Category: Existential-Humanistic

Encounter with Resistance

Posted on by rezendevknowfully.com

This excerpt is taken from Existential-Humanistic Therapy (3rd ed.) by Kirk J. Schneider & Orah T. Krug, 2026 (ISBN: 978-1-4338-4474-4) and printed here with permission of the American Psychological Association.

Resistance

When the invitation to explore, immerse, and interrelate is abruptly or repeatedly declined by clients, then the perplexing problem of resistance—or, as we are increasingly framing it, “protections”—must be considered.

Resistance is the blockage to that which is palpably (immediately, affectively, kinesthetically) relevant within the client and between client and therapist. Existential-Humanistic (EH) practitioners assume that resistance, or protections, are concrete manifestations of clients’ inabilities to fully face and accept some life experiences—especially those that are particularly painful and devastating. EH practitioners consequently appreciate resistance behaviors because they illuminate the ways in which a client views their sense of self and the world. The following vignette from my (Orah Krug’s) work with Diana provides an illustration. Our session began with Diana describing, with evident pride and satisfaction, how she had accepted a challenging task from her supervisor and had successfully completed it.

In Session

OTK: You seem very pleased with your accomplishment.

Diana: (exclaiming strongly) Following through on a commitment is very important to me.

OTK: There’s a lot of energy there. Your statement seems to have a great deal of meaning for you. Can you go inside and explore its meaning a little more? Just let your mind relax and say whatever is there. (I intentionally slowed the process down here because Diana’s energy identified aliveness. I try to encourage more of that with a person who typically tamps it down, as was Diana’s tendency. I sensed that a part of Diana was attempting to emerge, and so I invited her to make “space” for it.)

Diana: It’s about being responsible, showing up in life, growing as a person. (Suddenly she stopped and laughed.) I don’t know where I’m going.

OTK: You’re doing just fine. (I immediately realized my mistake. My comment was an attempt to rescue her from her discomfort instead of allowing her to explore and understand what had just happened. I backtracked and tried to have her get curious about her process.)

OTK: Did you notice that your comment about not knowing where you’re going seemed to stop you dead in your tracks? Go inside and see if you can discover what’s happening there.

Diana: (smiling) I thought I was saying something stupid, blah, blah, blah, and I thought you thought so, too.

OTK: You know in that moment of stopping yourself, you stopped showing up for yourself. The irony is that before you stopped yourself, you were showing up for yourself. Perhaps showing up for yourself triggers some fear?

Diana: (quiet for a moment, and then with tears in her eyes) Yes, a fear of being out there and not knowing what’s coming—I squish myself.

OTK: So, when some feeling is emerging inside, you get afraid? Can you go slow and explore what scares you in the emerging?

Diana: I feel exposed, I feel vulnerable.

OTK: Can you imagine another feeling you could have instead of fear?

Diana: I could be curious—that’s how I was last week, when I went out with a group of friends from work. I realized I was attracted to one of the men in the group and felt that curiosity. I thought, there are a lot of men out there that I could feel this way with, instead of going to that fear place of there’s only one man and I must attach to him.

OTK: How is it to share this with me?

Diana: I feel a little shy, but okay. I didn’t realize how and why I stop myself, and it feels good to have us both knowing what goes on with me.

This crucial therapeutic moment could have been lost if I hadn’t recognized that reassuring Diana in her moment of discomfort was not facilitative. Diana needed support to explore her repetitive pattern of stopping herself when feeling “out there and stupid.” A more therapeutic response prepared the soil for her to embody her silent, constricted way of being constructed long ago to avoid feelings of vulnerability and exposure. Diana’s painful shame-based feelings were so palpable that I reactively tried to protect her from them. This experience emphasizes how quickly subconscious reactivity can take the place of conscious presence.

@2025, American Psychological Association

Ben Yalom on Narrative Therapy, Theater, and Writing with my Father

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An Intellectual Heir to my Father?

Lawrence Rubin: I’m here today with Ben Yalom psychotherapist, theater-maker, and author. His book, Hour of the Heart, which he wrote along with his father, Irvin Yalom, explores the complexities of human relationships and personal transformation based on one-hour consultations between the senior Yalom and his clients. In addition to his therapeutic work, Ben is the founder and artistic director emeritus of fools FURY Theater Company in San Francisco, where he directed numerous acclaimed productions.

You’ve now written a book with your father, as his light is fading. I wonder if you consider yourself to be his intellectual heir.


Ben Yalom: I think I am “an” intellectual heir to my father [Irvin Yalom] to the extent that there are some things that I can do that he has done, and others that I can’t. I could never be my father’s full intellectual heir because I would have 40 or 50 years of reading to catch up on first!

But there are many things that we’ve experienced together, beginning when I was growing up. My parents were further along in their careers, and at that point, there was only one of me because my three siblings were already grown. So, I imagine that their dinner table conversations were a little different from the ones I had with my parents, which were definitely weighted towards their interests. So, almost by osmosis, I probably gathered a lot of knowledge in the humanities. I imagine my siblings did as well, but I think I probably was more exposed in many ways. That’s just in my DNA, or what might pass for my foundational upbringing.

I have done some thinking lately because I’m working on some essays and a book proposal, on what it would mean to sort of take up the mantle of some of my father’s and my mother’s intellectual work and writings. As I say, I don’t think I can ever really be my father’s heir or equal in the sense of having that deep wealth of knowledge about philosophy and therapy and the humanities that went into his writing.

But another very important aspect of his writing that resonates with therapists and students of therapy is that he’s extremely open and honest about himself and his flaws, as well as in the sharing of his ideas. And those are things I very much can do in my writing. In that regard I think I can deliver on his way of being and his way of sharing and his way of teaching.

I’ve certainly reached a place in my life which is quite relevant to the book we just completed, Hour of the Heart. I’ve reached a place in my life where I’m very willing to be quite transparent about most things in my life with my readers and with people who come to ask me for help, I am already finding that this is helpful, much in the way that my father describes in his work. One other aspect that I’m trying to bring into my work, both as a writer and a therapist, is my background in theater.

While that background and foundation does not come from mountains of books that I have not read, I do have something analogous to that in my 25 years in making theater. Particularly in doing types of theater that are deeply engaged in mining the richness of the actors’ lives, rather than the psychology of characters that comes from a script written by someone else. My experience in theater centers around working with peoples’ experiences and psychologies and stories, and in understanding how the body can be used along with the connections between the bodies and emotions in storytelling for character development.

This knowledge is quite real and substantive and can be very powerful for a lot of people. It has taken me some time to understand how to use it therapeutically. I’ve been trying to find my way to weaving these things together in a deep and compelling way to help people, and I’m now starting to see real results, which is exciting.


LR: You’re speaking of the FoolsFURY Theater Company. What was your role in it?
BY: I founded and led the company for most of its existence. I first went to the Iowa Writers Workshop for graduate school, to write fiction. But when I got out, I learned very quickly that I didn’t like sitting alone in a room writing. And all along I’d had a parallel passion which was doing theater.

But I found that I was not that interested, or satisfied, by the theater I was seeing produced. Even in a pretty interesting and experimental place like San Francisco, much of the mainstream work was very traditional American theater. That is, a script was given, people performed on a stage, and it was almost like in many ways, putting a movie on the stage. That’s a vast oversimplification, but to some extent it’s true.

I became really interested in ideas and concepts that could be expressed in metaphor and movement, and that tackled deep themes. I was much less interested in realism. What I really wanted to explore was “What could be unique about the experience of live theater?” which was completely different from trying to put realism on stage. So, I started exploring and meeting people in theater companies in the Bay area, trying to get them to hire me to direct plays. But I found quite quickly that people were interested in working with me, but nobody was going to hand over the keys of their theater company to let me create my sort of experimental vision. Finally, my mentor came to me and said, “Okay, well, I guess that means it’s time for you to start your own company.” So, I started a company to produce one play at the time, and when it came time to actually put it on stage, I was told I needed to have a company name.

You asked earlier about the name foolsFURY. I dreamt this up as a collision of fool – our absurd and comic human position in the universe – and fury at the injustices we do to one another. I meant only to do one or two plays in order to put my name on the map. Then it became a 20-year endeavor, because we got to do the things that I wanted to do artistically that nobody else was ever going to hire us to do––to raise complex questions and be deeply curious. It was a place of experimentation and research, and ultimately a place where we hosted many other companies and nurtured their creative visions, all working in this sort of space between somebody delivering a script versus the actors and the designers and the directors creating original plays.

What I wanted was people who could do powerful realist scenes but also explode the stage, do everything that was possible to create an experience that one had to be involved with live, and that could mean the type of immersive theater that we’re seeing very strongly now, 25 years later. It might mean acrobatics. It might mean dance. It might mean breaking out of realism into some sort of crazy imagination, stylized work, and then back into realism.

At the time, most of American theater, and definitely most of the mainstream theater that was happening in the Bay Area, as well as what all the major conservatories were teaching, were variations on realist acting and was psychologically driven from the top down. I had to become an expert in things that moved from the outside to enter the bottom up; start with the body, get to the mind as opposed to starting with the mind and getting to the body. So, my expertise is very much in a number of contemporary forms that are bodily-oriented, driven by impulses in the body, or understanding a feeling in the body and how that might come out, or how a certain use of the body might generate an emotion as opposed to the inverse.


Beyond Thought and Language

LR: How have you made the transition from the theater to the therapy space?
BY: I am trying to bring this “bottom up” orientation into some of my therapeutic work. This means developing ways of getting people to find or explore—if we think about Narrative Therapy—stories of self, not verbally, but through exercises that are more physically oriented. And my feeling is that one of the challenges of traditional talk therapy is that it’s so talk heavy; this works really well for some people, but not for others. The discursive, rational language that we use isn’t the easiest way for some clients to explore themselves, or to express what they find when they do. So, I’m trying to build some tools that go with narrative and existential therapies, but which help people explore and express themselves in a less language-centered way.

LR: It’s interesting that we started the conversation around the question of whether you are ‘the’ or ‘an’ intellectual heir to your parents’ careers, particularly your father’s and specifically with regard to therapy and your understanding of the human condition. But it sounds like your work in the theater, and how you’re integrating it into therapy is almost anti-intellectual or contra intellectualism.

BY: I’m not going to disagree, but I’d say it’s more a different angle than an anti-intellectual one. The first thing that comes to mind when I’m asked about my theory of change is that peoples’ living understanding of what is meaningful for them is critical. That might look like identifying their “quest in life” or their search for meaning in the universe, and then living in ways that are more aligned with those meanings or ethics. To me, that’s a very existentialist approach through which I’m saying, “What do you find truly important in your life at a deep level?” This is inherent in my father’s work, but I don’t know that all people can answer that solely through thought and language. I think meaning exists within the framework of all the other existential questions, but I don’t think that peoples’ understanding of what is meaningful for them is always easy to articulate verbally.

LR: How do you use movement or poetry or other experiential types of explorations to help your clients make sense of some of the larger existential questions?

BY: I’m doing it based on many, many years of experience with certain theatrical forms. I also have a great network of mentors that I’ve met over the decades that have guided me in explorations or exercises that allow people to go to deeper places within themselves both individually or within a group. Often, they come out with words on the other end, but the theatrical and dramatic and dance work is usually inspired by the internal work they’ve done or are doing.

Over the decades I’ve watched some of the best theater makers and dance makers I know do this kind of deep work, and I’m constantly reminded how powerful their experiences have been. My goal has been to use these highly developed skills and expertise to help therapy clients reach those deeper, meaningful places within themselves, and between themselves and others.

An Embodied, Experiential Journey

LR: Can you give me an example of a client who you helped to bridge that divide between word and experience?

BY: Right now I’m doing this work in groups. Maybe someday we’ll get to a point where I’ll bring it into individual sessions.

One person I was working with lived with a great deal of shame. She was a Middle Eastern woman battling the shaming cultural practices that came from being a woman and from her parents. Her constant pattern in life was to hide from her parents and then dig her way out and do the things that her parents then disapproved of. None of them were particularly bad things, but those things didn’t fit the culture.

Sometimes before group sessions, I will do what I call a “mission interview.” This is a format Tom Carlson, Garret Rutz, and I are working on which is basically a very short, intense, Narrative Therapy-based re-authoring exercise, in which I would say something like, “How did you decide that you wanted to become a therapist?” or, “Can you tell me a story about a moment where you made that decision by going down one path?” or, “What were the things you were fighting against in your life that then led you to take up the mantle of fighting against that?” The mission that she developed, should she become a therapist, was to provide a place where people could come to put down their shame and be treated with love, and that she would be the person to greet them with love and offer them a place of safety. So essentially, what I created in that hour for her was the opportunity to think about a story about where she came from, the practices she was up against in her life, what she was doing to combat those practices, and the solution or power or passion that she pursued to fight against those shame-inducing practices.

She understood the mission you jointly articulated for her, at which point I said something like, “We can do this verbally, or we can do it non-verbally where you can get into their body.” She picked, and we continued working together. I offered her some guidance, asking “As you reflect on what you’re really up against in your life, see what that feels like in your body? What is the power, the thing that’s driven you to keep fighting on it against this?” So, we work either way. We identify where they came from, what her big challenges in life are, and hopefully determine what are the strengths and skills or hopes and dreams that she has to fight against this.

Okay, that’s the conceptual background. Then I’ll get them into their bodies and teach them quickly what it is to make a gesture, because it’s the smallest building block of a dance. That seems to be much easier for people to instead of me saying, “go make a dance,” which can be very intimidating. For example , I can say, “Larry, make three gestures, and then let’s put them together.” You just created a little dance!

So then we’d do an exercise where they really get into a meditative space where they spend about 15 minutes just letting their body move, really articulating it and that becomes a bit of a meditation in its own right. I’ll ask them to follow one part of their body which may have begun as an impulse, and I ask them to start paying attention, trying to let their mind and body work together. At that point, I start to bring in the image of the thing that they’re up against in their life. I’ll ask, “How does that feel when you bring that into your story, into your body? Where does it go?” Usually, they’ll go on a little internal journey that’s physical and emotional.

From there, I’ll ask them to bring in the thing that they use to fight against that or to overcome that which takes the meditation in a different direction. I might ask them to just notice at some point and pull a couple of gestures that come up out of those two sides—the thing they’re up against and how they stand up to it. So here they are building a little vocabulary of movement related to their specific stories

Two more steps! They can then do something that’s called a “container exercise” where I ask them what it feels like if they’re inside a container or something that’s holding them in and feeling what that’s like. At some point I’ll say, “I want you to start finding your way out using your specific strengths and skills. And then go back into the container and force your way out again. Then I might say, “The thing that you identified as your challenge in life is that container…that’s the thing that’s forcing you when you go through that…so, how do you use your skills to get out and what does it feel like to get out?” They do it over and over again, and I ask them what they learned from that experience. (And just to note the lineage here, this is a modification of an exercise I learned from the brilliant teacher Steven Wangh, and which he in turn modified from work with the great Polish theater maker and theoretician Jerzy Grotowski.)

I ask them to focus on any gestures or thoughts or words that came out of that such as poetic or metaphorical words or sounds. Next, I might say, “I want you to start on one side of the room in your ‘up against’ state, or the place where you’re fighting against or being contained, and then to move to the other side of the room using all of these gestures that we’ve created, and while going from there to there, somewhere in the middle, there’s going to be a transition, (which in narrative terms is like an agentive turn) where you shift into taking control of this thing. Sometimes people have to go back and forth—but eventually we help them move through to this side. And so they’re getting a very embodied, experiential sense of this inner journey, This is the bottom-up process!

Writing with My Father

LR: I always considered traditional Narrative Therapy to be a very literary, intellectual type of clinical venture, but it sounds like your orientation is to the non-literary or anti-literary, sort of in the way that your divergence from your father’s work led you to an anti-intellectual, experiential place.

BY: One of the things that I saw in Narrative Therapy, at least in the readings, were ideas about ritual ceremonies. Those really caught my attention,. And now, in addition to traditional sessions, I do these experiential exercises in group format that can run six-hours long, and even multiple day intensives.

LR: So, because of your background in theater, interest in Narrative Therapy, and willingness to depart from the written word, you’re no longer committed to that traditional template of one-hour talk therapy. It’s interesting, however, that you just finished co-authoring a book with your father called, Hour of the Heart, where the explicit purpose was to highlight his commitment to continuing his therapeutic career in the shadow of some limitations by offering one-hour sessions with people around the world. Can you share what that experience was like for you?

BY: Strangely, not difficult because my understanding of therapy goes way back to my first exposure through my father’s vision, our dinner table conversations, and later his writings, particularly Love’s Executioner. I read those stories in draft and gave him feedback on those. I did the same on pretty much every book after that so I understood his thinking about therapy and his desire to make a literary form that incorporated therapy, and featured the clinician reflecting on his own thought process and the therapeutic encounter. So, my formation was not only as a therapist but as a writer.


LR: So, it was a natural progression for you?


BY: We had worked together in the past. I had edited a book called The Yalom Reader years ago which was the first big omnibus of his work. In more recent years, I had given very significant feedback on a number of his books.

I did, however, decide that it was just too demanding for both of us to work together until the mountain of stories for Hour of the Heart grew and his memory began to decay. Eventually the manuscript grew to be between 45 or 50 stories, and it was too challenging for him to put them side by side while holding onto the threads that were going on between them.

Some of the stories were sort of repetitive of one another. It’s not because he wasn’t interested in the process or fully invested in each one of those stories, but because he had forgotten what he had written. For example, story 40 may have covered some of the themes already covered in story number 12. At a certain point, we agreed that in order to help him pull it all together, he needed somebody to work with who knew him well enough, knew his way of writing well enough, felt confident enough, and had enough of his confidence to really revise and rewrite. So that’s the work that I undertook.
Embodied writing


LR: From a Narrative Therapy perspective, what do you think your dad values in you that led him to invite you into this project, even though you have a challenging history of working with him.
BY: That’s an excellent Narrative Therapy question. I can only speculate. I think we have a pretty powerful bond and it’s different for all the children. But I am the one who was most engaged in writing. As I went through grad school and after, when I wrote plays and some fiction, I certainly always shared my work with him, and we would discuss it. Likewise, he would share his work with me, and we would discuss that.

We’re certainly not the same writer, and we have different strengths. I found at some point in my 30’s by the time I had children, that it wasn’t always easy for us to collaborate because he is an anxious, and often impatient, person. And for me, working with an anxious collaborator who would often send me a draft, and then call the very next morning saying , “Do you have the edits yet? was challenging. I would come back with “I have it, I haven’t read it yet, I’m trying to get it!” I had three kids to get off to school and whatnot. While we eventually decided not to write together often, we did co-author a column for Inc. magazine for a year, and I’ve edited chapters of many of his books.

But I understood his work well enough to be able to try to write like him in a way, and not to stick things into the stories that sounded out of place. That might have come from my way of thinking but at the same time, we had spoken enough about therapy over the years that I think there was a lot of trust there as well.

It really helped that I had turned the page in my life and decided to pick up the family business and had started my education as a therapist and started seeing clients. So, the questions I was asking were really informed by some experience, as opposed to purely from the writer’s perspective. The other aspect is that I had suffered with depression back in my 20s and 30s, and we had very long talks about that. And similarly, he has had periods of anxiety, and particularly in the years since my mother died. And we had some very long talks about that. So, I think there was a certain amount of trust in one another. And for him, in my psychological acuity and compassion.


Lessons Learned

LR: In his words, “fellow travelers.” Did the nature of your collaborative efforts change from the beginning to the end of the project?

BY: Absolutely it did, and it was really interesting. At the beginning of the book, I would say my father was more concerned about me being interested in doing this, but little by little, he gave me more rope, if you will. I would bring back suggestions that he liked, and he became more and more willing to trust me as a writer. At the same time, I think there was the process of him becoming a little bit less invested in the book, or a little less interested in the book, as time went on because with his clock ticking, and realizing that he doesn’t have that much time left on the planet, there were other things he wanted to be doing and paying attention to.

Those two things allowed him to give me more and more freedom. We also moved from really looking at pages together at the beginning, to more of my doing the work and coming back to him in a Zoom session and saying, “Hey, I’ve got some questions about therapy for you.”

