Category: Approach

Christoffer Haugaard on Collaborating with Clients Who Hear Voices

Posted on by rezendevknowfully.com

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

Christoffer Haugaard: Thank you, Lawrence!

The Multiplicity of the Mind

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

A Relational Framework for Understanding Voices

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

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

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

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

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

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

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

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

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

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

In Relationship with Voices

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Narrative Therapy and Working with Voices

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

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

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

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

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

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

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

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

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

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

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

CH: In what sense?

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

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

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

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

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

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

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

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

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

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

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

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

Expanding the Subjectivity of Voice Hearers

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

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

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

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

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

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

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

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

©2025, Psychotherapy.net

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

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

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

Rose and the Whispering Voices

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

On the Therapeutic Power of Presence

Posted on by Psychotherapy.net Team

I’ve been a psychologist for almost 40 years, and I am constantly amazed at just how much neuroscience research is enhancing my clinical understanding of what psychotherapy clients may really need most. What I would like to talk about here is how the concept of presence—a state of grounded awareness of the present moment—can inform clinical practice and enhance the everyday lives of our clients.

Why Presence Is Important

Presence is a state of mind of selective and sustained attention where one is intentionally and nonjudgmentally receptive to one’s own senses, is active in reflecting on them, and is consciously directing their awareness to the present moment (1, 2). Presence first requires an awareness that we have, a capacity to experience it, and second, it requires the skills to make it happen. All clients—and clinicians—are on a continuum of both, so each client requires interventions tailored to their individual level of awareness and skills. But I am discovering more and more just how crucial it is to help clients learn how to be present with both difficult and life-affirming emotions. That is, how to sit with, better tolerate, and more fully embody those moments without reactively fighting them, distancing themselves from them, or becoming frozen by them.

Psychotherapy interventions are almost always chosen in the moment, because the timing of them is believed to be most helpful to the client. Cognitive-behavioral therapists may highlight a cognitive distortion, like all-or-none thinking; psychodynamic therapists may bring attention to a protective defense, like projection; Gestalt therapists may suggest the use of an I-statement to replace impersonal or blaming language. Even though the clinician’s application of their theoretical approach may be executed with textbook precision, the intervention can fall short.

For example, if a client repeatedly returns to a conditioned or protective response to difficult situations by jumping to unwarranted conclusions, by blaming themselves or others, or by characteristically pushing away or distancing themselves from their feelings, the best interventions of the clinician may not be enough. This is particularly true if developmental trauma or significant episodic injuries have occurred. When a client has difficulty taking in, processing, or applying the clinician’s intervention, or when emotional underpinnings of their symptoms may be so severe that access to the resources needed to make use of the clinician’s interventions are not available, building skills of presence may be needed.

The concept of presence is foundational to all psychotherapies but especially to somatic psychotherapies. From the early developers like Wilhelm Reich’s Orgone Therapy, Thomas Hanna’s Hanna Somatics, Alexander Lowen’s Bioenergetic Analysis, Moshé Feldenkrais’s Feldenkrais Method, and Ron Kurtz’s Hakomi Method to more modern approaches like Lisbeth Marcher’s Bodynamic Analysis, Pat Ogden’s Sensorymotor Psychotherapy, Peter Levine’s Somatic Experiencing, Raja Selvam’s Integral Somatic Psychology, and from the diverse work of Bessel van der Kolk, clinical practitioners have learned that using mind-body practices opens up new ways to strengthen their effectiveness—particularly for clients with chronic, unresponsive, recurrent, or refractory symptoms.

The Physiology of Presence

Modern neuroscience has provided a wealth of understanding of how presence operates and how it can be fostered. Being present in the moment causes neural and biochemical changes in the visual and prefrontal regions, causing increases in alpha and theta brainwave activity, reductions in autonomic nervous system activation, and changes in how information is processed and monitored. Research has shown that presence causes a cascading series of interactions between several identifiable regions of the brain, which sets in motion the activation of neurological and neurochemical changes that induce felt states of well-being.

More specifically, by setting our intention to be present, we activate a top-down process beginning in the dorsolateral pre-frontal cortex, which causes changes in two organizing cortical and subcortical superstructures known as the Default Mode Network (3) and the Salience Network (4). These superstructures coordinate distinct regions of the brain that are responsible for decreasing emotional arousal, reducing unpleasant self-referential thinking, and more effectively tolerating painful affect.

Merely intending to be present facilitates greater calm. When we begin to exercise greater presence, the Default Mode Network slows response reactivity. Additionally, substructures within the Salience Network (the anterior insular cortex and the anterior cingulate cortex) work synergistically with the Default Mode Network to a) detect mind-wandering to distressing thoughts and b) bring us back to a greater felt sense of calm and physiological homeostasis.

If our focus wavers, the Salience Network helps sustain our attention; it filters distractions; it slows our heart rate and breathing and decreases blood pressure and muscle tension; it increases heart rate variability; it downregulates the activation of our amygdala; and quite critically, it enhances our ability to monitor affective body states relative to actual occurrences in our external world. Stated somewhat differently, the neural circuit between the Salience Network and the amygdala allows us to accurately monitor the functional and dysfunctional interpretations we make about our outer world. For example, if we become frightened for no rational reason, presence triggers the Salience and Default Mode Networks that help bring us back to center.

Inducing Presence

There are literally hundreds of ways to induce presence in ourselves and in our clients. There may be several techniques that stand out and really work well for a particular client, and other clients may prefer using a wider variety of methods. Here are a few examples of ways clinicians have helped clients manage their physio-affective arousal by helping them make more consistent contact with the present moment.

Geller and Greenberg (5) believe that therapeutic presence is foundational to the therapeutic relationship, where the therapist’s whole self invites the client to become their whole self. The authors suggest the acronym P-R-E-S-E-N-C-E to organize a series of methods, where the client is asked to:

PAUSE (P)—stopping and creating a moment of stillness

RELAX/REST (R)

EMPTY (E) their mind of thoughts and judgements

SENSE (E) their physical and emotional state

EXPAND (E) their awareness of their external environment

NOTICE (N) the relationship or the connection between their inner and outer worlds

CENTER (C)—reconnecting with their core self and bodily groundedness,

ENTER (E) back into their immediate space or resume their actions or intentions prior to inducing the state of presence.

A method like this can be especially useful as an introduction to the notion of presence, as some clients may be quite unfamiliar with self-reflective and interoceptive processes.

In Somatic Experiencing (6), presence is induced when the clinician encourages the client to notice, observe, and become a witness to attendant body sensations, images, actions, impulses, emotions, or movements. If a calming or relaxing state is needed to temporarily offset the client’s overwhelming level of arousal, SE practitioners are encouraged to invite their client to slowly vocalize the sound “voooo,” which is reported to vibrate the vagus nerve, activating the parasympathetic (rest and digest) nervous system, and deactivating the dorsal vagal freeze response (7).

In addition to activating parasympathetic activity, the practitioner is also instructed to induce presence by prompting their client to notice their belly vibrating, to feel it do so, and to observe their overall physical reaction to making the sound. Levine also describes the use of Jin Shin Jyutsu, a Japanese mind-body system of self-regulation, where stronger states of presence and relaxation occur from better “energy flow” after performing a sequence of three body holds—placing one hand under the opposite armpit and placing the other hand over the opposite outer arm below the shoulder, placing one hand on the forehead and the other on the chest, and finally placing one hand on the chest and the other on the stomach.

For clinicians and clients who may be more familiar with interoception, Raja Selvam (8) highlights eight techniques for tolerating unpleasant emotions that also can enhance the experience of pleasant emotions. Each technique fosters greater presence with oneself and with one’s emotions:

a) breathing into and with the emotion

b) resonating with the emotion

c) heightening awareness of the emotion

d) visualizing the emotion dissipating, spreading more evenly in the body

e) vocalizing sounds that are congruent or resonant with the emotion

f) using self-touch to both support and make deeper contact with the emotion

g) enhancing one’s intention to make contact with, expand, or support the emotion

h) making very small body movements to release felt stuckness of the emotion

Applying these methods of presence to address an unpleasant emotion softens it and helps to better tolerate it. For clients with low tolerance for unpleasant emotions, the method is used in very shorts durations. At some point in the process, the client becomes aware they are tolerating the targeted emotion, when, at that point, they are prompted to notice the relief of having achieved it. Through the continued use of focused awareness and presence, the client is then guided to expand and make deeper contact with their relief. This typically results in a greater openness to and eventually a welcoming acceptance of the difficult emotion.

Other commonly employed presence inducing methods include inviting clients to:

a) name several things in their environment they can see, hear, smell, taste, and physically feel

b) scan and bring awareness to different parts of their body

c) take a long and audible sigh

d) gently stretch any part of their body

e) to look at something pleasurable in their environment and then to soften their eyes—relaxing their eyelids and facial muscles—while looking at it

f) simultaneously observe objects in their peripheral vision while focusing on a fixed point

g) toggle back and forth between looking at an object at a far distance—becoming curious about its nature, its history, its function—and then to notice how they are feeling about observing the object

Presence can also be fostered using the many forms of pranayama—a yogic breath control technique—an example of which is the mantra meditation So’ham, where on each in-breath one visualizes taking in all the positive energy of the universe and on each out-breath imagining expanding that positive energy to every part of the body. The very act of observing and reflecting on one’s internal states without judgement quiets the mind. Eastern philosophies and practices that emphasize living in the present moment are central to the many forms of meditation practiced throughout the world, which neuroscientific studies have shown similarly affect the brain superstructures discussed earlier (9).

As clinicians monitor their clients’ presence in sessions, they may already be well acquainted with when and how it fluctuates, and they may already be creatively using effective but less structured methods than those I have suggested. For example, I recently observed one of my client’s arousal level waxing and waning throughout a session, influenced by small things that were said by either them or me. By tracking these remarks along with correlated changes in their breathing, movements, and muscle tension, I was able to get subtle clues about what may be fostering or inhibiting presence. Monitoring my client’s real-time physio-emotional arousal, I was able to determine when the client was sufficiently present or needed support to do so—that is, whether they needed to build tolerance for a difficult emotion, rest from the unpleasant emotion, better regulate their arousal level, or expand their resources to address the emotion.

Lin: A Case Study

Lin had been my long-time client, who experienced significant developmental trauma from his father. At one point in our work together, he went through an extended period of unemployment in a vapid job market. Despite his considerable insight about his father’s impact on him and the substantial progress he had made with this issue, the stress of his unemployment was producing exacerbated and pronounced anxiety, which had brought him to the point of helplessness, exhaustion, and withdrawal. Lin’s precipitous overwhelm was also making it extremely difficult to calm him in the sessions, as he became more prone to unending ruminations about his difficulties, almost as if I were invisible to him. He was intellectually aware that his pondering was crippling him, but he could not relent from compulsively engaging in it while shaming himself for doing so. Despite my best efforts and those of his psychiatrist, something more was needed.

I decided to better employ the methods I have been discussing here to enhance Lin’s self-attunement. Although some aspects of what I was witnessing in Lin were related to his childhood, he was not in a resourced enough state of mind at that time to process interpretations about it. He was also not resourced enough to process feedback about cognitive distortions he was caught in, so I proceeded to address his immediate moment-to-moment, physio-emotional dynamic. He needed to become better present with how he was fanning his own flames, shutting me out as a support, and cutting himself off from his own psychic resources.

Because Lin seemed to need the simplest, most easily understood and tolerated intervention, I decided to begin the next session by encouraging him to take his time and look around the room, letting his eyes move the way they wanted to. . . and name five things he could see, then asking him to name two things he could hear, then one thing he could smell. Then I asked him how it felt to do so, to which he responded, “a little better.” I said, “That’s good, Lin.” He then quickly changed the focus and began characteristically ruminating on his troubles.

After empathizing with how tough a time he was having, I asked him how it felt at that moment in the session, and he responded, “Upset.” I then asked him if he noticed the shift he made, which he was able to acknowledge. I replied to him, “It’s excellent that you observed that, Lin.” Then I asked him to take a long, slow, audible sigh, where I could see him begin to settle. I could also feel myself settle a bit, which, in the resonance, helped me confirm I was on a good path in that moment with him. Although he soon began to agitate himself again with self-shaming accusations, it took him a little longer to start doing so. I’ve seen these delays occur with other clients, so it confirmed my intuition that his resilience for, and tolerance of, his troublesome emotions were growing.

I try to continuously monitor in real time my clients’ presence and their tolerance for unpleasant feelings. I think it helps me make better decisions about whether I should help them better tolerate their arousal or help them become better aware that they are tolerating it on their own. Sometimes clients need us to be their resource when they are having trouble maintaining access to their own inner resources. Sometimes it’s more important for them to see and feel our pride in them when they are handling their arousal just fine without us.

Gale: My Experience with Therapeutic Presence

This essay would not be complete without discussing the variety of ways clinicians wax and wane in maintaining their own steady presence with clients. Every day I work on learning how to be with my clients—to be awake, to how I repeatedly lose and regain attunement to them, to vacillations in my own internal emotional and physiological states, and to the subtle effects my degree of presence has on them. Being present is relationally essential: it facilitates empathic resonance, it prevents interpretive and empathic errors, and it makes my work and my life more enjoyable.

Like many, I grew up without being taught about emotions. It wasn’t until my late thirties that I realized I had feelings that I could identify and discuss. Through the study of academic psychology, through my clinical practice, and through my personal psychoanalysis, I have met many emotional mentors, some of whom, paradoxically, have been my clients.

Gale was a middle-aged, divorced client of mine, who regularly attended his sessions but who was highly reactive and talked incessantly without reflecting on his words or actions. Managing my own unpleasant internal reactions to him took some time. Although I recognized my countertransference reaction was stemming from my relationship with my father, this insight alone didn’t provide enough real and lasting emotional relief.

To regroup, I decided to take my own advice—that is, to apply to me and my own process with Gale, the recommendations I was making to my clients. In fact, this essay is a reaffirmation of what I continue to learn—how to authentically embody a better moment-by-moment attunement to “me” when being with my clients;how to give myself flashes of time to breathe, a moment to be with myself, to attend to me, to care for me, and to have an instant where I can honor and affirm my own existence.

