I try not to listen to it with the thought that I know what's best or I know what's healthy. I never use words like that—“healthy” or “correct” or “right.” I watch my language carefully and try to let the soul of a person be revealed. When they see who they are at that soul level, they can make better decisions for themselves.

A lot of people have not had much education in psychology, and they don't really understand too much what's going on with their emotional life or their relationships. So we have to go deep into it where they can see what's happening, and then make their own decisions.

“Who Wants to Adapt to a World That is Crazy?”

DK: You also said that you're not interested in helping people get by in the world. Is part of that because the world is kind of nuts?

TM: That's certainly a part of it. Who wants to adapt to a world that is crazy? I've been saying ever since I first wrote Care of the Soul that if you do care for your soul you're going to be quite eccentric because, for one thing, that's where your individuality is.

If you do care for your soul you're going to be quite eccentric because, for one thing, that's where your individuality is.

The more you get in touch with your own soul, the more individual you become. Jung called this work individuation, and I think that makes sense because you become more of an individual from being in tune with who you are.

Another piece of this modern approach that I don't agree with is this idea of having some kind of standard for normalcy. We have these standards that are expressed in these lists of disorders, the DSM-5, but behind all of that is the assumption that there is such a thing as being normal and well-adjusted. I would probably have a very different type of DSM myself because I'm not interested in adjustment and being normal so much as really being in touch with that deep place. People may not fit in very well when they do that. They may be odd, and their friends may wonder what's going on with them.

DK: Do you see yourself as radical?

TM: No, not at all. But I was in Berkeley a couple of months ago, and I was at what was considered, I guess, a radical radio station, and I was just talking about things that, to me, seem quite ordinary. Afterwards the two people interviewing me said that I fit into their program quite well because it was also radical. But I don’t see myself as radical; I’m quite traditional.

DK: Am I right that you didn't get any kind of traditional psychological training? You didn't go through a psychotherapy school, right?

TM: Well, my training was actually in Rogerian therapy. I did a lot of counseling work when I was doing my PhD in religion. I did my religious studies work at Syracuse University, which is a very broad program. I studied world religions in one phase of it and depth psychology in another phase and the arts, especially literature, in the third part. These three parts came together to be the focus of my study of religion. When I was doing that, it occurred to me—I don't know why—that the only way I could really learn psychology would be to also train as a therapist. So I did.

A lot of my work was in counseling psychology, which was mainly based on Carl Rogers' approach. I did a lot of coursework and supervised practice, practicums, and led groups. Usually you can get a license if you have a PhD in religion or if you have some background in religion plus some psychological training, and I had both, so I put those together and got my counselor’s license.

DK: Did you decide at a certain point to leave the constraints of being licensed or are you still licensed?

TM: No, I just moved to another state, and the state I moved to requires the kind of therapy that I just don't understand or really want to do. So I no longer do therapy as such as a licensed therapist. I counsel people on this work of the soul based on my books, and I tell people that I'm not a therapist in the sense that people do it today and that I can't do that kind of therapy anymore. I mean, I probably would do it if the system were set up in a way that I could fit in, but I can't, so I don't. In fact, it’s just not what I do at all.

DK: What is it about the system that you can't abide?

TM: Well, a number of things. I'm not interested in quantified studies at all. That's never been a part of my life. I'm trained in the classics. I know Greek mythology very well. I know history and the history of philosophy and theology and medicine.

I’ve never become a Jungian analyst because I feel it’s too narrow for me. I don't want to have to fit in with the language and ideas of Jungianism.

That gives you a great deal to work with. Anyone who knows Jungian psychology would know that my background in religion and mythology are perfect for a Jungian analyst. I've studied Jung for years. In fact, a week ago I was in Canada speaking to a Jung society, and I'm going in a couple of days to a Jung society in the Southern United States. I speak to Jung groups frequently because I do know Jung well. They're interested in my background in religious studies and the arts and also my work over all these years, all these books about the soul. So that’s an area where I could fit in more easily, but I’ve never become a Jungian analyst because I feel it’s too narrow for me. I don't want to have to fit in with the language and ideas of Jungianism.

A Religion of One's Own

DK: Your most recent book, A Religion of One's Own, is that a play on Virginia Woolf?

TM: Yes, it is.

DK: My sense from reading it and from reading many of your works is that every system of belief or philosophy is too narrow, that you're fundamentally ecumenical. You love to dive deeply into various traditions, but you’re not interested in being a certified member of anything.

TM: I don't think anyone should be confined to one particular system of belief.

If you really want to be someone who is alive in what you're doing and not just following a system, then you want to make it your own in some way.

I wrote A Religion of One's Own to make that clear. It could also be “a psychology of one’s own.” It’s important to honor the traditions and you can study any branch of psychology you want, but I think if you really want to be someone who is alive in what you're doing and not just following a system, then you want to make it your own in some way. I happened to take it pretty far in making it my own.

DK: You're a little eccentric.

TM: Yes. That's exactly it, and that's just the way it is. I'm surprised because I'm not a radical type. I'm kind of an easygoing person. I don't challenge the world too much except in my writing. In my style, I write a lot of things that go against the themes of the times and the spirit of the times, but I don't do it in a style or a manner that is confrontational. I simply present and say, "Well, if you want this, great. If you don't, forget it."

DK: So your style isn't confrontational, but your ideas are or could be perceived as such.

TM: Yes.

DK: I’m imagining with this recent book you’re being critiqued both from the Left and the Right.

TM: Yes.

DK: There’s a fair amount of religiophobia on the Left and there are a lot of therapists, in my experience, who harbor a not-so-subtle contempt for religious people. Or rather, some religions are considered okay: Buddhists are fine, Mormons are not. This really goes unchallenged in therapy culture.

TM: Yes, I agree.

DK: And then on the Right you’re probably just seen as an apostate. Are you getting challenged on that at all on this book tour?

TM: A little bit, but very little actually. People get the idea right away, and they're interested in it. The majority of people who hear this idea say to me, "Well, this is what I've been doing and thinking all along, and it's really helpful for me to have it articulated."

I’ve had feedback from people saying that they don't need religion. The secular world is all they need.

That's the response I get most of the time. Now, maybe there are people out there who are more traditional in their religious practice who just aren't interested and so aren't talking to me. On the other hand, I’ve certainly had feedback from people saying that they don't need religion. The secular world is all they need.

DK: I'm thinking of people like Bill Maher, and a lot of these so-called “new atheists” who think that religion is the root of all evil.

TM: The problem I have with them is that they usually pick a very childlike or fundamentalist type of religion and critique it as if it stands for all religions. Take me on, you know? Years ago, actually, I tried to have a debate with Carl Sagan because he was saying that a lot that goes by the name of religion is superstition. We had set up a debate, but then just at the point when we were making the arrangements he developed cancer, so it never happened.

Critiquing the most simple-minded and fundamentalist forms of religion is easy. I critique them, too, and have a lot of that kind of atheism in me as well. I have no problem with that; but when you look more deeply at the richness and depth of so many traditions, when you get right down to the subtleties, I'd hate to see us turn into a totally secular world.

DK: How do you deal with the reflexive antagonism that people have toward religion? If you were speaking to a group of therapists who were more of the secular type, how would you argue for integrating more of this soul work into therapy?

TM: I have worked with psychiatrists and other kinds of therapists, and a lot of them come to me and they want to open up. They want something more in their practice, but they don't know what that would be. I try to give them background, history, a lot of examples, a lot of material—to let them see the intelligence of the spiritual traditions. I present it to them as someone who really loves these traditions, but I'm not a member. I'm not defending them. I'm not that kind of person.

DK: You're not an “ist” or into “isms.”

TM:

I don’t actually participate in the Catholic Church, but that’s because I think they don't want me. I'm not sure it's because I don't want them.

No. I'm not. I'm not in one of these traditions either. Though I sometimes call myself a Zen Catholic, because in my own life, I was born into Catholicism. It's not something you just set aside intentionally; it's something that's just part of you. I don’t actually participate in the Catholic Church, but that’s because I think they don't want me. I'm not sure it's because I don't want them.

DK: Do you think you'd be excommunicated?

TM: Oh, yeah. There is plenty of grounds for that.

With therapists, though, I try to give them an intelligent approach to how to include spiritual matters in psychotherapy. I try to show them that you can't really separate spirit from soul. I talk about the difference between those things and how you can't separate them.

The Planet Has a Soul

DK: Can you talk about the difference between spirit and soul?

TM: Well, it's dicey in a way. In the traditions that I follow, the spirit takes us away from our bodies and our appetites and our relationships and our everyday lives in order to have a big vision, a cosmology, a cosmic vision to ask questions about how the world came to be or how to live and to meditate and pray. These are all things that take us up and away.

DK: Those are spiritual.

TM: Yes, and these things are good, very valuable and important.

The spirit takes us away from our bodies and our appetites and our relationships and our everyday lives in order to have a big vision, a cosmology, a cosmic vision to ask questions about how the world came to be or how to live and to meditate and pray.

But the soul at its depth has not been developed very much. There are many traditions that deal more with the depth of our everyday life, like the importance of home and the deep fantasies and emotions connected with home. Memories of home and the need to be at home and to feel at home with what we're doing, the importance of family and feeling family even if it's not literal. It might be the family spirit at work or in your town, to be living a sensual life or a sexual life. A lot of spiritual people have trouble with sexuality because it's in another direction. It seems to be a problem. So what I try to do is speak for those things, for the soul. I'm also someone who loves the spiritual as well. I value both of those directions.

DK: So the soul is more grounded. It's more earthbound.

TM: Yeah, definitely grounded.

DK: Is there more of an ethical dimension to it?

TM: Yes, there are ethics, but it's a different kind of ethics because soul ethics are rooted in, let's say, your love of the planet or your love of your place, your home, or your appreciation for the individuality of people because you know people directly. That's a more heart-centered ethics. But there is another important kind of ethics, which is spiritual, which would mean you have a vision about the planet and about history and people and how we need to behave. All of that kind of thing could be very spiritual. So I like to have those two together. You need both motivations for an ethical life.

DK: Given you're deeply rooted in your own ecumenism and ethics, what do you think our role is in trying to make the world a better place? You say we aren’t healers, that we help people only in the sense of getting people connected to their soul’s hunger. What about the world beyond the therapy room? Are we bound by ethics to try to, for example, fight against climate change and all the ways humans are destroying the planet and each other? Or is that separate from our work as therapists?

TM: Let's go back to the definition of therapy: care of the soul. One interesting aspect of soul is that in the traditions about the soul, it's not just humans. The planet itself has a soul. I’ve got some documents here in my study from five or six hundred years ago that say that the planet has a soul and that the things on the planet have a soul. So if psychotherapy is care of the soul, the care of the planet is a kind of psychotherapy. Do you know what I mean? You don't just care for people or individuals.

I do a lot of work with hospitals and have been for a long time. I go into a hospital and I try to talk to the doctors and nurses especially about the importance of family because the illness a person has is a soul illness as well as a body illness, and the family plays a role because that's part of a person's deep life. It's a very important part. So we try to talk to hospitals about the importance of including the family. Not just tolerating them, but really seeing them at the very center of illness, both to heal and even being partly responsible in some ways.

A Psychotherapy of One's Own

DK: I have been licensed for about a year after a very long process, many thousands of hours of unpaid labor and studying and writing a dissertation and post-doc hours and licensing exams, and I feel a little bit like after all that time I'm starting from scratch in a way. There was a lot along the journey that simply wasn't useful and I almost had to fight to keep my soul. There were things that I brought to my clients from the very first day that I value—just a certain way of loving and being with people that I feel is the most fundamental part of the work I do—more than any theories or techniques. Yet hardly anyone ever mentioned the word “love” in all my years of training. I felt like I had to fight to retain the soul of my own work and to not get all weird and rigid and overwhelmed with the whole professional side of being a therapist.

There are people I know who are seeing 10-12 clients a day, trying to pay off school loans, pay the mortgage—it can become a real grind. In private practice therapists often don’t see other therapists at all except in passing on the way to the bathroom between clients. It can be a very lonely business and it’s easy to feel isolated from the more systemic problems of the world. I do see myself as a bit of a radical and an activist, and it doesn't align very well with this ten-clients-a-day paradigm that keeps us from connecting with each other and leaves us too exhausted to think about larger world issues.

TM: Well, you might have to define psychotherapy as your own. For example, after doing therapy for a number of years I discovered I could be a writer and live that way. But I've seen myself as a therapist-writer, in the writing itself, which I try to do in a therapeutic way. Some people don't like that, but that's just the way it is.

DK: What don't they like?

TM: People think it's not substantive enough because I don't write academically or reference research studies. I'm writing therapeutically, so it doesn't look so substantive, but the average reader knows. I get feedback all the time from people saying, "This book came to me when I really needed it." I must have heard that a hundred times in the past week.

DK: That's all the evidence you need, right?

TM: It’s a different way of being a therapist. I also learned when my books began being read around the world—today it's a small globe so the books get out there—that therapy is not a narrow thing. When I work with an individual then, I really like it because it's a piece of a much bigger work that I'm doing.

After publishing Care of the Soul twenty years ago, immediately I began getting invitations to speak at medical conferences and hospitals and medical centers. I never intended to do that.

DK: That must have been surprising.

TM: It was very surprising, but you see, that's another example of what I do.

After doing therapy for a number of years I discovered I could be a writer and live that way. But I've seen myself as a therapist-writer, in the writing itself, which I try to do in a therapeutic way.

I go into a hospital or go to a medical conference. I'm the therapist really, and I'm representing the soul of the situation. So I try to work with doctors and nurses, and I listen to them and see what's going on there and I talk to them the way I would as a therapist. I talk to them about the soul of their building, "It's not doing well right now. What can we do to make it fit into this whole process more?" So all of that, to me, is therapy. Just as Socrates says that taking care of your horses and feeding them, that's what he means by therapeia or therapy, I'd say going into a hospital or going into your own home and looking it over and seeing how it is and what it needs also is therapy.

Looking at the planet and saying the planet needs us too, and we're not going to solve the problem of global warming just by convincing people that it's a moral need or your life is at stake. We need a therapy of the world. We need to be able to say, "There is reason for this. This is your home. Get motivated. Take care of it."

DK: That's not confrontational, right? Because that's not your approach.

TM: No, I don't agree with that approach.

DK: Can you say more?

TM: When we take the confrontational approach, we polarize right away. We tend then to see ourselves as right and the other person as wrong. And then we get into some type of moralistic debate that goes nowhere.

The Passion of James Hillman

DK: I think it would be interesting for our readers to know a little bit your relationship with James Hillman. It sounds like you two were very close. He was one of your teachers?

TM: He wasn't a teacher exactly, but he was a mentor. He was a friend more than anything. I met him in 1970 and I started corresponding with him in about 1973. He was living in Zurich at the time, and was sending me articles he was writing. I had been studying Jung very intensely, but I really liked Hillman's revision of Jung, the fresh direction that he took Jung's work. Then, just by accident, he and I ended up in Dallas, Texas. I was teaching at Southern Methodist University, and he got a job at the University of Dallas. So we both ended up in the same city by a fluke and that’s when we became very good friends. We did a lot of things together socially, spent a lot of time together the two of us, and we have a very similar type of temperament. Well, not temperament, but background and interests. He was very confrontational, and so when working together it was interesting because we had two very different styles. But we were passionate about the same things.

DK: What were those passions?

TM: We were passionate about psychology moving into the culture rather than just being individual. In fact he gave up doing individual therapy after a while.

DK: I didn’t realize that.

TM: He didn't agree with it.

DK: Then what did he do?

TM: “Therapy of the world,” he would call it. There's a tradition in the old writing, it's called anima mundi, the soul of the world. He picked up that theme, and he would give lectures and work with city governments, and give talks at political meetings and he would say he was bringing a “soul orientation” toward those kinds of subjects and those concerns. When we weren't in the same place, we exchanged a lot of letters and postcards because we didn't have email in those days. We were friends for over thirty-five years.

DK: You presided over his funeral, right?

TM: I did, yes. He was Jewish and he always had interesting things to say about my Catholic background, so it was kind of surprising that he would ask me to officiate at his funeral, but I think it was based on our friendship and his knowledge that we shared so many ideas about religion and psychology.

DK: My sense is that you can feel like you have much more in common with people from other religions than your own when you come from this more ecumenical place.

TM: That could be what it was, yeah. In our conversations he was always being the depth psychologist and trying to see in a deeper way what was happening in the world around him, so I learned a lot from him just being with him and used his work pretty directly at first. One big difference between us in our work was that he didn't have a very positive opinion of the spiritual dimension. He was good at criticizing it, but didn't have a real appreciation for the spiritual—and I do. So in that way we were very different.

DK: But he was into the concept of soul, right?

TM: Yes, but not in a spiritual or religious context.

“To really love a soul, even if it's weird and strange”

DK: Can you give us a sense of how you work with clients?

TM: Well, I started off by saying before that I'm not so interested in managing a person's life. That's not what I want to do. That's not how I see psychotherapy. That's something else. Psychotherapy is care of the soul. It's therapeia, serving the soul. So when someone comes to me, from the very beginning I'm interested in their soul. What are they coming in with? What's not visible? Not even what they tell me because they don't often know that deep level of themselves. So I don't just take everything at face value, but I do look for signs and try to join them. I agree with you that it’s based on love—love of the person and love of the material and what they're going through. There's a love. I learned that from Hillman—to really love a soul, whatever's going on, even if it's weird and strange.

DK: And dark.

TM: Yeah, dark. Whatever it is, you appreciate it. So I do that, and then I would say most of the time I spend working with dreams. My work is almost all dreams. It's not interpreting dreams. I don't say, "Give me your dream, and I'll tell you what it means, and we'll apply it." But I do ask people to bring their dreams because what I hear from their dream is this deeper level. That soul level comes through in their dreams. At first it takes a while to get it because the dream images are confusing initially. After a while you get to know the individual person's set of images in their dreams. I absolutely need them. I couldn't do the work without them. The dreams give us the direction to go in and what to talk about and how to understand what's happening.

DK: Does your interest in dreams stem from your study of Jung?

TM:

I've studied the imagery in religions, their stories and narratives and rituals, so when I hear a dream, I see a lot of those rituals and stories in the dream.

I think it came from Jung, yes. When I first started reading Jung, I was really taken by his own dreams, especially what he talks about in his memoir, Memories, Dreams, Reflections. He talks there about his own dream work being central to his life. Instead of talking about what's going on in the external world, most of what he writes about is this dreamland, this deep fantasyland. It was very substantial and really made an impression on me. There was so much more there than if you just talk about what's happening on the surface.

His other work, especially his alchemical work, also draws on dreams and shows the connection between alchemy, mythology, and the dream. I've studied the imagery in religions, their stories and narratives and rituals, so when I hear a dream, I see a lot of those rituals and stories in the dream. This was Jung's method too, to compare an individual's dream to what you know about religion and mythology and even art.

DK: Do you bring those associations into the therapy and give them some context?

TM: Yes. You compare them or just see them interact with each other, and that helps you see much more of what's going on in a dream, which otherwise could be quite confusing. Jung felt that if you know myth and religion and the arts well, then you'll have a much better chance of working with dreams, and that’s just what I did. The first thing I did in my studies of religion was to read Jung’s collected works. After that I was able to study all of these religions and their traditions with Jung in mind. I was always thinking, "How do they speak about what's going on in the psyche and the soul?" I bring that background in religion to the dream work. Then I see what's going on in a person's life, and I can see the roots of it more.

Airplanes and Rivers

DK: Can you give an example?

TM: Sure. I write about this one in my book, and I got permission from the dreamer to make it public. This was a young man who came to me with some OCD, some obsessive compulsive practices, little rituals that he did.

The first dream he told me was that he saw these sharks in a river, and he originally wanted to go down to the river. It looked like a nice thing to do. But then when he saw the sharks, he backed away and went away from it. That was the first dream. Well, that tells us quite a bit really. Right away you've got a river, and a river itself is a tremendous image in the history of religion. There are so many great rivers. I'm not saying that his river was one of those, but knowing about those rivers you have a deeper sense of what it means in a dream to have to approach a river.

Very often it might be something like this river is the stream of your life or the stream of your time going on as you experience it. If there are sharks in it, you may not want to go into it. Obsessional practices sometimes look like people are afraid to really live. They have these practices that keep them at a distance, that keep them protected. So that gave us a lot of help right away in the very first ten minutes of working with him. Then we just keep going, more dreams, more stories, and we get deeper and deeper. Not just the surface behavior, but what's going on deep. We discuss the person's family life, childhood, and you see the themes there. A person only has so many themes in life, and they remain, they don’t change radically over the course of one’s life.

DK: And they remain in the dreams?

TM: They come and go. Dreams tend to be cyclical. You may have a series of dreams that have a certain type of imagery in them for maybe six months or up to four or five years, but then they may shift. Or they may come back again later in life. For example, I could talk about my own. I had a series of airplane dreams that lasted maybe eight years, and then they just stopped coming. So the dreams may not last forever, but it’s interesting when they stop. You can ask yourself, "Why did they stop right now?"

DK: Were yours plane crash dreams?

TM: No. My dreams were about trying to take off in a city. The planes would try to get into the air, but they weren't on an open runway. They were in a city trying to take off.

DK: And what did you come to understand about that?

TM: Well, I felt all along that I needed to adjust to the world more. I had to grow up, essentially. I had to live in the culture more. In fact, my books got me more and more into society, into people's lives. As I got more grounded in the world and in society, that dream no longer appeared.

DK: I also have recurring airplane dreams. I was just going to ask you about them.

TM: Yes, go for it.

DK: Mine are also usually in a city, and I witness a terrible plane crash. The context is always different but basically I witness these horrifying plane crashes over and over again, and I can't do anything about it, and I'm completely freaking out. It's devastating every time.

TM: See this is interesting. Can we talk about that for a minute?

DK: I would love that.

TM: So my first reaction to it is that the interesting thing about it is that you freak out. It's not that the plane crashes. I think it's okay that planes crash in the dream because sometimes that high-flying, that airy kind of existence has to come down and you crash. I would connect that with the Icarus myth, the story of Icarus who flew too high to the sun and his wings melted, and he crashed down to the earth. So there's a kind of crashing that takes place when you fly too high or when you're flying too long, that kind of thing. I wouldn't explain this dream that way, but these thoughts would be in my mind as I thought of our continuing conversations. So I would think, "Well, this is an issue where it may be necessary for planes to crash, but that really bothered you. You really have a hard time with that.”

