Approach Archives - Page 21 of 41

Bilingualism as a Necessary Clinical Competence

Posted on February 21, 2019February 11, 2026 by Psychotherapy.net Team

The majority of people in the world speak more than one language, but in the United States people have primarily been monolingual. This may not be sustainable. Technology, mobile dominance, the internet, economic growth, and globalization have reconstructed our social sphere, exponentially amplifying social interaction between continental and national borders. In unprecedented ways, our world has transformed into a diverse multicultural and multinational global hub that is increasingly interconnected. An essential aspect of this global diversity includes an estimated 7,105 living languages¹. Of the more than 7 billion people on our planet, the largest portion, approximately 1.2 billion people, are first-language Chinese speakers, followed by Spanish, English, and Hindi. Countless interactions between speakers of these and many other languages happen daily, and predictably, this has steadily increased demand for bilingual psychotherapists.

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Despite the anti-immigration rhetoric prevalent in Washington, many non-English speakers continue to enter the country. In our age of technological boom and globalization, it is increasingly vital for psychotherapists to not only learn a second language but also to consider the unique and subtle implications of language differences and how an individual’s linguistic roots transect with their geographic location.

Psychotherapy, as taught in graduate programs nationwide, has recognized the need for therapists to address spirituality, religion, race, gender, ethnicity, class, gender, and sexual orientation. However, our field has only recently begun to widen its lens to address language in more depth. Language training will increasingly be not only relevant but also central in psychotherapy training curriculums as globalization, diversity, and intersections across national borders accelerate.

Psychotherapists are frequently in contact with clients whose first language is not English. The profound need for therapists to be able to communicate with non-English speaking clients already exists and is poised to expand exponentially. The most prominent language spoken in the United States after English is Spanish. Although a few graduate programs have integrated Spanish language training into their curriculum, not many recognize that this is a growing need². Currently, language training is considered supplemental, but now more than ever it must become more fundamental to training to keep up with where the world is heading.

One specific population I am passionate about working with is Spanish-speaking immigrants. They are the largest and most rapidly growing ethnic group in the United States. Not only do they underutilize mental health services, but they also tend to have high rates of mental health problems like trauma, domestic violence, depression, substance abuse, and family separations due to immigration restrictions. Research also suggests they tend to seek psychotherapy less frequently and tend not to view talk-therapy as a viable way of meeting their mental health needs, despite its demonstrated effectiveness across multiple studies, including meta-analyses.

Between 2011 to 2013, I completed my Master’s in International Counseling Psychology at the Mexico Campus of Alliant International University. I learned Spanish as I was completing my practicum in Mexico City, practicing solely with Spanish-speaking clients as well as speaking Spanish during class and supervision. We often discussed the nuances of the language differences and how they affected our work with clients, for better or worse. Toward the end of the degree, I completed a research project that covered this topic in greater depth³.

To briefly summarize, we found that in many instances participant clients described language differences as a non-issue, which should be encouraging to you, reading this, if you are considering strengthening your bilingual skills; you do not need to master a second language to make a difference.

Clients who are dominant in any other language than English are often honored by sincere and diligent attempts on the part of the clinician to learn their language. And, according to clients’ self-report (which may have been contaminated by wanting to please us, referred to broadly as research demand characteristics), language differences had unexpected clinical benefits, such as equalizing inherent power dynamics in therapy and strengthening rapport and collaboration as therapists and clients work to understand each other despite significant language differences. Predictably, in some ways, the language limitations of the therapists were also challenging and were related to clinical difficulties that we needed to creatively address with clients, such as not feeling understood by their therapists who were learning Spanish and psychotherapy simultaneously. Fast forward to today, my training has paid off; I work part-time at a non-profit called Palomar Family Counseling Service located in Escondido, California, with Spanish-speaking families.

Aside from broadening your opportunities as a psychotherapist and our field keeping up with our changing times, learning Spanish is a profound act of social justice: you can be the one decreasing the dire paucity of effective bilingual services as we take on the increasingly diverse mental health needs and challenges of clients whose languages and world views are different from ours.

(1) Paul, Simons & Fennig, 2013, Ethnologue: Languages of the world. Dallas, TX: SIL International.

(2) Platt, 2012, A Mexico City based immersion education program: Training mental health workers for practice with Latino communities. Journal of Marital and Family Therapy

(3) Linder, Platt, & Young, 2018¿Me explico?: Mexican client perspectives on therapy with Spanish as second language (SSL) Clinicians. Sage Research Methods.

Erica Anderson on Working Therapeutically Across the Gender Spectrum

Posted on February 19, 2019February 11, 2026 by rezendevknowfully.com

Transgender 101

Lawrence Rubin: Thank you for taking the time to speak with me this morning. Transgender issues have gained much attention in the last several years, but most therapists do not have experience working with these clients. What are some of the issues a therapist needs to know?

Erica Anderson: Thank you for this opportunity. I think it is a topic much discussed in society these days, and you're right that very few psychotherapists are trained to work with people with gender issues. One of the most important things to point out is that in years gone by, those of us in the mental health field were trained to understand gender development in a very limited, binary way, namely that one was born either male or female; "M" or "F" on their birth certificate, and then they just grew up. Puberty constituted a pretty significant change, and maybe at some point, someone would declare that they were gay, but otherwise there wasn't really much to do about the development of gender.

very few psychotherapists are trained to work with people with gender issues

What we now have come to appreciate is that gender identity exists on a spectrum, and that just as Kinsey pointed out more than half-century ago, many more people have complex sexual attractions or are bisexual than we ever thought. The same is true with gender differences. We used to think that transgender people were very rare, but in fact, people who are not binary in their gender identity or whose gender identity differs from the sex that they were assigned at birth, are in greater numbers in society than we ever really understood.

Society has become more accepting of some of these differences so more patients who are questioning their gender are coming forward to therapists. They are exploring who they are and may actually be willing to talk about some of their own self-doubts or self-realizations. So, therapists need to begin to understand how to work with such people by acquiring new knowledge, developing new skills and examining their own biases or potential biases around gender issues.

LR: Can you say more about the knowledge and skills therapists need to have when working with clients presenting with gender identity issues?

EA: The first point about knowledge is reflected in what I said a moment ago; that many people have presumed that gender really is simply a binary trait of human beings, and that is not the case. If you look at the history of human civilization, there have always been people who have not lined up in their gender identity with the sex they were assigned at birth. There have always been transgender people in society. Some of them have been acknowledged, and in some cultures, there is actually recognition of this. Many native peoples have something called "two spirit," which is a recognition of someone whose gender doesn't line up with their anatomical sex—it is a mixture of gender identities. And then there are some other cultures, in India, Brazil and Asia, where there have been transgender people recognized throughout history. We now know that, depending upon what you include in the category transgender, perhaps as many as one in 200 people in America could be said to be transgender (according to a recent study from UCLA).

LR: When we think of addressing diversity issues in counseling and therapy, we think of gender, race, age and religion. You're suggesting that within some populations, their spiritual-cultural practices may intertwine with gender identity issues?

EA: That's right and it’s a very important point here that gender identity cannot be dissected apart from the other aspects of a person. We talk these days about intersectionality and multiple identities, and that becomes acute when we then consider gender issues. This is because the experience of someone who is transgender of a certain cohort and a certain racial, ethnic or economic background might be very different from someone else whose identity is different in some of those aspects. So, it's not a situation where you can say, oh well, all transgender people are X or Y. In fact,

I say all the time, when you've seen one transgender person, you've seen one transgender person

I say all the time, when you've seen one transgender person, you've seen one transgender person. That is part of the challenge in terms of training and education in clinical practice.

One of the things I hear often is, "Oh, well, you know, coming out as transgender, well, that's like coming out as gay." Well, no, it's not. Gender identity has to do with every aspect of who you are. To equate the transition of someone who is trans from maybe being perceived as one gender into being perceived in a different way, is not exactly the same as someone who may have been closeted as a gay person and then comes out as gay and is living more openly as gay. But that's a common thought for some people who are not very well versed in these issues. It’s disturbing to some trans people to be thought of as, "Oh, well, at one point in time, you're just kind of revealing something about yourself." It's a lot more complex than that!

Beyond Binaries

LR: This suggests that clinicians need to be aware of the developmental trajectory, not just of gender, but the convergence of multiple trajectories across the lifespan that include, but are not limited to, gender.

EA: Absolutely. In fact, as we know from the traditional field of developmental psychology, people develop in lots of different ways, and that development is very uneven for most individuals through childhood and adolescence, and even into young adulthood. So, we know that we can narrow in on various aspects of development. I say all the time that everybody has their own individual developmental pathway, and that where they are at any given point in time is simply that, and it's subject to change.

The other takeaway from the emerging knowledge about transgender issues is that gender identity is something that's very fluid. So, there isn't a single narrative that explains the course of development of all transgender people. In fact, people can come to an awareness of themselves very early, in early childhood, or later in adulthood. And there's a mixture of factors in any individual case that may be contributing to those differences.

LR: It seems therefore that one of the core skills for a clinician to master is to think intersectionally—to broaden their case conceptualization and treatment planning to include these multiple converging trajectories.

EA: Exactly right, which is what makes the work so interesting for those of us who are doing it now. The evaluation process involves parsing, where we look at certain aspects of the situation, traits and historical trends of an individual, and interweave these factors. And because of the highly individual nature of gender identity, we really must listen carefully to each person, no matter what their age is. We must listen to what they say about themselves because gender, as identified by an individual, is a deeply internal and personal thing and we cannot assume that we wholly understand, in a simple way, what is going on with somebody unless we spend some time focused on it.

LR: So, one of the skills that a clinician should have is being able to move past not only binary thinking regarding sexuality and gender, but beyond binary thinking about people in general.

EA: I say all the time,

there's nothing about human beings that's binary

there's nothing about human beings that's binary. If you think about psychology as a field that has attempted to study individual differences, there's really no characteristic that is simply binary–yes or no, this or that, black or white, on or off. We're not machines. We generally think about individual differences and the intensity of various traits when we think about personality. Even in medicine, we think about laboratory studies, growth charts and laboratory ranges for all kinds of characteristics. So, there's nothing binary about human beings. But thinking about that in terms of gender requires a fundamental reordering of how we bring together all the aspects of who a person is, and a recognition that they have been evolving and changing and developing, and they're going to continue to do so.

LR: I joke sometimes with my students by saying that there are two types of people in the world, those people who believe in binaries and those who don’t.

EA: I love that. That's really cute and apt.

Words Matter

LR: Therapists not particularly trained or experienced with transgender or transitioning clients may be unsure how to start, what language or personal pronouns to use, or even how to broach the subject. What advice would you give them?

EA: This is a big challenge for all of us, even those of us who have more experience, because society has been changing rapidly. People are bringing to these discussions whatever they've known or learned or thought they knew, as well as what information is circulating now in the world, on the Internet and in professional circles. And we don’t all mean the same thing when we use the same words. I’ve seen this evolve in my career.

I was trained on DSM II which listed homosexuality as a sexual disorder. That came out in a revision of DSM II. But today's clinicians who have been trained more in DSM-IV and DSM-5 don't think about the fact that there are huge numbers of people who are still alive who were reared in an era when homosexuality was considered shameful and a psychological disorder. I had a patient years ago who was expelled from medical school because he was arrested in a gay bar for soliciting—and that’s in my lifetime.

So, the words that we use continue to evolve. An example is "gay." You know, "gay" used to be a slur, a pejorative word. It still is in some circles. But now we have the word "queer." People are using the word "queer" all the time but don't know what anybody else means by the word. So, if somebody comes in my office—and this is a tip for therapists—and starts using some of the words that have to do with gender and sexuality, I routinely will ask them, "Well, what do you mean by that word? What do you mean by queer? What do you mean by trans? What do you mean by gender? What do you mean by attraction?"

LR: So, letting the client lead in creating the definitions, and even helping them to make peace with a definition that best fits them at that point in their life…

EA:

Dr. Seuss wrote, "You are the you-est you can be. No one is more you-er than you."

