Consultation & Supervision Archives

When the Therapist Shares Too Much

Posted on April 1, 2026April 1, 2026 by Elizabeth Scozzari

Claire was working on her licensure, and she asked that I supervise her throughout the process. I’ve been lucky to have strong clinical mentors across my career, and so it felt like an honor to be asked for help. I was surprised to receive a text message from her first thing on Monday morning, “Can we touch base soon? I think I really messed up.”

My stomach tightened. I wondered how badly things could have really gone. Claire was a new therapist, but she had strong clinical skills. I hadn’t expected the urgency of this request. Soon after, she came into my office holding back tears. “I’m too close to one of my clients,” she spoke in low volume. “I don’t know how it happened. It’s not romantic, but I’ve told him about my family and my own problems. Now when we talk… it feels like a friendship. He’s been giving me advice. I screwed up and I don’t know what to do.”

I took a breath, “You made the right choice.”

“I know,” she said. She mistook my response for sarcasm. “I don’t know how I let this happen.”

“No. That’s not what I meant. You had a choice between embarrassment or secrecy. To share this with me or keep it to yourself. It’s a hard choice, but you made the right one.”

We explored the reasons why the relationship with her client had changed and what to do next. Her willingness to feel embarrassed, and to admit her mistake, was the first step towards repair. It was the first of many such conversations I’ve had since, both with new therapists and advanced ones, too. It’s also a conversation I’ve had with myself.

Leaving Our Post: Why Unskillful Self Disclosure Occurs

Unskillful self-disclosure is common; probably more common than we think when considering how many clinicians choose the path of secrecy over embarrassment. Choosing embarrassment by admitting our mistakes means walking against the wind, and so many therapists choose to have the wind at their back.

But how does this happen? Despite our good intentions, why do we leave our therapeutic post? There are probably many reasons, but the first is that the rules of healthy relationships are broken in good therapy. These are the rules of give-and-take, or reciprocity. When reciprocity is absent in our personal relationships, we tend to conclude these relationships aren’t desirable. Whether giving without receiving, or receiving without giving, these are usually signs that something has gone terribly wrong. If someone talks about themselves but never asks a question in return, we notice it. Somewhere in the back of our mind there’s an accountant who keeps tabs. And if this accountant doesn’t count every penny, they help us determine if our relationships are in general balance.

In therapy, our job is to fire the accountant. While reciprocity is beneficial in personal relationships, in therapy it undermines our ability to maintain focus on a client’s problem. So, we learn new conversational habits. We temporarily adopt a non-reciprocal style of relating to help our clients. It’s strange to acknowledge, but dysfunctional behavior outside of therapy is useful behavior within it.

Of course, some therapeutic approaches do emphasize mutuality and appropriate therapist disclosure. But even within these frameworks, disclosure serves therapeutic goals, not the therapist’s emotional needs. This distinction matters. If good therapy requires temporarily implementing this imbalanced dynamic, it shouldn’t be surprising that we struggle to make this adjustment. We’re asked to do something that, at its core, just feels wrong. Our inner accountant balks.

A second reason unskillful self-disclosure occurs is connected to the first, and it can relate to the problem of therapist loneliness. We are not like other professionals and therapy is not like other jobs. While our individual temperaments vary, most of us become therapists because we’re drawn to people for one reason or another. This draw towards others might seem like a good fit for a career in therapy, and sometimes it is, but other times, therapy can be a lonely place. Back-to-back appointments in empty office buildings or remote work from available bedrooms can bring with it a great silence.

And this silence isn’t only environmental. In our conversations with clients, we’re required to strategically deprioritize many of our reactions. This doesn’t mean these relationships are insincere, but that large parts of ourselves don’t participate in our discussions. When personal reactions aren’t in service to a client’s goals, we do our best to restrain them. We ask them to hide.

While we all have a strong interest in human connection, we’re met with more environmental and relational silence than expected. Loneliness is what happens when longing meets absence, and in therapy, there can be a great amount of both.

Returning to Our Post: The Art of Repairing Unskillful Self Disclosure

Understanding how unskillful self-disclosure happens is only half the task. The harder part is knowing how to return to the therapeutic framework without damaging the relationship. Once we’ve come to the realization that a clinical relationship has lost its professional shape, what can be done? This problem is difficult because while solving it, we simultaneously introduce three new risks into the therapy.

The first is that many clients enjoy having insider knowledge about their therapist. They may feel this is the basis of their rapport. To have insider knowledge is to feel special, and to lose access means losing this feeling of specialness. With open doors now closed, the sound of turning locks can create feelings of rejection. Feeling pushed away can damage the therapy, even while we’re trying to repair it.

Another risk is introduced when clients are more comfortable with the reciprocal dynamic. They may prefer to share the spotlight rather than feel its bright circle pointed at them alone. Reducing self-disclosure will increase the number of empty spaces in the conversation. There will be more silence, and with more silence, more discomfort. When we start walking back to our clinical post, new intensity emerges.

The last risk is that a client might decide that they’re to blame. They might conclude there’s something uniquely wrong with them if their therapist behaves differently with them than with other clients. Sensing that they lie at the center of their therapist’s dilemma, they might experience shame. It’s a shame that tells them that somehow, they’ve hurt their helper.

Whatever steps allow us to walk back to our clinical post, it’s important to think about managing the risks of rejection, new intensity, and shame. There’s no perfect script for this conversation, each therapeutic relationship requires its own approach, but one framework I’ve found useful centers around four steps:

Step 1: “I haven’t done a great job protecting your therapy…”

Expressing this step demonstrates that our aim is to protect their therapy, and to implicate ourselves at the heart of the problem. To name that we’ve failed to guard their therapy lessens the chances the client will blame themselves.

Step 2: “and so I’m going to pull back on how much I talk about myself…”

This signals the incoming adjustment. This statement is directive in nature as we’re not asking the client for permission with this new course of action. We’re telling them it’s happening. This is the first act of stepping away from the reciprocal dynamic, and instead, returning to the clinically imbalanced one.

Step 3: “but I want to let you know how to interpret this change.”

This step is particularly important because it helps reduce, though not eliminate, the new intensity that can emerge in the therapy. The client is being prepared to understand what new interactions mean, but also what they don’t.

Step 4: “The truth is that my enjoyment of our work hasn’t decreased, but my investment needs to increase.”

This final phrase reiterates that our adjustment reflects a stronger commitment to the client, not a weakened one. We’re disengaging in the wrong areas and reengaging in the right ones. We’re subtracting non-clinical interactions to deepen the clinical purpose. By expressing that our enjoyment hasn’t lessened, we maintain the appropriate degree of specialness that exists in every meaningful relationship.

Conclusion: The Ongoing Practice of Returning

Addressing unskillful self-disclosure isn’t a single moment but an ongoing practice. After we’ve initiated the repair, it’s important to continue monitoring our own pulls toward reciprocity. The loneliness that may have contributed to the initial drift doesn’t disappear simply because we’ve named the problem.

This is where consultation, supervision, and our own personal relationships become essential. We need spaces where we can acknowledge our humanity: our loneliness, our need for connection, our own vulnerability to unskillful self-disclosure. When Claire came into my office, she made the right choice because bringing it forward made the repair possible.

I’ve learned that therapeutic work isn’t about being perfect. It’s about being honest enough to recognize when we’ve drifted and courageous enough to find our way back. Every time we effectively manage our need for reciprocity and our loneliness, we strengthen our capacity to help our clients. Even when we don’t prevent unskillful self-disclosure, if we practice repair, we remind ourselves that while we may fail at our post, we’re still worthy of returning to it.

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

Posted on August 6, 2025February 12, 2026 by Psychotherapy.net Team

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

Creating a Supportive Supervision Model

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

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

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

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

Peer Support Groups: A Collective Approach to Emotional Resilience

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

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

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

Self-Care Encouragement: Prioritizing Individual Well-Being

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

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

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

Conclusion

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

Questions for Thought and Discussion

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

My Romance with Narrative Letters: Counter-Storying Through Letter Writing

Posted on November 29, 2023February 11, 2026 by Psychotherapy.net Team

How My Romance with Narrative Letters Began

From the second time I met with David Epston for supervision in December of 2003, learning to craft narrative letters became almost as important to me for learning to devise counter-stories as studying the verbatim transcriptions of my therapy conversations, which David had amended with his own questions. When I arrived at the door of David’s practice in Auckland on that December afternoon, he met me with these words:

“Kay, as chance would have it, Wally has just been meeting with me, and I wondered whether you would mind if he joined us for our supervision session today.”

Before I had had time to find out who on earth Wally was or why David might consider it a good idea for him to join us, “Yes of course,” popped out of my mouth. Despite my consent, I wasn’t at all sure about the idea, especially as this was the first transcript of one of the therapy sessions I had brought to my supervision with David. I was more than a little nervous and already the paper I clutched in my hand was somewhat damp with perspiration.

As if it were not enough to be presenting my first transcript, my anxiety was heightened because I had “failed” my first supervision session a month earlier. I had made the grave assumption that our inaugural meeting would be given over to an introductory chat, preparing a supervision contract which we would sign, after which away I would run until we met for supervision properly. Surely this is how my experience told me supervision was always done? I should have known that just as David’s approach to therapy is uniquely his, so too would be his approach to supervision. At that fateful first session, when David realized that I had arrived empty-handed, he almost threw me out on my ear, but thankfully relented, settling for a firm reprimand and gifting me two more sessions in which to prove myself as a worthy supervisee. This second session had to go well, so the surprise presence of Wally was something of a curveball.

The warmth of David’s greeting slightly thawed the edges of my anxiety, and when Wally rose to greet me with his broad smile, generous handshake, and cozy, bear-like presence, I was somewhat soothed. Wally turned out to be Wally McKenzie, a veteran narrative therapist, famous for his practice in Hamilton, and for his narrative teaching on the Waikato University Masters Programme in Narrative Therapy.

“Hey, Kay,” David said as he caught sight of the pages of transcript in my slightly sweaty palms. “I can see you have brought a transcript!” David, overcome with what I soon came to know as his irrepressible and indefatigable excitement, slapped me on the back and before I knew it, he was reading the transcript aloud whilst Wally, chin in hand, listened with the ears of a seasoned therapist.

The transcript was of the second session with Wiremu and Mere, M?ori couple whose fourteen-year-old son, Edward, had found himself on the “wrong side of the tracks,” and had taken to joyriding with his mates. Rather than see his son risking the wilds of the “West Auckland hood” on his own, Wiremu had begun to join his son in his drinking and driving escapades, much to the distress of his wife.

When David had finished reading, a fevered discussion followed. Alternative questions zoomed around like silver balls on a table — first one from David, then one from Wally, rapidly followed by another from David and so it went on. Feeling that I was on something of a joyride myself, I held onto my seat and observed the narrative spectacle unfolding before me. With his usual aplomb, David then announced that he thought a letter was in order. “A letter,” I thought “What does he mean?” I soon found out. I left that day holding in my hand the gift of a two-page letter, feverishly crafted by David and Wally for this beleaguered couple and for their son, Edward.

The letter spoke of how the couple had stuck together through hard times. It acknowledged the injustices and struggles that their son had experienced, and spoke of how, despite his understandable anger, his attributes shine through in his care of his siblings and in other ways. The letter went on to invite Edward to join his parents in their commitment to put the hard times, together with mistakes they had all made, behind them. It spoke to his parents’ conviction that life could get better for them all and that they all deserved a break. It ended with an invitation to “stick together as a family,” and for their son to join them at the next session. Edward did not come with them when we next met. I began our session by reading the letter out loud to Mere and Wiremu.

Here is the beginning of my email to David written straight after my next session with Wiremu and Mere:

“When I read the letter to Wiremu and Mere, it was emotional for them both. Mere cried quietly. Wiremu began to talk about wanting his place back in the family and declared to Mere that he was no longer going to try to be a ‘mate’ to his son and instead would learn to be a father.”

And so that was how my relationship with narrative letters began, even if it might have been better described as an arranged marriage.

Narrative letters have come to serve as extensions of sessions in my practice. Initially, they became the way in which I made up for what I judged to be mistakes in my conversations with people, or when I deemed that there was something missing from a conversation. As David once said to me with humility, “Kay, whenever I have messed up, I have always known that I could write a letter by way of apology.” While I am not immune from the need to write letters for such a reason, and I doubt if I ever will be, nowadays the purpose of my letters is almost entirely to add momentum to counter-storying. Sometimes they serve as counter-story “bombs” designed to explode the “Problem Story” between sessions.

Over the years, I have learnt how to write various types of narrative letters to serve different purposes. There are letters which act as a reminder of ideas discussed in a session; there are letters which serve to “keep the problem at bay;” letters which help to forge understandings and solidarity between the person, family members and friends; letters which recruit communities into a person’s life; letters which are written with a person to send to “a community of concern;” letters to respond to emergencies including life-saving letters; letters that I write with someone to another person or persons in their life to bring about changes in a relationship, and more. The letters that David has schooled me to write over many years have included all these intentions at times. However, despite the form of the letter, their purpose is always to give traction to an emerging counter-story.

How My Romance with Narrative Letters Evolved

For many years (roughly between 2004-2010), I would submit draft letters to David’s “narrative eye” as regularly as I would submit transcripts. Letter writing became my way of wrestling with intransigent problems in the hopes that doing so would aid me and the people with whom I worked to find quicker and more clever ways to evade the Problem. Along with “mind maps” of possible questions, they were also my “drawing board” for my practice.

For some time, my letters would be impossibly long. I would go through reams of notes to find ideas and the germs of counter-stories themes that I wished to include. Mind-mapping of conversations would give me a picture of the story so far. The maps would lay out the different threads of possible counter-stories before me and make visible possible lines of enquiry to form the backbone of the letter. Sometimes lengthy letters were invaluable with complex problems such as anorexia/bulimia and attempted suicide, as they pulled together vital counter-story threads from sessions and juxtaposed the problem’s story and the emerging counter-story, laying each of them bare for all to see. Over the years my letters have tended to become a great deal shorter as experience has enabled me to glimpse the counter-story more keenly and resolutely.

How I Compose Narrative Letters Today

Whenever possible, I write the letters immediately after a session. Letters written straight away have more effect because the conversation is still fresh in our minds (mine and my client’s) and in a manner of speaking, the Problem has less opportunity to displace the Counter-story. I put a limit on the time I will spend. Otherwise, I can become intoxicated with the emerging counter-story and a fifteen-minute letter can turn into a three-hour blockbuster. Rather than beginning by reading through my notes, I draft the key ideas of the letter in mind map form or by writing them down. I tend to find this easier to do on paper. Once I have a skeleton plan, I read through my notes from my sessions and circle or highlight key phrases. I then type my client’s words into the plan for the letter. As David has suggested, I aim for 40% of the letter to be in a client’s words, although sometimes this is too difficult or doesn’t ideally serve the purposes of the letter. The client’s words become the structure for the letter, arranged in a form that best “tells” the Counter-story. I then ruthlessly edit out whatever does not “move the action of the story forwards.” I then re-read and edit as I go.

Examples of Three Narrative Letters

I thought I would end with some examples of very different letters from my recent practice. The letters speak for themselves. In each letter you will see counter-stories unfolding.

This first letter is to “Leni,” a twelve-year-old girl who was referred to me through the Youth Health Hub, the community wing of the Child and Adolescent Mental Health Services here in Auckland. The letter was written after the second session. This is what her parents wrote on the referral form:

“As a family, we are struggling with Leni’s anxiety issues which have worsened since starting Intermediate School. It is getting increasingly difficult to get her to school as she worries about having to go to the toilet during class time, etc. We have talked to the school, and they are trying to work around the anxiety, but Leni gets extremely anxious when her school days involve any activities outside of her normal class (sport, drama, etc.). Normally, Leni becomes emotional during these mornings and refuses to go to school. We have managed to keep her attendance quite high, but we are usually emotionally drained each morning.

The anxiety over needing to go to the toilet so often is now affecting her out-of-school activities, and she is now refusing to go to her dance classes in case she needs to go to the toilet whilst she is at the class.