DK: With the fall?

TM: Yeah, with the fall.

DK: That resonates with me.

TM: You used the word fall. That would take us into all that mythology of the fall that's in the book of Genesis, you know the fall of Adam and Eve. There's a lot written about the fall, a fall from innocence, or a fall from whatever. So there's so much there already just without even knowing anything personally about it. There's a lot there to think about before we go too far.

DK: It's so different from the experience of having someone go, "Well, that sounds like depression." So often we therapists get habituated to using language that really lacks imagination. Even in this one minute improvisational therapy that we just did, the myth and the story and the way that you responded just now was almost with a kind of excitement. As opposed to, "Tell me about your sleep hygiene” or “what are your automatic thoughts?" That kind of rote diagnostic way of relating to clients.

TM: Yes, exactly.

There's No Done

DK: Do you tend to see people for a long time? How does therapy end? You don't want to make them better, so how do you know that they're done?

TM: There's no done.

DK: There's no done?

TM: No. There's no done. There can't be.

DK: I like that.

TM:

Therapy is care for the soul, so it's not about seeing a particular person or using a particular method. A person may decide, "I'm not going to do this anymore," but one hopes they'll continue to care for their soul in some way. They may find another therapeutic thing to do. They may take up gardening or make movies or something that will really be good for their soul. In going through that process, they're going through a process very similar to what therapy is.

That's the beauty of Jung's idea of alchemy. He thought that alchemy was the model for the therapeutic process. We can go through any kind of alchemy any place in life. Getting a new job, that's an alchemical process to some extent. You have to process it, go through various stages, and so the therapy never has an end. That doesn't make any sense.

DK: Do you ever fire people?

TM: That's a good question. I don't recall that happening. No, I never did that. Most of the time when people want something, there are a couple of reasons why they would stop. One is that they want something they think I'm not giving them. They want something more specific. They wanted just the practical stuff. I tell them I can't do that. That's not what I do. I don't just say that. I try my best to go deeper into whatever it is they bring up.

On the other hand, some people just don't want to face it. If we had an hour talking about your dream, you'd have to face some things that are not so easy to do. When people hear about dream work, they think “oh, that sounds fun!” But it turns out to be very challenging and some people find it to be too much and so they just leave. I usually think that it's too bad because the process seemed to be getting somewhere.

DK: So you've been fired, but you've never fired anyone.

TM: No, I don't think so.

DK: Well, thank you so much for taking the time to share a bit yourself with our readers. It’s been fascinating.

TM: Thank you, it’s been a pleasure.

After the Diagnosis: Helping Patients Cope With their Emotions

Posted on May 20, 2014February 11, 2026 by rezendevknowfully.com

The New Normal

“I just got diagnosed. Now what do I do?”

The focus of my professional work is on helping patients to cope with medical diagnosis, so I hear this question a lot. But many psychotherapists tell me that their patients also talk to them about their health issues, including sudden, serious medical diagnoses.

As mental health professionals, we may provide the only opportunity that newly-diagnosed patients have to talk to someone in this situation. The traditional medical establishment is equipped to help patients from a medical, but not an emotional, perspective. Family members and friends are also suddenly thrust into the emotional chaos surrounding the diagnosis, and often need help with their own emotions and helplessness.

Our patients facing a medical diagnosis look to us for help in sorting out complicated and scary feelings during a highly stressful time so that that they can move forward in their lives. In this regard, our job is to help patients define and embrace a “new normal” —with a positive self-image, retention of as many cherished routines and rituals as possible and supportive relationships—but also help them to integrate the effects of treatment and make ongoing lifestyle adjustments. Patients facing a diagnosis want nothing more than to be as normal as possible.

If newly-diagnosed patients are able to get needed emotional support early on in their diagnosis, they will be that much better prepared to cope as they move forward with their treatment. As therapists, we help them to prepare for the road ahead.

Medical Diagnosis=Stress

Receiving a catastrophic medical diagnosis is a stressful and sometimes traumatic event. Newly-diagnosed patients feel an immediate sense of uncertainty—life will never be quite the same. And life may end. And like other stressful events, our minds and bodies are hardwired by nature to react. The initial reaction is shock, as our conscious minds essentially shut down while, subconsciously, this information is processed.

As the shock fades, it gives way to one of three reactions that occur in response to stress: flight, freeze, and fight. The flight response is primarily an emotional reaction, and patients may be so caught up in their emotions that they may not be able to make objective decisions regarding their condition and its treatment. On the other hand, those having a freeze response may be unable to acknowledge their feelings at all or may have a fatalistic view, either of which may result in inaction. Those in fight response are best equipped to deal with a new diagnosis. They have access to their emotions as well as their logical resources, and are able to harness both as they face their illness. Most important, patients can be taught how to be Fighters.

These basic reactions impact the kinds of emotions that newly-diagnosed patients experience, and how they cope with these emotions, as well as how they deal with their diagnosis from a rational standpoint (e.g. information-gathering). For better or worse, how patients cope during those first few days and weeks after receiving the diagnosis will have implications throughout their treatment process—from decision-making to coping with the treatment to ongoing recovery and life management. And if those patients find their way to the office of a mental health professional, we can play a formative role in their journey.

The First Reaction

Whether catastrophic or chronic, almost invariably patients describe their reaction with one word: shock. People often experience numbness, as if they are in a trance, or simply have “no feeling at all.” The experience of shock is often associated with disbelief or a sense that their emotions might be so strong that they should be held at bay for fear that they might be overwhelming. There are of course exceptions. For example, when a condition from the past is recurring, or when symptoms over time have rendered the diagnosis inevitable, patients may report an initial feeling that “the other shoe has finally dropped” or that they are about to go down a road that that they have previously been on. Still, it is only human nature to cling to that possibility that “it won’t happen to me.” This belief is mainly unconscious; after all, most of us don’t spend our time assessing our chances of getting hit by a medical diagnosis.

Carole described her reaction when she was first diagnosed with cancer.

"It was like the world suddenly stood still. I mean, all I could hear was my own breathing, and the thumping of my heartbeat. At first, I was completely numb, and I wasn’t thinking anything. And then I started saying the word “cancer” over and over. Still, no feelings. But deep inside, I realized that, no matter what, my life was never going to be the same."

The initial shock may last a moment, hours, days, or may continue on, as the patient’s emotional and rational sides are both struggling with the news. If you have been through the experience of a diagnosis, you might remember how you first reacted, or didn’t react, to the news; or maybe you have seen someone else go through it and felt your own helplessness as you watched them struggle.

In a way, being faced with a diagnosis, while not usually a death sentence, is similar to hearing about a death. As Carole, in the example above, described her diagnosis—nothing will ever be quite the same. Newly-diagnosed patients are left with the knowledge that, yes, bad things can happen, that they really aren’t invincible after all. And the diagnosis —whether it requires extensive treatment that interrupts normal life for months or longer, or whether it requires medication and alterations in diet and lifestyle—will at some point require the patient’s acknowledgement and full attention. Knowing that this looms ahead can also be initially overwhelming for the patient, and the healthcare professionals they are working with may or may not be able to provide emotional support for their patients.

During this time of initial shock, patients are often not open to more information, nor willing to discuss their diagnosis and what it means. It is difficult to communicate with patients who may be unable to hear or comprehend what they are being told, which presents a particular challenge to their healthcare providers who may need to begin a medication regimen and/or make a decision about the path of treatment. The newly-diagnosed patient may need some time and space to sit with the news, and if the healthcare professional pushes them too hard to discuss the treatment plan or to make a treatment decision during this time, the patient may become defensive and refuse to talk further, potentially becoming even more resistant.

Patience is required. Human beings can’t be forced to take in more information than they can process at any given moment moment, and often the best way to help patience move through this early stage is to be willing to sit with them, offering support while being sensitive to the readiness of the patient to process this news. Psychotherapy can provide vital support during this time, a chance to vent about the frustrations and the fears.

Clearly, sensitivity to how a patient is responding must be balanced with the level of urgency in taking any necessary action. For example, it may be appropriate for the therapist to act as a patient advocate by encouraging the patient to schedule a follow-up appointment with their healthcare provider to further discuss the diagnosis and formulate his/her questions. And even to help the patient formulate a list of questions to ask their healthcare provider. Scheduling a follow-up session with the patient to discuss and process what they learned in this second appointment can also be invaluable.

The Three Fs

Accepting that life is going to change is the first step toward coping with the emotional impact of the diagnosis and making decisions. Though newly diagnosed patients come to this realization differently and at different times, most patients fall within one of the fight/flight/freeze responses.

Fight	Freeze	Flight
Positive Thinking	Isolation	Empowerment
Rigidity	Helplessness	Emotional Coping Skills
		Rational Thinking

Flight: The Case of Dave

The best way to introduce the Flight response is through a case example of a newly-diagnosed patient I’ll call Dave. An active man without a history of health problems, his diagnosis of a heart condition took him totally by surprise. His physician presented him with what she thought was the best recommendation, which was a triple bypass, and then suggested that Dave go home and do some thinking before making a decision.

Dave later reported that the sense of shock continued not only that evening, but for a couple of days afterward. He couldn’t believe that he, of all people, was being told that he was in anything but top condition. And his heart? Not a chance. He told his wife only that his doctor was watching his heart, but that he was absolutely fine, which of course she was skeptical of but knew better than to push if Dave wasn’t ready to talk. Dave describes the next few days like this:

"”Once the numbness started to wear off, I kind of went into a panic mode. It was like I had this thing around my heart and I wanted it cut out as soon as possible.” I was afraid to think because I was afraid I might talk myself into doing nothing, or that I might put too much strain on my heart. I imagined my doctor as my savior. I wanted to put all of my faith and trust in her and have her direct my path. I was in such a rush, I asked her to call the cardiologist she had recommended to try and influence him to schedule me for surgery as soon as possible"

While Dave is placing all of his trust in the first physician he encounters, he is also running toward the treatment that feels most expedient. He is not considering the implications of the treatment, in terms of side effects, recovery, and ongoing lifestyle management. As a result, he may later discover that this is not a treatment that he was prepared to deal with, which has implications for ongoing compliance as well as dissatisfaction with his healthcare provider.

The flight reaction has other implications as well. Individuals in this state may—out of a sense of panic—run toward unproven alternative treatments with potentially alarming results. They may also be susceptible to the recommendations of healthcare providers with whom they feel comfortable with emotionally but who may not offer the best treatment option. For example, they may profess to “love” their practitioners, which can preclude them from obtaining a second opinion on the diagnosis, investigating treatment options, and at least checking into the credentials and track record of their physician. Patients in Flight reaction may also attach themselves to an unproven, non-medical treatment with potentially alarming consequences.

The flight reaction can also result in such strong emotions that patients are unable to access their logical mind. Excessive crying, expressions of anger, giving in to fearfulness—these responses signify that a patient is also in flight of a different sort—not toward the first available treatment or the most loved practitioner, but instead running away from their diagnosis.

Freeze: The Case of John

Not all patients “take flight” toward the first available treatment. Some don’t take flight at all. Instead, the initial shock gives way to sitting and staring into space, waiting for the nightmare to pass, or for someone, often a family member, to step in and take charge. This is understandable. After all, between the shock of the diagnosis, and their perception that they are unprepared to make the decisions that are suddenly thrust upon them, or that they have no hope, they are essentially immobilized.

When in freeze reaction, emotions appear to stop working, not because they are broken but because they are being tightly held in place. And while this might be an opportunity for the rational side to kick in and take charge of the situation, logic without emotion is not necessarily going to result in rational thinking, as evidenced by John.

"I just sat there when the doctor told me, and I guess I’m still just sitting still. I can hardly get out of the chair, to tell you the truth. I kind of decided to be philosophical about it. I don’t know much about this but I do know that statistically, the numbers are against me. I mean, what can I do when fate isn’t on my side"

John is using the defense that individuals in freeze reaction often adopt: refusing to react emotionally. Not getting actively involved in learning about the condition and its treatment. Unfortunately, this also means giving up.

Essentially, the freeze reaction is an extension of the original feeling of shock, but with some key differences. Shock is the mind’s way of shutting down the emotions, and allowing the brain to process the information, before reaction. Patients in freeze reaction aren’t consciously suppressing their emotions, but their emotions are nonetheless inaccessible to them. They may think they are being “rational” based on their view of the facts, but there are risks involved when the logical mind is operating without the emotions.

Patients in freeze reaction, because they are operating without their emotional side, may adopt an attitude of hopelessness and helplessness. By not allowing themselves to work through the initial emotions, like anger and fear, they essentially remain stuck. Often they refuse to discuss their condition any more than absolutely necessary with their healthcare professionals, and may avoid telling family members as long as possible. Whereas patients in flight reaction may completely give themselves over to their emotions at the expense of rational thinking, patients in freeze don’t acknowledge their emotions, which leads inevitably to avoidance isolation.

One characteristic common among patients in freeze reaction is an unwillingness to make decisions about their treatment. They rely on their physicians, possibly working with family members, to make these decisions for them. In essence, they decide not to decide.

Fight: The Case of Marie

Being open to emotions can result in an inner sense of optimism and hope. If this optimism is balanced with rational thinking, patients are in the best position to make treatment decisions, deal effectively with treatment and lifestyle changes, and otherwise cope with the changes and challenges that may arise as they face the future. These are the fighters.

Fight doesn’t necessarily imply aggression and, in fact, sometimes patients resist this word because of that association. “Being a fighter means being empowered in terms of understanding the diagnosis, the options for treatment, and what lifestyle adjustments need to be made in the near future and beyond.” Being empowered is about arming oneself with emotional coping skills as well as rational thinking.

Fighters acknowledge the feelings that arise as a result of hearing the diagnosis and continue to honor their own emotions. It would even be reasonable to say that dealing with the emotional aspects of a diagnosis opens the door to rational decision making. Fear may, realistically, never fade away. The anger and disappointment may flare up at times. But emotions like fear and anger, when they are acknowledged and experienced, may also give way to hope, optimism, and a renewed passion for life.

Marie said it this way:

"I sat and cried and asked 'why me?' for quite awhile, maybe a few days. And then I stood up and said, 'I am going to fight this beast. I’m not going to let it beat me down.' The next day I made a list of who I needed to talk to, where I needed to go for information, and what I needed to start planning for. That doesn’t mean I don’t feel overwhelmed sometimes, because I still do. But I’m also in active mode."

Marie didn’t hold back on her emotions but, instead, faced her disappointment and fear. She sat alone with her emotions and, in her case, had a good cry. She also discussed her emotional reactions with a member of the healthcare team, who was comfortable being a “listening ear.” Had she not taken the time to experience how she was feeling, she would have been forced to sit with a large block of emotion, and it would have essentially taken all of her mental energy to hold it down. By doing so, she was able to start asking questions and making decisions.

Patients in fight reaction are more prepared to take action with their condition. By working through their emotional reactions—feeling their feelings and expressing them to supportive listeners—they are not running from their feelings, nor are they so overwhelmed by them that they can’t think. The result is a sense of self-confidence that comes from being aware of, and open to, emotions. Fighters also have access to their rational minds. This doesn’t mean that they are in perfect balance every day, or that they don’t have bad days when nothing seems to go right, but they are on the whole able to search for, and process, information. They are more likely to ask questions and to evaluate alternatives. They take more control over their treatment decisions and the ongoing lifestyle adjustments that they need to make.

Their balance of emotions and logic results in an attitude of empowerment toward their healthcare and the individuals who deliver it. For some patients, the fight attitude comes naturally; they may be more temperamentally inclined towards this kind of response to adversity once they move beyond the initial shock. These individuals will sometimes present challenges to their healthcare team, because they tend to be much more active in their own treatment, and believe that the ultimate decisions regarding sources of information, treatment alternatives, and lifestyle adjustments, lies in their own hands. However, the healthcare team can work with patients experiencing freeze and flight reactions to create and enhance fighter skills.

Psychotherapy: Bridging the Gap That Healthcare Professionals Can’t Fill

Healthcare professionals are not expected to be psychotherapists or counselors, nor to deliver direct mental health services to their patients. On the contrary, attempting to counsel patients without the benefit of being a trained mental health professional can be harmful to the patient and risky for the untrained professional. But newly diagnosed patients often have a hard time processing the overwhelming information they are bombarded with by their healthcare providers, and this is where psychotherapy can play a vital role.

Often patients are so flooded with emotion when they first receive their diagnosis that they aren’t really listening to what they are being told; they might “hear” it, but not be able to make sense of it and, as a result, they may miss key pieces of information or misinterpret what they’ve heard. This can be frustrating and alarming for the healthcare professional, who may or may not have the patience or skill to help their patients through this initial phase. Psychotherapy can help the patient to cope with the fear and anxiety that may be preventing them from processing information about their diagnosis and their treatment options, and to evaluate the options from both rational and emotional perspectives.

This can also be a good time to involve family members in the therapy. They often need support as well in processing and understanding the diagnosis, figuring out how best to support the patient, and deciphering what their role will be throughout the treatment process. Both patients and their families and close friends may not yet have the words they need to discuss their feelings and reactions with each other, and therapists can play an important role in helping to facilitate communication between patients and their loved ones.

Newly-Diagnosed Patients in Psychotherapy

A new medical diagnosis brings with it the probability of change—in routine, in relationships, in self-image—and human beings are creatures of habit, not wired to embrace change. Uncertainty about the future and what challenges might soon be presented, fears about loss, including finances, relationships, favorite activities and one’s future dreams are all a part of what the newly diagnosed patient brings to therapy.

Some of the factors that influence the way an individual reacts to a medical diagnosis include:

Perceptions of the severity of the diagnosis—Patients often have minimal information about their condition when they first receive their diagnosis, or erroneous information, or a vague awareness of the condition but not enough of the facts to evaluate it in terms of the implications for their own lives. These perceptions —and misperceptions —may lead to an emotional reaction that is not consistent with reality. Alternatively, patients may be well versed in their condition and experience emotions that are realistic and consistent with its severity. Either way, perceptions have a direct influence on emotions.

Personal coping style—Some people grow up in families in which emotions are always on the surface, and family members are encouraged to express how they are feeling. In other families, emotions are not so acceptable, and are suppressed. Newly-diagnosed patients who don’t have a history of being comfortable with their own feelings will most likely have difficulty talking about, or expressing, how they feel.

Prior experience of illness—Newly-diagnosed patients who have had a past illness may experience some of the same feelings that they experienced in the past. Having already dealt with a medical diagnosis may have provided them with coping skills to deal with a new diagnosis; alternatively, the diagnosis can reignite fears and other feelings that they had hoped not to re-experience. Patients who have helped a friend or family member cope with a medical condition may react similarly.

The Unanswerable Question

Newly-diagnosed patients inevitably ask one question: “Why me?” This may be a medical question, as the patient tries to understand the medical reasons behind the diagnosis, though there is usually an undercurrent of self-punishment—“If only I’d eaten better” or “if only I didn’t smoke” this would never have happened. People may also feel guilty about asking this question, as it can seem to suggest that it would be more fair and right if it happened to someone else. And patients may also express acceptance, but nevertheless ponder the randomness of life.

The point for therapists is not to answer this question. For many patients, “Why me?” opens the floodgate to releasing their own emotions, because it is a way of articulating that basic question of fairness and the role of fate, core issues that patients grapple with as they begin to process their diagnosis and move toward acceptance and empowerment. Ultimately, “Why me? is an existential question, and as therapists, we can use it to delve more deeply into the meaning of life for our clients and, if appropriate, work with them to cultivate a deeper connection to their religious or spiritual communities and practices.

Facing Difficult Emotions

When I first met with a patient I’ll call Yolanda, who had been diagnosed with cancer, she said:

“All I could think about was how concerned my doctor was when she told me I had cancer. I had never seen this look on her face before, and I just kept thinking that if she was this concerned, I must be in big trouble. I felt like I was on the edge of a cliff and I needed to hang on to something but there was nothing to hang on to. And at any second I might go falling into the darkness.”

During the course of our counseling sessions together, I was able to help Yolanda identify the emotions that she was experiencing, especially those that she thought she “shouldn’t” be feeling (I always begin by kicking the positive-thinking police out of the room). I also supported her as she began to deal with her diagnosis on a day-to-day basis, including giving the news to her family, making the treatment decision, undergoing surgery and chemotherapy, and making lifestyle changes. Helping Yolanda recognize, accept, and cope with the emotions around her illness allowed her to move into an empowered fighter position.

Yolanda gave voice to her greatest fears about cancer. As we worked through the “why me?” question, I told her about similar experiences by other patients facing cancer to help normalize her reaction. It’s important for people to remember that they are not alone and that many have walked the path before them. I also encouraged her to arm herself with real facts by asking questions of her treatment team and information-gathering on her own, and at her own pace. Information is an antidote to fear.

As Yolanda faced her fears about her cancer diagnosis, I encouraged her to express other emotions as they arose. Allowing herself to be angry was an important step for her, as she was able to express her frustration at having to take a break from her active life to go through treatment. As she stated, “I want to scream at life and how unfair everything is!” During a later session, as she was beginning cancer treatment, she talked about attending a wellness lecture and leaving feeling ashamed that she “might have avoided this if I had taken better care of myself.” And during chemotherapy, she expressed sadness that she wasn’t able to “be the mother that my kids need me to be.” Yolanda needed the opportunity to express these emotions in a safe, non-judgmental environment so that she could continue to cope with her day-to-day life and responsibilities.

Challenging Harmful Beliefs

As patients react to the stress of their diagnosis, their fundamental beliefs about life are put to the test, many of which, from a Rational Emotive Behavior (REBT) perspective, may be irrational and therefore lead to reactions and emotions that are unproductive and self-destructive. I was able to gently help Yolanda to identify beliefs that resulted in, as she said, “beating up on myself” and “telling myself that I shouldn’t feel the way that I do.” Irrational beliefs common to newly-diagnosed patients include:

My life will not change unless I want it to.
I must be available to the people who need me at all times.
If I live a good life, bad things won’t happen to me.
If I don’t keep a positive attitude, other people will think I am a failure.
If I don’t maintain control of my emotions I will collapse.

“I can’t emphasize enough the importance of first and foremost being a supportive, listening ear in the true sense of Carl Rogers—non-judgmental, unconditional positive regard.” This is what patients need most when they first get diagnosed. Motivational interviewing techniques can also be helpful in assessing readiness and introducing alternative ways of coping.