After a certain point, which was quite a bit later, he couldn’t even really remember the individual stories. And sometimes he would reread a story and then we’d talk about it, but often it would be me. I might say, “I’ve written the story. I feel good about it, but I’m not sure about this particular therapeutic dialog in here or this intervention here.” So, I would go back to him and say something like, “Hey, is this something you would say or does this feel right?” I might ask him to imagine he was in this situation with a client, so he didn’t have to remember all the details of the particular interaction in the story.

For instance, if one of the stories was about suicidal ideation, I would ask him how he would address that. It got to a point where what we were having was almost supervision conversations where I was saying, “Does this feel like the right therapeutic move?” and he would say, “Yeah, that that would be good,” or “Here’s a problem with that approach.”

LR: Your father has written and worked around death, dying, grief, and, of course, he lost his wife, your mother, just a few years ago, and now his memory is diminished. What have you learned as a person, as a therapist, and as an author, about death, dying, and mortality that you want to bring into your own life, as well as your therapeutic work? You know, staring at your own sun.

BY: Yeah, it’s been really powerful. Thank you for asking that. I can’t separate it from my particular stage in life. These things are definitely affecting me as a 56-year-old man with young kids. There’s been a certain awakening on my part to the time that I have left. But I’m not coming from zero because I’ve always been having these existential thoughts, because they were part of the air I breathed as a child where the idea of how we confront death was always a common topic around the table.

So, I think now it has made me look at my life, my kids, and my wife and thinking, yeah, I have X amount of time, and I really want to make the most of it. So that is helping me say “no” to things in a way that I probably didn’t before, and also say “yes” to other things and to other people and their needs, in ways that maybe I didn’t before. I think it has helped me in my mission to be a kinder person. Because we all have frailty.

It’s been difficult watching my father diminish to the extent that he has, not only because he’s my father, and that I think it’s difficult for anyone, but also because there’s this the air of the great man being diminished. Because I’m in the field, and because I’m managing his Facebook page, I’m constantly responding to people about the emotional impact on them of his decline. Everybody wants a little piece of him and wants him to know that they wish him well.

That this book itself deals with the aging question and the memory question means that these were very direct topics of conversation for us. We were often looking specifically at, “What it’s like for you to be having these memories slip away?” And “Sometimes we disagree about something that happened in your past.” But then we can’t just sort of let it go sometimes because it’s actually relevant to the story that we’re writing, so we had to stay with those things that were uncomfortable, linger over them together, and decide how to address them, both in life, and in our writing.

LR: We started the conversation around the issue of whether you are your father’s intellectual heir. But as we move to the very end of the conversation, I see you as more of the existential heir. Would this book be one that beginning clinicians could pick up?

BY: I took on the mission of making this an accessible book to a broad range of readers. I think many of his central therapeutic ideas are laid out well enough that one could pick this up as their first book during training. My guess, however, and given that most people who are beginning their journeys as therapists are much younger, is that some of the questions about aging which do make up a lot of this book, are probably not as relevant. I think picking up the Gift of Therapy or one of the books of stories is probably a better place to start. But I don’t think you would go wrong if you began with this one.

LR: I agree, Ben, and on that note, I’ll say thanks for this deep and powerful sharing, and good luck with the book.

BY: Thanks Larry. I enjoyed it as well.

©2025, Psychotherapy.net

References

Yalom, I. & Yalom, B. (2024). Hour of the heart: Connecting in the here and now. Harper Collins.

Yalom, I. (2002). The gift of therapy: An open letter to a new generation of therapists and their patients. Harper Collins.

Facing the Fear of Flying Together: Reconsidering Exposure Therapy

Posted on by Psychotherapy.net Team

Beyond Resistance to Exposure Therapy

Exposure therapy for anxiety and related problems gets a bad rap. It is often seen as mechanistic, simplistic, unimaginative, and even cruel. The suggestions that “coaches” or AI could do as good if not a better job with exposure treatment, compared to well-trained therapists, only reinforce these beliefs. This contrasts with the treatment outcome research studies that show it as one of the most effective approaches in psychotherapy.

During my early years of practicing in a CBT-focused clinical psychology program, we were taught and expected to use exposure therapy. Soon, I found that I was not looking forward to the sessions that included exposure, and I abstained from volunteering to take on new clients whose presenting problems indicated that they could benefit from exposure therapy. I viscerally understood why studies have also shown that a majority of therapists, even those who identify as cognitive behavioral, shy away from exposure therapy.

My supervisor was certain that my and my classmates’ feelings were related to what he believed was at the core of the exposure underutilization: Therapists are, by and large, very empathetic people and thus we hate “making” our clients suffer. If we only realized that a compassionate approach sometimes requires short-term pain toward long-term gain, it would lead to an exposure therapy renaissance — or so he believed.

His contention resonated with me. I certainly was concerned when witnessing my teen client’s face turn pale and eyes water while touching the floor, doorknob, and trash can in our clinic bathroom while engaging in exposures for contamination fears. And I deeply felt the anguish of a middle-aged mother trembling as she held a knife and recounted the obsessive fears of hurting her daughter. But very few worthwhile things come easily, without pain attached to them. With my supervisor’s help, I started paying attention to the uncomfortable emotions and physical sensations that were coming up for me during exposures and worked on accepting them in the service of helping my clients.

It was a long journey, but I slowly improved, vowing that the avoidance of my distress was not going to be the reason for the avoidance of exposure therapy. This was my way of bucking the trend — much more pronounced these days — in which therapists lean into validating, complimenting, and colluding with clients’ defenses at the expense of challenging, probing, and having difficult conversations with them. A majority of therapists I know have become very good at accepting clients and being liked by them, but not great at actually helping them change in meaningful ways. But exposure therapy is far from the only approach that can be challenging to do and can lead to heightened distress in the short-term. I would argue these conditions are true for any good therapy.

Another observation my supervisor made was that many therapists were afraid of “pushing clients too far,” potentially leading to crying, hyperventilating, or even decompensating. “First,” he stated impatiently, with a hint of agitation, “no client will decompensate because of heightened anxiety — this fear only mirrors unfounded fears that clients often have, and it needs to be dispelled through psychoeducation.” He then assured us that we would become better at knowing how quickly to go up the exposure hierarchy (constructed at the beginning of treatment to guide exposures) with experience. Over time, he insisted, good therapists get a sense what the optimal dose of exposures is. Like Goldilocks, we learn that it needs to be strong enough to cause significant anxiety, but not too overwhelming to paralyze the client. That was, in his view, the art of exposure therapy.

Over the years, I did become proficient in the practice of exposure therapy, even penning a Washington Post article extolling its virtues. I have witnessed the transformation of people’s lives with the help of imaginal, in-vivo, virtual reality, and interoceptive exposures. And, yet, I have felt that by focusing on doing the exposures, we are missing crucial elements that could help more clients decide to take the leap and keep them engaged until they improve.  

Most people are deeply ambivalent about change, especially the change that requires hard work and invites distress. When some realize that anxiety is contracting or even ruining their life, but they are not sure how to muster the courage to do something about it, internal (and sometimes external) conflicts ensue. Leveraging the therapeutic relationship to work with clients on these conflicts and on finding a way to integrate the parts of themselves pulling them in different directions is at the heart of what I do. In this process, my clients and I have come face-to-face with what it means to be human — to struggle with uncertainty, isolation, death, and the search for meaning. As Irvin Yalom suggested, all our fears emanate from trying to deal with these givens of the human condition.

Flying with Rick: A Case Study

“I don’t think I can get on that plane, I’m sorry,” said my client as we lined up to embark on a flight to Charlotte. He exited the queue and started walking away from the gate. When I saw him slowing down and stopping about 100 feet away, still facing away from me, I gave him a few minutes and then approached.

His face was contorted with fear and apprehension. I was concerned that he felt he needed to fly to be a “good client,” despite multiple discussions we had about him taking the pilot seat in his exposure therapy journey.

“I’m not going to ask you to get on the plane,” I said. “This is your choice.”  

Rick had contacted me a few months before and said he was in his late 20s, suffering from flying phobia. In our initial meeting, I explained how I practice Cognitive Behavior Therapy (CBT) with an existential slant. We discussed what our work might look like, including the exposure therapy part, in which one gradually confronts one’s fears. “So, you’ll fly with me?” asked Rick, with a nervous half-smile. “If need be?”

I hesitated uncharacteristically. Being a nervous flyer myself had never stopped me from visiting my family overseas, traveling, or doing exposure therapy with previous clients. But abstaining from flying during the pandemic had increased my apprehension. Still, how could I expect my clients to face their fears if I was not prepared to do the same? “Of course!” I said, before I could change my mind. I wanted to model the courage that is one of my strongest-held values.

We first explored Rick’s history. He’d been uncomfortable in planes for as long as he could remember. His mother was a very nervous flyer, so Rick’s family rarely flew. When they did, his mom looked petrified and once even dug her nails into his skin during turbulence. So, he came to his flying anxiety by both nature and nurture. As an adult, Rick continued to avoid flying, and the less he did it, the more afraid he became. He still felt tremendous guilt about bailing the night before the flight that was supposed to take him to his best friend’s wedding. 

Then, just before the pandemic, Rick was offered a dream job. Although it required frequent air travel, he decided it was too good a career opportunity to pass up. “I figured this would be exactly the kind of push I needed to get over my fear of flying,” he said. But the pandemic curtailed his new team’s travel, and Rick got few opportunities to fly. Later, when the U.S. reopened, he needed to be ready to fly anytime. He endured a business flight to Colorado with the help of Xanax but felt so miserable before the trip and after the medicine wore off, that he realized he needed to seek therapy.

We started by watching videos depicting a wide variety of flights, including turbulent ones, followed by vividly visualizing flying scenarios. I guided him to engage his imagination, focusing on all aspects of the experience, as if he were in a movie. When the imaginary exposures raised Rick’s anxiety, we practiced “sitting with” the anxious thoughts, feelings, and physical sensations. For example, I asked him to mindfully scan his body to notice where the uncomfortable sensations were showing up. Rick described his throat drying up and chest constricting, and he learned to allow them to be as they are, without judgment or suppression.  

We also practiced observing the stream of anxious thoughts and imagining “placing” them on, for example, leaves in a stream or clouds in the sky — thus letting them continuously come and go. We discussed how this acceptance approach works best in the long run. We also practiced several breathing and muscle-relaxation techniques to be used only occasionally when anxiety becomes paralyzing. I warned Rick against using these “quick fix” techniques habitually, as they could become another kind of counterproductive avoidance. After a few months, Rick said he wanted to try “the real thing.”

At the airport, Rick blurted out, “I really, really want to do this, but I think I’m getting a panic attack!”

“Let’s breathe together like we’ve practiced,” I said. “Inhale for four, hold for four, exhale for eight though the nose…And repeat.”

Soon, Rick appeared more resolute and started heading back toward the gate. As I walked beside him, I felt my own anxiety bubbling up, but I kept a calm demeanor. Just before joining the line of boarding passengers, Rick stopped again. “It’s like I want to go, but some invisible hand is not letting me,” he said.

It seemed like he still was not accepting his ambivalence. How much easier it is for all of us to externalize what we don’t like about ourselves!

“Perhaps the hand is also a part of you,” I said. “There seem to be two parts of you.”  

“Yes, it does feel like that.”

“What is each one saying?”

“One says, ‘You can do this, you’re strong, you’re not going to let the fear boss you around.’ And the other says, ‘You’ll faint or have a stroke if you get on that plane. If the plane doesn’t crash first. This is too much for you to handle!’” he said.

I waited, curious to see what he’d do with these two parts.

Rick asked for reassurance: “But it’s not going to crash, right?”

“Neither of us has a crystal ball,” I said with a slight smile, because Rick had been emphatic about his disdain for anything superstitious or new-agey.

He smiled back before his face turned solemn.

“I see more emotions coming up for you,” I said.

“A lot of irritation. Frustration with myself that I can’t be the person I want to be, that I am torn between these parts.”

“Is either part helping you expand or contract? Makes you larger or shrinks your world?”

“The first one makes me larger, but how do I make that one win?”

“It’s not about winning or losing. Only you know which one you’ll choose to listen to,” I said softly.

“I’m choosing to listen to the brave Rick, but the other part is still there…” his voice trailed off.

“That anxious Rick might always be a part of you. Can we just take him along for the ride?”  

The gate attendant announced the last call for passengers heading to Charlotte. My stomach began to ache. We might never get on this flight, I thought with mixed feelings. A part of me felt disappointed with my ineffectiveness as a therapist. And another part was relieved that I might be spared flying today. It was then that I decided that self-disclosure might be helpful to get us past this impasse — after all, we were in this together.

“The truth is, I’m not a fan of flying either, especially after a long hiatus. I haven’t flown since the pandemic began, and my hands are sweating.” I turned my palms around for him to see. “But I don’t want to look back on my life with regret for not taking a chance, the regret that I so often hear from my elderly clients.”

Encouraged by the look of grateful surprise that flashed across Rick’s face, I continued. “Imagine sitting with your grandkids on your 80th birthday. What would you like to tell them about how you approached this short and precious life?”

Rick’s eyes brimmed with tears. He rushed toward the attendant, but quickly turned around. “You’re coming?” he asked.

I followed him swiftly, letting my legs carry me and my anxiety. I was thankful he led us to the plane.

Once in the air, Rick was surprised that he was not as anxious as he thought he’d be. “Anticipatory anxiety is always the worst,” I said. When the plane started to shake and both of us noticed our anxiety rising, we practiced the acceptance strategies. The majority of the flight was smooth, and each of us enjoyed a soda and flipped through a magazine. On our descent, the plane shook slightly and moved from side to side as we went through a thick layer of stormy clouds. Rick’s face turned pale and he murmured, “What now?”

“You know what to do,” I said.   

Rick led us though some breathing exercises, and as his body relaxed a bit, he joked pointing out the window: “I am working hard to put my catastrophic thoughts onto these dark clouds!”

When we touched down, Rick turned toward me and mouthed, “Thank you.”

Now it was my turn to tear up. “Thank you. It was my honor to join you on this journey,” I said. 

***

I was grateful that we were able to find strength in vulnerability and face the fear together. When we own all parts of ourselves, we can come to terms with the existential givens in unison. Approaching each therapeutic encounter as an opportunity to delve into the fundamental challenges of human existence, we enable our clients to grow stronger in the face of life’s uncertainties. Rather than offering them absolute solutions aimed at minimizing their anxiety, we can join them in embracing the existential realities, along with the unease these bring. And confronting the core realities of our existence is essential for leading rich and purposeful lives.  

Exposure therapy is not about conquering anxiety but about finding a way to live authentically despite it. Instead of being technocratic cheerleaders, therapists using exposure have an opportunity to accompany clients on some of the scariest and most profound literal or figurative quests of their lives and witness the transformation that happens when we stop avoiding what matters.

“Have you decided how you’re coming back to D.C.?” I asked Rick as we exited the plane.

“I’m going to fly by myself!” he said with a smile. “And bring nervous Rick along.”  

Questions for thought and discussion

What were your impressions about this therapist’s approach to exposure therapy?

In what way or ways do you think the client benefited from her intervention?

In what ways have you found exposure therapy to be useful in your practice? Not useful?  

Existential-Spiritual Techniques for Fostering a Healthy Perspective on Aging

Posted on by Psychotherapy.net Team

Introduction: The Existential-Spiritual Model

The case vignette that I will share presents the application of an Existential-Spiritual model of coping when working with patients experiencing the natural inevitability of aging and the “normal” responses associated with it. The integrated model includes six intervention practices: self-compassion and mindfulness, discovering meaning in life, prayer, creativity, expressing gratitude, and being open to a sense of awe. Existentialism poses universal questions and concerns, while spirituality provides space to process grief and loss and create meaning in life (1). The aims of spirituality include having compassion for others’ pain and suffering, advocating for social justice, and gaining awareness of and learning from the tragic dimensions of existence, thereby enhancing an appreciation for and valuing of life. This case of Jonathan highlights how dreams can be a valuable resource in gaining a deeper understanding of an individual’s attempts to deal with their existential and spiritual challenges, as well as finding passion and purpose in life (2).

Initial Phase: Processing Unprocessed Grief and Loss

Jonathan is a 68-year-old male who entered individual psychotherapy for the first time. He reported that he has been married for 40 years and has a married adult daughter and two grandchildren, ages 8 and 12, who live nearby. He had retired just one year prior to the pandemic. Jonathan, who majored in English literature, pursued a law degree for financial stability and a personal value of and commitment to social justice. After law school, he worked in his father’s medical supply business to support his father’s declining health due to numerous medical problems and an early death from diabetes at age 56.

Jonathan expressed concerns of feeling “empty inside” and experienced lack of direction, meaning, and purpose in life since his mother died approximately five years ago, just six months after his retirement. He reported feeling numb and indifferent over the wars in Ukraine and Gaza/Israel, and the intensified polarization of political discourse he observed during his extensive time watching cable news. Given his commitment to social justice, these feelings were different for him. In addition, a close friend had died early on in the pandemic, but he was unable to visit him in the hospital or attend his funeral due to COVID-19 safety restrictions.

Jonathan wanted to work with a psychotherapist experienced in Existential-Humanistic approaches based on his longstanding interest in the existential writings of Tolstoy, Sartre, and Camus. During his initial psychotherapy session, Jonathan reported a disturbing dream from the night before. He was in a building with a male colleague and his own daughter trying to find a pool. His colleague pointed to some skin lesions on Jonathan’s body; one had rows of 20 elevated dots that looked like shingles. There was another area that had been festering for some time. He was preoccupied by his skin condition in the dream and when he looked up, his colleague and daughter were no longer there.

Jonathan frantically searched the building asking for help in finding his colleague, daughter, and the pool. He recalled walking into an office with an elderly woman who was volunteering in the building. She was unable to provide any guidance as to his colleague’s or daughter’s whereabouts. Jonathan felt anxious about missing out on seeing them and the opportunity to swim. He woke up feeling worried and not knowing what to do.

I used several existential approaches, including Jonathan telling the dream in the present tense to develop a sense of presence and agency. I asked him what he thought the dream meant and inquired about his main feelings in the dream. Jonathan responded that he felt that something was missing in his life and “life was passing me by.” Jonathan associated the dream skin lesions with his mother’s fatal skin melanoma. He also described the colleague in the dream as confident and adventuresome, much like his recently deceased friend. I wondered if the dream reflected Jonathan’s hope that his therapy would help reduce his anxiety, but also his fear of what his treatment would uncover.

When asked to elaborate on the circumstances of his mother’s death, Jonathan expressed that she had been living in an assistive living facility in Florida for three years with a full-time aide. He then expressed guilt that he only visited her a few times a year due to his busy work schedule. He said he felt emotionally overwhelmed being with her as she did not recognize him during his last few visits, and she needed everything repeated numerous times. Jonathan said he was actually relieved when she passed away but felt ashamed for having these feelings and did not share them with anyone.

To further his sense of agency, I asked Jonathan, “What is the existential message that can be taken from the dream?” He responded, “I need to stop avoiding making a medical appointment with my dermatologist because I am scared of what it could be” and that he might be paying a price for not processing his numerous losses. I then asked Jonathan, “If you could continue the dream, how would you want it to end?” After struggling with an answer, he said he missed seeing his colleague at work, swimming, and spending time with his daughter and grandchildren.

The initial phase of psychotherapy focused on his unprocessed grief and loss over his mother’s and close friend’s deaths, reflecting on the impact of the COVID-19 pandemic, and clarifying his values. He expressed resentment that he and his wife, who were eagerly looking forward to his retirement, were unable to fulfill longstanding travel plans to Asia, South America, and Alaska during the pandemic. Jonathan felt it unfair that he had sacrificed being a lawyer to help run his father’s medical supply business, and that he historically had placed others’ needs above his own.

He felt that it was unfair that these losses happened to him now, just as he was on the verge of finally pursuing his own dreams. He also felt that his mother’s and friend’s deaths, as well as the social isolation during COVID-19, were disruptions of the life “he was supposed to have,” rather than inevitable parts of anyone’s life. He wondered if he was being punished for not being compassionate and supportive of his mother at the end of her life. I suggested using self-compassion statements to soften some of the self-critical attitudes, such as how he should have grieved his mother’s passing.