As I permitted myself to focus on my needs while with Gale, a variety of methods to be more fully present spontaneously emerged. My next thought with Gale was to experiment with my own movement, so I consciously authorized myself to change my posture. Because I was so intent on focusing my attention on Gale, I realized that I wasn’t aware enough of my muscle tension and joint discomfort. As I crossed my legs, stretched my back, shifted my weight, I found myself quietly sighing. At first, it felt like a release, but it soon evolved into a wondrous return to a safe and grounded place—a place where I could give myself room to be with Gale’s loquacious tangentiality, without judging it or reacting to it.

From this place of peaceful inner calm, I started feeling more genuinely grateful for the relational space Gale and I were co-creating, and with it arose a greater sense of compassion and appreciation of his struggle. As I described in the earlier section on the physiology of presence, I could experience my arousal level diminishing, my dysfunctional interpretations of my outer world with Gale quieting, my capacity to accurately monitor my own body states increasing, and my tolerance for enduring my illusion that I was being ignored strengthening.

As if divinely inspired, my brain’s higher-order functions suddenly kicked in, and I realized at a visceral level that, not unlike myself growing up, Gale had no one in his childhood he could talk to about the things he wanted, for as long as he wanted. He never had anyone who wanted to be with him in the way he needed, to play with him on his terms, who conveyed to him that he was important, that he mattered. So, I sat with Gale, sometimes for whole sessions at a time, intently listening, staying present, breathing with intention, unobtrusively sighing, shifting my posture. . . until one day he began to slow and settle and finally voice, “I’ve had a lot to say,” to which I simply smiled and nodded.

At that moment, I could feel the resonance of his attunement with me and mine with his. Paradoxically, I became aware of what I believed I really wanted with Gale all along—not only for him to be aware of himself, but for me to be truly present with him, to connect with him, and to feel his connection with me.

References

(1) Kabat-Zinn, J. (2003). Mindfulness-based interventions in context: Past, present, and future. Clinical Psychology: Science and Practice, 10, 144–156. https://doi.org/10.1093/clipsy/bpg016

(2) Koch, C., & Tsuchiya, N. (2007). Attention and consciousness: Two distinct brain processes. Trends in Cognitive Sciences, 11, 16–22. https://doi.org/10.1016/j.tics.2006.10.012

(3) Malinowski, P. (2013). Neural mechanisms of attentional control in mindfulness meditation. Frontiers in Neuroscience, 7, Article 8. https://doi.org/10.3389/fnins.2013.00008

(4) Philip, N. S., Barredo, J., van ‘t Wout-Frank, M., Tyrka, A. R., Price, L. H., & Carpenter, L. L. (2017). Network mechanisms of clinical response to transcranial magnetic stimulation in posttraumatic stress disorder and major depressive disorder. Biological Psychiatry, 83, 263-272. https://doi.org/10.1016/j.biopsych.2017.07.021

(5) Geller, S. M., & Greenberg, L. S. (2012). Therapeutic presence: a mindful approach to effective therapy. American Psychological Association. https://doi.org/10.1037/13088-000

(6) Levine, P. A. (2010). In an unspoken voice: how the body releases trauma and restores goodness. Berkeley, CA: North Atlantic Books. https://www.northatlanticbooks.com/shop/inanunspoken-voice

(7) Porges, S. W. (2011). The polyvagal theory: neurophysiological foundations of emotions, attachment, communication, and self-regulation. New York: W. W. Norton & Company. https://wwnorton.com/books/9780393707007

(8) Selvam, R. (2022). The practice of embodying emotions: a guide for improving cognitive, emotional, and behavioral outcomes. Berkeley, CA: North Atlantic Books. https://www.penguinrandomhouse.com/books/673734/the-practice-of-embodying-emotions-by-raja-selvam-phd

(9) Bauer, C. C. C., Cabral, J., Stevner, A. B. A., Kirchhoff, D., Sousa, T., Violante, I. R., … & Kringelbach, M. L. (2022). Mindfulness meditation increases default mode, salience, and central executive network connectivity. Scientific Reports, 12, 13219. https://doi.org/10.1038/s41598-022-17325-6

Why Trauma Recovery Isn’t a Straight Line

Posted on by Psychotherapy.net Team

When clients begin trauma therapy many hold onto the hope that healing will follow a clear path. They picture a beginning, a middle, and an end. A moment where the past stops hurting, their relationships feel easier, and their bodies finally release the tension they’ve carried for years. But as therapists, we know it rarely unfolds that way. Healing is not linear. It comes in waves. Progress can be followed by regression. A moment of insight might be lost in a fog of overwhelm. A good week can lead to a hard month. It’s not a step-by-step climb. It’s a spiral. Clients return to the same emotional terrain again and again, but each time, hopefully, with a little more clarity, a little more stability, and a little more strength.

Clients Might Not Recognize Themselves at First

One of the earliest shifts I’ve witnessed in my trauma work is a client beginning to question long-held coping strategies, survival instincts, and automatic responses. These were the very tools that kept them safe in environments where safety was uncertain. They may start setting boundaries and feel a wave of guilt they can’t quite name. They may say no and spiral into fears of abandonment. They may feel anger surface for the first time in years and have no framework for how to manage it.

This stage can be disorienting. Clients often wonder if they’re regressing or doing it wrong. In truth, they are beginning to do something radically new. The nervous system often perceives unfamiliar experiences as potential threats, even when those changes are healthy. That is why growth frequently shows up as discomfort.

As a therapist, I have found it to be essential to help normalize this phase and support clients in tracking these shifts as evidence of progress. What once felt unsafe begins to register as tolerable. And over time, it begins to feel like safety. This is not failure. This is the nervous system recalibrating.

For clinicians interested in exploring the neurobiological foundations of this process, resources like Bessel van der Kolk’s work, and that of the National Child Traumatic Stress Network offer helpful frameworks for understanding how neuroplasticity supports recovery. I keep reminding my clients and myself that discomfort is often a sign of meaningful change. With time, what feels unfamiliar now can become a source of strength and stability.

The Nervous System Has a Story to Tell

Trauma doesn’t just live in your client’s memories. It lives in their bodies. It often shows up in the form of chronic tension, unexplained exhaustion, or a racing heart in situations that seem calm on the surface. I have noticed how a client becomes anxious in safe environments, withdrawn when connection is offered, or goes numb during moments that would typically bring joy. These aren’t signs of resistance or dysfunction. They are adaptive nervous system responses developed to survive past experiences.

The body carries what the mind may no longer recall. My client’s nervous system often reacts before their conscious awareness catches up. These responses made sense in the context of trauma, even if they seem confusing or disproportionate now. As a therapist, I can help clients begin to recognize these embodied patterns with curiosity and compassion. The healing process often starts with noticing—subtle shifts like shallow breathing, clenched jaws, or emotional distance in the room. These cues are the nervous system’s way of communicating safety or threat.

Rather than encouraging clients to override these sensations, I guide them toward listening to their bodies with gentleness. When I help create space between sensation and reaction, I offer a new way forward. That space is often where integration and healing begin. In learning about how the nervous system holds trauma and how regulation begins with awareness, I have found the Polyvagal Institute to be a particularly useful resource.

In one session, I have found that a client may speak with clarity and confidence. The next, they might come in feeling discouraged after falling into old patterns. Maybe they people-pleased, avoided conflict, or ignored their own needs. They begin to question whether any of their progress was real. It was!

Healing is not linear. The strategies that once helped a client survive can resurface, especially when they are tired, anxious, or uncertain. These moments are not evidence of failure. They are part of the natural rhythm of recovery. What begins to shift is their awareness. They notice the pattern more quickly. They pause before reacting. They ask themselves what they truly need in that moment. These subtle changes are meaningful. They mark the growth of resilience.

I have also found it important to help clients see these moments for what they are. Not as regressions, but as opportunities. This is where change begins to deepen. When someone catches themselves repeating an old behavior and chooses even a slightly different response, they are practicing something new. There is also something powerful that happens in these harder moments. Pain and struggle often reveal where care is still needed. They slow things down. They invite both the client and therapist to listen more closely to what is underneath the reaction.

This is where the deeper benefits of pain and suffering begin to emerge. These experiences have the potential to strengthen emotional awareness, deepen empathy, and reconnect a person with their values. Suffering, while never sought out, can become a guide that point to unmet needs, long-held beliefs, or unresolved grief that is asking to be seen. These moments help build presence, not perfection. Setbacks are not the end of healing. They are woven into the work. I have supported my clients in seeing these experiences not as detours, but as part of the path forward.

Healing Can Disrupt Your Relationships—And That’s Okay

As clients begin to heal, their relationships often start to shift. They may stop over-functioning. They may begin setting firmer boundaries or expressing their needs more clearly. Behaviors they once tolerated may no longer feel sustainable. These shifts, while healthy, can create waves. Not everyone in the client’s life will welcome or understand the changes. And that can bring grief, confusion, or even guilt.

Clients may feel lonely even as they move toward what’s best for them. They may grieve connections that once felt familiar, even if those dynamics were rooted in dysfunction or emotional distance. Letting go of old patterns often feels like loss, even when it is progress.

At junctions such as these, it’s important to normalize these growing pains. Healing doesn’t always feel good at the moment. It can challenge long-standing relational roles and bring uncertainty to familiar bonds.

These disruptions also signal movement toward something more grounded, more honest, and more self-respecting. Support clients in recognizing that discomfort in relationships is not a sign of regression and can be a sign of emerging authenticity. Healing doesn’t always preserve the old. Sometimes, it clears space for relationships that are built on emotional safety, mutual care, and respect.

It’s Normal to Feel Tired and Take Breaks of Healing

There have been moments in my clients’ journeys when the work feels like too much. They may grow tired of telling their story, tired of tracking every trigger, tired of examining old wounds. The weight of self-reflection can feel heavy. They might withdraw for a while. Maybe they spend more time scrolling, bury themselves in work, or cancel a session or two. These behaviors are not necessarily resistance. More often, they are signs of fatigue.

It is particularly important to name and normalize this part of the process. Healing is demanding. It takes emotional energy, and it does not always move at a steady pace. Help your clients understand that needing rest is not failure. Taking a break is not giving up. Slowing down does not erase progress. Sometimes the most meaningful work happens when clients step away and give themselves time to integrate what they’ve already uncovered. Growth needs room to breathe. It needs softness and space. When clients return, whether next week or next month, I acknowledge that return. Remind them that showing up, even imperfectly, is still showing up. That, too, is healing.

Clients often come into therapy carrying unspoken pressure. They want to get better quickly, move on from the past, and prove they’re strong by needing less. Some may feel shame for still struggling or frustration that their healing is taking “too long.”

There’s No Deadline for Healing

Therapeutically, it’s important to gently challenge this mindset. There is no prize for speed. No gold star for needing the least amount of help. Healing is not a race, and there is no finish line.

What matters is consistency, not perfection. It’s the willingness to return to work again and again, even after a setback. It’s the slow rebuilding of trust within themselves. I invite my clients to move at a pace that honors their body and nervous system. I help them see that slow progress is still progress. I let them know that taking the time they need is not only acceptable but it is wise. Therapy is not about rushing toward resolution. It is about creating a space where healing can unfold naturally, with patience, care, and room to breathe.

Postscript

If your clients’ healing journeys feel slow, confusing, or filled with setbacks, that doesn’t mean they’re getting it wrong. In fact, it often means they’re doing the hard, necessary work of integrating change. Recovery from trauma is rarely a linear process. It moves in spirals, detours, and pauses because that’s part of what makes it real.

As therapists, we can support this process by holding space for grief, for uncertainty, and for the parts of healing that take time. We can remind our clients that it’s okay to move at their own pace. That healing isn’t measured by speed but by presence, consistency, and the courage to keep showing up.

Nancy Haug on Psychedelic-Assisted Psychotherapy

Posted on by Psychotherapy.net Team
Lawrence Rubin: Hi Nancy, thanks so much for joining us today. You are a professor in the department of psychology at Palo Alto University, and an adjunct clinical professor in the department of psychiatry and behavioral sciences at Stanford University School of Medicine. You have ongoing collaborations with and a teaching role in the Stanford Psychiatry Addiction Medicine Program, where your current research interests include implementation of evidence-based practices in addiction treatment, harm reduction for substance use, cannabis vaping, and psychedelic-assisted psychotherapy. Welcome!
Nancy A. Haug: I would add to that that I do have a small private practice where I treat clients, some for addictive disorders, but I am mostly a generalist.
LR: I didn’t know that you also have a private practice. Do you practice psychedelic assisted psychotherapy?
NH: I do a little bit of that work, but it’s a very small percentage of my clients, and it’s mostly limited to the preparation and integration phases of psychedelic therapy. I’m not doing any kind of administration of psychedelics in my office or in my practice. My clients will get that elsewhere. And then I’ll help them integrate the experience into therapy. We can get more into that later.I’d like to start by acknowledging the indigenous peoples and practices, because many psychedelics are derived from sacred plant medicines that have been used for millennia by many cultures. This isn’t something new, because much of the work we’re doing with psychedelics comes from thousands of years of cultural shamanic traditions.