As Yolanda was ready for me to move from the role of supporting and normalizing her emotional reactions to examining her beliefs and understanding the connection with her emotions, I used a more active approach to help her identify her triggers, reframe her irrational beliefs, challenge either/or thinking, recognize and replace negative self-talk with health-enhancing affirmations and use progressive relaxation techniques.

A Note About Grief

Newly-diagnosed patients often go through a grieving process, and this can be an essential step in coming to terms with their condition and moving forward with treatment and lifestyle adjustments. When they grieve, they are beginning the process of accepting that a change is occurring in their life. Regardless of the diagnosis, accepting that life is going to be different in some way, and that these changes are out of their hands, is an important step forward. For many newly-diagnosed patients, their diagnosis causes them to take a look at one or more of their basic beliefs about life and to reevaluate them. This may be the first time that they have looked at these beliefs and how they affect their actions and emotional reactions. During this process, assessing a patient’s spiritually, and encouraging them to seek spiritual guidance in whatever way is meaningful to them can be helpful in getting through the grieving process.

Sensitivity to the Influence of Culture and Gender

It is also important for healthcare professionals to be aware of the influence of culture and gender. Cultural background can influence how patients interact with the medical establishment, how they experience and express emotions, and their willingness to accept mental health intervention. Gender can present further complications in expressing emotions around illness as well as in getting informed. In Western culture, women tend traditionally to be more active medical consumers than are men.

Working with the Healthcare Team

The healthcare professionals that are working with newly-diagnosed patients can greatly benefit from the ability to understand and recognize how patients are reacting to their diagnosis, and psychotherapists can play an important role in consulting with them. Understanding whether a patient is having a flight, freeze, or fight response, for example, will guide healthcare professionals in gauging their readiness to receive information, so that it is presented in a manner in which patients will most likely be receptive. Those in flight reaction may need some additional emotional support while those in freeze reaction may need some coaching in interpreting what they read and hear with a sense of optimism. Fighters may ask a lot of questions for which the team needs to be prepared. And going forward with treatment and recovery, patients who don’t become fighters may continuously erect barriers to compliance and life management.

I often work directly with physicians and, depending on the wishes and permission of the patient, will contact the healthcare team to share information and, as needed, to advocate for my patient. Where possible, maintaining open communications with healthcare providers, and offering to support them during especially difficult times during and after treatment, can be invaluable to the patient. Many healthcare providers also recognize the emotional component as key to enhancing recovery and ongoing compliance and are happy for the support.

Offering the healthcare team an understanding the patient’s particular reaction style can help them tailor their approach in ways that leverage the patient’s strengths. We can specifically give the team advice about how best to:

Present information on the condition and its treatment
Coach patients through the treatment process
Make recommendations on lifestyle management
Encourage patients to seek support with activities of daily living
Monitor ongoing compliance

Preparing for the Road Ahead

Finally, I always tell my clients: You are not a diagnosis. Your diagnosis is only part of who you are. Remind yourself every day that you are a fascinating, multi-dimensional creature with a past, a present, and a future that belongs to you and to you alone. Embrace life and your potential to live your life, with all of its triumphs, set-backs, surprises, and detours. Now, let’s get prepared for the road ahead!

Psychotherapy with Alien Beings: Cultural Competence (and Incompetence) in Psychotherapy Practice

Posted on April 5, 2014February 11, 2026 by rezendevknowfully.com

A Klingon, a Cardassian and a Betazoid walk into Coffee Bar…

However, as on Earth, ethnicity in the Trek world comes with assumptions about behavior—stereotypes, as it were. Our Klingon will be aggressive both verbally and physically, possessed of less than perfect impulse control, yet fiercely loyal and courageous. The Cardassians are a tad pompous, overweening, with a tendency to believe themselves correct in all things, which is perhaps why they were so effective as colonizers for so long. And the Betazoid is empathic, in fact way beyond empathic, because Betazoids can read minds and feelings. The first psychotherapist character in the Trek universe was a half-Betazoid/half-human.

So the Trek-savvy among us think that we know what to expect and how to respond to our trio as they order their double tall split shot one pump mocha light foam extra hot lattes from the barista at Fremont Coffee. Their coffee order, by the way, gives you the clue that they all live in Seattle, as locals are famous for complicated coffee ordering. We psychotherapists with our degrees from the Star Fleet Academy have taken a class in diversity. Some of us have even read the Handbook of Psychotherapy with Klingons, given that working with Klingons has become a very popular specialty in the aftermath of recent wars and the uptick in PTSD in the Klingon community.

However, our expectations are entirely unmet with these three. The Klingon turns out to be quiet, polite, and shy, joking a little with the barista about the new purple streaks in her hair. The Cardassian goofs around with the other two, and is wearing jeans with holes in the knees and has a pierced eyebrow. The Betazoid seems utterly insensitive to everything going on around the coffee-drinking threesome, and seems quite self-focused when we listen in on the conversation. We sit, confused, wondering if we missed a chapter in the handbook about special concerns of species living in Seattle. Maybe the communities here are different? (All that coffee and rain). We think that perhaps we should take a continuing education class to update ourselves about the latest findings on these ethnic groups.

You may at this point be wondering why I’m telling you this tale of the extraterrestrials in my local coffee house and the confused psychotherapists who are observing them. The answer is that it illustrates something about what psychotherapists have generally believed cultural competence to consist of, and lays a foundation for my discussion of what I believe cultural competence to truly be—as well as how and why culturally competent practice epitomizes an integrative stance on psychotherapy practice.

What is Cultural Competence?

The problem lies most fundamentally in the paradigms for culturally competent practice in which most psychotherapists are trained. These paradigms at best generate a false sense of capacity and at worst, and frequently, engender feelings of guilt, shame, and incompetence, none of which are salubrious affects to bring to the practice of psychotherapy.

In the majority of psychotherapy training programs in the U.S. of which I am aware, the development of cultural competence has, until quite recently, been framed as the acquisition of data and algorithms about various groups of people. I call this the "Handbook of Psychotherapy with Alien Beings" strategy. Psychotherapists taking coursework on this topic memorize the “fact” that Asian Americans tend not to be psychologically minded, and will do better with advice and CBT, or that respect is centrally important to Latino men. We learn that in many instances our best course of action is to refer out to the colleague who specializes in Asians, or Latinas, or Cardassians, particularly one who is her or himself a member of one of these groups.

Sometimes in this graduate school class, frequently called “multicultural awareness” or “diverse populations,” there’s a week on lesbian, gay, bisexual and transgendered (LGBT) people, another on aging. If the class is taught on the East Coast of the United States, the instructor may have spent some time on Jews and Italians, the not-quite-as-white Euro-American ethnic groups, while in California there might have been a lecture about Latinos, who occupy a similar niche in the social ecology of that state. A family therapy program may have assigned Monica McGoldrick and her colleagues’ work on the different kinds of ethnic families.

“No matter who’s included, the message of such training is that cultural competence is about them—it’s about the Other, the client who is “diverse,” and about how to address the problem of dealing with that other in psychotherapy.” These courses also commonly induce feelings of incompetence by conveying the message that psychotherapists probably don’t know how to work with the Other until they have acquired a set of rules about them. A strong subtext of this training is that the psychotherapist is not Other. Even when a psychotherapist is member of one of the groups being studied, such training communicates an interesting meta-message about the default assumption that, similar to police who define themselves as all blue, the therapist in training from the alien culture has now joined the new ethnic group of psychotherapists, who are de facto members of a dominant culture. As they say on Star Trek, “resistance is futile, you will be assimilated.”

This set of instructions is often intriguing to psychotherapists interested in psychotherapy integration. The “use this approach with this group” method encourages therapists to call on paradigms and interventions from several different approaches to psychotherapy, which they may or may not have in their toolbox. Thus when the integrative psychoanalyst meets the Asian client, she or he should have some CBT expertise to bring to bear.

This approach to teaching cultural competence conveys that clients who are Other don’t feel safe with or understood by most psychotherapists, and tends to induce feelings of guilt, shame, and incompetence in students. Psychotherapists will often develop anxiety about working with the Others, fearing that they will unwittingly be insensitive and hurt them, which in turn makes it that much harder for them to settle down and relate empathically with such clients. None of this is to say that having coursework on psychotherapy with the Other is inherently a bad idea; in fact, it has been a very good and necessary first step. The inclusion of any material on human diversity in psychotherapists’ training is a major advance from the state of affairs as late as the 1980s, when, as Robert Guthrie poignantly noted, “even the rat was white.”

My own training in clinical psychology in the early 1970s included absolutely no formal or informal instruction in human diversity. When I had my first African American client while in graduate school, my supervisor was as ignorant as I was about how to best make sense of him. Together we replicated the statistic about the Other dropping quickly out of therapy. We did that via a deadly combination of both therapist and supervisor feeling anxious and guilty, and my supervisor trying to school me, based only on his stereotypes and biases, in what to expect when working with one of “them.”

So the fact that by the 1990s it was becoming more commonplace for psychotherapists in the U.S. to encounter some formal coursework on human diversity in their training seemed wonderful to those of us who, like myself, had become passionate about making psychotherapy a more socially just enterprise. Even with the rules and the guilt and the shame, it was something. Attention to diversity had become a principle in the ethics code of American psychology, and a criterion by which training programs were accredited, and that was an important advance.

There were problems inherent in the first emergent model, however. “A therapist could read the Handbook of Psychotherapy with Klingons, and become known among the local psychotherapy community as the person who got the referral when a Klingon client showed up in their practice. This did nothing for one’s competence with Vulcans, though.” The norms for behavior in the two cultures are deeply opposite, the themes and metaphors distinct, and the approach to be used by a psychotherapist entirely different. The official Klingon expert might also not have learned much about gender roles in Klingon culture, and accidentally extrapolate earth-bound norms about gender to working with Klingon women, which would be deeply erroneous. Not many Klingons of earlier generations survived into later life, given their tendencies toward violence, so there was no chapter on aging in the Handbook. A 70-year-old Klingon shows up in your office—what do you do with him? The “learn a set of rules for the space aliens” that promoted doing cultural competence by rote gave you no instructions for this particular anomaly.

The reality that knowing a great deal of specific knowledge about a given group was a problematic paradigm for developing cultural competence as a psychotherapist became increasingly apparent toward the end of the '90s. Like the visitors to my neighborhood coffee house, many of our clients were refusing to follow the rules about their groups that psychotherapists had carefully learned and memorized in the diverse populations classes. Those of us who, like myself, had spent the '70s and '80s most preoccupied with gender and sexuality were impertinently commenting that these factors influenced expressions of ethnicity. The folks interested in social class and disability had similar notions about the possibility that those kinds of experiences might make for a different creature than the generic humanoid that we’d studied in our diverse populations class. Our coffee-drinking Klingon is a woman; the Cardassian is a trans man, and the Betazoid is a hip young cis-gender guy. The chapter on Cardassians never even mentioned gender expression. Eek. What’s the well-meaning psychotherapist to do?

Intersectionality and Integration

To understand these models, it helps to comprehend what we mean by the construct of intersectionality. Put simply, it is that each of us is more than the most obvious component of our identity, and that these mixtures of aspects of self occur in a myriad of ways. This also means that we have aspects of self, referred to as social locations, which inform identity even, or particularly, when they are invisible to others, and that relate one to another in a range of ways. As the protean actress Sarah Jones, who performs one-woman shows in which she becomes many characters, noted in a speech at the 2009 TED conference, “We are all born into certain circumstances with particular physical traits, unique developmental experiences, geographical and historical contexts, but then to what extent do we self-construct, do we self-invent? How do we self-identify? And how mutable is that self-identity?”

Psychotherapy is all about changing identities, from spoiled to whole—but perhaps we might find that we are more effective at making those changes when we are attuned to the component parts of the person’s tapestry of self. Appreciating intersectionality, which is core to culturally competent practice, to some degree requires openness and flexibility on the part of a psychotherapist; conducting psychotherapy from the starting point of grasping an individual’s intersecting identities is by and of itself an intentionally integrative strategy for conducting the business of psychotherapy.

Intersectionalities provide both psychotherapist and client with information about those processes of self-invention to which Sarah Jones refers. Attending to intersectionalities allows for interrogating the process of self-invention via the disentanglement of the strands of self, including those that have generated psychological distress and problematic behaviors. This disentanglement is to my way of thinking, central to the enterprise of psychotherapy. For many of the people who come to us with their misery, the process of self-construction has been one of problematic conflation—a tangling of negative characteristics and experiences of powerlessness and hopelessness with important aspects of self. All the while, other components of self, which might lead to a different and more functional and peaceful construction, remain in the background, ignored or unexplored.

ADDRESSING Multiple Identities

The first is a broadening of the dimensions on which human diversity might be considered. Rather than privileging ethnicity/phenotype as the sole or primary marker of human difference, these 21st Century models describe a multiplicity of the variables that I refer to as social locations—aspects of the social and interpersonal domain in which a person is located, some or all of which contribute to the development of identity.

ADDRESSING, for instance, stands for Age, Disability, Religion, Ethnicity, Social Class, Sexual orientation, Indigenous Origins, National Origin, and Gender. This is clearly not an exhaustive list—in my own recent work on cultural competence in trauma practice, for instance, I have expanded Hays’ list to include such factors as histories of colonization—both as colonizer and colonized—relationship and parenting statuses, size, attractiveness, combat experience, and interpersonal violence. Hays explicitly states, and I concur, that all humans have a stake in almost every one of these dimensions.

The second aspect that these emerging models of human difference offer is the vision of these factors intersecting in a multiplicity of ways. As I mentioned a moment ago, these intersections are not simply additive, or even multiplicative, nor necessarily layered. They are sometimes the sum of their parts; they are, on occasion, more than, or different from, that sum. Maria Root, who has been at the forefront of proposing new paradigms for theorizing the experience of people of mixed phenotype and heritage (aka “racially mixed”) has found, in her research on sibling pairs from such families, that there are as many as five different and equally likely trajectories of intersectional identity development. These include everything from going along with what the culture thinks you are, to “add and stir,” to the Tiger Woods “I’m a Casablanasian” strategy, to what Root calls “symbolic” identity in which the phenomenology of self is in no way visibly linked to biological characteristics such as phenotype or sex.

Understanding intersectionalities is a first step towards cultural competence. The parameters of cultural competence are no longer met by reading and memorizing the rules from the handbook of psychotherapy with the Other. “While some specific cultural knowledge can be helpful, we are beginning to see it as being as potentially misleading as it is informative. It is useful to know that Klingon culture is war-oriented largely so that we can consider what it means that our coffee-drinking Klingon is, herself, not.”

Instead, what the 21st century paradigms for cultural competence have generated is a new way of understanding how we, as psychotherapists, can understand the facets of people’s identities that are important to them, both those that transcend the distress for which they seek treatment, as well as those that inform that distress in terms of its etiology, its expression, and its treatment. From this standpoint of cultural competence, all symptoms are what the DSM calls “culture-bound.” A culturally competent lens lets us know that the thing we call Major Depressive Disorder is the Euro-American/European culture-bound version of expressing this particular subjective experience, for instance.

The next important component of these emerging paradigms is that they also require the psychotherapist to understand her or his own biases, and to engage with them mindfully rather than operate from the fantasy that they can be put aside in the name of that great illusion, objectivity. Culturally competent practice informs us that objectivity is what those in positions of power call their own subjectivities. Thus, the culturally competent psychotherapist has discarded the notion of neutrality in favor of that of compassion: observation without judgment, including judgment of oneself for being human and biased. She or he learns to notice bias, and to bring its realities into the foreground of consciousness, to say to the client, “Perhaps we can talk for a bit about the fact that I’m from Earth and you’re Klingon—what might that mean for you.” The old model of cultural competence that would be blind to difference is washing away; after all, how can one not notice the many deep furrows in a Klingon’s brow? Or the melanin tint in the skin of someone whose ancestors did not mostly come from Europe?

Working from the Inside Out

What if, instead of working in this top-down manner we switched polarities and, using our shared commitments to integrative work, began to tailor the therapy to the specific needs of our clients, and to work with them from the inside out? This is not a new idea; Prochaska and his colleagues’ “stages of change” model offers a meta-theory of psychotherapy which invites us to do just that, noticing that at each point in the process clients are more likely to respond to certain types of therapeutic interventions than to others. John Norcross has been suggesting using assessment of client stage of change as a strategy for customizing psychotherapy for most of this century. I’m suggesting we this a step further, and see cultural competence in psychotherapy as an ultimate outcome of integration, particularly of a common-factors model.

Working from the inside out with a model of intersectionality allows a psychotherapist to drill down deeply into the core of two things. The first are the sources of distress, of pain, of woundedness, of overload and disconnection—for it is at the emotional locations of our identities that many of our wounds lie. Sometimes the very fact of being wounded is one of the powerful threads running through the weave of our intersectional fabric; often, the wounds attach to other powerful threads. “Conceptualizing people’s psychological problems not only as symptoms to be eradicated, but also as evidence of aspects of identity, generates some very novel ways of approaching the problem of alleviating distress.”

The Ubiquity of Trauma

Many of us are children of trauma survivors, living with legacies of intergenerational transmission of trauma experiences. Indigenous peoples of this continent, African-Americans, Jews, Khmer, Native Hawaiians and Armenians are but a few of the groups that have been on the receiving end of genocidal violence.There is a plethora of additional examples, since trauma has been pervasive in human experience.

We are also perpetrators. Some of us are the descendants of slave-holders, of soldiers who shot women and children in this country’s genocidal wars against its indigenous people, of those who imprisoned or tortured others in the countries from which they came. Our ancestors suffered what Shays calls the “moral injury” of being trauma perpetrators, and in many cases that was traumatic to them, and to the family cultures that they created and of which we are the inheritors. Some of our families served in the governments of Batista’s Cuba, Stalin’s USSR, Hitler’s Germany, South Africa under apartheid. Some of our ancestors have been beaten; some of our ancestors administered those beatings. For some of us, our ancestors include both; many African Americans carry the genes of a slaveholder great-great-grandfather who raped their enslaved great-great-grandmother. Perpetrator and victim consciousness live within our cultures, our families, our psychological realities. They are a component of our constructions of identity.

The phenomenon of trauma attaches itself to the threads of intersectionality. Conceptualizing an individual’s distress from the standpoint of cultural competence leads us to query not only whether she or he is sleeping or eating or having terrible images of past or future come into her or his mind, but to consider the various facets of identity and how they interact one with another and create an individual’s suffering. We can then tailor our therapy relationship and the interventions that emerge from it to the identities and realities that are salient to this individual.

The second, equally important thing revealed by the adoption of an epistemology of intersectionality are the sources of strength, resilience, joy, and creativity that reside in the social locations which comprise the warp and woof of each individual’s identity. Just as these variables of identity inform distress, so they also generate narratives of survival, thriving, and active responses to the vicissitudes of the world.

Culturally competent psychotherapy practice thus begins with the client at the center of conceptualization, not with the diagnosis, not with a treatment manual, not with the therapist’s idea of what to do next. Rather than conceptualizing the problem, culturally competent practice “diagnoses” the person via a sensitive understanding of her or his identity, allowing that to generate a narrative which reveals distress and strengths alike. Questions of how to heal, and how to evoke strengths in the service of, and in collaboration with, the specific modalities of psychotherapy being offered, emerge from an understanding of those various strands of identity, rather than from the imposition of a particular psychotherapeutic model.

Evidenced-Based Failures and Common Factors Successes

As it turns out, an attention to the common factors and to psychotherapy relationship variables is frequently a way to be accidentally laying the foundation for culturally competent practice. What those of us who practice from the starting point of cultural competence have repeatedly found is that the intentional application of common factors, combined with a thoughtful and respectful attention to clients’ identities and intersectionalities, largely described how we operated. This has been true in my own work developing feminist therapy practice.

The more I developed theory in feminist therapy and deepened my own comprehension of what it implied, the more I realized that, not only is feminist practice a technically integrative one, as I had long been saying, but it is also a practice that is founded in the common factors, with strong emphasis on relationship variables. It is also founded most centrally in attention to cultural competence through the lens of gender. When, as feminist therapists do, I pay attention to intersectionalities via the strategy of analyzing gender, power, and social location, I inevitably find that my most effective therapeutic tools include the person-centered facilitative conditions of empathy, genuineness, and positive regard, as well as those variables that contribute to therapeutic alliance.

For instance: the presence of cultural empathy in a therapist—that is, the ability to suspend one’s frames of reference in order to deeply enter that of the client—has been strongly associated with good psychotherapy outcomes for clients who are members of target groups. The therapist’s capacity to own and acknowledge bias, and to apologize for its unintentional infliction (aka relationship repair) is also strongly associated with client reports of satisfaction and good outcome. Many clients who are members of target groups experience dominant group therapists as distant or chilly; these “cold therapist” variables, which are associated with weak therapeutic alliance, are often a by-product of the absence of a culturally-informed and competent stance on the client and the relationship.

Discourse needs to occur, in both and all directions, between those whose central focus on psychotherapy derives from the position of cultural competence and those most centrally interested in understanding the common factors of psychotherapy and integration across paradigms. One thing that I have found interesting, and curious, is that while the research on culturally competent practice comments on therapists’ capacities to engage in the sorts of behaviors that contribute to good outcomes through the lenses of cultural awareness, the common factors literature does not, at least in my reviews of it, pay any attention to issues of culture, identities or intersectionalities. While there is some very beginner work on matching of therapist and client on factors such as sex or ethnicity, there’s not really much in the psychotherapy outcome world that asks about identities, intersectionalities, and therapist awareness of bias and privilege. But how might the power of our work be enhanced if we also assessed such variables as the impact of cultural awareness and cultural empathy on client and therapist alike, and on the outcomes of psychotherapy? How might we be better served in our quest to develop psychotherapies that serve more people, more effectively, if researchers of outcomes routinely attempted to assess the cultural competence of the psychotherapist?

We Are All Other

My own bias, and that of the growing band of hardy souls who have been pioneering the broader model of culturally competent psychotherapy practice, is that when we start with the client’s identities and our own, and then work our way backwards into the therapy, we are not only more effective at integration across theories and applications, we are also more likely to meet clients where they are. This, I would argue, creates the interpersonal conditions within which people are more willing to take the risky steps inherent in a change process, because as psychotherapists we have initiated, and modeled, the willingness to change our stance, and modify our ways of seeing, and hearing, and knowing, in order to encounter our clients in their social and phenomenological realities. What I have learned by practicing from a foundation of striving toward cultural competence is that sometimes what looks like being stuck in the pre-contemplation stage can as easily be someone saying, “Why should I admit vulnerability and imperfection to you, oh member of the dominant group that already judges me from the moment you see me?”