Jonathan and I explored how his sense of guilt, regret, and shame over his mother’s death had drained his coping skills and flexibility to deal with his mourning process. We discussed how some of his basic assumptions of the world — such as “The world is fair,” “bad things should not happen to good people,” and “there is a reason for everything that happens,” — were shattered and left him “drifting at sea without a paddle,” not knowing what to do. We explored how these feelings were similar to how he felt at the end of his initial dream and how these factors may have impacted — and could continue to impact — his ability to mourn and grieve. Jonathan gradually was able to acknowledge, but not accept, that the world is unfair and unpredictable, and that random events can happen to good people.

I asked Jonathan to describe in more detail his last visit with his mother. He recalled her sitting up in bed requiring her full-time aide to feed her pureed food. She was staring out the window as if she was already in a different place. Jonathan said she was there physically, but in some ways she had died psychologically. I suggested that he was experiencing an ambiguous loss, making it challenging to start grieving her passing because she was still there physically. He tried to imagine what she might have been experiencing looking out of the window, and he wondered if she was scared of dying and being forgotten by others.

The next session included recalling positive memories of his mother — what kind of person she was before her Alzheimer disease diagnosis, and what values she lived by. He brought in photographs including her wedding picture and one where she was holding his daughter when she was an infant. His mother’s eyes in the second picture conveyed a warm, loving glow, which was comforting to Jonathan. He also recalled how she went back to school to become an elementary school teacher when Jonathan and his younger sister were in high school, and how much he enjoyed hearing stories about her work. He realized that his mother was more than his memory of what she was like at the end of her life.

Jonathan also discussed how his best friend, Michael, passed away three months into the pandemic. They had become best friends in 8th grade, and even though his friend moved out West after college, they maintained regular contact, including yearly visits. Michael was adventurous, loved hiking and fishing in the Pacific Northwest, and enjoyed talking to strangers. I suggested to Jonathan that the colleague from his initial dream might symbolize this friend, perhaps indicating a desire to emulate his confidence and adventurous spirit.  

Jonathan fondly recalled that the conversations he had with his friend always had the quality of picking up right where they left off. His beloved friend Michael, a social worker, always provided a listening ear and would ask challenging, but supportive questions. He was non-judgmental and helped Jonathan with various struggles. When asked what he missed most about his friend, he replied, “I could talk about anything without feeling judged, and he treated everyone with respect, always seeing the best in others.” When asked what Michael would say to him now in terms of how he should handle all his losses, he replied, “Just savor the preciousness of each moment, don’t take anything for granted, and take some risks.”

On top of these two significant losses, Jonathan felt that the pandemic was a very isolating and frustrating experience. His retirement dreams were put on hold, leading him into several unhealthy patterns, such as excessively, or perhaps obsessively watching cable news, growing more irritable with others, and being intolerant of conversations with friends and family members with opposing political viewpoints. His main pleasures during the pandemic were his weekly Zoom meeting with his daughter’s family, reading, and taking daily walks.  

I asked open-ended questions at this time, including: “What sustained you during the pandemic?” “What did you learn about yourself?” and, “Where did you find the strength?” Jonathan felt that his longstanding interest in Buddhism and the Jewish value of healing the world (tikkun olam) provided a sense of stability. Specifically, Buddhism stressed the importance of not getting too attached to things, the importance of just “being” and accepting things as they are. Although these beliefs provided some degree of intellectual comfort, they did not have a major impact on his actions or his self-confidence.

In order to provide Jonathan with a deeper foundation and sense of direction, I asked Jonathan to describe his core values, which he identified as supporting his family, treating others equally and with respect, and pursuing excellence in whatever he did. Since his retirement, he felt that part of his identity had been lost even though his career was never in line with his values of social justice and being a lawyer, leaving him lacking passion and direction. He was encouraged to explore if these values were still effective and whether he needed to reconsider refining them in some way. Jonathan was gradually able to realize that although he did not need to financially support his daughter and grandchildren, he could model for them how to handle adversity and aging in a graceful way, as well as find other ways to channel his need to treat others equally and with respect. I stressed that values are not fixed in nature but can be created. At this point in therapy, he was also encouraged to practice mindfulness exercises and self-compassion to increase his level of self-reflectiveness, to be less judgmental of his struggles, and to recognize that his feelings are transient.

Middle Phase: Establishing a New Sense of Self Through Existential Approaches

Four months into treatment, Jonathan reported a vivid dream where he was walking in New York City trying to get to a meeting in his office on the East Side. He was waiting with a group of people in a building near Central Park. Some of the people were taking too long so he decided to leave to make it to the 3:00 meeting. He was trying to find a cab, but they were all full. He walked down an area in midtown that was sectioned off with small houses that one would typically see in the suburbs. One of the buildings had a large window where he saw a group of people relaxing and socializing.

Jonathan realized he had to get to the office, so he finally got into a cab and saw he only had a $10 bill to pay for the short trip to the office. The traffic was slow, so he decided to get out of the cab to walk the remaining distance. There were long, winding, hilly sidewalks that are not typical of the city, and he realized that he was on the opposite side of Manhattan from his office. He sensed he would miss his meeting as he saw trains passing by near the Hudson River. He then found himself walking down a long, beautifully constructed road with tall, shady trees leaving the city through a tunnel. He woke up feeling that he wanted to stay in the city and that going through the tunnel was potentially dangerous.

Jonathan felt the dream meant that he was struggling to find a new path in life, that he had lost a core part of his identity in his retirement, and that he lacked a sense of community. Like in the Robert Frost poem, The Road Not Taken, he feared making the wrong choice, reminiscent of his decision not to pursue his dream of becoming a lawyer. He was asked to visualize what it would be like going through the tunnel. Jonathan imagined it would be dark, claustrophobic, and scary to walk on the narrow sidewalk with a guardrail with all the cars driving by fast. He felt that he would eventually be able to get to the other side, but it would take a great deal of effort and time. He was asked to imagine what it would be like if he went further into the tunnel to the other side.   

Jonathan struggled but was eventually able to say that he wished his parents and best friend were on the other side to greet him, saying how proud they were of him and the sacrifices he made for his family. He cried and realized that he had taken them for granted when they were alive. I acknowledged Jonathan’s determination, courage, and perseverance despite his anxiety and that the dream reflected his progress in therapy. At the end of the session, I asked him to think about if he was currently taking anything else for granted in his life. The following session, he mentioned that he felt gratitude that his family was healthy, that he had a few close friends, and that he could still give to others and pass on his knowledge and insights to his grandchildren. I then suggested that at the end of each day he write down what he was grateful for.

Consolidation Phase: Integrating Spirituality and Creativity and Reevaluating Values

In the subsequent sessions, I asked a number of open-ended questions to further work through Jonathan’s grief and mourning including, “Are there any ways you can honor your parents and friend by living out the values and causes they believed in?” Jonathan felt that his parents were generous in giving to those less fortunate, and that his mother had volunteered in a pediatric clinic at a local hospital after her retirement. Jonathan was also determined to honor his friend’s life for the years he did not get to experience by being more adventurous and taking more chances, including planning a trip with his entire family out west to a national park. He felt that identifying these values and living them out would be a way of honoring their memory and remaining close to them even after they passed.

Jonathan returned to the next session visibly shaken by an encounter at a supermarket the day before. He noticed a homeless man desperately wanting some food. The people in line were rude and impatient with him, avoiding eye contact as if they felt disgust at his condition and shame for looking away. Jonathan quickly went to the cashier and offered to pay. Jonathan’s and the man’s eyes met, and Jonathan felt that this was something his parents would have done without any recognition for it. He felt that this small moment of compassion was a way of honoring his parents’ values. He eventually decided that he wanted to volunteer in a nearby soup kitchen one day a week and to tutor local elementary school children in reading and writing.

The final stage of psychotherapy included a number of significant events and choices. Jonathan took a trip with his entire family to Yosemite National Park. While looking at the Sequoia trees with his family, he felt a deep sense of connection to his friend, Michael, and a feeling of awe in being in a place so vast and mysterious. He subsequently began to pray more consistently, to be more courageous and adventurous like his friend, gradually releasing his fears of the unknown and uncontrollable. Jonathan appreciated that although someone dies, the relationship does not end and can continue to evolve (3).

Upon return from his trip, Jonathan reported a dream where he was walking a tall winding staircase at a water amusement park. He recalled looking down and realized that he could seriously hurt himself if he fell. Despite his anxiety, he kept on walking up and was securely placed in a luge headfirst while lying on his back. He felt scared and excited about what it would feel like going fast down the waterslide. Jonathan woke up feeling energized and proud of his courage like he did on his recent trip with his family.

Jonathan began to read and write poetry, which he shared with his grandchildren. The poems reflected themes of savoring the moment, particularly in nature and while listening to music, avoiding getting lost in trivial complaints, and expressing gratitude for what one has. Jonathan felt that his creative writing was the beginning seeds of his own legacy.

As the psychotherapy concluded, Jonathan acknowledged how his parents’ and friend’s values and personal qualities had a significant impact on his life and that he shared these values of promoting the growth and well-being of the next generation. Generativity became a new core value that provided a sense of purpose and meaning in his life (Buechler, 2019).

Concluding Thoughts: What is Psychological Health When Working with Older Adults?

The case vignette highlights the benefits of integrating existential and spiritual interventions when working with older patients. Jonathan needed to gradually process his unresolved guilt, regret, and shame regarding his mother’s and friend’s deaths before he could fully experience joy, vitality, and meaning in life once again. His mourning process was further consolidated by honoring his parents’ and friend’s values, the causes they believed in and how their good qualities had changed him for the better (4). He recognized that he shared these same values, which was fulfilling for him in maintaining a deep connection to them even when they were no longer physically present. Jonathan was able to acknowledge the legacy he received from his parents and began to integrate the value of generativity in his life.

The theme of giving to others less fortunate become a unifying thread in his life narrative. While he could not prevent or slow down the inevitable tragedies in life and the regrets over past choices, the thread provided a meaningful foundation and compass in navigating new, turbulent challenges in life. When reflecting on his treatment, Jonathan recalled that his brief interaction with the stranger in the supermarket may have impacted the person’s life, and Jonathan experienced a sense of their shared humanity.

From a meaning-centered psychotherapy lens, Jonathan not only acknowledged the historical meaning of continuing his parents’ values and legacy, but also started creating and experiencing other sources of meaning in life (e.g., experiencing connection and awe in Yosemite (experiential) and deciding to embark on more adventures and being courageous in creating new experience himself (creative source of meaning)). Jonathan’s experience of awe enabled him to deepen his awareness of life’s fragility, resiliency, and sense of wonder (5). His involvement in reading and writing poetry facilitated a change in his attitude and perspective on life. His daily practice of mindfulness provided a safe space to observe his thoughts and feelings in a nonjudgmental and self-compassionate manner, while practicing gratitude increased his appreciation for the gifts of life and the legacy of those who passed before him. Prayer facilitated his ability to let go of his need to control life and provided a sense of safety in letting go of his fear of the unknown (6).

Jonathan’s journey highlights that psychotherapy with an older adult can bring “a heightened existential awareness…a new appreciation of the preciousness of life… (and the ability) to trivialize the trivialities” (7). At this development stage, there is a degree of comfort, meaning, and purpose that one’s actions, deeds, and values can have a known or unknown rippling effect on one’s family and others (8).

Questions for Thought and Discussion

What are your impressions about an existential-spiritual approach to therapy?

In what ways was this author effective in working with Jonathan?

Might you have worked differently with this particular client?

References
(1,6) Gordon, R. M., Groth, T., Choi, E., Galley, J., Marcantuono, J., & Kulzer, R (2023b). An Existential-Spiritual model for coping during and after COVID-19. Spirituality and Clinical Practice. Published online: December 11, 2023.

(2) Gordon, R. M. & Groth, T. D. (2023a). Relational and existential supervision and therapy for adolescents with life-threatening illness. Journal of Infant, Child, and Adolescent Psychotherapy, 22(4), 311-322.

(3) Buechler, S. (2019). Psychoanalytic approaches to problems in living. Routledge.

(4) Kessler, D. (2019). Finding meaning: The sixth stage of grief. Scribner.

(5) Schneider, K. J. (2004). Rediscovery of awe: Splendor, mystery, and the fluid center of life. Paragon House.

(7) Yalom, I. D. (1996). Lying on the couch. Basic Books.

(8) Yalom, I. D. (2008). Staring at the Sun: Overcoming the terror of death. Jossey-Bass.   

Satya Byock on the Search for Meaning and Stability in Quarterlife

Posted on by Psychotherapy.net Team

The Journey of Quarterlife

Lawrence Rubin: Thanks for joining me, Satya. You're a psychotherapist in private practice and founding director of the Salome Institute of Jungian Studies in Portland, Oregon. Your newly released book, Quarterlife: The Search for Self in Early Adulthood, deals with the developmental and clinical challenges of people in this phase of life. What about this phase of life is important for clinicians to appreciate?
Satya Doyle Byock:
my interest in this time of life coincided with my desire to be a therapist, which is to say when I was in my early 20s
My interest in this time of life coincided with my desire to be a therapist, which is to say when I was in my early 20s. I could not find anything in the psychological literature to help me understand what was happening in my life. Developmental psychology has historically focused on childhood and the teenage years, and then there's a big jump to midlife and the midlife crisis, and increasingly into the older years of adulthood.

But whether you're a clinician or a person going through this time of life, those years of the first part of adulthood are historically synonymous with normalcy. With just being an adult, with just getting your life together and buying a house, getting married, and having kids. And so, it was very disorienting for me to be so confused and to experience anxiety, depression, and existential questions. I truly felt as though there was a vacuum of information that would either help me get oriented or make me feel better. So, my journey really came out of my own anguish in those years, my journey to be a clinician. 

LR: Is there such a thing as “normal” when referring to the quarterlife passage?
SB:
what I'm trying to get away from is the idea that there is one single picture of what “normal” looks like in adulthood,
It's a great question. In my book, I lay out two extremely broad types of quarterlifers, who I define as “stability” types and “meaning” types. What I'm trying to get away from is the idea that there is one single picture of what “normal” looks like in adulthood, which is to say that historically, that has primarily emphasized gaining stability. But that’s a very externally oriented goal. And so “normal” quarterlifers have been those who don't cause a fuss in quarterlife, those who are pretty comfortable adhering to economic goals and expectations of dominant culture, as well as to what are considered heteronormative gender roles. The expectations of a man to get a job, or a woman maybe increasingly to have a job and have finished college, but to be moving towards marriage and children.

And for a lot of folks, those normal goals have never worked, and they are increasingly feeling unsafe and uncomfortable. So rather than defining “normal,” I'm trying to define a broad spectrum where we can see our quarterlife clients, and quarterlifers can see themselves so they can better understand how to obtain a sense of balance, and how to get to an experience of wholeness in quarterlife, versus trying to be normal and just adhere to social expectations.

LR: “Normal” is such a moving target. Is it possible that a client could arrive at quarterlife stable, ducks in a row — house, job, relationships — but still be hurting because the meaning part is not yet in place?
SB: Absolutely, that's what I talk about in my book. The stability types may feel quite secure in the external world and in doing what society has asked of them, but at some point, they are going to ask, what else is there? Is this all there is? And theirs becomes the search for meaning in some way. Of course, that shows up differently for every individual, but that inner longing for something more tends to come for all of us.

but the so-called midlife crisis has always really been about people who I refer to as stability types — checking all the boxes, reaching midlife, and then saying, wait a second. is this all there is?
And so, I speak about stability types starting a journey towards meaning, as happening more often in quarterlife than it used to. But the so-called midlife crisis has always really been about people who I refer to as stability types — checking all the boxes, reaching midlife, and then saying, “Wait a second. Is this all there is?”  
LR: Peggy Lee couldn’t have said it better. Some might wonder if dividing quarterlifers into these two camps — stability types and meaning types — might be overly-reductionist. I think society is sort of plagued by binaries, anyway. Are you comfortable with the binary?
SB: Well, no, I'm not comfortable with binary. To write a book and to speak about any kind of theory we need to be as clear cut as we can be, but I try to indicate in the book that while I am doing my best to assert a theory and a system of working with folks — and a system in which quarterlifers can see themselves — I am not trying to introduce a strict binary. That was never the point.

So, I really try to emphasize in the book that the goal is wholeness. The goal is a unification of these opposites. It is a journey towards having stability and meaning. But clinically what frequently happens is that our understanding of quarterlife is reduced to a search for stability. When meaning types walk into our office — and you can see this in other books about this period of life — the focus just gets to be about how to get them stable. How to get them moving towards the normative goals. And very frequently they crumble as a result.

Meanwhile, if those are the goals for clinicians in quarterlife, and a stability type comes in, there's very little to explain what's going on with them, and they frequently leave clinicians’ offices with less understanding or with minimal understanding about why it is that they're suffering, because they “should” have everything and be happy with what they have.

I attempt to bring this spectrum of types into our discussion to say that the more we can locate ourselves on this sliding spectrum, between stability and meaning, the more we can understand what we are longing for, what our shadow is, and what our longings are about, and as a result get oriented.  

Province of the Privileged

LR: I imagine that the quest for stability and/or meaning are neither linear nor sequential. How does this show up in therapy with the quarterlifer?
SB: }That’s exactly right, and so that's the whole discussion, right? That is to say that both of these goals are part of quarterlife. It’s not just that stability is quarterlife and meaning is midlife. That's been the developmental psychological framework; whether we have spoken about it explicitly or not, that's what it's been. What I'm expressing is that the journey of quarterlife is like two strands of DNA; these two elements are what we are trying to weave together all through adulthood. And we need to speak about that up front, and orient quarterlifers to the fact that they are going to have existential questions, especially on a planet with so much overlapping crisis all the time. We can't just keep emphasizing trying to get them back to stability and normalcy. 
LR: With so much of our society in crisis, isn’t the pursuit of meaning the province of the privileged?
SB: No, we all seek meaning. We all seek meaning on this planet, whether you are a quarterlifer in a refugee camp, or a quarterlifer who has inherited millions of dollars. There are questions about why you are alive and in the circumstances you're in that you want answers to. And privilege is absolutely a part of what is possible for those two groups, there is no question about that. And I try to open that up much more in the conclusion of my book where I talk about the systemic issues and social issues that that can make a fulfilling journey of existence nearly impossible for, frankly, billions of quarterlifers. I don't know the literal numbers, but enormous numbers of quarterlifers around the world don't have their basic needs met.

refugees arguably are predominantly made up of quarterlifers — people who are trying to pursue their journey of existence and find a better life, a better adulthood
I don’t think that the search for meaning is something that only exists for the privileged. I think it's actually infantilizing, in the end, for us to say as much, because people in every circumstance want to know how to feel better and have the best, most enriching life they can have. Which is why, in fact, refugees arguably are predominantly made up of quarterlifers — people who are trying to pursue their journey of existence and find a better life, a better adulthood.  
LR: Irrespective of possessions or stability, this reminds me of the work of Viktor Frankl and how nothing is really stable about the life of refugees, of political prisoners, of prisoners and the oppressed or marginalized. 
SB: That's right. Well, they're overlapping — this need for survival, this need for safety and comfort, and this longing for a sense of purpose in the world. If we really see it as the physical needs for safety and comfort, and the emotional and existential and mental needs, they're just overlapping all the time no matter who we are.

Clinical Work with Quarterlifers

LR: Are there particular symptoms or diagnoses that quarterlifers will bring to you? 
SB:
we have wanted to reduce the quarterlife population to the complaints of millennials, say, or to social media issues, or to dating, or something
I think like any demographic, quarterlifers come into therapy with a wide, wide range of issues, complaints, and anguish. And so, I'm asked this question a lot, but I struggled to answer it, because I find that we have wanted to reduce the quarterlife population to the complaints of millennials, say, or to social media issues, or to dating, or something, that we want it to be concise. In fact, quarterlifers are having a human journey. And on that journey, there is grief. People lose parents, they’re sorting through adoption issues, they're simultaneously thinking about pregnancy and parenting, they're dating, they're seeking partnership, they're trying to understand their sexuality and sexual orientation, their gender, and they're making sense of their race and ethnicity. Sometimes they're dealing with immigration issues, and on, and on, and on. People, however, may very well call and say, “I’m depressed, and I don't know why. I'm extremely anxious. I'm having panic attacks. I’m having difficulties with my father. I'm having confusion with my mother.” There may be some initial presenting issues, just like any client who walks through the door, but of course we know the story grows from there once they get into our office.