Psychedelics as Medicine

LR: Thank you for that acknowledgment. I think it’s important that clinicians appreciate the broader cultural and historical context of psychedelic use.So, there are practitioners of psychedelic medicine, and there are practitioners of psychedelic assisted psychotherapy—two distinct but overlapping applications.
NH: Sure. I think the medicine piece would be more in the context of something like Ketamine treatment and/or the administration of psychedelics in a more medicalized setting. Clinical trials are being conducted right now that are looking specifically at psychedelics as medications. But as a psychologist, I’m more focused on the therapy piece which I really believe is an important component. It is about the way that psychedelics can be therapeutic for psychological healing.
LR: much of the work we’re doing with psychedelics comes from thousands of years of cultural shamanic traditionsSo, you might have a client presenting with symptoms of depression or anxiety or trauma going exclusively to a medical professional and receiving one of the psychedelics, but not necessarily being referred to a mental health professional for integration into therapy?
NH: Exactly.
LR: Is there a turf battle between medical and mental health practitioners in the realm of psychedelics over who gets ownership over their use? A battle in which psychotherapy is considered a diminutive form, and the integration of psychedelics into therapy as an encroachment of sorts?
NH: I believe that a lot of the providers of Ketamine treatment would support integration into psychotherapy as part of that workIt depends on who you talk to. We can certainly get into the differences between the various psychedelics, but at this point, there are many clinics where people can receive Ketamine infusions for various conditions that don’t involve psychotherapy. But I believe that a lot of the providers of Ketamine treatment would support integration into psychotherapy as part of that work. I actually work with a psychiatrist who runs a ketamine clinic, and he is always asking me if I’m taking referrals or if I can give him referrals to other therapists. He does have some therapists built into his clinic, but there’s not enough of them to meet the patient needs. So, I think there is recognition that the therapy component is helpful and that it can improve outcomes.
LR: Which chemicals are most often used in this line of research and intervention?
NH: Ketamine was used as an anesthetic in veterinary clinics and given to soldiers in Vietnam in the 1970s as a field anesthetic. It’s also been used off-label for the treatment of refractory depression and suicidality.The classic psychedelics are LSD, psilocybin, DMT, which is dimethyltryptamine, ayahuasca, and mescaline, which comes from the peyote cactus. Of the hallucinogens that have been studied and are in current trials, I would say psilocybin has probably been looked at the most. And then we have MDMA––ecstasy or Molly, methylenedioxymethamphetamine, which is a serotonin, dopamine, or epinephrine agonist, It’s sometimes called empathogen or enactogen, which produces a heightened sense of connectedness or openness. It’s characterized by the person becoming very empathetic and compassionate. MDMA has stimulant properties, but it’s different from classic psychedelics, which affect more perception, cognition, mood, and sense of self.
LR: if someone is going to do this work, it’s very important to be familiar with the different compounds, their effects, and what conditions they’ve been applied toI would think that mental health professionals would really need to know their way around pharmacology to venture into this realm of practice.
NH: I really agree that if someone is going to do this work, it’s very important to be familiar with the different compounds, their effects, and what conditions they’ve been applied to—just knowing the research. Most training programs for therapists who are interested in integrating psychedelics into their work will include the history of psychedelics, and then there’s always a psychopharmacology piece that is addressed. I don’t really endorse one or the other training programs, but I think most of the established ones are pretty good. Psychedelics are classified as Schedule I drugs by the FDA, meaning they do not have an accepted medical use.Some states, including Oregon and Colorado, have initiatives supporting psilocybin use in therapy, but they do require therapists to go through training programs. I think they get certified or licensed somehow as being psychedelic providers, which I think is a good thing—just to put some controls around it. And this isn’t just limited to psychologists. Anyone who’s a licensed therapist can do this work and can get training. That includes licensed marriage and family therapists, and clinical counselors.
LR: Is there a national certification that is available, or is it currently a state-by-state affair?
NH: Not that I’m aware of. I think a lot of the training programs developed in the context of clinical trials, and now pharmaceutical companies that are doing drug development, like Compass Therapeutics, have developed their own kind of training protocols for doing this work, and there are a few manuals, like Deliberate Practice in Psychedelic Assisted Therapy, which is one of the volumes in APA’s Essentials of Deliberate Practice series.

Integrating Psychedelics into Psychotherapy

LR: Is there a standard definition of psychedelic assisted psychotherapy?
NH: psychedelic medicine may or may not involve therapy as it’s more focused on the administration of the psychedelic. I do have a definition of psychedelic assisted psychotherapy that I like to use which I pulled together for a presentation with one of my colleagues. Psychedelic assisted psychotherapy is a clinical intervention that combines preparation, psychedelic administration, and integration of experiences to facilitate psychological healing in the context of a therapeutic environment.All of these pieces are important components of psychedelic assisted psychotherapy. There’s also an umbrella term called psychedelic medicine, which you’ll also hear a lot, and that I simply define as applications of psychedelics or hallucinogenic drugs to the treatment of psychological conditions or psychiatric disorders. Psychedelic medicine may or may not involve therapy as it’s more focused on the administration of the psychedelic drugs. But I know you wanted to talk about the therapy piece.
LR: Am I correct in assuming that there are randomized controlled trial studies comparing psychological treatment with Ketamine alone and psychotherapy with a psychedelic?
NH: We’re still in the early stages of this work. There was a review paper that came out recently looking at the different types of therapy that have been implemented, but there’s not a gold standard at this point.
LR: if I’m going to do this work, I’m working closely with a physician or a psychiatrist who’s administering the medication in a controlled settingWould a psychologist need prescription privileges if they wanted to use psychedelics independent of a licensed physician?
NH: I don’t think that would really be part of our domain as psychologists. Our role is to provide the therapy! It’s important to work with other providers, so if I’m going to do this work, I’m working closely with a physician or a psychiatrist who’s administering the medication in a controlled setting. There is a treatment model where the patient will be prescribed sublingual Ketamine lozenges that they can take at home and then work with a psychologist or licensed clinician to do the therapy.
LR: I don’t know anything about half-lives of the various psychedelics, but must the client be in an active substance-induced state, and how do you know if they are?
NH: I think again it depends on which psychedelic medicine and on the particular model of treatment. With the IV Ketamine infusion, the person typically isn’t conscious, so you couldn’t really be doing the therapy while they’re under the influence. But you could afterwards, because there’s research suggesting that because of the brain’s plasticity after psychedelics, the patient may be more receptive to therapy within 24 to 48 hours after they’ve ingested the medication.Like I said, we really don’t have a gold standard. And I think there’s been some challenges in disentangling the effects of the psychedelic drugs from the therapy itself. Some trials have tried to incorporate evidence-based treatments like Cognitive Behavioral Therapy or Acceptance and Commitment Therapy. There is some evidence that this might promote better clinical outcomes. I think ACT specifically, and mindfulness therapies lend themselves really well as interventions because of the psychic or psychological flexibility that they target. So, combining that with the psychedelic might create synergistic effects. But again, we haven’t standardized it, so it’s really hard to even compare across studies. You asked earlier what I thought the mechanism of action was, so I did want to say that we really think that it’s a result of the interaction between the medicine, the therapeutic setting, and the mindset of the participant. People might take psychedelics like ecstasy at a rave, or mushrooms at a festival; but that doesn’t necessarily lead to them being cured of their trauma or depression. Because it’s a different setting that is not necessarily a therapeutic context, they don’t have a guide with them really exploring underlying processes. We really want to help the patient become clear about their intention, such as addressing their fixed beliefs or getting more in touch with certain emotions. The therapy can help loosen some of that up, which will allow for greater flexibility.
LR: there’s been some challenges in disentangling the effects of the psychedelic drugs from the therapy itselfWhat do you hope to tap into or capitalize on when applying psychedelic assisted psychotherapy?
NH: I think it’s different for each patient and depends on what they are coming in with. Are they coming in with an unresolved trauma? Are they coming in with existential depression? I try to determine where they’re stuck and what it is that they’re trying to get insight about. And if they have cognitive expectancies, which refers to what they expect might happen during the psychedelic experience, or their mindset. And that does require some preparation work.One of the things I would want to be clear about with my patients is what they are looking for and not overselling this therapy as a magic bullet or that they’re going to be cured of their depression. That’s not how it works, and so I would actually be hesitant to do this work with someone who came with the notion that psychedelic therapy is the end all, be all, and that they’re going to be fixed. That’s probably not going to be helpful for them. I might even want to temper those expectations by providing a more realistic picture of what could happen, which starts to get into some of the ethical issues around this, particularly with informed consent, because we don’t know what’s going to happen. How do we obtain informed consent when we can’t even explain the psychedelic experience? I can’t tell what’s going to come up, and sometimes there are even personality changes where the person becomes more open or has altered metaphysical beliefs. So, it’s important to provide a lot of education and information about what could happen, including some of the subjective effects. There are just so many possible outcomes.
LR: one of the things I would want to be clear about with my patients is what they are looking for and not overselling this therapy as a magic bulletIs there any solid research about how the brain actually changes under the influence of psychedelics that make it easier for the clinician to access conflicts, or to get through resistance, or for the clinician to more directly intervene on a particular issue? In other words, is there anything proven about what happens in the brain that allows for that?
NH: Absolutely. Psychedelics enhance neural plasticity. One model that’s been put forth is the REBUS model by Robin Carhart-Harris, which is about relaxed beliefs under psychedelics. The idea is that the psychedelics relax what they call priors, or prior beliefs, or assumptions to allow bottom-up processing in which information flows more freely, where the mind can really open. Psychedelics have also been referred to as “disruptive psychopharmacology” because they disrupt boundaries among brain networks, allowing for greater communication across the whole brain.Psychedelics are also considered nonspecific amplifiers of human experience. In other words, whatever the person is going into the experience with – their particular mindset and setting – is going to be amplified during the psychedelic-induced state of consciousness.
LR: one model that’s been put forth is the REBUS model by Robin Carhart-Harris, which is about relaxed beliefs under psychedelicsHave there been any randomized controlled trial studies involving the use of placebos?
NH: It’s really hard to come up with a placebo that is comparable to psychedelics because people usually know when they’ve been given a placebo. That’s actually been one of the most difficult pieces of doing this research is that we can’t actually blind people. I know with some of the Ketamine studies they’ve tried to use Midazolam, which is a benzodiazepine. Usually, people know the difference.
LR: Circling back a bit; you mentioned that ACT lends itself particularly well to psychedelic integration.
NH: I think that because ACT emphasizes mindfulness, anything–psychedelics in this instance– that allows for fuller contact in the present moment, can help the client more fully and deeply navigate the therapeutic experience including any states that may arise. As another example, I believe they’ve used Internal Family Systems model in the MAPS (Multidisciplinary Association for Psychedelic Studies) trainings; and while I’m not trained in IFS, some people report that it’s useful because it helps the person look at different parts of themselves that they might not otherwise.In general, I would say that the therapy that occurs while the person is under the influence of the psychedelic tends to be more nondirective. In this context, the clinician and the client can respond in the moment to what is coming up. If the clinician is using a somatic tool or some other type of cognitive reprocessing, you don’t want to try to direct them in a particular way. It is important that the client’s inner wisdom, rather than the clinician or any particular technique, be the guide.
LR: it is important that the client’s inner wisdom, rather than the clinician or any particular technique, be the guideYou describe the presence of the psychedelic drug or experience as a co-therapist; a therapeutic ally or resource. The disinhibiting or loosening helps the person to get more in touch with their somatic experience. Whatever intervention you use may be enhanced, accelerated, or deepened. So, the therapist is a facilitator or guide.
NH: Exactly! You’re a facilitator or guide. In the MDMA trials through the MAPS program, they actually have two therapists, male and female. They have various reasons for doing it that way, one of which is perhaps to facilitate projection that could take place as the client reflects on their relational experiences. But it gets very expensive to have two therapists in the room for eight hours doing this work. I’m not sure how they could scale that.
LR: we have a lot of evidence that MDMA really does work with veterans who have been in combat; but also with survivors of sexual abuse and traumaYou mentioned that Ketamine has been successfully used for clients with depression. Do you have a sense of what the mechanism of action is in this case as well as with PTSD?
NH: Typically, MDMA is going to be the psychedelic of choice for PTSD. My understanding is that it promotes emotional processing, and reprocessing of the memories in a way that the person feels safe, less threatened by the memories or the images which allows to experience a deeper contact with those emotions or memories so can work through them.We have a lot of evidence that MDMA really does work with veterans who have been in combat; but also with survivors of sexual abuse and trauma. MDMA was recently reviewed for approval by the FDA but was rejected for various reasons including lack of supportive research. It’s hard to quantify and standardize psychedelic therapy, and since the FDA is not in the business of approving therapies, more research will have to be done. I do know that this outcome was very disappointing to the psychedelic community because we’ve been working hard at this for a long time and thought there was sufficient evidence, especially with PTSD, where clients with PTSD improve more with MDMA than with other behavioral therapies.
LR: I’ve seen an acceleration in progress for those clients who try psychedelic therapiesSince you spoke earlier about the role of client expectancy in treatment outcome, I’m wondering if you’ve noticed a difference in your own therapeutic presence or expectancy when doing psychedelic assisted therapy?
NH: I think I am more optimistic because I’ve seen clients who’ve really benefited from this work. I am hopeful that they will have breakthroughs because I’ve seen an acceleration in progress for those clients who try psychedelic therapies. They kind of get to the heart of their issues and dig into the meat of where they’re stuck a lot faster than they would with regular psychotherapy. I try to go in without any expectations and just let it unfold like I have no idea what’s going to happen.
LR: There’s so much research these days comparing the efficacy of various therapies, but I wonder how much emphasis you place on the role of the relationship in therapy outcome, especially when psychedelics enter the frame? Are you a technique-oriented person or relationship-oriented person, if such a simple binary even makes sense?
NH: I think I would call myself both, but it’s a really interesting question. I recently had an expert speaker come into my class to talk about CBT for addiction. He was talking about how we have all of these branded therapies, but that all good therapy really comes down to common factors and the therapeutic alliance. We need to foster a sense of safety and trust with clients, irrespective of intervention. In using psychedelics, a lot of fear can emerge, so they really need that safe space, which is where the therapeutic relationship becomes all the more important.