Leni has always been an anxious girl, worrying about issues she has no control over. We are looking for strategies to help manage her anxiety. The whole family is struggling because of Leni’s emotional outbursts which seem to be increasing. We feel we need to help her before her next transition to high school.”

Dear Leni

“Dear Leni,

I looked at the date before I started writing to you and realized you had been 12 for a whole week! Do you think that you are noticing being 12 at all? Even though some people might only think of 12 as just being the number after 11, are you noticing that you are a little wiser and more mature than you were this time last year? If you are, are you noticing that you are more worry-wise this year than last? If you agree that you are becoming more worry-wise, do you think it is most unlikely that as you continue to mature and grow in your wisdom that the worries will ever worry you as much as they did when you were 11 or 10, or 9 or 8?

Anyway, I said I would write to you because I thought it would be good to collect up on paper all I have learnt from you about how you have been distracting and calming down the tiger worries. Leni, would you mind letting me know when we next meet if I have got anything wrong in my letter? Can I rely on you to let me know?

I am thinking that perhaps you haven’t realized how much worry-wisdom you have now. Do you think there might be some truth in that? I ask this because when we first met, I was expecting to find that the worries had really got the better of you. Instead, I discovered that you had been using your ability to ‘pick up on stuff,’ that your Mum told me about, and had already worked out that the best way of calming the worries down was to distract them. You told me about how you worked out that distraction was your best anti-worry tactic on your own and that compared to before, you were doing ‘quite good.’

Between you and me, I had to wonder whether I would be needed at all, and I got worried I might be out of a job. I thought to myself that if you just kept distracting the worries, there was a good chance that your strategy would pay off completely. I decided to hang on in there though just in case. I’ve noticed that worries can get pretty tricky so hoped I might still be of help in a backup kind of a way. After the first time we met, you told me that you had shrunk the worries down to about twenty centimetres from thirty centimetres and then the next time you shrunk them down to ten centimetres. I have to say that this made me think even more that you had become worry-wise and it might just be a matter of time before you got the better of them completely.

That first day we met, you also told me that you had worked out that talking about the worries made them stronger, and so you had stopped telling your Mum about them.

Keeping quiet about the worries had worked so well that your Mum even wondered if they had gone! You also told me about another anti-worry tactic you had devised — you had decided to go to a different toilet at school. I didn’t ask you why you did this and now I am wondering if you decided that this would confuse the worries because they were used to you going to another toilet? Is this why you decided to do this or was there another reason?

That first day we also talked about the worries as being ‘tiger worries’ because I got to wondering about whether the worries that have been bothering you come from the same place that lots of other people have told me that the worries that bother them come from. And truth be told, the worries that bother me come from. Do you think its possible, as we talked about, that they come from that old cave girl part of you which kind of got left behind and had not grown up over the centuries like most of the other parts of us have? People say this old, cave girl, cave boy, or cave man or cave woman part is a part we needed centuries ago in case there were dangers around like tigers because it helped us to run away from them or to fight them.

Some people also say that although the tiger worries are trying to protect us, they cause trouble and instead are ‘killjoys’ because there are no real tigers. So, there is nothing to get you to run from or fight and they end up running around in circles in people’s heads instead. Do you think that the tiger worries that have bothered you are like this? Do you think they might have been frozen in time and don’t realize that there are no tigers in Te Atatu (western suburb in Auckland)? Considering you are a very caring person, I am wondering if rather than being scared of the worries as much as you were, you have started to feel a bit sorry for them because they don’t know there are no tigers in Te Atatu and don’t know what to do except run around and around?

Do you know the phrase ‘why re-invent the wheel?’ Well, I thought to myself ‘why re-invent the wheel’ because you had already found out that distracting the tiger worries worked. Do you remember how we thought that you might have a go at distracting the worries with fun and how last time we met you told me how you and your Mum had been spending time being silly and entertaining each other (and perhaps the tiger worries too) whilst you were waiting to go to school?

Do you remember that we talked about your dog Henry when he first came to live with you, and how he was scared and cried in the kitchen the first night? Do you remember your Mum telling me about how your brother had to sleep with him to stop him crying because maybe he thought he was all alone? Do you also remember how we talked about how your whole family went with Henry to dog training to teach him how to be calm and to behave?

When we talked about Henry, I got to thinking about how it might be a bit the same for the tiger worries. You agreed that maybe they needed training, so they understood that there are no tigers in Te Atatu. We then had a bit of a problem though because the problem with these tiger worries is that you can’t see them, so how do you go about training them and calming them? We thought about you getting a little furry tiger keyring to put on your school bag to remind you to calm and train the tiger worries. We agreed that maybe you could stroke the little furry tiger on your bag when you sensed that the tiger worries might be about to come along so that you could calm them down. Do you think that this is maybe where your caring nature comes in so handy?

I am so looking forward to finding out how you have been getting on with this new anti-tiger worry tactic.

Yours in anti-tiger-worrydom,
Kay

P.S. Did I spell Henry’s name right? I don’t want to offend him or you, so please would you let me know? Thanks.”

After the letter, Leni continued to grow her anti-worry wisdom. We had two more sessions. She is now happily settled at high school.

Dear Jasmin

The next letter was written to “Jasmin,” a 20-year-old Egyptian, Muslim, young woman after our third session. She had also been referred by the Youth Health Hub. This is what she had written on her referral form.

“I am a 20-year-old girl who is dealing with homophobic parents. They have disowned me, and I have been living all over the country for the last year. My mood is so low that I have been in hospital four times this year and the police have been involved in helping me as well. I’m currently unsure if I should accept my parent’s support and ‘be straight,’ or live with my girlfriend… and be sad? I don’t know.”

“Dear Jasmin,

Here is your letter! We agreed I would write to you about some of what we have talked about in the hope that this gathering up of the very different strands of our conversation might help you to see them more clearly, and to support you in your attempts to ‘anchor myself inside of the two worlds I am struggling to live in.’

I have been sitting here today, reading through the notes from all our conversations, pondering the ideas, thoughts, and feelings that we have talked about and wondering what to include and what to leave out for now. Would you please let me know if you think I have not made mention of something that is important to you or if I have got anything wrong?

Jasmin, when I think of you, I think of that first day we met and how we likened your being shunned and cast out by your beloved family to being a refugee. Jasmin, would you say that for as long as you can remember you have tried to live with a foot in New Zealand and a foot in the miniature Egypt of your family home?

When you were cast out because you were in a relationship with Anna, do you ever suspect that although this casting out was more dramatic that you could ever have anticipated, that sooner or later the tensions between being ‘a Kiwi’(colloquial term for a New Zealander) and being Egyptian, would have caused a rift between you and your family as you attempted to navigate the territories of both worlds at the same time? Has your love of Anna and your parent's refusal to ‘accept me being with a woman’ intensified and perhaps hastened the tensions that might well have burst through, and perhaps forced you and your parents apart at some point or another?

As you wrestled with the heartbreak and feeling ‘so very lost,’ you also wrestled with seemingly impossible dilemmas: ‘My parents say come home, but what is home? Is it worth choosing my family over my partner or my partner over my family? If they love me, why do they not accept me?’ We talked about how perhaps your parents’ love for you and Anna’s love for you are not loves that can be compared; how your parents’ love for you is not less than Anna’s love for you and Anna’s love for you is not less than theirs.

We discussed how every culture has blind spots which render some other ways of living so alien that they either are not seen at all or are seen very differently from the inside than from the outside. Jasmin, do you think that same-sex love is so unfamiliar to your parents as an expression of love that, in fact, it does not appear to be love to them? Do you think that perhaps your love for Anna appears only to be a threat to the life that they believe will bring you happiness? If this is true, then is their casting out of you a misguided attempt to force you to choose the only way of life that they believe will bring you and your family happiness? Is it, in fact, a very awkward and confused expression of love?

Even though these are probably not dilemmas that can be resolved, we talked at our second meeting about ‘can I find a way of living in both worlds that is not a lie?’ Do you think it is possible, Jasmin, that this question may have come to seem unanswerable to you because you have been very understandably assured that there is a true way of living? If your love for your parents and their love for you is true, and your love for Anna and her love for you is true, then could looking through the lens of a ‘one truth’ be unhelpful? Would you be interested in playing with the idea of many truths? If so, then do you think it is possible that what is said or done in one world may possibly not belie what is said or done in another world even if they seem opposed at face value?

Jasmin, what do you think of extricating yourself from ideas of ‘truth’ and asking instead different questions? For instance, what if you were to ask yourself: ‘If my family’s love for me and my love for them is true, then is it a lie to express my love to them in a way that makes sense within that world?’ ‘In their world, can I speak my love for them “in Egyptian ways” without pretending to love in the same ways as they do?’ ‘If my love for Anna and her love for me is true, then when walking in Anna’s world, can I “speak love” as a modern, gay, Kiwi?’

Although speaking more than one language of love could be nigh impossible if these worlds collide, do you wonder whether sometime in the future, it may be possible to traverse these two worlds even if it remains hazardous and delicate? If this means agreeing to the pact that your parent’s proposed: ‘To never speak of this again,’ do you think that they and you could find some kind of unspoken understanding that, just as you will not speak of your love for women, that they will not push you towards heterosexual love? Jasmin, would you forgive me if these ideas seem impossible to you? Do they seem impossible, or do you think that there may be some virtue in considering them?

Warm regards,

Kay”

I met with Jasmin for three more sessions. She went back to work full-time, and she began to find ways to navigate ways of seeing her parents and her sister whilst remaining with her partner. Previously, her parents had refused to see her, and they had no contact for a year. When I called her recently to talk to her about publishing her letter, she was going through a tricky time after a whole year of doing very well. She is seeing a counsellor at her university.

Recent Developments

A recent development in my letter-writing has been my “four-letter-series" for young people, an idea invented from necessity when the mental health agency, which refers to me most of the young people with whom I work, recently had their funding reduced and consequently the entitlement of sessions was reduced from a possible five to eight to a maximum of four. As a way of reconciling this, I decided to shorten the sessions to 45 minutes and spend the fifteen minutes remaining crafting short counter-story letters.

Dear Lucy

Here is an example of a letter quartet which shows the development of the counter-story between sessions. The letters are to “Lucy,” a 14-year-old young woman. Here is what Lucy’s General Practitioner wrote on her referral from:

“Lucy presents with low mood and social anxiety worsening over the last few months. She would really benefit from some counselling.”

Again, I will let the letters speak for themselves and tell you the story of our four sessions. The letters are each written one week apart:

Letter after Session One

"Dear Lucy,

It was a real pleasure to meet you today! Here is the letter I promised. If there is anything that you think I have misunderstood or that I have missed out, would you please let me know when we meet? Would you also mind letting me know if there is anything in this letter which particularly interests you?

Lucy, we mostly talked about ‘the glass wall’ that seems to have appeared, separating you from others and the dreadful loneliness of life behind the wall. You told me how much you would like to be able to reach through the wall, and even that you might consider ‘letting people in more.’ As we talked, it was no surprise to me to find out that you have had your trust most hurtfully broken in the past, not only by other young people but by a teacher, an adult in authority, who should have known better. I suggested to you that just maybe the reason the wall suddenly appeared in high school might have been because your body remembered how badly and shockingly hurt you were in 5th form and leapt in to protect you with the wall. If this is indeed what has happened, then do you think that your body overdid it? In its attempts to protect you, has it left you out in the cold, and you have become a little rusty in the friendship-making department? Do you think that we might be able to teach your body that, slowly but surely it can allow you to risk getting a bit closer to people again?

At the same time as you have the gift of being able to enjoy your own company, do you think that you could give yourself permission to retreat into your own world whenever you need and want to?

As you taught me more about your experiences, it became apparent that you have learnt a great deal from these past hurts. You have learnt to speak out and to stand up to authority. Would you say that the suffering has not all been in vain because by un-suffering yourself, you have learnt to look after yourself better?

Lucy, next time we meet, how about we start to talk about what it is that you would look for in a friend and then we can start ‘testing’ people around you (even if they are only people who would be lesser friends or acquaintances), to slowly find out if they are worthy of your time, attention, and friendship?

Warm regards,

Kay”

Letter after Session Two

“Hi Lucy,

Good to see you today. So, here is a little account of what we spoke about today and some questions that we might both like to think about.

We began our chat today by reading the letter that I wrote to you after our first session. You looked very thoughtful as you told me that you agreed that the ‘wall had come up when I went to high school because I was going through puberty, and it made me more self-conscious.’

Lucy, if self-consciousness has grown with puberty, do you think it might also be possible that you might be able to shrink it back down again as you mature more?

Do you think that the difference between now and when you were little might just be that when you were little you didn’t need to learn how to be un-self-conscious (or out-going), it just kind of happened, but now as a young person, you have to learn how to do it?

We talked a little about how you made and kept friendships before the wall went up. You told me about a whole group of friends. Melinda was the person that you felt closest to. When I asked you what it would be like if the wall isolated you from others for the rest of your life, you told me that it was if you were ‘in a bubble,’ and if you remained in the bubble you would become ‘a hermit.’ You admitted that you really don’t want this life for yourself and if you did, you wouldn’t have come for counselling. Then, you told me something I found very interesting. You likened your friendships to an egg, telling me that ‘I only need one yolk and the others are acquaintances — they are

When the Therapist Turns Out to be Human

Posted on October 24, 2023February 11, 2026 by Psychotherapy.net Team

A Therapist Looks Inward

This year has been one that has proven challenging career-wise and personally. While these challenges have offered opportunities for growth, reflection, and introspective experiences, they have arrived at a point in my career as a therapist I had never anticipated. This has been the place where I have questioned my professional identity to the point that it affected my competence and well-being.

A large part of my therapeutic identity resides at the intersection of my race and gender. With much pride, I relish identifying as a Black female therapist because it gives me a unique lens of empathy, therapeutic alliance, co-regulation, and strength in my approach to psychotherapy. So, when that identity became weaponized against me in the therapy room, I wondered how that would influence my trajectory as that Black female therapist providing mental health services to clients of intersectional identities.

If They Knew I Was Black Beforehand, Would They Want Me as their Therapist?

Racial encounter experiences with clients often stick out in my mind and linger, leading me to wonder how many uncomfortable clinical experiences fellow Black female therapists have had like mine. Having a name that one may consider “white-passing” with a “different accent,” I often found my racial and ethnic identity a point of curiosity for new clients, particularly White clients. A few showed overt shock on their faces when they saw I was Black. Over a period, however, I have arrived at the more useful question, “If they knew I was Black beforehand, would they still have moved forward with having me as their therapist?”

A supervisor at that time called on me and a colleague with whom I had recently seen a new family for an initial co-therapy session. She told us that the parent of the identified child client expressed her desire to change therapists along with accompanying discomfort — without apparent or stated reason. My supervisor immediately expressed support for us knowing that race had to do with the parent’s choice. The atmosphere of the room was filled with laughter to “ease” the intensity of the discussion; however, at the same time, that faux lightness felt belittling to me and my own personal and professional struggles as a Black woman.

Following that early encounter with the parent of the “distressed” child, many similar experiences have occurred. These included clients requesting to change therapists due to me being “direct,” “challenging,” “a woman,” and many other reasons that had racial overtones which could easily be missed due to the ease with which these issues could be missed.

These common microaggressions directed at me as the therapist can and often have been difficult for me, as I suspect they can be for fellow clinicians in similar circumstances. I have always considered my primary role to be one of providing a brave space for clients to work towards a better and more improved mental health trajectory — while considering, when necessary, our racial differences.

I recall a former White client whom I had been seeing for a year expressing to me her desire to change therapists because my accent was not “American enough” for her. This came after a year into our work, which I thought was going well. I quickly — perhaps too much so — expressed that while I was American-born, I had not been raised in the US.