I will also say that most people don't identify as quarterlifers. I'm really trying to introduce this term, because I find the other terms to historically be very pejorative and misleading. The idea is young adulthood versus a stage of adulthood, for instance, in which we need to see a whole person, not just a young person tripping and falling.  

LR: Does your therapeutic approach, technique, or techniques differ if you're working with a client who presents with, say, anxiety, and is really at a deeper level struggling with meaning? Or a client who is depressed and is seemingly struggling with issues of stability? I don't mean to be so reductionist.
SB:
stability types often really benefit from a more imaginal body, artistic approach, even though they resist it
Well, yeah, it's a good question. I will say, I think my techniques certainly are, well — let me start over and say — I approach each individual differently, certainly. But if we want to speak about broad strokes, I might say that stability types often really benefit from a more imaginal body, artistic approach, even though they resist it. That's what's in their shadow. That's very often what they are seeking, but don't know how to get there, to a more right-brained approach. And meaning types can very often benefit from a little bit more of the cognitive-behavioral approach, a little more of the left-brain structure.

Neither can be forced on them, and neither can be imposed on them. But while stability types need to deepen into a sense of meaning and kind of a holistic experience of the world, it's helpful for clinicians to give them a taste of what that feels like. And similarly, as meaning types are often kind of floundering with executive functioning and external world stuff, it can be helpful for clinicians to be gently introducing structure in that way within therapy.  

LR: As you were talking, it almost seemed antithetical to me. My first impulse is to think that stability types, as I understand them, would benefit from a more concrete approach, because they're anchored more in the world, in the present, and in the zone of achievement and acquisition. Whereas the meaning types might be ready for or open to more existential, right-brain, artistic, creative. Initially, I think CBT and all that stuff might be more applicable, but you're saying it's the opposite.
SB: Well, it's really a question of what they are missing and where they're headed, right? So, there's no question. I think stability types are much more comfortable with more of a CBT approach, typically, than an imaginal body, art therapy approach. And yet my experience is, they ultimately feel quite unsatisfied if they don't experience in therapy a sense of what it is that they're looking for.

If they come to therapy over a period of four or five weeks and then leave without a feeling of expansion or a feeling of that inner anguish being witnessed and being met, they're unlikely to continue coming back. And so, while they think what they want is structure and just a couple of checklists for what they can do at home, it's not ultimately solving the larger issue. Which is that there's a deep question of dissatisfaction happening in their souls, and that needs to be met. It's not just about typically — I mean, sometimes it is — but often it's not just about anxiety or depression on a surface level.  

LR: In this context, but on a side note, I think we diminish children when we fail to consider that children have existential needs.  
SB:
we're born with questions. that's our birthright, and it's sort of irrelevant what age you are, really
No, but that's exactly right. And I would say again, similarly, of people in lower socioeconomic circumstances or people in other parts of the world, it's the same thing. We're born with questions. That's our birthright, and it's sort of irrelevant what age you are, really. But you're absolutely right. We have been discounting that for decades. I mean, we discount that in most decades of life until people reach midlife or the elderly years, when we kind of sanction the search.
LR: I’ll jump from childhood to later life for a moment. I read an essay by social gerontologist William Randall, whose idea is that we can help the elderly by helping them re-narrate their story, rather than one of decrepitude and impending demise, to one of expanding and growing. So right here in the middle is this emerging adulthood.
SB: That’s right. And I will say again, just for the transcript really, I don't use the term “emerging adulthood.” That's a Jeffrey Jensen Arnett term, and I'm trying to get away a little bit from that as well. Because again, I think this isn't so much about emerging anything, as a stage unto itself.
LR: As a quick aside, did the pandemic alter the trajectory of your quarterlife clients in particular ways? Or did you notice how the how the pandemic left its imprint on quarterlifers?
SB: Sure, but again, it wasn't a singular experience. For some of my clients it was a huge blessing, in that for the first time they had adequate unemployment money coming in and weren’t feeling the pressure to hustle from one place to another all day long and feeling exhausted and feeling depleted and depressed. So, some of my clients finally addressed emotional or childhood issues that we couldn't find space for before. Or they were able to deepen into intimate relationships they didn't have space for previously. There were many blessings in that respect. Ironically, of course, the opposite was also true, which is that for many quarterlifers it was extremely isolating. Their symptoms of depression and anxiety increased. It absolutely had an impact, as it did on all our lives, right? But it wasn't a unilateral, monolithic experience. 

The Real is What Works

LR: Nothing is singular and monolithic. It's such a nice fantasy to think that things can be reduced. How does your own approach to therapy jive or not with the predominant contemporary quest for evidence-based treatment?
SB:
to quote Carl Jung, the real is what works
You'd have to ask the evidence-based people, I guess. To quote Carl Jung, “the real is what works.” And so, I am working all the time, in every session, to stay present with my clients and be in a deep relationship with them, to understand, is this working? Is what we are doing affecting your life? Is it having a healing effect? Is it having an enlivening effect? And if the answers to both of those questions are “no” or “maybe,” I want to do a deep check-in of what we're doing and how to reorient. Because for me, the real is what works. And that must be on an individual level, not statistically. That's not the work I do.
LR: Can you give me an example from your clinical work?
SB: In other words, what works is what works, you know? And so, for me, it's not the statistics of any given approach, because in any statistical analysis there's people for whom it's not working. And so, as clinicians, our work has to be exceedingly individual, as individual as it gets. So, if my techniques, if my approach is not working for one of my clients, that's an issue. That either means I need to reorient, or I need to refer them to somebody who is going to be able to support them. Because they're not statistics, right? What works is what works, and that's where I try to stay present.
LR: One of my dear friends and mentor used to say, “people are not evidence-based.” 
SB: I'm not a dogmatist. My clients don't have to buy anything. We're working together for their benefit.
LR: Do you use art, and mandalas?
SB: I’m not an art therapist. I have a strong Jungian background. My tool is largely — certainly, my training and my theories are useful — is me. It's my relationship with them, my presence with them, my understanding of them, and then the techniques, whether it's trauma-informed care, dreamwork, or any number of things that we might do together. That's sort of secondary to the deep relationship that we have.
LR: Does the course of your work tend to be longer or shorter?
SB:
I am allergic to stagnation
Well, I have a lot of very long-term clients. And for me, again, the goal is always to stay present with whether we are continuing to have value in their lives. I am allergic to stagnation, so if things are stagnant and uncomfortable, I try to adjust that. And if things are stagnant and comfortable, I suggest the possibility of ending our work together, so they can move out into the world and kind of shift our dynamic and relationship. But generally, my work tends to be longer-term than shorter-term. 
LR: Can you give an example of a client where stagnation had entered the therapeutic work, and something you did to “de-stagnate?”
SB: Well, I think there's a lot of ways in which busyness, but also dissociation, trauma, and the freeze state, are reflections of stagnation. There are different ways in which we can kind of get stuck as clients, and that clinicians can inadvertently perceive that as being done with therapy. There are ways in which stagnation and stickiness are defense mechanisms, you know? There are other ways in which stagnation can be manifest in compulsions or addictions, where the clinician is unable to have any kind of effect until the client chooses, really in some significant way, to shift their relationship with that compulsion.

I terminated with clients because I couldn’t find a way to motivate them to battle with those inner demons, at which time it felt like termination was the best intervention I could offer. And there have been other times when clients reached what they were seeking and felt done, and that was a cause for celebration. That felt less like stagnation to me than a genuine completion of therapy.  

LR: A rarity for many therapists, especially when there's issues of insurance and accountability to an external payor. Have you worked with suicidal quarterlifers?
SB: I think most clinicians have suicidal clients at some point or another, and I think there are more of our clients who are suicidal in some respect than we always know. But there's certainly clients who have been hospitalized, or who have been significantly suicidal, who I'm glad to say have felt significantly better and gotten to a place of thriving in my practice. And that's absolutely a goal for me, of course. 
LR: I imagine if a client was acutely suicidal, that might present different challenges for you given your orientation.
SB: Of course, but again, presence, care, relationship, and me modeling that life can be beautiful. all have a significant impact.

Unique Quarterlife Issues

LR: For those folks who are no longer able to see that life is beautiful or meaning is possible, it sounds like you're journeying with them. Have you found unique challenges around gender identity issues in quarterlifers that may be different from gender identity issues in adolescents or later life?
SB:
I think gender identity has always been a huge component of the quarterlife years
Well, I don't know that they're different at different stages of life, per se. I mean, I work with quarterlifers. Let me start there. You can scratch the first part. I work with quarterlifers, right? So, I think gender identity has always been a huge component of the quarterlife years, in that we have been historically trained towards extremely heteronormative gender roles in quarterlife, almost specifically. You know, we might jump from gender reveal parties to, okay, now you're a 25-year-old. Are you going to have babies, women? Are you going to get a big important career, men?

In other words, we've been trained towards these gender roles in these adulthood years with remarkable ferocity, and that's what so many quarterlifers are rejecting, and have been rejecting, from Sylvia Plath's The Bell Jar and the entire feminist movement to a lot of what we're seeing around the exploration of gender and attempting to break out of the gender binary now.

The question for clinicians in these years is to stay really present with that, in an utterly nonjudgmental way in a deeply curious way and invite and encourage our clients to explore whatever they need to explore around gender. Because it's a sticky and complicated issue of self-identity with a lot of social implications.

I have a number of trans clients. I have clients who identify as nonbinary. I have clients for whom gender has never really posed that much of a question, but it might be something we talk about as well. It’s critical and it's an especially important part of the quarterlife years. I will also say, the question of the masculine and feminine is core to Carl Jung's psychology, and that search for wholeness is core to Carl Jung's psychology, and that that really does also inform the stability type versus meaning type spectrum that I lay out in which, on some level, it's also still the question of masculine goals versus feminine goals, in extremely broad terms, but it's a search to have all these things. The extroversion and introversion, the masculine and the feminine, the stability and the meaning.  

LR: And I would imagine that there are trans clients who have made the, if you will, full transition to the gender that they desire and still seek meaning, who still feel perhaps that something is missing.
SB: I would say, of course that the human experience of the search for meaning is endless.
LR: Endless. What are some of the challenges when working with quarterlifers and their elder parents? Have you noticed anything unique or challenging there?
SB:
we’re walking, moving, and separating bit by bit from our parents in that way, but that continues in a significant way in quarterlife
Chapter six of my book specifically emphasizes this, although it's part of the entire journey. But I talk about four pillars of growth in quarterlife. These are nonlinear pillars, just like stability types and meaning types are a non-strict binary. But I talk about the first pillar being that of separation, and a very, very significant developmental step of quarterlife — which goes on for frankly decades, but certainly needs to be emphasized in these years — which is understanding who we are as separate from our parents. Both in terms of physical space, financially, but also in terms of values, belief systems, anxiety and depression, all the ways in which we find ourselves tied to our parents. And working on shifting those and separating that sense of self from our parents. It’s a continuation of the work we start when we were toddlers. We’re walking, moving, and separating bit by bit from our parents in that way, but that continues in a significant way in quarterlife.

And I do think clinicians would better serve all our quarterlife clients to understand the nuances of that, because we've really kind of emphasized that separation is a midlife thing. When our parents die, we do these layers of separation. And I think we're all better off the more we're consciously working on doing that decades prior.  

LR: That developmental task of separation appears in the beginning and end of life, both for the quarterlife and their elder parents. What about quarterlifers and their kids? Any unique challenges? 
SB: Well, most quarterlifers don't have adult children. They'd be mid-lifers then. So quarterlifers, historically, barring teenage and child pregnancies, the horror of young pregnancies — most parents are quarterlifers. Most are parents of young children.

When we talk about young parents, we’re talking about quarterlifers typically. And this is also a core tenet of these years. Often, they have historically really been viewed as the years of reproduction, which is why they became sort of so fixed in notions of just stability and kind of biological requirements — marriage, children — that the work of quarterlife has really been seen as being parenting. Make money, buy a house, raise the next generation, then search for meaning. That's been the kind of framework.

So, I can't say there's unique challenges for quarterlifers. Again, most people who have kindergarteners, fifth graders, or whatnot, are often in their quarterlife years. Less and less, I mean, as parents get older when they first have their first child. But I will also say that a huge challenge for this age group is socioeconomics and utter lack of support for parents and society, that we don't have universal preschool or child income support for low-income parents. There are countless issues quarterli

Krista Tippett on the Immensity of Our Lives

Posted on by Psychotherapy.net Team

Dignification of the Person

Lawrence Rubin: Over these last two decades, your always fascinating and deeply provocative interviews on your show, On Being, have spanned the disciplines from genetics to cosmology. And despite the similarly broad range of thinkers and doers who have represented these disciplines, you’ve never strayed in your attempt to provide your global audience with answers to three seemingly simple questions: What does it mean to be human? How do we want to live? And who will we be to each other?Our readership is comprised largely of psychotherapists of varying disciplines, theoretical orientations, clinical specialties, and populations served, all of whom I think are attempting to help their clients, trainees, and students answer similar questions. My guess, however, is that most of them have not followed your podcast.

With that said, how do you think that your attempts to answer these three questions can guide psychotherapists in their clinical work? Sort of an open letter to psychotherapists.

Krista Tippett: I’ve heard a lot across the years from psychotherapists and from people who are in therapy, that therapists often recommend that people listen to On Being. I’ve been so honored by that, and I’ve also wondered about it. I’m told that some of the ways I listen and construct my conversations are in sync with things that one learns as a therapist, so that’s just kind of intriguing to me.I guess what I’m saying to you is that I’ve always been intrigued by the fact that my work does seem to be valuable for some people. What I’ve heard even from young journalists — which feels a little bit to be part of kind of a kindred phenomenon — is that I’m talking about things in a way in public that that kind of honors and elevates the basic struggles and challenges that we must figure out as we seek to understand what it means to be human, and then how that takes so many distinctive forms in any given life.

I also think that I try to have a conversation with the whole human being. So, I interview people who may be very well known, maybe not, but are just incredible influences and mentors in their disciplines or in their communities. And sometimes, these people who I interview are renowned for what they do or what they’ve done. I always try to get at the full dimensionality of who they are as a person and how they’ve learned and grown through these things that they know. I’m also as interested in the questions that they hold and the questions that keep emerging for them, as I am in the answers and the certainties and the knowledge that they possess.

I think the interviews I’ve had also model the reality and integrity, as well as the dignity and beauty of the adventure of being human. And isn’t this like the adventure that people are on in an individual way when they’re working with a therapist?

LR: As I’m listening to you and the way that you work with your interviewees, I recall a word invented by David Epston, the co-creator of Narrative Therapy — “dignification”. It is the process of seeking out and validating the dignity of the person on the other end of either the microphone or the couch. You are also intrigued by those that you interview which resonates with the work of good therapy — along, of course, with good listening. The last thing you said is that irrespective of how famous they are or how much they’ve contributed, you value the whole person. You seem to have this wonderful skill of finding the deep threads of humanity that run through all the people you’ve worked with. And I think that’s important for therapy as well.Ok, I’ll stop the shameless fawning and ask the next question. Existential psychotherapy attempts to help clients address fundamental issues related to being alive, to being human. What do you regard as some of the core existential challenges that we face as a species?

KT: What’s interesting as I’m letting that question kind of sink into my body, is how differently I think I would answer it right now, both in terms of where I am in my life now in my early sixties, but also where we are in the life of the world in 2023. So obviously sometimes — not always, but sometimes — at the very end of my interviews, my final question — and this kind of emerged a few years ago, this wasn’t always true — is “given this life you’ve lived and these particular fascinations you have, how would you begin to talk about what you’ve come to understand about what it means to be human?”But anyway, the thing is, as I said, it’s going to be a very partial answer because it’s vast. But the two things that come to mind to me, this time, is that the older I get, the longer I live, the more fascinating and perplexing the question of ‘what it means to be human’ becomes. I know that the discipline of psychotherapy understands this — how the crucible of our lives — our origins and original experiences and family lives so profoundly influence us. But also, that imprint doesn’t have to mean that they were shaped in a certain direction. Because there’s so much that can happen, with what that becomes, and what we do with it.

I think it’s fascinating that we’re in this century and at this juncture as a species where it becomes clearer and clearer to me that this matter of origins and telling the truth about the story of where we came from, and what we went through, and what our shadows are, and what we struggled with as individuals is also reflected in our national life, right? So, I think there is this never-ending dance with where we started, where we began, and what we do with that and make of it that defines our humanness. And there’s so much drama to that, and there’s so much possibility in it, but it never ends.

Getting back to this century and the post 2020 world we live in, I don’t know if it’s harder to be alive now as a general statement, or that we’re in a greater state of distress in 2023 than we were in 1918 or 1945. But the challenges before us, certainly our ecological one which gets at our bodily origins, is about being human in its most primal sense. Our challenges are truly existential.

And so, I actually have this feeling in myself, and I see it and others at this time, that the question of how to be present to the world has similarly become this existential question at an individual level. But I don’t think that we know what to do with it, but I think it’s become implicated kind of in the personal journey in a way that may be new.

Certainly, people before us have lived in times of war and genocide and holocaust, right? But now, in so many profound ways, we’re faced with those three questions both at the individual and societal level of what it means to be human, how we want to live, and who we will be to each other. And the answers to these questions get reflected at the personal and individual levels in how we behave, what we do, and how we orient ourselves in order to make the difference between surviving or finding a way to flourish.

The Science of Awe

LR: I think that “good therapy” is about helping clients understand and live in their stories, but to survive in society, I think it’s important to help them connect their stories to those of others. Instead, we isolate and divide ourselves along racial, cultural, age, and gender lines. I also think that your three existential questions might aid clients in this quest. From among the folks you’ve interviewed, which of their disciplines seem to be most closely related to the practice of psychotherapy?
KT: I always find it very hard when people ask me to think about a favorite interview, or even an example, because I’m usually very steeped in the most recent conversations I’ve had. So, what comes to mind is a conversation I had with a social psychologist, which is going to be featured in our first podcast of our new season.I’m not sure this is what you’re looking for, but there’s a lot of direct application of what I sometimes think of as spiritual technologies, like meditation, to mental health and to psychological growth. And I’ve seen that accelerate in these 20 years, in a way that is completely fascinating.

Dacher Keltner is a social psychologist who also works in neuroscience at Berkeley. He’s not a psychotherapist, but what strikes me is an offering towards vitality. He’s been working on the science of awe and wonder, and the neurophysiology and the immunological boost that we’re learning of experiences of awe and wonder, and kind of breaking that down.

They interviewed 2,600 people in 60 countries, around the range of the human experience of awe related to being in the natural world. It is very importantly about what they ended up calling our perceptions of moral beauty, which is the single most common thing that gave people a sense of awe. These researchers were blown away by the courage and resilience or acts of other human beings.

LR: Moral acts.
KT: Moral acts, right? But it’s also what they call experiences of “collective effervescence.” And it can be a sports event, or it can be singing in a choir. But it’s these experiences when we just know ourselves connected to other human beings, when we have this experience of being part of something larger than ourselves.

I’m completely fascinated by how science is taking aspects of human flourishing into the laboratory

And all these things I’m describing are aspects of psychological health and well-being, right? And so, I’m completely fascinated by how science is taking aspects of human flourishing into the laboratory. And what I love about this, this practice of awe is that we’re taking seriously an aspect of human experience and naming it as something that we can actively seek out. And that when we actively seek it out, we are investing in greater vitality.

I think you’ve alluded to this a little bit and it’s something we are in our time are filling out or correcting, is this bias towards attending to dysfunction and not attending to greater vitality and greater health. And what I love about the science of awe is that even the spiritual technologies, like meditation, that people have turned to in droves, also have physiological and psychological effects.

There’s so much being used remedially in lives of incredible stress, to get calm, to get grounded, to make it through the day, so what this other kind of science is doing is giving us tools for expanding, for not just getting calmed down, but planting the right life-giving kind of energy in ourselves.