A Few Challenging Issues

LR: I’d like to circle back to the beginning of our conversation where you mentioned the importance of psychedelics with indigenous cultures. I don’t know the extent to which indigenous people reach out to traditional [white] therapists, but is there research on the use of psychedelic assisted psychotherapy within specific cultures?
NH: I don’t know that we’ve done enough of this. There’s a movement to try to be more inclusive, particularly in developing our approaches by consulting with indigenous communities. MAPS was doing some training to be more inclusive of therapists and clients of color. There was a paper published suggesting there are very few therapists of color or researchers in the field who are doing this work, so there’s definitely a need for more of this. We do know that MDMA and other psychedelics can be helpful for racialized trauma. Monnica Williams has done some of this important work.I have a student who did a dissertation on this topic where she interviewed clinicians in the community who were administering psychedelic assisted therapy. She asked them about motivations and workplace values in serving diverse communities. She had therapists of color and from marginalized groups, including one indigenous therapist. It was a qualitative study, and she had some interesting findings around the values that were being incorporated into their training, their identities, and then in their work with clients, and how countertransference reactions came into play. We definitely need to do more of this kind of research and perhaps even studies that look at therapy performed by clinicians who are given the option to use psychedelics like Ketamine so they can understand what the experience is like, although there would be challenging legal parameters there, especially around some of the Schedule I psychedelics.
LR: we do know that MDMA and other psychedelics can be helpful for racialized traumaAre there any counter indications for the use of psychedelics in psychotherapy?
NH: Absolutely! I would say clients who experience depersonalization, derealization, and intense existential struggles. There can be personality changes and long-term negative effects. I think it’s a small percentage, but there’s always a risk. I would say the same risks you would have with other medications and with therapy, right? There’s a percentage of people that can be harmed in some way, or for whom it can make their symptoms worse. It’s not going to be a positive experience for everyone.I think particularly along the lines of existential struggles. Some people might even encounter a higher consciousness or spiritual or mystical experiences that they weren’t expecting which can be disturbing. A person’s outlook on the world can change or they can wind up with a totally different perspective. For some people, that can be helpful, especially around end of life anxiety, where they can begin to feel more connected and safer around their own death. But sometimes, people can feel like they’ve died when using psychedelics, and that can be very unsettling. It can take a long time to integrate these kinds of experiences and to process things they didn’t necessarily want to see.
LR: some people might even encounter a higher consciousness or spiritual or mystical experiences that they weren’t expecting which can be disturbingSort of seeing someone for good old cognitive behavioral therapy and ending up at some existential cliff, looking at an abyss that they didn’t anticipate.
NH: Exactly! There’s another model I wanted to mention called the FIBUS model, or the False Insights and Beliefs Under Psychedelics. We know that psychedelics can promote therapeutic insights, but a person may experience misleading beliefs and insights that feel like they’re profound and true but might actually not be. So, one role of a therapist would be to help guide them in distinguishing what’s helpful, what’s harmful, what’s real, and what’s not.
LR: In that vein, I can see that psychedelics might not be useful with clients experiencing dissociative disorders, delusions, or cognitive impairment where they can’t rely on their own cognitive processing.
NH: Right, right! So, this isn’t for everybody. I think the clinical trials have done a really good job screening people by using strict inclusion and exclusion criteria. But in clinical practice, we could do a better job at looking at who might and who might not benefit from this, such as a person with a history of serious mental illness like schizophrenia or bipolar disorder.
LR: Are there any particular resources that you would direct readers to if they wanted to learn more about psychedelic assisted psychotherapy.
NH: There are some professional practice guidelines for psychedelic assisted therapy, like the American Psychedelic Practitioners Association and the Ketamine Research Foundation. There was also a paper published on ethical guidelines for Ketamine clinicians. I know the VA provides Ketamine therapy for treatment resistant depression in some of the Ketamine clinics they’ve set up where they have established protocols. Yale University has a program for psychedelic science and published an article on the use of ACT with psychedelics. But, I would say the training piece is always of critical importance.
LR: many of my students come into the program really clear that they want to be psyche

Redefining Strength: A Black Woman’s Journey to Healing

Posted on by Psychotherapy.net Team

Redefining Strength: A Black Woman’s Journey to Healing

Kayla sat in my office with her arms crossed against her chest—a familiar shield against the world. At 23, she had grown accustomed to protecting herself, whether necessary or not. She avoided eye contact with me like the plague, guarding herself as hard as possible. “I don’t even know what I’m doing here,” she said, her eyes fixed on the floor. “This is so awkward.”

“That’s normal,” I said.

As a therapist, I have heard many clients share that they are unsure of what has led them to therapy. What was always different for me was tonality. I have heard people voice uncertainty about therapy with anger and even sadness. Kayla’s voice was filled with exhaustion.

“I feel so out of control as of late. I feel like I’m in a loop of the worst days of my life. I go to sleep thinking about my mistakes. I always wake up feeling worse than I did the day before. I’m eating and spending like crazy. I’m so tired.”

Kayla’s specific wording and my clinical judgment led me to believe there was more behind what she shared. So, I asked her, “What is weighing on you?”

Kayla burst into tears, and for the first time, she looked into my eyes, hers filled with anger and sorrow. “My mom died! I finally tell her how much I hate her, and she dies!” Kayla sobbed as her words lingered in the air. It had been a year since her mother passed, but as we know, there is no time limit on grief. Grief moves at its own pace and intensity. For Kayla, grief was feeding off her deep-rooted trauma.

“I keep replaying that argument with her over and over. Maybe what I said caused her too much heartbreak. Maybe she’d still be here if I had kept things unspoken.”

I leaned forward slightly.

“Kayla, your mother’s passing is not your fault.”

Kayla shook her head as tears continued to roll.

“Then why does it feel like it is?”

A Childhood Built on Survival

Kayla’s childhood was a lesson in what love wasn’t. She realized early on that her mother was not like the mothers she saw on television who supported their children and told them they loved them at the very least.

“My mom wasn’t like Clair Huxtable or anything. I didn’t get hugs or life lessons. She just wasn’t that kind of woman,” Kayla said. “I can’t recall her ever saying she was proud of me. When I would make good grades or clean my room, she would say,‘That’s what you supposed to do.’”

For Kayla, affection was nonexistent, validation was rare, and she never felt safe displaying anything other than strength. Kayla felt sympathy for her mother as she knew her mother faced hardships as a child herself. Kayla’s grandmother shaped her mother into the woman who raised her—distant and emotionally unavailable.

Over time, Kayla began to convince herself that she was the one who needed to change.

“I just stopped asking for things that she couldn’t give me. I consoled myself. I taught myself. I protected myself. I didn’t want to rock the boat with her because she was always extremely irritable. It annoyed her whenever I was in need, so I stopped needing her.”

By age ten, Kayla had perfected the art of being invisible. She didn’t ask her mom for love. She didn’t ask for affection. She didn’t ask for help. In turn, she saved herself from disappointment.

The “Strong Black Woman”

Kayla’s experience growing up was a complex one due to the emotional neglect and also the unwritten rules of what it takes to be a Black woman (1). She grew up being told to be strong and keep going no matter what. There was not enough room for anything else. Kayla comes from a family of Black women who embodied these qualities as armor against the world. Growing up in a space that offered little empathy to Black women, Kayla’s mother taught her how to survive, and that was her act of love.

“She used to tell me that if I think anyone cares about me crying, then I have a lot to learn,” Kayla stated angrily. “Like crying made you weak or something. In a way, she was right. I had to make sure people knew I was nothing to mess with!”Even after Kayla’s mother died, she felt like she had no space to grieve. “My aunt told me everything happens for a reason, and we can’t spend time crying. So, you mean to tell me I can’t have time to be sad about my mom’s passing? Even in death, do I have to push on? That’s a lot for anyone. If my family knew I was here, they would wonder why. After everything I have endured, they would still wonder why. Because we don’t do this.”

In addition to her trauma and grief, Kayla was struggling with knowing that she needed help but feeling uncomfortable while seeking it. There has been an undeniable stigma in the Black community when it comes to mental health. As a Black woman myself, I resonated deeply with her.

“My aunt would probably be like girl, you need to talk to God, and not no therapist! Talk to God, and you will be all right. Like I haven’t been talking to God. Talking to you is my last hope at this point.”

Kayla was plagued by wondering if she should even be here as a Black woman and also hoping that therapy would “work” for her.

“You know you can do both, right?” I asked. “You can talk to God and spend time in therapy.” Kayla arched her eyebrows as if she were in deep thought. I continued, “James 2:14 says, ‘Faith without works is dead.’ Kayla, you are doing the work right now.”

“Wow, I’ve never thought about it like that,” she smirked. “I like that!”

Naming the Wounds and Breaking the Cycle

Kayala learned to survive from an early age, and her defensive tactics served her well. Now, it was time for her to thrive. I discussed clinical diagnoses with her, and her mood instantly changed. I could tell she was not fond of labels.

“What is Post Traumatic Stress Disorder and Borderline Personality Disorder? Are you saying I’m crazy?” she asked, irritated.

“Absolutely not!” I said sternly. I swiftly disputed Kayla’s thoughts so she didn’t disengage with me. “A diagnosis is not about calling you crazy; it’s about creating a roadmap. Knowing your diagnosis helps us understand what’s wrong and how we can fix it.” I continued while I still had her attention, “Right now, your mind still seems to think that you are in danger, and it is responding accordingly. Kayla, you are safe now, but your experiences in life have wired your brain into a constant state of fear. When this happens to us, it is hard to regulate our emotions or trust new people because that is not a priority; safety is. That is why we are looking at Post Traumatic Stress Disorder or PTSD. We need to look at the research for what has been proven to work with your symptoms.” (2)

Kayla’s jaw tightened, but I saw a flicker of understanding.

I continued. “Now, some traits of Borderline Personality Disorder or BPD concern me. Again, this does not mean that there is something wrong with you. It simply means that something happened to you that is causing patterns similar to BPD to arise in your personality.”

Kayla previously reported mood swings, fear of abandonment, and impulsive choices that she wished to cease. I wanted her to understand that these symptoms made sense when one has endured the trauma that she has. Giving it a name only serves as a guide to addressing her symptoms.

“But here is the most important thing,” I said. “None of these things mean you’re crazy. They mean your brain did what it had to do to survive. And now, we’ll teach it a new way of looking at life.”

She nodded slowly. This time, she was really hearing me.

The Work: Using DBT to Rebuild Control

Kayla discussed feeling out of control when she first sat on my couch. She said she was tired and had exhausted all options. She wanted to feel different. Therefore, we had to try something different. Kayla was stuck in a cycle of emotional dysregulation, intrusive thoughts, and impulsive behaviors—trying to numb a pain that never seemed to dull. As a result of her trauma and grief, she had become avoidant. She had cut off her family in an attempt to forget her past and her unfavorable memories of her mother. She had also distanced herself from friends, convincing herself that being alone was the safest way to be. However, the isolation only compounded her sadness.

“I like to be alone. I don’t have to worry about anything…or anyone,” she said.

It was clear that avoidance had become a comforting survival mechanism for her, blocking her pathway to healing by dismissing the very things she needed to address. That is why Dialectical Behavior Therapy (DBT) was the chosen approach for Kayla—she didn’t just need to talk about her pain; she required structure. She was new to managing her emotions and grasping concepts of healthy communication. As someone who always “just dealt with it,” Kayla needed practical tools to help her regulate her emotions, tolerate distress, and rebuild her broken relationships with family and friends (3). DBT would allow Kayla to accept her past and present circumstances while learning tangible ways to help her approach her overwhelming emotions less detrimentally.

Kayla’s case and the use of DBT demonstrate its flexibility beyond its original purpose for borderline personality disorder for managing trauma and grief as well. Unlike traditional talk therapy, DBT provides tangible solutions to change. It was designed for people like Kayla—individuals who felt emotions so intensely that they often became destructive. With some culturally adapted tweaks, I knew DBT would be life-changing for her.

DBT Treatment Sessions: A Step-by-Step Process

Reframing Emotional Regulation Through Radical Acceptance

“So, what? I just breathe through my feelings? That’s not gonna do anything,” she snapped when I introduced emotional regulation techniques. Kayla came to therapy with the belief that any emotions outside of anger made her weak. She had been taught to be a strong Black woman. For her, that, unfortunately, meant suppressing pain and keeping her composure no matter what she faced—crying, asking for help, or expressing vulnerability felt like weakness. Regulating emotions meant giving in and giving up. We needed to reframe that thinking. I knew I had to introduce something concrete that would challenge this belief in a way that made sense to her lived experience.

That’s when I introduced Radical Acceptance.

“To radically accept something means acknowledging our reality no matter how much it hurts. It doesn’t mean you like it. It doesn’t mean it was fair. It simply means it happened and is out of our control.”

She narrowed her eyes.

“So, I just roll over and accept what happened to me? That sounds like letting people run over me.”

“It’s the opposite,” I assured her. “It means you stop wasting energy on what has happened and can’t be changed, then you can focus on healing and moving forward.”

We practiced this with a powerful exercise. I asked Kayla to create two different lists. On the first, I asked her to list everything she wished had been different. On the second, I asked her to write down the reality of what happened. Kayla hesitated, as if putting the truth into words would finally make things real for her. But eventually, she did it.

When she finished, I asked, “Which one is true?” She looked at them for a long time before responding.

“The second one.”

“And which one are you living in?”

She tearfully stated, “the first one.”

“That’s why it hurts so much.”

There was silence. I saw Kayla arch her brows again, as she always does when thinking.

“I guess I can’t change the past, huh? Being angry about it isn’t going to change it for me, either. I need to focus on what I want to be different now and make a plan to change my now.”

Managing Impulsivity Through Distress Tolerance

In our next session. I wanted to focus on Kayla’s binge eating and spending. These weren’t random actions. They were her mind’s way of coping with her trauma and grief. These behaviors were a quick way for Kayla to feel something other than discomfort, if only for a brief time.

“I don’t think—I just do it,” she admitted when we explored her excessive spending and binge eating.

I introduced distress tolerance skills to teach Kayla to sit with her uncomfortable feelings. One of the most valuable techniques for this was the STOP Method:

  • Stop – Pause before you react.
  • Take a step back – Create space to think before deciding.
  • Observe – Notice your emotions without judgment.
  • Proceed mindfully – Act with awareness.

At first, she was skeptical about being able to control her urges. But then, one evening, I received a text from her: “I almost spent $500 online on something silly, but I stepped away from my phone and did that STOP thing instead. So… yay, I guess.”

It was a small victory for Kayla but a critically important one. Over time, she began to master interrupting her impulsive urges. We were replacing her self-destructive behaviors with healthy coping skills.

Processing Trauma Through Mindfulness & Exposure Our next session was challenging as we addressed Kayla’s most potent and longest-held form of self-protection; we addressed her avoidance. I felt that Kayla had enough coping skills at this point to start to touch on some of her trauma that impacts her today. She shut down and cut off anyone who was a reminder of her trauma, further isolating herself and feeding her negative behaviors.

“I just don’t have time to think about any of that stuff. It feels bad,” she told me once.

But avoidance doesn’t erase trauma—it only buries it deeper.

