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Imagined into Agency: Goth Lolita Comes to Life

Posted on April 26, 2023February 11, 2026 by Psychotherapy.net Team

The Beginning of My Story with Misha

Misha had experienced several “failures” at therapy by the time she made up her mind to give it one last try with me. She gently and quietly summarized her hope at our first meeting.

“I want to feel something other than depressed and anxious…”

She had clearly decided to make this last effort at therapy count as she proceeded to offer a description of how she had felt compelled to “lie” to her previous therapists about the “usefulness of their suggestions” to her in living with the effects of what felt like an “all-encompassing depression” in her life. When I asked more about the purposes of such lying, Misha told me how she was too ashamed to return week after week having attempted her breathing exercises and not feeling any differently. I invited Misha to spare me the lies and instead requested she fire me immediately and without warning if I ended up setting her up to fail at our conversations. We giggled together at this and from that point, I vowed to forego any advice, suggestions, or tips for Misha’s life. Instead, I turned my efforts into learning more precisely how it was Misha had been hurt and also how she has held tightly to the idea that she has something far beyond depression: a life worth living.

In our first conversation, Misha invited me into the realm of her experience of “depression.” She spoke of the relentless “arguing” in her mind for her to finally learn to “suck it up,” “control herself,” “smile,” or else “be invisible,” and if she could not fulfill these demands, she ought to consider herself a “waste of space” and her life to have come to its end.

She spoke of the aching loneliness and strangeness she felt with the world and the people in it. She described the crushing pressures to “please others” and make “pretend appearances” in life as a “compliant and pretty girl.” Misha asked me to help her understand if she was “crazy.” How else could she come to understand the effects of a life of being neglected and the little favor she had experienced, especially at the hands of her respected parents? She told me of her sense of being an “unwanted burden” to others as a small child and her longing to be attended to in a loving way. She described her days as a child spent alone in an apartment from sunup to sundown scrounging for food and watching television. She recalled the many times her requests for company or attention were rebuffed as “complaints of a spoilt brat.” Misha told me of the time her caregivers made her role in life abundantly clear to her: at age 6, when she cried, a mirror was shoved in her face and she was admonished. “Look at yourself, you look ugly when you cry.” My heart broke for Misha upon hearing these stories of cruelty and haunting neglect.

She was born a girl

Nourished on scavenged milk and bread

Fed lies of illegitimacy

And yet she grew up

In hell – a place that whispered endlessly to her:

You don’t matter

Hell is scary and an all-alone place

It tears apart her insides

As she musters every ounce of faith

To beg — please, stop the punishment

Instead of a trip to Heaven,

She found the apartment cleared out

-The hell moved to its next phase…

“So you see,” Misha concluded, “all my life I have lived in a box and it was opened only for me to perform a perfectly good and cute girl. If the box was opened, and I happened to not be smiling to the pleasure of others, I was reprimanded to smile and not be so serious.”

“I do see, Misha. I do,” I said, feeling the sorrow of a young child who was in a horrible bind to please the whims of these adults and struggle with the confusion of these demands that left her lonely and bereft and at odds in her own skin. I was full of sadness for all that she had been deprived of when she was not treated as a precious child. But there was something intriguing about the fact that Misha did not flinch when she told the stories of her life. As a consequence, I felt my own hopefulness billowing within me as we set out to plot her escape from the box.

…She tells the truth

And she forms her words late into the night

Because she always knew how to hoard the most precious things

Like her very own life:

She knows how to lie to stay in school

She knows how to be enraged at comings and goings without explanation

She knows the pungent taste of hatred in her mouth

She knows how to rely on herself

She knows how to demand an explanation

She knows how to scream: HOW COULD YOU?

She knows she is not willing to live with disregard

She knows how it feels to be rejected by society

She knows how women are forced to make horrible choices

She knows how to shift her charms when need be

She knows how to hold onto tenderness and hints of love

She knows how to recognize soothing words

She knows how to silence taunting recollections of the past (Don’t ever talk about that again)

She knows what it feels like to live alongside angst and sorrow

She knows how to pick up the phone in the midst of darkness

In this first meeting, I came to imagine Misha’s life of invisibility, of performance pressures, and abandonment. I came to imagine and understand something of what it was like for Misha to live “shoved into a box.”

…It is tricky to spot me

Inside this box

Emerging with the masks

That will please you

And protect me

It’s a neutral costume

That has been skillfully sewn together…

I came to marvel how Misha had mustered up the energy and steadiness to walk herself up many flights of stairs to get to her university counselling center and to exclaim in her desperation, “I want to die.” I came to understand depression as a strong, argumentative voice in Misha’s life that functioned to keep her poor company inside the box. Depression’s tiresome arguments left Misha’s mind exhausted. They had diverted her from questioning the reality of the painful experiences she had endured so she might consider any sense of her own agency while navigating a lonely childhood and youth.

…It was then that we thought

Maybe the depression

Was leading her astray

With the idea that feelings

Are failures,

Tearful mirrors have been used against her after all.

But all the other stuff, it has to count, doesn’t it?

We wondered together…

“What would you say, Misha,” I asked towards the end of our first meeting, “if you and I were to set out in our conversations together to understand the makings of this box…” Misha seemed intrigued. And so, it was that we set out to understand the makings and effects of the worst of the good-girl cardboard, plastic, and paper boxes and to tell every story of the living girl and her efforts at liberation.

“She does have a logical voice and a tiny light with her in the box,” Misha ventured shyly. I was moved by her proposal! But that is not all she had as we were soon to discover together. Not by a long shot.

Beginning Leads into Our Work in The Imagination

Our lead into the realm of the imagination happened by surprise and was entirely guided by a moment of rare joy and delight on Misha’s face. It was the first time I had seen Misha smile a real smile since our first meeting, and this smile with the accompanying sarcasm in her voice set us both off for travelling far beyond boxes to another way of appearing.

At the time of this significant smile, Misha was struggling with her upcoming birthday. She told me that every year, her forthcoming birthday was a time of particularly intense arguments and accusations by depression. Depression was exacting “happiness performances” of her, as well as overwhelming her with memories of being scolded for acting like “she owned the day,” and reprimanded for not being sufficiently cheerful.

“The only time when I escaped this box…” she began shyly, but then stopped abruptly, as if embarrassed.

“The only time…?” I said, hoping to encourage her to continue speaking, holding my breath.

“Well, the only time was kind of using … makeup…”

“What do you mean?” I asked.

“Well, I remember when I was 11, I used to bring makeup to school and wear these really bright colors of eyeshadow and lipstick at school. I’d feel like such a rebel. I wiped it all off before I got home, of course… but…”

“But?” I asked, on the edge of my seat. Misha smiled at me full of mischief.

“On those days, it felt more like me…I wasn’t granted freedom to express myself at home at all, so it was these little wins that would keep me sane.”

…There are precious and hidden compartments

In the box

That represent secret freedoms

In moments when I remember

About all the selves I do not show

I impulsively

Kick myself out of the box

Like only the most daring kind of rebel would:

Full of cool piercings

Colourful lip balm and the boldest eyeshadow

Picking up little wins along the way to keep myself sane

I want the punk, the goth, the feminine frilly girl

To be expressed

One day I might march the streets

Right out there as myself

Holding placards:

ANTI-CONFORMITY

PRO-JOY

My black nails and Lolita dress

Will grab your eye

And you might wonder

How I got out of that box

But I will know it was a lifetime

Of hidden rebellions

One tiny kick at a time…

There was a growing excitement in this conversation that really captured my attention. Misha was laughing and being sarcastic; she was nearly “giddy” (Misha’s own word!) in recalling what she “got away with” with her joyous “makeup rebellion.” Here is the end of our conversation that day:

Chelsey: Given these little acts of breaking out of the box all along, how important is it for you to express yourself in these kinds of ways for your own freedom?

Misha: Umm, I mean they definitely do bring me joy. I can talk about my piercings. They are permanently there. When I see them I think they are so nice. I think I’ve learned that there is a “me” inside my head, the punk one, the frilly girly one, the one with tons of piercings, the one that likes things that aren’t the norm. I’m happy keeping her in my head. Yeah, it brings me joy. I’ve sort of learned that I’m not going to get that because society expects me to look a certain way. I can conform to that while living a fantasy in my head.

I was so delighted to witness Misha’s excitement in sharing these details of makeup and piercings and “alternative me’s.” When I remembered her smile long after she had left my office, I resolved to not let these details go, but instead to “delve” into them. I wondered where Misha’s imagination for bold expression might take us. I very much wanted to be front and center on the runway of Misha’s “expressive revolution,” and couldn’t help but wonder if this might be the very key to unlocking the “counter agent” that Misha had been shaping even from inside that box, safe from her critics.

What if her smile and the rebellion she had imagined into being at age 11 might have something to say about the pressures toward “good girl appearances?”

If she could wear daring makeup as a means of expressing the artistry and freedom of her soul at age 11, in what ways might she imagine responding to her neglect and the voice of depression now?

If the clothing one wears has the power to change the way one walks, as Misha proposed, might it also have the capacity to embolden her thoughts beyond the reaches of the punishments she had received?

If she could play with her senses in the world of color, texture, design, and movement, maybe Misha could walk right into a new kind of world.

And what would be possible for Misha to utter in this new world without depression arguing every one of her thoughts right out from underneath her?

In any case, I couldn’t let up on this realm that Misha just invited me into; there was hope in this land. I could see it in her smile.

Enter “Goth Lolita”

While holding on to Misha’s spontaneous expressions of delight and taking them as substantial guides for a possible path to walk out of misery and suffering, I trained my ears to listen to her expressions for what she could enact in this imaginary world. I heard her say, “Expressing myself brings me joy,” and “the idea that if I like it, that’s what matters.” These were entirely new ideas and words unlike the ones that “depression” had long whispered to her. “Joy” and “liking” — Misha and I coined these terms as part of her “hidden rebellion.”

…I thought of the unexpected giddiness, the unusual happiness.

An empowering action she did for the sake of possibility.

I thought of how she got away with it!

And there was this lightness that followed

It was a blue streak

Beaming with intention…

Here is the ensuing conversation that introduced us both to an imaginary character that would become our treasured guide:

Chelsey: Is it valuable to discern the parts of you that you’ve held onto, and secretly imagine yourself in these different looks…or maybe dress up in your room, but no one even sees you…have you tried that?

Misha: (with delight) Oh yeah! I know exactly what I’d wear. I’d wear black lipstick or crazy makeup…

Chelsey: The way you speak of this is so remarkable to me, Misha! You know, earlier you used the word rebellion…

Misha: (strongly) Yeah!

Chelsey: Is there something of a rebellion going on inside you that people don’t know about?

Misha: (smiling) Yeah!

Chelsey: Would it be fair to say it’s something of a protest against these restrictions that were set upon you?

Misha: Yeah.

Chelsey: Is this — the words “rebellion” or “protest” — is this a way you’ve known yourself before or is this a new idea to you?

Misha: No. I think it’s always been there since I was a little kid. I think it’s more internalized. I guess I knew I’d get in trouble or be reprimanded if I showed it. I don’t want to do that…but I’d still like to do that. While I’d still like it, I’m not going to show it. It will be my thing that I’ll keep to myself. Even if my parents accepted or tolerated it, it’s kind of like… hoarding things that are mine. When I was little, I was a tomboy, always in runners and tracksuits. They were telling me to be a pretty girl with white socks with a frill, which is funny because now I do like those things. Not dressing how they wanted me to… that was my little win. I was doing all these other things to please their demands, but I was doing this one little thing that wouldn’t get me into trouble, but it was my own.

Chelsey: Have you told anyone about this little rebellion before? I shouldn’t call it little…secret rebellion? Is that a good word? What do you want to call it? What’s a good name?

Misha: Hidden? Haha.

Chelsey: The hidden rebellion you’ve described as being internalized. In sharing it with me, is it getting out a little bit?

Misha: Yeah, parts of me think, maybe I should just do it. Almost like I should freak out and just do it.

Chelsey: You play with this in your mind?

Misha: Like, who cares.

Chelsey: Holy cow. And if you were, one morning — no, let’s say Monday, cause it’s your birthday — you were to wake up and something magical was in the air, maybe it was, when you wake up on your 26th birthday and you have this giddy feeling in your body like you described and you get out of bed and you think, “You know what, who cares, it’s my birthday, I’m just gonna do it.” What would you put on?

Misha: What would I put on?

Chelsey: Yeah.

Misha: Hmmm… I would say… a Lolita dress.

Chelsey: Do you have one? What would it look like? I don’t really know what that is… If I did, I’d be way cooler. (laughter)

Misha: It’s a Japanese alternate fashion. They look kind of like dolls, like cupcakes.

Chelsey: What color would yours be?

Misha: I’d merge them, like a Goth Lolita. Black dresses…yeah!

Chelsey: Okay, I gotta write all this down! I want to hear the rest of the outfit. We only have the dress down.

Misha: I’d wear a crazy color hair.

Chelsey: Like what? Pastel?