I encourage each of us to remember that while we are all human, we are all each, in some important way, Other. If cultural competence infuses our work, then we are more likely to make the connections from which genuine psychotherapy occurs. Cultural competence is not a special topic, nor a political interest; it is, and should be, central to the work of psychotherapists seeking to most effectively empower our clients.

Eduardo Duran on Psychotherapy with Native Americans

Posted on April 5, 2014February 11, 2026 by rezendevknowfully.com

Lost in the Wilderness

Deb Kory: You are a Native American clinical psychologist, scholar, teacher and healer, who has worked primarily in the Native American community over the last several decades. Your most recent book, Healing the Soul Wound: Counseling with American Indians and Other Native Peoples, centers on the theme of healing historical trauma. Can you describe what you mean by historical trauma, and how you came to this work?

Eduardo Duran: Well, it started very early on. I had just gotten out of the military, and I was working in this community up in the mountains, pretty much by myself. I was in graduate school at the California School of Professional Psychology (CSPP) and was supposed to be developing a mental health program. People were coming to me for help, but I frankly didn't know anything about therapy. They weren’t easy clients—they had serious issues—and my supervisor was in the city, so I had to kind of start inventing stuff.

DK: Was this on a reservation or just in a rural community?

ED: It was a reservation up in the mountains. Very remote. The curious thing was that people assumed, “He’s an Indian guy, so he must know how to do this therapy thing.” At that point nobody else wanted to do it, so it was kind of up to me. So I started developing a needs assessment and came up with the usual stuff—there was a lot of depression, alcoholism, and those types of problems in the community.

When I took my report back to the Tribal Council they said, “Those are not our problems,” which really threw me. I could see with my own eyes that these were their problems. They completely rejected what I was doing and told me to go back and try something else.

Basically everything I was doing was being rejected. And here I was paying a lot of money to go to graduate school and it was not working with my clients.

At the same time people were coming to me for therapy and I was doing the best I could with my limited knowledge of cognitive behavioral therapy. But these folks were also telling me, “We don’t want this. We don’t want to talk about this stuff.”

Basically everything I was doing was being rejected. And here I was paying a lot of money to go to graduate school and it was not working with my clients.

DK: They just weren’t having any of it.

ED: No they weren’t, and I was at my wit’s end. I went back to the Tribal Council with another report, and at this point I had switched over to using a qualitative methods approach and thought for sure I had the goods now. And they rejected it again. I had no idea what to do.

Then this old guy there says, “What you need to do is go up in the mountains and consult the spirits.” At that time, CSPP did not have a Consulting Spirits class.

DK: It’s probably safe to say they still don’t.

ED: I think you’re right. So I was like, “OK, now what? I don’t know how to do this.” I'd heard stories of ancient people and the burning bush and all that, so I went up into the mountains, and with nobody looking I just kind of walked around.

DK: Did you see a burning bush?

ED: No.

I was wandering around there like a dummy, hoping nobody saw me walking through the trees. I didn’t hear anything. Nobody talked to me. And no spirits came.

I was wandering around there like a dummy, hoping nobody saw me walking through the trees. I didn’t hear anything. Nobody talked to me. And no spirits came.

At the time I was sharing an office with a doctor and a nurse practitioner. It was actually an RV, an Indian Health Service RV, and we were so cramped. People just kept coming to me for help and I had exhausted my Western tool bag. What people wanted to talk about was their dreams and, of course, I didn't know anything about dreams. In grad school, they didn’t teach us anything about dreams.

So I would just sit there using the two techniques that I learned, that all psychologists need to know to be psychologists. The first one is when you have no idea what's going on—which is most of the time for me, anyway—you say, “Well, what do you think that means?” So I did that. And they said, “If we knew what it meant, we wouldn't be here talking to you, would we?”

So they took that one away from me, and all I had left was the deep-look-in-your-eye technique, and nodding “hmm.” Pretending that I knew stuff. Well, that bought me some space.

It was during this time that I started having the feeling that there were other people in the room.

Seven Generations

DK: Wow. That must have been unnerving.

ED: It sure was. And I couldn't very well acknowledge it with my clients who were coming to me for help. You know, because that’s against the rules. One of the rules of being a psychologist is, “Thou must not hallucinate in front of patients.”

DK: Did you worry that you were going crazy?

ED: Actually, yeah. It was a very difficult time because I didn't have any context for this. But it happened that around this time, there was a particular traditional healer, or medicine man, that I had heard a lot of stories about. He arrived at my door one day to kind of just help or check me out or something.

One of the rules of being a psychologist is, “Thou must not hallucinate in front of patients.”

As he was talking, and using tobacco in the sacred way, I thought, “He's probably as good a guy as any to run this by.” I figured he’d say I was stressed out from working and graduate school and needed to take a break or something.

So I told him what I was experiencing and he said the exact opposite of what I wanted to hear: “The reason you're feeling that is because they are there.” I was like, “What?! Who's there? I don't need this.”

DK: You were actually disappointed that he didn’t tell you that you were just going crazy and needed to stop what you were doing.

ED: Yeah. “Just go and take some time off. Take some nice anti-psychotic medication and all will be well.” He didn't do that. He told me that in most Native communities here and across the world where I've been, there's a very common saying that “everything you do affects seven generations.” And he said, “It's not just in one direction. In spirit time or dream time, it also can go backwards. So seven generations back, seven generations forward, which means a lot of the unborn ones are also being affected. You and me talking today, we're affecting seven generations of our ancestors and descendants.” Then he went on to explain that between the year 1870 and 1900, 80% of the Native people in the communities I was working with had been exterminated. By the military, through disease, complete tribes were wiped out.

Between the year 1870 and 1900, 80% of the Native people in the communities I was working with had been exterminated.

He said that what was happening was because of the rules of natural law, that there needed to be healing, but it had to take place in a particular way. There had to be grieving and healing of the trauma, but because there had been no time to do that in the past, the energies or the spirits of the ancestors of the people I was working with were showing up in sessions. They needed to heal through their descendant here.

I mean, what do you do with that?

DK: Yeah, what did you do with that?

ED: I sat with it in disbelief. But since nothing else I was doing was really making any sense to the people I was working with, I thought, “Well, I’ll try this. I'll tell some of these people what he said and just see what happens.” And it made perfect sense to the people I was working with. And it started helping me make more sense of the dreams, because a lot of the dreams involved trauma. Some of the people I was seeing had serious problems—addictions, violence, family dysfunction, all of that—and, to my surprise, using this frame to work through their dreams really started making people better.

DK: Did any of your clients also have the experience of other beings, spirits being in the room?

ED: They had experiences in their life where that had happened but, like me, they didn't have the context for understanding it. So, by me being able to talk about it, they were able to say, “Oh by the way, I've been seeing my great-great-grandpa appearing. But I can't tell people because they'll think I'm crazy.” And, of course, that was true.

"You're on the Right Track"

DK: They would be institutionalized.

ED: Exactly. In fact, I remember I was invited by the Federal Agency, the Indian Health Service, to give a report to them about what I was doing. So I gave a presentation about this—not like I’m talking to you; I tried to cover it up a little bit. And during my talk, these two guys in uniform from the Public Health Service came up to the podium and I thought they were going to congratulate me, but as they got to me, one of them whispered in my ear, “What the hell do you think you're doing?”

DK: Wow.

ED: And the other one said, “You're going to ruin your career before it starts.”

DK: Were they Native American?

ED: One was and the other one wasn't. But they were high-ranking people in the Public Health Corps and in the Indian Health Service. They were high up on the food chain and had control over the money, so they could mess with me.

By this time I had already encountered my teacher, Terrence, who would play such a big role in my life, so I went up to see him, and he basically said, “Don't worry about that. Keep going. You’re on the right track.”

DK: So you got important validation at a crucial moment.

ED: Right before he went on to the spirit world, one of the things he told me was, “If everybody's liking everything you're doing, you're doing something wrong.” I really try to honor that wherever I go.

DK: Pissing people off is kind of underrated in our field.

ED: Yes, and he was able to offer the container for me through all of it. In my meetings with him, he would kind of contain my psyche. My clinical supervisor could only do so much and I could only tell him so much if I wanted to stay in the profession.

DK: We’re going to be releasing a video this month featuring Derald Wing Sue, one of the main forces behind multicultural training in psychotherapy.

ED: Oh yeah, I know Derald.

DK: In the video he talks a little bit about his beginnings in this field, and there are commonalities in your stories. He got into psychology many decades ago and realized that the fundamental structure of the field was pathologizing to Asian culture. He had to figure out a way to carve out a space that made sense for his own culture and upbringing, and ended up shedding a lot of light on the profession’s profound inadequacies.

It sounds like you also had firsthand experience of being an outsider in this field—being told you were crazy and being shut down by people around you. I can imagine being pretty traumatized by that.

ED: I had an experience recently in New Zealand, reviewing a dissertation of a Maori man, where he talks about exactly this same phenomenon. In New Zealand, they’re in the beginning stages of this cultural competency training, and the Maori are pathologized in very much the same way that Native people here still are.

That’s why I write the stuff I write. There’s no other reason to write it. There's no money in academic publishing. But in the Western world, if it's published it's “true”; If you just say it, it's just anecdotal, right?

DK: Oral tradition isn’t considered scientific enough in the Western paradigm. How are you treated when you go to more traditional Western schools and talk about seeing spirits and having these scientifically unprovable experiences?

ED: It’s interesting. I did a talk for folks in the judicial system here in Montana—you know, cops and judges—and I thought, “This isn’t going to go well.” But I gave my talk and at the break, three or four officers came up and I thought they were really going to let me have it, but instead they said they were so relieved to hear me talk. They work with people who are locked up in jails and prisons, and they said that they were having these same experiences, of seeing people and thinking they were just going crazy. My stories gave them a context to understand their experiences and they were just very relieved. I was totally blown away by that. These were guys with guns and stuff.

So I think it’s more widespread than we think, but people stay closeted. What I do is validate it so they come out. The same with therapists. When I do these talks with therapists types, they don’t dare say it openly, but at breaks they’ll come and whisper in my ear that this has happened to them.

DK: Are these mostly Native American people?

ED: Not at all. I'm working with this one brother right now who happens to be from a Jewish tradition. And he's experiencing these things in the room and seeing ancestors with the patients.

All I'm doing is basically saying that it's okay to be human and to have a spirit. You have a soul, go with it.

He asked me, “What do I do with this?” And I told him, if it's going to help the patient, he’d better do something. He’s slowly allowing himself to go with the reality that he's experiencing.

All I'm doing is basically saying that it's okay to be human and to have a spirit. You have a soul, go with it. Because, that's what people really are needing at this point.

Colonial Research Methods

DK: I'm just imagining some people in this field, more traditional Western-trained types, who would not be inclined to believe any of this because there’s no way to measure and validate what you’re doing. There’s a big emphasis these days on evidence based treatments, and this kind of spirit-based treatment, or spiritually oriented treatment, isn’t quantifiable in any way.

ED: There's a big movement with a lot of Native scholars from all over the world to respond to the evidence-based demand, since the only way you can get your practice to be considered evidence-based in a Western world is by using Western based empirical methods.

DK: Is this what you’ve called in some of your writings, “historical narcissism”? Where one culture’s frame of reference is the frame with which to judge all others?

ED: Yeah. And it's also neo-colonialism, because if you set out rules that require everything to be validated through a certain filter, then what you're saying is that if it's not Western, it doesn't work.

If you're using colonial methods to do the research, there's only one thing that's going to come out. You're going to come out with a colonial result.

A lot of Native people all over the world, indigenous people, are really sensitive to that and say, “then we don't want it.” If you're using colonial methods to do the research, there's only one thing that's going to come out. You're going to come out with a colonial result. If we are to first “do no harm,” then this way of thinking and “validating” is unethical and immoral. It harms indigenous communities.

DK: The research itself is a form of harm? Or the methods?

ED: There has to be another way of doing research, of getting “evidence-based” approval of more historical, traditional healing methods that have been in our communities for thousands of years. Why aren't those evidence based? It’s the colonial mindset that cannot accept them.

The very definition of the Western medical model is adversarial and pathologizing. In Native communities, it's all about relationships. We create relationships, even with the pathology itself. To the Native person it's not a matter of getting rid of the depression. It's a matter of making a relative out of it and learning something. It’s kind of an existential trip. Not unlike the Irvin Yalom’s work, actually.

DK: Backing up for a minute, how is it that you were so decontextualized from your own roots? I read that you were born in New Mexico. Were you born in a tribal community?

ED: No, we moved all over. My dad worked construction, so we lived in places that weren't even places, up in the mountains.

DK: You also worked as a migrant farm worker.

ED: Yeah, I did. That's when I decided to go into the military, because that was too hard. Boy did I get that wrong.

DK: You served in Vietnam, correct?

ED: Yeah, I'm a veteran. The first day at boot camp I thought, “What the hell have I done? I should have stayed in the fields!”

DK: Migrant farm work was probably a piece of cake in comparison.

ED: I thought, “This was a big mistake”—but it was too late. But the experience was valuable. Out of that I was able to get the GI Bill, which helped me get educated and get where I am today.

A Nice White Guy

DK: So you went back to school to become a clinical psychologist?

ED: Not right away. The first college course I ever took was on the naval base. I didn't think I could go to college. I was told all along I couldn't. So I decided to try some classes on the naval base. I got B’s in the classes and thought, "Huh, maybe something is wrong here. Let me try another couple of classes." And I got A's in those. Then I thought, "I'm going to try the junior college, because this doesn't count." And I got A’s in those classes. By then I was like, “Somebody didn't tell me the truth here.”

DK: You found out you were quite smart.

ED: Yeah, so I kept going. But I got into trouble fairly early on, because I started saying stuff in class, especially psychology courses. One of my most momentous experiences was with this guy Jerome Sattler, a bigwig in assessment methods. I was in his class and started talking about how maybe assessment methods for Native children weren’t quite up to par. I'll never forget the last time I saw him I was at his door, and he closed the door, but as he was closing it he said, “You want to be a psychologist? Ha!” and he closed the door in my face.

DK: That’s appalling.

ED: I thought I was done and that my career was over before I started, but there was a Native woman teaching there, Gwen Cooper, and she said, “Don’t worry, you can do this.” She pointed me in the direction of my graduate school and the rest is history.

DK: Well you sure showed him.

ED: Yeah. The same thing happened in my Master’s program, in an assessment class, actually. I wrote a paper and the professor gave me a C. When I went to talk to him about it, he said, "It’s not because it’s not a good paper, it’s because you shouldn’t be saying what you’re saying in this paper." In that program, if you got two C’s you were kicked out, so I had to really learn early on to go underground and not say what I was thinking.

DK:

I went underground and just pretended to be this nice white guy for the remaining time.

That’s so dehumanizing. I found graduate school dehumanizing and I’m white and there were a bunch of multicultural courses required of us. I can’t even imagine what that was like for you.

ED: I went underground and just pretended to be this nice white guy for the remaining time.

DK: You lose a part of yourself that way. Then you have to work to get it back.

ED: That’s just what happens. A lot of Native students approach me and ask, “Where is there a program where we can study what you're doing?” And I tell them there isn’t one. You just have to go through it and hope you can keep your soul at the end of this. But a lot of them don't. If you pretend long enough, then you become it.

DK: Or you become depressed.

ED: Yeah. This is where Terrance really helped, because he wouldn’t let me become this middle American guy that just believed in that.

DK: It must have been kind of a shock to go back into those rural Indian communities and feel like after all of that, you had nothing to offer them. It sounds like you kind of got your ass handed back to you by those folks. And to connect with them you were forced to connect back with your own roots, your own spiritual traditions.

ED: It was really rough. Early on when I was doing the needs assessment, I had prepared this survey instrument, and I had sent it throughout the community. I thought, “Good, I'll have data so I can develop this program.” In that linear approach, you get the data, develop the program, implement and then evaluate. So I thought, “Voila, I'll cure this community in no time!”

Two weeks after the instruments went out in the community, they all came back to me and they were blank. I asked the community help workers, “Didn’t you guys take these out into the homes?”

Talk about cultural incompetence—I was the epitome of cultural incompetence. But I'm so blessed that they taught me.

They said, “Yeah, but the elders said that the reason they hired you in the first place was because they thought your grandmother taught you better manners than this. What gives you the right to go around asking us a bunch of stupid questions like this?” Talk about cultural incompetence—I was the epitome of cultural incompetence. But I'm so blessed that they taught me. A lot of times Native people are very polite and they won't say things like that.

DK: But you would have been shut out, right?

ED: Yeah, they would have pretended, and they would have paid me still, but nobody would have come. I would have just been wasting my time. I was very fortunate that they honored me enough to tell me the truth.

DK: Were you raised with some of these traditions or was it all new to you?

ED: Well, it was a mix. I got some of it, but because of the colonized way that it was treated, I had no real relationship with it. And I grew up in a very dysfunctional home with a lot of alcohol and violence, so those traditions were sort of on the periphery.

My grandparents followed a fairly spiritual way of being, were kind of models, but I didn't really know what it was that they were doing. They would take me to some of the ceremonial stuff, but there was often a lot of alcohol involved in that too, so there was a real contamination of the tradition with the dysfunction. So again, with the teachings of Terrance, I was able to finally see clearly through that.

DK: To see what was colonial intrusion and what was more of the essence of the tradition that you could reclaim?

ED: Yeah. That’s what I try to do with the people I see, because most of them are in the same situation where they're really struggling in between worlds—in between the religions and the loss of identity. By realizing who you are, your existence opens up and so much more becomes possible. If you don't know who you are, and there's no identity, it's real easy to kill yourself. If there's somebody there, it's a lot harder to commit suicide.

Cultural Competence

DK: I want to switch for a moment to the topic of cultural competence for psychotherapists. These days, most graduate schools have multicultural competence courses as part of their curriculum, and while this is certainly progress—considering the state of things when you went through graduate school—I think we’re still far from truly being trained competently in multicultural competence. The article written by Laura Brown that we’re releasing along with this interview offers a strong critique of what she calls the “Handbook for Therapy with Aliens” strategy that so many training programs offer.

In my own relatively recent graduate school experience, the cultural competency work that we did ended up being very divisive. People of color are still astonishingly under-represented in this field, and many in my program I think felt quite wounded by having to go through the process of people coming to terms with their own racism; but they were also wounded by the folks who weren’t willing to really dig deep into the work. Derald Wing Sue calls this latter phenomenon, “invisible whiteness,” where people just don’t see their privilege, or the fact that the dominant white-hetero-male-etc. culture even is a culture.

And then on the other hand, a number of white students felt like it was just a long guilt trip, and that the ways in which they’d experienced oppression weren’t privileged in the multicultural context. You know, the white woman who was born to heroin addicts and grew up in desperate poverty having a hard time identifying with the word “privileged.” And yet, of course white folks have white privilege. It was and remains a deeply important process, but in my experience we were more divided into factions after the training. The environment hadn’t really been able to contain us as a group and it left me wondering if cultural competence was even possible.

What has your experience been in cultural competency training? Is it preferable to have Native psychologists treating Native communities? Or is it possible for non-Natives to become truly competent in treating Native communities?

ED: Well, just being Native isn't the answer either. There are a lot of not just Native, but African-American, Latino and Asian psychologists who are being co-opted and internalize the oppression and that's even worse than being oppressed by a white person. Because you kind of expect it from the white person, but it’s a double hit when one of your own with internalized oppression does it to you.

But of course it can be done. Otherwise, it would be really hopeless and we should just shoot ourselves right now, right? But cultural competency training can't be a paternalistic, three-unit course where we learn little techniques to use with each culture—like not looking people in the eye as a sign of respect or whatever. There’s no list of stuff to make you culturally competent if everything coming out of your mouth is Westernese. That doesn't work.

Cultural competency training can't be a paternalistic, three-unit course where we learn little techniques to use with each culture—like not looking people in the eye as a sign of respect or whatever.

I was invited to do a talk to a bunch of doctors and pharmacists and also a bunch of Native, traditional people about how to work in each other's worlds. I knew if I went in there and talked Westernese, then the Indians were going to shut down; and if I talked about traditional Indian stuff, then the doctors were going to shut down. So I came up with the idea of going back to the birth of the archetypes, where the female energy of the earth herself gives form to everything that is. The essence of my talk was that everything in Western medicine and Western philosophy, as well as Native philosophy and medicine, comes from the same source—that one great mother gave birth to all of it, and we then put the cultural flavor on it.

I gave examples of the ancient Greek doctor Asclepius, who is considered the first Western physician, and how he used the dreams of his patients to help heal them, in much the same way that Natives did and do.

DK: The Rod of Asclepius is the universal sign for medicine, right? With the snake?

ED: Yeah, exactly. He would take people into caves and wash them with water and steam, and that initial process was called a catharsis. Then they were taken into an inner chamber where they were supposed to have a healing dream. They would sit on this little stone couch, which was called a clinic, and they would have their healing dream. A lot of these dreams were recorded; you can look them up online.

For ancient Greeks, a medical doctor was a doctor of the body, of the mind, and of the spirit who was able, through dreams, to allow the patient to have their healing. That’s the root of Western medicine.

So I was talking about all this stuff and all the Indians were like, “Whoa, that's like what we do.” And the doctors were like, “We did that?” And I said, “Yeah, where did you lose it?”

Western medical models are pretty guy-oriented, built around antagonism. That’s why we have wars on sickness, wars on cancer, etc. The Native way is more female oriented, about relationship. Instead of saying, “You have a major depressive disorder,” which crystallizes the sickness, we say, “You are being visited by the spirit of sadness.” It’s a very different message to give the patient. They are more empowered, they feel they can actually move through it.

In English, there’s a noun-ing that happens that freezes you in space and time. If you say you are a woman, well, that's all you can be. But if it's woman-ing that’s happening, then guess what? Man-ning can also happen over there.

DK: Womaning and manning in one person.

ED: Yeah. Those energies can move. And what a way to live—you’re free to be whatever at any moment in time. I met this elder in Canada a couple years ago, and he told me that in his language there are no nouns.

DK: My brain can’t even compute that.

ED: What do you do with that, right? But that's how he walks through the world, with no nouns; so everything's in movement. And in quantum theory we're finding out that that's really the way it is. The universe is really in movement, and nothing really exists, right?