I introduced mindfulness-based exposure therapy, where she slowly confronted the memories she had been running from. We spent half of one session just looking at a picture of her mother and addressing the emotions that rose from that. Eventually, we reached a point where Kayla was listening to an old voicemail her mother had left her shortly before her passing. Her mother called to check on her as she had not seen her since their argument. Kayla’s hands began to tremble; her breathing became shallow.

“This hurts me so much,” she whispered.

I nodded.

“I know. Just go with it.”

As she let the tears roll, she didn’t dissociate. She sat in how she felt. That was a breakthrough!

Breakthrough Session: Onward to Healing

Months into therapy, Kayla no longer felt like she was spinning out of control.

“I still have my bad days,” she sighed. “But I don’t feel like I can’t do anything about it anymore.”

Her progress was never about curing her pain. It was about living with it more healthily. She was still grieving, still processing, only this time around, she had the tools to cope. As she stood up to leave our session today, she paused. “You know,” she said, “I think my mom would’ve liked you.”

I smiled, and said, “I think she would’ve liked you too.”

Kayla walked out of my office that day, not healed, but healing. For now, that was enough.

Reflections from the Therapist’s Perspective

My experience with Kayla has grown me in ways no training or manual could. After some time sitting across from her, I realized that I was doing much more than simply applying interventions to an issue. What I was providing Kayla was a safe space. As big as the world is, many people do not have the space to be truly vulnerable and seen in their pain. In that space, it was not about how much I knew academically, but how deeply I could listen, be present, and make it safe for her to unravel.

Therapy is often misunderstood as something people do to “fix” an issue. However, healing does not come from quick fixes. Healing comes from connection when I can help carry the weight someone shouldered alone for far too long. Kayla reminded me that everything I do matters. My patience, validation, and commitment to her healing mattered so much. These small and consistent actions are the most powerful tools a therapist can implement during therapy. Most importantly, I learned I cannot validate what I do not acknowledge.

Kayla’s life experiences, beliefs, and values all stemmed from her upbringing. They stemmed from her identity as a Black woman in her home and the world. As a Black woman myself, I resonated deeply with the themes around mental health that Kayla had come to know as truth. As a Black therapist, I am even more grounded in my belief that therapy must make space for cultural humility and the intersectionality of the people we sit across from. Their identity, history, and experiences make them unique. That said, we must see our clients for all that they are.

References

(1) Carter, L., & Rossi, A. (2021). Embodying strength: The origin, representations, and socialization of the strong Black woman ideal and its effect on Black women’s mental health. In WE matter! (pp. 43–54). Routledge.

(2) Bremner, J. D., & Wittbrodt, M. T. (2020). Stress, the brain, and trauma spectrum disorders. International review of neurobiology, 152, 1-22.

(3) Prillinger, K., Goreis, A., Macura, S., Hajek Gross, C., Lozar, A., Fanninger, S., … Kothgassner, O. D. (2024). A systematic review and meta-analysis on the efficacy of dialectical behavior therapy variants for the treatment of post-traumatic stress disorder. European Journal of Psychotraumatology, 15(1), 2406662.

Therapeutic Reimagining

Posted on by Psychotherapy.net Team

An Introduction to Therapeutic Reimagining

I’m very proud to have recently published my first book, Reimagine Your Life: How to Change Your Past and Transform Your Future, in which I introduce a process that I have named “therapeutic reimagining.”

There are many reasons why I am proud of this book, but the greatest achievement is to have overcome the intergenerational narrative provided by my “working class” upbringing in the United Kingdom, with its self-limiting beliefs about myself, others and the world.

I come from a family of six siblings, three of whom left school virtually unable to read or write. My father was an Irish immigrant who worked on a building site doing unskilled work, and my mother left school at the age of 14 to look after cows on a local farm. I too was educationally backward as a child, and was never given a book, or helped with reading by my parents. So, if they were alive today and I told them that I have written a book about a new way of doing psychotherapy, it would be incomprehensible to them.

It has taken me 20 years of hard study and practice to put all of the puzzle pieces together and create this process that I call therapeutic reimagining. I simply couldn’t have done it earlier in my life. That is the gift of ageing: being able, over time, to integrate a multitude of different experiences.

Although writing Reimagine Your Life was conceived as a way of helping people who either couldn’t afford therapy or couldn’t access it for other reasons, the core process of therapeutic reimagining was born in my psychotherapy practice in Cambridge, England as a way of accelerating clients’ progress in therapy. Simply put, they were able to get much further forward in their healing journey by being empowered and encouraged to continue their transformational work outside of sessions.

The book cover has a clock face and the question, “How far would you wind back time and what would you change?” This gives us a clue that it is about overcoming trauma by redoing the past.

Often in people’s lives something goes wrong or there is trauma that leads to a whole downward trajectory of events. So, I invite my clients to wind back time to a point before it happened and explore an alternate timeline or alternate history.

This might sound like time travel and science fiction. However, it is actually science fact: the psychology of counterfactual thinking. You may have never heard of it, but it is something we do with our clients all the time. Every time we ask a question like “How do you wish your childhood was different” we are inviting them to imagine an alternate history with a new narrative.

In Gestalt Therapy, we ask the client to go back in time and “Be there now.” In Transactional Analysis, it is called “early scene work;” “enactments” in Psychodynamic Therapy, and “portrayals” in some other therapies.

However, where therapeutic reimagining is different from all of the above, is that it provides a roadmap of how to do the process, so that clients can create their own portrayals at home. It has worked so well with my clients that I wanted to write a self-help book that would allow those who can’t afford or can’t access one-to-one therapy to benefit from the process. It is safe to do at home because the reader is invited to imagine a more pleasant alternative to what actually happened.

The book contains nine stories, written by the clients themselves, explaining how they used therapeutic reimagining to overcome shame, guilt, fear, anxiety, overeating, and even medically unexplained physical symptoms.

One of the stories concerns a theme that many people encounter in later life, the illness and death of their life partner. Stephanie was 73 when she came to see me, full of toxic guilt related to the circumstances of the death of her husband several years earlier. Her guilt interfered with the grieving process and caused her a great deal of emotional pain and suffering. With Stephanie’s consent I am sharing her therapeutic reimagining journey.

Stephanie’s Story: Grief Without End

I was struggling with the knowledge that I had not done everything that I could have done for my husband in his last few days of life. He was in hospital, and the doctors told me he had kidney failure which they were planning to treat with dialysis.

I had no idea that he was going to die soon. On the fourth night, they called me into the hospital because he was dying. He died the next day. All the time that he was in the hospital I believed that they were trying to help him.

All the time he was in the hospital he was asking me to take him home. Once he had died, I realized that he knew he was dying, and he wanted to die at home. I had no way of knowing that he was dying at the time, and I persuaded him to stay in the hospital where I believed that he was getting treatment that would help him, and that although he was seriously ill with lymphoma and we knew that it could not be cured, we thought we had a few years more.

For more than three years after he died, I suffered profound guilt about my behavior during these days. This feeling haunted me, and even though I knew that I wasn’t aware that he was dying during his last days, I found it hard to forgive myself for not paying attention to his requests to be taken home. My intelligent self knew that if I had known, I would have acted differently, but this knowledge had little or no effect on the extremely painful feelings that I was experiencing day after day.

Anthony encouraged me to visualize an alternative narrative. To imagine moment by moment what would happen if I had taken him home instead of persuading him to stay in the hospital. I found this extremely difficult at first, I could imagine investigating the possibilities of bringing him home, of engaging a nurse and arranging for a hospital bed to be brought to our flat. I got as far as imagining the ambulance people bringing him up the flight of stairs to the room I had prepared for him. But it was really difficult to continue the story.

At first, I found it very difficult to imagine him actually in his bedroom and actually dying there. But I persisted and over a week I was able to visualize everything from the point of deciding to bring him home and preparing a room for him and then imagining his death at home. I was able to borrow from the actual experiences. For example, there was a very compassionate nurse who had helped him in the hospital. In my imagination, she was in the bedroom at home. I remembered the night I spent stroking and talking to him whilst he was dying and unconscious, but I reimagined these experiences and saw them in the bedroom in our flat with me sitting on one of our chairs and not the hospital chair.

This new experience became very real to me. Although I knew it was a new narrative, and I knew that it hadn’t happened this way, I was able to experience the events emotionally. It made such a difference, and afterwards I didn’t dwell on the original painful experience to the same extent. Over time that pain has receded: not the pain of his death, but the pain of the guilt that I felt around the circumstances of his death.

In some ways, it feels like magic. I know how things happened. I know the real story of how John died. But I have been able to overcome the extremely painful feelings of guilt and responsibility that had troubled me so deeply and for such a long time. Something had changed, and it has helped me to recover. I’m not sure I forgive myself entirely for not being aware enough at the time to act differently, but I’m not punishing myself for my oversight anymore.

Learning Points from Stephanie’s Story

I’ve re-read Stephanie’s story many times over the last few years, but I still feel very moved by it. Her story gives us an idea of how simple, yet powerful, therapeutic reimagining can be. Although she says, “At first I found it extremely difficult to imagine,” she persists over one week and is able to add all of the details. Crucially, she is able to include the very moving emotional elements of her husband actually dying in his bedroom at home.

As a human being, I felt some resistance to suggesting she imagine this very emotionally challenging scene, especially knowing I would not be with her when she did. However, as a therapist, I knew there was a very good chance that if she did, she would be freed from endless toxic guilt. She would no longer be “haunted” by it and would get the closure that she needed.

In session, as soon as Stephanie said, “If I had known he was going to die, I would have looked after him at home,” I was immediately alerted to the possibility of using counterfactual thinking to redo the past. This was a classic “If I knew then what I know now” example of a situation in which we can use counterfactual thinking to heal a painful regret. In fact, whenever a client says, “If only” or “I wish,” it is a cue for therapeutic reimagining.

However, I don’t wait for the client to stumble across the answer. Instead, I ask questions like “What should have happened?” and “What could have happened differently?” These are the key questions that I encourage clients to ask themselves, in order to reimagine their life.

Another way in which to conceptualize what needs to happen differently is: what happened that shouldn’t have happened, for example trauma; and what didn’t happen that should have, for example being loved by one’s parents as a child, or getting to say goodbye before the death of a loved one. Although she never wrote about it in her brief story, saying all the things she had wanted to say to her husband before he died was another aspect of Stephanie’s healing in her therapeutic reimagining. It helped give her closure and is sometimes called a completion portrayal when done in the therapy room. We had never discussed doing a completion portrayal in session. However, her creative unconscious guided her in doing it on her own.

Trusting the Client’s Creative Unconscious

Although I offer lots of ideas and suggestions, it is always the client’s choice of what new narrative they will create in their therapeutic reimagining at home. Sometimes, I suggest they write a letter to their younger self or even an internalized parent, imparting important information about their future that will help their younger self. However, they often come back the following week and rather sheepishly say, I did the homework, but not as you suggested. I usually say, “Great! I bet your creative unconscious mind came up with something even better than either of us could come up with in the session.” And often, they have.

This was the case in Viktor’s story. He had come to see me about his problem of forming relationships with women. After some time, we realized that part of the problem was connected with his relationship with his mother as a child. I suggested that maybe he should write a letter to his mother from his childhood, warning her that the way she was treating him would have serious consequences for him in the future.

However, he seemed to have intuitively known that his mother from the past wouldn’t have listened to his present-day self, so he chose to do the process in a very different way. He informed me that, instead, he had talked to his present-day mother (the version of her in his head) who “instantly knew what to do,” he said. She then talked to her younger self, explaining why she must desist from her harsh treatment of him. Victor explained that it was hard work even for his present-day mother to get through to her younger self, but eventually she succeeded. This all occurred at home as a conversation in his mind between these parts of himself, which he created entirely on his own.

Now that he had found a viable solution that was believable to him, Viktor was able to imagine his mother being different in his childhood, he was able to experience a number of therapeutically reimagined scenes, where she did not treat him so harshly. Victor reported that the effect of this work on his present-day relationships with women, had been rapid and transformational.

All of the nine stories in the book are very different and so the therapeutic reimagining scenes that they needed were also very different, but it is always the client who decides what they need. However, I do always encourage the client to experience the emotions of the new scenes, so that it feels real, as this is a key ingredient in making the outcome therapeutic.

Why ‘Therapeutic Reimagining’ Works

Some of the theory of why it works comes from the neuroscience of memory reconsolidation and the juxtaposition of old and new memories. Creating an imaginary alternate timeline with a new narrative may allow the brain to un-anchor from the old painful memory. However, it is more important to understand psychologically what was needed in the past and to know how to do the process of therapeutic reimagining than to understand why it works at a neuronal level. This is what the book provides, a roadmap for the process. The nine client stories offer lots of examples of what could be reimagined and how they did it.

Although I do explain some of the theory of why the technique works in the main chapters, I’ve gone a lot deeper into the theoretical underpinnings of the process for mental health professionals in “Appendix A for therapists” at the back of the book.

How Hard do Clients Find Therapeutic Reimagining?
For some clients like Stephanie, who had been dealing with chronic toxic guilt, the solution and resolution of the problem can be surprisingly rapid because they have always unconsciously known the solution. “If I had known he was going to die, I would have looked after him at home,” she said. If we stay alert, we can often notice that the client has already glimpsed an alternate timeline that will allow them to create a new narrative. All we need to do is encourage them to explore that new path.

With others, it may take longer as the client hits some blocks to doing therapeutic reimagining. We saw this in Victor’s story. Initially, he could not see his mother in his childhood treating him any differently, not even if he explained to her the consequences of her actions in a letter. However, he quickly came up with an ingenious solution of speaking to his internalized mother from the present who was able to persuade herself from the past. I’m often amazed and delighted by my client’s creative unconscious ability to find exactly what they need to set themselves free.

There have been a few clients for whom therapeutic reimagining didn’t work initially, until we figured out what the block was. For example, Fergus, who had a problem with catastrophizing events in the future. When he first tried to use the technique, instead of imagining therapeutic outcomes, he simply catastrophized the past instead of the future, and we abandoned using it for some time as it was not helpful. However, one day we did get to the bottom of what function catastrophizing was fulfilling for him, and then he was able to use the process therapeutically.