Misha: Yeah, pastel would be good, I like alternate color hair. Something crazy… maybe pastel blue or something, yeah.

In the above transcript, I was introduced to someone whom Misha and I would from here on out refer to as “Goth Lolita.” Goth Lolita, according to Misha, is a woman who has some very clear ideas about how she can take up some alternative ways of being in her world. Goth Lolita is an expert in doing what she wants, which was exceedingly important to Misha. For example, Goth Lolita had ideas for Misha’s birthday; she thought that Misha might go out in her dress and have a picnic in the park and that she might like to see others go by and marvel at her freedom of self-expression. I was floored to discover that Goth Lolita could so easily speak about her clear vision of a riotous birthday outing. Misha herself for the first time spoke of the word “bravery,” relating to Goth Lolita’s ideas for her life. Our conversation on that day ended like this:

Chelsey: You know what I’m noticing right now? You may not agree with this… but guess who didn’t boss around our conversation? Like this was you and me really talking, like the you you. Is this right? Do you agree that depression was shutting up while we were talking today?

Misha: Yes.

Chelsey: (smiling) Did you just rebel against depression in this conversation?

Misha: (smiling) It was freeing. Everything I’ve shared is a secret, but this is a secret that I’m not ashamed of. It doesn’t bring pain to my life. It’s something weird about me, but not messed up.

“Goth Lolita” Shows the Way

When Misha came into my office for our next meeting after her birthday, I was in for a surprise. Misha appeared with her hair dyed blue and her nails painted black. Misha laughed at my dumb-struckness and my attempts to ask about how she had gone and taken up Goth Lolita’s ideas! She was beaming as I asked questions about this “visible action” toward her invention for her much-dreaded birthday.

In addition to hair dye and nail polish, Misha also took to the page and wrote me a letter that week that outlined the “worst of her stories” of her growing-up experience. She told me she sent the letter to me with shaky hands and a beating heart and was up all night after hitting send. She had never before uttered these words to any living soul. She had dreaded feeling horrible regret and shame and perhaps even getting scolded by me or her family for her change in appearance and spirit.

However, in our conversation following these developments, Misha found herself questioning the voice of depression about its threats regarding her “shaping rights” of her own life because she did not suffer retaliation for her bold new actions. Misha wondered if this had to do with the spirit of Goth Lolita appearing by her side, the spirit of a young woman who can catch her eye in the mirror and be surprised by happiness and stand proud in her “breaking out of the box.”

…It did not lead to spirals

But to a woman

Who caught a glance of herself in the mirror

Except this time

She knew something of happiness

The depression shrivelled so small in that moment

Like a wrinkled raisin

Its power was diminished….

At this, I wondered if there was a way to speak to Goth Lolita herself. If Misha and I might travel together into the imaginary realm of Goth Lolita and her ideas, what possibilities alongside “snacks for a picnic” might we consider?

Misha and I decided to invite Goth Lolita to be interviewed during our conversation. I was attempting to learn Goth Lolita’s thoughts on Misha’s behalf, and to bolster Misha’s agency as she had already begun to bring this inner idea about an “alternate self” into the outer world through her hair, makeup, and writing down the “unspeakable.” I was wondering how Goth Lolita might lend her voice to Misha as she was stepping into these new questions, words, possibilities, and experiences in her life. I puzzled over what would happen if Misha could be witness to Goth Lolita’s thoughts on her recent efforts in living. Could this imaginary realm expand Misha’s possibilities further?

(*Note: In my study of this transcript, and on behalf of any future ventures into such imaginary realms, I found myself wishing to refine the questions I asked of Goth Lolita that day. I have included my revised questions in the following excerpt for further consideration.)

Chelsey: Goth Lolita, are there any particular words or sayings or phrases that come to mind? You don’t have to censor them…they can be horrible swears, or not, in Spanish, or not…that you would say to this shame and blame. If Misha’s voice was shaky and her mind was blanking and she needed you to speak up for her and push back, what would you actually say?

Misha: (as Goth Lolita) That there is nothing to be ashamed of who you are or what happened to you. That there was no —you didn’t have a choice, it wasn’t by your own doing. That in many ways, surviving it shows some strength or some resilience and that even though it happened, and you may never want to talk about it or acknowledge it, maybe you can take it and sort of build yourself up knowing you can overcome things that you thought you couldn’t. [PAUSE] But that girl grew up and is no longer in that situation. So, I guess she can jump out of the box and be Goth Lolita.

Chelsey: HOLD ON GOTH LOLITA! You’re saying, “Hey Misha, join me!” Is that how you’d say it?

(Chelsey, revised: Hold on Goth Lolita! Are you suggesting that Misha has lived in such a way that you would be honoured for her to escape from that box and join you? Why is it that Misha earned this spot as your companion in living? Do you have some stories coming to mind about how she has befitted such an honoured position as a co-picnic enjoyer, style-star, and freedom fighter? When did you first get the sense that Misha would one day join you and what you stand for in life?)

Misha: Sort of. Break all the barriers… whether it is you or other people have placed them around you. Whether it’s “break the box” or “jump out of the box.” I guess it’s don’t let the errors of everybody in that story hold you captive in the box.

Chelsey: I’m having a clearer picture now, Goth Lolita, of you saying these things out loud with a conviction, almost like talking to the box. I see you in your dress, like this maybe talking to this box. Is there an action you’d take, Goth Lolita? Do you extend your hand? Do you help pry open the box? What do you do as you encourage Misha to break the barriers?

(Chelsey, revised: What have you witnessed Misha doing to escape the box that she was held captive in? What kind of unboxed life was Misha reaching for when she pried open the box enough to see you standing there with your hand extended?)

Misha: I guess it’s sort of rebelling one step at a time. And maybe it is working on the things that made Misha more Goth Lolita. So, whether its Step 1: dye your hair blue, or step 2: wear black nails, find what other steps or what other actions or what other feelings can be given to Misha so that she can break out of the box, or walk out more Goth Lolita and less childhood-stuck-in-her-past-Misha.

Chelsey: And Goth Lolita! You have this idea and you have even laid it out in step form! Does this get you thinking Goth Lolita about what might be next for Misha if she were to see these steps as things that she could do or take up in her life?

Misha: It’s an overall arc of accepting her weirdness or her alternate tastes that might bring joy. It may make her more comfortable in her own skin. Maybe it’s working through her self-worth because right now there isn’t much of that.

(Chelsey revised: Are you suggesting somehow, Goth Lolita, that there might be some worth in accepting an overall arc of Misha’s weirdness? Just how much worth do you think Misha has had to hold onto in order to keep her ideas and alternate tastes alive despite the boxed life that others had in mind for her? In this overall arc do you imagine Misha’s dyed-blue hair might hold more worth than what the tab at the salon might have been?)

“Goth Lolita” Takes Back Stage While Misha Stands

This imaginary conversation with Goth Lolita as a witness to Misha’s actions made it far more difficult for the arguments of depression to dismiss Misha’s imaginative ways of responding to the narrow life proposed by the dull rules, the dress code, and the dismissal of her person. At the beginning of Goth Lolita’s companionship, Misha would always anticipate what the voice of the depression would have her believe about the insignificance of her own actions in life, but Goth Lolita served as a lively counterargument with flesh and blood and bold ideas. Misha said to me at one point: “I started this. I voiced it. This gives it a shape and physicality. There is something worth trying for in this push against the voice of depression.” Misha recalled how the arguments of depression were losing their influence in her life. She began to be curious about the criteria by which she could stand behind her actions rather than having the voice of depression and its counsel of regret and shame be the sole judge of her life. Misha started to move beyond being a model for the purposes of others to being a designer of her own future.

As an example of this reorientation, Misha shared a story of living in residence at university. She told me that historically she struggled to find meaningful connections with peers. However, when she was in university, she had developed some friendships. Misha was putting in all of her best efforts to achieve this aim. They had, to Misha’s surprise, developed a supportive back and forth when it came to studying and leisure, often going for ice cream together to unwind after exams. The voice of depression had overshadowed the friendship successes Misha had accomplished with one person’s casual comment about Misha being “weird.” Misha initially grew destitute as the depression told her she was a failure and would never have any real friends. Once we knew something about how Goth Lolita might have experienced these same events, Misha was able to evaluate her own efforts and actions as “wins” in the realm of developing connections and relating with others. Misha’s imagination had allowed her to recalibrate her own barometer toward making meaningful actions against the depression.

Misha continued taking these agentive steps when she told me more stories of her life. Now they included tender memories of her and her family creating art together and caring for one another, not just the harsh tales of mistreatment. Her eyes, even when focused on the past, were able to see a fuller picture of how she was living. This made it possible for her to reinvigorate joyfulness and connection and hold it close to her heart for the future she was imagining.

These steps amounted to a grand leap in sharing the truth of her inner world after feeling very struck down by arguments with her mother who had trouble understanding exactly what Misha had been up against. In these arguments Misha had, for the first time, attempted to share her confusion about her mother’s attempts at “tough love” throughout her life. This argument felt insurmountable to Misha, however, and she considered cutting her mom out of her life as she had done many times before. But upon consideration of her new ways of expression, Misha wrote a letter to her mother outlining what it is like to live with the voice of depression in her mind and shared all the ways she had tried to be a perfect daughter and

Krista Tippett on the Immensity of Our Lives

Posted on April 12, 2023February 27, 2026 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.

Addressing Countertransference in Grief Counseling

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

Jordan’s Angry Grief

Jordan walked into my office, smiled, and sat down in the chair across from me. Then she burst into tears. She sobbed uncontrollably for about two minutes, but it felt like hours. Ripping tissues from the box on the small table in front of her, she seemed intent, perhaps aggressively so, on showing me just how much she was suffering. When she finally looked at me, her face was blotchy, her nose was still running, and she hiccuped with the last of her sobs. “I’ve been waiting for days to be able to do this,” she said.

I asked her if she could tell me what she was so upset about. “You know!” she said, “we’ve talked about it so much. I’m still mourning my dad’s passing.”

Jordan was right. We had talked about her father’s illness and death many times in the course of our work together. But I found myself wondering if our talking was doing any good. Jordan’s father had died when she was in her mid-twenties. She was now in her early thirties. There was no question that his death had been painful and perhaps even traumatic for Jordan, but it seemed to me that it sometimes became more significant when Jordan needed to avoid dealing with a present-day difficulty. Further, I found myself thinking — with some guilt for even having the thought — that Jordan became particularly distressed about having lost her father when she felt criticized, whether at work or by someone with whom she was in a relationship, for instance, her mother, sister, or girlfriend.

As these thoughts passed through my mind, I asked myself, not for the first time since I’d begun working with Jordan, what was the matter with me? What kind of therapist was I that I couldn’t feel sympathy for a client who was so clearly suffering? I’m not normally so hard-hearted, so as I listened to her sobs and murmured sympathetic words, I wondered how to explain what was making it so hard to empathize.

As a psychotherapist, I recognize that my reactions to clients are based on a complex combination of factors, including their personalities, psychodynamics, personal styles, and histories — both mine and theirs. The interaction between who I am and who they are, what I have experienced and what they have experienced, and what we both expect from and see in our relationships can create a fascinating, complicated, and often confusing experience for both me and the client. The image I find most helpful when I’m thinking about this co-created experience is Winnicott’s concept of “the squiggle.”1

Winnicott worked for a time with young children, and during that time he devised a game that he called “the squiggle.” He used it to explain to therapists how we and our clients co-create an experience that has part of each of us in it but is not created or owned by either of us. In this game the therapist and the child each have a pen or a pencil, and they have a piece of paper between them. The child makes a mark on the paper, and the therapist makes a mark connecting to the child’s mark. Taking turns, they gradually make a design over the entire paper. It’s a design that they create together. Winnicott suggested that this is what happens in therapy.

In the room and in our work, Jordan and I were not yet able to talk about — or even formulate for ourselves — the ways that we were co-creating an experience that in some ways replicated old experiences, and in some ways represented new possibilities for us both. My job was to step back enough from what we were creating to be able to be curious about it. That curiosity, as the relational psychoanalyst Stephen Mitchell suggested in much of his writing, is a huge part of what makes therapy therapeutic.2

Changing the metaphor, Mitchell likened therapy to a dance. He suggests that a therapist’s job is to stop every so often, and ask “Why are we dancing to this music? And why this step?”

Instead of asking myself what the matter with me was — or, as I might also have done, what was the matter with Jordan — my job was to ask why Jordan and I were engaged in this particular relational interaction; this particular dance step, so to speak. But when you have a visceral reaction to someone, as I was having to Jordan’s pain, it’s hard to take that step back. It’s hard to ask those questions, and harder to get a reasonable response from yourself.

Magda’s Quiet Pain

As I was struggling to understand my powerful reaction to Jordan, Magda, a client of mine in her fifties, was grieving and trying to put her life back together after her husband died of a massive heart attack. I remember how she had walked into my office and started to cry. Unlike Jordan, Magda was embarrassed about crying and quickly got her tears under control. She smiled and said, “I don’t cry anywhere else but here. You keep encouraging me to let myself cry, so I do, with you. But I’m not sure what the point is.”