Exactly, and I love to invoke my favorite philosopher, Dr. Seuss, who wrote, "You are the you-est you can be. No one is more you-er than you." You know, we really fundamentally have to accept that people define themselves. And people who have deep-seated psychiatric disorders may be defining themselves in ways that are not helpful and maybe even toxic, but we must start there. We have to start with what's going on with someone. And there is no more significant area to do this in than gender and gender identity.

Gender Politics

LR: What if a client comes to you and doesn't broach the subject of sexuality or sexual identity or gender identity? What's the therapist's role? Is it their place to ask a pointed question? Or is it sort of a Rogerian thing, to just let the client be and go with wherever they are?

EA: As you infer, I see a lot of people who come to me because they are dealing with some of these issues that we're talking about today, but not always. I will sometimes see people who are straight who have anxiety or depression. In my long career as a psychologist I've treated people with many different conditions. I don’t assume anything about what someone wants to focus on. On my website, I have a section called "Permission to Be," where I write about my philosophy. If someone comes to me and says, "I'm coming to you because I think I'm trans, or because I am trans, or because I want to explore my gender expression and identity," then we're off to the races. By contrast some clients come to me and say, "Well, I know I'm trans. I don’t really need to deal with that. But I'm really depressed" So, it depends on the particulars of a client.

In terms of advice to other therapists, I would say, don’t assume that something having to do with sexuality or gender is a problem for someone. If it is obviously a problem and they're asking you to help them with it, help them. But if they are coming to see you for other reasons, their relationship with their gender and sexual identity doesn't necessarily require any intervention.

I want to say something else about this that I think is significant. Transsexuality, as it used to be called, was categorized as a sexual perversion, and was nested in the DSM in the section on fetishes-paraphilias. But now we're at a point where we are questioning whether it is true that everyone who has a different-than-heteronormative or cisgendered identity has a psychological problem at all. In fact, the current DSM lists "gender dysphoria" to describe those who are trans, basically. The International Classification of Diseases 11 (ICD-11) that's coming out from the WHO, will be using the term "gender incongruence," and they are taking this label out of the psychiatric section and putting it into the sexual health category.

For the first time, we’re going to see a dramatic shift in de-pathologizing transgender identity

There are several reports, including ones published by SAMHSA in 2015 and documents from the American Psychological Association concluding that differences in sexual orientation and gender identity are normal variations. There is no presumption of psychological disorder.

Interestingly, there is a task force on gender dysphoria constituted by the American Psychiatric Association. They are going to be looking at the disparity between the DSM, which does in effect pathologize trans identity, and the ICD. It is going to be a challenge to reconcile those differences. I predict that the APA will come into agreement or alignment with the rest of the world, which uses the ICD and not the DSM. For the first time, we’re going to see a dramatic shift in de-pathologizing transgender identity. And I, for one, am welcoming that change.

LR: If a transgender client visits a therapist who's not particularly experienced in transgender issues, and presents with issues seemingly unrelated to gender such as anxiety, depression or even sexuality; is it a mistake for the therapist to assume that these other non-gender-related issues are the cause?

EA: I think assumptions of any kind about etiology are always suspect. I think we must examine our own biases and expectations. A co-occurring disorder is simply that. It may be a contributing factor to distress about gender identity. Gender dysphoria often is reflected in interpersonal conflict and anxiety, sometimes depression. But it isn't necessary to treat them separately. It also is a mistake to assume that they're related in some systematic way.

LR: Some argue that therapists need not have personal experiences similar to a client’s in order to be empathetic. How does that apply here?

EA: On the one hand, I think sometimes we take therapist-client matching a little too far. On listservs here in the Bay Area, requests for referrals to therapists usually list eight or ten characteristics that they're trying to match up. I think to myself, “whatever happened to general training and the recognition of one's competencies or limitations?” However, I also think that this is an area that one shouldn't enter cavalierly. There is a limit on the empathy that a cisgender person can have towards a transgender person. The level of complexity and the extent of personal transformation that happens when someone comes to terms with a trans identity and then embarks on a gender transition is so complete that it's hard to explain simply, and it's certainly hard to imagine.

I hear all the time lay and professional people alike, saying, "I don't understand how this person can be trans. I knew them before. There was no hint of an identity other than sex assigned at birth. I don’t understand." And I say all the time that it's not so important that you understand. What is important is that you accept that this is a deeply felt identity by this person. And if they are disclosing it to other people, they've probably been struggling with it for a long time. In fact, it's well established that, at least until now, transgender people in American society have suffered trauma and continue to suffer trauma, and some more than others. I believe that if you've been transgender for more than 15 minutes, you probably have complex trauma. And that's a joke. Thank you for laughing. Because nobody is transgender for 15 minutes or three weeks or a month. It's a long, long thing.

There's another controversy in that regard that is currently swirling. There's a term being thrown around, which is not a scientific term: rapid onset gender dysphoria. Have you heard that term?

Families in Transition

LR: No. Is that like acute stress disorder affecting gender?

EA: It's a term made up by parents who are concerned that their teenage children are asserting a trans identity from out of the blue. They are worried that there's some kind of social contagion going on with teenagers where it's cool to be trans. More kids are trans than ever before, and they wonder if maybe they catch it from each other. But

I can assure you, transgender identity is not something one catches. It's not infectious

I can assure you, transgender identity is not something one catches. It's not infectious.

LR: Toilet seats and door knobs won't do it?

EA: Nope, won't do it at all. Even sexual contact between two consenting adults will not affect someone with a transgender identity. But this term has been thrown around. And one of the key issues is that teenagers, as they always have, talk with each other about things that they don’t talk with their parents about. And so they're exploring this with each other. And now we have the Internet, so they're going online and finding out all kinds of stuff, and they have friends online, and so forth. They explore for a while, and they get affirmed by their peers, and they draw their own conclusions, and then maybe they tell their parents, "I think I'm trans." The parents are, in some cases, surprised. In many cases, they're not, because there were indications earlier in the life of this child. But for those who are totally surprised, they think this is a recent phenomenon. But in reality, probably it has been percolating with this child for a while, and finally they come forward.

One of the issues for us in evaluating kids, though, is to be cautious about offering medical interventions—you know, puberty blockers or hormones, certainly surgery—until we're pretty satisfied that this really is an enduring identity of this person, and that it's the right thing, it's affirming of them, and it's medical necessary. I work at the Child and Adolescent Gender Clinic at UCSF and we see kids and their families, all ages, young children, preschool children to older teenagers and young adults. And as I was saying earlier in our conversation today, there's no one narrative, there's no one pathway that explains everybody. So, we have to be cautious where there isn't an obvious track record of development of a gender different than the assigned sex. But it doesn't necessarily rule out the legitimacy of it. It may mean that we'll have to have a longer period of observation than with some other kids, where it's quite obvious to everybody that this is a trans kid.

LR: I wonder if there's a correlation in the literature between children with rapid onset transgender disorder and parental unawareness disorder?

EA: Yeah, that's a good one. Certain parents, as you were implying by your very cute comment, find it harder to accept the reality of a child whose identity is very different than what they expect. They may have somewhat rigid views of sex and gender, and they may subscribe to the dominant gender schema of binary, and they may be, as you say, unaware of the fact that gay and trans people have been around throughout human history.

LR: How can therapists help parents enter the conversation once the kid or teen begins talking about it, even though it may have been evolving for years?

EA: Some of the basic principles that have peppered our conversation so far are relevant here, and that is, as a therapist, try to avoid bringing your own bias into the situation or the conversation. Try to maintain an open mind and be focused around listening carefully to the various people. Everyone in the family—no matter what kind of family, if it's a traditional heterosexual couple with kids or whether it's any one of the many versions of "modern family"—is coming at this from a different perspective. The

older people are coming at it having grown up in an era that was less open and less aware of some of these issues

older people are coming at it having grown up in an era that was less open and less aware of some of these issues. Kids may be bringing their own perspective, which could be quite spontaneous and quite free and quite direct. And so we need to listen to each other.

The word that's often bandied around and disregarded is "transition." A trans person goes through a transition of sorts to bring their life and even their body into consistency with their identity. Everybody gets that. But everyone else around that person is also going through a transition, and it's very uneven. Some resist it, some embrace it, and some are more troubled by it than others. Literally, I've had parents of teenagers cry in the consulting room, saying, "I thought I had a daughter, and I guess I have a son, but now I'm grieving the loss of my daughter." Or the other way around, "I thought I had a son, and now I know I have a daughter, but I'm grieving the loss of my son." These are very personal and poignant moments when someone is really trying to come to terms with the reality of what's going on. It's a very tender time and we have to be kind to each other about what we're going through.

LR: Everyone is in transition and may have been struggling to come out of their own mental closets in acknowledging and embracing that their child or their teen has been struggling for so long.

EA: Every family is different. There are some themes that are common and that are often shared, but the nuance can be so subtle and important. I had a trans teenager in my consulting room last night, and we were talking about the resistance of their mother to their identity and the struggles that this teenager has had for years with a mother who has not found it easy to accept her child on the child's terms. It was really quite a pivotal moment in my work with this young person in that they disclosed for the first time the extent of verbal abuse that their mother had given to them throughout the years. And the child's efforts to cope with this meant that they kind of shut down and are currently afraid of going forward with transition, because they’re worried that their mother is going to say, "I can't accept this," and that their father would side with the mother. And my client is saying to me, "I'm worried they're going to kick me out. They're going to kick me out of the house."

LR: So, these kids are sometimes put in the position of bearing the burden of holding the family together or reducing conflict by remaining silent? You must be so skilled as a therapist to address this once you open yourself up to the systemic and contextual nature of it.

EA: It's a challenging thing. But in the case of this young person, critical. I have to address the dynamics between the parents and between the parents and this teenager because they’re really hurting.

Complicating Issues

LR: You were just talking about transitioning, so I'm wondering if there are different clinical needs for clients who are in surgical transition as opposed to those who, for whatever reason—health, finance or choice—can't or don’t pursue surgical transition?

EA: Each of the phases of the transition has its own set of challenges. One of the things that I'm impressed with by those who get surgery is that the characteristics of the person are all-important. So, if they're healthy, have realistic expectations and a good surgeon, they have a good result and there are no consequences. That's one process. Another might be someone who has health issues, who might be a little more likely to have some kind of untoward consequence of a surgical procedure and are then frustrated afterward because their recovery is a little choppy, and maybe the result isn't exactly what they had hoped.

The differences between people are clear. Historically, surgery has been largely confined to adults 18 and over. But more and more, the trans kids that we're working with whose identity is clear at a young age and who have been on puberty blockers and cross-sex hormones as young teenagers, are getting surgery in their teenage years. This is, of course, with the full consent of their parents when everyone agrees that it's medically indicated.

These kids are being given a gift that someone in that situation a generation ago would never have had

These kids are being given a gift that someone in that situation a generation ago would never have had, which is to avoid some of the life experience in the gender they don’t want, and some of the physical changes in their body that they're not completely comfortable with. They're able to move ahead with their physical transition in such a way that by the time they're in middle to late teenage years, they're fully embodied as the person they see themselves to be and the gender that they assert. From that point on, all their experience is in that gender. So, they go to college and the people at college only know them that way. They've done their name and legal gender change, and so forth. That's a whole interesting set of patients.

By contrast, you also have people who are married, have children, have started a career or are deep into a career, and then they come to terms with who they are, and they transition. And I'm thinking of two people I’m currently working with who were assigned as male at birth. They are in their 30s and 40s, married with children, going ahead with the transition and all the complications that you would expect based on having to deal with the reaction of the spouse, the children and the people in their professional world. It's a whole different set of issues.

The Psychologist’s Role

LR: More and more, psychologists are being called on by doctors who are working with patients contemplating anything from gastric bypass surgery to—I don't know if I'm using the right word—gender reassignment?

EA: Currently, gender confirmation surgery.

LR: Thanks. These psychologists are being called on to perform evaluations to provide physicians with concrete validation that this person is psychologically ready for surgery. Do you have any recommendations for these psychologists?