Is it Safe When the Client’s Sense of Reality is Distorted?
Some clients are already living constantly in a fantasy world, one where they are always the hero. This was beautifully depicted in the film, The Secret Life of Walter Mitty played by Ben Stiller. With such clients, it is important to first confront them with the reality of their actual life before using therapeutic reimagining otherwise they would most likely do what Fergus did above, take his defense into the reimagined past, which would have no therapeutic benefit.

The process of therapeutic reimagining was even used successfully with a client who was recovering from psychosis and hospitalization, and was still taking anti-psychotic medication. However, it was only after thoroughly assessing the client’s current grasp on reality that I considered using it with him. Additionally, I regularly checked with him to see that he was completely aware of the differences between his actual life and the therapeutically reimagined scenes that he created to resolve attachment issues with his father.

Clients who Might Struggle to do Therapeutic Reimagining

One category of clients who often find therapeutic reimagining more difficult to do at home on their own is people with ADHD. These clients, who struggle to remain focused enough to imagine scenes outside of sessions, may need the work to be done as a portrayal in the therapy room instead. Similarly, some clients might need the work to be done in session for their therapist to help them regulate their emotions. My experience, however, has shown me that our clients are often more resilient than we believe and able to reimagine scenes that are healing.

***

Although Reimagine Your Life was conceived as a book that could help a lot of people who can’t for some reason access therapy, therapeutic reimagining was born in my psychotherapy practice as a way of accelerating clients’ progress. Simply put, clients were able to get much further forward in their healing journey by empowering them and encouraging them to continue their transformational work outside of sessions.

Hide & Seek: Evoking Desires to be Seen, Heard, and Found

Posted on by Psychotherapy.net Team

Separation and Reunion

Hide-and-seek is a universal game enjoyed by children across different cultures and ages. It reflects the ongoing interaction of separation and reunion that begins in infancy. As children develop emotionally, they transition from infancy to toddlerhood and eventually to childhood, engaging in various play activities such as peekaboo, chasing, and hide-and-seek. These games help children navigate developmental challenges, allowing them to experience loss and learn how to manage the dynamics of separation and reunion while forming close relationships with others. Playing peekaboo and hide-and-seek help children transition from relying on the physical presence of their caregivers to developing mental representations of them that they can recall when the caregivers are not around.

Play allows a child to make sense of their experiences. Play Therapy provides a therapeutic environment in which children can explore the unconscious independently. Children inherently strive for growth and healing. Our role as play therapists is simply to create the right therapeutic space and setup, enabling them to express and address what needs to be transformed or resolved. This is why play therapists don’t have to actively introduce concepts; children naturally initiate hide-and-seek themes on their own in the playroom.

Attachment and Loss

The presence of repetitive hide-and-seek in play therapy suggests the child may have experienced an inability to master the developmental task of emotional constancy, had (or has) a break in attachment where the child did not feel wanted or desired, or weak attachment bonds.

A major task of childhood is achieving emotional constancy. Emotional constancy is the ability to have an inner conviction of being ‘me and no one else’ while also respecting and valuing the separateness of others. Achieving emotional constancy enhances one’s ability to manage emotions during change or in response to anger, disappointment, and frustration. Hide-and-seek is essentially the child’s attempt to overcome and work through the earlier developmental need to understand that people can disappear but then return.

Boy who wanted to be found

Jeremy is an 8-year-old boy who faced medical complications at birth and continues to live with a rare heart condition. He was separated from his mother and spent several months in the Intensive Care Unit before his parents could bring him home from the hospital.

As we entered the playroom, he looked at me with the biggest smile on his face. I looked back with glee.

“You’re excited to play today,” I said.

“Yes. Because I am going to hide now, don’t look,” he shouted! “Close your eyes,” he added as he ran toward the other end of the playroom.

With my eyes closed and my hands over them, I waited while he hid. After some time, I softly walked around looking for him.

“Oh, where are you,” I asked. “Where did you go?”

Before I could make my way around the playroom, he popped out.

“Here I am!”

“Oh, there you are. I was wondering where you went.”

He shook his head in agreement.

“Again, find me again,” he quickly directed!

Jeremy played variations of hide-and-seek with me, and also in the burying and unburying objects in the sand during our time together in the play. He often struggled to stay hidden during the process, popping out or revealing himself before I could find him (or the object) suggesting he struggled with the tensions of aloneness and deep down feared no one would notice or “find him.” Across time and throughout the sessions, he was able to spend more time hidden and eventually developed confidence in sitting with tensions of oneness and separateness. I was careful to attune to his desire to be seen, heard, and found.

***

For Jeremy, and others his age and developmental level, hide-and-seek symbolizes the universal human desire to be seen and heard. Play therapy allows children to explore, restore, and practice the concerns that occupy their inner world. Engaging in hide-and-seek with me helped him to manage anxiety, while also fostering a sense of mastery and reinforcing his self-worth.

Questions for Thought and Discussion

What childhood games have you effectively utilized in therapy?

What are your impressions of the way this author used hide-and-seek?

Given the child’s presenting issue, what might you have focused on in the playroom with him?

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

Posted on by Psychotherapy.net Team

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

Creating a Supportive Supervision Model

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

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

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

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

Peer Support Groups: A Collective Approach to Emotional Resilience

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

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

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

Self-Care Encouragement: Prioritizing Individual Well-Being

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

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

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

Conclusion

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

Questions for Thought and Discussion

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

Getting Started as a Therapist: 50+ Tips for Clinical Effectiveness

Posted on by Psychotherapy.net Team

New therapists are eager to help, which can be a strength and a deficit. To gauge the mindsets of supervisees or students, I ask, “What do you do in psychotherapy?” A common response is some form of, “People come in with problems. I need to have the solutions to make their problems go away.” It’s as if therapy is perceived as a special forces operation, picking off the bad guys.

It has been my experience that students and new therapists, when asked about their theoretical preference, express wanting to develop a cognitive-behavioral (CBT) skill set. This is likely, at least in part, because it’s what they are primarily exposed to in today’s graduate programs. Further, I’m told, “It gets right to fixing the problem.”

Upon further examination, their expanded definition is sometimes nothing more than identifying symptoms and providing coping skills. Psychotherapy is thus reduced to the fastest possible symptom reduction, as if it were a paint-by-number procedure. While seemingly efficient, there are inherent and fatal flaws in this approach, perhaps most thoroughly examined by Enrico Gnaulati in his, Saving Talk Therapy (1).

Over the years I’ve noticed an increasing assumption that therapy is not, or should not be, an exploratory process. Rather, there is an idea it should be neatly packaged solutions ostensibly remedying problems in short order. This is no doubt further fueled by the uptick in manualized, short-term (8-12 sessions) interventions, implying therapy is supposed to be short.

Despite the implication of these popular tools, psychotherapy is not a race. What’s more, it does not take long in the field to realize that it’s not unusual for any level of meaningful, lasting change to takes six months to a year, regardless of theoretical approach (2).

Sure, therapists wish to relieve patients’ symptoms as soon as possible, but it’s important to realize that ground must be broken to accomplish this. While therapists can offer immediate objective interventions, like diaphragmatic breathing to combat panic, or grounding techniques to interrupt dissociations, it is still necessary to examine the uniqueness of each person’s experience. Do we not need to get to know the person, and allow the person to get to know themselves?

Getting to understand the meaning behind people’s experiences can help unveil the foundational complication for ultimate resolution. This is not a Victorian relic. Modern psychoanalysts and existentialists operate as such, and traditional cognitive-behavioral therapists explore thought processes behind behaviors on the principle that thoughts drive feelings, which drive behaviors.

From its inception, psychotherapy was an activity in exploration and allowing the patient to unfold. By helping a patient explore their being, we help them come to realizations, make painful or shameful confessions, and share intimate details that almost certainly have a bearing on the problematic feelings and symptoms that led to seeking therapy. It is then that the more substantial work may begin of pulling up the anchor of deeply seated dilemmas, and allowing the person to work towards sailing freely once again.

While symptom reduction is relieving, symptoms are just the fruit of a deeper-rooted conflict. I’ve yet to meet, for instance, someone with illness anxiety (hypochondriasis) who simply developed the symptoms, which in turn can simply be given replacement behaviors, and life goes on happily.

While working with patients on reducing their preoccupation with perhaps having a serious illness, I’ve many times discovered they have an unusually pervasive fear of death. This tends to be correlated with a feeling they are not living authentically and fear dying because they have not truly lived. In effect, the hypervigilance for serious illness serves as a check to catch any illness that may prematurely terminate their chance to live authentically. Clearly, helping this type of patient recover from illness anxiety also involves resolving the driving conflict.

Even in this age of increasingly popular, ultra-brief CBT protocols, icons in the CBT field have illustrated that deeper exploration provides a foundation for more substantial work to begin. For example, Jeffrey Young created the “Young Schema Questionnaire” to help such exploration. This is a standardized tool created to help patients with deep-seated maladaptive beliefs explore the troubling way they conceptualize their world and how that leads to their struggle (3). Thus, this insight becomes a springboard for patients to identify and accept what needs changing, and bolsters a collaborative intervention environment.

While people come to therapy for symptom relief, it’s not always as easy as categorical symptom reduction with intensive exposure therapy or teaching them to be responsive and not reactive through a Dialectical Behavioral Therapy (DBT) skills manual. Even DBT, considered a relatively quick and effective approach to borderline personality disorder, involves some deeper exploration for sustained success, and averages six months to one year of treatment.

While successful ultra-brief and single-session therapy does occur, it’s usually a very specific issue with a very motivated person that makes it successful. Most patients are going to need to unfold.

Perhaps the fastest way to psychotherapeutic success is taking the required time, which will vary amongst patients. Before deep work can begin, a therapeutic alliance must be forged, where patients come to trust that the therapist is interested and cares. It is necessary to establish a dynamic where patients may be vulnerable and reveal themselves to expose the conflicts to resolve that will ensure long-term symptom relief.

People in therapy are seeking lasting change. What is the point of quick symptom reduction if the therapist does not work with the person to make sure improvement is sustained, and this newfound way of being has not been woven into the fabric of their lives?

Find Value in Silence

The poet Thomas Carlyle wrote, “Silence is the element in which great things fashion themselves together; that at length they may emerge, full-formed and majestic, into the daylight of Life, which they are thenceforth to rule.” It is no different in psychotherapy, but many therapists squirm in silence, and opportunities for things to emerge can get lost.

When I was new in the field, the most anxiety-provoking encounters in a session were periods of silence. I felt I must have something to say, lest I wasn’t being helpful. Even worse, perhaps it painted me as inept in the eyes of the patient. In time, I learned this was mostly projection, or the assumption others perceived me the way I was viewing myself, as an insecure new therapist.

Today, I’m often reminded of how disquieting silences can be at the outset, as practicum students confess or demonstrate a similar fear. While reviewing student’s practicum videos, palpable discomfort may follow the briefest silence, and there’s a desperate attempt to fill the void. The follow-up supervisory meetings are always rich as the student digests their experience, only to be surprised to discover that filling the void can threaten the therapeutic process.

Once meeting their “silence threshold” a therapist might tell themselves, as an excuse to break the silence, that the patient’s momentary quiet means they no longer want to discuss the topic. Panicked, the therapist offers impulsive commentary or abruptly changes the topic to have something to say. After all, who wants to see a therapist with nothing to offer?

Upon inspection, however, silence is not always indicative of, “It’s your turn to talk.” The patient could be contemplating something the therapist said. Perhaps, while silent, they are mustering the guts, or finding the words for, something that requires attention. Can you think of a time, perhaps in a meeting, when you had something to say but weren’t sure if you should, or how to say it? Now imagine having something critical to share, such as disclosure of abuse, or revealing something one feels ashamed about, and the space that could require to confess or articulate.

With that space in mind, when it seems like the right moment for clients to bring to light an uncomfortable item, any excuse to not have to might be capitalized on. If the therapist becomes talkative during such a pregnant pause, the patient might not try to bring up the topic again, at least not that session, Clearly, providing patients with an ample silence berth is a valuable gesture. With enough silence, they are more likely to crack and use the moment. Like a buried seed, once the shell breaks, new growth begins to emerge.

Indeed, try giving the silence an opportunity to resolve on its own. This will be less of a task with some patients than others, and will become easier as you get to know them.

I frequently sat in silence for up to five minutes with Corrine, a patient I knew well. She would trail off and become contemplative, sometimes spontaneously. At the same time, she began to rhythmically draw her fingertips of one hand down her fingers of the other hand and across her palms in a self-soothing activity. I learned to let Corrine be and focused on watching her hand motions for their hypnotic relaxing effect, which broke any of the silence discomfort I may have experienced as minutes ticked away. More often than not, she would start to reflect on something poignant we touched on immediately prior.

If she did not speak after some time, Corrine would look up and produce a pained smile. This was my cue to coax her. “If I know anything about you,” I’d begin, “when you get quiet and play with your fingers this long, something is brewing inside, and you’re either not sure how to say it or are a little afraid to.” Merely getting her to acknowledge this was usually enough to spur her on. It was as if my reminder of how well we knew each other assured her it was safe to broach any concern.

Being someone ashamed of her body and who generally didn’t think highly of herself, the material sometimes related to intimacy with her boyfriend. Other times, Corrine, afraid to disappoint me, struggled to let me know she had re-engaged in self-destructive activity like drinking benders. Both items were important grist for the therapy mill, which would have been lost if Corrine was not allowed to engage in her process.

When a therapist is just getting to know a patient, it can be helpful to be especially careful not to force away silence. This might occur with an observation like, “What are you thinking about?” It could seem you want to know too much, too fast. It is less confrontational to offer an observation, like, “It’s been my experience that when someone sits quietly in here, there’s something knocking that wants out.” If affirmed, helping the patient partner with their silence can help the state of arrested expression. Posing the paradoxical question, “If that silence was words, what would it be telling me?” has been notably productive over the years.