My reaction to Magda was very different from my reaction to Jordan. It wasn’t simply that I felt more sympathy toward Magda than Jordan. I felt something angry or aggressive in Jordan’s pain, almost as if she was trying to push it onto or into me, and I wanted to ward it off. Magda, on the other hand, was careful with what she brought into my office and gave to me to hold. With her, I had more of an impulse to let her know that I could handle her sadness, and that I thought she would find it helpful to share it rather than keep it inside her.

In other words, I wanted to stop Jordan’s outburst and I wanted to encourage Magda to allow her emotions into the room.

Among my psychodynamically-oriented colleagues, there is a recognition that our responses to our clients contain helpful information about them as well as about us. What did my reactions have to tell me that could help me work differently with each of them?

Many clinicians suggest the use of diagnoses to help clarify what techniques are most useful with what clients. While I agree that an assessment of a client’s personality structure and psychodynamics can help pinpoint important factors that will influence their ability to respond to one sort of intervention over another, I also think it’s important to remember that assessments of clients can — and should — change over time. As a relationship with a client deepens as we get to know them and, conversely, they get to know us, some of the dynamics that may initially seem paramount turn out to be part of a temporary self-protection or façade that kept other things out of our awareness.

Further, diagnosis may capture our own hostility or negativity about a client. For instance, I found myself diagnosing Jordan as having a personality disorder, but when I questioned myself about this diagnosis, I realized it was a way of giving myself permission to keep my distance from her. The most obvious truth was that because of my own personality structure and dynamics, I was more comfortable with Magda’s sadness than with Jordan’s angry grief.

Dueling Countertransference

But there was, of course, more going on. Interestingly, I identified with the losses both women were facing. Like Jordan, I was mourning my father, who had died sometime before her father died. Our relationships with our fathers were quite different, but the sense of loss had many parallels. On the other hand, Jordan told me that she had always been “daddy’s little girl,” and that she didn’t think she could live without his constant praise and reinforcement that she was special. My relationship with my own father had been different, and I asked myself if I was envious of the special connection Jordan kept talking about.

As I opened myself up to the possibility that some of my reaction to Jordan was related to envy, I began to hear some of her words and view her actions differently. I began to wonder if Jordan unconsciously wanted me — or someone I represented — to feel envious of her relationship with her father. And if so, why? Was she angry at, or hurt by that other person? Did she need that reaction to get revenge on them? Or did she need to see their (my) envy to feel special? Was there something she had not internalized about the special relationship? Or was the relationship really not so special after all?

For quite a while I didn’t say anything about any of my thoughts to Jordan. As I was letting these ideas begin to gel, I was also working with Magda and exploring some of my countertransference reactions to her. While it’s easy to coast with positive feelings about a client, it can also be useful to try to understand what makes that person so much easier for us than someone else. I asked myself why I was so much more empathic to Magda’s quiet grieving than to Jordan’s loud, almost aggressive pain. There was the fact that it fit better with my own personality structure, but was there more to it?

I tried to put into words for myself what I admired about Magda’s way of expressing her feelings, and the words that immediately came to my mind were “elegant, self-contained, quiet dignity.” I realized that there were several personal connections in my life to those words, and that my countertransference to Magda also had something to do with my relationship with my own father. But as I was thinking more about some of these issues, I was also reading more about grief, and I realized that perhaps even more than the most obvious relational dynamics that were emerging in the work with each woman was the question of each of our relationship to grief itself.

I have always found the idea of stages of grief simultaneously useful and disturbing. On the one hand, it can be useful to know that some of the difficult emotions that emerge after a loss are a normal part of a process, and that many of them will gradually diminish as the process moves forward. On the other hand, I have never known anyone who goes through a neatly organized process of grieving that follows a particular outline. Of course, many of the current experts on grieving point this out as well. But once I began to add the idea of grieving to the “squiggles” that were emerging in my work with each client, our discussions took on more shape.

Making Space in Therapy for Pain

I began to gently explore with both Magda and Jordan some of the complexities not only of their relationships with the people they were mourning, but also with their respective feelings of loss. Not surprisingly, Jordan reacted angrily, telling me that I was trying to push her through the stages of grief, not letting her manage them on her own time. She was surprised when I replied that she might be right. “I’m not really sure what stage you’re in right now,” I said. “Can you tell me?”

Jordan turned out to be well-read in grief literature. “I think I’m in denial,” she said more quietly than usual. “I don’t want it to be true.” It turned out that Jordan had been angrily fighting the feeling of sadness, despite all the tears and sobbing.

Magda, too, had been fighting her feelings of grief. “If I don’t cry,” she said, “I think I won’t feel it. But when I come into your office, I get hit with all those feelings.”

“Is that a good or bad thing?” I asked.

“Probably good,” she said. “I think I need to let myself feel them.”

Listening to both women talk in very different ways about their styles of mourning made me realize that an important part of my countertransference had been about my own ways of dealing with grief. According to some grief specialists, the hardest thing for most of us is to make emotional space for grief, and yet, making space for it is the only way to let ourselves move forward. As many of these specialists tell us, making space for grief allows us to make room to grow and to live, even with loss. Paying attention to my countertransference reactions to each of these very different clients’ grieving styles allowed all of us to find a new way to make space for this painful but unavoidable emotion. And making space allowed for growth. Jordan and I continued to struggle with many distinct aspects of our relationship, while Magda and I felt like a much more comfortable fit. But as we made space for the pain in our different ways, Jordan and I found moments of connection, while Magda and I found moments of difference. And all of us grew in a variety of interesting and often different ways.

References

1 Winnicott, D.W. (1989) “The Squiggle Game.” In Psychoanalytic Explorations, Routledge.

2 Mitchell, S. (1995). Hope and Dread in Psychoanalysis. Basic Books, Inc.

Current Developments in Clinical Suicidology and Mental Health Crisis Management

Posted on April 4, 2023February 11, 2026 by Psychotherapy.net Team

* If you or someone you know is struggling or in crisis, help is available. Call or text 988 or chat 988lifeline.org. Text MHA to 741741 to connect with a trained Crisis Counselor from Crisis Text Line.

There are significant developments in the world, the United States, and our field in recent years that are significantly impacting contemporary clinical suicide prevention. The Covid-19 worldwide pandemic, the launch of the 3-digit 988 Suicide and Crisis Line in the U.S., and recent SAMHSA and Centers for Disease Control data are all examples of major forces that are fundamentally transforming the field of clinical suicidology. Many of these contemporary developments are spawning necessary and overdue changes and adaptations as to how mental health providers can more effectively work with suicidal risk. And to this end, I will explore these major developments and their impact on clinical suicidology.

Telehealth Care and Suicidal Risk

An impressive development in response to the coronavirus outbreak was the remarkably rapid embrace of telehealth to deliver mental health care. As the worldwide pandemic spread rapidly in early 2020 there was an initial hesitation of widespread use of telehealth with people who were suicidal. Indeed, there were certain large healthcare systems who moved, suspended, and even discontinued screening for suicidal risk with patients online because of a flawed presumption that one can only work with a person who is suicidal face-to-face. In other words, if you cannot tackle the patient at risk who is fleeing your office to take their life it is better not to ask! In response to this naive notion, certain leaders in the field of suicide prevention made significant efforts to identify key adaptations to working with suicide risk remotely. These adaptations mostly involve using informed consent carefully, identifying third parties who could intervene in case of an acute emergency, and anticipating issues such as a poor Wi-Fi connection and what to do in such an event (e.g., having a phone number to call if online connectivity is an issue).

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As we were all collectively compelled to learn to provide care online perforce, many unexpected developments followed. For example, telehealth now offers a genuine opportunity to democratize the delivery of care to rural, frontier, and potentially more diverse populations. Another development in psychology was the advent of PSYPAC which enables providers to increase clinical care across state lines. Another notable Covid-based development was the common practice of instructing people who are acutely suicidal to go to their nearest emergency department for care.

With emergency departments brimming with coronavirus patients, such a recommendation became ethically and clinically dubious. Common reliance on inpatient care similarly posed the increased risk of patients contracting Covid during the pandemic's height. As the developer of the Collaborative Assessment and Management of Suicidality (CAMS), I have long been a vocal advocate of keeping patients who are at risk of suicide out of hospital emergency departments and inpatient care (if at all possible) by providing proven suicide-focused care supported by randomized controlled trials (RCTs). In response to the early stages of the pandemic, our training company CAMS-care converted the training and delivery of CAMS to online modalities (including the use of CAMS in three RCTs). We soon discovered that both training and clinical care can be effectively rendered online, and this development is helping to transform clinical care for those at risk for suicide.

The 988 Suicide and Crisis Line

In July of 2022, a major federal law was put into effect that is profoundly transforming how we must think about suicide risk and mental health crises. The “National Suicide Hotline Improvement Act of 2018” is one of the most significant legislative developments in the history of U.S. mental health care. Suddenly, we have an easy-to-remember 3-digit number that connects callers who are suicidal or otherwise in a mental health crisis to crisis professionals who are ready and able to effectively deal with them. With the knowledge that the pre-existing Lifeline was already having capacity issues, millions of dollars were subsequently allocated to help better support the new 988 mental health crisis line.

While all of this is very encouraging, the launch of 988 has created some growing pains and posed various challenges to policymakers, systems of care, and clinical providers. For example, how well do Americans know the difference between calling 911 and 988? There is a need to educate the public as to how to re-think emergencies that would have previously prompted calls to 911. There are significant issues related to “wellness checks” or “safety checks” that are primarily conducted by law enforcement officers who may have limited to no training as to how to deal effectively with mental health care crisis. For a person of color, having a police officer show up uninvited to protect you from yourself has inherent issues. 988 also brings a major focus to our existing healthcare model that is overly reliant on emergency departments and inpatient hospitalizations that too often may not be altogether therapeutic.

Fortunately, alternative models of crisis response are emerging. For example, “The Hope Institute” in Perrysburg, Ohio, provides intensive outpatient suicide-focused care using next day appointments (NDAs) wherein either CAMS or Dialectical Behavior Therapy (or both) can be provided up to four times a week to help stabilize a person who is suicidal as they await weeks — sometimes months — `to engage in available outpatient care. Within this model, adults are stabilized in six weeks while youth at risk are stabilized in just over five weeks. This is but one promising model that is re-imagining working with suicidal crises. Other promising approaches include mobile crisis response, respite care, retreat centers, certain crises-oriented technologies, and extensive use of peer support which can help reshape crisis responses.

Recent Trends in Suicide-Related Data

Over the last several years there have been notable developments in suicide-related phenomena. While we were initially encouraged when suicide rates declined a bit in 2019 and 2020, this decline was erased by an increase in 2021 (the most recent data reported by CDC). And with Covid-19 becoming a leading killer, suicide is no longer a top ten leading cause of death with 48,183 lives lost to suicide in 2021. But what has preoccupied my attention has been steady increases in the number of Americans who report having “serious thoughts of suicide” within 30 days of a survey completed by SAMHSA. Indeed, in 2021 this amounted to 12,300,000 adults and another 3,300,000 teens, altogether a whopping 15,600,000 Americans with serious suicidal thoughts! This number is over 300 times greater than the number who died by suicide in 2021.

While we grieve the loss of Americans to suicide, I would argue that we must do a much better job of identifying, assessing, and treating millions of those who suffer such that they seriously consider suicide. In truth, the suicide problem we have in the U.S. is a suicidal ideation problem — by a lot. It therefore behooves all mental health professionals to learn proven interventions like Dialectical Behavior Therapy (DBT), suicide focused cognitive behavioral therapy (CT-SP and BCBT), CAMS, or Attachment-Based Family Therapy (ABFT) to name a few of the rigorously proven interventions for suicide risk. Moreover, there have been other demographic developments of note. As suicide rates among white males have decreased, we have seen in recent CDC data that suicide ideation and behavior is on the increase among young people, particularly those of color. We certainly know the pandemic has been tough on all of us with clear increases in depression, anxiety, substance abuse, and suicidal ideation.

***

Given these recent developments in our world, I would assert that it is critical for mental health providers to become a part of the solution to suicidal suffering. We are uniquely positioned to make a life-saving difference and help decrease suicide-related suffering by keeping abreast of major developments in the field and learning to use evidence-based approaches to suicidal risk.

Questions for Thought and Discussion

In what ways did this article impact you personally and professionally?

How have you modified your own approach to suicidality in recent years?

How have you collaborated with colleagues in and around the mental health community to improve your services to suicidal clients?

How to Use Play Therapy in Prisons to Create Hope

Posted on March 16, 2023February 26, 2026 by Psychotherapy.net Team

Imagine this scene with me: 15 men sitting across from each other at a long table, deeply engrossed in building with LEGOs. Joking and laughter punctuate moments of serious concentration as pieces of LEGOs are found and various minifigures find their place within the emerging structures. In another group, there is the eruption of victorious joy and the groan of agonizing defeat as the men play a variety of board and skill-based games in small groups and pairs. Two of the men simply throw a rubber ball to each other, a timeless game of catch.