In the Navajo tradition, there’s an idea of Changing Woman, where there’s no image that can be made of her because she is constantly changing, and because she’s constantly changing, she’s not anything. But if she’s not anything, she can be everything.

DK: That's some deep wisdom right there. So it seems like you’re trying to unify people by harkening back to unifying metaphors.

ED: Yes. I did the anger thing, where I critiqued and rejected white culture, but that didn’t work, they just got more dug in. And now it’s more that we can share these traditions in a way that will serve everyone.

"We're Modern People"

DK: Have you had the experience of treating Native Americans who just don’t want to hear about tradition? Who flat out reject their roots?

ED: Oh, absolutely.

DK: How do you deal with that? Is it a necessary part of their healing to be able return to their Native traditions?

ED: Oh yeah, identity needs to be restored; without that they're going to be flailing out there. But initially I don't tell them that. We psychologists are supposed to be tricky right? That's the whole tradition.

DK: So first you gain their trust?

ED: Gain their trust, the therapeutic alliance and all that good stuff—again through their own dreams, their own process, it's restored. I’ll give you an example. I do dream groups, especially in substance abuse programs, and this one day I was leading a group and I was talking about the spirit of alcohol and how it’s an energy, and this young Indian guy rolled his eyes and said, “You sound just like my grandmother.” Which I took as a great compliment. He said, “We're modern people,” and I said, “Well that’s good. You don't have to believe this. I'm just offering another idea here.”

In my experience, patients in treatment for substance abuse have moments of being trapped in bed—they can't scream, they can't get up, and it's very terrifying. So two days later I came back to the program to do my dream group, and this guy was at the door waiting for me. He was ashen. “That thing happened to me. I couldn't get up and I couldn't cry. I couldn't move. I couldn't breathe, and it was really scary.” So here's where my psychologist manipulation came in. I said, “Well, gee, I wonder what happened?” He answered, “It was the spirit of alcohol.”

“I wonder what you could do about that?” I had already talked to the group about what to do. And he said, “Well, I could make an offering to the spirit.” I encouraged him to make an offering to that energy, whether it was alcohol or depression. He said, “How do I do that?”

See, so now his identity's starting to be turned. He’s doing the intervention, but he's also bringing himself back. And of course I always tease people. “What kind of Indian are you, anyway?”

DK: Kind of like you were, right?

ED: Exactly. So I said, “You use some tobacco, because that's the form of offering that is used by most Native people, and give the spirit of alcohol some of that and see what it does. It might accept it, it might not. I don't know.”

Two days later I come back for the group and he’s waiting for me at the door, looking worse than before. So I'm like, now what? And he said, “I put my offerings in this place, and they took them.” Whoever they are, they literally took the physical tobacco, and that really freaked him out. He’d been sober for a couple of months, so it wasn’t a hallucination or anything. So now he's realizing that he's moving in a whole other world. He's moving back into the Indian world.

I said, “Having a conversation with that energy, maybe it will let you go enough to where you can deal with what's bothering you, so that you don't have to use it anymore.” Because using alcohol as a Native person is abusing sacred medicine, and that a terrible accusation. That's like telling a Christian that they're blaspheming against Christ.

Using alcohol as a Native person is abusing sacred medicine, and that a terrible accusation. That's like telling a Christian that they're blaspheming against Christ.

So I said, “Now you need to make amends to the spirit of alcohol. Because, as a Native person, it knows that you know better.” So now it's shifted the situation into a whole other place—and if nothing else, it’s weird enough to be interesting.

DK: It sure is!

ED: He said, “Are you kidding?” I said, “You don't have to take my word, just do it and see what happens.” By doing these things, he started reconnecting himself to himself, and at the same time working on the addiction, so that now he’s lost his thirst for alcohol. Because the spirit of alcohol is also letting him go in that relationship. It’s like divorce. If you want to divorce somebody, you don't just walk away. You've got to go through a process. Here you've been married to this medicine, and now you just want to walk away. That's bad manners. It’s an interesting way of looking at things and it changes the way you think.

DK: It reminds me of motivational interviewing, the way you kind of let him come to his own insights in his own time, but prompt him and give him tools along the way.

ED: During this process, their dreams get really intense to where the spirit of alcohol actually shows up, and it’s really terrifying for people. But now they're dealing with the real issue.

DK: Do you incorporate the Twelve-Step programs in with your substance abuse work?

ED: Oh, sure, yes, if that's working for them. It says right there in the Twelve Steps that you need to make amends. So make amends to the medicine. AA founder Bill W. developed the Twelve Steps in part through a conversation with Jung, where he basically told him exactly what I'm telling you—that this is an energy, this is a spirit, and you're in a state of possession. You can look at the letter Jung wrote online. He also consulted with Native elders in developing the Twelve Steps. You can see the influence, but he westernized it so that it's more palatable.

DK: He made it more Christian-based.

ED: But if you look into the subtext, you can see Jung’s influence and that of the Native elders. A lot of these elders were present at his funeral.

DK: So what I’m hearing is, you use whatever works.

ED: Yes, exactly.

Leave Your Westernese at the Teepee Door

DK: What do you recommend for practitioners who want to be culturally competent with Native American clients?

ED: Well, I’ve trained quite a few interns over the span of my career and I basically let them dive into the work and then try to help move them away from the thinking function. For example, in supervision they'll come in with little yellow tablets ready to take notes. And I'll say stupid stuff like, “What's that for? You’re really going to take notes?” And then I try to deconstruct their thinking so that they can start moving down into their heart. I also ask them if they’re dreaming, and if their patients are dreaming, and basically immerse them into the Native worldview.

Of course, that can be really frightening.

I've had interns almost lose it because they started hallucinating and seeing stuff when they were awake.

I've had interns almost lose it because they started hallucinating and seeing stuff when they were awake. I had to really contain that process for them, because it gets really scary once you start moving out of your Western-thinking paradigm. It’s foreign to the ego and the ego can start to disintegrate without proper containment.

I had a Jewish intern, actually, who was pretty non-identified with his Jewish culture, not practicing or anything. He was irreverent and would do things like bring pork to potlucks and laugh about it. He thought all this spirit stuff was crap.

One day he came to a Native ceremony. It was an all night ceremony and there happened to be a fire at the ceremony, and prayer and singing. And that night in the fire he said he saw God. It totally transformed him. He became ultra-Jewish, and even started rabbinical studies. It was a really interesting metamorphosis for him, like regaining his soul. Him being completely present to who he is allows him to be present for that Native person.

In another instance, a Korean woman from a very prestigious school was working with us, and we were going to have an all-night ceremony again. She was really worried that she might run into her clients at the ceremony and was struggling with the whole ethics side of things. I said, “Well, who knows?” I try not to contain it too much, because the ego needs to experience some unsettling.

So she decided to go, and she's sitting there in the teepee all night, and who walks in but the one family that she's been working with that's really difficult. They sit right next to her and since she doesn't know anything about the ceremony, they start helping her with the ceremony. It was such a tremendous transformation for her, and a tremendous validation for the family, because she was praying their way now. It really brought their relationship and the treatment to a whole new level.

DK: It also turns the “expert” role on its head. We psychologists like to be experts.

ED: It took away that thinking function and at the end of it she was so grateful. Their work progressed quickly after that.

DK: So getting beyond thinking, beyond the ego, is a big part of your work.

ED: Yeah. Absolutely. Since the ego's in complete control and knows everything, you can't go into other cultures, because then you’re just bringing your Westernese with you. But if you're a little big fragmented, maybe you'll be open to something else.

DK: So you're modeling that for them.

ED: I try. A lot of times I say stupid stuff to patients also, to confuse the ego.

DK: I say stupid stuff all the time, too! I didn’t realize it served such a therapeutic purpose. Well thank you so much for taking the time to share your wisdom with us today.

ED: It was my pleasure, thank you.

Love Sense: The Revolutionary New Science of Romantic Relationships

Posted on February 18, 2014February 11, 2026 by rezendevknowfully.com

Editor's Note: The following is adapted from Sue Johnson's latest book, Love Sense: The Revolutionary New Science of Romantic Relationships (Little, Brown and Company, 2013).

The Rhythm of Disconnection and Reconnection

A love relationship is never static; it ebbs and flows. If we want love to last, we have to grasp this fact and get used to paying attention to and readjusting our level of emotional engagement.

“I just assumed that once you are married, you both know you are partners and you can kind of relax and take the relationship for granted,” Jeremy tells Harriet. “You can focus on the big picture. You know I love you. We aren’t mean to each other. I haven’t been unfaithful to you or anything like that. Can’t you just roll with the less romantic, less touchy-feely times?” Harriet sits up straight in her chair and declares, “No, Jeremy. I can’t. Not anymore.”

“Well, that is just very immature, then,” Jeremy replies.

He is right in a way. In a good relationship, where we feel basically secure, we can fill in the blanks left by our partner’s occasional emotional absence. We can substitute positive feelings from past encounters and accept that there may be legitimate reasons for the inattention. But only some of the time, and only if we know we can reconnect if we really need to.

Loving is a process that constantly moves from harmony to disharmony, from mutual attunement and responsiveness to misattunement and disconnection—and back again. But to really understand what happens, we have to zoom down into these interactions and atomize them. Think of Georges Seurat’s paintings: when we move in really close, we realize that the vast scenes are composed of thousands and thousands of little dots. Researchers are doing the same with love relationships. By freeze-framing videos of romantic partners talking or arguing, and of babies playing with a parent, they are discovering how love, without our being aware, is shaped, for better or worse, in micromoments and micromoves of connection and disconnection.

“Up close, this is what love looks like: I look at you with my eyes wide open, trying to capture your glance, and you catch my expression, widen your eyes, and take my arm.” Alternatively, you ignore my bid for your attention, continue talking about your thoughts, and I turn away. In the next step, we resynchronize and reconnect. I turn back to you and lean forward and touch your arm; this time, you get my cue and turn toward me, smile, and ask me how I am. This tiny, fleeting moment of repair brings a rush of positive emotion. Moments of meeting are mutually delightful. (I always think that if we stopped and verbalized our innermost thoughts at this point, we would say something like “Oh, there you are” or even “Ah, here we are together.”)

It’s important to emphasize that misattunement is not a sign of lack of love or commitment. It is inevitable and normal; in fact, it is startlingly common. Ed Tronick of Harvard Medical School, who has spent years absorbed in monitoring the interactions between mother and child, finds that even happily bonded mothers and infants miss each other’s signals fully 70 percent of the time. Adults miss their partner’s cues most of the time, too! We all send unclear signals and misread cues. We become distracted, we suddenly shift our level of emotional intensity and leave our partner behind, or we simply overload each other with too many signals and messages. Only in the movies does one poignant gaze predictably follow another and one small touch always elicit an exquisitely timed gesture in return. We are sorely mistaken if we believe that love is about always being in tune.

What matters is if we can repair tiny moments of misattunement and come back into harmony. Bonding is an eternal process of renewal. “Relationship stability depends not on healing huge rifts but on mending the constant small tears.” Indeed, says John Gottman of the University of Washington, what distinguishes master couples, the term he gives successful pairs, is not the ability to avoid fights but the ability to repair routine disconnections.

We learn about mini-misattunement and repair in our earliest interactions. Tronick and his team have detailed what happens by analyzing videos of infants and their mothers playing a game of peekaboo that grows gradually more intense. At first the infant is happy, but as the game builds, he becomes overstimulated and turns away and sucks his thumb. Mom, intent on playing, misses this cue, and loudly cries “boo” again. The baby looks down with no expression. He shuts down to avoid her signals, which are suddenly too fast and too strong for him.

There are two basic scenarios for what happens next, one positive, the other negative. In the first, Mom picks up the cue that her child is overwhelmed, and she goes quiet. She tunes in to his emotional expression. She waits until he looks up and smiles at him very slowly, and then more invitingly, lifting her eyebrows and opening her eyes. Then she starts the game again. Misattunement and momentary disconnection shift to renewed attunement and easy synchrony. All it takes is a smile or tender touch.

In the second scenario, Mom ignores or doesn’t get her baby’s signal. She moves in faster and closer, insisting her child stay engaged with her. He continues to turn away, and the mother reaches out and pushes his face back toward her. The infant closes his eyes and erupts in agitated wails. The mother, annoyed, now turns away. This is misattunement with no repair, what Tronick calls “interactive failure.” Both mother and infant feel disconnected and emotionally upset.

Over time, thousands of these micromoves accumulate until they coalesce into a pattern typical of secure or insecure bonding. Tronick notes that at just seven months of age, infants with the most positive, attuned mothers express the most joy and positive emotion, while those with the most disengaged moms show the greatest amount of crying and other protest behaviors. Those with the most intrusive moms look away the most. We learn in these earliest exchanges with our loved ones whether people are likely to respond to our cues and just how correctable moments of misattunement are.

Those of us who wind up securely attached have learned that momentary disconnection is tolerable rather than catastrophic and that another person will be there to help us regain our emotional balance and reconnect. Those who become anxiously attached have been taught a different lesson: that we cannot rely on another person to respond and reconnect, and so momentary disconnection is always potentially calamitous. Those who become avoidant have absorbed a still harsher lesson: that no one will come when needed no matter what we do, so it’s better not to bother trying to connect at all.

We carry these lessons forward into adulthood, where they color our romantic relationships. “The past is never dead,” wrote novelist William Faulkner. “It’s not even past.” Psychologist Jessica Salvatore, along with her colleagues at the University of Minnesota, studied the romantic relationships of 73 young adult men and women. They had all been enrolled since birth in a longitudinal study of attachment, and their relationship with their mother had been assessed when they were between twelve and eighteen months old. They were invited to the lab with their romantic partner, where they were interviewed separately. Then they were instructed to discuss a key conflict between them for ten minutes and then talk about areas where they were in agreement for another four “cool down” minutes.

Researchers videotaped these talks and observed how well the 73 adults could let go of their conflict and shift out of a negative emotional tone. Some made the switch quickly and easily; others persisted in talking about the conflict and brought up new issues; still others refused to talk at all. Those who were good at cool down were generally happier in their relationship, and so was their partner. And, as we might expect, those who had been rated securely attached as babies generally moved out of the conflict discussion most successfully.

But is a person’s own attachment history the key predictor of stability in a romantic relationship? Or is a partner’s ability to resolve conflict also a major factor? Salvatore assessed the 73 subjects two years later and found that even among those who had histories marked by insecurity, their romantic relationship was more likely to have endured if their partner was able to recover well from an argument and help them transition into a positive conversation.

I call this the buffer, balance, bounce effect. A more secure partner buffers your fears and helps you regain your emotional balance so you can reconnect. Then together, you both bounce back from separation distress, distance, and conflict. “We are never so secure that we do not need our partner’s help in readjusting the emotional music in our attachment dance.” Relationship distress and repair are always a two-person affair; a dance is never defined by just one person.

Some of us, however, need more structured help in finding our way back to emotional harmony. Drawing from my discoveries in thirty years of practice and research and the findings of the new science of love outlined in these pages, I and my colleagues have created a powerful model for repairing relationship bonds, Emotionally Focused Therapy. The only intervention based on attachment, EFT is redefining the field of couple therapy and education. Sixteen studies now validate its success. Couples who have had EFT show overall increased satisfaction with their relationships and in the elements of secure attachment, including intimacy, trust, and forgiveness. Moreover, the more secure emotional bond remains stable years after therapy.

One of our newest and most exciting studies demonstrates through fMRI brain scans that after couples go through EFT and become more secure, holding the hand of their partner actually dampens fear and the pain of an electric shock. Just as predicted by attachment science, contact with a loving, responsive partner is a powerful buffer against danger and threat. When we change our love relationships, we change our brains and change our world.

The science of love allows us to hone our interventions—to be on target and aim high. The goal is to create lasting lifelong bonds that offer safe-haven security to both partners. Recently we have also created a group educational program based on my earlier book Hold Me Tight: Seven Conversations for a Lifetime of Love that helps couples take all we have learned in decades of research and use it in their own relationship.

Repairing Bonds Moment to Moment

Lasting bonds are all about emotional responsiveness. The core attachment question—“Are you there for me?”— requires a “yes” in response. A secure bond has three basic elements:

accessibility—you give me your attention and are emotionally open to what I am saying;
responsiveness—you accept my needs and fears and offer comfort and caring; and
engagement—you are emotionally present, absorbed, and involved with me.

When these elements are missing and alienation and disconnection take over, renewing a bond that is truly coming undone is essentially a two-step process. First, partners have to help each other slow down and contain the circular dance that keeps them emotionally off balance and hypervigilant for signs of threat or loss. Relationships begin to improve when partners can stop these runaway cycles that create emotional starvation and attachment panic.

To curb these demand-withdraw cycles, we first need to recognize that they are cycles. We get caught up in focusing on our partner’s actions and forget that we are players, too. We have to realize that we are in a feedback loop that we both contribute to. When we see that this is a dance we do together, we can stop our automatic, blaming, “You always step on my foot” response. This allows us to see the power and momentum of the dance and how we are both controlled and freaked out by it.

Prue accuses Larry of being hypercritical. “He’s always complaining about whatever I do—how I cook, how I make love. I feel picked on all the time. It’s devastating.” Larry argues that Prue always refuses to talk seriously about any problems they’re having. “She just goes distant. I can’t find her,” he says. In our sessions, they’ve now realized that they are prisoners of a pattern they call “the Pit.” “I encourage clients to give a name to their pattern to help them see it and begin to recognize that the pattern, not the partner, is the enemy.” They have both unwittingly created this enemy that is taking over their relationship, and they must work together to wrest their relationship from its clutches.

Now we can explore the triggers and emotions that shape the pattern. Prue and Larry recount a specific incident when they fell into the Pit, and we bring it into high focus and play it in slow motion, scrutinizing each detail, until its impact on each partner and their bond is clear. They were on holiday in Europe after a period when Prue had been away taking care of her dying aunt and Larry had resented her absence. They were in a station heading to catch a train when Larry suddenly realized that it had begun moving. Afraid they would miss it, he jumped on the step and yelled to Prue, who was carrying a coffee cup, “Run.” Larry shouted to the conductor to slow down and held his hand out to Prue, but she froze. Finally, she grasped his hand and struggled onto the train, out of breath. Larry turned to her and said, “You are so damn slow.” Shocked and hurt, she refused to speak to him the rest of the journey. Inside, she vacillated between rage at Larry’s reprimands and dread that she really is too “slow” and too flawed for him to love. She shut him out and, preoccupied with her own fears of inadequacy, began a downward spiral into depression.

I turn to Larry and we go over and over this incident moment by moment and tune in to the emotions he was feeling then and how they reflect his overall feeling about Prue and their relationship. He says he feels “agitated” when she does not keep up with him on hikes. He notes she doesn’t take her arthritis medication consistently. “I get anxious when she does not stay with me. I can’t count on her.” He recalls the image of “distance” that flooded him when the train started to move off and Prue froze. “She wasn’t running, working to be with me,” he says. He felt panicked. Larry then begins to talk about his sense of isolation when Prue stayed with her aunt for three months and his habit of dismissing, or “pushing down,” this frequent feeling. Sometimes he can’t, though, and it rises up and engulfs him, and he winds up being angry and sarcastic. He begins weeping as he realizes just how much he needs her and is afraid that she will remain “unavailable.” The slide into the Pit begins with attachment terror.

For Prue, too, the terror that freezes her and turns her away from Larry is a hopeless certainty that she is flawed and worthless, so rejection is certain. As they recognize and find their balance in these emotional moments, they can see the drama of distress as it occurs in their everyday life and then help each other halt its momentum. They can limit the extent of the rift between them and find a secure base. The next night, Larry lashes out, and Prue responds, “Is this a panic moment for you? I am not going to freeze up here, and I want you to slow down.” Each partner begins to see the other in a new light: Prue sees Larry as afraid rather than judgmental and aggressive, and he sees her as protecting herself from rejection rather than simply abandoning him and “sulking.”

Recent research by psychologist Shiri Cohen and her colleagues at Harvard Medical School confirms that partners do not suddenly have to become masters of empathy or emotional gymnasts in this kind of process. Partners, especially women, really respond to signs that their loved one is trying to tune in and actually cares about their feelings. This, in and of itself, creates a new safety zone where partners can begin to expand their dance steps and take risks with each other. New ways of dealing with emotion shape new steps in the dance, which in turn shape new chances for reattunement and repair. But this ability to keep miscues and missteps in check is not enough.

The second step in renewing bonds is much harder but more significant. This is when we move into powerful positive interactions and actually reach for each other. Specifically, withdrawn partners have to open up and engage on an emotional level, and blaming partners have to risk asking for what they need from a place of vulnerability. Partners have to tune in to the bonding channel and stay there. They find this process risky, but if they follow it through, their relationship becomes flooded with positive emotion and ascends to a whole new level. This process is not only a corrective move that kick-starts trust but also, for many, a transforming and liberating emotional experience.

These experiences are deeply emotional; partners each reach for the other in a simple and coherent way that pulls forth a tender, compassionate response. This begins a new positive bonding cycle, a reach-and-respond sequence that builds a mental model of relationships as a safe haven. It addresses each person’s most basic needs for safety, connection, and comfort. “These kinds of primal emotional moments are so significant that, as with all such “hot” moments, our brain seems to faithfully store them, filing them in our neural networks as the protocol for how to be close to others.” Our follow-up studies of EFT couples show that their ability to stay with and shape these emotional moments is the best predictor of stable relationship repair and satisfaction years later.

So what actually happens in these exchanges—I call them Hold Me Tight conversations—when real connection begins to form and a couple moves from antagonism into harmony? Until recently we have not known what specific responses in intimate exchanges make for tender loving bonds between adults. We have had, to quote psychologists Linda Roberts and Danielle Greenberg of the University of Wisconsin, “a typology of conflict . . . but no road maps for positive intimate behavior.” Years of watching couples reconnect in a therapy that deliberately builds bonds can offer us just this.

In Hold Me Tight conversations, couples have to handle a series of mini-tasks. Partners, whether pursuing and blaming or defending and withdrawing, attempt to:

Tune in to and stay with their own softer emotions and hold on to the hope of potential connection with the loved one.

John: “I did snap at you. But when I look inside, it’s that I find it worrying, upsetting that you go out to those clubs with your girlfriends. It somehow messes me up. It’s hard to tell you this. I am not used to talking about this kind of stuff.”