Other scenarios that can generate patients’ silence as if they are unused to talking about themselves, or are fearful of exposing themselves and appearing weak. This could be related to cultural matters, machismo, or fear of vulnerability. They might answer your questions as briefly as possible, and offer no spontaneous dialogue. Not surprisingly, this terse presentation is a common scenario in males, who are often socialized to feel negatively about help-seeking (4, 5). Autistic people, given the inherent social deficits, can present similarly. It’s important to know your audience, for, in these cases, prolonged silences that were beneficial for others could be very difficult to endure. A therapist would do well to seize these opportunities to teach a patient to interact and communicate.

In situations like this, the patient honestly may not know what to say, awaiting the therapist’s prompts. To promote a forum of focused sharing, the therapist can be productive by blowing on the embers that have begun glowing with simple persuasion, like asking for clarification or other details. Simply being curious and using the most open-ended questioning style is invaluable. “What more can you tell me about that?” “How has that affected you?” or “What’s been helpful to deal with that?” can gain discussion traction.

Showing those prone to this behavior that we’re interested in what they have to say, or gradually exposing them to self-revelation and having them see that it is not disastrous, can work wonders.

Clearly, if someone is not good at sharing themselves, a goal of therapy may have to be improving their ability to be more articulate and willing to share, so we can better understand and address the chief complaint.

Lastly, surely there will be purely oppositional silence, like with rebellious teenagers who see therapy as “stupid,” and they feel they’re forced to be there. No amount of cajoling is likely to make them participate, and it has nothing to do with being an unworthy therapist. Patients like this take significant rapport building, and supervision is often invaluable.

Ask About Meaning

“How does that make you feel?” has its place in the psychotherapist’s arsenal, but it’s not the sharpest tool. If therapists want to cut deeper, asking “What does that mean to you?” or “What’s that like for you?” can engender more robust revelations and therapeutic exchanges.

It’s been my experience that asking about feeling can be a perfunctory activity leading to a dead-end answer. Great, the therapist knows the patient is anxious, depressed or feeling betrayed, but then what? There might be a great leap from “how does that make you feel?” to offering depression or anxiety management skills. Perhaps the therapist attempts to reason with the patient that they have a right to feel betrayed. There is then a comment that the patient doesn’t deserve that, rendering the therapist a cheerleader. Then what?

Although well-meaning, these responses miss a major point of therapy. That is, the necessity to explore the patient’s experience. Whether analytic, cognitive, or person-centered-based approaches, patients must get to know themselves if they are going to change. Thus, feelings are not always the most lucrative query.

Therapists need to be able to mine for, and work with, substantive data for clinical gains. Thankfully, a little curiosity can go a long way. For instance, talking to someone grieving a close relative or friend, their feelings of sorrow and emptiness are often palpable. Asking what the loss means to them, however, can open new therapeutic doors. The emotional turmoil is not only the effect of the deceased’s absence, but the death causes reflections that instigate anxieties about their own mortality or unresolved conflicts.

One patient with this experience offered that since her parents died, it was as if there was nothing between her and the grave now and there is so much more she wanted to do. This revelation made it clear that the loss, though more than a year prior, stirred her own existential angst. Exploration of her life satisfaction and how to achieve goals to feel she had “lived more” followed. Another individual, in therapy after losing a long-term, close friend, lamented that the friend’s absence meant they could never better resolve a conflict that lurked in the shadows. Clinical focus turned towards self-redemption for his role in the conflict.

In another example, Jackson, a 16-year-old teen, while working through his parents’ divorce, discovered his girlfriend cheated on him.

“She said she was only sticking around because she felt bad for me,” lamented Jackson, tearing up.

“What’s it been like for you the past week since it happened?” I asked.

“So angry my head spun. I’m drained. I’ve got no energy to be angry anymore. I want to scream, but I don’t have the energy.”

“Sounds like insult to injury,” I offered. “You were already dealing with so much.” He nodded.

“Jackson,” I continued, “what does all this mean to you?”

“It means I’m on my own. I can’t trust anyone. My parents are too wrapped up in their mess to care about the mess they made for me, and, I guess, I just suck. I give my heart to someone for the first time, and without warning, it doesn’t matter.”

Asking Jackson about the meaning of his experience led him to put words to his internal landscape. This inside-out synopsis provided more than focusing on feelings could provide. His description created an opportunity to examine the maladaptive beliefs that germinated from the problematic experiences, which only served to compound his bad moods. Navigating these beliefs became part of the plan to relieve Jackson of depression.

Therapists working with trauma may also find it a therapy-accelerating question to help understand how trauma affected someone. Therapists can ask about symptoms and provide coping skills and guidance for achieving goals, but wouldn’t it also be helpful to know how a patient is shaped by the meaning they assigned to their experience? Having a patient share that their traumatic experience made them feel “forever broken,” for example, is more fertile ground than an inventory of symptoms to assign coping skills to for a treatment plan.

Asking this “forever broken” patient, “What exactly do you mean by ‘forever broken?’” was crucial to our work. They described an overidentification with the role of victim, perpetuating the other symptoms. Hypervigilance soared, nightmares involved reaching for goals, only to be sabotaged. Understanding this schema helped treatment in that the focus centered on empowerment; cultivating and magnifying other components of her life that negated the role of victim.

Often the juveniles I interview for court are enmeshed in daily marijuana use, binge drinking or vaping nicotine. Problems follow like infractions for marijuana possession in school, perhaps public drunkenness, or getting caught stealing vaping paraphernalia. During the assessments I ask not only about their use history and how it affects them, but what sort of meaning do they assign to the substance use?

I’ve been given answers that it is how they identify with their family, or that they can control how they feel and when. In the cases involving drug dealing, while the money is a motivator, drug culture guarantees excitement in an otherwise dull existence.

In each instance, asking about meaning yielded more potent information than “why” or “how” was likely to. Inquiring about meaning encourages an answer that captures more of the experience. This includes revealing deeper causal factors than self-medication or boredom, or at least factors that encourage the substance use under the circumstances.

Be Attentive to Your Intuition

My colleague, Joseph Shannon, a psychologist specializing in personality, once told me that “listening with the third ear” is a top skill to hone as a therapist. According to author Lee Wallas, the term was first used by the existentialist Friedrich Nietzsche in his 1886 book, Beyond Good and Evil. Given my lack of familiarity with the term I was intrigued, but quickly discovered it’s simply an elaboration of something most people are familiar with: intuition.

While this clinical skill might sound unusual, if you have ever sensed there is more than meets the eye to what the patient is relaying, you’ve experienced it. Clinically, the third ear quietly deciphers indirect communication, helping the therapist read between lines. Just as Spiderman heeds his tingling “Spidey sense” that something is askew and someone needs help, it’s important for clinicians to heed their “Spidey sense.”

Sometimes supervisees confess to encountering situations where it seems their patient is indirectly trying to say something. However, they wonder if it’s too speculative or confrontational to heed the tingling and “go there.” Usually, they fear they may be off the mark, deeming them incompetent and pushing the patient away. Some have justified their defensive unwillingness to consider their intuition by noting, “When the patient is ready, they’ll tell me.”

Or not. Not regarding the intuition could inadvertently prolong misery and unnecessarily perpetuate treatment.

Is it not part of therapist’s duty, part of the therapeutic process, to explore and help patients learn about themselves so they may advance? Is it not poor practice to potentially be encouraging internalization of things that need saying; to not help patients discover and deal with, emerging elephants in the room?

It’s not unusual that patients are on the couch due to some such ineffectual coping strategy as internalization or denial. Thus, the very thing the therapist might be apprehensive of doing is just what they need, and perhaps are even carefully, consciously, asking for. Would you be surprised to learn that sometimes patients (consciously or unconsciously) guide us to make the observation so they don’t have to say it? Something that requires purging may be too painful or embarrassing to mouth, and it’s easier to acknowledge than to explain in order to get it out there. Consider the case of Rob, a successful 34-year-old, who entered therapy for “feeling emptier with age.”

As we explored his life, Rob disclosed an early history of social anxiety that he overcame with therapy. He confessed he was a late bloomer for dating given his teenage angst, but had managed a few, year-long relationships as he emerged from his shell in his 20’s. “As a kid, all I wanted was a nice girlfriend, but I didn’t get that young adult dating experience. The older I get, the harder it is meeting eligible ladies,” Rob lamented. Not about to let it sink him, he accepted singlehood as best he could, travelling abroad and exploring locally on his own.

Rob occasionally traveled with friends, but the ones he had traveled with began having children and were no longer available for adventures. “My friends had to go have kids,” he’d joke, “They don’t know what they’re missing!” Despite this, he regularly spoke of being “Uncle Rob” and beamed when talking about his friends’ toddlers. Other times Rob said, “I do love kids, I just like to give them back. Kids aren’t for me,” noting they’d be hang-ups for his ostensible free spirit.

Soon, my Spidey sense tickled that Rob’s emptiness may well stem from being childless, and I had enough evidence to justify exploration. In a subsequent session, I said, “Rob, we’ve met a few times now, and I’d like to review a bit deeper. Given your history of social anxiety, it’s impressive you’ve become so social and had some successful romantic relationships. It’s got to be disappointing to have progressed exponentially with social comfort, just to encounter the frustration of not securing the relationship you always wanted. While talking about your frustrations with the romantic void, though, you’ve also made some curious comments about kids that I feel deserve exploration. On the one hand, you depict how kids cramp your style. On the other, your happiness is palpable when you bring up kids that are in your life. Correct me if I’m wrong, but I can’t help wondering if there’s an internal conflict regarding kids of your own contributing to that complaint of increasing emptiness.”

Rob eventually confessed, “It’s much easier to say you don’t want kids than to admit you can’t pull it together enough to make it happen.” What followed was an unfolding of Rob’s fear he’d be like his father, plus he feared his own children could be tormented with anxiety as he was. Being in denial allowed him to save face about imperfections. As Rob reflected, he realized that while he enjoyed the women he was with, when talk of longevity and family surfaced, he invariably sabotaged the relationship. He was capable of getting what he wanted, but subconscious security guards only let romance go so far.

Rob isn’t unusual in that patients may be avoiding the truth as ego damage control when they aren’t procuring what they want. As we explored over time, it came to light that the more Rob could not find someone, the more he traveled solo to prove he did not need anyone and to convince himself of his rationalization defense that kids just complicate things. He needed an excuse not only for himself, but as deflection for appearing defective to others.

Imagine if I had not shared what was on my mind about Rob’s material? Clearly, selective hearing for the third ear could have grave consequences to patients. Further, it is important to note that, unlike therapists we might see on the screen, it’s not about trying to shake sense into someone by saying, “Listen to yourself! You’re not finding a relationship because you’re in denial about wanting kids.”

Framed in a disarming way that makes patients see it’s to their benefit, your hunch can be explored and will likely make them interested in examining the idea and weighing its merit. Even if it’s off the mark, that’s not synonymous with therapist incompetence. It demonstrates the need for curiosity about the self, urges willingness to explore, and shows the therapist wants to get to know and understand them, which only strengthens the therapeutic foundation.

***

This content is excerpted and adapted from Smith, A. (2024). Getting Started as a Therapist: 50+ Tips for Clinical Effectiveness. Routledge., with explicit permission from the publisher.  

(1) Gnaulati, E. (2018). Saving talk therapy: How health insurers, big pharma, and slanted science are ruining good mental health practice. Beacon Press.

(2) Shedler, J. & Gnaulati, E. (2020, March/April). The tyranny of time. Psychotherapy Networker. https://www.psychotherapynetworker.org/article/tyranny-time

(3) Yalcin, O., Marais. I., Lee C.W., & Correia, H. (2023). The YSQ-R: Predictive validity and comparison to the short and long form Young Schema Questionnaire. International Journal of Environmental Research and Public Health, 20(3).

(4) Cole, B.P., Petronzi, G.J. Singley, D.B., & Baglieri, M. (2018). Predictors of men’s psychotherapy preferences. Counselling and Psychotherapy Research, 19(1), 45-56.

(5) Wendt, D. & Shafer, K., (2016). Gender and attitudes about mental health help seeking: Results from national data. Health & Social Work, 41(1), 20-28.

(6) Wallas, L. (1985). Stories for the third ear: Using hypnotic fables in psychotherapy. Norton.

Josh Coleman on the Roadmap to Healing Family Estrangement

Posted on by Psychotherapy.net Team
Lawrence Rubin: I’m here today with Joshua Coleman, a psychologist in private practice in the San Francisco Bay area, and a senior fellow with the Council on Contemporary Families. He’s the author of numerous articles and book chapters, and has written four books, the most recent of which is The Rules of Estrangement. Welcome, Josh.
Joshua Coleman: Thank you for having me. Pleasure to be here.