EA: There are guidelines for this, we call such reports "letters of support." They're really what you and I would consider evaluation reports. They are a review of this person, their history, any co-occurring issues, and their life circumstances. In addition, as we would agree, a necessary part of this is essentially the informed consent, you know, to talk through what is going to happen with this surgery by a skilled surgeon who is well trained and experienced with this procedure. And then, does the person really understand the risks and the benefits of this surgical procedure? And what are their expectations of what it's going to be like for them after they have this surgery? I was referring to that earlier today as we were talking about how realistic the person’s expectations are about surgery.

Most people who think about gender confirmation surgery have done extensive research on it. So, I find that—maybe it's a selection bias—the people who come to me are those who are a little more sophisticated. But I must satisfy myself that they've gone through that process, and that they've asked and had answered all the questions that they have, and that they've thought through whatever the likely consequences are, and they've considered the possible unexpected consequences. And if they have, if we've done all of that, and if there isn't an outstanding psychological issue or an acute psychiatric problem, then I'm inclined to write the letter and say, yes, I recommend that this is medically necessary for this patient.

Surgeons do require such letters still, at least according to the standard of practice. There is an organization called WPATH, that has standards of care, currently in its seventh edition. These are standards of care for medical and psychological service to trans people. The 8th edition is currently under preparation. And just like everything else that we're talking about today, things are moving in the direction of de-pathologizing. The question in the future will be, "What is the purpose of the evaluation? Is it to screen for any contraindications? Is it to satisfy the psychologist and the surgeon that this person is a good candidate for this surgery?” Those are open questions as far as I'm concerned. But I do believe that because of the wide-sweeping consequences of a gender transition—and if you add into it gender surgery which is irreversible—that performing these evaluations requires serious skill and should not be done lightly.

LR: Therapists and clinicians want to render the most competent services in a way that is correct, ethical and moral. So, it's not just laying a quick MMPI on someone and saying, "Yeah, ready to cut."

EA: Exactly.

Closing Thoughts

LR: What should therapists be wary of within themselves when working with clients who are either contemplating surgery or thinking and feeling deeply about gender identity?

EA: I have been doing a lot of thinking in the last few years about our whole paradigm of transference and countertransference, and how that might need to be adjusted for work with transgender people., I myself am transgender. I ask myself all the time, "Do I bring any bias to my work with an individual client or patient?" I try not to, of course. But, in a slightly different way, I know that some people come to see me not only because I'm a qualified psychologist, but because I'm trans. They want to know about me and will ask me personal questions which is historically seen as being out of bounds. And I wonder, how is that related to transference or not?

My inclination is that if client questions are not too deeply personal—nobody asks me about my sex life—I will answer them.

My inclination is that if client questions are not too deeply personal—nobody asks me about my sex life—I will answer them. These include questions like, "What is it like to go through hormone changes? What happens in the surgery?" And I will selectively tell them a little bit about me, because it does reassure them. It's kind of like, "Oh, yeah, she went through this, so I can do that too."

Some of the questions therapists can ask themselves could include, “What are you bringing to that discussion with someone? Do you really have empathy for what they're going through? Do you have a bias? Have you examined your perspective about this?” I think the therapeutic pitfalls are to assume that someone is too young to decide, to assume that someone is neglecting their family responsibilities if they transition and they're married with a family, to assume that someone is not going to be able to have sex if they change their body. There are a lot of potential assumptions, and we just have to be careful not to hold them because we have a bias.

LR: So, the same general concerns about countertransference, self-disclosure, presumptions and biases, but a little bit more finely tuned to the needs of clients who are in transition.

EA: I am concerned that therapists who are relatively inexperienced in this area may have a hard time parsing the co-occurring disorders. And so they might think, "Okay, we can't go ahead with hormones or anything else, or certainly not transition, until we deal with your depression. And we've got to cure all your psychological problems before I feel comfortable encouraging you to go ahead." That is, in my judgment, a mistake, and often kind of a rookie mistake. I think the literature on co-occurring disorders suggests that there are many situations where we treat concurrently, not consecutively. To pretend that we can separate aspects of a human being and treat one part and ignore the other or set aside the other for a while doesn't work very well in this area.

LR: We can’t surgically remove pieces of pathology, revealing the true issues—it is simplistic and naïve.

EA: Here's the challenge! We have inadequate empirical bases for a lot of the things that we're doing. We're doing what we're doing based on the data we do have. This includes longitudinal information we have about patients, comparing and contrasting patients who do well and patients who don’t do as well, and bringing into our work in this area what we know about other clinical challenges. If we waited until we had long-term treatment outcome studies on all these things, there would be a lot of people who would struggle.

As you know, the rate of suicidal ideation and suicide attempts is very high in trans people. So, we're going to lose a lot of people if we deny treatment to trans people until we have what the rigorous scientists consider to be adequate empirical justification for what we're doing. There is a five-year research study going on at UCSF, one of four sites for a multi-site NIH study of transgender kids and the first of its kind. But that's a five-year study. The research is looking at both medical and psychological factors having to do with how kids do when they go on puberty blockers and how kids do when they go on cross-sex hormones. And in five to ten years, we'll have some data that will help illuminate what we're doing.

Hopefully it's going to confirm what we think we know about best practices with kids. We're one of the more advanced centers in terms of embracing what we call the gender affirmative model. We're very interested in affirming kids and their gender, and not putting roadblocks in their way to living authentically. We work hard to reach consensus about the truth about any individual kid, and then a consensus about what we know about this kid and what we are going to do. We ask important questions including, “What's the timing of various things? Are we holding off on things for specific reasons?” It's a very individual matter with both kids and older patients and it’s about crafting a plan for the gender journey heading towards transition. It is about trying to responsibly approach each of the potential decisions and make the best decision that we can at the time based on what we know for each patient. And that is, I think, a sound approach, but it isn't necessarily justified by empirical findings.

Gender identity isn't something that easily lends itself to measurement. Earlier, you invoked the Minnesota Multiphasic Personality Inventory (MMPI). I was at the University of Minnesota for a number of years, and I interpreted thousands of MMPIs. I don't know that we're going to ever have, at least in my career, any kind of test for who's trans and who isn't, or what level of trans-ness exists, and, oh, this means that they should proceed at this kind of pace in terms of decisions regarding medical supports for identity.

LR: You're a transgender woman. How has your own personal journey prepared you to work as a therapist? No easy question, right?

EA: Like most of us who have been psychologists or therapists for a long time, every chapter in our lives does inform who we are and gives us insight into how life is for other people. I emphatically believe that I could not do what I do without incorporating some of what I've learned about myself and the world.

I will tell you that it is amazing to have lived as a man in society and now live as a woman in society

I will tell you that it is amazing to have lived as a man in society and now live as a woman in society. Sometimes I joke with other women and say, “I’m on our team now, and I get it. I get what it's like to be treated differently by men.” I had another interview recently in which I was “mansplained” many times. It's really hilarious when I get mansplained.

The subtlety of what I've experienced is not lost on me or some of my clients in that I know what the experiential aspects of this are, exquisitely! And although I didn't keep a careful journal of what I went through, I remember many aspects of it very, very clearly. I sometimes bring this subjective understanding into my work. I'm sure you could appreciate this. Sometimes, when my clients or patients are really struggling, I lean in, and say, "You know, I really do understand what you're going through, and I want to help you." And they realize that I'm being honest and direct about it, and it means something to them.

I'll tell you one other little anecdote which is kind of special for me. When I see trans kids at the UCSF clinic, I'll say to them, "Do you know any other trans kids?" Sometimes they shake their head, and say, "No, I don't know any other transgender kids." I'll then say, "Well, do you know any other transgender adults?" They'll shake their head, and say, "No, I don’t know any other transgender adults." I look at them and say, "Well, honey, you can't say that anymore, because I'm trans." Their eyes get big, their jaws drop. Sometimes they gasp, sometimes they break into a big smile. And it's such a sweet, special moment for me. Sometimes the parents are not surprised and other times they say, "Really?" And then they say to their child, "See, honey, you can be a doctor. You can have a good life." And I feel, in that moment, like this is a gift to me, to be there with that child.

LR: A gift to you, indeed. I was reading a book by Fred Rogers who quoted someone something along the lines of, "You're not just your age; you're every age you've ever been." And that makes me think of what you just said. You're not just your gender; you're every gender you've ever been.

EA: Yep!

Having the Hard Conversations in Sport

Posted on February 18, 2019February 11, 2026 by Psychotherapy.net Team

We watch what seem to be superhuman feats of athletic performance on TV and hear about the dedicated efforts and sacrifices it took for these elite performers to achieve the impossible. While these feats may, in fact, be extraordinary, the people performing them may also be struggling with real-life issues like any other individual who turns to psychotherapy. This was a major takeaway during my masters training when I studied counseling psychology with an emphasis on sports at the University of Missouri.

With a desire to delve more deeply into the complexity that exists at the intersection of mental health and athletic performance, I sought doctoral training, and am currently in my third year of the Counseling Psychology program at the University of Wisconsin-Milwaukee. I also am the mental conditioning coach at a local high school, which is how I met Brian, a football standout. I want to provide a glimpse into the lived experience of a student-athlete whose concerns fall outside of stats and figures, and instead in the realm of mental health.

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It’s 5 o’clock on Friday. Many have been looking forward to this all week, and the time has finally come. Some can’t wait to get home and unwind for the weekend, while others look forward to going out. If you’re in high school, there’s a good chance you’ll end up at a football game around 7 to watch your team play under those Friday night lights.

Society has a fascination with sports. People sit around for hours sharing their athletic feats that range from avoiding the gym class mile to their time playing in college. We’re willing to pay a lot of money to see our favorite teams play, and parents put hard-earned miles on the family car to drive their kids to practices and games. Sometimes, sports are associated with enjoyment and growth, while other times it’s fraught with pressure and anxiety. The student-athlete suiting up to hit the gridiron is exempt from neither.

“Hey coach, can we talk?”

This all too common question from a student-athlete to their coach could result in any number of conversations. Am I traveling this weekend? What’s the workout tomorrow? How’s recruiting going? Sometimes, these questions are geared toward acquiring information, while other times, they’re intended to start a conversation about something much deeper.

When Brian approached me that night, the fall chill still hanging in the air after a tough mid-season loss, I could tell the look on his face meant one of those heavy conversations was about to begin. “It’s just been really hard lately.”

Almost immediately, his eyes welled up with tears and Brian, the otherwise outspoken leader and all around tough-guy, opened up about his difficulty coping with the divorce of his parents. Things had not been alright for a while, and Brian was finding it difficult to manage the myriad of emotions that seemed to come and go without warning.

Brian opened up about expectations from coaches, parents and himself and how as a result, he was no longer having fun, wanted to quit the team and stop working out altogether. He even shared that he had previously considered taking his own life. We walked and talked for a while, and Brian shared his gratitude for having someone to listen to the painful feelings he was expressing, who saw him as a person rather than only as the blue-chip recruit the media made him out to be. Before we parted ways, Brian denied a current plan or intent to end his life, and agreed to stop by to see the school counselor on Monday.

Win or lose, the result of competition is often met with critique—from fellow athletes, coaches, and the public. Newspaper columns share stats and opinions about athletic performance, and interviews about last week’s performance are nitpicked until the next big news story hits. If the internal experience of the athlete is explored, it’s often approached from a mental performance perspective as opposed to one grounded in a genuine interest in their mental health and wellbeing.

The brutal nature of the win-loss column is characterized by attempts to tell the tale of the game, but numbers cannot always recount a personal best, or growth, or even effort. The numbers can’t tell the story of the internal battles and triumphs plaguing the minds of 1.7 million high school student-athletes nationwide.

While I may be somewhat qualified by virtue of my ongoing training in sports psychology and my years studying the complexity of optimal human performance and wellbeing, that talk with Brian could have been held by anyone with a genuine concern for who he was beneath the helmet and shoulder pads. All we did that night after a gutting loss to a cross-town rival was have a conversation. Person to person, and of course, I had the wherewithal to refer him to a professional counselor.

That night Brian had someone to talk to, and today he’s back out at practice trying to improve his skill in the game he loves, along with his mental health in the course of a painful family-life transition. We all know someone like Brian, whether that above-average skill is in sport, academics or the boardroom. They may not share their concerns with us, but those concerns may be impacting their life in a paramount way—unless we have those tough conversations.