Regulate their emotions so they can look out at the other person with some openness and curiosity and show willingness to listen to incoming cues. They are not flooded or trying to shut down and stay numb.

John: “I feel a little silly, kind of wide open saying this. But there it is. It doesn’t work to deny it and say nothing. Then we get farther apart. Can you hear me? What do you think?” His wife, Kim, comes and hugs him.

Turn their emotions into clear, specific signals. Messages are not conflicted or garbled. Clear communication flows from a clear inner sense of feared danger and longed-for safety.

John: “I know I sometimes go off about you being tired after coming home late or the money you spend. But that is not it. Those are side issues. It reminds me of past relationships. I guess I am really sensitive here. I really find it difficult. It scares me. I wanted to run after you and say, ‘Don’t go.’ It’s like you are choosing them and the club scene over me, over us. That is how it feels.” His eyes widen, showing how anxious he is.

Tolerate fears of the other’s response enough to stay engaged and give the other a chance to respond.

John: “You aren’t saying anything. Are you mad now? I want us to talk about this kind of stuff when I get unsure of us and not push things under the rug. I want to hear how you feel right now.” Kim tells him she is confused because she feels loyal to her friends but that his feelings are important.

Explicitly state needs. To do this they have to recognize and accept their attachment needs.

John: “I want to know you are committed to us, to me. I want to feel like you are my partner and that nothing is more important than that. I need that reassurance that my needs matter. Then I can keep taking risks here. I am out on a limb otherwise.”

Hear and accept the needs of the other. Respond to these needs with empathy and honesty.

John: “I know I have been kind of controlling in the past. It’s a bit hard to hear you talk about it, but I know you need to make choices, and you have fun with your friends. I am not giving orders here. I want to know if we can work this out together.”

React to the other’s response, even if it is not what is hoped for, in a way that is relatively balanced and, especially if it is what is hoped for, with increased trust and positive emotion.

John: “Well, you have tickets for the concert, so I guess you will go. I can handle that. I hadn’t really shared with you openly about this. It helps if I feel included somehow, if you tell me about it afterward. And I appreciate that you are listening and telling me that you can consider how I feel about this.” Kim tells him she still feels scared to put herself in his hands completely. Her nights out are her statement that she is still holding on to her boundaries and showing she can stand up to him. But she hears his fears. She tells him that she does not flirt or drink too much on her outings, and she reminds him that she is going out less often now.

Explore and take into account the partner’s reality and make sense of, rather than dismiss, his or her response.

John: “I don’t want to tell you what to do. I know this upsets you. You have good reasons for this. I get that you are not trying to hurt me. I don’t want you to feel dictated to. I just get anxious about this stuff.” He reaches out for her, and she turns to him and holds him.

When this conversation goes off track, John—and hopefully Kim—can bring it back and stay with the main emotional message, the need to connect. For example, if John gets caught up ranting about the “seedy” clubs she visits, she is able to stay calm and soothe him by telling him that she is concerned that he worries about this, and this brings him back to talking about his fears. Both partners help each other keep their emotional balance and stay in the deeper emotion and bonding channel. John is attempting to repair his sense of disconnection, and he does it by exploring his own emotions and engaging with Kim. In the past he had tried criticizing his lover’s taste in friends or making deals about how many times each could go out without the other every month. Now he goes to the core dialogue in an attachment relationship, the one that matters most, where the question “Are you there for me?” is palpable. He shares and asks for her emotional support, for her help in dealing with his attachment fears.

This is very different from the way attempts at connection show up in distressed relationships and even in routine interactions in relatively happy relationships. We often bypass the attachment emotions and messages. We do not say what we need. Our signals to our loved one remain hidden, general, and ambiguous. Hal tells Lulu, “I don’t think I have ever asked you for affection. It’s not what I do. When you just give it, everything is fine. But when you get depressed . . . So then I say, ‘Want to watch a movie?’ or ‘You should go for a walk and cheer up.’ But you turn away, and in two seconds flat I am enraged. In my head, I am still thinking it’s about the movie or you not taking care of yourself. Not that you have gone missing on me.” When Hal can express his sense of loss at Lulu’s withdrawal, they can deal with it and her bout of depression differently—that is, in a way that leaves them more connected rather than less.

The most intense and attachment-focused Hold Me Tight conversations build tangible safety and connection, even in secure, happy relationships. They can occur at times when partners do not feel disconnected but simply want more intense intimacy. Lulu opens up one night and tells Hal of a moment after their lovemaking when she felt herself “sinking into a certain soft place where we just belong and belong and there is no more fear of risking.” He responds and shares his similar feelings. Each time these lovers share their “soft places” and their need for each other and respond with empathy and care, they offer their loved one reassurance that he or she is the chosen, irreplaceable one, and the bond between them deepens.

Anita Barrows on Love, Poetry and Autism

Posted on February 14, 2014February 24, 2026 by rezendevknowfully.com

I Have My Very Troubled Childhood to Thank for This Career

Deb Kory: You are a long-time psychotherapist, a well-known poet, social activist and autism specialist. In the interest of full disclosure, I should also mention that you are a former teacher of mine at the Wright Institute in Berkeley, you chaired my dissertation, and are now my friend as well.

Anita Barrows: Indeed.

DK: As a newly licensed therapist who came to the field with a background in journalism and political activism, I’m exploring for myself how to not get compartmentalized in my role as a therapist and to feel integrated in and out of the therapy office.

I wanted to interview you for Psychotherapy.net in large part because you embody many identities. I think most people know you as a poet and a translator of, among others, poet Rainer Maria Rilke’s work, along with your co-translator, Joanna Macy, the environmental activist and Buddhist scholar. Were you a poet before you became a therapist?

AB: Long before. I was a poet from the time I was about six years old. In fact, through my childhood and up through my years in college, there was nothing else I ever thought about doing. Writing poetry was really it. And I was always interested in politics. I was lucky enough to be a teenager in the 1960s and my political identity was also really strong for me at that point, as I was very involved in the Civil Rights Movement and the anti-Vietnam War movement.

But writing was really the only thing I thought I would ever do. After I got out of college and I realized that I had to do something to make a living, I began working with the Poets in the Schools program. I was also working with a radical law students group, placing law students in internships with radical lawyers like the lawyers for Cesar Chavez and the Black Panthers.

DK: But you yourself were not involved in law.

AB: I wasn’t, but I considered it at that time because it had become clear that I couldn’t earn a living writing poetry. I had studied French, Italian, Latin and German in college and did a Masters at Boston University in English literature and creative writing, and was working as a translator when I enrolled in a doctoral program in comparative literature.

DK: So language is a real passion for you.

AB: I just love language.

DK: Language, poetry, radical politics and law—how did you end up becoming a therapist?

AB: I think I have to thank my very, very troubled childhood for this career.

DK: Not uncommon for us therapists.

AB: Not at all. I had a mother who was chronically depressed and a father who was violent, and I did everything I could to escape that household, mostly adopting myself out to the families of friends. I was pretty good at establishing relationships outside of my home, and wrote poetry from an early age, which helped me process some of the pain I was going through, but when I had my own first child, it came back to haunt me.

I essentially had a breakdown. It ended up being diagnosed as autoimmune thyroid disease, but when I look at it now, I think the thyroid disease was a physical manifestation of what was going on inside me emotionally.

I had read a lot of Jung and was interested in Jung’s approach to literature and symbolism and the collective unconscious, and I was lucky enough to be referred to an extraordinary Jungian therapist, Rosamund Gardner, who died about ten years ago. I was in Jungian analysis with her for more than ten years.

DK: So it was your experience of the transformation that occurred for you in therapy that made you want to become a therapist?

AB: It was, yeah.

DK: I think that’s also a pretty common reason that people end up becoming therapists. My own therapy has influenced me enormously.

AB: Frankly, I don’t know who I would be today if it weren’t for the work I did with Rosamund. I can’t even begin to imagine. I was sort of casting about for some kind of work that felt meaningful, and it didn’t feel like teaching poetry at the university level would be enough, and it really came home to me that therapy can be a deep transformation that can liberate people. I remember Rosamund saying to me at one point, “When you have done this work, you will free your energy.” I was not a very energetic person in my 20s. Now, in my 60s, I’m full of energy.

DK: You’re one of the most energetic people I know!

AB: I think I’m making up for lost time.

During the course of that therapy, I began having dreams—and in Jungian analysis, you do a lot of dream work—and my dreams suggested that I might want to do therapy myself. We had to ferret out what was identification and transference and what was a genuine desire to do this work.

DK: Are you transparent about this backstory with your students?

AB: Very much so. I feel like that kind of transparency can be so helpful—especially in a field where there’s so much fear about revealing that you’ve suffered personally. I’m less likely to reveal it to some colleagues of mine, who seem so tight-lipped and collected.

DK: You imagine that they didn’t have such childhoods? Or is it that they just aren’t open about it?

AB: It’s hard to know, but I can’t imagine that the majority of people who come into this field had a Mary Poppins kind of childhood.

What Happened to the Wounded Healer?

DK: I also had that experience going through graduate training. People were really reluctant to share the fact that they had suffered trauma. And if they did, it was often like, “but I’ve done so much work around it and it’s all resolved now.”

What happened to the “wounded healer”? It’s a powerful framework, in my experience. When therapists are willing to be honest and open and not try to come off as “expertly healed,” it can be extremely transformative. Those moments of genuine, mutual vulnerability can be so helpful in diffusing that sense of shame and isolation that brings so many people into therapy in the first place.

AB: I learned it from Rosamund. She was very open about the pain that she had experienced. It would come up in dreams sometimes where I had sensed something about her childhood, and she was very honest about saying, “Yes, in fact this happened,” or, “No, it wasn’t quite like that, but this was the way it was.” Those were moments when I felt like you really can emerge from traumatic experiences, deep losses, and come out as a person who can have a rich and full life and be able to receive other people’s pain. I say that to my students all the time.

I can’t think of anybody in my education at the Wright Institute, anybody who trained me, who was that open about their experience. In fact, I went through several years while I was a student and then shortly after of not wanting to talk to anybody about my childhood.

I was really afraid that if anybody found out some of the things that had happened to me as a child, they would think, “She can’t possibly be a therapist. Somebody with that kind of childhood turns into a Borderline”—or some other Axis II diagnosis.

So I just didn’t talk about it. I didn’t even tell people I was a poet. At that point I had two books of poems published and had won a $20,000 grant from the National Endowment for the Arts for my poetry. And I didn’t tell anybody.

DK: What were you afraid of?

AB: I was afraid that if I was known as a poet, I would have less legitimacy in their eyes as a therapist. It’s kind of amazing when I think about it now. I remember once I was at a party where there were a lot of Wright Institute people, and somebody who wasn’t from the Wright came up to me and said, “Oh, hi, I’m so-and-so. Who are you and what do you do?” I opened my mouth and started to cry because I felt like my real identity was something I had to hide and that if I had something else that I belonged to, it would take away from people’s beliefs that I could really do therapy.

When I went to take my oral licensing exam, I think it was 1990, I had a recurrent dream for weeks before I took the exam. I’ve always worn a lot of rings on my fingers, and in my dream, I had lost all my rings. It

became really clear that I was afraid that assuming the mantle of psychologist meant that I would lose what was different and kind of quirky and colorful about me, and I’d have to become this straight person.

In fact, these much straighter friends of mine had loaned me clothes to wear at the oral exam. I was going to put my hair in some kind of bun, and I was going to wear this tailored suit and a white shirt. In the end, I gave them all back and said, “I’m just going as myself.” And I passed.

Therapist Identity Disorder

DK: This hits on a fundamental problem I’ve been chewing on. You’ve been licensed for 25 years and have reached a place of integration. I’m just starting out on the path and really want to steer clear of the therapist identity box. I like therapists, I am a therapist, but I kind of got the feeling all through my training that we are expected to keep a really low-profile outside of the office. While we’re given the message that being relational or “intersubjective” is a good way to practice, we’re taught to keep a pretty tight lid on our spontaneity. I heard horror stories of people who would bring their session notes into supervision and just get creamed for any hint of getting too conversational, revealing too much about themselves, whatever. Obviously this depends on the theory of the supervisor, but enough of those kinds of stories were going around to give me the notion that all such events should, in fact, be left out of session notes.

My sense was that we were not really supposed to be in the world, that our job is to stay kind of objectified in our therapist role, and that allowing our wounded selves, our writer or activist selves, our real selves into the room or, worse yet, being seen outside of the room, constituted a great risk of some sort. But what exactly is at risk? Our privacy? The projections of our clients? Our professional legitimacy? A case could be made for these things, but I think the balance is way out of whack.

AB: That’s a really good question. At the beginning of my work as a psychotherapist, I kept my identities pushed very far apart, but as I went along, I started to devote more time to my writing. I created a little study downstairs in my house that I just used for writing, and then began to give more public readings, which I hadn’t done for a period of time. There would be fliers around Berkeley saying I was going to read, and sometimes my patients would show up at my readings.

I remember talking about that with some people who were much straighter psychologists than I was, and they were saying things like, “Well, you really shouldn’t publish if you’re a therapist. And you certainly shouldn’t give readings.” My poetry is not confessional poetry. It’s not like I talk about my father’s abuse or my mother’s depression all that much. But it certainly reveals my politics and my sense of engagement in the world and also facts of my life: I am a single person. I have two daughters. I have a granddaughter. They come into my work in one way or another.

So, short of writing under a pseudonym, which I didn’t want to do, there seemed to be nothing I could do to keep them pushed apart if I wasn’t going to stop writing altogether, which I absolutely realized I couldn’t do. If I go for several months without writing, I just don’t feel like myself. I can’t do it. If I have a core identity, if there’s any one thing that’s my core identity, it’s a poet. And being a psychotherapist is the work I do, and it’s work I love, but it’s not my core identity.

When the first translation of Rilke came out in 1995, the Book of Hours, Joanna Macy, my co-translator, and I did a bunch of public readings for that. It says right there on the flap of the book that I am a poet, a translator, and I work as a clinical psychologist and a professor at the Wright Institute. There it was all laid out. And now when I think about it, it feels so clear to me that my life as a poet informs the work I do as a therapist.

DK: How so?

AB: I think I write poetry to document my sense of engagement with the world in whatever form that takes. It may be a poem about the trees outside my window in the morning or my dog sleeping, or it may be a poem about the children in Palestine or Rwanda. Poetry is the best way I know to make sense of the world. The fact that I write and that I see as a poet is the way I make meaning of things.

In fact, I have a patient in his early 30s who is, among other things, a musician. He’s very attuned to anything artistic, although that’s not what he earns his living at, and he teases me sometimes when I say something, “That’s certainly something a poet would say.” He was referred by someone and googled me and there was all sorts of stuff about me online. These days it’s all out there. If you don’t want to go see a poet, don’t come and see me.

DK: Your clients can self-select.

AB: Exactly.

DK: Do you think having a public identity as a poet and activist has changed your work with clients?

AB: I think it has. I gave a reading some years ago as part of a group of Jewish women who were politically engaged. Grace Paley read, and it was the last time I saw her before she died. Someone came up to me afterward and said, “So, you’re really a clinical psychologist? Are you practicing?” I ended up working with her for several years.

On Love (and Torture)

DK: One thing I have appreciated about your work is that you explicitly acknowledge the importance of love in therapy. When I was in graduate school at the Wright, I remember there was a panel discussion with various clinicians on the faculty, and I asked very pointedly, “How come no one ever talks about love?” It was always “countertransference” or “compassion,” but God forbid you mention love. The responses I got were, “It’s not my job to love clients. I respect them.” Another person joked, “What about hate?” and then proceeded to actually put an article in my mailbox about “hate in the countertransference” and how love was some kind of narcissistic fantasy on the part of the therapist. It was so irritating. I wish I could find the article because I remember the author talking about how it was OK to love the theory, but not our clients.

But I think we are engaged in all manner of love. Therapy can be a profoundly loving experience on both sides, and it can be erotic and romantic and mysterious. Sure, there can also be hate, boredom, “negative countertransference,” but the avoidance of any talk about love is phobic in my opinion.

AB: It’s so true!

DK: How do you conceptualize love in psychotherapy?

AB: Wow. What a wonderful question. I’m really glad to have an opportunity to talk about it. I think it’s the basis of all of it. I really do. I think you can’t do this work without love. And I don’t just mean compassion, I mean really loving somebody.

Of course we all have some patients who are more challenging than others. I have one patient who argues with everything I say, and it can be incredibly frustrating, but if I didn’t underneath it all love that patient, I wouldn’t be able to continue doing the work. And I think you’re absolutely right, people in the field are terrified of it.

One of the arguments made by certain psychologists in the APA who justified “enhanced interrogation techniques”—AKA torture—at places like Guantanamo, was that they don’t consider psychology to be a healing profession. For them it’s a profession where one investigates the workings of the human mind and analyzes them. Therefore, one can investigate the workings of the human mind in situations of interrogation. I have a lot of trouble with that on many different levels.

DK: As you know, I wrote my dissertation about the central role psychologists played in the creation of the torture program used under the Bush Administration. Psychologists were given access to the highest levels of power during the “War on Terror,” and they turned out to be very corruptible. One of my conclusions was that this desire on the part of certain elements of the psychology profession to be legitimated through power and “hard science” is fundamentally at odds with the healing, nurturing, soft nature of this work.

AB: Yes, I think there’s a fear of being soft and compassionate and nurturing and sort of what’s traditionally thought of as feminine or maternal. There’s a desire to be taken seriously in this profession, to be seen as a serious science. The insurance companies are also setting the stage for this, with their insistence on quantifiable evidence and “empirically validated” treatments. I’m not anti-science—I love science, but we shouldn’t value it at the expense of love.

I talk to my students about love all the time. They will come to me sometimes very sheepishly and admit that they really love a particular patient of theirs. I’m not talking about them coming to me and saying, “I really want to go to bed with this person,” or, “I’m going to ask him out for coffee as soon as the therapy is over.” We are so reductionist in this culture. It’s a reflection of the incredible lack of imagination that we have reduced the word love to wanting to fuck.

DK: Sing it, sister!

AB: That love wouldn’t be a component of transformation is just unimaginable to me. I think it has to be. In my own therapy with Rosamund, there was a moment that still brings tears to my eyes when I think about it. I was very, very ravaged in the first year that I was seeing her. I had an infant. I had a bad marriage, and I felt really overwhelmed. All of my own mother’s incapacity to care for me flooded back to me and made me terribly afraid that I couldn’t care for my child, my daughter.

There was one day where I didn’t know if I should be hospitalized or locked up or what, but I just felt unable to go on. I hadn’t slept in days, weeks, not just because my baby was waking up at night, but because I was really a wreck. So I called Rosamund on a Friday, and she said, “Come and see me tomorrow morning.” She didn’t see people on Saturday mornings, but I think she could hear how ravaged I was feeling. So I went to see her the next morning, and I was still just exhausted because I hadn’t slept.

And she said, “Why don’t you just lie down on my couch? I have some paperwork to do. We don’t need to talk. There’s really nothing to talk about right now. Just lie down on my couch and see if you can rest a little.” So I lay down, and she covered me with a blanket, and she stayed in the room and did some paperwork or whatever—I don’t know what she did, but I fell asleep. I napped for maybe two, two-and-a-half hours. When I woke up, she was still there in the room, and I was able to go home and feel better. That was a real turning point.

Two Souls Speaking To Each Other

DK: That’s such a profoundly loving gesture. A kind of accompaniment, a being with without having to talk or engage.

AB: It was just that. I felt sheltered and contained and held, and I hadn’t had that in my childhood from my mother—ever probably. Rosamund knew that. We didn’t need to speak about it. There didn’t need to be interpretation. At that moment I just needed some holding, and I knew it came from love. I was then able to go home and take care of my baby.

DK: I can imagine in the hands of another therapist you might have been 5150’d.

AB: I had actually called her the previous day and said, “I think I need to be hospitalized. I am so profoundly depressed—beyond depressed, agitated. I don’t know what’s wrong with me.” Her response was wonderful. She immediately asked, “Who’s going to pick up your daughter from daycare?” And I said, “Well, I am. I actually need to leave to pick her up in a few minutes.” And she said, “You’re far too sane to be hospitalized.” And that was that.

Love means suffering. I say to my students all the time, “You’re going to suffer from this work—if it goes badly, if someone commits suicide or gets ill and dies.” One of my patients died a few years ago. I hadn’t seen her for a few years, and I knew that she was somebody who had a heart condition, but she wasn’t much older than I am. And when I found out just by chance that she had died, I suffered, and there was really no place for my grief. I couldn’t call her family. I had never met any of them.

DK: Because there’s confidentiality after death.

AB: I didn’t even know if they knew that I was her therapist and I couldn’t legally get in touch with them. So I just had to hold it myself. Things like that happen and we’re not automatons, we’re not computers. We’re human beings.

I had one kid whom I saw for 12 years. She came to me when she was five and I was working at Children’s Hospital in Oakland, CA. She was a very intelligent, exceptional child with Asperger’s syndrome.

A year after I started working with her, her mother was diagnosed with a very serious cancer, and she hung in there for another four years, but then she died. So I saw this child from the time she was five through the time she graduated from high school and was getting ready to go away to college, and we were very, very close.

In one of our termination sessions she said, “I still can’t stand it that the person that I feel closest to in the world is my therapist. It just doesn’t feel right. It should be a friend. I should have a friend or a boyfriend or a girlfriend or somebody who’s the person I’m closest to. It shouldn’t be you.” And then she said, “It’s such a weird thing anyway, this whole therapy thing. I sort of wish you had been somebody else in my life.”

So we talked about how, if I had been her next-door neighbor or her auntie or a friend of the family, we probably wouldn’t have been able to see each other regularly. For awhile I was seeing her three times a week, then twice a week for years, and then it became once a week as we were winding down. It never would have been that regular, and it wouldn’t have been just the two of us in the room. Maybe I could’ve taken her out to the movies, but it would’ve been a totally different kind of relationship.

DK: Your attention would have been divided, for one.

AB: Exactly. So she said, “Okay. I get it. In this room, it didn’t really matter that I was your patient and you were my therapist. And it didn’t really matter that, when I met you, I was five and you were 38. And it didn’t really matter that I was diagnosed with Asperger’s syndrome and you weren’t. In this room, we were just two souls speaking to each other.” And I thought, “wow.”

DK: Wow.

AB: That, to me, is the work. Personally, I would so much rather see therapy considered a spiritual discipline than a scientific discipline, because I think that’s really where it is. That’s really where the work happens.