Common Therapeutic Themes in Inmates

Grown men playing and telling stories from their play?! Yes, the scenes described above take place in a prison, a place where themes of “play” and “play therapy” are not usually enacted.

This work was born from my realization that if play could heal wounds in my adolescent and adult private-practice clients, it could be a powerful agent in reconnecting a former inmate with his child. After witnessing that reconnection firsthand, I could not get the thought out of my head of how many fathers there must be sitting behind bars, isolated from their children.

I discovered that there are many. There is also a great deal of recidivism, as incarcerated men face not only the daunting task of assimilating back into life outside of prison walls and the demanding requirements of parole, but also of rejoining families, rebuilding careers, and adjusting to a new chapter post-incarceration.

For many, it is overwhelming and confusing. Low self-worth, lack of self-awareness, deficient resources for self-repair, and difficulties in self-regulation contribute mightily to probation violations, inability to establish steady jobs, and difficulty reassimilating into their families and communities.

I soon discovered that prior to their time in the penal system, many of these men had spent time in foster care. I heard stories of abandonment, abuse, and self-rejection, often resulting in alcohol and drug abuse. It became painfully clear that many of the men were in desperate need of self-repair, and that these unresolved wounds played a large part in not being able to rebuild their life after leaving prison.

I experienced firsthand through my visits that prison is terrifying and chaotic. I have never witnessed a more stressful and unpredictable environment. For each visit, I passed through four checkpoints with buzzers, and the ominous and jarring sound of iron and steel slamming behind me. I would then walk a quarter mile surrounded by razor wire that gleamed in the sun like wolf teeth. I was constantly reminded of the utterly unforgiving conditions and lack of beauty that embodies this place.

I was, and still am, continually alert for the unpredictable, while at the same time, buoyed by my playful interactions with the men. Deep within this place there is a room where something miraculous happens. It is where play transcends the bonds of despair, transporting men — if only for brief moments — to a place of inner freedom and exploration.

How to Use Play Therapy in Prison

The Play in Prison Project that I developed is multi-faceted. It is scaffolded within the framework of “self-development” built upon the psychic Lego pieces of self-regulation, self-understanding, self-acceptance/forgiveness, and self-repair. Group members are taught self-regulation skills, how to identify negative schemas and change them, and how to build tools to identify and express feelings in an adaptive, prosocial way.

Play is woven throughout each of the group activities which incorporate the use of building toys, toy figures, games, and expressive art material (drawing and painting) designed to create a sense of safety, while also stimulating a curious mindset as new narratives of self are created. Overall, play is the glue and the foundation, making it possible for these men to be anchored in the here and now, looking at the self through the lens of this very moment while staying regulated and processing emotions and thoughts in real-time with the other men in the group.

Within the structure of this group, my role is that of a play therapist: tracking, reflecting, affirming, and even joining in play if invited. Through the group processing, I facilitate discussion using summaries, reflections of content and meaning, and affirming the observations and insight of the group members.

As a play therapist, I have spent years observing and joining others in play. I play regularly as an open-water swimmer, basking in the feeling of being lost in something huge while adapting my body to whatever the ocean offers me that day. Play lessens defenses. After just a few minutes, the men are laughing and conversing; even those that are silent often emit a smile.

Play allows for self-expression and ownership with no apologies, as evidenced by a victory whoop, and the feeling of mastery as a creation finds its way to completion. Play creates pathways for language. The men share stories through their creations, identifying emotions, and expressing themselves without shame or pretense. Play breeds a spirit of authenticity and presence. During our play, many of the men have new realizations of their worth and value as they can be present and comfortable.

Play is healing. The men can return to something awful that occurred in their pre-prison life, playing it out sometimes non-verbally, and changing the outcome based on what they know about themselves in the present moment. Play allows for connection and relationship building.

An all-too-common theme within prison walls is the lurking paranoia of being unsafe and the urge not to trust anyone. The men practice bonding through play, and elements of rough and tumble play within competitive gaming allow for the testing of these bonds.

Finally, play allows for self-repair. Through storytelling, the men engage in working through conflict with others, opening pockets of shame and self-rejection, and finding forgiveness that comes through creative and intentional play.

Clinical Case Study: Hope Shatters the Darkness

Jimmy has three years left to serve on a 15-year sentence. He is a father of two adult children and has grandchildren.

Jimmy was raised by his grandmother after his own mother lost her parental rights due to drug use and incarceration. Jimmy never knew his father. His grandmother passed away when Jimmy was nine, and he went to live with extended family members.

Eventually, Jimmy ended up in foster care where he remained until he turned 18. This period of his life was turbulent and involved many foster placements, poor school performance, and return stays in various juvenile detention centers. As Jimmy entered adulthood, he became involved in street life, leading to arrests and eventually long-term incarceration.

Jimmy was drawn to the Play in Prison Project because of his desire to rebuild his relationship with his adult children. He admitted that he carried shame and suffered daily from remorse and self-loathing. Life had hardened him, and he wore that hardness as a shield.

The toy he chose to represent himself in the first session was a big truck with blacked-out windows. “I’m big, people see me coming, but I keep everything hidden from everyone. When things get hard, I drive away.” During LEGO play, Jimmy created a tall building and used LEGO minifigures to represent guards. “I’ve tried my whole life to protect myself because nobody was there to protect me.” During a play session using expressive arts, he drew a dark cave with a solitary figure. “My brain tells me I’m living the life I deserve. My choices have put me here and there’s no light in sight.”

Halfway through The Project, Jimmy told the group that he wrote a letter to his children and had received one back in return. He wept as he read part of it aloud — it contained words of anger and hurt. The group helped Jimmy see that even though the letter was painful, it was at least an opportunity to communicate.

Play in the form of competitive games helped Jimmy to see and slowly accept himself in the moment. Playing a game in which he and a partner were paired together, he realized that it was not realistic to judge himself based on his past. Using LEGO bricks and minifigures, he built a large house with windows and an open door. The minifigures represented his children, grandchild, friends, and other family members.

He told the group he felt empowered to respond to the letter he received because of slowly learning to evaluate himself more fairly and positively in the present, as opposed to the horrible and painful events of his past. “The old me would have just stayed away. I don’t want to do that anymore.”

At the final session of the group, Jimmy drew a shattered cave with light streaming out of it, emanating from the solitary figure. At the end of the rays of light were people that represented his family and community. At the top of the picture, he wrote the words, “Free in My Light.”

Final Reflections on the Healing Power of Play Therapy

The Play in Prison Project has provided me with a rare opportunity to witness the power of play in a dark place with forgotten people. At this stage in The Project, I am volunteering because I saw a need in my community.

I am gathering data with the hope of submitting a grant to expand this work with other practitioners of play into other facilities. I have learned to be particularly mindful of being respectful of the institution, its employees, and its residents.

There are far too many examples of good programs that were started in prison settings for the purpose of research but ended abruptly when the researchers moved on. Because play and play therapy are novel and nourishing experiences, they were quickly, and perhaps not unsurprisingly, embraced during participation in The Project. Group members enjoyed the opportunity for safety and self-expression in an otherwise hostile environment where self-defense, hopelessness, and a constant state of vigilance were necessary for survival, both emotional and physical.

Some of the incidental comments in the surveys I collected and positive behavioral outcomes of The Project were a testament to the power of play in creating self-understanding and self-regulation. “For the first time in my life, I have learned to stay relaxed and not react.”

Comments about play creating a pathway for self-forgiveness and self-repair often surfaced: “I finally understand that I’m not the person who did the things that got me here; it’s part of my story, but I am who I choose to be in this moment.”

Play for some of these men led them closer to authenticity, intentionality, and connection in their everyday lives, helping to step closer to erasing shame, isolation, anger, and despair. Not uncommonly, I heard comments like, “I reached out to my children/grandchildren; I rebuilt the relationship with my wife/family members; now I know how to play with my kids, and I look forward to seeing them at visitation because I’m not ashamed of who I am anymore.”

Building on Family Strengths to Solve the Puzzle of Child Protection Work

Posted on March 9, 2023February 11, 2026 by Psychotherapy.net Team

Information is a difference that makes a difference.
— Gregory Bateson

In nature, it is said that whenever there is a poisonous plant, there can be another nearby which contains its antidote. When it comes to helping families, the same is true that for every problem identified, the resources for resolution can be present somewhere in the family’s ecology.]

Unfortunately, especially for underserved families, competition among divergent treatment philosophies, practices, and limited resources create an unintended conspiracy within the mental health and social service delivery systems — perhaps a benevolent one, but one which nonetheless curtails the identification of systemic homeopaths. The unfortunate consequence of this inability to use potential “antitoxins” naturally present within the client’s ecosystem is inefficiency for the service delivery system, stressed-out workers, high turnover, burnout, and a spiral of reduced possibility in which hope’s grasp is tentative at best, and non-existent at worst.

Mental health and social service clinicians working within the childcare system must search for strengths and solutions that are present, though perhaps hidden, in clients’ ecosystems. The approach is based on systems thinking and the idea gleaned from the practice of Structural Family Therapy (SFT) that change in any system, whether it be a family system or a social services agency, is best affected by the lived experience of doing.

Crossword puzzles as a paradigm stresses thinking and doing as an “out of the box” means to a problem-solving end. This practice mines the strength-based belief of creating a “virtuous circle” — one which recognizes clinicians’ and supervisors’ capacities and creativity, like those of the families they serve.

In resource-poor environments, when the goal of training is the enhanced ability to search for strength, this is not simply a training “add-on.” Rather, it is a foundational principle that requires the same persistence and consistency that Minuchin and other family therapists demonstrated was present in the natural environment in which clients and their families are embedded. The naturally occurring strengths in clients’ ecosystems can be uncovered by robust “doing,” which is an optimistic and energetic search for resources and resilience within both the family and the larger ecosystem of change.

Collaborative Case Planning

Like the proverbial butterfly catcher with net in hand, human service organizations have long been involved in a quest to capture the elusive chrysalis of change. What distinguishes efforts at reform and the ability to succeed is an ecological, “whole systems” approach. Children, families, problems, and possibilities are viewed in toto — economics, social, political, educational, gender, vocational, racial, location, class, and psychological elements are all in play. It acknowledges the margins and builds accountability.

The human and fiscal expense of doing otherwise speaks to the futility of programs that do not account for the organic and sometimes chaotic environment that families attempt to survive and thrive in.
As the 19th century Prussian Field Marshal Helmuth Carl Bernard Von Moltke reminded us, “No plan survives contact with the enemy.” In this instance, the enemy of high-quality service delivery is the tendency to replicate the existing system rather than undergo the reformation needed to absorb the family’s own healing powers.

Another systemically inspired practice that infuses underserved families with greater choice, and ultimately health, is collaborative case planning. This time-honored intervention gets all the major players to the table — including the family — and in the process, becomes a kind of exercise in agency topography that borrows from the tradition of Hartman and her colleagues, who pioneered ecomapping of family systems for adoptive placements.

By using the wide-angle lens of mapping families in all their contexts, resources and potential pressure points can emerge for their potential effect on the child and family. From the agency perspective, efficiency and collaboration are increased with an ecomap; everyone can see who is doing what and when and how it is being done. As a form of “observational therapy,” an ecomap can have the same heliotropic potential. However, as business has learned, outcomes can be improved, but not always for the reasons one might think.

Unfortunately, the promise of systemic work and its healing potential as envisioned by therapists who worked in the family trenches is not always realized in the battles to transform larger systems. For clinicians in the human services, or for those who train them, the pitch of a systemic perspective too often mirrors the president throwing out the first ball of baseball season — well intended, lots of hoopla, but doesn’t reach the plate. Without a clear picture of where they fit in the larger service-delivery system or a sense that they can make a difference, workers can feel overwhelmed, disempowered, and disheartened.

The financial cost to the system in turnover and lost productivity can be measured. The loss of wisdom, the discontinuity of care, and the loss of hope, however, are beyond calculation. In that regard, the experiences of child welfare clinicians mirror the isolation that can permeate the system within which they work and the families that they treat.

It is for this reason that systems of care were re-designed to “wrap” services around families and to minimize the dilution of family processes that occur as a by-product of traditional service delivery. In a sense, “wrapping” can enrich underserved families with a wider net of resources in the way families of higher classes can choose their providers and supports more selectively.

Capitalizing on Strengths

In tracing the strands of effective, systemically inspired service delivery, there is one constant thread: strengths. Thank goodness! But just as it was found that a rising economic tide does not raise all boats, so too can the tidal waters of strength not elevate the all-too-often porous vessels of bureaucracy.

What is amazing is how far a little strength can go, even in conditions that are wanting. There are, after all, some quite beautiful plants that flourish in the shade. Sadly, however, in the wrong bureaucratic hands, even strengths-based practice can invite the agency equivalent of Frankenstein picking flowers with the little girl — it’s a nice idea, but eventually the monster kills it.