I wondered what being American enough really meant, knowing once again I was experiencing racial discrimination and prejudice. Experiences like these have often traveled alongside me. These particular clients are blind spots, as I attempt to re-focus, or perhaps shift the focus to the basic, familiar, and comfortable principles of therapy, at the clinical expense of dealing with the racial issues head-on, in –the moment.

The Importance of Community for Black Female Therapists

My road to growth, acceptance of vulnerability, and wisdom as a mental health professional has been paved by the nurturing, direct, and protective guidance of other Black women. Through their lessons and guidance, I have come to appreciate the importance of community for Black female therapists.

When I think of community, I think of phrases like safety, transparency, guidance, mutuality of goals, productivity, culture, support, open-mindedness, and encouragement. If any of these notions are also useful to other Black female therapists, then more communities need to be established for therapists with marginalized intersectional identities.

Psychologist Ariane Thomas has highlighted the importance of community for her professional growth as a private practitioner and educator. She stated, “My career started with Black women taking care of me and mentoring me into the roles that would distinguish my career as a private practitioner and educator. Two incredibly important Black women ushered and mentored me into those roles, and I will be forever grateful to them both. I have found that in both roles, I've come to the point in my career when I'm able to pay it forward. I take great pride in my ability to support and mentor young Black women entering the field both as an educator and as a clinician.”

Thomas expressed the importance of paying it forward for other generations of therapists like me and Aisha Popoola, who shared her views with me on the pressure on Black female therapists to present as role models. She said, “Being a minority in the field, I often feel the pressure to serve as a role model for aspiring Black mental health professionals, and I also want to be the best at my job in order to prove my competence as a therapist.”

The complexity of how Black female therapists show up in the therapy room is further proof of the importance of community for Black female clinicians. Having this sense of community as a clinician is particularly important in validating the core shared, and often very challenging, experience of navigating the professional demands of the work world.

Clinician and now clinical educator, Laura Dupiton, has often raised awareness of the impact of professional growth not taught in graduate school. She said, “none of my diversity courses gave me a blueprint for holding space for someone who questioned my humanity. Learning how to hold space and boundaries that protected my personhood was pivotal to my work.”

My Boundaries Come First

Author therapist Nedra Tawab described boundaries as “expectations and needs that help you stay mentally and emotionally well.” Establishing professional boundaries as a therapist is hard enough, let alone as a Black female therapist. I have often been faced with personal and societal expectations to be cooperative, pleasant, and easily available to my clients. However, when my boundaries have been violated, and I have asserted their importance by setting limits with clients around what I will and will not accept, strong, and often negative reactions ensue.

Such was the case with a recent therapeutic encounter I had with a White client that centered around microaggression. When setting the boundaries and expressing expectations that my client respects my racial identity by bringing awareness to the insensitive and prejudiced remarks she made, I was initially met with resistance and the expectation to appease her. I felt it necessary in that moment to provide unsolicited, and more than likely unwanted racial psychoeducation.

Laura Dupiton referenced the stereotype of “The Mammy Myth,” which portrays the Black woman as subservient and happy to first meet the needs of her superiors. Laura stated, “As a supervisor and professor, being in a position of power challenged me in new ways. I was surprised to be met with entitlement, an expectation for me to be lenient and nurturing despite unethical behavior or not meeting basic expectations. I was expected to play the role and stereotype of the Mammy. This process unlocked more of a need for me to create new boundaries and expectations for myself as a leader.”

The importance of setting a tone from the beginning of treatment as well as in work environments is expected for the Black female professional. Clinician Aisha Popoola explains, “I have learned that from the outset that setting clear and transparent boundaries with clients regarding session times, communication channels, and the scope of therapeutic involvement is always helpful. And consistently upholding these boundaries can help maintain a professional and structured therapeutic relationship.” With such stereotypes as the Mammy Myth, setting boundaries has often proven to be difficult in my experiences as a Black female therapist

The Power of Genuine and Affirming Intersectional Identities

When I asked how each of these women would describe their Black woman experience as therapists, I was met with colorful descriptions, such as a learning experience that comes with navigating stereotypes and biases, microaggressions and racial stress, trust and rapport, representation, and role modeling, and balancing professional and personal identities. Other descriptions have included “paradoxically sacred, powerful, heartbreaking, and terrifying,” and “a charmed experience that is different now than it was then.”

In my experience, some factors that contribute to this “paradoxically sacred, powerful and terrifying” experience, come from the interactions that occur between intersectional identities of me, the therapist, and those of my clients. A complicated example would be a BIPOC cis female, disabled, Christian therapist from a high socio-economic background, working with a White, non-binary, Seventh-day Adventist client from a low socio-economic background.

Ariane Thomas shares the power of genuine and affirming encounters of intersectional identities in the therapy room as she stated, “I think race, gender, and all our intersectional identities if incorporated genuinely and with affirmation into our work, can only enhance the relationships we have with clients. It is also essential that we work to find power within all their identities. I cannot imagine expecting a client to bring about change in their lives if I believe their race and gender render them basically powerless”.

She further states, “What has surprised me most that I was not taught, but that I now teach, is that in the process of engaging with a client in a way that celebrates and affirms all the identities we bring to a relationship, I learn and grow as well. I believe that in the protected space we create in a therapeutic relationship, it is important to value those aspects of our identities as strengths and sources of power”.

What Thomas highlights here is the need to recognize humanity even in professional relationships like that between the therapist and client. It is important that Black female therapists as well as others with intersectional identities be given the same respect as that which is afforded their clients. I have personally experienced collective growth between my clients and me in the therapy room which has led to a stronger therapeutic alliance and productive clinical work.

A Most Challenging Clinical Experience

More recently, I suffered from a therapeutic experience I believe to be common among the Black woman’s struggles at work and in career-driven environments: downplaying her value to make others comfortable, proving her competence and ability to navigate explicit racist or sexist encounters.

Following this experience, I began struggling with self-doubt, motivation, imposter syndrome, and my commitment to being the best culturally sensitive and competent therapist I could be. I quickly realized that well beyond being a clinician, I was human, which led me down the path of exploring how race, racism, and discrimination happen to the therapist in the therapy room. Through that experience and that of other respected Black female therapists, I examined the importance of community, boundaries, and the impact genuine and affirming intersectional identities play in the Black female therapist’s experience.

As I sat during my session with my long-term client with whom I had built a strong therapeutic alliance, I experienced a chilling feeling; one I liken to feeling “small.” I sat and listened as my client recounted the difficulties and challenges of being a White woman from a middle-class family with nothing more than an undergraduate degree. She made comparisons between herself and other White colleagues whom she described as more privileged; hence, why she was more deserving of financial and professional promotions than other colleagues, including the Black ones. Additionally, she expressed feeling tired of jobs that required her to serve racially marginalized communities and stated that she has given back as much as she could.

I sat in disbelief at what I was hearing, recounting the recent incidents I had with this client where my boundaries as a Black therapist were not respected. I noticed that it became difficult for me to engage in further conversation with this client about the presenting issues that brought her to therapy as my own ruminations and feelings of just experiencing racial prejudice and ignorance came to the surface. I thought it was fortunate for this client, with whom I had a longstanding relationship, to be able to raise this racially charged topic, and in doing so, bring to their awareness the bias and ignorance in their remarks. I soon learned that I was wrong!

I took what I thought was a golden opportunity with her to say, “I am currently struggling to be present in session with you as your therapist because I could not move past some of the offensive statements that were previously said about your Black colleagues. As a Black woman who happens to be your therapist, I must bring that up with you as it is currently clouding my judgment and making it difficult to be professional.” In all honesty, I felt small, shocked, hurt, and responsible for what was happening. While trying to hold my tears and hide my fear, my immediate thought was to put my client’s needs first despite her negative reaction to me pointing out what was going on.

This client went on to respond defensively and immediately dismissed and minimized my feelings as she expressed, not understanding why I would feel triggered by the statements she made about deserving more professional benefits than her Black co-workers. She consistently put the responsibility on me to explain to her why my feelings and experiences of her racial ignorance were valid. The more I felt spoken down to, the more fear I experienced. As I tried to make sense of the interaction while remaining professional, I began experiencing physical symptoms like a headache, tightness in my chest, chills, and stutters.

I expressed to her that I needed time to process what I was experiencing with her, as it would be unfair as her therapist to carry on our work in light of this therapeutic rupture. And this rupture, I believed, was directly due to her failure to recognize and take ownership for making remarks that were racially ignorant and biased — and that hurt me deeply. The conversation became slightly heated as she persistently asked me to tell her that she was not a racist and often made apparent attempts to induce guilt because I “[was] the ‘therapist’ in the situation.” I recall stating that despite being a therapist, I was also a human being with real marginalized experiences that often led me to feel unsafe, and that I was experiencing those feelings in session with her.

I had to make the difficult decision to terminate my relationship with her, but not before and without seeking comfort and encouragement from amazing Black female supervisors who validated my experiences of guilt, responsibility, emotional dysregulation, and anxiety.

Some other experiences I had following this incident were a lot of doubt in my competency as a professional, hyper vigilance with other White clients, low mood, lack of motivation to be diligent in my work, and struggles with controlling emotional responses. Overall, as difficult as this experience was, it led me to a reflective season that birthed “the human therapist.”

After much-needed supervision, time, and education, this client and I were able to mutually terminate our professional relationship. In addition, she seemed able, or at least willing, to take accountability, which highlighted the growth she experienced in our work. It helped teach me the importance of forgiveness — even during racial encounters — and reiterated that in therapy with her, it was not about being right or wrong, but on making intentional spaces to learn from one another to be better humans.

The Realm of Our Industry

Posted on July 6, 2023February 11, 2026 by Psychotherapy.net Team

“In the beginning, we were all psychotherapists. And it was good.”

—Bruce Minor, Minnesota Member of the MFT Community

THE TIME HAS COME to face our industry and sit with the ways the therapy system in which we work helps us, hurts us, and holds us to a standard impossible to meet. Throughout this book we have touched on many issues facing our work; now we are looking specifically at the system in which we work. No longer a collection of individual practitioners who see each other as fellow members of a therapeutic federation, our industry (therapy) has become compartmentalized, industrialized, and controlled by third-party payers.

As you begin this leg of the journey, we invite you to pause and reflect on the mentors and experiences who supported you on your quest to become a therapist. We welcome you to reflect on mentors of both the past and the present, as well as those with whom you had a challenging or even fraught relationship. Even those mentors and supervisors who we experience as awful can teach us valuable lessons (though that does not exonerate them).

When it comes to mentors and supervisors, we, the authors, have had the best and the worst. For this chapter, we reflect on some of the greats from our local MFT community: Anne Ramage, PsyD, LMFT, our graduate school professor who taught us so much more than we ever realized there was to know about Carl Whitaker; and the collective of marriage and family therapists who have sustained the Minnesota field for decades, some of whom also became our supervisors and mentors: Ginny D’Angelo, LICSW, LMFT, Bruce Minor, LMFT, Briar Miller, LMFT, and Michelle Libi, LMFT.

You blink and end your repose to find that you’re alone. It feels as if you have awoken from a dream. You rise from your resting spot and begin to walk down the winding path toward the sound of a river. As you walk, you notice the crunch of twigs underfoot and hear distant birds. Is one of them the red-winged blackbird? Neither your bird friend nor the forest yeti are anywhere in sight. Perhaps you dreamed them.

You look up at the branches of a nearby tree and notice a small silver shape clinging to a twig. Pausing, you raise up onto your tiptoes and realize that this is a cocoon, perhaps belonging to a butterfly or a moth. You gaze at the cocoon for a moment longer, noticing it shake as the small creature inside struggles with its transformation. Change is such hard work, you muse, and resume the hike. As you walk you notice that you have many aches in your body. How long were you sitting in meditation? You stretch your neck from side to side as you continue to make your way down the mountainside.

As you breathe in, the air is fragrant with the scent of dried leaves and warm earth. You wonder at the way the seasons seem to have shifted around you on your travels. As you look around the forest bordering either side of the path, you notice hints of yellow and orange in many of the leaves. The wind shifts, blowing the undersides of the leaves up, causing them to shift and sway. It reminds you of a distant memory, but as you grasp for it, the memory skitters out of reach.

The path winds down the slope, and you lean slightly backward against the tug of inertia and gravity. The sun’s rays are just the right amount of warmth, offering a radiating blanket of heat against the cooler air temperature. You look down and slightly to your left, and you see a ribbon of blue snaking through the undergrowth far below: a river. It looks like a nice place to pause and rest. You estimate that you have at least another mile to walk down the mountain before you reach the riverbank. You walk down toward it.

Therapy’s Big Brother

Once upon a time, as Bruce Minor reminds us, we were all just psychotherapists. In the very, very beginning of our industry, there were just small- to medium-sized collectives of human beings throughout the American and European continents — composed mostly of wealthy men and a few audacious women — gathering together in an attempt to suss out the nature of the human mind and heart. From these meetings, the field of psychoanalysis was born.

While these early theorists and practitioners engaged in practices that we would gasp at today — Freud psychoanalyzing his daughter, Jung sleeping with several of his patients who then became therapists-in-training — their mistakes became the foundations upon which rules like “no dual relationships” were based.

These early therapists did not have insurance agencies or managed care with which to deal. But they also tended to focus on treating the bourgeoisie — the European upper middle class who could afford to pay for things like this newfangled “talking cure,” thanks to their monopoly on industry. Neither Jung, Adler, nor Freud himself (founding psychoanalysts all) had to consider whether high-quality psychotherapy happens in increments of forty-five, sixty, or ninety minutes. We bring you this abbreviated history lesson to remind us all that our present constructs have not always existed. Not only have they not always existed, but they might not actually be the most effective structure for treatment.

When family therapy was new, co-therapy and one-way mirrors with reflection teams were the standard of the day. When Justine tells graduate students about these once-standard training practices, they are in awe. “But how did that get paid for?!” they exclaim. The short answer is that decades ago, universities, particularly public universities, had more money in the humanities and social science departments.

Insurance once reimbursed for far more therapeutic services than they do now. Then Justine will often go on to tell her students about sitting in her own graduate school classroom at Hazelden Graduate School of Addiction Studies (now Hazelden Betty Ford) and hearing her professors talk about the changing landscape of drug and alcohol treatment.

Structured limitations are necessary for high-quality therapy (recall the example of sandtray therapy and the need for a literal box within which to put the sand, from chapter 2). Certainly, the case could be made that American psychoanalysis and drug treatment of the 1970s and 1980s was in need of a bit more clinical oversight. But the evolution that followed brings us to a dystopian present where third-party payers like insurance companies are dictating the terms and conditions of treatment. They’re also dictating the amount of money that the clinician receives for the work they do based solely on their licensure, rather than on the type of work they’re doing. These payouts are often inadequate at best and paltry at worst. Because of variable reimbursement rates, the amount of time and effort needed to handle billing issues, and the hoops clinicians need to navigate to get even the small amount of money they’re paid, private-practice clinicians are increasingly opting out of the insurance model. This causes frustration for would-be clients, and for other clinicians.

Licensure Drama

Have you ever had an issue with another clinician and thought, “Well, that’s just because they’re a Ph.D.; doctorate school sucks all of the fun out of you”? Or perhaps you’ve thought, “They don’t teach master’s-level clinicians anything about diagnostics.” Third-party payers and clinicians determine their reimbursement or compensation rates based on a number of factors, including education. Hierarchical thinking dictates that the more education and experience a person has, the more they should be valued.

The main way that we express or show value is through monetary compensation. However, this very quickly leads to confusion and resentment when master’s-level clinicians and doctoral-level clinicians are working at the same practice or agency, and are performing, at least on paper, the same job functions. Disparate training and licensure requirements can lead to differences in case conceptualizations, standards of care, and clinical interventions.

Certainly, these varied perspectives can be helpful if discussed and processed through open and honest clinical dialogue. But who has time for that? We don’t say this to minimize or undermine the value of care coordination. The reality, though, is that third-party payers don’t reimburse for care coordination. Contemporary clinicians are lucky if they can connect for five or ten minutes via phone either just before the beginning (seven a.m.) or just after the end (seven p.m.) of their clinical day. Thus, it’s no surprise that confusion and even infighting across licenses and education levels abound.