DK: I would agree. She was so articulate about naming the paradox of the therapy relationship. It really is a strange relationship. But at it’s best it’s a sacred relationship. When it works, it really works, and there’s no mistake about it. Unfortunately our culture doesn’t provide many opportunities for the kind of depth and closeness that we get in a good therapy relationship.

AB: And it’s simply not quantifiable. How do you quantify a child who begins at five with Asperger’s Syndrome, never talking to any other children in the school? Then her mother gets sick when she’s six and dies when she’s ten. How do you quantify whether that child got better or not? She says “hello” three times out of five? She makes eye contact seven times out of nine? When I was on insurance panels, those were the kinds of ways I had to report progress.

Yet when she was able to sit there and say what she said, I knew that this child had what she needed to go on with her life.

Autism

DK: This would be a good time to switch over and talk about your work with kids and with autism. I know you’ve always loved kids and been interested in treating kids, but how did you end up being interested in autism?

AB: Well, I started out doing languages and literature, and when I started preparing for graduate work in psychology, I worked with Dan Slobin and Susan Ervin-Tripp, both well-known in the world of child language development. I got very interested in how language develops and how skewed language can develop in some people, including people with autism. Then when I got to the Wright Institute, I joined a study at the Child Development Center at Children’s Hospital in Oakland where, over a period of 18 months, kids with autism were being studied. Half were on a particular medication that was supposed to enhance their social awareness, and half of them weren’t, but it was a double-blind study, so we didn’t know which kids we were working with. I was just fascinated with those kids.

This was 1980, and all of a sudden there was a burgeoning of autistic children, and the director of the Child Development Center asked me if I would be interested in setting up an autism clinic as part of my practicum. I of course said yes, and over that year worked with people on developing diagnostic criteria, and then the following year I did therapy with some kids, including the child I just mentioned. The Interpersonal World of the Infant by Daniel Stern had just come out and I ended up writing my dissertation about Asperger’s Syndrome.

If I dig a bit deeper, though, I think the reason I got involved in autism was my inability all throughout my childhood to reach my mother. She wasn’t autistic, and I wasn’t either, but there was a huge barrier, a huge wall between us.

DK: You felt like you were in a kind of autistic bubble?

AB: Yes. It took me a while to really understand that that was why I was so compelled by it.

The more superficial level was my interest in language development, but looking back, there were eight students involved in that research study, and I’m the only one who wound up seeing autistic kids all through my career. I was drawn to figuring out who is reachable and who is unreachable and how do we find each other as human beings?

DK: So you became an autism specialist.

AB: What’s happened in my practice as time has gone on is that I see children and also adults on the spectrum, mostly on the higher-functioning end, because that’s what the kind of therapy I do can treat. And the adults I see who have autism must have the capacity to take in the kind of weekly, deeply interpersonal therapy that I do. But I also see children and adults who are not on the spectrum and who are coming to explore developmental existential issues in their lives.

DK: Let’s back up for a second. What exactly is autism?

AB: The standard scientific definition is that it’s an impairment involving the child’s cognition, language, and often the child’s intelligence. At the very high-functioning end, I’ve had autistic kids with IQs in the 140s, so intelligence doesn’t always have to be impaired. I haven’t seen a recent statistic, but it used to be that 3/4 of kids diagnosed with autism were also diagnosed with at least mild mental retardation. But some of them, who used to be diagnosed with Asperger’s until the DSM-V got rid of that diagnosis in favor of “Autism Spectrum Disorder,” can be extremely intelligent.

It is essentially a pervasive developmental disability that affects the child’s capacity to function in society. Autism means “in the self,” and so the child has a hard time making attachments. Daniel Stern studied attunement and how in a normal caretaker-infant pair, the caretaker—mother, father, grandmother, whoever it happens to be—attunes to that child incredibly frequently, many, many times a minute in various ways. The baby shifts a little, so the caretaker shifts a little. The baby gets excited about something, and the mother’s voice will mimic that excitement. Generally those kinds of attunements are done cross-modally—so it’s not like the baby flaps her hands, and the mother flaps her hands. Instead he baby will flap her hands, and the mother will say, “Oh, you love these scrambled eggs!” That kind of thing.

But with autistic children, it’s much harder for them to take in information cross-modally, so they don’t feel the parent’s attunement. They don’t get attuned to. And it’s not because they don’t want to.

DK: And it’s not because the mothers are “cold.”

AB: Absolutely not. It’s more like, “this system does not translate what you’re doing into anything I can understand.” When I first started working with autistic kids, a lot of the parents had been called “refrigerator mothers.” It was their coldness or their “death wish” toward the child that was supposed to have caused the child’s autism. That was the standard psychoanalytic understanding of autism. And I think there are some practicing psychoanalysts who still see it that way.

DK: Like the schizophrenogenic mothers of people with schizophrenia?

AB: Exactly. But it’s very clear that both those disorders are biologically-based and that a parent can have a perfectly normal child and then give birth to a child who develops autism or schizophrenia. Does she really love one child and have a death wish toward the other one? I don’t think so.

DK: Do we know yet whether it’s genetic or environmental? I know there’s a theory that environmental toxins play a role. There’s a high prevalence around here in the Bay Area.

AB: When I was first studying autism, the incidence of autism was 1 in 2500. Now it’s about 1 in 66, and in the Bay Area especially there’s a huge prevalence. It’s really burgeoned over the course of my practicing in the field. I’ve watched it carefully and there’s no way that a purely genetic disorder can increase that hugely over such a short period of time. For instance, as long as we’ve been measuring schizophrenia, it seems that about 1% of the population is schizophrenic, and this is across culture, across socioeconomic status, across everything that we know.

It certainly seems as though there are more learning disabilities diagnosed now, too, and more ADHD. Whether that’s a fiction of the pharmaceutical companies remains to be studied. I think that’s certainly something worth looking into.

There’s a pediatric neurologist at Harvard named Martha Herbert who is researching the ways in which all of the neurotoxins in our environment potentiate each other. So it’s not just that there are thousands of neurotoxins, it’s that if you put this one together with these six, you are going to get something that’s way more powerful than any one of them alone.

So it may be that the huge preponderance of neurotoxins is intersecting with some genetic predispositions so that this child will develop autism from these neurotoxins and this other child might develop epilepsy or Tourette’s or anxiety or learning disabilities or maybe nothing. We don’t know for sure, but if I had to stake my career on it, I would say that there’s no question that the environment is involved in this.

DK: I’ve heard a couple of people say that the higher rates of autism in the Bay Area are either due to the fact that people didn’t know about it back when, so it wasn’t being diagnosed, or that this is where the tech boom happened and there’s a huge number of tech geniuses on the autism spectrum here having kids with one another.

AB: Well, the first claim I can throw out immediately. You see a kid who’s flapping his arms and not making any kind of eye contact, and who’s talking in this professorial way and doesn’t care whether anyone is listening or not—don’t tell me that nobody noticed this kid 20 years ago. Maybe they were just called weird kids, but come on, if they were there, they would have been noticed.

The second claim is more compelling. It could be that there are more Asperger types in Silicon Valley. I’ve certainly seen some in my practice who have gone in that direction and are making hundreds of thousands of dollars straight out of an engineering program in a university. They’re drawn to that kind of work. So if indeed there is a genetic component, then a high concentration of these folks all in once place would certainly make having kids on the autism spectrum more likely. But beyond genetics, how are they going to raise their kids? If they can’t relate well with other people, then they’re not going to be super related with their kids. Unless they have partners who are able to compensate for that, the kids are going to be raised with that kind of relational style.

If we think of what we do as a “hard science,” then we’re driven to push these folks into categories. But I think there’s such an intersection of environment—and by that I don’t mean just the physical environment, but the psychological environment that a child is raised in—and the child’s biology. And the family environment is different for each child.

DK: You mean how children develop differently in the same family?

AB: I once saw a family that had eight kids, and I saw several children within the family individually, as well as the family as a whole. The three older ones had been sexually abused by the father, who was in prison, and they had in turn abused the five kids younger than them.

One of those kids developed schizophrenia. I don’t know how much the schizophrenia was triggered by what had happened to him. One of them was so emotionally fragile and had such a severe anxiety disorder that she went to live in a group home. Three of those kids wound up going to college and making really interesting lives for themselves. And one of them had chosen at about 12 to go and live with her best friend’s family, who were highly-functional, wonderful and generous. So she was raised from age 12 on by a good family. She had the resources to go and seek that out and her sibling, a year younger, ended up in a group home. Why? We really don’t know. They both came from the same family environment.

Some things can look neurological and certainly be neurological which then, when the environment shifts, can be lifted. My own granddaughter had tics through her late-middle childhood, and when things shifted in her family, the tics disappeared. So were they neurologically based? They were tics rather than something else, but could they be altered by a better environment and more happiness? It seems to have been the case.

DK: So the environment can both trigger a latent illness and also resolve it.

AB: Right.

DK: Can you describe what standard autism treatment is and what you do that is or isn’t different from that treatment?

AB: Well, in the old days, they used to put an autistic kid on an electrified floor and apply electric shocks until the child performed certain behaviors.

DK: No way. You’re lying.

AB: I’m not kidding.

DK: When was this?

AB: This was in 1950s, and I think it went on for a while. There was a guy named Ivar Lovaas at UCLA who developed it.

DK: It reminds me of the experiments Martin Seligman did with dogs. Shock treatments that created his theory of learned helplessness.

AB: These days standard autism treatment is cognitive behavioral therapy and social skills groups, where you learn particular formulas for social skills.

DK: Like when somebody asks you for something, you say—

AB: “No, thank you” or “Please” or “Hello, my name is Henry. What is your name? What school do you go to?”

DK: So, how to look normal.

AB: Right. What I do with autistic kids instead is I try to enter their world. I try to help them express themselves. I work with my dog in the room, and he is a really good co-therapist, especially with kids whose verbal ability is not so great. They get a lot of physical comfort from holding him.

My work with autistic children is not all that different from the way I work with non-autistic kids, except that it’s harder to reach them and they’re not as reciprocal.

Throwing Marbles

DK: What are some general principles about treating kids on the autism spectrum? How does therapy look with them?

AB: The most important thing for a child on the spectrum is for them to be able to experience that somebody else is sharing their world. The loneliness that they feel, the terrible isolation, and the desperation they feel ends up creating their symptoms. So a parent will bring a child in and say, “He’s shrieking, and he’s up all night long and jumping around the house and repeating learned lines from TV commercials instead of talking about his day at school.”

All of it is the attempt of a child with a big fault in neurotransmitters to reach other human beings, because I think that’s what we all want to do. We all want to be connected. So what I try to do is to enter a child’s world in whatever way I can. Whatever level of functioning they’re at, that’s my biggest guiding principle.

DK: Can you give an example?

AB: I had a woman who brought her 2 1/2-year-old to see me, and she lived somewhere far away like Fresno, so she basically got up at five in the morning and got her kid to my office and then took her home, and that was her day. Because of that, we had agreed that we would only do six sessions. The mother herself was a physician, highly articulate, highly intelligent, highly trained, and she didn’t know what to do with her kid, who was totally nonverbal. She seemed nonresponsive and unable to take in anything that this mother was giving her, and the mother didn’t know whether to institutionalize her or what. She was in a very desperate place when she came to see me.

At the first session I had with this child, I have a basket of marbles, and she took a handful of marbles and threw them across the room. So I did the same thing.

When I work with kids that young, I am constantly trying to interpret to the parent what it is that I’m doing with their child so that the parent can do it, because they’re the one that’s with them all day. And I’m trying to interpret to them also what I see happening with their child, because sometimes they don’t see it.

The kid threw another handful of marbles, so I did too, and after not very long, she began looking at me. And her mother was saying, “She’s making eye contact with you. She never makes eye contact.” And then I thought, let me try to enlarge this a little bit. So I made a little noise while I was throwing the marbles—and she did too. That was session one.

The next four sessions, we continued to do things like that, where she saw that I could enter her world. And I kept saying to her mother, “Look. She does this when I do that. Maybe you could do some of this at home.” We played with different materials. We played with water. We played with sand. I took her into the garden at my therapy office, and she liked playing with the dirt. It wasn’t sophisticated play—we weren’t feeding the baby doll or anything like that. It was sort of infant-level play and infant-level communication, and I just gathered a sense of where she was and what she was feeling and went as close into that as I could.

In our last session, I made a number of recommendations to the mother. I don’t know how much receptive language this child actually had—she certainly had no expressive language—but somewhere in her body she absolutely understood that it was the last session.

So we went out in the garden, and she was sort of recapitulating a lot of the things that we had done together. In the garden outside of my therapy office, there’s a little fountain that doesn’t have any water in it anymore, but has pebbles in it. She took those pebbles and threw them down the path and I went and chased them. She was all excited to make me go do something. And then I did the same for her, and she went and did it. We were doing reciprocal play, where the child had never done anything reciprocal. And the mother was saying that, at home, she was also doing more reciprocal play.

At one point, she did it in a particular sort of winsome way. As she was running, she threw the pebbles and then she made a gesture to let me know that she wanted to go chase them. I thought, “That’s so cool,” and intuitively I just put my hand on her back as she was running, to pat her and say, “Good girl. That’s great.” And for the rest of the session, on and off, this child kept touching the place on her back that I had touched.

As she left and I said goodbye to her and goodbye to her mother, she touched that place on her back, and it was like, “I’m taking you with me. This is how I’m taking you with me. I know this is the last time.” It was so poignant and amazing. The whole thing was as nonverbal as it could get, but it was right there at the level of feeling. It was like letting her know that, regardless of her skewed neurology, it was possible for another person to enter her world, to share her experience, for somebody to touch her back in tenderness and love. It was like we were saying, “I may not see you again, but I know this happened between us.”

DK: That’s such a beautiful story.

AB: It was amazing. The sad thing is I never found out what happened after that.

Parenting Children with Autism

DK: It sounds like you do a lot of work with the parents also. Is that right?

AB: I do a lot of work with the parents. It’s hard to be the parent of an autistic child because you don’t get a lot of the usual rewards. One of the things that makes it possible to be a parent is it’s very rewarding. Sometimes it’s horrible, of course, but it usually becomes rewarding at some point in the not-too-distant future. But with an autistic child, you don’t get a lot of feedback that what you’re doing is working, so a lot of parents lose confidence and they also grieve.

What’s going to happen to their kid when they’re an adult? It’s cute to be an eight-year-old autistic kid; it’s not so cute to be a 27-year-old autistic person. How are they going to make a living? How are they going to survive? What’s going to happen to them when the parents die? I do a lot of work with the parents around their grief over their autistic children and also around accepting that this is the child they have and that he may not be “normal,” he may not do the things that other kids will do, but it’s possible for this child to have fulfillment.

DK: And for the parent to have fulfillment?

AB: Yes, absolutely.

DK: I was just imagining the anxiety and the sense of frustration that the mother must have felt. Driving all the way from Fresno, feeling desperate to make some kind of connection with her child. Finally she makes eye contact with you, makes some emotional contact with you. I imagine that what you were modeling for her was just a profound patience and non-worry, along with a great deal of curiosity.

AB: Right, exactly.

DK: My sense is that that would be so hard for a parent. They must have so much anxiety and shame around their desire for their kids to be different than they are.

AB: It’s a profound, profound feeling of helplessness. I’m actually working on a novel about an autistic child, narrated by her older sister, who isn’t autistic. At the beginning of the novel, the autistic child is quite profoundly autistic, nonverbal. She becomes verbal later, a little bit like the kid I was describing before, but the sister really wishes that her little sister would die. She wishes that she would get lost. The little sister constantly escapes, and the older sister wishes that she would escape one day and never come back. It’s totally understandable, and parents sometimes feel that as well.

It’s so important to legitimize those feelings for parents. When you can’t reach a child and the child is driving you crazy because he is up all night and screaming half the day— it’s so understandable why parents would feel so frustrated and unhappy with their kids.

Deconstructing the American Dream

DK: Autism seems like a disease with a somewhat limited cure rate. There’s of course people like Temple Grandin, who was able to come out of her autistic shell with a great deal of help from her mom, but that’s kind of unusual right?

AB: In some ways that’s true. I see one boy in my practice now who is in his senior year in high school. And when he was a young child, he didn’t have language. It used to be that not having language before five was a pretty bad prognosis. But this kid is amazing. He’s getting straight As in high school. He’s a genius. I’ve never beaten him in a game of Chess or Scrabble. And as a linguist I’m really good at Scrabble!

I think he’s going to have a pretty good life, so the prognosis was wrong. But on the other hand, relationships with other people, fulfillment in any kind of way that is not sort of limited to technology? Probably not. He’ll be better off in that regard than many people with autism, but not like somebody who doesn’t have autism.

DK: So is some of your work with him then about depathologizing this aspect of his reality? Not trying to get him to become “normal” and push him to date and such, but instead redefining a meaningful life in terms that are meaningful to him?

AB: Yes, exactly, and also working with the parents of these kids to help them accept that they are going to have a different way of being happy than their kid who doesn’t have autism, and that it’s really not about following a formula, but about finding what turns them on.

If what turns their kid on is sitting in his room and trying to develop a videogame, fabulous. If he finds joy in that, why not? Why send him out to be on the football team and hold that as the criterion for social success, or having 60 friends? All of us have different ways of being happy. Despite feminism and everything else, there’s still one formula for happiness in this culture that looms above all others.

DK: Married with kids and money.

AB: Exactly. And if you don’t follow that formula, by those standards, you’re a failure. So for the people I work with who have autism, the most painful thing for them is that they don’t have that. They haven’t been able to accomplish the American success formula. It’s important to help them see that despite that, they can have fulfillment in their lives.

DK: In other words, deconstructing the American dream.

AB: Yes!

DK: I don’t treat people with autism, although I’ve worked with a couple of people on the spectrum. But I feel like deconstructing the American dream is standard practice for me. That unattainable, glossy life haunts almost everyone in one way or another.

AB: It’s so true. This is a culture that is so based on the Protestant work ethic and the Calvinist idea of individual responsibility that, if somebody hasn’t “made it,” they believe they are personally responsible.

DK: Particularly since the economy tanked, a lot of people are struggling just to get by and it’s amazing how people personalize failures that are clearly not their fault.

AB: They take it so personally and feel so ashamed. It’s important to say, “Hold on a minute. Take a look at what happened over the last decade, where our tax dollars have gone, who is being bailed out and who is having their food stamps taken away”

DK: But even for people who have a lot of material wealth, they suffer a great deal because they feel that since they have “made it,” they should be happy, because material success brings happiness, right?

AB: I once worked for a couple of years with a person who was going to inherit a huge amount of money and already was living on a trust fund. This person had the kind of money that people dream will make them happy. And I really got an eye into the unhappiness that can exist despite huge amounts of money.

DK: The American dream ain’t all it’s cracked up to be.

AB: It sure isn’t.

DK: Well, it’s been a delight to talk with you today. Thank you so much for sharing your wisdom.

AB: It was my pleasure. Thank you.

Poem

AB: Questro muroQuando mi vide star pur fermo e duro / turbato un poco disse: “Or vedi figlio:/ tra Beatrice e te e questo muro.”

(When he [Virgil] saw me standing there unmoving, he was a bit disturbed and said, “No look, son, between Beatrice and you there is this wall.”)

—Dante, Purgatorio XXVII

You will come at a turning of the trail
to a wall of flame

After the hard climb & the exhausted dreaming

you will come to a place where he
with whom you have walked this far
will stop, will stand

beside you on the treacherous steep path
& stare as you shiver at the moving wall, the flame

that blocks your vision of what
comes after. And that one
who you thought would accompany you always,

who held your face
tenderly a little while in his hands—
who pressed the palms of his hands into drenched grass
& washed from your cheeks the soot, the tear-tracks—

he is telling you now
that all that stands between you
& everything you have known since the beginning

is this: this wall. Between yourself
& the beloved, between yourself & your joy,
the riverbank swaying with wildflowers, the shaft

of sunlight on the rock, the song.
Will you pass through it now, will you let it consume

whatever solidness this is
you call your life, & send
you out, a tremor of heat,

a radiance, a changed
flickering thing?

—Anita Barrows

John Sommers-Flanagan on Clinical Interviewing and the Highly Unmotivated Client

Posted on January 19, 2014February 24, 2026 by rezendevknowfully.com

When In Doubt, Act Like Carl Rogers

Victor Yalom: You and your wife, Rita Sommers-Flanagan, are well known in the field for your work in Clinical Interviewing, and we are delighted to be releasing your video on this topic concurrently with this interview, but before we get into that, I know you’ve also done work with mandated or otherwise unlikely and unwilling clients. Much that’s written about therapy implicitly assumes that the client is there willingly, but in many settings, clients are overtly coerced into coming by courts or institutions, or they’re strongly nudged into treatment by their parents or spouses. How do you work with these clients?

John Sommers-Flanagan, PhD: A lot of my thinking in this area sprang from the work I did in private practice, primarily with challenging teenagers. As you can imagine, many of them did not want to be in the room with me, so the challenge was, “How do I engage this person?”

I have a vivid memory of a young man who spent 30 minutes just saying, “fuck you” to me. I remember trying to go through every strategy I could think of. But probably the best of all was just to try to be like Carl Rogers and listen in an accepting way to that particular message over and over again.

VY: Did you literally reflect it back to him like Carl did, verbatim?

JSF: Well, Carl had a case known as, “The Silent Young Man,” where he’s treating this young man who doesn’t want to speak at all, and I think I was trying to channel him in that situation. So I started off by saying things like, “Well, it sounds like all of a sudden you’re pretty angry with me.” And all I got was, “Fuck You.” Then I was saying things like, “It’s clear that there was something I did or said that offended you and I’m not sure what it was.” Then I did a little self-disclosure. After about 15 or 20 minutes, he was still just saying, “fuck you,” but he started singing it to me as 15-year olds might be inclined to do. That went on for 10 minutes and I’m doing my Carl Rogers impersonation, “Well, you sound like you’re not happy, but even though you’re still swearing at me, you’re not angry any more. Now you’re happy and singing it to me.”

What happened next was really interesting. Keep in mind this was not a first session, it was a sixth, maybe seventh session. When he came in the next week, he sat down in the same chair and looked at me. I was anticipating more anger and more resistance, but the first words that he said were, “I’m just wondering, how would you feel if you were to adopt me?” Which was kind of a shocking change, and actually much more difficult than, “fuck you.”

VY: What did you say?