When I think back to that conversation with Brian, I realize that the experience helped to shape the way I see the role of a sports psychologist working to improve either mental health or mental performance. It helped to deepen my belief that sometimes we need to take a step back from the game and slow down. We need to take a moment to check in with the student-athlete, who may be concerned about far more than the outcome of the next game or whether they will earn that free ride to college sports celebrity. Next time the question of, “Hey Coach, can we talk?” comes up, I’ll think back to Brian, even if the question is only about the game.

Language as Boundary

Posted on February 12, 2019February 11, 2026 by Psychotherapy.net Team

A Child of Tongues

In the post-Soviet world, boundaries were scarce. Growing up in the Russia of the 1990s, I had a heightened awareness of crumbling walls. Though that time felt mainly liberating, it was also scary; many of us felt unsafe in this new suddenly-turned-turbulent, wall-less world.

Unsurprisingly, in the same 1990s, learning foreign languages became the most obvious and appealing choice for many Russian youngsters, myself included. It was our way of pushing the barriers. “When I proudly announced to my father that I would pursue studying linguistics, he bursted out in anger” saying that languages were futile and would not give me any tangible skills. Growing up in the Soviet Union, my father had never had an opportunity to master a foreign language. This skill was not on the state’s agenda for its citizens, probably another means of keeping the iron curtain in place. In the most classical Ivan Turgenev way, what was the most liberating and empowering choice for me reminded my father of his own inability to speak any tongue other than his own, naturally triggering a feeling of shame.

Jhumpa Lahiri, an American writer of Bengali origin, reflects on her relationship with Italian, a language that she learned later in life and adopted for her writing. Her love affair with Italian resonates with my own feelings about speaking other languages and abounds in separations—shut doors, locked gates, permeable skin: “A new language, Italian, covers me like a kind of bark. I remain inside: renewed, trapped, relieved, uncomfortable.” This sensitivity to separateness is familiar to many of my multilingual clients who evolve on cultural boundaries and countries’ frontiers.

Language as Boundary

I have ended up practicing psychotherapy in three languages that were not originally mine; and through dialogues with my displaced clients, I have realized that learning a foreign tongue not only opens new doors but, in some cases, also becomes a way of installing a boundary where there was none.

In environments where we must put up with an intrusive parent who does not respect our boundaries, or with a totalitarian state that scrambles our personal space, we survive in different ways. Some make inner safe spaces of creativity, like my artist father; others actively rebel and flee to a different land, like many of my emigrant clients and myself. When leaving is the only way to develop better boundaries with the original context and with others, mastering a new language becomes a crucial step towards this goal.

“Much of my therapy work with displaced individuals happens through video conferencing”, thus we keep our regular sessions even when they return to visit their parents for holidays. As they connect “from home,” they sometimes choose to use their second language (when we share one), in order to protect their privacy from their family members. These sessions open a window to their original context—a concrete opportunity for me to get a sense of the place which they come from.

This way, I get to enter vibrant Indian houses filled with the whir of fans; small Russian kitchens where I can nearly smell the sour cabbage soup of my childhood; Victorian manors straight out of British novels; and other colorful contexts in which my clients were brought up. In such situations, the language that they have acquired later in life acts as a shield protecting them from the intrusiveness of their home; something that was not possible for them during their childhood.

The Case of Andrey

In the case of Andrey, the first and only session we had in English offered a fascinating opportunity to reflect on his past. Andrey was a Russian violin player who had made a life in the United States. He came to therapy because of his feelings of shame about his failure to find stable orchestra work and about his deteriorating marriage.

We started off rather smoothly, as Andrey was able to identify the main reason for his struggles—his incapacity to be emotionally present with others. He was fearing intimacy and had found refuge in music, which now seemed to isolate him from his wife and friends. He would easily blame himself for his shortcomings, never questioning the adequacy or fairness of others, nor the environment itself. Was he unable to secure a stable orchestra appointment because of a lack of talent, or was it due to the competitiveness of the field and bad luck? Despite his multiple prizes and other achievements, it felt clear to Andrey that he was just not good enough.

This tendency to take the blame too quickly and entirely made it difficult to access his real feelings. This was another boundary—a cover up—a way of hiding from the more complex reality in which others failed to meet his needs. I was feeling frustrated with having to constantly point out this unbalance when Andrey decided to go back home for Christmas.

His parents were living in a small town in the very North of Russia. Snow covered much of the industrial squalor for six months in a row, offering an immaculate landscape to those who would dare to go outside; many preferred to contemplate this view from behind a frosted window. Andrey had often felt guilty about not being back home more often, but the trip was complicated and costly.

Just after Christmas, he connected from his parents’ flat, the very one where he had grown up. In the background, I could spot the familiar, trapped-in-the-past decorum of a Russian kitchen. To my surprise, even before I could greet him, Andrey kicked off in English. “My parents are just behind the wall,” he said in a whisper; “so for them, you are an American colleague, and we are talking about a forthcoming concert.” It felt odd to be suddenly transformed into an American musician.

The stigma associated with mental health issues and therapy was still omnipresent in this remote corner of Russia. In order to be able to talk openly, Andrey had to use our shared second language. His English was fluent, but during the first minutes, I had to make an effort to switch off an uncanny voice in my head that offered synchronous translation of his words back to Russian, our usual therapy language.

In Search of Sanctuary

During the session, Andrey recognized that having privacy had always been a struggle when he was a child: his mother always insisted that the doors of their small flat should stay wide open. “Why are you closing the door?” her high-pitched voice would resonate in the small flat every time Andrey would try to isolate himself in his small bedroom.

Maybe she wanted to make sure that her teenage son practiced his violin, or she was just too scared to be alone in front of her own inner realities. Back then, unable to find any space unpolluted by his mother’s intrusive presence, Andrey found refuge in music. She was not a musician, and through interpreting the most rebellious and passionate Romantic pieces, he was able to express his anger, his pain, and his isolation.

With time, this protective boundary turned into a fortified wall, efficiently separating him from others. His wife was bitterly complaining about the lack of intimacy that was haunting their marriage. He found it increasingly strenuous to get out of this space, or to let her in. Their marriage was on the brink of failure.

As Andrey was talking in English from his parents’ kitchen, we managed to recognize his feeling of shame, nurtured by the pressure to succeed that he had always felt. In his native town, the only hope for a brighter future was to work hard and be chosen for the Moscow Conservatorium. His father was a violin teacher in the local music school for children. He was drinking most of the evenings, as a way of escaping his own disappointments. Andrey had always known that he had to become a solo player to realize the dream his parents had instilled in him. But bursting out to the bigger classical music world had come with a price—the competition was such that Andrey had quickly realized that the soloist career was not for him.

During that ‘kitchen session’, Andrey told me how, the day before, he had picked up his grandfather’s old violin inherited by his father. He had not played the family instrument in years. Its sound, smell, and smooth touch brought up so many memories—the first time his father had let him play that violin was after he had successfully passed his music school exam, opening the direct path to Moscow…and freedom. What a pride he felt back then, what a commitment to music! All this had faded away, he had now lost these higher aspirations, after years of teaching American kids in a foreign language that he would never master as he mastered playing violin.

His parents had grown older but had not changed. His father was drinking less, as his health had deteriorated. But he had kept following his son’s artistic career with anguish. His mother was suspicious of his “frivolous” wife (she was French and a dancer). She was also pressuring him about having a grandchild. Andrey strongly suspected that she was eavesdropping from the corridor every time he was speaking to his local friends over the phone.

Andrey was not able to open up to either of them, out of fear of being judged or causing distress. His mother had a habit of crying, slamming doors (only to insist that they remain open later), and threatening him with heart failure. They were totally unaware of his anguish about his unemployment and his collapsing marriage.

“Ironically, Andrey had never been able to share all this in Russian”. The perceived neutrality of the English language may have provided the necessary distance for him to get in touch with the feelings he had previously been avoiding as unacceptable or threatening. What had allowed this shift to happen? Was it the juxtaposition of his original environment (filled with familiar significant objects like the old violin) with the neutrality of his second language that had built a bridge between his younger and adult selves?

In retrospect, Andrey recognized that being able to connect with me from his parents’ place had allowed his adult part (usually pertaining to his “life abroad”) to penetrate his original home. He felt supported and valued by me, as he had never been able to feel at home with his parents.

Maybe the fact that I could understand both facets of his life helped this integration—I was familiar with the peculiar culture of the intimate Russian kitchen conversations. I was also familiar with the intricate dynamics of the broader professional music world. Making links and recognizing echoes between these two realities that constituted his fragmented world, helped Andrey sort through his struggle. After all, he did not really have to endure the continuous pressure of his professional world. This was no promise of a sustainable subsistence. Once he recognized the shortcomings of his original environment, Andrey was finally able to think more creatively about his career and find other less mainstream ways of developing his potential.

Soon after that session, Andrey returned to the United States, and we have never spoken again in English. At the opposite side of the border, our native Russian is a perfect shield to protect our therapy space when his French wife is around. The session in English has remained our shared anchor, a time when we both started to see and understand him better.

The Value of Evidence-Based Treatment That Fails

Posted on February 11, 2019February 11, 2026 by Psychotherapy.net Team

In CBT I Trust

I became a psychotherapist because I wanted to help people feel better. I’m sure all therapists share that motivation. In my master’s program, I learned about cognitive behavioral therapy (CBT), and that no other type of therapy had as much research evidence to support it. I was drawn to its promise of rapid relief from suffering.

I sought out a doctoral program where I could receive specialized training in CBT for depression and anxiety. During my training, I saw firsthand how a few weeks of treatment could lead to big improvements in symptoms—not for everyone, but for many.

As an assistant professor I joined a leading center for the treatment of PTSD and OCD, and I witnessed the power of CBT to reopen lives that had been completely subverted by these conditions. When I found that cognitive and behavioral techniques weren’t always effective, I sought training in mindfulness and acceptance-based approaches. I wanted to be equipped to help everyone who came to me. Just as when I began this journey, I wanted to be a healer.

Later, I added CBT for insomnia so I could treat the frequent sleeping problems I encountered in my work. I began writing about the power of CBT to relieve suffering, first on my blog, then through a co-authored account of recovery from OCD, and then in two self-directed books on CBT techniques. I developed a blog and a podcast under a label that captures cognitive, behavioral and mindfulness-based approaches: “Think Act Be.” I was fully immersed in the evidence-based model, and I continued to be inspired by the successes I witnessed.

And yet I often remembered best the people I couldn’t help—the ones who came to me for a few sessions, or for many months, and never experienced lasting progress. They seemed to feel just as depressed, just as anxious, just as gripped by constant worries or obsessions as they did on the day I first met them. Some felt worse. My inability to help them weighed on me as I felt I’d let them down. Sometimes, when they left my office in obvious emotional pain, I cried at my desk.

Another Form of Healing

My work with Evan comes to mind (details changed to protect his identity). Evan was in his fifties and had been dealing with anxiety, depression, and obsessional thinking for his entire adult life. I introduced the standard CBT and mindfulness-based strategies, which Evan struggled to use. He experienced some relief from the meditations I led him in, but otherwise continued to have debilitatingly severe anxiety and depression. I could have blamed his lack of progress on his infrequent practice between sessions, but I didn’t believe that was the whole story, or even most of it. Whatever the reason, I couldn’t help him find relief.

And yet Evan often expressed his gratitude for everything I did for him. Like what?, I often wondered to myself. On one occasion when he thanked me “for everything,” I told him I wished I could do more to take away his pain. He expressed how much relief he found in our meetings, and particularly in the meditations I led him in and which he diligently recorded for listening between our sessions. “And you listen to me,” he said, “and you don’t give up on me. And I can tell sometimes when we’re talking that you’re feeling what I feel. And that’s huge.”

Many other names and faces stand out from over the years, people whose symptoms I seemed unable to touch. No one ever yelled at me or demanded that I do more to help them. Some expressed frustration at their continued suffering, occasionally directed at me, but most were entirely gracious, even grateful despite our lack of progress. Some even referred their friends or family members to me. It took me several years to realize that some of the deepest work I’ve done as a therapist has been with individuals whose symptoms didn’t improve.