Justine recalls a question from a student about this infighting: “But who is actually above the others? There has to be a hierarchy, right?” Justine responded that while it may feel as though there is a hierarchy, the reality is that we’re a community with a variety of skills. We don’t need to fight among ourselves. She said that just because someone with a doctorate has more education than someone with a master’s degree, that doesn’t make them better than or above the master’s-level clinician. This is a social construct that we get to question and challenge, because it no longer serves us.

The tangible difference between master’s-level and doctoral-level clinicians lies in the area of assessment. Folks who complete doctoral programs are schooled in the practice of psychological assessment and usually graduate with the third party-payer reimbursable skill of psychological assessment.

With gravity on your side, you make it to the bottom of the mountain faster than anticipated. The sound of the river rings in your ears as you push through the bracken toward the riverbank. The grass along the shore is a deep green and only slightly prickly as you kneel down and bend over the water, cupping your hands to take a long, cool drink. Once you have quenched your thirst, you sit back on your heels and stare out across the blue water, leaning into the rays of the sun at your back. You notice a butterfly flapping its wings and landing on a nearby flower.

App Therapy Is the New In-Home Therapy

Newly-minted therapy graduates find themselves staring down the gauntlet of the licensure process, which usually entails several examinations, hours of supervision, and even more hours of direct client care. Depending upon the state where you live and the license you’re pursuing, you may find it very difficult to get a job that pays you money while you acquire hours you can count toward licensure.

Over the past few decades, the entry-level job for graduates in this predicament was in-home family therapy. Often considered the grunt work of the therapy industry, in-home family therapy requires practitioners to work long hours and drive long distances for very minimal pay. In 2014, when Larisa was working as an in-home clinician, she didn’t even make minimum wage, so she worked another job part time as an after-hours crisis counselor.

Today’s graduates have a new, additional option: they can become app therapists. Similar to other gig jobs like Uber Eats and Lyft, clinicians who work for therapy apps such as BetterHelp, TalkSpace, and Larkr are either populated by associate-licensed or fully licensed clinicians, and they work entirely through their company’s telehealth app interface. They tend to have very large caseloads (pitched to them as a “great opportunity to get your licensure hours”), minimal time with an assigned clinical supervisor, and demanding clinical expectations. Most therapy app jobs market their services to prospective clients with the promise of a readily available therapist, translating to the expectation that the therapist is available to the client at least via chat through most hours of the day and night.

Larisa vividly recalls many of her lectures with Dr. Anne Ramage for a number of reasons, not the least of which is that Dr. Ramage is an excellent professor and an enigmatic speaker. Among all of Larisa’s memories of Dr. Ramage’s Carl Whitaker quotes and experiential roleplays, she recalls the professor advising time and again that “in-home jobs will be waiting for you as soon as you graduate. They’re tough. You need to be ready. But they’ll give you excellent experience in working with families.” Then Dr. Ramage discussed the MFT techniques from that particular lecture that might apply to in-home work, and she explained the basic safety strategies of which in-home clinicians needed to be aware.

When Larisa graduated, she did indeed take a job as an in-home family therapist. The night before her first day, she reviewed the strategies she had learned from Dr. Ramage:

1. Arrive five minutes early and look up the homes you’ll be visiting in advance so you can plan your parking strategy. Never schedule sessions late in the evening or after dark.

2. Be ready to set clear and consistent boundaries, and for those boundaries to be tested.

3. Pack a change of clothes and hand sanitizer.

4. Review your agency’s privacy policies.

5. When you enter someone’s home, assess for safety and your own exit strategy. Although it is rare that clients will ever mean you harm, things can and do get out of hand when you are in the family’s own space. You get to protect yourself first.

This survival guide doesn’t apply to folks who are working for therapy apps, but the need for both support and coping strategies is no less acute. If you’re working for a therapy app, we, the authors, offer you deep compassion and the following tips:

1. Plan an exit strategy. What does this mean? It means a human being can’t sustain years of work at the rate demanded by therapy apps. So, it’s essential for you to decide how long you can sustain working for a therapy app before you go the way of a younger Larisa and start losing your hair and developing insomnia.

2. Find a supervisor outside the therapy app. Yes, you will probably have to pay for this supervision, and that will likely cause financial stress. However, it is crucial for you to have a guide whose sole investment is in you and who exists outside the system in which you work, to help you regain perspective and hold boundaries around things like time management and availability.

3. Remember that any symptoms of burnout (i.e., signs of physical or emotional distress) you’re experiencing are likely the cause of moral injury — harm caused by the system in which you work — rather than any fault of your own (we’ll discuss these concepts in more detail in the next section of this chapter).

4. Manage your expectations for yourself. However, you envisioned your therapy experience, it likely did not involve a smartphone application called “Better-something.” You can’t do depth psychotherapy in this kind of context; what you can do is help your clients with basic coping strategies and compassionate presence — sometimes, but not all the time. You’re not required to have 24/7 availability, no matter what your company tells you. Not even standard laptops can run constantly forever; they need to rest and update.

5. Reach out to your community. When you work in an online environment, it can be difficult to get your emotional needs met. Please remember to engage with other living beings outside your work environment who understand some of what you’re going through and who can show up for you.

Burnout and Moral Injury

The Realm of Our Work has changed in ways that we never imagined over the course of the collective traumas of the 2020s. Suddenly the norm is to work in a virtual therapy room, and some clients expect to have regular access to their therapist via text messages and video chat services. This isn’t what we thought the field would look like.

When Justine imagined her future as a therapist, she saw herself engulfed in a scarf, with a teacup in hand, sitting across from her client in an overstuffed chair near a small fire in a fireplace, surrounded by books. She envisioned herself helping people and feeling filled up by the work, then returning home to a pleasant evening all to herself — overall a very calm and steady way of life.

This is not reality. For a time, she did have the tea and the overstuffed chair, but the rest of the fantasy was just that — a fantasy. Justine now works behind a computer and sits in a rolling chair; her view is full of microphones, a ring light, and multiple monitors. For her, the change in our industry has been the death of a dream. The death of any dream is an ambiguous loss that even therapists are not always good at recognizing and finding compassion and ritual to help them move through it.

Of course, parts of what Justine imagined the life of a therapist to be all those many years ago, before she ever entered the field, were simply inaccurate. Even before teletherapy and therapy apps took over the field, the life of a therapist was rarely calm and steady. It had moments and longer periods of such calm, but the nature of therapy is to work with volatile emotions. The emotional intensity inherent to the profession impacts even the most experienced and boundaried of therapists.

Larisa’s experience differed in that she had a logical view of what life in the field would be like. She felt like she had prepared herself emotionally for the trials of holding space for people and their emotions day in and day out. She believed that this preparation would act as a shield against any future catastrophe. The sadness came when she realized that no matter how prepared she had been, the situation was worse, and far more unpredictable, than she could have imagined. She was ready for the stresses of people’s everyday lives and even for their great despair and trauma, but she was unprepared for the collective trauma of our age stepping into the therapy room and into her own life. She was totally unprepared for how political leadership would fail her and everyone else in her country during this time of great collective need.

In her younger and more impressionable years, she believed that even though power is corrosive and toxic to politicians, when they were faced with clear and present disaster, they would channel their highest selves and work to help people. Now Larisa realizes that America’s representative government has devolved into rule by the wealthy elite who use their resources to buffer themselves from the pain and the needs of their constituents. Sometimes the despair she feels is crushing. Perhaps you can relate.

As we sit with the tragedies that have befallen our profession, it is no wonder that so many therapists struggle with burnout. Burnout can be defined from many perspectives. For the sake of brevity and clarity, we offer definitions of both individualized burnout and systemic burnout. Individualized burnout occurs when a person is so emotionally exhausted that they chronically struggle with depersonalization, which is emotional, physical, and cognitive numbness that makes the person unable to feel present in their own body or life.

Systemic burnout is also known as moral injury, which is when a person experiences symptoms through no fault of their own; rather, the symptoms result from harm caused by the system in which they work. Moral injury was first defined by psychiatrist Jonathan Shay as a “betrayal of what is right by someone who holds legitimate authority in a high stakes situation.” Wendy Dean, Simon Talbot, and Austin Dean expanded upon this definition when they argued for clinician burnout to be redefined as moral injury:

Moral injury occurs when we perpetrate, bear witness to, or fail to prevent an act that transgresses our deeply held moral beliefs. In the health care context, that deeply held moral belief is the oath each of us took when embarking on our paths as health care providers: Put the needs of patients first. That oath is the lynchpin [sic] of our working lives and our guiding principle when searching for the right course of action.

But as clinicians, we are increasingly forced to consider the demands of other stakeholders — the electronic medical record (EMR), the insurers, the hospital, the health care system, even our own financial security —before the needs of our patients. Every time we are forced to make a decision that contravenes our patients’ best interests, we feel a sting of moral injustice. Over time, these repetitive insults amass into moral injury.

The article quoted above speaks solely to the experience of medical doctors, but its implications are clear for the chronic systemic burnout faced by so many in helping professions, including (but not limited to) therapists, medical technicians, nurses, and case managers. Helping professionals are increasingly placed in a double bind; that is, they’re being placed in situations from which there is no escape, and they’re being asked to perform at least two mutually exclusive actions simultaneously. They’re being asked to care for clients but also to please many other stakeholders, all without the amount or quality of support that they need. Just like all double binds, this is an untenable situation that causes distress within the clinician.

We, the authors, appreciate the distinction between burnout and moral injury. The concept of moral injury takes the onus off the individual, because there’s not enough self-care in the world to account for a system that’s set up as a no-win situation. When larger systems talk about “burnout,” that terminology allows them to let themselves off the hook for the clinician’s pain. The system can then pass the problem back to the clinician as a personal failing, rather than a systemic one. The therapy field is currently crying out for systemic change. We cannot do everything and be everything to everyone. It is impossible, and it is destroying us.

The butterfly’s orange and black wings flutter back and forth as it buries its face in a Black-eyed Susan. You contemplate the effort that it took for this butterfly to metamorphose from a caterpillar. It went through a violent transformation in the cocoon to become this creature. It’s not a pretty process. The butterfly must flap and flap and flap its wings inside the cocoon to strengthen them. It can be a difficult struggle to watch, and an onlooker often wants to help the butterfly be free from its enclosure.

But if it’s released from the cocoon early, the butterfly won’t have the strength to fly and survive. It must struggle to become strong. As you stare at the butterfly, considering its beautiful wings, you start to breathe into your own bodily awareness. You notice the many places where you’re holding tension and feeling stiff and sore. Perhaps you have also been flapping your metaphorical wings, becoming something new.

Grieving Tools — The Pain Paradox

As you might remember from chapter 2, pain can be a pivotal part of the meaning-making process. When paired with reflection time, pain can help us learn about our core values and live a life in accordance with them.

Yet because we work in a field that values sacrifice and the pain that entails, therapists are also far more susceptible to what Freud would call the martyr complex, and what we refer to as hero/savior/sacrifice syndrome. The pain paradox explores the tension between pain as both catalyst for change and a state of prolonged suffering. Particularly in helping professions, suffering for our work is often framed as positive, meaningful, or altruistic. This harmful social construct can lead clinicians to stay in harmful jobs “for the sake of the clients” and sacrifice their own health in the process.

The pain paradox invites clinicians to question their social constructs around both pain and meaning-making. In the therapy room, the pain paradox is a tool that clinicians can use to help clients who are themselves engaging in harmful behaviors for the sake of “meaningful pain.” Let us explore how you can use the tool of the pain paradox as you navigate your personal struggles outside of session, and how to use this tool with clients inside the therapy space.

Client

Pain is not the enemy, nor is it to be avoided at all costs. Sometimes what brings clients to therapy is the erroneous idea that we, their therapist, can help them learn how to disengage with their feelings entirely because these feelings are causing them pain. Of course, the reality is that we can teach them distress tolerance skills to be present with their pain and their feelings so they can learn to listen to the important messages carried by their feelings.

However, clients can sometimes mistake pain for purpose. We see this frequently with our creative clients. So often the idea of the “crazy artist” takes hold of clients. Several of Justine’s clients were terrified of feeling better. They believed that their sickness and the distress it caused fueled their art. But the reality was that after going through treatment, these clients were all able to continue making amazing art, and in fact they did so with more frequency and focus. Another part of the process of working with these folks is helping them see that they’re full human beings who are more than just the art they craft.

Many fear that if they lose the art then they lose themselves and they no longer matter. However, in our experience, part of their healing journey entails exploring areas of their life outside of art. Eventually, they come to see their art as but an aspect or a planet within the vast cosmos of their lives.

Therapist

For many of us, the desire to make meaning from our own pain drew us to the field of psychotherapy. Most therapists have experienced some type of mental distress, whether it’s childhood trauma, an eating disorder, bullying, discrimination, or an abusive relationship with chemicals. For many of us, surviving this kind of pain was only the first phase of the healing process, with the second phase being meaning-making.

The pain paradox is a gentle invitation for therapists to carefully consider ways to cultivate meaning and joy outside the therapy field. Although our work as therapists is absolutely meaningful, it is also back-breakingly painful at times. If you don’t have other avenues or ways to make meaning and find purpose, you’ll find it even more challenging to take breaks from the field, regardless of how long such a break lasts, because you struggle to see the “you” outside the office. You need not try something life altering or huge. When Larisa was recovering from a severe case of moral injury, she began making playlists, an activity she had not engaged in since her college days. This small daily activity helped her to begin to reconnect with playful and creative energies outside her clinical and professional work.

The difficult message that Justine received was that her time as a direct-care therapist was coming to a close. After over a decade of work, and so many clients helped, she began to feel that her meaning-making was now to be found in the classroom, on the stage, and on the page. She experienced a great deal of pain as a therapist during the pandemic and the social justice uprising, but the pain invited her to consider where new meaning could form. The answer was that it was time to guide the next generation of clinicians and to hold the hands of those who are still in the trenches. As of this writing, Justine is currently working on the slow transition out of direct client care.

Due North: Self of the Therapist

One of the struggles inherent in walking the dialectic between the system and the individual is despair. In the case of moral injury, which is caused by a series of broken systems subjecting clinicians to harmful double binds, it can feel like there’s little or nothing for a therapist to do beyond retiring from the field. While this certainly is an option, we offer you another one: harm reduction and intentional activism.

As you may already know, the harm-reduction model of addiction recovery focuses on making small, actionable changes that mitigate abusing behaviors, rather than prescribing total sobriety. Our intention is to invite you as a clinician to assess the harm you’re currently facing in your career and how it’s affecting you. You can’t immediately change the systems in which you practice therapy, but you can make a concerted effort to mitigate the negative impact that these systems have upon you.

Some ways that you might limit the harm you experience include limiting the number of hours you work or the types of clients or clinical presentations with which you work. Perhaps you currently work in a place with an unreliable schedule, and that causes you distress; is it possible to have a more structured schedule? If you’re not being given time for breaks or lunch, is this a conversation you can have and a boundary you can set with your site supervisor? These can be small or large changes, but any change can go a long way to help mitigate the harm you’re experiencing.

Victor Yalom on Psychotherapy and the Pursuit of Mastery

Posted on October 5, 2022March 26, 2026 by rezendevknowfully.com

Keeping Current

Lawrence Rubin: Dr. Yalom, you are the founder of Psychotherapy.net so by definition, an entrepreneur. But as your Editor, I also know you to be a self-taught tinkerer, craftsman, and artist, as well as a practicing psychotherapist. While I’d like to touch on each of these facets in our conversation, please tell us first what are you working on now?

Victor Yalom: Well, I am always working on many things at the same time. I don't know if that's due to an inability to focus on one thing or just that I have multiple interests and duties running this small enterprise of Psychotherapy.net.