JSF: Well, he said it in this kind of off-handed way, and I just decided at that moment in time that I should try to be genuine and I responded with some disclosure about feeling a little nervous because this was a young man who had a pretty significant history of violence. I said, “I think I would feel pretty nervous about some of the ways that you’ve been with people.” And that launched us into a different discussion.

For me, it sort of captured how important it is to be, as Marsha Linehan might say, “radically accepting of what the client brings into the room.” Or as Rogers would say, “You just kind of work with what you’re getting.” It seemed to help us go deeper and it facilitated exploration and more engagement.

“You sound like a stupid shrink and I punched my last therapist”

VY: So one thing I get from this nice story is the underlying message of really hanging in there with a client, even in an extreme case where they’re coming in and swearing at you perhaps for the whole session or half a session. Really being there and meeting them head on, and being as genuine as you can.

JSF: Absolutely. A more common example is one that I get all the time with some of the difficult young adults I work with now. A 20-year old very recently came into therapy and I said something like, “Welcome to therapy, how can I help you?” And he says, “You sound like a stupid shrink and I punched my last therapist.”

This again captures a lot of the pushing and testing that happens with reluctant clients. I said, “Well, thank you very much for telling me that. I would never want to say anything that would lead you to punch me, so, how about if we decide that if I say anything that makes you want to punch me, you just tell me and I’ll not to say it anymore?”And the kid sat back and said, “Wow. Okay. That’s alright with me.”

VY: How do you conceptualize uncooperative or unwilling clients?

JSF: Well, there are few different dimensions. The first is how they’re referred. They’re often referred by a probation officer or principal, or the parents bring in someone or someone is abusing substances and has been given an ultimatum, or a spouse insists on some kind of counseling and so they come sort of unwillingly into the room.

Then there is the way that their resistance manifests in the room. Sometimes it manifests in silence. “I’m not going to talk to you and you can’t make me.” My standard response to that is what I think people have referred to as a concession where I say, “You are absolutely right. I cannot make you talk about anything in here. I especially can’t make you talk about anything you don’t want to talk about.” With teenagers, I will say that and then I’ll pause and I’ll say, “Well what do you want to talk about?” It’s like they need to posture by saying that they won’t talk, and when I concede that they’re right, that they do have control over themselves, then they tend to respond.

Other times, as I’ve just talked about, resistance is much more aggressive. I remember an older man who said, “We might get in a fight in this meeting.” That’s a much more aggressive kind of resisting the initial contact.

And, lastly, there are some people who resist through externalizing, as in, “the problem is with my school,” or “It’s with my spouse,” “it’s with work,” “it’s with everyone but me.” The challenge then is to listen empathically without getting too frustrated, because if I get frustrated and accuse the person of externalizing, oftentimes it just makes them more defensive. Those are three different categories I can think of off the top of my head: the very silent client, the very aggressive, and the very externalizing client who has a lot of trouble taking any initial responsibility for his or her problems.

VY: So aside from acceptance, empathy, and trying to really be there authentically, what are some other key principals for the therapists working with these kinds of clients?

JSF: I don’t know if you remember Mary Cover Jones, who did some of the early work with John Watson on helping young children desensitize their fears, but she said, “We have two means through which we can help decondition people. One is counter conditioning, where you have some kind of positive stimulus that you pair with the anxiety-provoking stimulus. And the other one is through participant modeling.” She wrote about that in 1924, and it was pretty amazing stuff at the time.

So I have started to reconceptualize people who are resistant to therapy as people who are anxious about the situation. I think, “How do I produce an environment that is going to counter-condition anxiety? What’s in my environment that might help people feel more comfortable and less anxious?” It’s another principal I’m often thinking of in a clinical situation.

VY: I can’t help but note that you’re pleasantly eclectic. You’re combining the epitome of humanism, the person-centered approach of Carl Rogers, with hardcore behaviorism.

JSF: I don’t consider myself a behaviorist, but I also think that if we don’t understand behavioral principals of reinforcement and classical conditioning, we can inadvertently do all the wrong things.

Foundationally, I want to have an office, I want to have a wardrobe, I want to have a way of being with clients that is going to counter-condition any anxiety that the person might feel.

I want to have an office, I want to have a wardrobe, I want to have a way of being with clients that is going to counter-condition any anxiety that the person might feel. Mary Cover Jones used cookies with children, and when I work with teenagers, I absolutely use food. I will have some food, fruit snacks or something nutritional in the room that I can offer, and in some ways I’m thinking absolutely behaviorally at that point. And I’m also thinking relationally—it’s about having a supportive, mutually collaborative relationship. We’re working together.

VY: Can you say a little more what you mean by examples of counter-conditioning anxiety?

JSF: Well, I was just looking through Skype into your space and you have some fabulous artwork. And I think it’s important to have a room that has comforting, pleasant artwork and other kinds of symbols that will help put people at ease. And if you’re working with LGBTQ people, there should be some kind of symbolic communication that you are welcoming those people into your office.

Same thing here in Montana. We work a lot with the Native American population, and it’s really important to have some sensitivity and representation in our office of that sensitivity.

When working with younger clients, the same thing applies. I was supervising a young man who had a 16-year-old boy client who said, “I will never speak to you about anything important in my life, period.” We knew from his referral info that he had been the person to discover his father had hanged himself, so he had some terrible, complex, traumatic grief.

My supervisee said, “What am I going to do?” And I said, “Take the checkers. Take backgammon. Take some games. Take some clay. Take some things into the room. And don’t force him to talk. Just be with him. Play.”

They played for three sessions, just played backgammon. And at the end of the third session, the client looked at the counselor and said, “Well, should we keep seeing each other? Because you said I only needed to come three times.”

And the counselor said, “Yeah, I think we should keep going.”

And the client said, “Well, okay then,” and he pushed the backgammon set aside and starting talking. To me it seemed like a great example of counter-conditioning. They used playing games as the stimulus that was pleasant and non-threatening.

VY: And participant modeling?

JSF: That’s really important, although obviously you can’t really have other people in the room modeling, so the therapist is the model, and is modeling comfort in all things. Comfort when the client says, “I’m feeling suicidal.” Comfort when the client says, “I want to punch you in the nose.” The response is to appreciate those disclosures, instead of being frightened by them. Being frightened by the client’s disclosures is going to feed the anxiety, instead of counter-condition it or instead of modeling, “We can handle this. We can handle this together. It’s best if we do talk about all these things, even the disturbing things that you bring into the room.”

VY: How do you help students, beginning therapists, achieve that? And, how do you balance that portrayal of comfort with authenticity when, in fact, beginning therapists may not feel at all comfortable?

JSF: That’s a great question, and it’s one of the challenges because you want the therapist to be genuine, and yet at the same time you want them to be comfortable. And often those two things are a little bit mutually exclusive.

But I think first of all, information helps. It’s helpful to our trainees and interns and young therapists to really understand and believe that, for example, suicidal ideation is not deviant. It’s not pathology. It’s an expression of distress, and if people don’t tell you about their suicidal ideation, then they are keeping it inside, and they’re not sharing their personal private experience of distress.

I try to do a lot of education around that, whether it’s suicidal or homicidal ideation or trauma or whatever it is that clients might talk about. It’s really important for young therapists to know if they don’t talk about it, we’ll never have a chance to help them with those legitimate, real thoughts and experiences that they’re having.

And the other big piece is practice, practice, practice.

VY: How do you practice these things?

JSF: To give an example, a lot our students initially do suicide assessment interviews, and they’ll say to their role-play client, “Have you thought about hurting yourself?” I’ll interrupt and say, “Okay, now use the word ‘suicide.’” Now say, “Have you thought about killing yourself?” I’m wanting them to get comfortable with the words and to practice using those words so that they aren’t so terribly frightening.

I remember supervising a new student who was conducting an initial assessment, and about half-way through the 30-minute interview, his client says, “I used to have a terrible addiction problem, and one of the things that really has helped me with my recovery is cycling. I’m an avid cycler and it’s really helped me with my drug and alcohol problems.”

At which point, he freezes in panic and says, “So what kind of bike do you have?”

I stopped the tape and said, “Hey, what was going on?” He says, “I was scared, I didn’t want to open things up.”

I said, “Well she did. She opened it up. She shared with you that she had an addiction problem, that she was in recovery, and that she had a method that really is helpful to her. So it would be perfectly natural for you to then use your good active listening skills and ask an open question or do a paraphrase or reflection of feeling, and to stay focused on the target, which was addiction recovery coping, instead of asking what kind of bike she had.”

So it’s a combination of offering encouragement, practice, and feedback.

VY: In addition to behavioral principles and humanist principles, what other theories or principles do you draw from?

JSF: Well, in the psychodynamic realm, I’m thinking of Edward Borden’s work on the working alliance and his effort to generalize it from the psychoanalytic frame to other frames. And the emotional bond between therapist and client, which Anna Freud wrote about initially. We really try to facilitate that.

We also engage in collaborative work toward goal consensus between therapist and client, and it could be that we agree that the therapeutic task involves free association and interpretation and working through. Or it could be a therapeutic task that involves exposure and a real behavior modification approach.

Clinical Interviewing

VY: You and your wife Rita Sommers-Flanagan have written a comprehensive and widely-used textbook entitled, Clinical Interviewing, about the initial stage of therapy, where you’ve examined and broken down in great detail all the aspects that those first few sessions. Can you explain what you mean by “clinical interviewing?”

JSF: It’s a term that originally referred to the initial psychiatric interview, which has a lot of assessment in it. So it refers to that initial contact. But as we have grown, we’ve come to see it as not just an initial contact. In some ways, every contact is a clinical interview in that every contact involves this sort of two-headed goal of assessment and helping. And then the third component is the working alliance, or the therapeutic relationship.

As we know, assessments in a clinical interview produce more valid data if we have a good working or therapeutic relationship. The evidence is very clear that therapy outcomes are more positive if we have a positive emotional bond, and we’re working collaboratively on goals and tasks. So I see the therapeutic relationship as central to the assessment and the helping dimension of the clinical interview.

VY: It’s the beginning phase of therapy.

JSF: Yes.

VY: In reading your text and also in viewing the video we’re releasing conjointly with this interview, you really emphasize the importance of the therapeutic relationship or rapport-building as an integral part of that initial contact.

JSF: Right. Even if you’re doing something as straightforward as a structured diagnostic interview, or a mental status examination, you really want to engage in a therapeutic way with the patient or the client.

VY: Because you’re not going to get much information or accurate information if they don’t feel like you’re on their side?

JSF: Absolutely. It’s about establishing trust and helping people to be open. I’m very familiar with your father’s work, and in The Gift of Therapy, he writes, “In recent and initial interviews, this inquiry into the typical day allowed me to learn of activities I might not otherwise have known for months.

Even if you’re doing something as straightforward as a structured diagnostic interview, or a mental status examination, you really want to engage in a therapeutic way with the patient or the client.

A few hours a day of computer solitaire, three hours a night in Internet sex chat rooms under a different identity, massive procrastination at work, ensuing shame. A daily schedule so demanding that I was exhausted listening to it.”

And he goes on and on about these disclosures that he was able to get by asking a simple question, “Tell me about your usual day.” To me, that’s a great example of how rich the assessment data can be with a simple question, if you have a positive rapport and therapeutic relationship.

VY: So it seems like a fundamental balancing act that you’re always dealing with is how do you balance getting sufficient information—particularly if you work for an agency where forms are a part of the process—while establishing sufficient rapport. Because if they don’t come back for a second session, the treatment is surely a failure.

JSF: Right, how do we balance the information-gathering task that we might have for our agency with the relationship task? And how do we do that with culturally diverse clients?

One of the things we try to do in the Clinical Interviewing book is to go into detail—with an outline and structure—of different kinds of initial clinical interviews, including the intake and the mental status exam, suicide assessment, diagnostic interviewing, and other kinds of interviews, yet emphasizing throughout the importance of the relationship.

So if I have a checklist that my clinic is requiring me to fill out, I would say to the client, “This part of our task today. I am supposed to ask these questions and record your answers, but I also want to hear from you in your own words things that you’re experiencing. So I’ll try to balance that with you.” And I’ll actually show them the questionnaire or the checklist.

VY: So be transparent.

JSF: Be transparent. Absolutely.

Multicultural Competence and Moving Beyond Your Comfort Zone

VY: You mentioned different cultures. What are some particular considerations that come to mind about that?

JSF: Well, some of the principals that come to mind for me involve respect for the native culture here in Montana and throughout the U.S. I think respect is a core part of beginning any relationship. And I think respect involves understanding and being able to pronounce the names of various tribes, asking very gently and respectfully about tribal affiliation here in Montana. I will sometimes say that I know some people from, say, the Crow tribe who have been students in our program. Even if they don’t know the particular students, it can be helpful to hear that I have had contact with somebody who’s got the same tribal affiliation as them.

Cultural competence also means that we take the time to read and study about working with Latino or Latina clients. It also involves using what Stanley Sue referred to as “dynamic sizing” and “scientific mindedness,” where we try to figure out, “Does this cultural generality apply to the specific cultural being in my office?” That’s a difficult but very important thing to determine.

VY: Just a couple weeks ago I had the privilege of interviewing Stanley Sue’s brother, Derald Wing Sue, on multi-cultural issues. One of the things he emphasized was really getting outside of your comfort zone and getting to know these other cultures on a more than superficial level.

JSF: Another thing he really emphasizes is the question that can’t help but be in the back of the mind of many minority clients: “Is this therapist the kind of person who will oppress me in ways that other people in the dominant culture have oppressed me and my family, my tribe, or my culture?”

One of the remedies that he and others have talked about is for therapists to be more transparent, and use a little more self-disclosure. Because without doing that, there’s just no good evidence that we’re not the oppressor or the “downpressor” as some Jamaicans would say.

So diving into the culture, getting to know it on more than a surface level, and then being able to use some of the principals that Stanley and Derald Wing Sue have articulated well is essential. It makes things much more complicated and much more rewarding.

Intake Essentials

VY: There are many models of how that initial client contact occurs—from a brief telephone intake to, in certain settings like substance abuse or mental health treatment centers, having a designated intake worker who passes on the client to interns or therapists. Do you have a general recommendation or sense of what the best practices are for the initial intake?

JSF: Well, in agencies where there is a handoff from an intake worker to other therapists, it can be difficult to maintain the therapeutic connection. In that case the initial session becomes much more about clinical assessment than initiating therapy.

Constance Fischer and Stephen Finn have written about these kinds of therapeutic assessments since at least the late 1970’s, and they suggest complete transparency through the process. “Here’s how things work in this agency.

This will be my only session with you. I would like to work longer with you, but what I’m going to be thinking about during our time together is who might be the best match for you for ongoing counseling or psychotherapy.”

Without that transparency we run the risk of alienating the client—leaving them feeling like, “Oh, man, I have to go through all this again with another person next week?”

VY: It’s hard enough for people to get into treatment in the first place. As I often say to clients, “People are not usually waiting in line to get the therapy.” It often takes people years.

JSF: Right, and when we put another hurdle there it makes it even more difficult. So it’s important to explain the hurdles and let them know how best to get over the next hurdle.

VY: Is your general sense that it’s better not to have a separate person doing the intake if possible?

JSF: I think it’s better to have the same person do the intake and then continue with therapy. There are, of course, exceptions to that. If you have someone who is not well-trained in substance abuse therapy, and then it becomes clear in the first intake session that this person has an active substance abuse problem, transferring the person to a therapist or counselor who has that experience would be a better fit.

And you can just explain that to the client, although oftentimes the client will still say, “Oh, but I’d rather work with you.” But as long as you have a good rationale, you can make that transition relatively easily. So, yes, it’s best to have the same person do the intake and then continue with the therapy, except in situations where there’s a clear rationale to do otherwise.

Treatment Planning

VY: What are your thoughts about treatment planning? There’s a lot of emphasis on that in many agencies. Do you think that’s something that actually can be done with any specificity? So often someone comes in thinking they’re here to work on X, and six weeks later, you’re really working more on Y. So at times I wonder who the treatment planning process is really serving. Is it really serving the client, or is it serving some agency needs, some funding needs, or the anxiety of the therapist?

JSF: I remember an old supervisor saying to a group of us, “We’re not technicians. We can’t really lay out a protocol for exactly how to act with every client. Every client’s unique, so we need to go deeper than that. We’re professionals, and we bring both art and science into the room.”

I think it’s important to blend the two.

I’m not a big fan of cookie cutter treatment plans. But I am a fan of looking at the plan, talking with the client about what our plan is, and being somewhat explicit and collaborative in that process. I see it as a kind of dialectic—it’s a little bit cookie cutter in that it doesn’t bring in much of the individuality of the client but it does have some important information for us. From there we can dive into the unique qualities of the client and their experiences.

As an example, let’s just say you have a client who’s impulsive. We know that there are certain kinds of treatments that we might use with someone who is diagnosed with ADHD who is impulsive, where those impulsive behaviors are getting him or her in trouble. It’s good to know about CBT and other kinds of therapies that might help with impulsivity. But it’s also really important to get into the mind and, in some sense, the body of that individual client to understand what’s going on with that person.

But knowing that there are probably triggers that increase and decrease impulsivity is something you’d want to work on with a CBT treatment plan. It can help focus the questioning, even if you’re working from an existential perspective.

“Evidence-Based” Treatment

VY: As you’re a professor at the University of Montana, and actively involved in training students, I’m wondering what your thoughts are about the major trend towards “evidence-based” treatment? There are a lot of leading figures in the field who are critiquing this trend. John Norcross talks about evidence-based relationships, since research actually shows that most of the positive outcomes in therapy are based on the relationships and not on this or that technique or procedure. Are you pressured by accrediting agencies to teach evidence-based treatments? What have your experiences been in this regard?

JSF: Yes, there is a lot of pressure to incorporate “evidence-based,” or “empirically-supported treatments.” When you look at Norcross’ work, you have to shake your head and wonder why we focus so much on technical procedures and evidence-based treatments. The science just really isn’t there. There are studies done that show X or Y treatment is effective and, therefore, it becomes evidence-based. And yet there’s a mountain of evidence saying otherwise, that it’s not the specific protocols that make a positive treatment outcome.

There are these voices in the wilderness, like Norcross, crying out about this, but there’s still this inexorable trend towards requiring these evidence-based treatments in training students and in various government agencies, for example.

The cynical side of me would say it’s about trying to get our share of the healthcare dollars. Shaping ourselves to be in the medical model, since there are empirically-supported medical treatments. Of course, there is some real scientific evidence that we should be aware of when working with our clients. We should be, because we’re professionals in this area. Like Norcross writes about, there are evidence-based relationship principals that account for positive outcomes and so we need to look at those, and we need to emphasize those more than the technical procedures. There are evidence-based relationship principals that account for positive outcomes and so we need to look at those, and we need to emphasize those more than the technical procedures.

But we shouldn’t ignore all technical procedures because, even Carl Rogers would say, “If the technique arises spontaneously out of a particular place where you are in the counseling process, then it may be appropriate.”

VY: In wrapping up, any advice you would give for students or early career therapists just starting out?

JSF: I think my biggest advice these days is to focus on balance: The balance between the science and the art, the balance between the relationship and assessment and diagnosis. We need some diagnostic information in many real world situations, but we should not try to get that at the risk of damaging the therapeutic relationship. The impulse is for people to go one direction or the other. I was at a workshop one time where a woman referred to people as science “fundamentalists,” which I thought was a very apt description of some people. They have this allegiance to the paradigm of modernist science, and that’s the only way truth is known.

Then there are people who are much more touchy-feely and go with the flow. My general advice would be, if you’re more of a touchy-feely person, you really still need to learn the science. You still need to read the clinical interviewing text and understand the content that is our professional foundation. And if you’re more inclined toward scientific fundamentalism, you need to get out of that box and try to learn from the other side of the dialectic, which is the relational, emotional side of things that happen in the therapy office.

Advice for the Late-Career Therapist

VY: So let’s use mid- or later-career therapists as an example. By that time in their careers, many have migrated to private practice and have gotten very comfortable in their own ways of being with clients. In many ways that’s a good thing—it’s part of the career progression to take everything you’ve learned along the way and integrate that into who you are as a person. But one drawback I see is the possibility of just jumping into therapy with any client who walks in your office—assuming they’re a good fit for you—without maybe doing a proper assessment. And then they find out six months down the road that the client has a drinking issue that they hadn’t disclosed before. Any advice for these later-career therapists?

JSF: Yes. I’m not in full-time private practice right now but I have friends who see 35 people a week, and are doing the kind of thing you’re talking about.

It’s so easy for us to get into a little niche where we do it our way, and we’re no longer open to other ways of thinking. I’d say it’s really important to keep stretching yourself, to keep reading, to keep going to professional workshops, because we can do things wrong for years and think that we’re actually being successful.

Scott Miller is emphasizing it now more than anyone else–but it’s incredibly important to get systematic feedback from our clients so that we can get a sense whether we’re on the right track with each individual client.

Even though we sometimes can convince ourselves that we’re incredibly intuitive and we can, therefore, launch into therapy immediately, there is some research that suggests that negative outcomes correlate with inadequate assessment. So we do need to step back and do a little formal assessment here and there, even though, as experienced practitioners, we might think, “I know what to do here. This is not a problem.”

Instead, step back and to say, “Let’s do a little bit of assessment here so we can work together to make sure that we’re on the right track.” In other words, mid-therapy adjustments and assessments to make sure that we are helping our clients as effectively as possible.

VY: A final question: What’s your growing edge right now as a teacher and practitioner?

JSF: I have several growing edges. One growing edge that’s pretty constant for me is working toward greater cultural sensitivity, and being able to know more deeply about people who come from diverse minority kinds of backgrounds.

Another growing edge for me is the whole idea of mindfulness and how to incorporate that into some of the more traditional ways that I was taught to do psychotherapy.

I think the other growing edge for me is kind of a growing foundation. The person-centered principals for me have always been foundational and I find myself sometimes really wanting to go back to those. I can see myself in future months or years going to some trainings to get even better at the things that I think are my basic foundational skills.

VY: I often have the opportunity to review some old videos that we’ve acquired or produced and just recently watched the first video produced with James Bugental, a human-centered existential therapist. I’ve probably seen that video 20 times and I still appreciate it, perhaps on an even deeper level.Well, I want to thank you for taking the time to talk with us today.

JSF: Thank you very much, Victor. I very much appreciate your work and the fact that you have dedicated a lot of your life to making the work of other great therapists accessible to all of us.

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