This realization didn’t come until a few years ago as I sat with my friend Jim at his kitchen table. Jim had been battling an aggressive form of cancer for two years and had just learned it had returned. I didn’t realize as we sat there that it was the last time I would see him; Jim died two months later.

What surprised me in our final conversation was the gratitude Jim expressed for his treatment team. I expected he would be disappointed in them; after all, he was receiving the most state-of-the-art cancer treatment in the world, and yet it hadn’t kept his cancer away. I could imagine being bitter if I were in his shoes, and not at all happy to have to return for treatment.

Quite the contrary, Jim described how grateful he was for the care he’d received over the past two years. He noted that his medical team had extended his life, giving him time to put his things in order. He had been given more time with his family than he would have had without treatment. He was dying, and yet he was thankful to those who had done all they could to help him.

And more than the cutting edge care they provided, Jim seemed to appreciate that they cared. Jim wasn’t treated as a cancer case, or a research trial number. He was a complete human being, with a family, with hopes and fears, and likely a foreshortened future. The professionals with whom he worked provided compassionate care right until the end.

When I went through my own debilitating illness—much less severe than Jim’s, I learned what it meant to receive compassionate care. By my count, I saw 13 specialists over a 4-year period, and none of them was able to completely resolve my health problems. And yet most of them provided another form of healing—not of the body and mind, but perhaps of the spirit. I would leave their offices feeling a little less alone, a bit less afraid.

A True Presence

When I was in my late thirties, I was diagnosed with open-angle glaucoma. My optometrist who detected it reassured me that I wasn’t “guaranteed to lose my vision,” but the prospect of going blind hadn’t occurred to me until his reassurance. I didn’t ever want to not be able to see my kids.

The ophthalmologist I was referred to treated me with two rounds of laser surgery in each eye. The first involved boring a hole in the iris, making a tiny second pupil to decrease the dangerously high pressure inside the eye that could destroy the optic nerve. The second was meant to dissolve the blockage in the eye’s drainage ducts, allowing the pressure to return to normal. Unless it wouldn’t!

I learned through my own research that these procedures are effective in about seventy-five percent of patients. Thankfully, mine were successful and my pressures have been in a healthy range for the past few years. But I was struck by the failure rate of this treatment, given how directly it seems to target the root of the problem. Examples like this one abound across medical specialties; whatever the medication or procedure, the success rate of evidence-based interventions is significantly less than one hundred percent.

In light of the limitations of modern medicine, we shouldn’t be surprised at our limits as therapists. And yet many of us are quick to assign blame when a client isn’t showing obvious improvement. Often, we’ll blame the client, assuming there must be personality pathology or that they “don’t want to get better.” We may assume the symptoms bring secondary gain. We might prefer to believe that the treatment is effective, but the client just isn’t ready for change. These factors may be present, but they also have the convenient effect of letting us off the hook. It’s not us, it’s them.

The danger that I found in my own reaction to ineffective treatment was running ahead of the client, as it were, and trying to pull them along. This tendency showed up in things like assigning homework that I knew they weren’t going to complete, so at least I could feel like I was “doing something.” My conscience could be clear. Except it wasn’t, because I knew on a deep level that I wasn’t meeting the person where they were. They needed me to walk alongside them, to sit down with them when they sat to rest. They needed my true presence.

Our presence is what matters most. Otherwise, we would dispense therapy techniques from vending machines, or in fortune cookies. Even self-guided CBT books are written with a personal and encouraging tone. It’s crucial to feel that the guidance is coming not only from someone who is supposedly an authority, but from someone who wants the best for us, who’s in it with us. The relationship with an author matters.

Lessons Learned

I suspect I’m not alone in finding that my eagerness to help is actually unhelpful at times. For example, when Rick told me he felt like his life “hadn’t even been a prelude to anything,” I immediately jumped into cognitive therapist mode. My knee-jerk assumption was that this belief was exaggerated; after all, Rick had done many things in his life–graduated at the top of his high school and college classes, worked abroad, completed law school.

“Is that true?” I asked with skepticism. Immediately I knew I’d missed the mark. Rick wasn’t asking me to change his mind, especially not before he felt I’d really heard him. The truth was that his life hadn’t turned out the way he’d imagined. He’d come close to getting married twice, but never tied the knot, and he never had children. And despite his intelligence and education, his major struggles with anxiety and depression had left him unable to work since a year after he got his law degree. His life consisted mostly of tending to his garden, reading the news, and occasionally seeing a friend.

While I may have been on the lookout for distorted cognitions, on an unconscious emotional level I was motivated to look away from the deep pain expressed in Rick’s statement. It would have been much easier if I could have fixed his thinking and taken away his unhappiness. “See! It’s not that bad,” I wanted to say. But maybe it was. And the life Rick had lived wasn’t a problem I could solve.

As a therapist, I have come to appreciate the importance of remaining with and tolerating my discomfort and feelings of inadequacy, if I am going to serve as a full human being to those I treat. I must make peace with what I can’t change. Otherwise, I run the risk of compelling my clients to fight on two fronts, as they must contend not only with their suffering but with my expectations that there must be a solution.

All of this probably seems patently obvious to many therapists, perhaps especially those from a more psychodynamic background. Maybe my tendencies are specific to CBT, or to me. I do suspect CBT fosters some of the expectation about taking away symptoms, but I imagine some form of that expectation lives in all of us in the healing professions.

Sometimes life-changing work gets done while the symptoms are unchanged. For some that might mean connecting with the strength they have to meet their challenges. Others may discover the life that’s possible even through ongoing struggles. Still others will have their experience validated after a lifetime of being told what they felt wasn’t real or will simply feel less alone.

A Broader Lens

Hopefully it goes without saying that I still want to help people reduce their symptoms, and I want to offer each person all the tools that might be useful. Accepting the limits of my abilities and the value of our presence doesn’t mean I must stop trying to reduce suffering in any way I can. It’s also not a way to settle for less than optimal outcomes for my clients. And it certainly doesn’t mean that I have secret insights into what my clients really came to treatment for and that MY job is somehow to get them there.

I still want everyone I treat to experience less anxiety, better sleep, fewer OCD compulsions, or whatever else they came to me for. I provide referrals when I don’t feel that I have the expertise a person needs. At the same time, I’m trying to use a broader lens through which I see a person’s experience. As physician Rachel Naomi Remen suggests, there is a difference between fixing and healing. This stance isn’t a cop out, as I used to believe—a way to make myself feel better about my lack of skill. Rather, it’s a recognition of the reality that there is pain I cannot take away, and that “treatment success” is a bigger concept than can be easily captured in data from a randomized clinical trial, or from a well-validated self-report measure.

Therapy is as complex as any human relationship, with effects that potentially penetrate much more deeply than the apparent symptoms. The best we can do for anyone is to provide compassionate care until the end, whether that means a triumphant recovery, ruinous tragedy or the wide expanse in between.

I’ve also come to recognize that the end of our time together is not the end of the person’s road to healing. For some the time we spend together will be transformational, while for others there will be no obvious effect. For many others, the work we do together will plant seeds that grow only later, well after therapy has ended. It’s easy for me now to recognize the hubris in believing that the evidence-based therapy I offered was the person’s last hope. Now I know that I’m only ever part of a longer journey.

Hotel Room Therapy

Posted on February 6, 2019February 11, 2026 by Psychotherapy.net Team

As I offer therapy online, many highly mobile and displaced individuals naturally drift into my practice. “We meet in a couchless space unattached to any physical location”, or rather suspended in between the two places—my office perched below the Parisian rooftops and the often-fluid, ever-changing locations of my fidgety clients.

Sometimes they connect for our sessions from a hotel room. I always pay attention to my client’s surrounding—and when an unfamiliar background sparks my curiosity, I naturally inquire into this new place, and we spend some time locating ourselves. The client might tell me about the country or town they are currently in, about this particular hotel or the area.

These “hotel sessions” tend to bring up “a sense of discomfort that resembles lostness—a feeling of displacement, of not-quite-being there,” in the striking words of a wandering writer Anna Badkhen. As a displaced person myself (I grew up in Russia but now live in France), I can easily relate to this feeling, and every time I notice an anonymous hotel room behind my client’s back, my heart sinks in recognition.

Lorraine

One day I stumbled on an essay by Suzanne Joinson dedicated to “hotel melancholia”, and the author’s experience reminded me of so many of my mobile and displaced clients; especially, Lorraine.

“Lorraine’s consultancy work made her travel constantly”. She would usually spend a four-month period in a country, only to then move to the next assignment, always located in a different country, often on a different continent. I cannot remember ever seeing her connecting from any other place than a hotel—she was my quintessential ‘hotel room client.’

Lorraine was in her mid-30s, bright, successful, and extremely lonely. After a few sessions, I finally asked about whether she had a “base.” Lorraine marked a short silence—her beautiful pale face rarely showed any emotion: she did not. Her very few belongings were stored at her parents’ basement in Canada. She had given up on having a home years ago. She travelled light; just a big suitcase and a laptop.

Lorraine lived in hotels, usually big chains—comfortable, impersonal and exactly as Suzanne Joinson describes “it was fun, for a few years, until suddenly it wasn’t.” I came into the picture when the fun had gone. However, Lorraine never complained—it was “not too bad”, and, after all, every couple of months she would be allowed a break to spend a few days elsewhere. These short trips would be just enough to keep her sanity.

In our co-created placeless bubble, we communicated in English—a second language for both of us. We also had French in common, but Lorraine had unequivocally chosen English from our very first email exchange. She confided that she felt more comfortable in this language that she acquired as a teenager when her family relocated to Canada.

“Lorraine was a Third Culture Kid”—brought up by a biracial family in a country that was neither of her parents’ original home. She was half-Korean, half-French.

Why was she in therapy? Sometimes I wondered, as she seemed rather content with her transient life. Talking with her often created a strange cognitive dissonance—I sensed her distinct unhappiness, but she would never verbalize it, never express any deep dissatisfaction or nostalgia for a home or a relationship.

She had friends of course—mostly dispersed all around the globe. She would visit them during her breaks, sometimes for an adventurous holiday, sometimes in their homes in case they were freshly settled and building a family. Strangely, after these trips Lorraine would not express any more desire to settle or to attach than usual. “It was nice,” she would comment.

Lorraine seemed attached to her itinerant lifestyle more than to anybody or anything else. She did not seem to miss her parents. Their presence in her adult life seemed to create more hassle than anything, as they got used to asking her for help in doing their paperwork, relying on their daughter’s indisputable competence. In her constant relocating from one place to another, being able to deal with paperwork efficiently was a question of survival. Efficiency was something Lorraine valued highly. I learned that in her vocabulary “being inefficient,” meant many other things too; like being overwhelmed, exhausted, or emotional.

When she was a child, her family moved a few times for her father’s professional assignments. I never really got a sense of how it was to grow up in her family. She was an incredibly docile child and later a very capable adolescent, never creating problems for her parents. She simply did what she was supposed to do and did it well. She worked hard at school, gained a commendable degree and went on to take a lucrative job. It seems that in her family everything was about efficiency. Her Korean mother was a perfectionist and would get very upset if something was not done exactly how it should be, whilst her French father was hard on people who did not live up to his expectations.

Emotions had little or no place in this family. For somebody as well educated as Lorraine, she had little awareness of her emotions and struggled to name her feelings, usually using the words “bored” or “frustrated” to cover up other emotional experiences.

In therapy, she was hard work for me.

Holidays and Homes

Of course, occasionally she would travel back to Canada to spend Christmas or Easter with her parents. Every time I offered to maintain our session during those holidays, she would decline—too busy with playing catch-ups with family and friends. So, I never had an opportunity to have a glimpse of her childhood home, and my attempts to suggest that such session ‘from home’ would be interesting, never produced results. This house in Canada that she never really described felt ghostly to me, and I wondered if she had the same feelings about it.

Interestingly enough, when her parents retired and decided to sell their family house, Lorraine seemed indifferent. They bought an apartment in the South of France, in the village they used to visit during their European holidays. Wasn’t she sad about her childhood home which contained her memories, her things in the basement, disappearing forever? No, she was not. After all, she always knew her family would never settle there forever. Almost all of her friends from that place had already left and had either settled elsewhere or were travelling around the globe.