We're always thinking of ways to provide content in a form that is useful to therapists practicing in the field as well as adapting to current times

One of my focuses after 27 or so years of recording who I consider to be the greats in our field and making training videos, is finally stepping up to the plate and doing some recordings of my own work as a therapist. Just yesterday, I recorded a case consultation group that I led online. This should result in one or more online courses in which I will be teaching some core skills in therapy that I have learned from my mentors as well as from my clients. So, that's very exciting.

In addition, we at Psychotherapy.net are always scouting out and finding experts to be featured in videos. We have a new video coming out on Emotionally Focused Therapy and another on online crisis counseling. We're always thinking of ways to provide content in a form that is useful to therapists practicing in the field as well as adapting to current times. We realize that while people have grown accustomed to receiving video content in shorter bursts, we haven't quite reduced ours to the 15-second clips of TikTok. However, we are producing, for example, a shorter series called Mastery in Minutes that are up to 30 minutes long where we're trying to present core ideas or skills to therapists.

LR: Now that you’ve made this transition from interviewing experts in the psychotherapy field to being videotaped while you personally do psychotherapy, do you see yourself at this stage in your therapeutic career as an expert?

VY:

doubt and uncertainty are inherent in our work

I do feel that after practicing for almost 40 years now, I've acquired some valuable skills that I think are important to pass on that are not commonly being taught by others. It's an evolution because I think like most therapists, even experienced ones, that there's so much ambiguity in our work that a lot of the time I feel like, gee, I'm not sure what I’m doing. Would X or Y expert think that I’ve studied enough to be doing this? What will other colleagues think? How will the establishment of experts, or those who are practicing evidence-based techniques or teaching them in universities view this?

So, those are some of my doubts. But then the other side is that doubt and uncertainty are inherent in our work. I don't think it's a realistic or even desirable idea that we should reach a state of certainty about our work, but perhaps more comfort with our doubts and our questioning, and our realization that therapy is an ambiguous and creative enterprise.

LR: I hope that the younger therapists who read this interview will embrace this idea that certainty is elusive, and therapy works but sometimes for reasons that are simply outside of our understanding. I understand that you've also been doing work with foreign distributors so I'm wondering what that looks like and what are some of the challenges?

VY: To a great degree, we've been trying to take the valuable, rich library that we've created over the last 27 years and make it as widely available as possible. It started very slowly at first with VHS tapes and then DVDs, but once we got into streaming, it was a lot easier to get it out there widely and internationally.

a lot of businesses have pulled out from Russia, but it's not something I've struggled with too much because the therapists there want to learn

But obviously, not everyone speaks English, so we've partnered with some businesses and organizations overseas to translate our videos and make them available. We have distributors in China, Italy, Greece, Russia, and a couple other countries. Typically, they've simply translated our videos with subtitles, but the Russians have been dubbing them using voice actors as well and so it's pretty simple in that sense, but there are unique challenges.

Our Russian distributors, not surprisingly, are having incredible challenges given the war and the boycotts. We were speaking with them yesterday and they’re actually moving to Georgia, the country, not the state, and we're finding ways to advertise, get payments, have money transferred to Georgia, and then sent here. At least that's the plan.

And with that, there's the potential ethical concern. Obviously, a lot of businesses have pulled out from Russia, but it's not something I've struggled with too much because the therapists there want to learn. They’re certainly not responsible for Putin's madness and butchery. I feel pretty clear that if we can find a way to continue to offer our videos to Russian therapists, that's a good thing.

LR: That's interesting. I was going to ask you about possible ethical concerns and conflicts, but when you couch it in the context of therapists, whether in Russia or China still want to learn, you are providing a needed service. The therapeutic skills that these therapists will learn because of our association with them will help the citizens of these countries who have access to therapy. I don't know how widely accessible therapy is, however.

VY: Right. It reminds me several years ago, we had an inquiry from some Iranian therapists who wanted to publish our videos there. Let's just be upfront, in smaller countries like that, it’s not really about making significant profit. They’re relatively small markets. But it’s more just wanting what we’ve done to be viewed and used in training therapists. It turns out they were on the list of nations that the US does not look favorably upon. We finally figured out how to apply to the US State Department to get permission to have our videos translated and sold in Iran. But, after about a year and a half, we got a one-page letter that said, “Sorry, no!”

LR: It’s interesting with regard to Russia and Ukraine and the Middle East, that some of the contributors to our websites, some of the folks who write blogs and articles are doing so from those places about some of the challenges of delivering therapeutic services to people who are directly impacted by the war and related political tensions. So, I can see the benefit of partnerships with some of these entities. I also see the ethical concerns. Are there any other challenges when translating therapy into different languages considering that much that occurs in the therapy space is non-verbal?

VY:

in Russia, they're using voice actors to dub our videos, apparently because that's quite common there as well as in other countries

As I said, in Russia, they're using voice actors to dub our videos, apparently because that's quite common there as well as in other countries. I was concerned about that. It’s so important and that's one of the reasons I started producing videos in the first place—to capture the non-content information, like body language, facial expression, tone of voice, inflection, and all that. I was concerned that a lot might be lost or missed. However, they've assured me that their actors are capable to a remarkable degree of mirroring that of the recording. Since I don’t speak Russian, I’ve got to take their word for it that they’ve done a good job. But they typically offer both, the option to listen to the dubbed version and/or subtitles.

Well, if it's a good translation, then it should work and that's not my area of expertise but just a little example. I recall looking at one of the transcripts initially done in China many years ago be one of our distributors. They were translating some discussion with my former teacher and mentor, James Bugental, who was referring to growing up in the Great Depression and the ways that impacted him in terms of his attitude towards money. It was quite a traumatic thing for that generation.

I came across the transcript, and I don't recall how I did it, because I don't speak Chinese, but somehow I became aware that they referred to the Great Depression, the historical event, as major depression, the psychiatric diagnosis. So, you have to have good translators. Language is very nuanced.

With our Chinese distributor, they're used to presenting videos in more of a weekly webinar format, so they've taken our videos and chopped them up into 30-minute segments that they offer once a week. They’ve wanted to add some live Q&A to some of our videos. For example, we have a popular course with my father, Irvin Yalom, “The Art of Psychotherapy,” and I've done some live Q&A even though I’m not him. I know the content well, so I’ve been able to answer some questions from the Chinese students that hopefully helps make it more understandable to them.

How I Built This

LR: All meaningful ventures such as creating Psychotherapy.net have an origin story, so I think our readers would be interested to know yours.

VY:

I had the chance to study in-depth with James Bugental, who was a real master psychologist, psychotherapist, and teacher

After I completed my doctorate in psychology, I had the chance to study in-depth with James Bugental, who was a real master psychologist, psychotherapist, and teacher. I felt in many ways that my education or training as a psychotherapist really commenced with him. There was a group of us who learned from him in yearly five-day retreats, after which I formed a monthly consultation group with a smaller group. I call him a master because of his skill and dedication to the work and his thoughtfulness in teaching others.

As part of his work, he often demonstrated various aspects of psychotherapy, including doing demonstrations with us, either through role plays or with those of us who wished to be able to explore our own personal issues, particularly as they impacted our work as psychotherapists, which it always does, of course.

For several years, we kept saying “We needed to get this guy on tape” for the benefit of those around the world who haven’t had a chance to work with him personally. And at some point, I had the great realization that he wasn’t getting any younger. He was 80 years old, so a buddy and I recruited a couple of volunteer clients and secured the services of a videographer to record him doing two sessions with two clients.

Like many ventures, we didn’t really have a goal in mind at that early point

So, we created a videotape, VHS, which was an initial venture in crowdfunding. We actually snail mailed his mailing list of about 200 folks saying, “Would you be willing to purchase a copy of this videotape to help us in our production?” We raised a few thousand dollars, which got us maybe halfway there to the costs, chipped in some of our own money, and ended up producing a videotape.

Like many ventures, we didn’t really have a goal in mind at that early point. It was not my plan to start a business. I just wanted to make a tape and ended up going to the Evolution of Psychotherapy conference, getting a booth there selling some of these and some other videotapes. One thing led to another after that. But that’s the short version.

LR: If I were to magically transport myself to that Evolution of Psychotherapy conference and interview that guy in the corner with the booth and the VHS tapes and asked him, “Have any idea where this thing’s going?” or “Do you have your next master in mind?” what would he have said?

VY: It was very exciting because Jeff Zeig, who runs those conferences, was kind enough to send out a letter to other speakers telling them that Victor Yalom, the son of Irvin Yalom, was going to be selling some tapes, and if others had some to contact me. I ended up getting a small collection of videotapes, including some group tapes of my father, and pricing them much lower than they were otherwise available, at the price of a textbook or a professional book. Not some of the very high-cost textbooks that we see today.

There was tremendous demand and excitement, so I realized I was onto something. Now recall this was 1995, right at the birth of the internet, so if you were a professor or a therapist wanting to get or see therapy in action, it was very hard to do. There was no YouTube. There were no online courses. And the few videos that were out there were hard to track down.

I realized I had found an untapped need

At that point, I realized I had found an untapped need. I’m not a trained businessperson, but I did learn a bit over the years, like when folks are pitching business ideas now, one of the things they think about is what problem are they solving? In looking back, I was solving a problem that I had experienced in graduate school. Up to that time, I had hardly ever seen a therapist do therapy, and I thought, “This is crazy.” So, I clearly felt there was something there.

LR: So, an unintended pioneer in a market that didn’t yet exist. A venturer without capital. Aside from the technological savvy that you had to acquire along the way, were there any major obstacles in accessing the masters or getting people to sign on to this “little engine that could?”

VY:

What was more surprising was that clients were and still are willing to be on camera and reveal personal things about themselves

I think I’ve been pretty fortunate. Perhaps my enthusiasm has carried me quite a long way, and honestly, sharing the last name of my father certainly opened some doors for me. I can’t say that was a great benefit in what I was doing at the time, which was doing private practice. Certainly, name recognition is nice—and has some downsides as well—but nobody refers patients to you just because you have a famous last name. But in terms of getting legendary clinicians to return a phone call or be willing to trust themselves with me to make a recording of them, I’m sure that helped.

What was more surprising was that clients were and still are willing to be on camera and reveal personal things about themselves for the benefit of having the opportunity to get some free treatment by famous therapists, as well as contribute to the training of our field. Of course, not all clients are willing to do so, but every time we’ve wanted to produce a video, we’ve been able to find clients who are willing to bare their souls to a wider audience. I’m always grateful for that, and also feel protective of them in terms of wanting to carefully screen them to make sure that they are comfortable with the types of things that might come up and be willing to edit out material that just felt too sensitive, even if they were willing to share.

LR: That’s an interesting perspective because in Narrative Therapy, one of the goals is to help the client assert expertise over their own life, and one aspect of that expertise is giving clients the opportunity to teach other clients through written narratives or through videotaping.

I hadn’t thought until you just mentioned it how much value, over and above whatever benefits accrue to the audience of these videos, the clients might reap in being with a master, and how putting themselves out there might give them an opportunity to share in some way beyond the isolated room of therapy, and even truly benefit others who might be reluctant.

VY: I feel, although I don’t know this for a fact, that some of the clients with whom we’ve worked obtain a sense of advocacy from their participation, particularly when they are part of an underrepresented population, for example, a military veteran or an African American client. We recently published a video series on counseling African American men. You know because you were a part of that.

I strongly suspect that part of the clients’ motivation in that series was, “I can help normalize this therapy process for African American men who have certain struggles often related to racism, and I want to encourage others who may have similar struggles as me to get therapy and to train therapists in how to better work with this population.” So, I suspect there’s some sense of advocacy and caring that therapists get the best training possible to treat folks that are similar to them in whatever characteristics.

LR: Having well over 300 video titles, how has Psychotherapy.net kept pace with the expanding demographics that psychotherapists serve?

VY: Just to be clear, yes, we do have over 350 titles now, but we have not produced all of those ourselves—maybe a third of those. The rest we’ve found by going far and wide looking for videos that were out there but, in many cases, not widely available.

I made a conscious effort starting several years ago to produce videos with both therapists and clients of more diversity

One case always stands to mind. I made a video with Natalie Rogers, art therapist and daughter of Carl Rogers. At the end of the production, we were filming in her house, and she brought out a shoebox full of old VHS tapes and DVDs for me to look through. She entrusted me to take them home, and I reviewed them. Some were home recordings with poor video or audio quality. But I came across one excellent interview of him, professional quality, and finally tracked down that this was produced in Ireland by RTE, I believe it stands for Radio Television of Ireland. Lo and behold, they had the original master in the vault and managed to work out a deal so we could distribute it, so I recorded a new introduction with Natalie. That’s a little aside just to state that we haven’t produced all the videos we offer.

But we have a legacy of titles. And I realized some time ago that we were, not surprisingly, overrepresented with master therapists. Let’s take out the term master therapists, but with White male therapists and Caucasian clients. So I made a conscious effort starting several years ago to produce videos with both therapists and clients of more diversity. So, we’ve been doing that, but I have a lot of catch-up to do.

LR: In this era of YouTube and TikTok, the consuming public seems to crave products that pack their punch in shorter bursts. Do you see that as an obstacle to your goal at Psychotherapy.net of portraying therapists doing the real and often laborious work of therapy?

VY: It’s a balancing act, indeed. Several years ago, we did a focus group with some of our customers to try to better understand their needs, and that was certainly one of them. Therapists told us they may have a 30-minute gap in their schedule, or they may have a cancellation, and your typical videos of one or two hours in length, often showing full sessions of therapy, didn’t fit that particular need. So, we launched a collection of videos called “Mastery in Minutes” that are 30 minutes or less. They are at times new productions, at other times excerpts of our longer videos with some additional introduction or discussion.

So, we try to meet both needs. We do try to offer shorter videos, and our longer videos are broken up into chapters. We have some very long courses that might be 6 to 10 hours, but they’re broken up into shorter chapters.

One of our productions I'm most proud of, Emotionally Focused Therapy Step by Step, is the most ambitious project we’ve ever done

One of our productions I'm most proud of, Emotionally Focused Therapy Step by Step, is the most ambitious project we’ve ever done and frankly, I think that anyone has done. We filmed over 100 hours of EFT sessions with six couples and four different therapists over a year and a half, edited that down to about eight hours of sessions and a few hours of discussion and commentary. I have to give my wife, Marie-Hélène Yalom, our Senior Director of Strategy and Product Development, a lot of credit. While she’s not a therapist, she’s learned a lot about EFT and painstakingly edited this down with Rebecca Jorgensen, the main therapist featured in this project.

Obviously, we don’t expect someone to sit down and watch that all at once. So it’s broken down as the title implies, step by step, into many small skill sets, and EFT, for people who know, is broken down into steps and stages. So, you can watch our longer videos in shorter chunks and skip from chapter to chapter.

LR: It sounds like a real challenge to balance the demand to satisfy the customer but remain faithful to the practice of psychotherapy. From an insider’s perspective, I think you’ve done a nice job of that balance, but I’m a bit biased.

VY: Yeah, it’s a tension that exists in our field and in many aspects of society, people want short-term fixes, quick fixes. People want short-term therapy. Some therapists promise that. Some approaches promise that, but whether they’re able to fulfill that promise? That’s debatable. I think at times you can convey some powerful ideas in a short amount of time. But to master them, like anything, takes—

LR: Hours….

VY: Dedication. Practice. Maybe some luck, or the right circumstances with the right clients who are ready to make some changes. Other times it’s painstaking, and you may work with a client for years and not see a lot of changes but nonetheless, they may benefit greatly from having support.

LR: How have you evolved in your approach to interviewing the masters over the last several decades?

VY:

I’m able to be myself more and reveal more of myself in all aspects of my life. I believe that shows up in doing interviews

I think it parallels my development as a human being, which is not an unusual progression in that I feel more comfortable in my skin, have more confidence that I have something to offer, and have come to accept parts of myself that I felt uncomfortable with or ashamed of not as only part of who I am, but that I like and feel proud of. So, I’m able to be myself more and reveal more of myself in all aspects of my life. I believe that shows up in doing interviews. That hopefully shows up in how I do therapy, how I relate to my friends and loved ones.