How, then, to help clinicians to see that “It’s the difference that makes a difference”? Is there a way to aerate the sometimes root-bound tangle of the childcare bureaucracy so that its ability to heal can be given the room to breathe and prosper? How to give clinicians — especially those just out of school — the understanding and confidence to “trust the process” of searching for strengths, both within disrupted families and the systems designed to serve them? Moreover, are there ways to create a culture of caring and learning transfer so that clinicians see themselves as “action agents” within the larger bureaucratic tangle?

Part of the answer lies in family therapy’s history and co-development with cybernetics — the study of how systems developed the concepts of circularity, non-linearity, recursion, the process of self-correction, and the ways family and organizational systems maintain stability/homeostasis while balancing that with change and transformation. Gregory Bateson and his colleagues at the Mental Research Institute (MRI) in California, along with other early adapters, were the pioneers in this new way of thinking that set the stage for family therapy as we know it today.

Using a notion central to Structural Family Therapy (SFT) about strength and extending it to conceptualizing strength as a verb can be unintentionally overlooked when children and families in dire need get lost within the morass of bureaucracy. The SFT concept of healing is more about thinking of strength as a verb. It’s not so much a matter of finding strengths within the family’s ecosystem as it is strengthening the resources that are hiding in the weeds, so to speak. In that regard, it is more of a leap of faith — that whatever challenges a case presents, health can prevail.

Businesses and non-profits share a challenge: getting their message through environmental “clutter,” or the glut of choices that compete for our attention. How, then, can human service organizations solve the multiple staff training dilemmas they face?

The skills and belief set needed are interwoven and important: ensure the safety of the child and family, reduce decision clutter, increase the active search for strengths, attend to and nurture family connections, expand the problem-solving lens to include extended family, community and idiosyncratic, home-grown resources, and get paperwork in on time. One path on the way toward answering this organizational koan is this: increase experiential capital by linking the worker and their day-to-day decisions with the larger mission of the organization.

Thinking Outside the Therapeutic Box

Bridging the gap between what we know and what we do, however, is no small feat. In Why Didn’t You Say that in the First Place: How to Be Understood at Work, Richard Heyman unravels this knotty problem with a question and a refreshing answer: “Why is it that ‘a picture is worth a thousand words?’ The picture is not talking about something — it is the thing the talk is about.”

From this perspective, to truly “get” the uber-goal of searching for strength and translating that into action, workers must experience the “felt sense” of search and discovery —finding something where apparently nothing exists. This experience is analogous to an “enactment” in SFT, in which the family is guided by the therapist in an interactive experience between members that is designed to offer them new opportunities to use underutilized strengths.

Many consider enactments to be the heart of Structural Family Therapy. The value of enactments is two-fold. First, as a “real-time” assessment tool, and second, for their change-producing potential, both of which scaffold nicely for training in human services.

Enactments between family members during therapy can principally occur in two ways, either spontaneously or through the therapist’s direction, and they are used in two ways, to assess family patterns and to promote change. Spontaneous enactments are readily available ways of interacting that might be thought of as familial “tells” (like the poker player whose nervous smile foretells the bluff), showing habits of relating in which relational organization is embedded. While some might consider these patterns to be so deep as to be unconscious, another way to think of them is as learned ways to relate and survive in the world.

The persistence of patterns can transcend the pull of context. Habituated behaviors tend to reveal themselves in multiple settings— a therapist’s office, a restaurant, school, work, or home. The persistence of these patterns can be linked to the tendency to reduce anxiety through prediction and habit. As the pioneer family therapist, Virginia Satir notably said, “Most people would prefer the misery of certainty over the misery of uncertainty.”

Like an artist who steps back from the picture they are painting, clinicians have the capacity to use themselves differentially, moving in and out of the family system to gain perspective. Minuchin described this as “use of self,” in which the therapist positions themself with the family from “proximate, median or distant” perspectives.

Harry Aponte has written about how therapists can make use of their own personalities, family of origin, and life experiences to guide clients during enactments in the “then and there” of limiting patterns so that they experience themselves and one another with increased possibility and hope.

Like a music student first learning scales as a prelude to improvisation, experiential training can evolve into a more responsive, “whole systems, both-and” approach in which requirements and innovation can co-occur. For example, when supervisors at one county office of a state child welfare agency were asked about their staff’s training needs, their response was, “To be able to think on their own/to think outside of the box.”

Their request comes from the experience of guiding their workers through the complicated bureaucratic and interpersonal seas of child protection. As Mumma wrote in his insightful piece about his agency training in systems work, “Taking these concepts (ways of thinking) and making them work in a particular agency setting is the real work of training.” The analogy of crossword puzzles can make that work a bit easier.

Finding Best Clinical Practices

Just thinking about all the aspects of a case — its who’s, what’s, and how’s — can be a bit overwhelming. Cases in the investigative and early treatment stages, particularly for newer clinicians and social workers, may seem all forest and trees, abounding with unanswered questions.
Over the years, agencies have found genograms, ecomaps, and structural maps to create a set of “blueprints” that graphically represent families and agencies in a way that quickly sorts out relationships and priorities. These tools have been essential in widening the practice/thinking lens to include others who may have clues to potential resources.

The rise in “manualized” treatment and the emphasis on evidence-based treatments has helped to sort through these difficult choices and prescribe “best practices.” While this is a necessary step in the right direction — much like learning scales is in music — it can be insufficient to encompass the unpredictable nature of cases. There needs to be a “both-and” approach that brackets safety, consistency, and growth with improvisation. Thinking in terms of crosswords can do just that.

In its own way, a blank crossword puzzle graphically resembles a complex clinical and, in this case, social services-related case — lots of questions, some inter-related, some not, and just to make it interesting, a few black boxes. As President Clinton said in the crosswords-based movie, Wordplay:

Sometimes you have to go at a problem the way I go at a complicated crossword puzzle. You start where you know the answer and you build on it and eventually you unravel the whole puzzle. And so, I rarely work a puzzle with any difficulty, one across and one down all the way to the end in a totally logical fashion. A lot of difficult, complex problems are like that. You must find some aspect of it you understand and build on it until you can unravel the mystery you are trying to understand and then you build on it and eventually you unravel the whole puzzle.

When one acts as if the answers are there, though perhaps hidden, the puzzle’s resolution moves from the shakier, contingent ground of “if” it will be resolved, to the more possibilistic ground of “how.”

Crossword Puzzles as Metaphor in Child Protection Work

Do you think I know what I am doing?

That for one breath or half-breath I belong to myself?

As much as a pen knows what it is writing,

Or the ball can guess where it’s going next.

Rumi

When a case opens in child protection, the most compelling, sometimes unanswerable question is “Who will keep this child safe?”
If an injury has occurred in the home, the prima facie answer may seem obvious: “no one.” In this instance, unless resources are surfaced, the child will need to be placed outside of the home, “in the system.”

Starting the exploration of strengths from a crossword paradigm assumes that like the printed puzzle, all the answers may not be initially apparent, but once safety is established, one can begin to answer the eternal risk-safety dilemma: Can the person(s) who caused or permitted harm now be responsible for safety? If one only looks at the alleged abuser, then the likelihood is that the answer to the question will be “no.” If more contextual factors are also considered, so, too, are possibilities.

The work becomes both retrospective and prospective, invoking Einstein’s dictum, “You can never solve a problem on the level at which it was created.” The “who” and “when” questions are now also answered by “how.”

The “how” to find and fill those potential strength-based empty boxes begins with questions like “Who else watches the kids when you go out?” or, “When you are having a rough day, who do you talk to?” or, “Who are some of the people you count on?” These ground-level questions are more than a set of techniques, they are the personal implementation of a larger policy that has the capacity to both be safe and value the child’s primary connection.

Enacting Possibility to Help Families in Crisis

Like the Zoysia grass, the grass/weed whose initial plugs merge over time into a uniform carpet, training from a Crosswords perspective can grow the seeds of organizational interpersonal attachment. One way to underscore the marriage of mission and method is to give training participants a felt sense of difference.

The enactment of possibility begins when participants fill out a blank crossword on their own. After five minutes of working alone in silence, the trainer helps the participants process their “silent” experience at multiple levels: What did you notice? Did you fill in the boxes you knew first, or did you have a system? What did it feel like? Did any of you get stuck? How did you get out of that — what did you do? Typically, people report a range of answering strategies — some very methodical, “I do every ‘across' first, then I start with the ‘downs,’” others more radiant, “I just see which ones I know and then go from there.”

Next, the trainer asks the participants what it felt like to do the puzzle. What did they notice about their mental/emotional and physical states? “It was quiet.” “I kind of got into it.” “It was frustrating.” “I felt tense.” “I was worried other people would see how much I didn’t know.” “I kind of enjoyed it.” “It’s like Solitaire or Wordle, I just got lost in it.” All their answers provide abundant raw material to talk about their work, their stresses, successes, and the strategies they use to problem solve. And it sets the stage for helping them think “out of the box” by using the other boxes.

To widen the lens, the trainer may provide another enactment. This time, they can ask participants to form small groups of six or fewer, telling them that they have another five minutes to work on their puzzles, but this time, together. People begin to talk, share their answers, laugh, and fill in the blanks as they see how quickly they can solve the new crossword together as a team.

When the time is up, the group is asked to process their experience and compare it with doing the puzzle alone. Inevitably, they notice the energy level, productivity, speed of producing answers, and their own internal experience of connecting while connecting the dots. In future puzzling cases, this brainstorming model can supply added, shared resource clues to support and, most importantly, help the clinician in their search for resources within the family and larger system.

Materials Needed: Copies of a Crossword Puzzle

Total Amount of time: 10–20 minutes

Lessons Learned: Start with strengths within and around the family, fill in the answers you know to discover the answers you don’t.

One does not need to know all the answers to get all the answers.

A “wrong” answer is eventually corrected by the context of right answers.

Just like a case, one does not know all the answers when starting — answers emerge over time often from unexpected sources.

Persistence pays off — but so does taking a break and getting help.

A Family Crossword Comes Together

The first time I (LPM) met Kyla and her mother, Teresa, was across a cold table in an institutional room. Kyla had been in the residential treatment facility for almost ten months following a series of escalating behavioral incidents in her previous foster home. I thought back to my meeting with the family’s caseworker, who told me that Teresa and her partner Linda’s relationship was volatile and created an unsafe environment in the home. Kyla’s father, according to the caseworker, was out of the picture.

During my first several months working with the family, I felt as if very little progress had been made. Each week, I’d pick Teresa up and drive her to the residential facility for family sessions. Dutifully, I went to family court, holding space for an equally enraged and devastated Teresa on the way home each time reunification was pushed back. I consistently showed up for the family, and despite good rapport with both mother and daughter, Kyla’s behavior remained a challenge and our family sessions felt focused on the crisis of the week, as opposed to addressing underlying family dynamics and struggles.

One day, Teresa unannouncedly brought her partner Linda to session. From that point, treatment changed almost immediately, as both Kyla and Teresa seemed more engaged and open during family therapy, and we began to focus less on minor incidents and more on boundaries and communication within the family system.

Still, somehow, it felt like a piece of the family puzzle was missing. I could sense that Teresa and Linda were holding something back, particularly when we discussed their co-parenting practices. This final piece fell into place one day when I went to pick up Teresa and Linda and Robert, Kyla’s father, eagerly and unexpectedly hopped into the van. It quickly became clear that Robert had been actively involved with the family all along.

I finally could see the full picture of the family structure and their dynamic. Teresa, Linda, and Robert were in a polyamorous relationship. Robert had been understandably hesitant to engage with the child welfare system out of concern that the polyamorous relationship would be condemned, and reunification denied.

The case that had “simply” been presented to me as an unreliable mother with a violent partner unable to meet the emotional needs of her unstable daughter was actually one where a child had three caring adults who wanted to support her. With all the pieces in place and the entire family finally engaged in treatment, meaningful therapeutic work ensued, Kyla’s behavior improved, and she came home.

Conclusion

“The solution to pollution is dilution.”

Using crossword puzzles as a conceptual framework and training method opens workers and the organization to both the learned and the lived experience of complexity, strength, possibility, and the importance of connective relationships when working in child protection. We know that systems can mirror the systems that they treat. For instance, In Child Welfare, the insidious nature of poverty is such that it can quietly, but inexorably, leach into the soil of good intentions in such a way that the attachments between worker and family, workers and other agencies, worker and supervisor, and workers themselves, can suffer the pollution of despair.

This is not to say that using crossword puzzles will wall off the effects of these potential systemic toxins. It is to say, however, that healthy, connected relationships can be grown and nurtured and, over time, create “the difference that makes a difference.”

***

The author would like to thank my friends and colleagues who helped me fill in the blanks, both across as well as up and down. A special thanks go to Lauren McCarthy (LM) for providing the case of Kyla.

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

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

In Search of Golden Geese

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

Joe Bavonese:

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

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

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

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

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

JB:

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

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

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

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

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

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

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

JB:

over the last two years hiring has been very difficult

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

Winds of Change

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

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

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

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

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

JB:

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

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

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

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

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

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

LR: Then that slowed down?