Would I feel the same numbness if I was to lose connection with my original town? This thought only fills me with sadness. Even after living all my adult life abroad, I still feel attached to my native Saint Petersburg, where all my childhood memories reside. Lorraine’s displacement was of a different nature; she grew up out of place, with no deep roots in any of the cultures she was surrounded by. The Korean world was only barely familiar to her; she identified herself as French, but even that belonging had some clear limits.

This state of things was going on for quite a while. Lorraine moved from one country to another a few times, and I grew more and more frustrated with the lack of depth that our work was presenting.

Occasionally, I would be travelling too, and also connect for our sessions from a hotel room. The first time this happened, Lorraine looked strangely annoyed. She was even less talkative than usual, and I could sense that something was going on, but as usual she resisted my questions.

“Would your bad mood be linked to my being elsewhere than in my office?” I asked.

She paused, seemingly perplexed. “Maybe.” She was used to seeing on her screen my now familiar background, filled with bookshelves and artwork. The consistency of place that our sessions offered her was actually something that meant a lot to her. That ‘double hotel session’ was not a breakthrough in any spectacular way, but something had shifted, allowing more awareness into her displaced condition.

Several weeks after that session, Lorraine passed through Paris, and we were finally able to meet in person. I always feel a mixture of excitement and apprehension when an online client of mine visits my city, and we plan for an in-person session. Not having a screen between us breaks the settled frame; with some clients it feels like a welcomed change, with others less so. In Lorraine’s case, I was hoping that the encounter could bring some interesting grist to the mill.

Facetime

She sat in front of me; composed, pale as usual and much smaller than I had ever realized—a not unusual surprise of screen relationships. All the semblance of closeness we were able to build online seemed to dissipate. Lorraine was back to her shell.

She was between two assignments, but not for long, and seemed ready, almost eager, to move into the new hotel located somewhere in the Southeastern Asia that was soon to become her “home” for the next four months. She had already checked its situation—it was one of her favorite chains and was equipped with a decent size gym and a swimming pool. She seemed a bit lost, homeless for real, without the hotel room that usually would contain, at least temporarily, her belongings and her life. She made no comments about the area of my office, or about the room that she had seen only on her screen before.

“How do you feel about us being in the same room?”

“Not much, maybe a little uncomfortable.”

She was not used to sharing her room with anybody; she actually never had. Her childhood family home was big enough for everybody to have their own bedroom. They rarely spent time together downstairs, as both parents had their own office space. When she would come home from school, she would usually grab something from the fridge and retreat upstairs, directly to her bedroom.

This was actually the first time Lorraine was sharing some tangible details about her childhood. As she spoke, I could finally picture this big, perfectly organized house surrounded by snow. Her mother loved white lacquered furniture and was always preoccupied about keeping everything in perfect order and maintaining all the surfaces spotless. This was probably the reason why Lorraine was never allowed to invite friends to her house; and none of her birthday parties took place at her home. Her home had always felt like a hotel to her—it was comfortable, clean and temporary. Since a very young age, Lorraine knew that she would leave and go elsewhere. Her childhood was about waiting for this to happen, and now that it had finally happened she did not really know how to live any differently.

Now, as an adult, she had to learn how to develop an attachment, to a place, to a person. Our shared online space was a tentative model; a little relational bubble in which this process hopefully could begin. At this point Lorraine was not ready to fully grasp that the life she had built was as dysfunctional as her childhood. The defensive walls that she had built in the past were still in place, protecting her from the terror of her attachment-less reality.

I chose not to accompany her there, not yet.

Therapy with Latinx DACA Clients and Their Families: A Therapist’s Primer

Posted on January 30, 2019February 11, 2026 by Psychotherapy.net Team

A DACA Primer

Many therapists are unfamiliar with the Deferred Action for Childhood Arrivals (DACA) program and have little experience serving clients and families with DACA status. I lived in Mexico City for almost 3 years, earned my masters degree there, speak Spanish, and have worked with many immigrant families over the last six years, and thus I feel a civic duty to share my experience and knowledge with the psychotherapy community.

DACA is a temporary protected legal status (TPS) created by the Obama Administration in 2012 to protect children from deportation after arriving without legal authorization (usually with undocumented parents). I use the word “undocumented” instead of “illegal,” because “I believe that no human is illegal”. We don’t call a 14-year-old driver “illegal,” or a 17-year-old drinker either. Language matters; we want to use inclusive, respectful and empowering language—after all, as therapists, language is our primary tool to promote healing and change.

There are roughly 800,000 DACA recipients in the U.S. (not including the additional 300,000 who are eligible but don’t have DACA status), approximately 75,000 of whom reside in California, and around 40,000 in San Diego. Most are Latinx, have undocumented parents and have migrated in search of safety and economic opportunities unavailable in their countries of origin. You can also use the term “DACA-mented” to describe the unique experience many DACA-mented folks experience of feeling like a foreigner—unable to access government assistance such as student loans or the vote, yet simultaneously feeling like the U.S. is the only place to call home because most DACA recipients grew up here. It is very important to be aware of how the individuals and families with whom you work self-identify. For example, I have a few female clients who have told me that although they appreciate the term “latinx,” they prefer “Latina” instead to emphasize their pride in being female.

To make matters more complicated for families of DACA status, on September 5, 2017 the Trump Administration canceled the DACA program. Although current recipients can still renew their status every 2 years for $495 plus legal fees, no new applications are being accepted. There is currently no guarantee of permanent residence or citizenship as DACA status only provides a social security number, authorization to work, and a driver license. The future of DACA remains undecided in two pending Federal court cases. Added to this, a majority of DACA recipients have parents who are undocumented, which is terrifying for them given the increasing anti-immigrant sentiment and recent increases in ethnic profiling, detainments, raids, distressing executive orders, and deportations.

Resilience

Clearly this population is at risk and needs competent, knowledgeable and supportive mental health practitioners. DACA families commonly face poverty-stricken households and neighborhoods, PTSD, agoraphobia and depression, and other psychological distress emanating from family separation, and a realistic fear of leaving the home for fear of deportation and societal discrimination. Our job as therapists is to educate, understand, heal and help manage the numerous traumas related to fearing for their own and their family’s future. The exclusionary and dehumanizing messages, xenophobia, and ethnocentrism rampant in the current political rhetoric has contributed to the hyper-vigilance and fear this population faces daily. It’s vital that these families attribute their pain mainly to the adverse events and unjust immigration circumstances instead of to themselves personally. More crimes are committed against undocumented and DACA families than by them. They live and contribute to society the same way that legal citizens do—working, studying and paying taxes. Yet they aren’t afforded the short or long-term security of citizenship, which can be so easily taken for granted. We can’t afford to ignore that one’s immigration and legal status, which in many ways form the bedrock of identity, have become so politicized on the national stage at the expense of the individual caught in the rhetoric.

Although this discrimination can gradually erode physical and mental health for families of DACA status, it’s crucial to recognize and appreciate the resilience that I have witnessed in my clinical work with this is population. Even though health settings tend to focus mainly on the risks and deficits associated with DACA, undocumented and mixed-status families, Latinx DACA recipients and their families, have in my experience been a strong group of people. “Latinx DACA and mixed-status families tend to be hopeful about a better future”, even given the current political climate. Immigration scholar and professor Dr. Carola Suárez-Orozco at UCLA refers to this as “immigrant-optimism.” They also tend to value education and have a robust work-ethic—many are excelling in schools and in their jobs. Moreover, these families tend to be closely-knit and extremely affectionate, loving and supportive, a major sign of strength. Unfortunately, this has been periodically pathologized as “enmeshment” by Western-oriented therapists and other practitioners who are not as knowledgeable about cultural norms and sociopolitical contextual variables affecting our clients.

The resilience doesn’t end there; DACA recipients often benefit from the advantages of being bilingual, binational, and bicultural, which is correlated with increased employability, cognitive flexibility and enhanced capacity for perspective-taking. I have witnessed immense cultural pride, religious and spiritual strength and social support within this population. There is also a present-time orientation—contrasted with the greater emphasis on past and future in the U.S. that helps affected families enjoy and appreciate their time together and to stay closely knit and loving, despite the fear of uncertainty always lurking in the background. Understandably, DACA recipients have reported that “coming out” publicly has been tremendously difficult; many parents coach their children to be furtive with their immigration status for protection and unity. This appears to be very appropriate given the associated risks of “going public.”

Consistently witnessing these families strive, grow stronger, wiser, and more resilient as time passes and therapy progresses, has not only encouraged me to continue this work but has also instilled a sense of vicarious resilience within me. As I mindfully reflect, I feel that I have grown stronger and wiser personally and professionally from continually seeing these families do so time after time. I owe this vicarious resilience to this population’s courage in their work with me. Next, I’ll share a brief snippet of my work with one family. I’m eternally thankful to this family for allowing me to share their story, of course with their identities concealed.

Sergio

Sergio, age 17 and a DACA recipient since 2013, was brought to therapy by his parents, Tina and Jorge, who were concerned that he hadn’t been sleeping or eating well, had been struggling academically, worrying excessively and had become increasingly nervous and irritable. His parents brought him to California when he was 11 months old in search of better economic opportunities. They hired a “Coyote” to cross from Tijuana—fortunately, they were neither abused nor robbed en route which are very common occurrences.

After a careful assessment, Sergio met the diagnostic criteria for Adjustment Disorder with Anxiety. Jorge, his father, had been suddenly detained by ICE (Immigration and Customs Enforcement) when walking from the car to a restaurant where he had planned to dine with his wife and Sergio’s two siblings. Jorge was detained for the night and released in the morning. Sergio remembered experiencing a panic-filled and sleepless night following his father’s detention. Although Jorge was detained only briefly, a court date for the following year was scheduled at which time his deportation would be decided. This only added to his son’s sense of impermanence and anxiety. We don’t currently know the extent to which Jorge’s previous DUI contributed to his arrest or will factor into the court’s impending decision regarding his status. I have collaborated with Jorge’s lawyer in documenting what I considered would be an adverse impact of deportation on Jorge’s family.

Sergio has shared that he constantly worries about “having to be the man of the house” and having to help raise his younger brother and sister if his father is deported. He also worries about his own future in the country since the DACA program was rescinded last year. Because Sergio is old enough to understand and psychologically strong enough and high-functioning, we have collaborated on a “family preparedness plan.” Fortunately, Sergio’s family is closely-knit and resourceful and has supportive relatives in the area who have lent his family money to cover Jorge’s legal fees. Sergio also speaks English and Spanish, a big plus when he enters the job market, and has maintained a 3.84 GPA up to his senior year in high school. We have discussed the traumatic nature of his father’s arrest along with the wider socio-political injustice and hateful rhetoric that have contributed to his symptoms; shifting the narrative from believing something is wrong with him to his anxiety being a normal response to abnormal circumstances. Together, we have highlighted the strengths he’s developed from coping with this uncertainty. We also review mindfulness strategies to embrace the here-and-now, so that he may sleep better, and utilize EMDR to reprocess the horror that periodically torments him from that day.

“It’s essential to emphasize that therapy has significant limitations if wider sociocultural and political influences are not considered in the work”. No therapy can resolve the uncertainty of Jorge’s future in this country with its increasingly strict immigration policies. Helping families talk about injustice in therapy is a step toward effectively managing it. In fact, Sergio shared helpful information with his community such as the app Migrawatch for warnings of any future raids in real-time, which we agree has helped his anxiety symptoms. As Sergio’s therapist, I know that symptom management isn’t enough and realize the importance of opening a dialogue with him and other such clients. I also consider it crucial to share my personal commitment to progressive politics and public advocacy of immigrant rights that have helped Sergio and his family embrace their resilience, and that will hopefully challenge the injustice in his own community.