Specifically, in interviews, I feel more confidence that I know a lot about therapy. I have to be a jack of all trades to know a little bit about different techniques and approaches as I’m producing videos of various types. I don’t have the academic background like you do, and don’t keep up as much with the research, but I feel I know enough to ask questions and engage in dialogues that I hope are informative to our viewers and entertaining to watch in the sense of seeing the discussions and the therapy sessions, which are typically featured in our videos as being alive and representing the best of humanity.

LR: One of the qualities of your interviewing style, which I assume filters into your therapeutic style as well, and perhaps into your personal style, is that you don’t seem afraid to ask hard questions. You’re clearly willing to put someone on the spot in search of the most real they will allow you to have access to.

And that, to me, suggests a certain degree of confidence, and also an unwillingness to accept what’s offered as expertise without proof of that expertise. So, that’s just sort of a side comment for those of who will venture into this interview, which will probably take more than five minutes to read. I think it’s as important to watch your style of interviewing these masters, and the way you hold them accountable for their presumed expertise, rather than just fawning over these masters.

The Art and Artistry of Psychotherapy

LR: Most of your audience “knows” you through the interviews you’ve done with master therapists and through the cartoons you create for the site, but they likely don’t know that you also work in paint, metal, and wood. I’m wondering how this continual drive to express your creativity has manifested in your own identity and practice as a therapist?

VY: Interestingly enough, I didn’t grow up doing things I considered artistic, certainly not in the visual arts. This all started at a workshop with my mentor, James Bugental. I have a hard time sitting still and listening, so I would draw. I was drawing little stick figure cartoons, one of which eventually evolved into a cartoon. It was a stick figure of a cactus laying on a sofa saying, “Well, I didn’t come from what you would call a touchy-feely family.”

My drawings were literally stick figures. And when I created the website, I had an idea to put a few cartoons up there, so I hired some people who knew how to draw and took these ideas and made cartoons out of them. And then at some point, an ex-girlfriend of mine said, “Well, you have a very primitive drawing style, you should draw them yourself.” So, I started drawing my own cartoons, and that led me to taking a painting class, and as you mentioned, I now do metal sculptures. But this all started maybe 20 years ago when I was about 40. So, I credit Psychotherapy.net with helping me to discover some activities that bring me a great deal of pleasure.

increasingly view therapy as a creative enterprise

In terms of your question about how that may impact my therapy or show up in my therapy, I increasingly view therapy as a creative enterprise. I grew up in an academic family. My parents are writers. I’m taking another little aside here, but I always had an interest in or fascination with the business world but was very much an outsider, and back then, you know, when I graduated from college, you couldn’t start a business as you can today. If you wanted to work in the business world, you worked in a Fortune 500 company. I tried and I was fired. I failed miserably.

And in the process of creating Psychotherapy.net, which was just a side hobby for many years while I was in full-time practice, I came to realize that building and growing a business is the ultimate creative enterprise. I had an idea to make a videotape, I took that idea and created something from it, and then that evolved to something else, which evolved into something else.

And now here, you and I are having this interview on a technology that didn’t exist when I started this, so getting finally to your question about psychotherapy; it’s an extremely creative enterprise, just like this conversation. A client comes in and says something and you react, you have internal reactions, and then somehow words come out of your mouth and you say something, and it goes from there.

You don’t know what’s going to happen with what you do with them and what’s going to happen with their life. You try to adapt what you do and what you say in a way that’s going to be helpful. Certainly, there are certain approaches that give you more structure or guidance, and those can be critiqued as overly manualized or cookie-cutter, but ultimately, in my opinion, if you’re going to do work that’s at all meaningful and helpful, you need to find a way to enter their world and to do so in a creative and imaginative way.

LR: And that goes back to what you were saying before in terms of your own personal evolution, becoming more comfortable with who you are in your own skin, warts and all. I think therapists are most effective when they are most genuine and when they’re most vulnerable, and they invite themselves into a co-creative experience with their client. That’s evident in watching you work, at least in the interviews.

You have taken what I consider a heroic step, as you recently transitioned from the man behind the camera to the man in front of it. You did part one of an experiential teletherapeutic interview with an Italian woman. I wonder what it took for you to put the director’s hat down and step in front of the camera and, in a sense, expose yourself to your audience in a new way?

VY: I feel very fortunate that I had a chance to study with quite talented therapists like James Bugental and, of course, learn a tremendous amount from my father, and then in the process of creating other videos work with and get to know Sue Johnson and Peter Levine and Otto Kernberg and Reid Wilson, and many others. Some I had more contact with and thus learned more from, and others less.

I feel reasonably confident that I have some things to offer myself and some important things I’ve learned that I don’t think are widely taught

And over the years, like I think any maturing therapist, I have been able to integrate and internalize that into my own style of working to the point where I feel reasonably confident that I have some things to offer myself and some important things I’ve learned that I don’t think are widely taught.

LR: Such as?

VY: Two things come to mind. From Bugental, some specific techniques to help clients more vibrantly explore their internal world, their subjective experience in an alive and present way versus just talking about themselves. In particular, he taught some specific techniques as well as an underlying philosophy, and numerous ways to deepen that exploration. He suggested that therapists often encounter what he referred to as resistance, which can be a confusing term. Another way of thinking of it is that we get stuck in our ways, whether you call them defense mechanisms or just modes of coping or ways of being.

As we know as therapists, it’s hard for clients to really change the way they adapt to situations even when they aren’t helpful. So, we can help clients explore themselves, but often they reach a wall or there are restrictions in their ability to explore freely, and those could be that they intellectualize, that they shut down, that they focus excessively on pleasing you and the people around them and have a hard time accessing their own experiences and needs. So, in the process of getting them to do this internal searching, as he called it, you hit these roadblocks. He taught ways to help identify and loosen up those roadblocks; that might be a way of putting it. So those are some things that he taught me that feel very vital and powerful, and I don’t think are widely known.

with the advent of online therapy, it's been much easier to make recordings of not just one session, but longer-term therapy

And my father writes a lot about working interpersonally in the here and now between client and therapist in a way that I haven’t seen discussed much in other forms of therapy. How do you use the here and now of the therapeutic relationship? How do you work with that in a way that’s beneficial to the client?

So those are a few ideas that I feel are important and I don’t see discussed or represented in most of the types of therapies that are generally taught. Now, there are exceptions to that, but I feel compelled to teach them. And I’ve been mulling over this for several years now. And finally, with the advent of online therapy, it's been much easier to make recordings of not just one session, but longer-term therapy. I’ve just completed the course of seeing a client for 18 sessions, which we recorded, and I’m at the beginning stages of producing a course that will include excerpts of these sessions, and hopefully of some other colleagues as well, to teach some of these ideas.

LR: You’ve mentioned James Bugental numerous times as being historically and personally influential in your own life’s work. So, I want to ask you, Victor Yalom—perhaps you haven’t thought in these terms before, but do you see yourself as an influencer?

VY:

I’m proud of what we’ve created with Psychotherapy.net, and I think we’ve done something useful and I’m certainly part of that

IOver the years running Psychotherapy.net, we’d get phone calls and emails, and sometimes when I’d answer the phone, I would get comments like, “Oh, I can’t believe I’m talking to Dr. Yalom,” and I always assumed they were confusing me with my father.

LR: would never do that. [Note: LR actually did this when first applying for the Editorship].

VY: And many times they were. But since you asked, I can’t resist responding from time to time to customer emails. I find it helpful to keep my finger on the pulse of what’s happening there. And occasionally I do get people who know me from the videos I’ve made. Our videos are widely used in universities in the US and around the world, so it’s fair to say that I’m proud of what we’ve created with Psychotherapy.net, and I think we’ve done something useful and I’m certainly part of that.

The Long View

LR: As someone who has had a front seat to the evolution of the field of psychotherapy over three decades, how do you think the field has changed on your watch? Or more specifically, what tensions in the field have you noticed?

VY: It’s really hard to say. I remember when I just started grad school, Nick Cummings, who started the California School of Professional Psychology, and hence the whole professional psychology school movement (we have an interview of him on our site), gave us a rousing lecture about how private practice is dead. This was in the late 80s, and that hasn’t come to pass.

In terms of approaches, CBT and other so-called evidence-based approaches are being taught much more widely. I have concerns about that. I think that yes, we want to do therapy that’s effective, and yet we seem to have traded on the idea that evidence-based treatment somehow defies this entire other line of valid research showing that the most important elements of change are the therapeutic relationship and client factors.

The research consistently shows that one approach is not better than another approach

The research consistently shows that one approach is not better than another approach. And that may be just a research limitation—there are so many complexities and variables involved. But it’s clearly easier to research treatment methods than relationship variables, and there’s more funding available to research certain types, so there may be more data showing that those approaches are effective, but that does not mean that other approaches are less effective.

So I don’t know what the answer is. I’m not involved in policy making or in formal training programs. But I am concerned about the narrowness or limitations that seem to be taught in many of the clinical graduate programs that students are being trained in.

There are obvious other big changes in the field, the most striking of which is the move to online therapy that accelerated with the onset of COVID. And that’s never going to go back to fully in-person, though it’ll be a hybrid model. I think in many ways, it’s a good thing. It’s going to increase accessibility. It’s going to increase availability.

I continue to do a group that moved online. While I was reluctant to do so initially, it allowed people who have moved or are on vacation or in another town to continue to be in the group. So, it’s better in that way, but you do lose the vitality of the in-person group experience.

We all know of these other changes, app-based therapy, chat therapy, different pricing models, etc. There are problems with many of them, the reimbursement rates for therapists are quite low. Does chat have a useful place in therapy? The good thing, I think, is that it’s loosened up this historic and restrictive idea that therapy should be once a week in the office for 50 minutes, which came out of the idea that people have to get in their cars every day and drive to the office. Well, you know, I was guilty of that as well, in having our staff work primarily in the office. Suddenly we realized, as with all our assumptions, that doesn’t need to be the case.

Therapy, like most every other business, has moved online and is doing just fine. So, in terms of therapy, what’s the best way to do it? Can it be fully online? Can you, when possible, combine online with in-person sessions? Should it be every week for 50 minutes? Should it be some more fluid model? I mean, for clients in crisis, why not meet for 90 minutes or two hours, and why not be able to have email or text during the week? Then you have to come up with different pricing models for reimbursement. But surely, we’re not going to go back to once a week in the office for 50 minutes, and I think that’s a good thing.

LR: Traditional models have to be challenged and evaluated on a regular basis, or else they just become vestigial.

As we near the end of our time together and this journey you’ve taken us on, I can’t help but to reflect on the passage of time since I was in graduate school and what I have witnessed. And maybe it’s just a function of my getting older, but are therapists getting younger? It seems that therapists are getting younger and younger each day.

VY: It’s incredible.

LR: They’re getting master’s degrees at 22 years old and within a year, and at the cost of sounding jaded and cynical, they have business cards advertising that they specialize in working with children, adults, and the elderly.

VY: I don’t know if people even have business cards anymore.

LR: Right. We have websites. It just seems that the entire field, both therapists and clients, if not society, is so much more restless, so much more impatient, and as you said before, hungry for quick change. Everybody’s an expert. There are a thousand books out there, 18 ways to this and 17 ways to that. How will Psychotherapy.net survive that seemingly insatiable hunger for more, faster, shorter, and sexier? What will be the secret to your survival?

VY:

as many of the masters die off or have died already, we try to find clinicians who are doing good work and try to capture that work on camera

I’m not worried about that. I think we just have to keep producing relevant, good content, and as many of the masters die off or have died already, we try to find clinicians who are doing good work and try to capture that work on camera. That’s what differentiates us from most of the competition out there.

Most of the online training seems to be done primarily by talking heads, lectures, webinars, and it just seems crazy to me that this is the way training has traditionally been done in our field, reading books, talking about therapy. In every other field, and I’ve said this over and over and over again, whether you’re a plumber, a dancer, a lawyer, or an architect, you learn by watching others do their work. I mean, you have to study and know the basics, but you learn by watching other masters doing their work, your bosses.

You’re in court. You’re in second seat in a trial, and then your bosses are watching you do the work and giving you feedback, giving you coaching. Hopefully, constructive feedback. So, that’s kind of the essence of what we do, which is to show excerpts of therapy in action and explain why we’re doing it. Now, certainly, we’ll adapt. We’d like to do some live events, live webinars, and do these interviews. I don’t know what we’ll be doing, exactly. People talk about gamification and interactive video. I haven’t seen much of that yet, at least in our field, that’s useful. So, I’m not worried about that.

I think the great thing about our field is that life experience helps

In terms of your thing about therapists getting younger, well, obviously, there’s partly a tongue-in-cheek thing going on there, because we’re getting older. I still have this little thing going back to Transactional Analysis, kind of a one-down stance where I still feel like I’m the kid in the room. I’m often surprised, I may be emailing people, I get on a Zoom call, and “Hey! You look so young.” I’m still kind of assuming that I’m going to be the youngest.

But I think the great thing about our field is that life experience helps. Yes, you’re more in touch with young students, or have been as a professor for many years, but it’s a great profession for people to go into as a second career. If you start doing this when you’re 30 or 40 or 50, what a gift that you know something about life, having worked in other fields, having children, having a family, having suffered losses that invariably occur. So, you do what you can with the resources you have, and hopefully those grow over time.

LR: Kicking and screaming in some cases. I think that’s it for me for now, Victor. Do you have any last thoughts or questions you want to ask me or reflections on how our time together went for you?

VY: It’s been a pleasure working with you over the last several years, Larry. In terms of this conversation, what I’ve tried to do is to respond in the moment to thoughts or feelings that come up as we’ve been talking.

I’ve done a number of these interviews, we’ve been on podcasts, and I just realized it’s easy to start telling the same stories over and over again. It’s an interesting phenomenon. And if you think about therapy, it’s easy for clients to do that. They tell a story about the losses they’ve had or the disappointments they’ve had, and it’s important for them to convey that to you. But as Frieda Reichmann has allegedly said, “Patients need an experience, not an explanation.”

It’s strange and honorable, and at times a captivating and rewarding profession to be able to sit with clients and enter their world

I don’t know if I’ve said anything new. Hopefully, I’ve conveyed some ideas that someone will find interesting. As I reflect on our conversation, the one thing that stands out is when you asked me about my own evolution and I talked about becoming more comfortable with myself and things that I was uncomfortable with, and I used the words “ashamed of.” That felt like one moment where I said something I don’t think I’ve said before.

I’m sure it’s true for all of us. We have things about ourselves that we don’t feel good about or feel ashamed of or feel vulnerable around. And it’s also true that those, in general, for me, are much more contained and more in the past, and I’m grateful for that.

As I say that, it makes me think about the work of a therapist and the work we do with clients to really cherish and embrace the idea that everyone has this unique world inside of them, and sometimes that world is extremely painful and chaotic. Sometimes that world is just chugging along and doing okay, and sometimes that world is expansive and exciting. It’s strange and honorable, and at times a captivating and rewarding profession to be able to sit with clients and enter their world and see what help we can be to them in navigating their life’s journey.

LR: From my perspective, and as I prepared for this interview, I was acutely aware that our relationships these past five years have evolved. And as I became more comfortable in my space in our relationship, I’ve come to feel more confident, not just in my role as Psychotherapy.net’s Editor, but also in my own skin. I think every good relationship, whether it’s therapeutic or not, is a growth opportunity, whether it’s inside of a therapy room or not.

And I wasn’t looking for this interview to be a growth opportunity per se. I wanted to offer you something interesting; how do I ask interesting questions when you’ve been asked so many similar questions before? There was a part of me that wanted to ask interesting enough questions to interest you, to please you. I wanted, and perhaps still do want, to be interesting, relevant. Perhaps even more so after having retired from the university. I wanted to honor what you’ve done, and I wanted to also provoke you when I could without unnecessarily doing so. I wanted to create, I guess, as in therapy, a safe space where sharing could happen.