A Place at the Table

LR: I love the idea of connecting with a sense of awe — a fascination with something so small as the heartbeat to the way the stars seemingly line up in the sky. I think you’ve answered that question quite nicely, without directly answering it. Krista, that’s the beauty of conversation, as opposed to just formulaic interviewing. Something new always happens, and I appreciate you for your willingness to be interested enough and awed enough in our conversation to make it grow.What have you taken away from your interviews with faith leaders and healers that might be useful for psychotherapists who traditionally have not incorporated faith or spirituality or religion into their practice?

KT: This was my big focus when I first started this work in the early part of this century. One of the things that’s been really fascinating in these decades is how this human experience of faith identity, religious identity, has been so rapidly evolving from something that not that long ago was just a given — you know, people were born into this. And it could be good, bad, or different, but depending on the tradition and the context, it was almost like genetic inheritance, right? This identity, these rituals, these communities.And especially in the US and in Western Europe — not everywhere in the world in the same way — but that’s just fallen away in such a short period of time. I think that’s one of the things that keeps rising in my conversation and then reintroduces the question of, “if this container for spiritual experience, for the human religious experience, is completely shape-shifting and falling away, then is there anything left? And I think the answer is yes that even the containers, the forms, the inherited identities don’t mean what they once did.

Then there’s this freshness to the question of, “what is this religious part of us?” And the experience of awe is one of those things that points people back to the notion that life is mysterious. I think mystery is a common human experience. And in some ways, we’re not as connected to the traditions that gave names to that and ritual to that, but that experience doesn’t diminish. I think to me the interesting question that we’re now able to pick up is, what is human wholeness, right? And this is an aspect of human wholeness. There is a lot of dysfunction in terms of official religion or the religious voices that are in the news or that become….

LR: Politicized?
KT: Right, what gets politicized, like the violence that is done in the name of religion. And that tends to be what people think of. And that is what respectable fields and intellectuals have distanced themselves from. But what I have sought out across the years are people who live this with deep integrity.In my mind, these traditions that have carried across time and generations are essential human experiences that we need, like rituals, like sacred stories. Stories that make sense. Community song. And really these traditions are a conversation across generations. And also, I think there is a deep, deep intelligence in this part of the human enterprise. Religion is a part of the human enterprise just as science is a part of the human enterprise. There’s a deep intelligence in language and practices around language, that we simply don’t have in other parts of our life together, that to me has never felt more relevant. Language like repentance, confession, lamentation, repair, mindfulness, and other language that emerges from religious and spiritual tradition.

And so, I’ve seen this fascinating thing happen. That even as these forms and the institutions are in total flux, there is essential intelligence, there’s essential vocabulary, and spiritual and social technologies that absolutely have their place in life together, in being fully human. And yeah, in living into the challenges before us, kind of communally as well as individually.

LR: I think that while the field of psychotherapy has evolved, there has been a reluctance to embrace spirituality and religion, aided perhaps by the polarizing effects of politicization. I think good psychotherapy, like if I can say good religion, is about going back to those basic existential and transcendent issues related to your three questions, what does it mean to be truly human? So, I’m hoping that some of the psychotherapists who are reading this interview will look a little bit more differently or openly into the possibility of seeing that psychotherapy is just one branch of knowing, one way of knowing the experience, and it really is diminished if it excludes others like religion and spirituality.

In COVID’s Wake

LR: In addition to the medical, of course, what does the field of psychotherapy need to focus on when it comes to the epidemic of anxiety and depression that has arisen and continues in COVID’s wake?
KT: As you were saying just a minute ago about, all our disciplines have kind of walled themselves off from each other others, right? And psychotherapy, the Academy, and journalism have been suspicious of religion for all kinds of good reasons that we can name. And those separations have been made culturally over the last few hundred years. What has intrigued me, and what I feel COVID has kind of called us to — a track we were already on — is for these disciplines to all agree that the other one is wonderful, and that we need them to be in conversation with each other. Each of these disciplines are essential aspects of this human enterprise. What I’ve become aware of in my investigations across these years of COVID, as I try to use my interviews, not just to be offering something up that would be helpful for my listeners, but even for me to investigate what was going on in my own body, my own psyche; is how there are these fields that have offered new insight about the human nervous system. All this wonderful research has been happening about the fear response, and the vagus nerve, and the stress response. And this is despite this being a little off to mainstream medicine, and I suspect a bit off to psychotherapy.

And yet I think when we’re talking about anxiety in this time, there’s as much that has happened in our bodies below the level of consciousness, below the level of anything that we know is happening — much less could talk about — that is interacting with what we can in a more traditional way identify as aspects of mental health. So, I think to me that’s felt like an urgent call. We’ve lived through this period where the ground shook beneath our feet. And we’re learning about the effects of uncertainty, which is as stressful for us as when something goes wrong.

All of this is happening inside our bodies, and some of it comes out and expresses itself psychologically. Additionally, we are not in the natural world, we are of the natural world. And I think that the ecological disarray of the natural world, of our planet, is something that we feel at a cellular level.

What we need in this time regarding anxiety is a whole analysis and for our disciplines to be talking to each other. We need to gather this scattered intelligence because there is so much coming together that can be healing in a broader way than we’ve been able to do. So, I mean, that’s what this time has surfaced for me.

On Death and Dying

LR: One way or another, clinicians, either explicitly or implicitly, address issues of death, dying, and mortality. Is there hope that we will get better as a society at allowing death inside our lives? And what can psychotherapists do to open the door to these universal concerns?
KT: I absolutely agree that that is imperative, and I am finding in new generations a real openness to this — a kind of insistence. All our disciplines in the West have bought into this weird idea of “up, up, up.” And with this came the idea that we were on this track of always forward progress, which meant denying that things end, and that we are so fragile. And along the way, we seem to have developed a very brittle understanding of human strength and success.I think that illusion just doesn’t hold anymore. And younger people, even pre-COVID — but Covid has certainly just intensified this big reality check. There are these things called “death cafés.” Have you heard about this?

our religious traditions have been the only place — again, in the human enterprise — that addressed mortality and finitude

There’s a movement that was led by people in their twenties who are now in their thirties called the “Dinner Party,” which is all about people bringing death and dying and grief, like, wearing it on their sleeves. That this is something that happens. Yeah, it’s absolutely fascinating. And our religious traditions have been the only place — again, in the human enterprise — that addressed mortality and finitude.

LR: And we’ve excluded them.
KT: And we’ve excluded it, right? We said, ‘no, we don’t want that, and we will pretend like it’s not true.’ So, there’s health in returning to this reality and honoring it. I do see new generations doing that because it’s just the truth. There are certain lies we’ve told in the name of progress that are exposed as fallacies now.
LR: Based on that, Krista, what advice would you give to therapists who work with clients whose focus on happiness comes at the expense of acknowledging their brittleness, their vulnerability, their mortality, and their limited time in this universe? Or am I being too morbid?
KT: No, I mean, again, it sounds paradoxical, but acknowledging fragility and things failing, as much as our strengths and things that go well, is how we become whole. This is how it works. I think one thing I’ve really been privileged by has been interviewing tremendously wise people. I think about somebody like the late Desmond Tutu, who absolutely had seen the worst of humanity, right? He knew what it was to suffer and lose, many times along the way to achieving something astonishing.It’s not like people who become wise and whole have it better than the rest of us, or had it easy, right? Like, hadn’t had the adversity? It’s what we do with that. It’s not about overcoming it so much as …

LR: Integrating it.
KT: Yes, how you walk with it and through it, and integrate it into your wholeness on the other side. I’ve seen that over and over and over again. I think about this Buddhist monk who actually started out his life as a scientist, a molecular biologist. He’s French, and his father was one of the great atheist philosophers of France. He’s talked a lot about happiness, this notion of happiness, and how in spiritual perspective — I would say in an enlightened spiritual perspective — happiness is not a state of being that you achieve, sustain, or return to. It is a way of moving through whatever happens, which will include sadness, loss, and failure. It’s an orientation. And you know, I think the language of flourishing is much more useful than that. I think, really, we have so many pathologies as a nation that are just out on the surface now, but I think it was probably a real tragedy for us, that the pursuit of happiness was given to us as a right when we don’t have…

LR: Tools?
KT: Yeah, and we don’t even have a working definition of happiness that is actually good for us. But psychotherapists and spiritual teachers owe it to each other to formulate that meaningful definition of what happiness can be.
LR: And it’s not just happiness — it’s not just about more.
KT: It’s not just about more.
LR: It’s not just about better.
KT: It’s not a mood. It’s not just about something you can achieve and then you have it forever. What a recipe for always being depressed and anxious if that’s what you think life is going to be like.
LR: The recipe that life begins when your symptomatology ends, as opposed to life is in part built on the stories that carry with them symptomatology. What tips would you offer psychotherapists, based on your intimate interviews with these people like Desmond Tutu that you’ve described as “wise.”
KT: I feel so humbled to be telling psychotherapists to do anything. But here’s what I want to say. I wrote an entire book called Becoming Wise, and I realized after I finished that I had not ever defined what “wisdom” was. So, when I went out talking about the book, people have asked me, “So what’s your definition of wisdom?”Achieving a state of wisdom is different from, say, becoming knowledgeable or accomplished. A wise person might be both knowledgeable and accomplished. Whereas I think the measure of a wise life starts with the imprint they’ve made on other lives around them. And if that is the measure of a wise life, then people who are wise are also at home in themselves, in their bodies, and their experiences. I never met a wise person who doesn’t know how to laugh and smile. And that’s not because everything is funny or they’re always happy in that simplistic way, but they understand that the capacity for humor and joy is actually part of our birthright. It’s part of resilience. It’s life giving, its resilience-making, and it belongs in a life alongside all the other things.

So, if that is a good life, then how do we talk and work towards that? Is it a different direction from feeling better every day? Or how do you accomplish your goals? I’m not saying those things become unimportant, but this is a different orientation, and it’s more fulfilling and grounding than much of what we aspire to and are better at training in each other. But it does not take us where we want to go.

My definition of spirituality at its best is befriending reality, and surely that’s also a goal of psychotherapy. But I don’t know if it’s what people come to psychotherapy for, so there’s a there’s a little challenge for your profession.

LR: Thank you so much, Krista. I can’t wait to share your wisdom with my colleagues.

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

Posted on by rezendevknowfully.com

In Search of Golden Geese

Lawrence Rubin: You are a practicing psychotherapist, owner of a large group practice, and consultant to other practitioners around practice development — including selling those practices. You have also mentioned to me that you twice went through the full process of selling your own practice to private equity firms but changed your mind in each instance. What exactly is a private equity firm, and why the seeming current high level of interest in psychotherapy practices? 
Joe Bavonese:
private equity firms tend to be these rather large companies whose sole purpose is to buy other businesses as an investment and then flip them in a couple years
Private equity firms tend to be these rather large companies whose sole purpose is to buy other businesses as an investment and then flip them in a couple years, hopefully making a profit. In the last five years, they’ve figured out that mental health practices can be a very profitable company to purchase in lieu of trying to make a profit. So, we’ve seen this influx of these large national companies that are heavily funded who have either started their own practice — like BetterHelp — or are simply purchasing practices with the goal that “We’re going to buy maybe 5 or 10 practices and then in 3 years we’ll sell them all to a bigger fish and we’ll make 50 percent profit.”  
LR: If the sole purpose behind private equity firms buying practices is flipping and profiting from the sale, does it really benefit the owner of the practice beyond whatever remuneration they receive? Or perhaps what I’m asking is if there is any fidelity to the practice of psychotherapy involved in these purchases. 
JB: Well, that’s been the big controversy, Lawrence, because in the last few years, it seems like the larger the private equity firm and the more money they have, the less concerned they seem to be about patient care and/or how the staff is treated. So, that’s one of the ethical issues that I think a lot of practice owners are experiencing. You know, “Do I want to sell my practice to a company where the care of the clients may deteriorate, the staff may be unhappy, and I’ve nurtured this baby from day one as my legacy, and it’s all going to get trashed?” So, that’s definitely one of the big problems. 
LR: They say that you never really lose money buying real estate or gold, but why do these equity firms think that psychotherapy practices are golden geese, so to speak?  
JB:
what’s attractive about psychotherapy practices is that they are relatively inexpensive to run — you don’t need any fancy, expensive equipment
What’s attractive about psychotherapy practices is that they are relatively inexpensive to run — you don’t need any fancy, expensive equipment. The demand for mental health, especially since COVID, is through the roof. Then what they typically do is buy a practice that only has psychotherapists and immediately hire several psychiatrists which adds tremendously to the revenue and the profit margin. They’ll do things like this just to eke out as much profit as they can, but it’s really a volume game. In other words, they are really looking for large practices where there are 30, 40, or 50 therapists and then they can really show a higher profit margin on volume. 
LR: Is that common? Are there that many group practices of that size in this country to be bought? 
JB: Oh, yes. There are. I can talk in terms of revenue over size of the practice, but there are quite a few group practices that have revenue of at least $2 million. I know quite a few that are between $4 and $6 million gross revenue, and then the profit of that ranges from 15 to 25 percent. So, if you have a $5 million practice and you make a 20 percent profit, that’s a $1 million profit a year. That’s not chump change. 
LR: No. That’s not chump change at all. Is there a difference between a venture capital organization and a private equity firm when it comes to buying and selling psychotherapy practices? 
JB: I’ve not heard of a venture capital company wanting to buy a psychotherapy practice. You hear about how they seem to go after tech start-ups and things that really have a chance to scale tremendously. Psychotherapy doesn’t scale tremendously like a Facebook or Amazon.  
LR: What does scalability mean when it comes to selling and buying a private practice? 
JB:
over the last two years hiring has been very difficult
Scalability means you can grow exponentially. So, a typical experience would be that of a practice owner who has three therapists who says, “Wow, this is great. I’m making $1,000 profit a month for doing nothing.” Then suddenly, they have 6, 9, 12, 15, and 20 therapists, and they’re making $200,000/year profit, and it just grows rapidly exponentially. Almost everybody I know who has a large group practice never thought they’d get as big as they are. They’re always like, “Well, I thought I might get 5 or 10 therapists and have a nice little cushy cash flow on the side.” But once it takes off it’s almost like it just gathers momentum and more people hear about it. Now, having said that, over the last two years hiring has been very difficult. I think the pace of scalability and growth exponentially has slowed down for many practices. 

Winds of Change

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

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

There are more and more group practices. On Facebook, there’s a page called “The Group Practice Exchange.” It has like 3,000 members. There are more people who have realized that just having a solo practice may not provide enough money to live the lifestyle that they desire. That was certainly my motivation. I thought when I got out of grad school, “Oh, I just need to fill out my practice, my wife’s a therapist and there’s two of us, and we’ll be fine.” Well, life is expensive when you have kids, a retirement, college savings, and all that, and a lot of us realized it’s not enough money.  
LR: So, there was an exponential increase in group practices. Did COVID impact the scalability of practices and their value? 
JB:
as the interest rates have gone up along with fears of a recession the valuations that private equity firms have given group practice owners have gone down significantly
The peak valuations group practice owners were getting was around 2020. However, as the interest rates have gone up along with fears of a recession, the valuations that private equity firms have given group practice owners have gone down significantly. But in terms of your question, during COVID I think the virtual therapy businesses like Talkspace and BetterHelp, who had massive backup funding from Wall Street, just poured millions of dollars into hiring and advertising. So, that created a real problem. The other thing I’ve been hearing in the last six months from several group practice owners is that some of these companies are poaching their therapists. So, yes. It’s just created a whole different climate. Now, referrals are plentiful, although that seems to be slowing down a little lately. But finding therapists is much more difficult. 
LR: So, these trends are making private practices less attractive to equity firms right now, or more attractive? 
JB: Less. They’re willing to pay a lot less than they were just two years ago. The other trend I should mention, Lawrence, is that it’s never been easier for a therapist to go out on their own. I’ve heard so many cases over the last two years during COVID of good therapists leaving group practices saying, “I’m going to sit at home and do what we’re doing right now on Zoom or on some other platform, and I’m going to make 100 percent of the money, and I don’t need to pay for an office.”  
LR: So, there was a massive increase in interest in group practices, followed by decreased valuation related to COVID? 
JB: Yes, because the people that were able to hire during COVID did very well. I have several colleagues and friends who put a massive amount of money into hiring and retention. They hired recruiters and did all sorts of things. Many of them expanded tremendously during COVID because the referrals were plentiful, and it was just a matter of finding bodies and you could fill them up instantly with referrals. 
LR: Then that slowed down? 
JB: Yes. Group practice owners' ability to hire has been a problem. I was just talking to someone yesterday in Oregon. He has a large group practice and said, “The problem is that therapists are leaving to go on their own just to do teletherapy. No office payment. Plenty of referrals if they’re just on Psychology Today. And they’ve been able to keep 100 percent of the money.” 
LR:
but with COVID and the exodus into teletherapy these same therapists figured I don’t need to pay overhead anymore I can work in my pajamas out of my basement
So, the group therapy practices were a haven for therapists who didn’t want to run their own practices, but with COVID and the exodus into teletherapy, these same therapists figured, “I don’t need to pay overhead anymore. I can work in my pajamas out of my basement.” So, there’s been a retreat from group practices and the group practices became less profitable, scalable, and thus less interesting to private equity firms? 
JB: Yes. They’re still interested. It just seems like they are willing to pay less. There’s a concept when you value a practice called EBITDA, which stands for “earnings before interest, taxes, depreciation, and amortization.” But what it really means, to simplify it for our discussion today, is the profit of your business plus whatever you pay yourself that a buyer wouldn’t have to pay. So, for example, let’s say your practice value is $200,000 a year, but you pay yourself $50,000 a year for salary and you pay yourself $50,000 a year for healthcare and other miscellaneous personal expenses. Well, the new owner isn’t going to have to pay for either of those, so you add that to the $200,000 and now your valuation is suddenly $300,000. Then they give you a multiple of that as the ultimate value they’re willing to pay for the practice. Two years ago, people were getting multiples of 10 or 12 times their EBITDA. So, again, if it was $300,000, that could translate into a $3 million value. Now, in the last few months, I’m hearing 4 to 6 is typical, with occasionally an 8. So, the value you could get two years ago could be double what you get today. 

The Business of Practice Ownership

LR: It sounds like owning a group practice, or even a private practice, requires a certain degree of entrepreneurial skill. My understanding and my experience are that psychotherapists who are there to help others are not necessarily entrepreneurs. Do you find that that’s the case?  
JB:
one of the biggest struggles a lot of private practice owners have is separating the need for service from the need for paying attention to the bottom line, the numbers, and the money
Yes, absolutely. I’ve been coaching therapists since 2005. One of the biggest struggles a lot of private practice owners have is separating the need for service from the need for paying attention to the bottom line, the numbers, and the money. A lot of therapists tell me they feel guilty if they promote themselves. A lot of therapists are not good at numbers and keeping track of all the metrics. What I would say is the group practice owners who have succeeded at a high level are all entrepreneurial, have all studied business in various ways, and have figured out how to be a business owner as well as a clinician. 
LR: That makes sense. You certainly seem business savvy, so what was your experience like each time you went through the process of selling your practice but then pulled back? 
JB: It’s interesting. The first time I went through the process was in 2018. Valuations were still pretty low back then. But the process was that you got a letter saying, “This is what we’re willing to pay for your practice,” and then you have a 60-day period of due diligence where the company that wants to buy your practice wants to look at all your metrics to make sure that what you told them was accurate, which makes sense. So, if you said your revenue was $2 million and it was really $1 million, they would want to know that. So, you had to give them a slew of things like years of tax returns, profit and loss statements, and a lot of just busy work. A lot of spreadsheets, PDFs, and things like that.  