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

LR:

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

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

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

The Business of Practice Ownership

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

JB:

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

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

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

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

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

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

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

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

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

LR: But?

JB:

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

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

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

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

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

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

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

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

JB:

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

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

LR: Stock options?

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

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

JB: Yes.

Ethical Concerns and Red Flags

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

JB:

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

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

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

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

JB:

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

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

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

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

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

JB:

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

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

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

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

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

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

A Short List of Tips

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

JB:

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

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

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

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

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

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

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

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

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

JB:

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

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

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

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

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

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

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

JB:

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

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

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

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

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

JB:

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

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

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

LR: Or climb mountains or go to baseball games.

JB: That’s right.

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

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

A Powerful Therapeutic Tool for Defeating Negative Self-Talk

Posted on February 14, 2023February 11, 2026 by Psychotherapy.net Team

A client of mine, let’s call her “Jill,” got nervous for business meetings no matter what they were about. She often worried, daydreamed, and lost sleep the night before meetings. Afterward, she typically acknowledged something to the extent of, “It wasn’t as bad as I thought.”

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This was an exhausting strategy. Jill was convinced that her stream of hyperactive self-talk was preparing her for what was to come, but the amount of bandwidth chewed up by worry undercut her ability to plan well, if at all. On the day of the meeting, Jill presented as anxious, at least at first, until she realized that all was well. Fear of the moment was worse than the moment itself.

Sound familiar? Many of our clients experience similar struggles with anxiety and negative self-talk.

Eventually, Jill enlisted a strategy called WBL. Instead of steering her away from negative thinking (which would have felt precipitously close to telling her ‘How to feel’), we tapped into her brain’s natural predisposition to predict and created some parameters around it. It proved to be a powerful tool in our work.

A Cognitive Behavioral Intervention: The WBL Strategy

I adapted the WBL model from core CBT principles and have found it useful while working with clients like Jill. At the beginning of our work together, Jill and I defined the specifics of situations that aroused her anxiety. Often when anxious a set of varied concerns coalesced and appeared as one item. We combatted this generalized anxiety through a process called “unbraiding,” wherein we specified one particular concern from among the many. When her concerns appeared tangled, we pulled at only one thread.

Despite her competence and high level of achievement, Jill had grappled with imposter syndrome in the past, and at each new meeting, was inclined to “prove” her professional value.

After identifying the concern, we began the WBL process. The W stands for Worst. Jill was asked to imagine the worst possible scenario, with two limits: 1) take notes; and 2) keep time. We did this with pen and paper handy. The task was to write the ideas down and, importantly, to be honest. This was an important phase for multiple reasons.

First, we honored the inclination of her mind at that moment. In a recent incident, Jill was afraid of being shouted at. She said she did not want to feel powerless. She recounted her journey to achieve her position in the company and was terrified of losing that status. Once this worst-case scenario had been named, we were able to create space for it and distance from it. By talking through the W, we determined that it was not the business meeting that was bothering her, but the fear of feeling inadequate.

Together we agreed not to focus on the W for too long. We set a timer for five minutes and stuck to it. Importantly, Jill was the one who physically set the timer on her phone. She owned the duration; she set a barrier around the time we were allowed to spend considering the W. Before we started this process, Jill spent too much time contemplating the worst possible outcome.

The longer she sat in that hypothetical, negative situation, the more she colored her mind with negativity. Prior to beginning the WBL process, she would enter business meetings in that hyper-negative state, and as soon as she sensed that the meeting felt “off,” she would interpret it as a confirmation.

Therefore, the immediate next step, B, asked her to consider the Best possible outcome of the situation. Entertain the idea that the meeting will be full of praise, ending in a big promotion. What would that look like? Would it come with more free time? More money? More travel? It took considerable effort for Jill to allow herself to consider such a positive outcome. This phase of our work was not about considering what was “pretty good,” but instead, what the best could look like.

Jill had trouble getting to this place. She was hesitant to think big. She had no trouble going to the W but believed that the wonderful reaches of the B were not likely, so she talked herself out of them. Over time, we worked together to understand that the best was, by definition, just as likely as the worst — they were two ends of a hypothetical spectrum that she created.

Once we identified those two poles, we found a spot in between (it can be helpful to draw out the continuum on a piece of paper). In the L phase, which stands for Likeliest, we took a moment to be truly sensible. The outcome of Jill’s upcoming meeting was not likely to be at the worst pole, and, unfortunately, not likely to be at the best pole.

So where was it most likely to be? At this point, she tended to lean back toward the W side of the spectrum. It was important that she catch herself leaning into that negative default and do the work to stay centered. I encouraged her to, if anything, lean toward the B and let her mind be colored by positive thoughts, as they would have an impact on her interactions.

Once we did the work of naming the concern, then working through the WBL model, we put it all together. She had the power to influence the direction of the meeting through the energy she would bring to it.

Cognitive Strategies Lead to Successful Outcomes

Cognitive strategies like CBT did not rid Jill’s professional life of challenge but improved her approach to challenges. Jill was successful and driven. She was accomplished and continued to move in a positive direction. She credited taking control of her self-talk as an important step in the future she imagined for herself.

Deliberately cultivating Jill’s mindset was not a soft, feel-good skill (though it did feel good). It positively impacted outcomes. We call those positive outcomes feedback. The more positive feedback she received, the more confidence was built, and the less likely she would default the next time around toward a worst-case scenario. The more we repeated this process, the more we shifted the default positions away from the worst and toward the best.

The brain is, first and foremost, a prediction machine. The WBL tool helped us get behind the wheel of that machine and steer it. The difficult journey for Jill turned out to be well worth the effort.

In the Shadow of COVID, It’s Play Therapy to the Rescue

Posted on February 8, 2023February 11, 2026 by Psychotherapy.net Team

Kevin’s Worried Parents

In March of 2021, families were emerging from almost a year of isolation due to the COVID pandemic. As a Licensed Professional Counselor Supervisor and Registered Play Therapist Supervisor in private practice specializing in children, I was flooded with requests for services.

During one particular intake interview, the parents of a four-year-old boy I’ll call Kevin asked me a fair question. “How will our son’s development and mental health be impacted by this year of isolation?” I immediately reflected their feelings with, “You are really worried about the long-term impact on your son.”

Their worry was understandable given the emerging research showing increases in children’s anxiety and depression since COVID began. Yet, multiple factors of genetics, parents’ behavior, peer interaction, and available resources contribute to children’s developmental and mental health trajectory after a crisis. To respond to their fair question, I needed more information from them.

I asked, “What is concerning you the most?” Both parents had college degrees and were well read so they had valid concerns in mind. “Our son has not seen, much less interacted with, another child for over a year. He is our only child. Even though we took him to the public playground, as soon as another child got within 20 feet of us, we would leave quickly.” I thought to myself, risk factor one — no peer interaction during a critical developmental period.

Preschool is when children learn to tune into peer facial cues, scaffold their own physical and cognitive learning by watching other children, negotiate sharing, and so on. I needed to provide some hope to the worried parents, so I tried to normalize the fact that most of his peers had a similar experience. I replied, “Some children’s social, physical, and cognitive development may be a bit delayed during COVID. Fortunately, children are resilient and can learn together, starting from where they left off.” They nodded with seeming understanding.

Then Kevin’s parents said, “Our son could tell we were stressed when we were working from home and paying bills with less money. We tried to play with him, but we had many conference calls. He didn’t understand and thought that we were ignoring him. He became clingy and we became irritated, occasionally speaking to him more harshly than we desired.”

I thought to myself, risk factor two — parent behavior that was interpreted by the son as anger, resulting in increased anxiety. Being a parent myself of an only child who also has ADHD, I empathized and normalized with a compassionate groan. “I get it. I experienced something similar with my child.

We can feel so disheartened, trying our best to juggle it all, and losing our temper more than we want. We are human, not superheroes. We need self-compassion. That’s why I go by the 80-80 rule of parenting. About 80 percent of the time, I try to do about 80% of what I know to be helpful. But during COVID, I lowered my standard to 70-70 because that is passing.” They laughed!

The parents added with a heavier tone, “We are also concerned about his anxiety because we both suffered with anxiety during our childhoods.” I thought to myself, risk factor three — genetics. Research shows a strong genetic influence on the development of childhood anxiety disorders. Again, the parents needed some hope. I reflected, “You both know the pain and struggle as a child with anxiety. You love your son so much that you want to intervene as early as possible. You are wise to do so. I can help with that. Research shows that play therapy can decrease children’s anxiety. Together, we can work to build those limbic system neural networks toward calmness rather than fight or flight.”

Yes, the risk factors for this child were compounded during COVID. He had no peer interaction for a year, stressed and distracted parents, and a genetic predisposition toward anxiety. Yet, he also had the biggest protective factor we could hope for — caring and proactive parents. This plus mental health treatment, interventions of parent guidance, twelve sessions of Child-Centered Play Therapy (CCPT), and psychoeducation could shift this boy’s development and mental health toward a more positive path.

Prior to beginning my work with Kevin and his parents, and to gauge the level of his behavioral and emotional difficulties, I sent his parents a link for the web-based child version of Achenbach’s System of Empirically Based Assessment (ASEBA) Child Behavior Checklist for ages one and a half to five. The results revealed a pattern of emotional reactivity, anxious and depressive symptoms, and sleep problems. While Kevin’s scores on the DSM-related scales for Autism and ADHD were in the normal ranges, his other scores were consistent with DSM anxiety and depressive symptomatology. These results corroborated his parents’ concerns.

The parents’ main goal was to decrease Kevin’s anxiety so that he could calmly engage with others without clinging to his parents. Their prior attempts to reassure him through reason were ineffective. Using Daniel Siegal’s Hand Model of the Brain, I explained strategies to calm the lower regions of the brain through deep breathing, rocking, and soft voice rather than trying to reason with his prefrontal cortex, which was “offline” during his anxious times.

To reinforce these concepts, I asked Kevin’s parents to watch a parenting video by Tina Payne Bryson called 10 Brain-Based Strategies: Help Children Handle Their Emotions, and to read Siegal and Payne Bryson’s No Drama Discipline. These two resources helped them improve their ability to calm their own anxieties so their son would co-regulate with their calmness. To deal specifically with anxiety, I also recommended Calming Your Anxious Child: Words to Say and Things to Do by Kathleen Trainor to guide them in the step-by-step process of systematically desensitizing his fears.

A World Opens

In the waiting room prior to his first play therapy session, I greeted Kevin, commented on his red tennis shoes and matching shirt, and said, “It is time to go to the playroom. Your mom will be waiting right here.”

I smiled with friendly confidence, moving toward the door, and gestured for him to follow me. “We have lots of toys there.” His curiosity was stronger than his anxiety, so, he followed me. Kevin’s eyes opened wide seeing my play therapy room filled with carefully selected toys for nurturing (dolls, doctor’s kit), creativity (puppets, paints and easel, dress-up clothes), real-life mastery (kitchen, tool bench), and aggressive release (swords, bop bag, army men). As we entered, I said, “In here you can play with all the toys in most of the ways you like.”

Kevin was hesitant and stood near me, asking questions. “What do I do first?” Given his anxiety, this was not surprising. “In here you can decide.” He moved his eyes but not his body. I view this as a “freeze” state, a survival response for people perceiving threat and feeling overwhelmed. The threat was not necessarily coming from the playroom but from being separated from his parents or close family members for the first time in over a year. I reflected his feeling with reassurance, “You are a little scared being in a new place,” and role modeled taking a deep breath. I waited patiently so he could sense my calmness and confidence, thereby communicating this was a safe place.

Kevin moved toward some small cars on the shelf and pushed them along the floor. This action with familiar toys gave him a sense of security and mastery. I reflected his feelings by saying, “You enjoy seeing how far you can push those cars.” My statement reassured him that he really was welcome to play and built his confidence. He said, “Yes, I have a blue and red one at home that I like to race.” I gave him credit for his skills, “You are an experienced car racer!” He smiled and pushed the cars toward the four-foot red bop bag, named “Bobo.” Kevin lightly pushed on it to see how quickly it moved. “What’s this for?”, he asked. I returned responsibility to him with “You are curious what you can do with that. In here, you can play with it in most of the ways you like.”

Little by little, he courageously experimented with different actions from punching it, sitting on it, hitting it with a sword, and shooting at it with a dart gun. With each step, his sense of power grew. Toward the end of the session, he expressed creativity by painting a picture of the bobo. I ended the session with 10 minutes of psychoeducation on managing stress. I demonstrated and guided him through deep breathing, progressive muscle relaxation, and a self-soothing butterfly hug. After walking Kevin back to the waiting room, I prompted him to demonstrate his new skills for his parents and asked them to practice at home each day.

Bugs All Over You

In the fourth session, Kevin began with rolling cars again followed by punching Bobo, providing him with a familiar rhythm and routine. Once he established his sense of mastery and power, he collected toy spiders, snakes, and bugs and put them on my legs, hands, and shoulders. “You have bugs all over you. You can’t move.” I stated, “You are showing me it is scary to have bugs on me and not be able to move around.”