This was different from some of the other interviews that I’ve seen conducted with you. I sensed an even greater level of vulnerability, especially in that comment you made about shame, and I was very impressed with your willingness to share that. So, before we sign up as the first two members of the mutual admiration society, I’ll say goodbye and thank you again for welcoming us into your space.

VY: Well, thank you very much, Larry. It’s been a wonderful and enriching conversation.

Will Your Treatment Plans Actually Survive a Doomsday Scenario?

Posted on August 5, 2022February 11, 2026 by Psychotherapy.net Team

As a practicing clinical supervisor, and when I have attempted to teach graduate counseling students the differences between the art and science of psychotherapy, I have been careful to flavor my guidance with what I hoped would be just the right amount of professional ethics. And sometimes for good luck, I would add a pinch of legal-speak. But what seems to have resounded most loudly from my lessons were those that were worst case scenario-infused examples of what to do in clinical work to avoid, or at least contend with what one of my supervisees called, “Dr. Rubin’s Doomsday Scenario.” And this particular form of supervision-by-terrorization centered around the simple question, “what if you had to defend your treatment plan and/or intervention on the stand to an overly aggressive plaintiff’s attorney whose aggrieved client claimed that your treatment had caused them harm?

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With the exception of those students/supervisees who were subsequently influenced to reconsider their professional trajectories, the rest learned the importance of justifying their treatment plan and techniques by locating their foundation in the quantitative research literature and/or the position statements/practice parameters/best practices guidelines of respectable and respected clinical organizations such as the American Psychological Association, American Counseling Association, National Association of Social Workers, American Association of Marriage and Family Therapy, American Academy of Child and Adolescent Psychiatry.

So, when I recently met with one of my clinical supervisees who had implemented what seemed to be a creative, and as he related, effective intervention around trauma in a therapy group, I asked him the simple question, “Where did this technique come from?” Quite pleased with himself and the apparent sweet fruits of his empathetic and creative labors, he couldn’t quite recall the source of the intervention. “I did my research….I found it somewhere online,” he said sheepishly, knowing from his experience with me, that such a response would likely be met with less than positivity, enthusiasm, and accolades for his clinical decision making.

“Somewhere online,” I mused inwardly. Oy! Where had my lessons gone? Had I failed him? Had he failed his clients? Would he fail on the stand if even one of the clients in that trauma group complained about his intervention or its unintended aftermath? So, I asked for more feedback to which he responded by saying that he had chosen the exercise for the group because after reviewing their clinical files and having worked with them both individually and in group, and due to their shared histories of trauma, the intervention made sense at that juncture. And because these clients had other group activities throughout the day that did not rely on creative/expressive media, he thought that inclusion of such would be particularly appealing to them and provide them with an alternative means of expressing their trauma-related feelings, memories, and somatic experiences. He added that he had tried using this exercise in the past but was not successful because those clients were far less open about their trauma and generally treatment resistant. Further, past therapy groups had not gelled as did the current one with which the intervention seemed so successful. He concluded his justification non-defensively by saying that group members responded very well to the exercise, seemed generally and genuinely grateful, were able to express their vulnerabilities, and had even highlighted each other's strengths during the debriefing.

Truth be told, I was pleased with what I heard. And I was quite proud with the way he had accumulated his “practice-based evidence” (as opposed to evidence-based practice), had taken the time to study the clients’ individual and collective histories, drew from his experience with each off them and as a cohort, and then tailor-made the intervention to their collective needs. And while that fictitious plaintiff’s attorney might have torn him to shreds on the stand, even if the counterargument was made that this was a well-researched, deliberated, and implemented intervention, he demonstrated a scientific and artistic approach to clinical service delivery. And isn’t that what we hope our interns and counseling students will be able to do some day?

***

I remember something David Nylund once said when presenting at the 2001 Pan-Pacific Brief Psychotherapy Conference in Japan. He mused, “I believe in evidence, but I am more interested in what constitutes evidence, and who gets to decide on what counts as evidence. Is it professionals, licensing boards, researchers, and journal editors? Or is it clients? If a young person can reclaim his life from ADHD, for example, and we create and circulate a therapeutic letter about his experience, I consider that just as compelling as a randomized clinical trial.”

Well, I don’t think that Nylund’s constructivist rejoinder would satisfy that attorney, but it works for me, as did the intervention and justification my intern demonstrated.

Whose Exposure Is It, Anyway?

Posted on May 12, 2022February 11, 2026 by Psychotherapy.net Team

My guess is that most therapists, even if neither trained in or actively practicing CBT, are familiar with the technique of Exposure with Response Prevention (ERP). Simply put, it is one in which the client, typically struggling with OCD, is systematically exposed to thoughts, objects, images, or situations that fuel their anxiety, which in turn triggers their obsessions and compulsions. As they are guided through the exposure scenarios, which can be imaginal, “real,” or more recently through the use of VR technology, they are provided with alternative skills for coping with and reducing the triggering anxiety. Over time, the anxiety diminishes, as do the obsessions and compulsions.

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I had been working for a relatively short time with my newest clinical supervisee, S, who shared a heartrending account of a childhood scarred by parental instability and early sexualization, profound feelings of vulnerability and insecurity, and his subsequent trajectory beginning in adolescence along a painful path of sexual compulsion and risk-taking behavior, including high-risk sexual hookups with strangers.

This was quite distressing to hear, considering that he was working in a treatment facility with highly disturbed clients, half of whom were referred for “mental health” issues and the other half for substance use disorders. Triggers abounded for this emerging clinician, who thankfully and much to his credit was simultaneously receiving counseling, attending Sex Addiction Anonymous (SAA), and supervision with me.

And then came C, an attractive, thirty-something, HIV-positive client with an early family history not very different from S’s, and who like him was a self-described “sex addict,” was involved in a BDSM relationship with someone considerably older, who worked in a sex shop much like the ones S historically frequented, and who also sought sexual hookups with strangers like he had (up until only recently).

While my primary obligation was to my supervisee, I was also technically accountable to his client. And in light of the similarity of their early adversities and subsequent behavior, I was compelled to carefully monitor what I considered to be the inevitable emergence of countertransference.

As a clinician, clinical educator, and supervisor, I am familiar with the many manifestations of countertransference, especially among freshly-minted therapists and those who may not yet have met, let alone confronted, their own demons. And I know that although clinicians sometimes benefit psychologically from their work with clients, there is a powerful edict in our field that says, “thou shall not use your clients for self-healing.” But it happens, and sometimes, as they say, the universe sends us the clients we need, although it remains important that the clinician not use or exploit the therapeutic relationship for their own psychological gain.

At the outset of his work with C, and much to his credit, S immediately recognized similarities between his and his client’s story and problematic behaviors. He knew that a minefield lay ahead, saying to me, “My mind was racing 100 miles per hour when he told me about his life.” C was the kind of person—young, attractive, needy—that he might have hooked up with on the outside, although he very quickly recognized that crossing this particular boundary would be career suicide and would leave everyone devastated in its wake. While he wasn’t concerned that he might cross that particular line, S was deeply concerned that his client would trigger him to act out in his own life, so had to be vigilant for feelings and thoughts that heightened his own anxiety and which were historically triggers for his compulsive use of pornography and search for hookups. I was very relieved that he had broached this difficult topic with his own therapist, was sharing it with me in supervision, and had been attending a local SAA meeting.

Along this path of inquiry, I have conceptualized S’s treatment of C as his own, rather than his client’s exposure with response prevention (ERP). In this case, the ERP is not being used directly, or even consciously, in the service of the client’s sexual obsessions and compulsions as it might otherwise be, but instead as S’s own means of monitoring the triggers that the therapeutic work has evoked, and thus as a way to mitigate the impact of those triggers within himself so he is able to control his own sexual obsessions and compulsions. While I initially thought it might be more effective to keep this insight to myself, I decided that sharing it with S might aid the supervision, and in turn positively impact his therapeutic work with C.

And so, I inquired and learned that in addition to his own therapeutic and supervisory work, S was doing some powerful internal work when in the room with C. Like himself, C had survived, albeit scathed, from a traumatic earlier life and had stopped growing in early adolescence. It helped S to conceptualize him as a vulnerable teenager who needed a deeply supportive and empathetic clinician who could relate, although not project. Only in this way could he simultaneously help C to develop more mature, effective, and developmentally appropriate intrapsychic and behavioral coping skills for addressing his own intra and interpersonal challenges. My supervisee and his client, both wounded and fragile in their own right, are growing together.

***

As of this writing, I have yet to speak with S’s therapist and may or may not, but I am very appreciative to know that together they are discussing, among his other issues, countertransference matters and how they are factoring into his therapy with C. I felt and still do that it is my role to carefully explore the countertransference for the purpose of helping S recognize not only the triggers in the therapeutic work, but to become as aware as possible of the ways they impact not only that work but his own personal life.

Countertransference: How Are We Doing?

Posted on June 5, 2020February 11, 2026 by Psychotherapy.net Team

The subject of countertransference, or the sum total of our conscious and unconscious emotional responses to our clients, has fascinated me since I first learned about it in graduate school. Our instructors repeatedly emphasized the importance of self-care, but their focus was more on burnout and compassion fatigue than active engagement with our countertransference.

Most clinicians have some way that they unwind after a day of intense sessions. Perhaps they get some exercise, read a book, binge watch their favorite show, or spend time with loved ones. All these activities feel good, help us to rest and stay connected to our sense of peace or calm, and keep us stable enough to continue to do the hard work of being a therapist. For many practitioners, this will be enough to sustain them for many years in the field.

But how do we therapists continually manage our own emotional responses to the myriad of clients and stories we hear day in and day out? Should we have better systems in place specifically for the management of countertransference? “Traditional self-care activities, which are usually focused on relaxing, reducing stress, and increasing our joy, may be inadequate in and of themselves for managing countertransference”.

That we would have emotional responses at all to our clients is natural. Human beings are social and relational animals, and when we work in such proximity to one another, dealing with such intensely personal subject matter, countertransference is inevitable. These responses in clinicians can be constructive when they are recognized and contextualized, but they can become obstacles to good treatment when they are ignored, devalued, or isolated in our psyches. Countertransference has valuable lessons to teach us if we pay attention. The question is… are we?

Unrecognized Countertransference

Unrecognized countertransference may not be just a barrier to doing great clinical work; perhaps it is the barrier. I should ask myself: Who am I attending to? When I do or say anything in session, For whose benefit is it? I have found that when I can quickly answer, “For the client,” I am generally on the right track. If that answer comes more slowly or with more hesitation, it usually cues me to look inward at my own feelings and motivations.

We have all had clients who trigger an emotional response in us. If I am working with someone who is intimidating to me, I may be more hesitant to challenge that person or hold professional boundaries when appropriate. If I am working with someone who is experiencing something similar to what I have gone through, I may suggest that they do what I did, or do the thing that I failed to do. This is one of the most classic examples of countertransference, wherein I attempt to resolve conflicts in myself via my work with the client. In another example, when I am more interested in a particular aspect of the client’s story, I will probably focus on it more, and when I am less interested, that experience will receive less focus. In all these instances, the direction I take is informed by my own feelings rather than the client’s needs.

To use a real example from my own practice, some months back I found myself feeling impatient with one client in particular and was frustrated that he was not applying the skills and concepts we were practicing in session. I had a very difficult time getting him to engage with nearly anything I thought was indicated. He would almost exclusively recount stories in which he was the hero. In his narratives, he always did the right thing, made the hard choice, and overcame the villains. I was aware of my impatience and frustration, but at the time I still attributed my feelings to his lack of engagement and insecurity. In other words, with all my education, training and experience, I was inwardly blaming the client for my emotional state. “I began to dread sessions with him” and engaged in avoidant behaviors while working with him. I fell into a pattern of offering tepid, half-hearted validation instead of addressing his avoidance and hesitation. My approach served more to make the sessions bearable to me by reducing my frustration, and less to help him reduce his chronic PTSD symptoms. He didn’t seem to be making progress, so what did that say about me? Sound familiar?

Is Self-Care Enough?

At around this time, I attended a workshop on trauma treatment. I asked the facilitator how he stayed calm and well-adjusted while doing so much trauma work. He responded that positive self-care was critical to this process; he did not elaborate further. He clearly knew something, because he has been doing trauma treatment for decades. He was a wonderful clinician and trainer and I suspect that at that moment, he just did not want to get sidetracked on that issue. But I found the response for my own training and understanding to be inadequate. You might be surprised to hear how many times I have received this response from the numerous professionals I have asked. As clinicians, I think we need to have a collective strategy for countertransference, and one that has an active dialogue around it.

There are many skilled clinicians who specialize in working with countertransference issues; the problem for me is that they are not getting much notice or airtime in the profession. When I have spoken about this issue with colleagues, I have encountered a wide range of responses. Usually, what I find is that they have a basic familiarity with the concept of countertransference but no actual working tools for recognizing, addressing, and resolving it. We teach our clients that we are emotional beings, and that we are experiencing some level of affective response throughout the day. Is it possible that countertransference is taking place with our clients all or much of the time, whether we notice it or not? The critical aspect of this is how and when we begin to notice that it is occurring.

In Ernest Hemingway’s novel The Sun Also Rises, the character Mike Campbell is asked, “How did you go bankrupt?"

“Two ways,” he replies. “Gradually, and then suddenly.”

So, “it is in that way countertransference starts to impair our clinical work: gradually, and then suddenly”. Like any problem, it is always best to catch it early, when it is a small and manageable issue.

The Solution Must Be Social

Experienced clinicians can teach and model that self-care is not the miracle cure that will resolve countertransference. Taking a bath or watching Netflix will not resolve countertransference, because these activities do not address some of the underlying mechanisms through which it takes place. Stress and fatigue are important factors, but they are not always the principal engines that drive our experience of countertransference. It arises from a very complex set of interpersonal and neurobiological factors. As such, simply relaxing more often or more effectively is not always an appropriate solution by itself. A close friend and colleague of mine once said to me that “social problems require social solutions.” Much of my self-care is not sufficiently social in nature; being in such a social job, my reset button often involves solitary pursuits like playing music, writing, and woodworking — all things that I do by myself. Perhaps a social phenomenon like countertransference can only be resolved in a social situation. We need other people to help us get through it.

Given the appropriate limitations of confidentiality in our profession, this leaves the earnest clinician with a few viable options. Much has been written about the benefits of social relationships, personal therapy, supervision, and consultation, and I agree with many of these points. All of these provide a social experience to solve a social problem. There are, however, some limitations to regular socializing, supervision, and therapy for resolving countertransference.

Social Relationships

Our social relationships with friends and family should provide us with outlets to find support, reduce our stress, and feel a sense of community. Sometimes our friends and family are not as equipped to hold the enormity of what we might have to share. Therapists tend to develop a fairly thick skin for hearing about truly awful human experiences. It is not that we are numb to them, it is probably more the case that experience in the profession has allowed us to develop the proper cognitive and emotional mechanisms to deal with them on a daily basis — just as the trauma surgeon is not probably too distressed by what she sees on a regular day, but her neighbor might not be able to handle the details of what her job requires her to see and experience. This leaves us with the option to share some feelings, perhaps, but not the intimate aspects of our experience with our friends and families.

Supervision

A supervisory relationship offers support, is social in nature, and is often accepted as the place for clinicians to deal with countertransference. Numerous therapists receive effective support and leadership from very capable and experienced supervisors. For everyone to work through countertransference in this way presumes every therapist’s having access to a very competent supervisor. For my colleagues who place their trust in statistics, an analysis of any bell curve should suggest that supervisor competency follows the same statistical rules as nearly anything else in the natural world. There will be exceptional supervisors who can hold and handle anything, and there will be supervisors who are not equipped for the challenge of addressing therapist countertransference effectively. In many situations, the supervisee often does not feel free to authentically share an experience of countertransference, and for good reason: it could easily be perceived as a limitation, and therefore hinder advancement opportunities. It can result in very real consequences.