Therapeutic Tips

Here are some practical tips I hope will be helpful in your own practice if you have the privilege of working with clients like Sergio and his family. Additional information can be found in the article Ten Psychotherapeutic Considerations to Assist Young Undocumented Latinx by LaRoche, Lowy & Rivera⁽¹⁾

Remind them in the informed consent that disclosing their status, is never part of your mandated-reporting requirements, and unwaveringly commit to confidentiality.
Shift problem-saturated narratives around DACA and U.S. immigration-policy toward resilience.
Emphasize their many strengths alluded to above; use them as assets in treatment-planning.
Help families create a “preparedness plan” in the event that a member is suddenly deported, and capitalize on other aspects of their lives that they can control in the here-and-now. This can include appointing guardianship for children and referring families to the “Toolkit for DACA Families” by Chavez-Dueñas and Ademes⁽²⁾. Be careful that although this helps by increasing a sense of power/control, these can initially foster anxiety. The same is true for rehearsals of the plan or confrontation with officials. DACA families have the constitutional right to “remain silent” and contact their lawyers in response to police, ICE, or immigration officers.
Use a genogram to help families understand the current makeup of their transnational extended family. Unlike the generic caucasian nuclear family, Latinx families often include non-blood relatives, who should be included in the “preparedness plan.”
Check your assumptions; don’t assume they speak Spanish because their parents brought them here from Latin America.
Speaking and learning some Spanish is always a plus.
Be bold; don’t only have the LGBTQ pride flag in your office but have the butterfly symbol to show your support for this population.
Remind them that Title IX prohibits discrimination based on ethnicity, nationality, or race for organizations that receive federal funding; DACA recipients arguably are included.
Since these families don’t leave their homes because everything is fine in their native countries, it’s vital to know why they left and their immigration story, which is likely to reflect trauma and separation, and help clients understand and overcome trauma from these adverse experiences.
Encourage families to use the app Migrawatch to see if a raid is taking place
Know the limitations of weekly therapy in helping families cope with intense and chronic immigration stressors and societal discrimination.
Collaborate with a multi-disciplinary group of lawyers and medical doctors.
Use your privilege! Utilize your civic rights to advocate (a good therapist is always a good case manager) and censure deleterious deportation policies through organized protests and rallies, and calling local politicians or elected officials. As therapists, I believe we have a civic duty to advocate for this community and promote sociocultural transformation. As therapists, we cannot be quiet or neutral in the face of the numerous injustices this population faces.

In the words of Dr. Martin Luther King, “In the end, we will remember not the words of our enemies, but the silence of our friends.”

1 https://www.researchgate.net/profile/Martin_La_Roche/publication/322255405_Ten_Psychotherapeutic_Considerations_to_Assist_Young_Undocumented_Latinx/links/5a4e832a458515e71b085836/Ten-Psychotherapeutic-Considerations-to-Assist-Young-Undocumented-Latinx.pdf

2 https://icrace.files.wordpress.com/2018/05/final-immigrant-parent-toolkit.pdf

Teaching Adolescents Mindfulness Using the Morita Therapy Concept

Posted on January 24, 2019February 11, 2026 by Psychotherapy.net Team

Life presents us with many challenges; successes, failures, negative and positive experiences, and everything in between. Usually, when challenges occur, teens try to manage them on their own. As a marriage and family therapist who believes that we all possess the ability to overcome these challenges, helping my young clients to navigate them is particularly rewarding.

I practice and teach mindfulness including the Morita concept, which is about seeing and experiencing things as they are–in Japanese this is referred to as “ARUGAMAMA,” to accept things as they are. I am aware that the only way for me to find out how things will turn out is to begin taking on a challenge despite how anxious I may feel about it.

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Japanese psychiatrist, Masatake Morita stated that the reason why we may feel anxious or scared to take action is because we have a desire to do well. He framed this as “A desire for life.” If we can try not to be overly concerned about the outcome, we may not feel as hesitant to take on challenges. While the Morita concept teaches us to be mindful about our feelings, it does not ask us to forget what we set out to accomplish. We must realize that the process of achieving a goal often does not happen overnight and that the process may involve a series of mundane steps that we must constantly take. While we may not necessary to enjoy the process of meeting our goal, we must not forget there is important value in accomplishing what we set out to achieve.

I recently had several opportunities to discuss this topic with groups of Japanese high school students who were visiting the United States during the summer to learn how to mindfully take on a leadership role. I was asked by their program coordinator to present how I managed to live in the United States as a young Japanese woman and achieve success. I was also asked to share the same mindfulness techniques, including the Morita therapy concept, that I teach my clients when they face life's challenges.

During the discussion with these Japanese students, some realized that it is very natural to experience a spectrum of feelings as they go through life. They told me that they have more positive attitudes when taking small steps to achieve a goal rather than focusing on one big action. These students learned that life will continue regardless of how they felt in the process, and in fact, many of them already did take an action regardless of how they felt, in order to achieve their goals.

As part of my PowerPoint presentation, I discussed how my life was full of both failures and achievements. I was not aware of the Morita concept when I was a young student, so I gained the necessary life skills the hard way in order to persevere after failure. After my presentation, I asked these students to participate in a short activity to demonstrate how they could pull themselves together in a challenging situation that I created for them. As they struggled to figure out how to achieve their goals, they acknowledged their negative feelings, struggled, contemplated with their fellow students, came together to support each other and laughed when they were able to work through their challenges even though they did not feel empowered during the process. I was impressed with their ability to overcome how they were feeling by reminding themselves of their purpose. It was a powerful experience for me as well to witness the shift in their mindset and see how they were feeling at the end as well.

I thought it was ironic that my teaching of mindfulness, which is rooted in Japanese culture and specifically in Buddhist philosophy, to these young Japanese students was taking place in the United States. In other words, they came all the way to the United States to learn something from their own culture.

As they go through life, I sincerely hope these students remember the Morita concept when they face a challenge and can use it to help them in managing their response to their difficult feelings. After all, it is natural to feel bad when we must do something that we are not enthusiastic about, even though it is necessary in order to achieve a goal. Acknowledging all the feelings as they are, “ARUGAMAMA,” frees us from the need to fight them. We just must find a small action that we feel comfortable enough to take today, tomorrow and every day until we reach what we set out to accomplish.

For a small mindfulness activity suggestion, you may want to discuss the following with your teen clients:

Is it true that you must feel good in order to tackle our challenging or new tasks? Why?
Explore what your anxious feeling is trying to tell you? Why is it there?
Can you be worried about tomorrow and experience what’s present at the same time? How so?
How can you be mindful when you face challenges?
What is your goal or value in life and your current tasks?

Janelle Johnson on College Counseling

Posted on January 23, 2019February 11, 2026 by Psychotherapy.net Team

The Clinical Landscape

Lawrence Rubin: You’ve dedicated your career to college counseling, working with students who appear to experience many of the same problems clinicians encounter in outpatient clinics, crisis centers, and substance abuse facilities. Are college counseling centers microcosms for the clinical world outside of the campus?

Janelle Johnson: I would definitely say what we’re seeing at community colleges and at universities around the United States is reflective of what’s going on in the nation

LR: Can you give me some examples?

JJ: There has been a trend where colleges have been able to provide more support services so students can attend. In the past, these students were not able to attend because of a diagnosis or not having the right medication. They couldn’t perform in college. But now we see a lot of students coming that have schizophrenia or bipolar disorder and we have disability accessibility services to help them. Here at our college,

one third of the students we see are diagnosed with a mental health disability rather than a physical or learning disability

one third of the students we see are diagnosed with a mental health disability rather than a physical or learning disability.

LR: So, they come in with previously diagnosed mental health conditions which may run the gamut from adjustment and anxiety disorders all the way out to schizophrenia?

JJ: Absolutely. We see students every day that may have a lifelong diagnosis, who are able to come to college now, but they need resources around their diagnosis. Student counseling services often try to work with their outside providers because we see ourselves as providing supportive counseling. At larger universities, there is access to medical providers to help with monitoring medications. It depends on what your setting is at your school. If a college center does not have a medical provider, then we obtain a release, so we can actually work with a psychiatrist or a therapist that’s not on the campus, especially when it comes to monitoring medications for more serious diagnoses.

Emerging Adults

LR: So, these students that you’re seeing who have come with diagnoses are accustomed to being in treatment, are they open to being referred back into the community, even after they’re in a college counseling setting, or do they hope the counseling center will give them all they need?

JJ: That’s a very interesting question. It depends on their maturity level and how they’ve worked with medications in the past. Even with a seemingly simple diagnosis like ADHD students will often say, “I had these accommodations in high school. They sent me to a counselor.” Perhaps they had more of a medical professional do an assessment. But they come to college with the idea “well I’m in college now, I don’t need any of this.” I think most colleges experience students who come to college and try to maintain, but whatever their diagnosis is we also know that this is an age where certain mental illnesses start to show up.

Sometimes there’s an incident that brings a student like this to the counseling center where, depending upon its size, they may be able to receive an assessment. Large schools like the University of North Carolina has around 30 people on staff with psychiatrists, licensed psychologists and licensed counselors. But in a smaller private school or community college, we send them out into the community for some type of assessment or we refer them back to professionals they may have seen in the past

LR: So, a third of the students who visit the counseling center come with a previous diagnosis and may be accustomed to treatment, and they may be receptive to referrals back out into the community. What about the other two thirds? The ones who come to you and may not realize that they’re struggling or may have an emergent psychiatric disorder. How do you hook them?

JJ: What we see, especially with younger students, is emerging adulthood—that transition where they’re starting to be responsible for themselves. We try to talk to them about how they want to live their lives and how they want to express themselves as adults. In the past, when there have been mental health issues, a lot of that push either came from the parents or the school. Whereas in college, I think one of the mental health hooks that we offer them is saying, “you know, these are decisions you can make yourself. How do you want to be?” We give them some options as compared to the past where they were told what to do.

I’ve met a lot of students who were actually on medications for ADHD or who were taking antidepressants. Their parents said to them, “oh, you don’t need this anymore” and took them off. They were in that gray area of not functioning that well but having that parental oversight to get things done. And

then they come to college, and without their medications or follow up, the parents just expect them to do well, but they don’t

then they come to college, and without their medications or follow up, the parents just expect them to do well, but they don’t.

LR: So, these are emerging adults with whom you try to work developmentally around taking responsibility and seeking resources, which sometimes helps them to reach out for and effectively use treatment.

JJ: Yes, and at the community college level, we try to partner with community agencies so oftentimes, we can make those referrals right in our office with the student sitting here. We can put the student on the phone and facilitate appointments.

Getting Them Hooked

LR: So, you may actually be the frontline for these kids. Do you find that some of these students are resistant to the services that you provide? Or resistant to being referred out for more serious problems that they may not even think they have?

JJ: Yes, I think that we do see some resistance. The BITs (behavior intervention teams) or campus care teams sometimes need to intervene when students become disruptive in the classroom learning setting. We talk to them and try to engage them in counseling. Faculty and other students try to be patient, but I think when a student becomes disruptive, we try to figure out what’s going because we tell them that they are jeopardizing their ability to be on campus.

LR: It sounds like you have to be a little more heavy-handed or hope that the campus support teams can build enough of a relationship with the student and walk them over to the counseling center.

JJ: That’s absolutely true. You know, some people are very compliant. Other people are interested in finding out what’s going on with them because they may have that feeling like, “I don’t want to keep living like this. I don’t feel good.” But, then other students have a hard time recognizing that their behavior is disruptive or that there’s any issue. It really depends on how they’re supported when they’re at home and then how they’re treated. Sometimes I find students with very high intellectual functioning have their own unique mental health issues. It’s really difficult with some of those students because you can talk to them very intellectually and they can process what you’re saying, but

they feel like treatment is going to somehow interfere with their creativity or their ability to perform in school

they feel like treatment is going to somehow interfere with their creativity or their ability to perform in school.

LR: Is there a specific student that comes to mind?

JJ: A young male student I recently spoke with had a bipolar-one diagnosis and had recently received an ADHD diagnosis. He was watching his peers advancing on to their master’s degrees while he was struggling to complete school—but having this very fatalistic attitude about himself and about his ability to complete. But when you speak to him, when you look at his courses and grades, he’s got As. Schoolwork is not an issue but he lives in this sort of fatalistic place. “Why am I doing this? I’ll never amount to anything. I always fail at everything. Look what all my peers have already done.”