He exclaimed, “Yes, you are going to be stuck there forever.” I responded, “It seems like it will never end!” Eventually, Kevin decided to rescue me by knocking off the bugs with a sword. His symbolic play reflected his experience during the pandemic of feeling scared and trapped. Yet now he was in charge, rather than being the one trapped. He was gaining an emotional understanding to master his traumatic experience of COVID isolation.

At the end of the session, I engaged him in a children’s book that illustrated listening to his body to notice when he may need to take deep breaths and seek soothing sensations such as rubbing his hands and legs. This combination of child-led restorative play reenactment plus the intentionality of anxiety management skills strengthened his ability to emotionally self-regulate.

Mommy Dies

By the sixth play session, Kevin had gained enough comfort in the playroom that he was ready to play out a hidden fear — mommy dying. He approached the playhouse and put the “daddy doll” upstairs in the office to do his work. The “boy doll” was downstairs by himself watching TV. The mommy doll ran out of the house to go to a work meeting on a nearby table. Kevin drably said, “Mommy went out of the house, got COVID and died.” I reflected, “Super scary and so sad she died.” Kevin quipped, “Yup. Now who’s going to make dinner? Daddy is busy working.The boy will have to go out and hunt for food.”

I responded, “The boy feels all alone AND he knows how to get some of what he needs.” Eventually, Kevin brought in the army to help him hunt for food. I facilitated understanding: “There were strong people out there who could help the boy when he needed it. They kept him safe.”

Underlying Kevin’s fear of his mother dying was the basic existential question of “Will I survive?” Through play, Kevin created his answer — letting strong people help him. During the last 10 minutes of the session, I facilitated psychoeducation by playing a detective game with Kevin. “Let’s list lots of things many kids are worried about these days.” Kevin said, “Losing their favorite toy and their dog running away.” I added, “Family members getting sick, going to the hospital, and dying.”

Then I challenged his all-or-nothing thinking. “There are 100 kids. One kid loses their toy. Does that mean every kid loses their toy?” “No.” “There are 100 dogs. One dog runs away, does that mean everyone’s dog will run away?” “No.” “There are thousands of people. One person may get sick from COVID and die. Does that mean everyone will?” “No. If someone gets sick, they go to the doctor and the doctors do their best to help them.” “Let’s think about all the kids who are playing with their toys, dogs, and family members. What would they be doing?” “Playing fetch.” “Yes! I love to play fetch with my dog.” Since Kevin was calm, he could engage in basic reasoning that most people will be OK and the importance of focusing on the positives in the here and now.

Doctor Superhero

In the tenth session, Kevin walked in with confidence. He rolled the cars, punched the Bobo, and took the baby to the doctor. “Your baby is sick. I am the doctor.” He used the stethoscope, took the temperature and blood pressure, and gave the baby a shot. I reflected, “You knew how to doctor the sick baby and get the baby better.” He got the cash register and declared, “That will be $10,000.” I paid up — a small price for his victory.

Then Kevin put on the Superman costume and flew around the room “saving everyone.” I enlarged the meaning: “You are an important, powerful person who can help so many — even yourself.” With his chin tilted up, he said, “Yup, I’m not scared anymore!” Indeed, his parents had confirmed that he was no longer sleeping with them, and he was willing to stay with a babysitter for them to have a date night.

Reflections

From a Child-Centered Play Therapy perspective, Kevin was experiencing incongruence between his ideal self as a confident, engaging boy, his current self as an anxious boy, and his experiences of isolation and fear during the COVID pandemic. He was not accurately symbolizing the behavior of his parents and other adults in that he interpreted their cautions as a lack of confidence in him. Over months of physical and emotional isolation, his self-concept was of a timid, weak child who was unable to move forward in his world.

Kevin’s time in the playroom with me along with his parents’ support provided him with a developmentally appropriate intervention in a safe playroom with an empathic play therapist, representing a microcosm through which he could master his world. He was able to come to an emotional understanding that his past anxious experiences were about an illness doctors were trying to heal and not about him. His self-concept strengthened to see himself as a strong, powerful boy who knew how to get help, help others, and help himself. Parent consultation, Child-Centered Play Therapy, and psychoeducation were the healing components of treatments that showed such love to this family. Kevin emerged from his isolation and anxiety. He flies like Superman toward a more positive developmental trajectory.

Parents and children experienced suffering during COVID. Many experienced existential anxiety from recognizing mortality, confronting pain and suffering, and struggling to survive. Mental health professionals were trained to support people in crises such as COVID. Yalom and Josselson remind us, “No relationship can eliminate existential isolation, but aloneness can be shared in such a way that love compensates for its pain.”

Reference

1. Yalom, I. D., & Josselson, R. (2011). Existential Psychotherapy. In R. Corsini & D. Wedding (Eds.), Current psychotherapies (9th ed., pp. 310–341). Brooks/Cole, Cengage Learning.

Spitting Truth from My Soul: A Case Story of Rapping, Probation, and the Narrative Practices- Part II

Posted on February 2, 2023February 11, 2026 by Psychotherapy.net Team

Recapitulation

This is the second part of a two-part case story that focuses on a 24-year-old African American client named Ray who was referred to me (TH) by probation services. In this brief introduction I will try to summarize what transpired in Part I. Whenever possible, I will attempt to provide phrases or “pieces” of Ray’s language so the reader can begin to get a “feel” for him and our work.

Rap music was introduced as an entry point to our work. After our first session Ray could probably best be described as equal parts skeptical and intrigued. He enjoyed sharing rap songs that were meaningful to him as well as having the opportunity to create rhymes of his own.

We rather quickly discussed ways in which rap music was misunderstood (“Adults throughout my whole life telling me it’s violent and the music of the devil . . .”) and how others could not or were not willing to hear the important messages that can be contained within certain songs. We proposed a pair of magic headphones (“Magic Beats”) as a way to help those who would not listen begin to hear rap’s message. This idea will prove particularly important as our conversation progresses in Part II.

As our first conversation continued, we started exploring the sociopolitical implications of rap music and hip-hop culture. We framed rap as a kind of philosophy (“But without all the white cats . . .”) that served as a voice for the voiceless. We also stumbled across a connection between Ray’s grandmother and rap music (“I’m rapping about the same s**t she’s saying but in my own way . . .”). This struck him as perplexing (“That’s crazy bro . . .”) and also enlightening (“I never thought of it like that . . .”) given the disdain she had expressed for rap music throughout his youth. Our first meeting came to a close by having a conversation about our conversation.

We explored the difference between just talking and rapping, to which Ray responded, “It’s like when I rhyme . . . I spit truth from my soul.” We both agreed that inviting rap to our future meetings would be of benefit. More specifically, we discovered that rapping might serve as a pathway to liberation (“Remove the shackles from my soul . . .”). I invited Ray to consider composing a rhyme that paints the part of the picture that probation services doesn’t see. He responded enthusiastically but seemingly nervous that probation services would discover the way we were working and somehow veto it (“You’re the weirdest shrink they have ever sent me to. Not weird like bad, not bad at all, but does probation know you do this?”). We then decided that calling our work together a “studio session” was a better fit than therapy.

Ray picked up in our second meeting directly where he left off in the first. He came prepared with a rhyme that would be the foundation of a counter-story. He noted in that rhyme the importance of challenging rules (“Just because these are the rules you play the game by doesn’t mean these are the only rules . . .”). The conversation evolved into looking at whether or not Ray had found some ways of challenging rules more effectively than others. He then traced the relationship between rap and anger (“It’s like my anger would leave my mouth through my rhymes . . .”). Part I concluded with a pensive Ray searching for a rhyme that captured this most important function of rap music as an antidote to anger and aggression. The following rhyme picks up where our original story concluded.

An Antidote to Anger

Judicial system mad puzzling

DA presents two options
Jail cell or rat on my cousin
Death sentence if I’m released
Seen on the streets
All free
They’ll be like “who you dropped a dime on g’”
Obscene language make them ends
So I’m squeezing my pen
That’s mightier than the blade
Not trying to see death
Strategize and not be so impulsive
Quiet cats survive
Bullets for the ones boasting
Friday night drive on Colfax
Enjoying the madness
That was created by fascists
Reagan-nomics took our tools away it’s so savage
Regardless of politics
This my Mile High life
Shout out to my bail bonds-man.

Travis (T): What speaks to you in this verse?

Ray (R): The line, ‘So I’m squeezing my pen, that’s mightier than the blade,’ is the main one. I mean, the rhyme talks about the stress, the penitentiary, but then boom (begins rapping) So I’m squeezing my pen, that’s mightier than the blade.

T: Did you fight with your pen instead of your blade before you ended up on probation?

R: Usually, yes. But there are these times where I just lost it.

T: The pen was knocked out of your hand?

R: Yeah, you could say that.

T: What happens when the pen gets knocked out of your hand?

R: It’s like I’m a different person. I do these things I know are stupid, but I just do them, anyway. It makes no damn sense.

T: But when you have the pen?

R: I can do anything.

T: Would it be accurate to say that when you have the pen you can spit truth like you said in our last meeting and that’s when Ray The Philosopher comes out (I uttered the term Ray The Philosopher without giving it much thought and certainly without an understanding of how it would later be adopted in our work together)?

R: For sure. That’s kind of a dope name right there, brother… Ray The Philosopher (said with gusto)

T: Do many people in your life know Ray The philosopher?

R: My homies do.

T: Is there anyone else you can think of?

R: No, not really.

T: What do you think would happen if we introduced more people in your life to Ray The Philosopher and his rhymes?

R: I think it would be good, but like I said last time, nobody wants to listen. They think rap is corrupt.

T: What if we were to inform them that when you can think ahead and fight with your pen through rap it helps you avoid anger and thus probation? Do you think they know this about you?

R: Nah, they don’t know that. I still don’t know if they would hear me.

T: Even if they knew that it would help you avoid future relationships with probation, they still wouldn’t hear you?

R: (silence for 15-20 seconds) Maybe. I mean, I hope so.

T: What do you think your grandmother would think about rap as a way to fight with your pen instead of your fists? Have you spoken with her about how you and rap have this kind of relationship?

R: No. I’ve never spoken much about my rhymes at all with my grandmother. I’ve just always known how much she hates rap. Like if I bring it up, I know she’s going to roll her eyes at me.

T: Do you think the kind of rap she hates and the kind of rap you’re tight with when you’re fighting with your pen are different?

R: Oh, yeah! She thinks rap music is just about cursing, talking about hoes and drugs and shit like that.

T: If she truly knew how rap music unshackled your soul do you think she might begin to have a change of heart?

R: Yeah, I still just don’t know if she would listen, though.

T: What if we created a space in here where you could perform for her, and we constructed a marquee (points upward) that lights up and says Ray The Philosopher!?!

R: (Laughs)

T: If you rapped for her and she could feel the words instead of just hearing them, what do you think might happen?

R: I really don’t know.

T: Would you say that your grandmother’s wisdom finds its way into your rhymes?

R: Oh yeah, I know it’s in there a lot.

T: Can you think of an example in the rhyme that you shared with me at the beginning of our conversation today?

R: My grandmother has always wanted the best for me. That’s why I started out that first line with her. You know, (begins rapping) Grandma said I should reconsider law school. I was sampling from another rhyme that starts with mama instead of grandma, but it’s because I know she wants the best for me and that’s why she’s always bothering me about school.

The thing is, she also taught me to be street smart, which is why I like to challenge the whole foundation that student loans and shit are built upon. It’s like a scam for poor people. You know what I mean? I would have never thought about shit in these terms if it weren’t for her. I would have never looked deeper. And that’s what that second verse is about, too, with people on TV commercials acting like they can save your life and shit. You ever watched TV at like 2:00am?

T: I have a few times, yes.

R: Then you know what I mean, right? There’s these cats trying to sell hocus-pocus. They are saying shit like, (changes voice to that of a highly embellished television salesperson) “For 20 years now I’ve been helping people change their lives. For only three easy payments of $99.95 you can get the 7 secrets that will make you rich. Order now!”

(Both bellowing with laughter)

T: I didn’t know you were an actor, too, Ray?!

R: (Laughs)

T: In all seriousness, if I’m hearing you right, Ray, your grandmother’s wisdom is everywhere in your rhymes, and she doesn’t even know it?

R: Yeah, I guess you’re right.

T: Do you think we might be able to invite your grandmother to see, hear, and feel that rap can be a philosophy of street smarts and wisdom and not just a form of music that young people like to listen to?

R: I think so.

T: If we are successful do you think this would be sort of like putting the Magic Beats we talked about on your grandmother’s ears?

R: Yeah, but the rhymes will need to be just right.

T: Perhaps we should take some time in here to get them where you want them?

R: For sure.