Imagine a supervisee reporting experiencing a romantic attraction to the client. The supervisee finds her or himself trying to impress the client, or to be seen as funny. He or she notices that being liked has suddenly become a distraction and wants to work through this. In clinical work, scenarios like these happen from time to time. In the best-case scenario, the supervisor would help the supervisee address this countertransference, work through it, and hopefully resolve it. It is possible that they would agree that referring the client out to another therapist is necessary; it is also possible that they would not come to this conclusion, if the supervisee can effectively work through their emotional responses to the client. But what if the supervisor is incredibly stressed out because his agency is currently being sued for malpractice? What if the supervisor is dealing with the same issue with one of her clients? What if her name is on the building? A supervisor, by definition, is in a position of power which is greater relative to that of the supervisee. It is not hard to imagine scenarios where a supervisee could be negatively affected by sincerely trying to seek out help in resolving countertransference, which is an ethical thing to do.

There is a time in most clinicians’ development where supervision often sounds like, “Have you tried this intervention? Have you tried that technique?” As clinicians progress in their skill development, if and when they get stuck, supervisors can assume that they have tried their usual go-to stock of interventions and tools. While training therapists in new techniques and interventions has a large role to play, they may also search for emotional barriers in their supervisees to carrying out good clinical work. The Discrimination Model of supervision in particular allows that sometimes, the supervisor will act as your counselor in the process. As stated above, many experienced and skilled supervisors can expertly help their supervisees navigate countertransference issues. The problem is that supervisees will not know who can and cannot do this until they have truly put ourselves out there. “Revealing our struggles with countertransference can be a deeply vulnerable experience”. It must be held in a safe and supportive environment. While supervision is enormously helpful, it has limitations for addressing countertransference. I write this as a supervisor myself, and someone who has had some truly phenomenal supervisors.

Personal Therapy

Doing our own personal therapy will certainly help us recognize our patterns of relating and certain triggers that may set us off. It is invaluable for our overall health and well-being. It seems fair to say that anything I do in my own personal therapy is about me, and therefore when I bring things from that personal therapy into my working sessions with clients, I will at least sometimes be dealing with my own issues. This is not black and white; some countertransference is diagnostic in the sense that I may infer that if I feel a certain way around the client, then others likely feel the same. From there, I can make educated guesses about the client’s social world and ways of relating. I may gather additional psychosocial information based on this. And then there is the kind of countertransference that has little or nothing to do with the client but is based on my own history and experiences. In short, just because I am frustrated in session with a client does not mean that everyone gets frustrated when interacting with this person. It is critical that we are able to separate these two ideas.

A psychologist whom I greatly admire once told me that he works through countertransference in his own personal therapy. While I do not begrudge him that preference and have done so myself, there is potential for us to muddy the personal and professional waters there. I may end up setting goals in my own personal therapy, such as being more assertive or holding better boundaries, and I may then bring those ideas into the professional session with my clients. These are fine things to work on and have obvious application in therapy. But there will be times when those pursuits have absolutely nothing to do with my clients. I will refer to earlier questions I asked in this article: Who am I attending to? For whose benefit is this? In my previous example about the client who only wanted to tell stories that bolstered his sense of personal power, suppose my well-meaning therapist encourages me to name this behavior and challenge it, even if gently. Perhaps I will return and in the next session challenge the client on his avoidance. In response, he stops showing up to sessions with me. On one hand, I overcame my own hesitance and mustered the courage to challenge him. On the other hand, a traumatized client who was in therapy is now not in therapy. Have I, in a stroke of clinical genius, revealed the client’s lack of readiness for treatment? Is it possible that if I were simply more patient, this client would come around in time, even absent any challenge or confrontation from me?

Consultation

Consultation, in my opinion, holds more promise than supervision or personal therapy for addressing countertransference, for several reasons. These groups can be set up so there are not marked power differentials. Given the reduction in power dynamics in a consultation group, it follows that each attendee incurs less risk by sharing authentically. In addition, the group’s diversity of experience, perspectives and opinions can offer any therapist increased response flexibility for countertransference when compared with the judgement of almost any lone supervisor or therapist. A consultation group of peers can be more objective, explorative, and therefore helpful, given that they also do not incur any personal risk based on what they hear. I should note the exception, of course, is when unethical or negligent behaviors are revealed in a consultation group. Then the members of that group will need to decide if they should report that behavior to their state licensing board, just as a supervisor or therapist might.

Returning to the example discussed earlier, simply experiencing a romantic attraction to a client is not in and of itself unethical. Whereas a lone supervisor with a large personal stake in the clinician’s performance may have a disproportionate reaction to that, a consultation group made up of peers is less likely to have the same response. They are more likely to consider the times they may have experienced this and what might have been helpful to them at the time. “The consultation group format also provides a social solution to the social problem”.

As part of this exploration, some colleagues of mine formed a consultation group that was focused on countertransference. I have found it enormously helpful to share my own internal conflicts in the profession with a group of trusted professionals. They help to normalize and contextualize my experience, while showing me where my blind spots are and where there is room for growth and development. Because these clinicians are not signing my paychecks, I feel a certain freedom to share openly. And in doing so, I have found that countertransference really can be addressed, processed, and resolved.

Regarding the client I was working with, the consultation group helped me to recognize that my impatience had more to do with my own desire to be competent and achieve some specific result. I needed to solve the client’s problem to end my frustration and thereby feel effective. How much more cliché could I get? My peers helped me to see that this client has lacked safety most of his life. As a result, he has crafted an internal narrative where he occupies a position of power and influence. I can reduce my frustration outside of session and work to increase my sense of competence on my own time. I now have more confidence that I can thread the needle by being patient and allowing him to establish safety and comfort with me, while also moving in the direction of gently prompting him to engage more with working to reduce his symptoms. My personal feelings are not all tied up in this client’s progress now. I was lucky to have a community of knowledgeable and supportive clinicians with whom I could consult. These friends and colleagues were able to create a helpful container in which I could safely discuss this issue and ultimately resolve it.

Flexibility is Key

Examining our own countertransference regularly and often is an important part of being an effective clinician.

I wholeheartedly believe that self-care is a critical aspect in maintaining one’s own wellness and longevity in the profession. We all encourage our clients to reduce their stress and to engage in hobbies and activities that bring them peace or joy, and we should absolutely walk the talk. When we are calm, healthy, and centered, we can do our very best work. As countertransference is a social and relational issue, the more solitary pursuits involved in self-care may not be of much help in recognizing and resolving it. This was true in my case.

“Friends and family can be an outlet for support, although we may feel limited in what we can share” by their lack of familiarity with the profession’s norms and difficulties. Capable and experienced supervisors can provide a wonderful space for working on countertransference. But there is usually a power differential, and with natural variability in supervisor’s competence, these factors can become limits. For those of us who examine countertransference in our personal therapy sessions, I hope we can recognize our patterns and responses, and apply those lessons to our work somewhat dispassionately. Otherwise we run the risk of inadvertently playing out our own therapeutic goals with our clients and will continue to experience unresolved countertransference. Consultation would seem to offer positive support in addressing countertransference, both in the variety of opinions that can be expressed and the potential for reducing or removing power differentials among the participants. I would recommend doing all the above. The important thing is that we keep looking at our countertransference and keep paying attention to what it is telling us.

What’s the Limit? Maintaining and Understanding Boundaries in Psychotherapy

Posted on September 23, 2019February 19, 2026 by Psychotherapy.net Team

Anita* was an experienced therapist who consulted with me about a client who consistently arrived late for sessions and refused to leave when his time was up. “I don’t usually have difficulties setting limits with clients,” she told me. “But I’ve tried everything with him, and nothing is working. In our last session, I told him that I was going to have to start charging him for the extra time. He just said, ‘okay.’ And he still didn’t leave.”

We all know that boundaries are extremely important in any psychotherapy relationship, but they are not always easy to define or to maintain. They’re also not always easy to identify.

Defining Boundaries in Psychotherapy

What is a boundary, in fact? I like what a group of physicians has said: “A boundary may be defined as the ‘edge of appropriate professional behavior, transgression of which involves the therapist stepping out of the clinical role or breaching the clinical role.” I also like what Gary and Joy Lundberg write in their book I Don’t Have to Make Everything All Better: In daily interactions with others, boundaries “are statements of what you will or won’t do, what you like and don’t like, how far you will or won’t go, how close someone can get to you or how close you will get to another person…they are your value system in action.”

These definitions apply to both therapists and clients, yet other factors also play important roles. For instance, how we set and maintain boundaries reflects not only our personal and professional values, but also respect for our clients and their boundary needs. Furthermore, boundaries reflect something important about our respect for ourselves.

In fact, this was one of the problems that Anita was struggling with. She wanted her client to respect her, and his behavior around the scheduling of sessions felt to her as though he was disrespecting her. She was having difficulties finding a way to maintain her boundaries, her self-respect, and his respect for her

Boundaries also reflect important information about a relationship between two people, whether the relationship is a personal one or a professional one. Boundaries can be ephemeral and often confusing, in part because they embody the often-unclear lines of connection and separation in a relationship. In psychotherapy, a significant amount of work is done within the relationship between therapist and client. Individuals have an opportunity to work on their relational difficulties. Boundaries, whether they have to do with office rules, payment, scheduling, electronic communication or a therapist’s personal life can become the medium for exploring, understanding and working on issues that emerge in a client’s life with others.

“Freud sometimes made house calls to do therapy with patients and often interacted with them socially”; such behavior is seen as boundary-crossing today. Yet the Internet has created dramatic changes in traditional boundaries. While some therapists refuse to communicate anything other than appointment times in electronic communication, many others conduct psychotherapy online and by telephone, even exploring the benefits of doing online psychotherapy with clients in their beds.

Boundaries Have Meaning

While both a therapist’s and a client’s boundaries need to be clarified and respected, a therapist’s curiosity about any boundary question that comes up for a client can be an important tool in the therapeutic process. In their Psychotherapy.net essay on doing therapy with clients in bed, Giré and Burgo tell us, “Therapists need to pay ongoing attention to boundaries and transference issues, of course; but if we’re mindful, we can also focus on the purpose and meaning of any boundary transgressions.”

For instance, over the years many clients have asked to hug me. Physical contact between therapist and client has long been an area of controversy, and, of course, a question of boundaries. Not only is it significant in terms of potential sexual coercion and assault, but it also raises important questions about both the therapist’s and the client’s comfort with non-sexual physical touch.

I am not a particularly physically demonstrative person and do not always find that kind of contact comfortable. Because I know that to cross my own boundary in those cases would be harmful to the therapeutic work, I have found ways to tactfully and gently refuse the request, often explaining that it is one of my own boundaries that I am careful not to override. Such an explanation often leads to a client’s apologies, and sometimes to a painful discussion of their fear that they are not only unlovable, but also so repulsive that no one would ever want to touch them.

In one instance, with a client who seemed to go out of his way to make himself as unattractive as possible, I asked if it was possible that he actually did not want to be touched. He seemed taken aback by my question, but then he began to wonder out loud. “I think I want to be touched,” he said. “It’s not that. But I think I’m afraid that I’m going to be rejected; so, I sort of set it up that I’m so disgusting that I know that it’s going to happen.” I replied that that made sense to me. I said that I thought he was trying to take control of something that he feared. “It’s better if it doesn’t come as a surprise,” he agreed. “Somehow it doesn’t hurt so much that way.” That client and I spent many years working together, and the process of trying to understand what might be going on with each of us, and within our relationship, helped us to understand some extremely important, complex and subtle aspects of many of his other relationships.

I have learned to share this information about myself with clients in a way that often leads to our finding other ways that they can feel soothed and comforted by me and close to me without touching. In many instances, the process of talking about our different needs has also opened areas in which they struggle with similar issues in their personal lives.

Role Modeling and Boundaries

How we look at and work with boundaries can also serve as a role model for clients, whether it is in the service of protecting their own or respecting the boundaries of others.

For example, there are times when I am comfortable hugging a client. I am not always sure exactly what makes me feel comfortable with the contact, but I have learned to respect my internal communications – the same way that I encourage clients to pay attention to their own wishes not to always do what someone else wants them to do.

Not too long ago, two separate clients who were struggling with painful realities in their lives brought up the issue of hugs. Both had been in therapy with me for some time. One shyly asked if it would be okay if she hugged me. The other told me that I was not to hug her and was not even to look at her sympathetically. In both cases, I agreed to the request. I also asked if we could talk about what their requests were about – what they were hoping for and what they were hoping to avoid. And finally, I asked if they could talk to me about their responses to my response.

I was willing to accept and respond to what they needed, but I also maintained my curiosity about what was going on beneath the surface – what either the hug or the restrictions meant in terms of the larger picture of their lives. In part I was able to provide this kind of approach because of my awareness and respect for my clients’ boundaries and for my own.

Exploring, Understanding and Maintaining Boundaries

To return to Anita: as we attempted to understand her client’s refusal to accept her boundaries, we began to see that the dynamic between them was complicated not only by each of their personal dynamics, but also by social and cultural factors. “I feel like he’s being sadistic,” she said. “By refusing to accept limits that I set, he’s setting up a ‘MeToo’ situation. He’s being an aggressive male and putting me in the position of being a compliant victim. And I refuse to be in that position.”

In his book Attachment in Psychotherapy, David Wallin explores some of the links between a client’s behavior, a clinician’s reactions, and unarticulated, often unknown attachment issues. Because I thought that her client’s behavior might be related to some unspoken, maybe inaccessible relational dynamics, I asked Anita if she could imagine talking about her dilemma with her client. At first she doubted that it would be useful. “Why would I make myself vulnerable in that way?” she asked.

I told her that I thought by sharing some of her dilemma, she might also be putting into words some feelings and relational issues that her client was enacting with her. I said that I thought he might even be relieved that she was able to articulate something that he felt but could not talk or even think about. I said that I also was hoping that by putting her dilemma into words, she would be altering the power struggle between them. She decided that there was really nothing to lose. “I’ve tried everything else I can come up with,” she said.

When he arrived late for his next appointment, Anita brought up the combination of his late arrival and refusal to leave on time. She said, “I’ve been thinking about what’s going on here, and, although I’m not sure you’re going to like them, I’d like to share my thoughts with you. Would that be okay with you?” He nodded, but she said he looked uncomfortable. She then told him what she had told me.

The client seemed deeply moved by her comments. After sitting quietly for a few minutes, he said, “”Wow. I’ve been feeling resentful that you have all the power in this relationship. And you’ve been feeling assaulted by me”. I think you might have just solved a puzzle I’ve been unable to solve for a long time. I haven’t even had a way to think about until now.”

He went on to explain that he often seemed to get into similar kinds of power struggles at work and in his personal relationships with women. “I’ve always felt like I was the one who was being forced to do things against my will,” he said slowly. “But maybe other people feel like you do—like I’m the one who’s pushing them around. That’s really weird. But it kind of explains why people get so mad at me when I’m feeling like I’m just trying to protect myself.”

This insight did not change the power struggle completely, nor did it magically shift the client’s difficulties with other people. In fact, they had to repeatedly revisit the same dynamics both in their relationship and as they discussed his interactions with other people in his life. The client began arriving closer to the proper time for his appointment, but he continued to have difficulty leaving. But now they were able to look at some of the reasons for both behaviors, not as a power struggle, but as an attempt to control both the connection to and the separation from his therapist. Exploration revealed that he found separation extremely painful, but that he was embarrassed to admit how much it hurt him to have to leave—or to be left by—someone he felt close to.

Theirs was a long and productive therapeutic relationship, and the early struggle over the end of sessions became an experience that the two of them referred to over and over again as a template for understanding what was going on when the client began testing boundaries and acting (and feeling) like a rebellious teenager.

Conclusion

Boundaries are crucial to any relationship, including a relationship between a therapist and a client. Yet these often unclear, ephemeral lines between connection and separation and self and other can become the means by which we can understand a client’s self and relational struggles. A clear and consistent frame protects the work of therapy. But that work can be greatly enhanced through the process of exploring, understanding and reflecting on those boundaries.

*names and identifying information changed to protect privacy

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