The part I found uncomfortable was that they basically try to prove that you’re lying to them. And you’re pretty much talking to a bean counter. You’re not talking to a therapist. So, their job is to prove that the numbers are valid and accurate. But my experience was they did it in a fairly demeaning way, which was uncomfortable. Like I said, “I gave you all these tax returns, all these bank statements, and you think I’m lying or hiding? What could I be hiding?” So, that was part of the process. Then what happens is that you start out with an offer and then their job is to whittle it down by saying fairly trivial things just to keep lowering the number, which can’t go up from the original number — but it can certainly go down. 
LR: Like car dealers. Just it’s not a car, it’s a practice. So, it was demeaning, it was patronizing, it was nickel and diming, and that sort of took the wind out of your sails? 
JB: Yes. Ultimately, we ended up with a number that I didn’t think was worth it because one of the things you think about is, well, how much profit do I make in a year? And if I could make up in two or three years what they were going to pay me in one lump sum, well, that seemed kind of stupid. I figured I could make a lot more money in 5 or 10 years than getting out now and just having this one lump sum. 
LR: It seems that the group practice owner contemplating a sale must consider not only financial issues, but lifestyle issues, existential issues, family issues. It’s not just a matter of how much money, but it’s what’s left for me professionally and financially if and when I do sell. 
JB: Yes, exactly. Because if I said to you, “I’m going to give you $3 million,” well, that sounds like a good chunk of money. 
LR: But? 
JB:
if you sell your practice and you leave, and you’ve devoted every waking second to this for the last 10 years, it’s a huge loss of meaning
But you’re going to pay taxes, you’re going to pay broker fees, you’re going to pay attorney fees. So, you usually end up with about two-thirds of that, and then is that enough money to live on for the rest of your life? In most cases, not. So, part of it is, do I have enough money to do this, or do I want to stay on and keep working like a lot of people do? I wasn’t interested in that when I was doing it, but a lot of people stay on once they sell and take an annual salary.

I’ve seen $125 to $250,000 a year, and that of course makes it easier to see if the money will last. But then you have the other issue of, “Now, I have a boss when I haven’t had a boss in years and I’m part of a large organization with politics and other things.” But you use the word existential. The meaning question I think is one of the significant ones because if you sell your practice and you leave, and you’ve devoted every waking second to this for the last 10 years, it’s a huge loss of meaning, and I don’t believe one that’s easily replaced. 
LR: What types of psychotherapy practices seem most attractive to private equity firms? 
JB: What they’re looking for is consistent growth over the last three years — 20 to 30 percent per year. They want to see an expansion in staff. They want to see diversification of services. They’d rather have a company that’s the one-stop-shop that deals with anxiety, depression, couples, and trauma rather than just somebody who has one specialty. They’re also interested to know if medication is prescribed by a nurse practitioner or psychiatrist, which is a huge bonus because it’s a cash cow for them. They’re also interested in geography — they want to enter a territory and start you as the hub of that territory. Or if they already have practices in your location, they may want to add you as one of the spokes around the hub. Those are some of the main factors that they’re looking for. Also, a healthy profit margin. If your profit margin is 8 percent instead of 20, well, you’re not going to get as much money because there’s an inefficiency there that they’re going to uncover. 
LR: Have sellers of group practices ever been held liable by these equity firms for unmet financial promises? “ 
JB: This is what happens. Usually, they structure the deal where they’ll say something like, “This is the price I’m willing to pay, but it’s contingent on a certain percentage of therapists staying,” because a certain percentage of therapists will typically leave after a sale. So, for example, what they’ll often do is they’ll say, “I’m going to pay you $1 million for the practice, but only $500,000 today, and then depending on the size of the staff in 6 or 12 months, I may only pay you $200,000 more because you’ve lost 20 percent of your staff.” So, it’s incumbent on the owner to be the cheerleader to encourage all the staff to stay on. Typically, they have better benefits than they had previously, so there are some incentives to stay on. But again, if the quality of the client care and the staff care decreases significantly, a lot of people are going to leave. 
LR: When a group practice owner is planning a sale, do they ask or have their therapists sign an “I will not leave” contract to protect themselves against that?  
JB:
almost every mental health stock in the last 2 years has gone down 70 or 80 percent
No. The company buying the practice will have a contract everybody must sign. They typically don’t tell them until the ninth inning. It might be two weeks before they close. So, all the therapists will usually meet with the group practice owner as well as somebody representing the buying company, and they’ll present them with a contract. Then they’ll say, “You have two weeks to sign this contract,” and if a significant number don’t sign it then the deal is off. So, that’s the tense part. I have known some deals where they didn’t have a thing like that. The other thing I should mention, Lawrence, is often the companies that are buying prefer that some of the compensation be in the form of stock options instead of cash. So, I might say to you, “Okay, I’m going to pay you $2 million, but $500,000 of that is going to be in stock options.” Then they’ll tout the potential of the stock. However, almost every mental health stock in the last 2 years has gone down 70 or 80 percent, so if you were one of the ones who were banking for a big payday because of your stock options you may have lost quite a bit of what you thought you were getting. 
LR: Stock options? 
JB: Yes. In other words, I’m a big company that’s on the stock exchange and I have shares that I will give you. I’m going to give you so many thousands of shares. But you can’t sell them right away. You’ve got to have two or three years before you can sell them. But remember, in the last two years, almost every mental health stock has gone down like the rest of the market. 
LR: So, when you’re saying mental health stock, you’re not talking mental health stock. You’re talking about the stocks and the shares in the private equity firms or the firms that own the firms? 
JB: Yes. 

Ethical Concerns and Red Flags

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

Sometimes what we’ve seen is that some of these large national companies really don’t have anybody who’s ever run a group practice at the higher levels. So, some of the things that they do don’t work very well. I’ll give you an example. A large national company may, for example, have five practices around Tampa and only one regional call center. A potential client can’t walk into the actual practice and make an appointment. They can’t walk into the office where their therapist works to speak with that therapist or check on their bill. They have to call this regional center that has no idea who they are. The feedback I hear is it’s been awful because people are used to getting answers right away with a friendly face in the office. There might be an office manager they can talk to. Suddenly, there’s this impersonal regional center that answers the calls and a lot of people don’t like that. 
LR: Along these lines, you mentioned that you’ve had serious concerns about the ethical issues of selling. This is obviously one of them — the stakeholder, the client getting lost in a large corporate machine. What other ethical concerns have arisen from this for both practitioners and clients? 
JB:
i think a lot of the ethical issues I hear are about the unknown part of the sale and how the staff will be treated
The other one is how the staff is treated. Again, when you run a group practice, you usually have a dedicated admin staff who have grown with you. It feels like your family. They’ve gone through all the tough times with you and the good times, so they’re very loyal. So, the idea of throwing these people to the wolves is part of the ethical issue. I think most group practice owners worry less about the therapists because there’s so many opportunities nowadays for them to land on their feet or go on their own. But I think a lot of the ethical issues I hear are about the unknown part of the sale and how the staff will be treated. For example, an owner may sell their practice in 2022, and the purchasing company says, “Yes, in 2025, we hope to sell out to another company and then all the policies and procedures are going to change again.” So, there’s this unknown. What am I subjecting my staff to? It’s just impossible to know. 
LR: Aside from the impersonal nature of practices that are regionally managed, are there other downsides? 
JB: In addition to feeling like things have gotten more impersonal and colder, there may be changes in insurance. There may be changes in therapists’ availability. There may be changes in non-competes. They may feel more locked into a schedule. Those are mostly the things that I think the clients or patients feel. 
LR: Are there any red or green flags when a group practice owner is sent a letter of interest by one of these national equity firms? 
JB:
in retrospect, I’m grateful I didn’t sell because I had no idea what I was doing
The group practice owner must do their own due diligence. In the last couple of years, most group practice owners of a significant size have gotten two to five letters like that in the mail. So, usually, they just want to talk to you on the phone initially and give you the sales pitch about why you should consider this. But I think the red flags would be you really need to be part of a support group of other group practice owners. I run or co-facilitate four different group practice online groups of various sizes and we share resources. Somebody said, “Oh, I’ve got a new one. I just got a letter today. Has anybody heard of this one?” So, it really helps, because when I first did this in 2018, I didn’t know anybody back then who had been approached or tried to sell so I was really shooting in the dark. In retrospect, I’m grateful I didn’t sell because I had no idea what I was doing. 
LR: What about when a single therapist gets a letter about joining a group practice that has been purchased? Any red flags there? Because I get several of these a week. 
JB: Again, you just have to do due diligence and see what they’re really offering and ask if it’s really any better than what you’re doing right now. You’re definitely going to lose some freedom. It may make certain aspects of your practice easier. But you really have to research. The companies are so different. Some of them seem very focused on clinical care, and with others it just seems like an afterthought, just as an example. 
LR: Have there been reports to the Better Business Bureau or to the APA, or are there similar places where someone while doing their due diligence could go to see if these private equity firms have not met their promise or been abusive? 
JB: As simple as this sounds, Lawrence, the best thing is often to go on Google and just type in the name of the company with the word reviews and it reveals quite a bit. Some of the companies are listed in the Better Business Bureau, though not all of them, and you can get some feedback there. But I’m just finding that the word of mouth through the community probably gives the best information. But I’m surprised by just how much you can get just from a simple Google search. 

A Short List of Tips

LR: Is there a short list of tips and guidance you could offer a practitioner who is approached by or seeks out a private equity firm?  
JB:
some of these equity firms not all are just ruthlessly focused on growth and all they care about is bigger bigger and bigger
Well, like I said, do your due diligence. Get as much information about the company as you can. Especially ask, “Why are you interested in my practice now? What is your goal for the next few years? What is your philosophy about how you treat the staff and the clients?” Because, like I said, some of these equity firms, not all, are just ruthlessly focused on growth and all they care about is bigger, bigger, and bigger, and it comes through clearly when you talk to them. Others will slow it down and talk about their philosophy. But you really want to zero in on how much do you really care about clinical care? How much do you care about the competence of the staff, or is it just a numbers game to you? So, those are some of the things you want to find out. 
LR: So, theoretically, a private equity firm could come in and just fire the whole staff? 
JB: Well, they wouldn’t do that because hiring even for them is still difficult these days. Really the only value of the whole enterprise is the staff and the client, so if you fired them, you’d lose the whole revenue. 
LR: In insurance companies there’s usually a psychologist who oversees claims and answers difficult questions. In your experience, has there been a clinical point person in these equity firms? 
JB: Yes. Usually, they have a clinical director, a regional clinical director, or a national one that you’ll talk to who will make everything sound sweet and rosy. But during that 60-day due diligence, that person is pretty absent and you’re mostly just talking to the accountants or the attorneys. 
LR: Boy, you’ve really got to be sharp and on your game. 
JB: Yes. That’s what I should mention. There’s no way as a licensed psychotherapist to do this on your own. You have to get a broker or some financial person to help you through it. It’s just too much stuff that you have no idea about. You need somebody who understands the lingo and can help you avoid the obvious traps. 
LR: Have private equity firms favored white-owned, white-serving practices? Is there a racial/cultural line? 
JB:
i would say the percentage of black owned group practices is lower than the percentage of Blacks in the population
That’s a good question. I would say the percentage of Black-owned group practices is lower than the percentage of Blacks in the population. Like I said, I’ve talked to probably 80 to 120 group practices in the last 5 years. It’s not an exhaustive search, but it probably gives me a fairly decent survey of who is out there. I haven’t heard of that. I think they’re more focused on the numbers and whether the location fits into their long-term strategy, but I really don’t have any data on that. 
LR: Of those 80-120 practices you’ve spoken with over the last 5 years, have you found that there’s a consensus around the right time to sell, or is it more idiosyncratic? 
JB: Well, it is idiosyncratic, but there are some categories I think people fall into. One category is that “I’m so burned out and sick of this, I’ve got to get out,” which unfortunately I know a fair number of people like that where they are constantly stressed out by their group practices, constantly stressed out, and physically and emotionally exhausted by the demands of dealing with the staff. For those people, I think if they can afford the deal financially, it is probably best to get out because they’re not happy. They’re really not enjoying the ride. Then the other thing is the category of people that just want to say, “I don’t want to ever have to work again if I can get a good enough deal, and if I like the philosophy of the company buying me, then that’s good and I’m happy to do it.” But again, it depends on your age, the age of your kids, all those financial things, and your lifestyle. So, I’m thinking the most common thing is that the motivation is financial, clearly. A good friend of mine recently said, “I’m looking for a new challenge. I’ve been doing this for 10 years. It works well, I know how to do it, but it’s getting kind of boring. And a lot of the private equity firms are saying, ‘I want to buy your practice and then I want you to spearhead the project of adding eight more locations around the area of your practice.’” 
LR: And they don’t want to do that. They just want the hell out. 
JB: Yes. But if they want to stay on to keep a salary coming, that’s basically what they’re going to be doing for a while. It’s just, “Okay, what do you think of this one?” More than likely, the parent company will fund it. One of the nice things people have told me is not having to worry about the price of furniture or computers — it’s sort of like a blank check. Whatever you need in terms of a new location, we’ll provide it. 
LR: So, the group practice owner who is ambivalent or who is not quite at the stage of life where they should make the decision probably needs to be coached? And that’s where you come in with your consulting service. 
JB:
i do one on one coaching. I have other colleagues who do one-on-one coaching for the same reason for those people
Yes. There are a lot of people who are interested in it, but they don’t know some of the things we’re talking about today. They don’t know the realities. Or somebody promised them something on the phone that turned out to be false in the long run. So, I do one-on-one coaching. I have other colleagues who do one-on-one coaching for the same reason for those people. 
LR: Joe, to turn the tables; if you were me interviewing you, is there anything I’ve missed? Any questions I could’ve asked that would deepen our readers’ understanding of the issues? 
JB: JB: I just think the existential issue gets minimalized by people. I really don’t think people realize how hard it is to replace meaning in their life because it’s not like most entrepreneurial-minded people who are successful at a group practice do not do well with free time. One of the phenomena I’ve seen which is interesting is that as people get bigger and more successful, they stop seeing clients totally and then they delegate more and more stuff, and suddenly they might only be working 10 or 20 hours a week. You would think on the surface that would be great, but what I hear is, “What do I do with my time?” So, it’s like having gaps in their schedule after working crazy hours for years to build this thing up is often difficult. It sounds funny, but it’s a real issue that I think people minimize when they go into this process. 
LR: So, I would imagine you often coach these folks around the existential issue, almost like doing therapy?  
JB:
one of the things that I did was to ask myself what were some of the things that I stopped doing when I had kids and when I started my group practice that I wished I could have continued
Yes. It becomes more therapy than business coaching at that point because everybody’s sense of meaning is different. But I guess it’s no different than retirement coaching other than they’re still working to some degree. But yes, it becomes more like therapy to kind of tease out, “Well, what are the most meaningful things?”

One of the things that I did was to ask myself, “What were some of the things that I stopped doing when I had kids and when I started my group practice that I wished I could have continued?” Then I made a list and that’s what I’m doing now, so it works out nicely. But I still think a lot of people have never thought about it. “Well, it’ll just be an endless vacation, or I’ll just play golf.”   
LR: Or climb mountains or go to baseball games. 
JB: That’s right. 
LR: Thanks so much for sharing your expertise and experience with me today, Joe. This area is so new to me, and I think it’s going to be equally new and hopefully helpful to many of our readers, some of whom may be contemplating joining a group practice or building a group practice or selling their group practice.  
JB: Well, good. I’m glad to hear that, thanks. 

The Existential Importance of the Penis: A Guide to Understanding Male Sexuality – Daniel N. Watter, EdD

Posted on by Psychotherapy.net Team

Existential Sex Therapy in Practice

The practice of sex therapy and psychotherapy can be done utilizing many different modes and theoretical orientations. Yalom reminds us that existential psychotherapy does not represent a standard set of techniques, styles, or protocols. The concepts of existential therapy can be best understood as a lens or guide by which psychotherapy is practiced. Practitioners of all theoretical philosophies can bring an existential perspective to their treatment process. 

When I treat my male sex therapy patients, I follow a similar pattern with all as a starting point. Whether I am treating an individual male or a couple, I like to begin by asking about what brings them in to see me and allow the story to unfold in whatever manner they choose. I am particularly interested in the description of the problem, the conditions under which the problem manifests itself, and the timeline regarding when the symptom first presented. My goal is to begin to get an understanding of the meaning and protective/adaptive purpose the sexual difficulty may represent. Typically, men will present with little to no insight as to the reason for their sexual shutdown. They often describe a generally satisfying relationship with a partner they find attractive. Most of the men I treat, especially those experiencing erectile difficulties, will report relative ease at attaining penile tumescence, and engorgement will be maintained through extended periods of sexual foreplay. But the erection fades as intercourse approaches or shortly after penetration occurs. Typically, these men reveal a current history of satisfying and frequent masturbation. They will often express a vague notion of being anxious about sexual function and a firm belief that their penile difficulties have some medical basis. However, they are at a loss to explain how a physical or medical issue allows for erections that are fully functional during masturbation but not penetrative sex. Their partners are similarly stymied. 

Following the initial consultation, I will focus on family and developmental history. If I’m treating a couple, I will ask to do three individual sessions with each before resuming couples’ work. It is important to me to develop a good understanding of each person’s experience in his or her family of origin and to identify any patterns of trauma that might be getting triggered in the current relationship. I want to learn about the personalities of family members, their relationship with each of them, and their relationship with each other. I want to know if this was a family that was able to communicate about and/or demonstrate emotions, or if theirs was a family of secrets and repressed suffering. I want to know if there was any presence of substance abuse or domestic violence and/or parental neglect/over-involvement. In essence, I am looking to gain an appreciation for any family dynamic that may have felt threatening that could be reenacting itself in the current relationship and, thereby, creating a threat to the man’s existence and well-being.

Many highly regarded sex therapists will spend a great deal of time taking an in-depth sexual history. I do not, as I find much of the information in a standard sex history to be irrelevant, particularly in those men who have had a prior history of good sexual functioning. Through an existential lens, the sexual “problem” is often not about how the man feels about sex per se. The sexual problem is more typically understood as an attempt for the man’s penis to communicate some deep anxiety, concern, and existential threat to his existence. Therefore, to more fully comprehend the message the penis is sending, a comprehensive developmental/family-of-origin/ relational history will be of greater value. Let’s consider the case of Russ from the perspective of an existentially oriented sex therapist. 

The Case of Russ

Fifty-one-year-old Russ came to see me shortly after his wedding to Sarah. This was a first marriage for Russ and the second for Sarah. Both had come from traumatic families of origin, and Sarah’s first marriage was to a man who regularly abused her. Russ’s primary complaint was a lifelong inability to ejaculate. I began by asking Russ for a timeline regarding his ejaculatory difficulties. I have found that the time of onset of problematic sexual symptoms is often of great significance in understanding what may be triggering the current inhibition. While most men presenting with this complaint have their ejaculatory difficulty limited to their time with a partner and have little to no difficulty ejaculating during masturbation, Russ reported that Sarah was his first sexual partner, and ejaculation during masturbation was problematic as well, although it would occur on occasion. Given the unusualness of this situation, I asked if Russ had consulted a urologist or other physician, and he indicated that it was his urologist who provided him the referral to me. His urologist did not detect any medical explanation for Russ’s ejaculation problem. 

We next began to talk about Russ’s upbringing and family of origin. Russ came from a family with two professionally educated parents, both of whom enjoyed great professional success and respect. They also were rather puritanical and punitive. Russ was the oldest of four children, and the siblings all have minimal interaction with each other. Despite the fine professional reputation his parents possessed, Russ recalls them as constantly fighting, explosively angry, sleeping in separate rooms, engaging in multiple infidelities, and hardly being civil to each other. Neither had much to do with the children, his father due to excessive alcohol use and his mother using her work to avoid being at home. He recalls his mother telling him in a fit of rage that she never wanted to be a mother and blamed his father for forcing parenthood on her.