Turn Up the Sound

Ray and I spent our next two conversations focused on taking the various rhymes rapped during our first two meetings and worked on creating a mega-anthology. It was a scintillating process that saw KRS-ONE, Tupac Shakur, and other artists rapping in unison through Ray’s mouth. I brought in my laptop computer to help with the process, and Ray made it do things I did not know it was capable of.

He turned my computer, and my office along with it, into a fully functioning recording studio. I even created a marquee (clearly the work of a second-rate artist) that read “Ray The Philosopher,” which always led to a hearty chuckle from Ray every time I hung it up at the beginning of our meetings.

“Yo, Travis. Turn up the sound a little bit,” Ray said as I scurried over to the computer. “Yeah, that’s good right there,” he reassured me making an ‘a-ok’ sign with the finger and thumb on his right hand. I watched, often in awe, as Ray meticulously perfected his craft. He was locked in his element, and I was an enthusiastic fellow traveler.

“Nah, we need to change up that baseline a little bit,” he said shaking his head and taking a swig of water. “It doesn’t quite pop. I need more time.”

I have had the great fortune of working on similar projects with people who had sought my counsel in the past, but this was among the most ambitious ventures I had encountered. As we started to make our way toward the end of our fourth session together, I started to wonder if perhaps we had bitten off more than we could chew. Now I knew that Ray had similar feelings. It wasn’t as though we hadn’t been aware of time but more like we had lost ourselves in it.

T: Ray, the last thing I want to do is rush you through this process.

R: But I only get to come here one more time.

T: Well, I know that’s the initial agreement you had with probation, but I can see you as many times as we think would be best.

R: What about you, though? I don’t want to be a leach?

T: What do you mean?

R: You’ve got to get paid, man. This ain’t no charity. This is your livelihood, bro.

T: I really appreciate you thinking of me, Ray. Tell you what, how about I give probation a call and tell them a bit about the situation and see if we can get some more time? In the past this is something they have often been willing to do.

R: What if they’re not?

T: Then we will see the work through to its completion anyway, Ray. As long as it takes. This is just too important. Don’t you agree? Besides, I have been thinking about something. Would it be okay if I shared it with you?

R: Of course.

T: I know your grandmother is going to come in at the conclusion of our work to celebrate with us. I was wondering what you thought about perhaps inviting other people to meet Ray The Philosopher? Is there anyone else you who you think it might be good to invite to wear the Magic Beats?

R: Hmm… I haven’t really though about it too much.

T: I’m just thinking out loud here, Ray, so stop me if this doesn’t make sense, okay?

R: Okay.

T: What do you think would happen if your probation officer were introduced to this idea of you fighting with your pen instead of your fists?

R: I mean, I’m sure he would like it. He just wants me to keep my hands clean for the next year.

T: What do you think would be the consequences of us not bringing him up to speed on this?

R: I don’t know.

T: As it stands now, do you think your PO views you as someone who is going to fight with his fists and get into trouble again or someone who is going to keep his hands clean?

R: (Laughs cynically) I damn sure don’t think he trusts me. I think he believes I’m going to be out gang-banging (a hip-hop term for engaging in violent acts as a member of a street gang), and I don’t even do that shit.

T: How has it come to be that you don’t even do that shit and yet your PO thinks you do? Do you think we should try and set the record straight and let him know how rap allows you to fight with your pen instead of your fists?

R: But he’s going to give me that same old bullshit about how I don’t take responsibility and blah, blah, blah (uses his right hand to imitate a talking mouth).

T: Do you think if you rapped for him and let him know how rap can strangle the advances of anger and aggression, he would look at you as more likely to keep your hands clean or less likely?

R: (Pauses for 10-15 seconds) More likely to keep my hands clean.

T: What do you think the consequences would be if we weren’t to set the record straight?

R: Yeah, I get what you’re saying now.

T: How do you mean?

R: Like, it’s not enough for just me to come up with this plan if he still thinks about me a certain way… like I’m a criminal.

T: Do you believe this is an opportunity for Ray The Philosopher to replace the other names that have been placed on you in the past like criminal?

R: Now that you mention it, yeah, I guess so.

T: Would you say that sometimes your PO is a tough nut to crack?

R: C’mon, now! That dude is like impossible to crack.

T: Do you think then that we might have to prove to him just how effective fighting with your pen can be?

R: Sure, but how the hell are we going to do that?

T: How long have you seen me for now, Ray?

R: (Pauses to think) Like about a month.

T: I know this is a tricky question because I’m asking you to guess what another person might be feeling, but do you have any sense for how your PO would say this last month has been for you.

R: I actually talked to him about this last week. I’ve been squeaky clean. Not one single issue, homie.

T: What do you think he would have told me about how things were going if I had talked to him prior to you coming to see me?

R: Man, he was always in my grill about shit saying I was defiant, I was going to go to jail, and this and that.

T: Fair to say then that he believes things are going better now?

R: No doubt.

T: Has one month been enough to convince him that you are on the right track?

R: Hell no! It’s like he’s just waiting for me to fuck up.

T: How many months do you think it might take to convince him that you are on the right track and ready to end your relationship with probation?

R: I mean, I still have over a year of this.

T: Do you think it will take all of that time to show him just how effective fighting with your pen can be?

R: Probably so.

T: What if we were to invite him in here, bring him up to speed on your philosophy of fighting with your pen and not your fists, and then make a commitment to this going forward?

R: I don’t know if he’ll believe it.

T: You make a good point. Like you’ve told me, he can be a bit stubborn and so can your grandmother! Even as tough as it is going to be, are you willing to fight with your pen and prove to your grandmother, your family, and your PO the true character of Ray The Philosopher? You already have one-month under your belt!

Ray paused after my question. I started to wonder if perhaps my query had pushed him a bit too far. His face remained stoic as the silence continued beyond 30 seconds. Just as I started to ponder my next move fearing I had lost him, he replied, “I’m down (a hip-hop term voicing agreement).”

After the conclusion of our fourth session Ray and I agreed that it would be good to check in with his PO together. We decided that in addition to talking about the need for more sessions, we would also let his PO know (a signed release was already in place) about how Ray had been fighting with his pen instead of his fists. The PO acknowledged that things were going better the past month, but he remained skeptical. He agreed to get payment covered for half of every session for the next month. The way the following month was structured it would afford us five more weekly meetings.

Two Different Stories

Ray seemed somewhat relieved that more sessions had been granted but also a little bit ticked that his PO was still unconvinced. He felt his PO was “playing games” and “testing me.”

Our next three meetings were spent wrestling with these feelings. Ray began discovering that restoring his reputation burned nearly as many calories as he was taking in. Instead of being consumed by anger towards his PO, Ray stayed true to his word to fight with his pen. He remixed a song by the artist Common:

We should name the block poverty
That rock stole our humanity
You hear that glock pop?
For dough we perform beastiality
“Fucking each other over
What you expect they animals”
Then act like they the ones offended
When TMZ release the audio
If life’s a game
They withhold that playbook
But playas make that scratch
We get the itch
Run your shit
This a jook
Or a lick
See that’s a stick-up if you down with my click
We starving in the darkness
Force upon us they man made eclipse
Is it a curse?
Mad poisons in our blood?
My pops tried to disinfect it
Chugging that rum
And I do the same (word?)
Like father like son.

Ray no longer waited for me to inquire about the lyrics. He would deconstruct them now almost as a natural part of our process. “See, this is what he (probation officer) doesn’t understand. I was born behind the god damn eight-ball. No father. Poor. I’ve always had to hustle to survive. He doesn’t know my pain. Does he even care to know it? But that don’t even matter. Is he testing me? I’m going to pass that test.”

Ray began rapping the second verse from this song:

To my reflection I scribed
What I be feeling inside
Can’t leave it buried in the dirt
Gotta breathe it and give it life
My neighborhood taught us no self-control
That boom-bap made us feel like it’s our right to explode
No positive role-model
The hustlers were our fathers
Rappers instructed us to spit rhymes
And don’t bother
With the life of an outlaw
It’s a trick to keep us blind
And deny our title as God
Preventing our rise
They been doing this for centuries
Stolen lands from our North and South American fam
Jews burnt
Japanese thrown in determent camps
Hatred can hide
Right in front of our eyes
But I flipped that same hate
Used it as fuel to survive
I’m of a mind that believes love will conquer hate
They be seeing black and white
While my crew is dazed by all the gray
So gather around the fire
Light it up
Continue the cipher
Cause in the darkness of nights
Our stars still shine brighter
This is my dream!

T: Ray, are there two different stories in the two beats you have shared with me today?

R: Yeah, the first one is the pain and strife. The second is what happens when I look ahead and fight with my pen.

T: Pain and strife and fighting with your pen… both of those are rhymes that you brought into our work earlier, right?

R: Yep.

T: Would it be right to say then that these last two verses are a sort of remix of all of the beats we’ve heard in here so far?

R: Pretty much.

T: Would these verses be good to share with the folks who join us for our final celebration of the work you’ve accomplished in here?

R: Yeah, but I might tweak them throw in a couple of other verses from different rhymes to get it just where I want it.

Our second to last session was a dress rehearsal. Ray came with the beats he wanted to perform and refined them. We also talked about how he wanted our final celebration to commence, what would happen, and who to invite.

He joked that it “would be kind of like a block party, but where a therapist lives in the house on the corner.” We also decided that those in attendance would have an opportunity to voice their support of Ray’s efforts over the past two months as well as hopes and dreams for the future. As this session came to a close I could detect a nervousness that was following Ray.

T: Ray, I could be wrong here, but I am wondering if some nervousness is hanging with us right now.

R: Yeah, I guess so.

T: Do you mind if I ask you what kind of nervousness it is? People I’ve worked with before have taught me that there are different kinds? Do you know what I mean?

R: You know, I’m not like a professional rapper or anything like that, but I’ve performed in my neighborhood before. It feels like that. Like, you think you have a good rhyme, but you never know for sure until you get on stage and the crowd is feelin’ it.

T: What gives you confidence that the rhyme you have created in our work together will deliver just the message you hoped it would?

R: I put my whole heart and soul into it. I didn’t leave one drop.

T: Do you think the people who are here with us next time will feel your heart and soul coming out through your lyrics?

R: (Pauses for 10 seconds or so) I really think so.

T: Do you remember when I first asked you about what would happen if you rapped for your grandmother or your probation officer?

R: Yeah, I said they wouldn’t hear it.

T: Are you saying that you feel differently about that now?

R: Yeah, I guess so.

T: What would you say has shifted?

R: These rhymes are me but just in lyrical form.

T: And you don't believe your grandmother or those who love and care about you would reject this gift that is a lyrical manifestation of you?

R: No, my grandmother always tells me that she’ll never run out of love for me.

T: Hey, something just struck me, Ray. Would it be okay if I share it with you?

R: For sure.

T: I wonder if you just discovered the Magic Beats?

R: What do you mean?

T: Do you believe that when you create a rhyme that fully represents you and comes from the deepest depths of your soul that even those who don’t prefer rap music could still hear it?

R: (A smile overwhelmed the now dwindling doubt on his face as he nodded affirmatively)

T: Ray! This is great! What an incredible discovery you have made!

Ray often tried to minimize any expressions of emotion, but even he smiled loudly at this development. In our excitement we almost instinctively exchanged daps (gesture similar to a handshake) with our right hands before giving one another a quick hug. With this we had established an unspoken agreement that we were ready for Ray’s performance and celebration next week.

A Celebration of Hope

Ray and I agreed to meet about a half an hour before everyone else to prepare the room for the celebration. As we moved tables and chairs and geared up the laptop computer everything was coming together. “Alright, I think we’ve got it,” I said looking in Ray’s direction. He then shook his head ‘no’ and looked upward to indicate to me to direct my gaze towards the ceiling. “What?” I said with a perplexed look.

He nodded upward once more. I stared skyward still trying to decipher what Ray was communicating. Then I realized that in my haste to make sure there were enough chairs for everyone I had forgotten to hang up the marquee. Like a dog with his tail between his legs I went back to my desk in the back room and removed from the top drawer the “Ray The Philosopher” marquee. I dashed back out to the main office and hung it up in its customary location. “Now we got it,” Ray asserted.

Soon, Ray’s grandmother, his sister, and a few other people from his neighborhood began making their way into the office. There was a sort of nervous excitement that filled the room. Lost in conversation, time had escaped me. I

reached into my pocket and pulled out my phone to take a quick look at the time. In doing so I noticed a message was waiting for me from Ray’s probation officer. Oh no, I thought to myself. He had left me a message stating that something had come up and he wasn’t going to be able to make it. Just as I was about to hold the phone to my ear to listen to it, he lumbered through the front door. “Sorry I’m late,” he said. “Did you get my message? I got caught up with a few things at the office.”

Relieved that everyone was now here, I looked at Ray to see if he was ready to go. Ray had asked that I start by saying a few words to give folks a sense of what today’s meeting was all about. After welcoming everyone and thanking them for attending, I began discussing a bit about Ray’s journey.

“During our two months together, Ray has reaffirmed how rap music can be an ally in helping him be the person he wants to be. He has composed a series of beats he would like to perform for you today. Ray suggested that

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