The Face of Family Estrangement

LR: I’ll just jump out of the gate by asking you, why do you describe estrangement within families as an epidemic?
JC: Well, there’s a variety of reasons for that. One is, and I don’t know about you in your practice, but in the past few years, my practice, as well as those of my colleagues, has become flooded by clients dealing with this estrangement. Another reason comes from a recent survey by Rin Reszek at Ohio State, who found that 27% of fathers are currently estranged from a child. That’s a new statistic. While we haven’t really been tracking these statistics, non-marital childbirth is also a big cause of estrangement, which is 40% currently compared to 5% in 1960.Divorce is also a very big pathway to estrangement, especially in the wake of more liberalized divorce laws. When you look at the effect of divorce on families once there’s been a divorce, the likelihood of a later estrangement goes way up. This is especially so when you add social media as an amplifier, our cultural emphasis on individualism, influencers talking about the value of going ‘no contact’ after the divorce, and family conflict around politics, especially in the recent election. All these point to a rise in family estrangement, particularly parental.
LR: in the past few years, my practice, as well as those of my colleagues, has become flooded by clients dealing with this estrangementI know the there is a historical rise in divorce. Is there a parallel rise in estrangement with the rising divorce rate?
JC: I don’t think it’s a 1 to 1 relationship, but I think both occur in the culture of individualism, which prioritizes personal happiness, personal growth, protection and mental health. Prior to the 1960s, people would get married to be happy, but more often for financial security, particularly for women as a place to have children. But today, people get married or divorced based on whether that relationship is in line with their ideals for happiness and mental health and the like.The relationships between parents and adult children are constituted in a very similar way, people don’t stay in touch or close to their parents unless it’s in line with their ideals for happiness and mental health. It’s what the British sociologist Anthony Giddens calls pure relationships. Those are relationships that became purely constituted on the basis of whether or not they were inline with that person’s ambitions for happiness and identity. So, it’s a parallel process. I don’t think it’s completely dependent on divorce because there’s many pathways to estrangement.
LR: if the adult child cuts off the parents, they also cut off access to the grandchildren which can cause marital tensions for couples that are still marriedWhy is estrangement so different from other problematic family dynamics?
JC: Because of how disruptive it is to the adult parent and because of the cataclysmic nature of event and its consequences for the rest of the family. Once there’s an estrangement, it isn’t just between that adult child and that parent. It also can cause one set of siblings, or one sibling, to ally with the parent, another with the adult child. Typically, if the adult child cuts off the parents, they also cut off access to the grandchildren which can cause marital tensions for couples that are still married. So, it’s really a cataclysmic event in the whole family system.
LR: In your clinical experience, are there identifiable risk patterns for the eventuality of estrangement?
JC: Divorce is a huge risk, especially when it is accompanied by parental alienation, where one parent poisons a child against the other parent. Untrained or poorly trained therapists sort of assume that every problem in adulthood that can be traced back to a traumatic childhood experience. There seems to be no shortage of those therapists who think everything that is problematic in adulthood is due to some kind of family dysfunction or trauma.Another pathway to estrangement is when the adult child married somebody who’s troubled and says, “choose them or me.” Mental illness in the adult child is also potentially destructive. And last, when parents have been doing something much more psychologically destructive over the years, certain adult children just don’t know any other way to feel separate from the parent beyond cutting them off.
LR: Before we move forward, can you give us a clear definition of estrangement?
JC:  It’s when there is little to no contact. If we’re just thinking of the parent-adult child relationship where there’s little to no contact, and underlying is some kind of, complaint or disruption in the relationship, the adult child is typically the one initiating the estrangement. They determine that it’s better for them not to be in contact with the parent or to grossly limit the contact. Maybe they send a holiday card or something, otherwise they have no contact with their parent.
LR: t’s a complete cut off.
JC: Complete cut off, or a nearly complete cut off. Exactly.
LR: the adult child may not be as motivated to solve the problem as the parent isAnd is the focus of your clinical work mostly on estrangement between adult children and their parents?
JC: Typically, because they’re the ones who are reaching out to me. Occasionally, I’ll have siblings reach out to me, but more typically it’s the parents who are estranged. From their perspective, they’re the ones who are in much more pain. The adult child may have cut off the parent because of their pain, but by the time the parent reaches me, the adult child has concluded that it is in their best interest to estrange their parent. So, the adult child may not be as motivated to solve the problem as the parent is.
LR: Do you have estranged grandparents reaching out to you?
JC: Yeah, and a lot of grandparents say, ‘look, I could probably tolerate estrangement from my child, but not from my grandchildren.’ This feels intolerable, particularly for those who have been actively involved with their grandchildren, as many of these grandparents have been.
LR: This “grandparent alienation syndrome” must be particularly tormenting for them. Have you experienced different cultural manifestations of estrangement?
JC: The data from the largest study, which was by Rin Reczek at Ohio State, found that, for example, Black mothers were the least likely to be estranged. White fathers are the most likely to be estranged. Latino mothers are also less likely to be estranged than White mothers. Fathers in general are very much at risk for estrangement regardless of race.There’s relatively low estrangement in Latin American families as well as Asian American families. And similarly, within Asia, we assume that there’s not a lot of estrangement because the culture of filial obligation is still quite active. So, estrangement tends to predominate in those countries and cultures, like ours, that have high rates of individualism and preoccupation with one’s own happiness and mental health.

Detachment Brokers

LR: That’s interesting. So, there’s a parallel between estrangement and the value particular cultures place on either individualism or commutarianism.
JC: Exactly. Some are much more communitarian, emphasizing the well-being of the family and the group, while others are much more individualistic, like we are here. The sociologist Amy Charlotte calls American individualism ‘adversarial individualism,’ which is the idea that you become an individual through an adversarial relationship with your parent, or you rebel against that. But not all cultures have that kind of adversarial positioning as the way that you become an adult.
LR: You had mentioned earlier that some therapists can actually make things worse.
JC: I think that all therapists want to do good, but some simply don’t think through all of the factors. We have to not only think about the person in the room, but also the related people, because estrangement is a cataclysmic event that affects many beyond the person sitting in front of you. Grandchildren are involved and get cut out from their grandparents’ lives. Siblings typically get divided into those who support the estrangements and those who don’t. It’s also very hard on marriages. It’s easy to get sidetracked into focusing on the mental health of the adult child who is cutting off their parent(s) in the name of self-care and self-protection. We have a rich language in our culture around individualism, but a poverty of language that’s oriented around interconnectedness, interdependence, and care.It’s easy to pathologize someone’s feelings of guilt or responsibility for a parent that may just be a part of their own humanity. By giving them the language and moral permission to cut off a parent without doing due diligence on whether or not that parent really is as hopeless as their client is making them to be, contributes to this kind of atomization.Therapists can contribute to the tearing apart of the fabric of the American family, acting as accelerants to that process. We become what the sociologist Allison Pugh calls detachment brokers in her book, Tumbleweed Society. When we support clients’ absolute need or desire to estrange their parents due to their need for happiness and personal growth, we help them detach from the feelings of obligation, duty, responsibility that prior generations just assumed one should have.

LR: Do you ever encourage or facilitate estrangement as a solution?
JC: The same way that I would never lead the charge into divorce with a couple with minor children because of the long-term consequences, I wouldn’t charge ahead with estrangement either. But I do try to help the person to do their due diligence on the parent. Let’s say the parent who is completely unrepentant and constantly shames the adult child about their sexuality, their identity, who they’ve married, or what their career is every time that adult child is around the parent. It’s sort of hard for me to ethically say, “give them a chance!”But I do think it’s our responsibility to ask them: what other relationships will be impacted if you decide to go no contact, is there some way to sort of have some kind of a relationship where you are protected from their influence, or why don’t we think about why is it so hard on you? A newly reconciled adult child recently suggested to me that, ‘if the adult child is insisting that your parents are the ones that need to change to have a relationship, maybe you’re the one that needs to change.’ I liked that because I don’t think everybody has to stay involved with their parents.I do think parents have a moral obligation to address their children’s complaints and empathize with them and take responsibility. Just like the adult children have a moral obligation to give their parents a chance. I work with parents every day who are suicidal or sobbing in my office, and that really gives you a different view of this.
LR: I imagine the most deeply wounded adult children are the most difficult ones to work with around reconciliation. Can countertransference enter the clinical frame at that juncture?
JC: There have been a few occasions where the adult child was so self-righteous and contemptuous of the parent, despite the parent’s willingness to make amends for their so-called crimes––which were more on the misdemeanor side than the felony side––they remained unforgiving. Even when the parent showed empathy and took responsibility in the ways that I insist that parents do, the adult child remained in this very censorious, self-righteous, lecturing place.There haven’t been very many times when I felt provoked on the parent’s behalf, but there have been a couple times where the adult child was earnest, open and vulnerable, and the parent was not willing to do some basic things at the request of the adult child, like accepting basic limits. The parent was insistent. I just felt like you can’t have it both ways. I remember thinking, ‘You can want to have your child to be in contact with you, but you’re going to have to accept the limits that your child is setting, otherwise, I can’t really encourage your child to stay in contact with you in the way that you want me to.’ The transference is worked on both sides of the equation.

A Roadmap for Change

LR: Is there a roadmap for healing estrangement as you suggest in your book?
JC: Typically, if the parent has reached out to me for the reasons I was just saying, the roadmap begins with taking responsibility and the willingness to make amends. I ask that they try to find the kernel, if not the bushel of truth in their child’s complaints. They can’t use guilt or influence or pressure in the way that maybe their own parents might have used with them, and they can’t explain away their behavior. They have to show some dedication to reconciling. It must come with some sincerity. The challenging part for parents is often that they can’t really identify with what they’re being accused of, particularly since emotional abuse is the most common reason for these estrangements.A lot of parents say, ‘wow, emotional abuse, I would have killed for your childhood.’ The threshold for what gets labeled as emotional abuse is much lower for the adult child than it is for the parents. So, a lot of the roadmap for the parent is just accepting that difference and learning how to understand why the adult child is labeling it as such and not really debating it with them or complaining about it. Instead, that roadmap includes a way to empathize with that and understand that those are the most key aspects.
LR: What about when the road to reconciliation has been damaged by physical/sexual abuse?
JC: You have to go there if you have any chance of healing the relationship. If a parent is lucky enough to get an adult child in the room after that child being a victim of more serious traumas on the parents part, the parent has to be willing to sit there and face all the ways that they have failed their child and how much they hurt and wounded them.And it’s not an easy thing to do, typically, because hurt people hurt people. There is high likelihood that the parent who did the traumatizing was traumatized themselves, but if anything is going to happen, it’s going to be because the parent can take responsibility and do a deeper dive and not sweep it under the rug. And that’s very hard work, especially for the adult child who must expose themselves.
LR: Would you work with the adult child separately from the parent and then together by collaborating with all the players in the same room?
JC: Typically, I will meet with each side separately because I want to see what the obstacles are, what each person’s narrative is, assuming that I think everybody’s ready to go forward, I’ll bring everyone together. I usually don’t keep them separate for more than one session, but not everybody is ready to go forward at the same time. If I think that people are sort of ready to engage, then I’ll do a session separately and then everybody together. I tell parents that this is not marriage therapy. The therapy is around helping the adult child feel like their parent is willing to respect their boundaries and accept versions of their narrative sufficiently that they feel more cared about and understood. It’s not going to be as much about the parent getting to explain their reasons or decisions, at least not early into the therapy. If therapy goes on long enough, and people are healthy enough to have that conversation, then it can happen. But it doesn’t always.
LR: What do you consider to be a successful outcome, and at what point do you say that’s enough for now?
JC: I think when they’ve all had enough time outside of therapy, and they were able, to debrief if there was conflict, and if I feel confident that they have the tools to walk them themselves through the conflict and resolve it. I try to help each person set realistic goals and let them know that they are going to make mistakes going forward. The goal isn’t to be perfect, but instead to communicate around feelings and taking each other’s perspectives so all members feel safe and skilled enough to overcome whatever conflict arises. I don’t want anyone feeling discouraged and helpless.
LR: What protective factors do you look for when working with estrangement? The glimmers of hope that you search for with your therapeutic flashlight?
JC: The biggest one is a capacity for self-reflection on the part of both the parents and the adult children. In the parent, I look for a willingness to take responsibility, the capacity for non-defensiveness, vulnerability, and tolerance for hearing their child(ren)’s complaints without being completely undone. For the adult child, I look for acknowledgment that what they’ve done is difficult for the parent, and that their own issues might have contributed to their decision to estrange them.I look for an adult child to say things like, ‘I acknowledge that I was a really tough kid to raise,’ ‘I’ve been a tough as an adult,’ ‘I can give as well as I get,’ or ‘I know that I have an anger issue.’ Those help me, as the therapist, to feel like, ‘okay, you’re not just here to blame and shame the others.’ It’s about a willingness and ability to come to a shared reality, which is important for these dynamics.
LR: At what point might you suggest stopping with a client?
JC: I’ll keep working with people as long as they want to get somewhere. I don’t usually fire clients. But, for example, if I have an adult child who is just insisting that their parent has to change, and it’s clear to me that the parent has changed as much as they’re going to, my goal would be helping them shift towards radical acceptance, rather than to keep beating their head against the wall. And similarly with a parent, if their adult child is just not willing to reconcile, then it isn’t useful for the parent just to keep trying and banging their head against the reconciliation wall either.
LR: Recognizing not only your own limitations, but those that the family system brings to you.
JC: Exactly! I think an important part of our work is to help people to radically accept what they can’t change and influence. As painful as that is to reckon with.
LR: What does radical acceptance mean in this context?
JC: The term came from Marsha Linehan who developed Dialectical Behavior Therapy. It’s not sort of a soft acceptance, but instead a deep dive that you have to do. She has a great quote that says, ‘the pathway out of hell is your misery.’ It’s a great quote because you must first acknowledge that you’re miserable and accept it and maybe not even hope for change. But it does mean you have to acknowledge that you’re currently in hell. And unless you can really accept that reality, nothing good is going to come of it. The other saying that I like that comes from mindfulness or Buddhism is that pain plus struggle equals suffering. That the more you fight against the pain, the more you’re going to suffer. So, I think those are useful concepts.
LR: In this context, at what point does grief and loss work enter the clinical frame?
JC: Grief work is really part of it. Even if I can’t facilitate a reconciliation, it is important helping parents to feel like, ‘yeah, I think you’ve turned over every stone here.’ At that point, it is important to help them accept it and focus more on their own happiness and well-being, and on other relationships. This would include working on self-compassion while mourning the loss of the relationship that may never be.
LR: In closing, Josh, can someone who’s trained in individual therapy do this kind of work?
JC: If you are an individual therapist, you can’t just sort of suddenly start doing couples therapy. You have to have some facility at keeping two subjectivities in your mind at the same time. You know, being able to, to speak to both people in a way that shows that you’re neutral, even when you’re temporarily siding with one person over the other. I think it’s important to have a sociological framework for this part. You also need to set your own limits and boundaries. Doing family work is a very different sort of orientation and requires a unique skill set.
LR: On that note, I’ll say thanks. Josh, I appreciate the time.
JC: It was my pleasure, Lawrence.
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Joshua Coleman, PhD, is a psychologist in private practice in the San Francisco Bay Area and a Senior Fellow with the Council on Contemporary Families, a non-partisan organization of leading sociologists, historians, psychologists and demographers dedicated to providing the press and public with the latest research and best practice findings about American families. He is the author of numerous articles and chapters and has written four books: The Rules of Estrangement (Random House); The Marriage Makeover: Finding Happiness in Imperfect Harmony (St. Martin’s Press); The Lazy Husband: How to Get Men to Do More Parenting and Housework (St. Martin’s Press); When Parents Hurt: Compassionate Strategies When You and Your Grown Child Don’t Get Along (HarperCollins). His website is www.drjoshuacoleman.com/.