Russ also reported that laughter, enjoyment, and pleasure were not only absent in his home but were considered sinful and to be averted at all costs. Any expressions of joy were severely reprimanded and punished. As a result, Russ learned as a young boy to repress any feelings or demonstrations of delight, joyfulness, and pleasure. He recalled that to the present day, if he is enjoying a television show or a musical piece, he will turn it off. He does not enjoy comedians or most other forms of entertainment. His free time is spent reading serious, nonfiction books and tinkering with electronic devices. Regarding the specifics of sex, he reports a strong libido and easy arousal, but he begins to panic as he approaches ejaculation and, thus, ceases all stimulation. In addition to shutting down all sensations of pleasure, Russ reports learning to be exquisitely attuned to the displeasure of his parents. He was constantly scanning the home environment to head off any actions or commotions that would rouse the ire of his chronically unhappy and volatile parents. Russ grew up a very lonely child. Despite having three siblings, the home was minimally interactive, and Russ did all he could to avoid other family members. He spent a great deal of time alone in his bedroom or in the local branch library. He recalls few friendships with schoolmates, as his parents discouraged such contacts. His activities were primarily solo, and this pattern continued through college and his career. In high school, Russ discovered a love of the sciences, and he decided to pursue a career in medicine. While he enjoyed his studies, he found his clinical rotations to be laborious. For a time, Russ thought he had made a poor career choice until he discovered the field of pathology. Pathology afforded him the solitude he found comforting as well as the opportunity to pursue his interest in lab sciences. In addition, being a pathologist required minimal interaction with colleagues, offered steady, predictable hours, and relieved Russ of the burden of having to deal directly with patients. He had a reputation at work as a hardworking and dependable physician but also as a loner who showed little interest in the lives of his co-workers. Oddly, his workplace was where he met the person who would dramatically alter his life’s course, Sarah.

Sarah was a pathologist in the same lab as Russ. She was also a serious- minded and reserved person, but she was more social and outgoing than was Russ. She found Russ to be appealing for several reasons. She liked that he was smart, hardworking, and seemingly uninterested in office gossip and politics. She also discovered Russ’s dry, witty sense of humor as being particularly self-effacing and clever. She decided to ask him to join her for dinner one evening, and Russ, to his surprise, accepted.

Russ did not date and reports no prior relationships before meeting Sarah. He was quite taken aback when Sarah invited him to dinner, as no other women had ever pursued him. He liked Sarah, thought she was beautiful, and found her laugh to be quite charming. She always seemed to genuinely enjoy her conversations with him, and this was a most unfamiliar experience. Russ recalls being nervous before the date but also excited to go. He reported they had a surprisingly nice evening, and he felt a lightness that was both strange and pleasing. He very much wanted to continue dating Sarah. Fortunately, Sarah, too, recalled enjoying her evening with Russ, and the two began to spend a considerable amount of nonworking time together. Sex proceeded slowly, which was fine for them both. Russ was unable to ejaculate during intercourse and soon began to develop erectile difficulties. Russ found erections fairly easy to achieve and maintain until it was time for vaginal penetration. Russ would then begin to lose tumescence. Sarah was unflustered and patient, but Russ was frustrated. He wanted to be able to fully experience sex with Sarah, mostly because he did not want her to feel bad or worry that he wasn’t attracted to/interested in her.

It seemed readily apparent to me that Russ’s traumatic upbringing was affecting his sexual functioning. His penis was speaking to him and cautioning him against allowing himself to be vulnerable to others. We spent a good deal of time discussing his family of origin and how his penis might be trying to send him a message of prudence. Existentially, Russ suffered from fears of mortality and isolation. Specifically, Russ found his existence threatened by his feelings of vulnerability with Sarah. His past relationships with family left him vigilant against allowing others to get close and potentially harm him. He had spent most of his life as a loner, and this allowed him to feel protected and safe. However, meeting Sarah made him aware of the depth of his loneliness, and he longed for companionship and love. While his conscious mind was telling him how wonderful life with Sarah would be, his protective unconscious was alerting him to the peril and fragility of his existence should he allow himself to be exposed and laid bare to another. The threat of hurt, rejection, and grief was palpable as Russ continued to deepen his affection and connection to Sarah.

In addition to the threat of annihilation, Russ also was becoming increasingly aware of his isolation from self. His perpetual scanning of his childhood home environment and vigilance for any signs of upset from his parents made him unaware of what his own needs were. That, combined with the family’s disdain for anything pleasurable, left Russ in a constant state of anxiety during partnered sex. When in sexual situations with Sarah, Russ was so preoccupied with whether Sarah was responding positively that he was oblivious to his own sense of sexual arousal. Psychotherapy focused on Russ allowing himself to become comfortable with experiencing nonsexual pleasure and then moving to sexual pleasure during solo masturbation. A combination of dealing with the trauma of his childhood environment along with some directed behavioral suggestions allowed this to be accomplished over a period of several months.

Allowing himself to ejaculate during his time with Sarah proved more challenging, and improvements came about in small, inconsistent increments. Russ’s ability to fully let go when in the presence of another was (not surprisingly) difficult to overcome. Russ’s childhood home taught him to self-protectively be on guard against the ire of his warring parents. Hypervigilance in the presence of others became his lifelong strategy for survival. Overcoming the trauma of his childhood took considerable work in psychotherapy, but eventually, Russ was able to ejaculate in Sarah’s presence. First, he was able to ejaculate in her presence via solo masturbation. This then progressed to Sarah being able to bring Russ to ejaculation using her hand, and eventually, Russ was able to ejaculate during sexual intercourse. Each of these successive advances occurred inconsistently for quite some time but gradually became easier and easier to achieve. During times of emotional stress/dysregulation on either of their parts, Russ will regress, but such regressions are temporary and typically resolve in a matter of days to weeks. Both Russ and Sarah are pleased with their movement, and treatment is ongoing.

Russ and Sarah’s story illustrates many of the seminal points in existential sex therapy. Note the existential concerns of a threatened existence and the penis speaking through a self-protective shutdown of sexual functioning. Russ feared his existence would be snuffed out if he allowed himself to be emotionally close to Sarah or allow himself to feel joy/ pleasure. In addition, Russ became increasingly aware of his isolation from himself. When with Sarah, he was so consumed with scanning her reactions that he completely lost sight of his own desires. Russ’s anxiety about displeasing another meant that the only time he felt sexually comfortable was during solo sexual activity, when he could focus exclusively on himself with no distraction.

Russ was a man who was deeply untrusting of others, and this, along with his isolation from self, negatively affected his budding relationship with Sarah. While what makes psychotherapy work is always somewhat mysterious, it seems clear to me that a significant aspect of Russ’s improvement was the quality of the therapeutic relationship built between the two of us. Over time, Russ came to trust that my interest in him and his well-being was genuine. As his comfort with me increased, Russ was able to take more risks in therapy and reveal more and more of himself. In addition, he was able to venture into unexplored territory as he began to learn more about himself, his feelings, his fears, and his desires. Existential sex therapy, like existential psychotherapy, is rooted in the depth of the therapeutic relationship. The elements of connection, genuineness, compassion, and safety are the most potent tools available to the practicing sex therapist.

I am often asked if behavioral sex therapy exercises have a place in existential sex therapy. While I tend to use them sparingly, they certainly have an important place in providing some immediate relief of symptoms and encouraging patients to take risks and move forward. However, I believe that a therapy that was primarily based in behavioral exercises would have been ultimately ineffective for Russ. Russ had suffered so much damage from his family of origin that without doing deep trauma work with an existential lens, he would not have allowed himself to move toward tolerating the experience of pleasure. In addition, exercises that focused directly on the functioning of his penis would have been of little value until Russ better understood the messages of anxiety and trauma being communicated to him through his penis. Frankl’s process of dereflection allowed Russ to focus on triggering of childhood trauma and allow his protective unconscious to loosen its grip. Still, behavioral suggestions clearly had a place in Russ’s treatment, as merely working through the trauma of childhood would not have given him the sexual skills he required. I am often reminded of one of Yalom’s most important axioms: “Insight without action is merely interesting.” All good therapy needs to move the patient beyond the point of insight to take the necessary emotional risks to make use of such insights and awarenesses. As a result, even though the bulk of my therapy focuses on deep reflection and insight to assist the man in better understanding the message his penis is sending him, I often find behavioral exercises or suggestions to be of great value.

Let’s examine another case that illustrates the principles and process of existential sex therapy. 

The Case of Ascher

Ascher was a 44-year-old man who had been married for 21 years to Marcie. Both reported a generally satisfying relationship that had recently become distressed due to Marcie’s discovery of Asher’s many infidelities. Ascher admitted to frequent use of pornography, chatrooms, and sex workers. Marcie discovered Ascher’s transgressions after being diagnosed with a sexually transmitted infection at a routine GYN exam. 

Both Ascher and Marcie were religiously observant, and sexual intercourse was not attempted until after marriage. Sex seemed to proceed smoothly with little complication for the first 12 to 24 months of marriage. Both reported a high level of sexual satisfaction during this time. However, Ascher began to pull away from Marcie sexually, and their sexual frequency quickly diminished. When Marcie questioned Ascher about his apparent sexual avoidance, he offered some vague explanations and vowed to increase the frequency of his sexual initiations. Ascher did begin to initiate sex more often, but then he often would experience erectile loss just prior to vaginal penetration. Both Ascher and Marcie found this distressing, but Ascher was reluctant to consult his physician and instead just drifted further away from Marcie sexually. Marcie was troubled by Ascher’s lack of interest in pursuing an answer to this conundrum, and the two began to fight repeatedly. It was later discovered that Ascher’s reluctance to consult his physician was due to his awareness that his erectile difficulties did not occur during solo masturbation or inter- actions with sex workers. Had Marcie not been diagnosed with an STI, this cycle of sexual avoidance may have continued indefinitely, as divorce was not a consideration for either of them.

Ascher agreed to begin psychotherapy and consulted a “sex addiction specialist.” Sex addiction therapy proceeded for about a year, but improvement was minimal. Therapy focused primarily on behavioral interventions designed to control Ascher’s urges to sexually “act out,” as well as regular attendance at a 12-step sex addiction group. Ascher reported enjoying both the individual therapy and the group meetings and found the support he received from both to be very meaningful. However, Ascher felt that his issues were not being adequately identified and addressed, and change was negligible. Both Ascher and Marcie were frustrated by the lack of progress, and they were referred to me for an alternative approach to the problem.

My initial meeting was with both Ascher and Marcie, but their wish was for Ascher to receive individual psychotherapy. Marcie attended the session to be supportive and offer to be helpful in any way she was needed. However, Ascher felt he needed to “confront his inner demons” and wanted to do this via individual treatment. I agreed, as I thought Ascher’s difficulties preceded and were separate from his relationship with Marcie, and we agreed to begin individual therapy with the idea of bringing Marcie into the therapy at a later point if necessary.

Ascher and I began by discussing the onset of his problematic behavior. He reported that he had never felt sexually conflicted or compulsive prior to his marriage to Marcie. He reported loving Marcie and thought she was an outstanding wife, mother, and friend. He found his behavior puzzling, as he found her sexually attractive and enjoyed sex with her greatly. We also discussed his prior psychotherapy and what he found helpful and not helpful about it. Ascher recalled liking his therapist and felt great relief at being able to discuss what he had been keeping hidden for so long. He also enjoyed the support and camaraderie of the 12-step group but had a nagging sense that as inconceivable as it was to him, his problem was not really about sex, which was the sole focus of his prior therapy and the 12-step group. I asked him if his problem was not about sex, what did he think it was about, but he had no answer and found his situation to be quite puzzling.

We next began to talk about Ascher’s family of origin and childhood memories. Ascher was the oldest of five boys born to a religiously observant mother and father. He reports a generally happy home environment in which the laws and rituals of Judaism were practiced, celebrated, and enforced. Ascher was educated in Jewish day schools, where he received both secular and nonsecular education. He recalls enjoying school and being a very good and popular student. Ascher was very much committed to his religious teachings and practices but recollects always fighting a desire to rebel. He didn’t mind or object to any of his religious obligations but always felt an objection to being “controlled.” Ascher described himself as being an intensely curious youngster who frequently questioned the absoluteness of rabbinic authority and wanted to know what the “forbidden” experiences would be like. He had questions about the laws of kashrut (the requirement to keep a kosher diet) and often felt a strong urge to sample non-kosher food and, on occasion, did secretly indulge. As an adolescent, Ascher experienced the expected sexual urges and desires and would occasionally allow himself to masturbate. These transgressions left him feeling guilty but pleased by his displays of autonomy and independence. Again, it was not that Ascher felt forced into a life of religious observance that he did not want, but Ascher abjured feeling controlled, stifled, and limited.

Ascher reported that while he was eager to marry Marcie, he felt rather quickly like marriage was “suffocating.” This feeling was quite surprising to him, since he believed he enjoyed being with Marcie a great deal. Nevertheless, marriage quickly felt confining, limiting, and controlling. Since Ascher did not engage in premarital sex, he did not know how he would have behaved sexually in another relationship with someone besides Marcie, but he suspects he may have felt suffocated in any relationship that removed his ability to feel as if he had choices.

It was becoming increasingly clear that Ascher was reacting to feelings of being controlled (losing his autonomy) and suffocated. Existentially, this would correspond to Yalom’s dilemmas of freedom and mortality. Ascher’s problematic sexual behavior was likely his response to these internal and unacknowledged conflicts, much like his desire to sneak non-kosher foods when a young boy.

When I mentioned this to Ascher, he responded immediately and enthusiastically that this conceptualization resonated strongly. Ascher then described the strong obligation he felt to not disappoint his parents or to be a poor role model for his brothers. Throughout his life, he felt both proud of and burdened with these responsibilities. The combination of family and religious obligation often made Ascher feel as if his life was not his own, and he struggled with his desires for freedom and autonomy against the perceived constraints imbedded in so much of his life. He reported never having expressed these feelings to anyone before, and this was never explored in his prior therapy. As our discussion continued over the weeks and months, it became increasingly clear to Ascher why he was behaving as he was, and he felt that now that he had a substantially greater insight into the meaning behind his actions, he would have an easier time dealing with them. It was now time to ask Marcie to rejoin the therapy.

Marcie was pleased to participate in the therapy, and she had been doing important work on herself in individual therapy. She reported being pleased with Ascher’s new understandings and insights but found herself struggling with issues of trust. Her existence now also felt threatened, as she saw Ascher as not only someone she loved but also as someone who had the ability to do her great harm and destroy the life that she loved. It was determined that they would be best served by another psychotherapist for couples’ therapy, since Ascher wished to continue his individual therapy and growth with me. Both Ascher and Marcie agreed that this was the best way to go, and I referred them to one of my colleagues who did couples’ work. At the time of this writing, Ascher continues a productive individual psychotherapy with me, and the two of them are doing well in couples’ therapy, having recently begun resuming their sexual relationship.

The case of Ascher again highlights how the penis speaks for distressed men. Ascher shut down sexually when he began feeling suffocated and constrained. First, he pulled away sexually from Marcie. This was of great concern for her, and she began to push Ascher for an explanation. Since Ascher felt unable to express his feelings for fear of acknowledging his “less than pure” urges, he subordinated his emotions and tried to bypass them. He then tried to accede to Marcie’s wishes and continue to interact sexually with her, but his protective unconscious would not let his penis function, and the sexual shutdown took a much harder-to-explain path. All of this was further complicated by Ascher’s frequent use of pornography and sex workers. These outlets, while making Ascher feel extremely guilty, also provided him with the “reassurance” that he was not being controlled and still possessed the autonomy to rebel against expectations. Given the internal conflicts Ascher was battling, it is little wonder that a therapy primarily focused on behavioral exercises designed to increase sexual interest and improve erectile functioning fell short. Ascher’s protective unconscious would thwart all efforts to move into territory that created an existential threat to him. Until those unacknowledged and unexpressed conflicts had been exposed, Ascher was unable to understand, and therefore change, any of his problematic behaviors.

Oftentimes, behavioral sex therapy’s treatment failures alert us to the possibility that something else is going on, and it is in these cases that an exploration of existential issues may be most helpful. In the case of Ascher and Marcie, we see that once again, the penis speaks and, according to well-known psychologist and sex therapist Kathryn S.K. Hall [with whom I had personal communication, sometimes it yells!

***
 

In this chapter, we have explored many of the most salient features of existential sex therapy and how sex therapy with an existential lens differs from most traditional forms of sex therapy. Ascher’s case provides us with an excellent transition to our next chapter, hypersexuality, or what is often referred to as sex addiction. Many of the patients we see in sex therapy practice are not suffering from a sexual shutdown but what appears to be quite the opposite — a pattern of sexual behavior that they find difficult to control and manage. The existential issues in cases of hypersexuality are often most closely aligned with fears of death and mortality. Let&

Dr. Shelley F. Diamond: A Psychotherapist Facing Death

Posted on by Psychotherapy.net Team

How to Tell My Patients

My doctor at first thought my month-long pain was probably heartburn, and I said “No, I’ve had heartburn before, and this does not feel like that.” And she said, “Well, take some Prilosec for a week.” I did that, but the pain was getting worse. That’s when she said, “Well, let’s do some tests.”

They tested my urine and blood, which determined that I needed an ultrasound, and that determined that I needed a CT scan, and that showed I needed a biopsy, which diagnosed pancreatic cancer.

All that was very disturbing, of course—medically and existentially. Once I got that clear information, my first thought was, “Oh my god, I have all my patients!” and my first decision was, “I can’t deal with my personal issues until after I figure out what am I going to do about all my patients first.”

I’ve been a psychologist in private practice since July 1, 2006. It’s been over 15 years. I have a full seven day-a-week practice. I had to deal with all the patients that were currently scheduled and those calling for an appointment.

So I realized I had to come up with something to tell my patients. Each person is different, so how would each of these people need to hear this news? Certain patients do everything over email, including arranging appointments, and I realized—okay, certain people I can tell over email. But some people don’t do email.

I knew I would have to tell some people over the phone, and I was concerned this might cause them harm. One older woman only communicated through phone calls, and I knew I would have to tell her on the phone; I knew that would be the most difficult person to tell. In my own life I’ve been told that way that loved ones of mine were dying, and it felt like a horrible way to hear this news. And I didn’t want to tell anyone via text, so I just sent them a text saying “I sent you an important email. Please read it.” It required juggling several different communication methods.

Some of my patients were going through a bad time in their lives, and I knew I needed to wait a few weeks to see if there was a better time to tell them this bad news.

What I realized was that for most of my people, it would be best to compose an email message that I sent them the day before our scheduled session. I had a template with the first paragraph, and then I customized the rest of it for each person.

Most of the people received the subject line: “Bad News.” They needed to have a heads up so that before they opened it, at least they knew it was bad. It would be helpful for a lot of my people to prepare them to open the message.

Then I started out with their name and, “I have some bad news to tell you. I’ve been diagnosed with pancreatic cancer, and I only have a short time to live.” Then I said, “Please accept my apologies for this abrupt change in our relationship. It hurts me to have to share this bad news. I wish this wasn’t happening.” It was important to connect with them in a human way, because anyone knows this is a horrible thing to have to write.

The third paragraph was, “The only good thing is that I know you have learned a lot in the time that we’ve been talking together. We can still have our session scheduled for tomorrow, but that will probably have to be our last session. In the last session we will review the progress you’ve made, because I don’t want you to forget what you’ve learned.”

Each in Their Own Way

I had to send this to about 40 patients. There were a couple of people that I thought were going to need more than one final session. So, for a few of them, I wrote, “If you need more time we can have another meeting, but let’s see what we can talk about tomorrow.” But no one wanted more than one session. I think it was too painful for everyone. The one last session was so intense that they couldn’t open up again in another session.

They all expressed a concern about taking up my time, and I had to reassure several that it was important to me that we have that last session. There was one person who couldn’t respond at all, and just didn’t show up for the last session. I sent him a message saying, “I understand this was probably too much to deal with, and I have known you long enough to know how you feel, and it’s okay.” And then there was nothing else from that person. I knew he needed me to acknowledge that, because I DO know how he feels. I have several patients that I’ve been seeing for years. He was the kind of person who expressed very frequently, “Oh, I’m so grateful for our work together.” He didn’t need to repeat that, I knew how he felt.

I had a different relationship with each person, of course. Some of them needed to say things in the last session, and some of them didn’t. One woman was inappropriate, in that she had boundary issues. She said, “I looked up your home address on the Internet, and I want to come over and feed you soup, and I want to take care of you.” She had an “I’m going to smother you with love” kind of response. And so I had to make the boundaries clear and told her, “I appreciate your intentions, but that’s just not appropriate at this time.”

With her and several other people, I had to immediately connect them to another therapist. That was the other challenge I had—getting them referrals. Because I knew someone like her needed to transfer immediately to someone else. Luckily with her, I was able to identify a therapist I knew would be good, and she did connect with that person right away. Then I was able to say, “Talk to your new therapist about how you’re feeling. I know you’re grieving, and this is your way of trying to stay connected to me, and I know this is part of the grieving process. This is reminding you of all the people in your life who have died and you’ve lost connection with. There is a lot to talk about, and this will be a good way to connect to your new therapist.”

With some people, I had to help facilitate their taking their emotions and using them to be with someone else, because that I couldn’t do that with them anymore.

I’m taking this opportunity to say a little bit about what I did because when it happened to me, I had no idea what to do. Graduate schools and continuing education need to show therapists how to deal with such situations as I found myself in. It seemed up to me to reinvent the wheel, or perhaps even to invent it. The only good thing was that I was very aware that I had to figure this out. I had an intense feeling of urgency. I just used what I felt with my patients to guide me in sensing what each person needed from me in each moment.

And for people who I had seen for many, many years, I was able to say things like “I know you’re in a stronger place now than you were when we first connected, and I know you have the resilience now to deal with the ongoing challenges in your life.” I needed to reinforce some of the ways that I really did know that they had grown over time. To one person I said, “I know you have more confidence in dealing with the challenges in your life. It’s made me happy to see you grow and change for the better over time. I’ve seen you so many years, it feels bizarre that I won’t ever see you again;” validating the feelings that I knew they would have. I would add, “I’m glad I was able to be there for you during your long divorce process;” “I’m glad I was a witness to your changes in emotional maturity over time;” “I know you’re capable of commitment, and I hope you can find someone else who is capable of that.”

Email communication was good because it’s a document that they could come back to. I made sure that I wrote things to people who I knew used written materials in their process. In their last session, they said, “Oh, I’m going to keep this by my bedside, so I can read it again when I get discouraged.” That’s why I sent them these things the day before, and then in the last session reinforced this again. I said, “Let’s talk about your progress and how we can make sure that this grief doesn’t trigger a relapse into your old unhealthy ways of coping with things.” I said, “The only good thing is I know you’ve made great progress, and it’s been a pleasure to watch you free yourself from all the old patterns in your life.”

People responded with, “I’ve never talked to anybody about death like this before.” In the last session, I would ask them, “Who have you known that was dying or died. What did happen?” And 99% of the people said, “We never talked about it. It was just something that you didn’t talk about. It was always something to avoid as a terrible thing.”

One thing I do want to mention is that when I put my original notice to the San Francisco Psychological Association, with the subject line, “Telling my patients I’m dying,” I received an outpouring of support and messages from my colleagues who were wonderful. People were very kind.

One of my colleagues who responded shared that she had also faced cancer, and that she had talked to her patients and said, “I know that it’s scary to talk about cancer and death.” She added, “I’ve had some very good conversations, and it was important to talk about it, and it was helpful to them…We’ve had some profound conversations.” Her saying that really helped me become more conscious of what these last sessions could be. I realized, this is a therapeutic issue, and I need to think about how this could help them to talk about death. Because before that I was thinking, “Oh my God, I’m causing them harm by having to tell them this.”

I knew I needed to be thoughtful about not causing them harm. But my colleague’s message awakened me to the possibility that this discussion could be a profound therapeutic gift. And that is exactly what happened; I would say 98% of the people had an amazingly deep therapeutic session where they opened up about how talking about death was something they’d never done before. Even the men were sobbing. I’ve never heard the men cry like that before, even the very macho kind. They said things like, “I could never talk to my mother or grandmother like this when she was dying,” and, “I wish my mother had been able to talk about this”—they grieved not getting that opportunity before with various people in their lives.

They were able to talk about our relationship and what they had gotten out of being in therapy with me. And they were able to expand it to the idea of death in general, how we don’t talk about it, and were glad that we were able to do so. Some said, “I’m going to live a better life because of this. You’re helping me realize I can’t take each day for granted, and I can appreciate everything more.” “Because this has happened, I’ve reached out to my family and told them that I needed their support.” “Now I feel more connected to my support people because you’ve given me the courage to talk about this, so I’m going to talk about it more with them. You’re helping my whole family.” People were very effusive and heartfelt. I mean, many were sobbing. The only people who didn’t really cry were a few people from cultures that taught them not to show deep feelings, but I could tell they were shocked and saddened. Everybody was profoundly touched. Some said, “Thank you for being so honest about what’s happening,” and “I had people who died, but they just disappeared, and I didn’t even know what happened or why they died. There was no way to get any questions answered.”

Grokking the Infinite

There’s another kind of pain. I’ve almost died many times from eating nuts. I’ve always felt that I wasn’t afraid to die simply because I’d come so close to it before. It was always an experience of just letting go and surrendering to the process. Because what I learned from that is, don’t fight it, just relax. The best thing always in that situation for me was when I realized, “Uh-oh, I’m having anaphylaxis, and so I might die right now,” was to be as completely physically relaxed as possible, and sort of go into a trance. That’s really what helped me. I would go into what I would call a hypnagogic state, where I was conscious, but it’s an altered consciousness. Like just before sleep, for some people. I really use that time as I’m falling asleep or as I’m waking up, to hold onto that hypnagogic state. It’s an altered state, but it’s a very peaceful state. I always associate that with a dying experience because it feels like it’s between worlds.

I remember one of my early existential experiences, when I went on a camping trip with my family. We were outside at night under the stars. I remember I was with my father and we were looking up at the sky, and it was one of those places where there were no lights, so you really could see more stars than you could at my suburban home. And I remember looking at the sky, and at that time, they had this TV show called Ben Casey, M.D., and in the beginning of each episode a Dr. Zorba would write symbols on a blackboard, and say, “Man, woman, birth, death, infinity.” And I remember asking my dad, “Dad, what’s infinity?” And he just said, “Look up at the stars, that’s infinity.” He said something very simple like, “It goes on forever.”

I looked up at the stars, and I felt I could suddenly grok the idea of infinity. It was like the movie about Helen Keller learning the sign for water by feeling the water coming out of the pump. I must have been about eight years old, and I remember this intense awareness of the immensity of the universe. For a moment I felt it, and then the next it felt too intense, and I shut it down. But I always remembered that moment I did let it in, I could let it in, and it has stayed with me all these years. I can go to a planetarium and feel it in a way I couldn’t feel it when I was a little girl. Now I love to go to the planetarium and be absorbed into that immensity for an extended period.

To me that’s what death is, you get absorbed into that infinity, that immense infinity that our human brains are too small to comprehend, the totality of the cosmos. Humans are probably too fragile and limited to hold the voltage of that infinity experience, and so we have to kind of shut it down to some degree. Because when you really think about how vast it is, it’s beyond our capacities. We blow fuses.

As my Zen friend says, Death really is the Great Mystery. And I’ve always said it’s a mystery what the true cosmos is; I don’t believe we can comprehend it. Every human finds some way of explaining it for themselves, whether it’s a religion or a faith or a philosophy. I just think of it as all philosophy, of what helps them tolerate this ongoing uncertainty, that we’ll never know. We cannot know. But we need to know. That’s what being a human is. We want to know, we need to know. We need an explanation.

My recent experience has been sort of a building on that foundation, in that my experiential reality since I’ve been given this diagnosis is that I have a felt sense of my molecules preparing to disperse. It’s very hard to put into words, but I feel my—that’s the only way I can say it—my molecules are preparing to disperse into the cosmos. There’s some—it feels almost physiological, but it’s clearly a psychophysiological experience—it feels like my molecules are preparing to expand. There’s a sense that something is expanding and opening. Every single cell in my body is starting a journey.

It’s very subtle. I feel slight changes in every level: my body, my thoughts, and my emotions. I had to go through a process of understanding what’s been happening to me. I’ve been writing in my journals, and that’s been very good. In these hypnagogic states I’ve been trying to process, how do I conceive of this? I’ve always been prepared to die, from having had childhood medical problems; for so many years I was suffering a lot, and spent most of my life thinking that I would be so glad when I die and be done with all this suffering. I was always expecting to have no problem jettisoning everything.

But I’ve been feeling very good physically these last five years, and I’m 65 now, so I’m having a different experience, “I’m feeling good now! Oh no, I see why people don’t want to die. I’m having mixed feelings because I just figured out how to feel good and now, I must go?”

Another level of it is being aware that my sense of time has changed. I now live with a time reference point that other people don’t have. I talk to people and I’m aware they’re living in a time structure that I used to live in, and I’m not in that anymore. I’m in a different group now. Over the last five years, whatever happened, I’d think, “Well, I’ll do that someday. At some point I’ll get around to that. If it doesn’t happen this week, that’s okay, it’ll happen at some point soon.” I can’t use any of those reference points now.

I’m very glad I had those experiences with anaphylaxis from exposure to nuts, because I know I’m so much better prepared for what I’m going through than someone who’s never had that. And I can tell from talking to other people, the way they are imagining what this would be like is so different. It’s been interesting to talk to people. Some people say things like, “So now you know you’re going to live less than six months, do you have a bucket list? Are you going to go have fun and do whatever you never got a chance to do?”

No Bucket List, Just Gratitude

No. Number one, for my whole life I did everything I wanted to do because I knew I might not live very long. I’ve always done everything I wanted to do. I was never waiting for retirement to do fun things. That would never have occurred to me.

Number two, I have so many things I HAVE to do right now, I don’t have time to go have fun. I’m grateful that I am not going through any medical procedures, because the only suffering I have is pain. Other than that, I feel fine. I can do everything I want to do. My mind is sharp. I’m in charge of everything that’s happening. I’m juggling ten different things. I’m juggling attorneys, and accountants, and doctors, and who’s going to help with my patient files. I’m juggling so many different projects that I probably wouldn’t be able to do if I were sedated or going through some sort of medical procedure.

Another thing I am grateful for—and I spend a lot of time writing about what I’m grateful for—is that I am still mentally fine right now. I didn’t add more side effects from medical problems to my suffering. I have had a certain amount of time to get my affairs in order, for which I am truly grateful. Some people get this diagnosis and they’re dead in a week or other very short time. I’m grateful, I’ve had months, because when I first got the diagnosis, I thought I’d better act as if I were dying next week. “You better get into gear, overdrive, because you may be dead in a week. You have no idea how much time you have.” And so I’ve been very, very active, as much as I possibly could, from the day I got this diagnosis.

I’m grateful that I have lived as long as I have, because I thought I was going to be dead before I was 20. My father died when he was 60, and at the time I thought he was an old man. I was 19 when he died. At the time I thought that at 60, a person is old. And I remember people saying, “Oh, your father, it’s such a shame he’s dying at 60.” I thought, “What’s he going to do after he’s 60?” I remember I didn’t understand why people thought that was a short time to live.

For resources I recommend an organization called You’re Going to Die, which does public gatherings where people talk about death. They tell stories, sing songs, read poems, and they share whatever they need to talk about in terms of an awareness of the fact that “you’re going to die.” I think they are a beautiful organization. They’re here in the San Francisco Bay Area. During COVID they are doing it over the Internet, but they did do them in person.

They have a little coin they give out. On one side it says “You’re going to die,” and on the other side it says “You’re not dead yet.” The whole point of it is to raise your consciousness to be aware that yes, you’re going to die, and we need to be able to talk about the pain of knowing that is going to happen, but we want you to be aware that you’re not dead yet. You need to have both so that you can be present in the moment in a more helpful way.

I also recommend the Ernest Becker Organization (ernestbecker.org). He was a cultural anthropologist who wrote the ground-breaking Denial of Death in 1973. Another resource is Death Café (deathcafe.com), which I have attended in the past.

Thank you, dear readers. I will just say goodbye for now. I hope to encounter your spirit again.

Shelley Diamond, PhD
San Francisco, California, USA
 

***
 

Editor’s Note: Dr. Diamond closed this conversation by sharing the 2019 poem “You Will Lose Everything” by Jeff Foster, noting that she had shared it with people who said it was helpful to them. It begins with “You will lose everything” and ends, “Loss has already transfigured your life into an altar.”

This article was excerpted from a conversation between Dr. Shelley Diamond and Dr. David Bullard on January 23, 2022. 
 

Existentialism and the Environmental Crisis: The Urgency of Meaning

Posted on by Psychotherapy.net Team

Many years ago, while taking a summer class at a local university, I happened upon a copy of Existential Psychotherapy by Irvin Yalom, a title which appealed to me given that I was a newly graduated philosophy major. Reading that book was the tipping point in my decision to go to graduate school. Throughout my graduate studies, I kept searching for a faculty member or practicum site supervisor to engage me in mutual exploration of the existential concerns that were elaborated in that work. Unfortunately, those discussions never really materialized in the way that I envisioned or hoped, as at that time Cognitive Behavioral Therapy was emerging as the predominant school of thought informing most psychology graduate programs.

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Since then, my clinical work with children, adolescents, and adults who have experienced complex trauma has brought me face-to-face with these fundamental human concerns, in particular with the need for meaning and purpose and for a sense of belonging in a sustaining community where we work out our identity and contribute to the welfare of others. Many of the leaders in the trauma field have emphasized the critical importance of these most basic human needs, which have also been identified and expanded upon by the work of clinicians, teachers, and researchers in the fields of constructive developmental psychology, mindfulness, and social neuroscience.

Recently I have started re-reading Existential Therapy, motivated by the ever-increasing number of clients with whom I have worked who struggle with existential concerns arising out of the unfolding environmental crisis. While my own understanding and confrontation with the “givens of existence,” as Yalom refers to them, has evolved significantly over the decades, his work and that of others such as Frankl and Buber assume heightened significance for me today. Clients struggling with often debilitating anxiety in the face of climate change span a wide range of ages, occupations, socioeconomic statuses, and cultures. Perhaps they are somewhat over-represented by younger adults and adolescents, but questions of meaning, purpose, and belonging are common, pressing concerns for many persons who have sought psychotherapy with me.

The COVID pandemic, the ongoing traumas associated with colonialism, systemic oppression, discrimination, and marginalization of people of color and others, political and social unrest, economic injustice, and now the invasion of Ukraine, impact our individual and collective health and well-being in significant and interacting ways. As such, I realize that I cannot isolate the environmental crisis apart from other highly stressful conditions of our time that my clients share with me. I believe, however, that the environmental crisis is unique in that it serves as the broader context or background against which other challenges play out, and that its impact on these other factors is both pervasive and at times subtle, factors which invite us to avert our gaze from the potentially catastrophic and irreversible effects of climate change. This latter dynamic heightens the distress felt by many.

While I approach diagnosis with healthy doses of skepticism and caution, I believe that a good argument can be made for a new DSM diagnostic category, “existential anxiety disorder,” one that recognizes the serious, traumatic impact of climate change on mental health—an impact that I believe will only increase in the coming years. I think it important that psychotherapists recognize and address the very real, oftentimes terrifying, fears and anxieties associated with climate change that clients bring into therapy.

***

Co-authored by 270 prominent researchers from 67 countries, the most recent report (2022) from the United Nations’ Intergovernmental Panel on Climate Change is a 3000+ page document with which a surprising number of my clients are familiar. They are aware of the disproportionate impact of climate change due to social factors such as economic inequities, marginalization, and colonialism, especially for indigenous peoples and those whose basic daily needs are directly dependent on the local ecosystem. The report addresses the unsustainability of natural resources related to both consumption and production, and how this contributes to a situation where half of the world’s population experiences water shortages, where increased incidence of flood and drought lead to acute food insecurity and malnutrition, as well as where forced displacement and immigration have disproportionately impacted those parts of the world with the least ability to supply basic infrastructure needs and provide a safety net for residents. Issues of justice and morality are evident here, and I often witness aspects of moral injury as my clients recount their struggles living as witnesses to and participants in actions that they find ethically and morally unacceptable.

This situation is only going to grow more urgent as the reality of an ever-degrading environment finally breaks through our collective denial and we can no longer avoid the reality of what we have wrought upon ourselves. Several of my clients have expressed a fear that as a species, we are collectively committing suicide, and they struggle with hopelessness, despair, depression, and a genuine lack of purpose and motivation. For many of them, existing meaning-making narratives are inadequate to the task of grounding oneself in a time of great uncertainty. At the core, these clients are experiencing a crisis of meaning, one that calls to mind the words of William Butler Yeats from The Second Coming:

“Things fall apart; the centre cannot hold;
The best lack all conviction, while the worst
Are full of passionate intensity.”

It has been personally challenging for me to serve these clients, especially as the collective “we” are all facing the same increasingly dire situation. My ability to maintain consistent self-care and sustaining connections with others, and my own spirituality and meaning-making narratives, are frequently challenged.

***

I do not believe that manualized treatment protocols targeting cognitive distortions and maladaptive schema are up to the task of adequately addressing our clients and their fears over the possible extinction of humanity. I suspect that this might be a very opportune time as a profession to refamiliarize ourselves with some of the grounding ideas of existential psychotherapy that have been elaborated in the fields of psychology, philosophy, and spirituality.

As an illustration of what I am seeing in my practice, let me introduce Maria, a young professional who initially came to therapy describing herself as “quite anxious” and concerned by increasing difficulties in maintaining focus and motivation at work. At the time, she was employed as an organizational consultant in a field that she finds intrinsically rewarding, and until recently had found her work highly satisfying. In the initial session she described a tendency to “overthink everything,” a gnawing self-doubt that was both new and troubling, anxiety related to health concerns, and a vague sense of purposelessness.

Maria also shared that she had started asking herself the question “Is this all there is?” when reflecting on her chosen career and lifestyle. Maria had begun to seriously question notions of hard work, productivity, and success in life and career, questions that cast doubt on the inherent value of the ideals of progress, advancement, and acquisition underlying our capitalist society. Indeed, as her awareness of the factors contributing to the environmental crisis broadened, she had given voice to a growing conviction that this worldview was itself toxic, unsustainable, and as it has played out, immoral. Her developing recognition of the interdependence of people, and indeed of all life and the planet itself, had further served to catalyze her current crisis of meaning.

Aware of the disproportionate burden that residents of the world’s least resourced countries are bearing, she became increasingly uncomfortable with her privileged position. She was actively involved in advocacy efforts at raising awareness of the need for more urgent, far-reaching and impactful action to protect our environment through comprehensive, long-term adaptation planning and implementation. Nonetheless, Maria often felt an almost paralyzing guilt that, coupled with the realization that she could do very little to directly affect significant change, had seriously impacted her ability to appreciate life. Maria’s anger over the lack of resolve on the part of world leaders and governments alternated between increased irritability and open expressions of frustration, and times where she felt stuck, powerless, and hopeless. She and her partner also struggled with the question of whether to become parents, painfully aware of the moral implications of bringing children into a world where the future appears so uncertain.

Throughout the course of our work, Maria has explored questions of purpose and meaning, of personal values and considerations of social justice, and how these might guide her daily life. Against the finitude of human existence, the question of whether and how our individual lives matter has been a prominent theme. While not religious, she is a deeply spiritual person, and this has been an important aspect of our work together.

Questioning the dominant Western view of the autonomous, independent self and developing a more nuanced appreciation for human altruism and the self within the context of neuroscience have challenged traditional notions of the “selfish” self by providing Maria evidence that one’s sense of self can contribute to a broader social cohesiveness. Finally, recognizing the impact of small, personal acts of kindness flowing outward like ripples on a pond, interacting with other ripples, changing one another as they interact and spread out across the water, have all been important aspects of a therapy seeking to address existential concerns arising out of the environmental crisis.

***

Like Maria, many of my clients are struggling to fashion a coherent framework for meaning-making, one that accounts for our interrelatedness with the Earth and her creatures, one that recognizes and honors that we are part of an interdependent whole, a living organism where the fate of one is tied inextricably to the fate of all. They recognize, some explicitly, others on an intuitive level, that many of the religious traditions that they are familiar with do not adequately address these relational, contextual realities. Neither do the guiding myths of hard work, resource exploitation, unsustainable consumption, and success that are embedded within capitalism. Not in a world where these notions have run amok and have brought us collectively to the precipice of an unimaginable environmental crisis, which is simultaneously a crisis of meaning and purpose.

It is my hope that professional training opportunities will develop to help prepare therapists for what I suspect is going to be a growing number of clients who are struggling with issues of meaning, hopelessness, and despair as they attempt to find the motivation to get out of bed in the morning and put one foot in front of the other. I am constantly running into these issues in my private practice, and I suspect that I am not alone.