I think oftentimes a student feels overwhelmed on the campus and sort of wanders into our area hoping that someone will speak with them. What we usually do in that case is to obtain a release. We try to follow up to let the outside providers know that perhaps the student is in a downward spiral and perhaps he needs his medications checked.

That’s also where Cognitive Behavioral Therapy (CBT) comes in. It helps the students to look at thoughts that really aren’t helpful—the misconceptions that they have about themselves which sometimes can be very challenging.

LR: Do you get a sense, at least on your campus, that there’s a stigma associated with going to the counseling center or being seen coming out of the counseling center? And if so, how do you address that on campus?

JJ: I have a sense of that most campuses are working really hard with different kinds of programs to remove that stigma around coming to the counseling center. We see different initiatives like the JED and Active Minds programs and peer support groups. I could give an example like suicide prevention. Some campuses do things where they lay out backpacks in the quad for how many students have been lost. And then they have a place where you can come out to honor somebody you’ve lost or write something about yourself—some kind of thing where you can participate. I feel like there is increasing recognition of mental health on campuses and getting help if you need it.

On our campus, in particular, and I think on a lot of campuses, we do classroom outreach. We appeal to students to refer other students to us. Sometimes we find that’s even better than faculty referring students. Staff bring students over. But we find sometimes if your peer, another student says to you, “Oh my gosh, you’re just going through a horrible time. You know there are counseling services here on campus? You know, let me walk you over there or let me show where that’s at.” We find that’s really beneficial.

Challenges of Dual Enrollment

LR: Yours is a two-year college. But there are also high school students on campus. Do you find that these young people have unique clinical problems and challenges?

JJ: We’re seeing a lot of early admission, college dual-credit high schools on campuses. And at Santa Fe Community College we do have a high school right on our campus. It’s even happening at some four-year schools where there’s a high school house. They have some high school teachers and some high school curriculum, but almost immediately students are being placed into college-level classes. What you see happening is

they’re graduating from high schools one day and then receiving either a certificate or an associate’s degree the next

they’re graduating from high schools one day and then receiving either a certificate or an associate’s degree the next.

Regarding the mental health of these particular students, some are very high functioning, very motivated, but some of these students are in this fast-track program because they’ve not done well in the traditional public high school. They’ve had conduct problems or social interaction problems. The parents think, “we’ll take you over here to our college so you’ll be able to take college classes and you’ll be in this high school but it’ll be a lot more flexible for you.” But these students who haven’t performed well in the past may have an inability to follow through and can’t really manage themselves in college. One of our counselors in particular had a student with a very high level of ADHD who didn’t come to the counseling appointments on time. This sort of high school/college program can actually create more anxiety and more unmanageability and adjustment disorders for students.

LR: So, these kids may not be in an appropriate fit for college life just yet?

JJ: Perhaps, but it’s hard to say. What schools are doing with this early college high school programs are really a positive move for a lot of students because I think high school has let a lot of them down. I think high school is a really difficult time for a lot of students because of pressures around social media and bullying. So, being on a college campus really helps them be with other college students who are motivated to get a degree. But there is always the question of whether they are developmentally ready or mentally ready. And while there is a high school counselor here for those particular students, they are spending a lot of time on other things like scheduling and achievement testing.

Addressing Suicide on Campus

LR: Suicide rates are very high in the college-age demographic. How are college counseling centers set up to address that?

JJ: I think a lot of college counseling centers are trying to address that with different kinds of programming. The JED foundation, for example, offers programming for college campuses. Active Minds is another one that offer all kinds of wellness programming for campuses that also addresses suicide prevention. Also the American Foundation on Suicide Prevention in New York.

Suicide is the second-highest cause of death for our demographic.

Suicide is the second-highest cause of death for our demographic. Even if you go up in age a little bit, which is the demographic for a lot of community colleges, then suicide is the third-highest cause of death. So, I think on most campuses we are all actively working with programming and bringing support.

At Santa Fe Community College we actually have a certified faculty member do Mental Health First Aid Training. Mental Health First Aid is a program that originally came out of Australia that has been embraced in the United States. It’s a day-long program for people in the community who are not mental health professionals. Here at Santa Fe, it would be our campus community—our faculty, staff, other students who take the training.

LR: So, when it comes to the more serious disorders, and suicide in particular, it’s critical that college counseling centers work in conjunction with community agencies and have programs on campus so that students are never alone. And neither are college counselors alone because they’re always linked to other resources?

JJ: Right. College counselors work with these different available resources, create their own programming or belong to these organizations that provide free programming.

The idea is to eliminate the stigma, raise awareness and have people participate.

The idea is to eliminate the stigma, raise awareness and have people participate. The campus is a community and we encourage students to participate in these suicide prevention programs and to be part of a campus community that supports helping students reach out. People need to recognize the signs and to be comfortable approaching people.

Disconnected from Families

LR: On a related note, we know that LGBT youth are at particularly high risk for suicide. How do you address the needs of these students?

JJ: A lot of campuses are looking to find ways to support students who are in the process of self-identifying or have someone on their staff assigned to programming in that area who works on removing stigma. In New Mexico, which is a very Catholic state with a lot of immigrants, some of these families persist in saying to their children, “your religion doesn’t accept this. You can’t do this. If you do this, you can’t live with us.” So, we try to work on that by asking these students, “How can you speak with your family? How do you want to live your life?” These students still recognize their religious teachings but don’t want that being used against their identity.

LR: So, you try to work within their families and with the cultural issues that impact their emerging LGBT identities?

JJ: Campuses will either look for programming or design their own programming around supporting these students, and then work with them on these issues in counseling.

A lot of these students actually feel safer on campus than they do at home.

LR: Speaking of unique challenges, what about first-generation college students.

JJ: I do believe they have unique clinical challenges because many of them do not have a history of going to college. Additionally, many of these young people also have to help out financially in their homes. So they live at home, come to college but also work to help pay the rent, the utilities and the car payments. And then there are issues around their transition to adulthood. We help them speak to their parents about what they need to be a successful college student.

Some of them will say “my parents are making me feel like I’m crazy because I need more time to study and I can’t take care of my little brother or pick him up from school every day.” It’s an interesting dynamic that plays into their mental health because when they don’t feel supported or understood at home, they experience anxiety, depression and acting out behaviors. It’s not that families don’t support going to college—they absolutely do. But they don’t know what that means or what it looks like.

Raising Awareness

LR: There’s a lot of research into the short and long-term effects of adverse early childhood experiences and the need for trauma-informed education. The idea is that some of these kids are coming to school with such a heavy trauma burden that they can’t concentrate, can’t relate and are at high risk for drinking or self-harm. Have you seen this on your campus and how do you deal with that?

JJ: There are different kinds of trauma. Here

in New Mexico, we have a lot of Native Americans, so we talk about historical trauma

in New Mexico, we have a lot of Native Americans, so we talk about historical trauma. In addition to these historical events, some of our students come from a background of trauma in their home or in their childhoods. In the college counseling setting, we work with these students around issues of safety, peer support and collaboration—empowering the student to have a voice while they are exploring their issues. We are not dismissing what has happened to them but we’re looking at how the therapy works for them, helping them to move forward with that trauma and not to feel re-traumatized by being in our college setting.

LR: Are drinking and substance abuse significant problems on college campuses?

JJ: We’re not seeing it as much on commuter campuses like ours that do not have housing, although I do think it is a presenting problem in our counseling centers. It’s different on residential campuses, and particularly in the dorms. But we do see students coming to campus who are inebriated, or who have problems that other students are reporting. They may be coming to class and they sound like they’re drunk or other students can smell it on them.

I do think it is an issue that is hard issue to address. College counseling centers try to work with students on maintaining their sobriety. I think if they’re actively using or they can’t even function then it is critical to refer them to treatment center. Another student may binge drink only on weekends and otherwise be high functioning, but it also starts to catch up with them. They may not be getting proper nutrition, or may be having problems with sleep, hygiene or relationships. These effects of drinking begin to interfere with their functioning in the college setting. With these students, we try to talk more about responsible drinking and help them to understand how their drinking interferes with their learning and progress and help them explore how they can be more responsible.

Serving our Veterans

LR: You had mentioned that you have a veteran’s program on campus? Are there unique clinical needs for these students?

JJ: Often college campuses have veteran support centers which provide resources for veterans and their families. These resources include counseling services. Although we are not housed with the veteran’s service center on our campus, veterans know about our counseling services. We also have a veteran’s hospital in Albuquerque, New Mexico, which is about 60 miles away and a veteran's counseling center in Santa Fe.

Our veteran’s center also brings counselors onto our campus about once a week to meet with the veterans. This is not to say that some of the veterans don’t come to our regular college counseling center. Having served first and then coming to college can be a challenge and clinical needs depend on whether or not they are a combat veteran. The

combat veterans may feel that there is a stigma around coming to the regular college counselor

combat veterans may feel that there is a stigma around coming to the regular college counselor who hasn’t experienced what they have or have a military background. Larger campuses actually hire counselors who have served in the military. This can be helpful because veterans have trauma about reintegrating. They’re used to following authority and a more established and structured day. Sometimes they have difficulty with younger students who aren’t respectful.

LR: Or knowledgeable!

JJ: Sometimes, these younger, less sensitive or aware students don’t conduct themselves very well in class which is very troubling for veterans. And then of course, we do have veterans that have PTSD or depression; situations that require more treatment. But a lot of times, I think it is more about adjustment, depending on how long they served and the college program they’re in.

CBT and Beyond

LR: We’ve been talking about various treatment needs of college students and I know that CBT and other empirically supported treatments are the rage these days. I’m wondering if it also dominates the college counseling landscape.

JJ: I think there is a lot of support on college campuses to use research-supported therapy modalities. CBT has a lot of related therapies including DBT, solution focused and even positive psychology. The reason it works in our setting is because we’re tasked to triage students that come in. There can be a high need for services and students oftentimes wait to get in to see a counselor or a mental health provider. So, I think we want to use therapies that we know can assist with more immediate behavior change.

We don’t have the luxury for long-term care with students.

We don’t have the luxury—and I don’t know if it is a luxury—for long-term care with students. So, those kinds of therapies can really be useful. You can give the student homework and worksheets—something they can hold onto so that they can feel like they’re moving forward and like they’ve accomplished something. I’ve even had students with whom I’ve suggested a reward system to help when they were struggling with something and want to see improvement. Larger campuses can even incorporate these kinds of therapies into a group setting and can direct students to be part of therapy groups.

LR: Would you say that college counselors are pressured to use these proven methods and not encouraged to use creative-expressive modalities that incorporate art, play and music?

JJ: We’re not forced to do that—it would depend on the counseling center and how many staff members they have. I do see the creative going on as well. In New Mexico, Southwestern College offers a master’s degree in art therapy and I’ve had interns from there on my campus who have done art therapy with our students and they’ve really liked that.

There is some room for creativity, but you have to be working to move the student forward especially because you’re working in a limited timeframe; a college semester or a college quarter and then there’s a break and they go home. I am at a community college where we are looking toward a goal-oriented type of therapy. If they bring in extreme trauma or are in an abusive relationship or are fighting an addiction, treatment is better is referred to a community partner. We use whatever modality is supportive of their counseling and helps them to meet their goals.

And for most of them, their goal is to complete college, find a career and move forward. So, we try to facilitate that. If there is a major mental illness diagnosis, we make sure that they have a community provider who may be doing something like DBT groups. I don’t feel like college counseling can replace that.

College Counseling Competencies

LR: With regard to the provision of treatment, what are some the unique competencies that a college counselor should possess?

JJ: At the university level, a lot of schools hire licensed doctoral-level clinical directors. The counseling staff is sometimes made up of licensed counselors. In New Mexico, I’m a licensed clinical mental health counselor. Some college centers hire licensed clinical social workers who are in clinical practice. That’s is the more traditional set up. Our organization, the American College Counseling Association expects that any counselors working in a college setting be licensed.

What we see in California is an interesting example where most of the universities are using doctoral level licensed psychologists in their counseling centers. In their community colleges, they are using master’s level clinicians. But they don’t have licensure at that level. It’s hard for me to talk across the board, however the American Counseling Association has been working on licensure portability along with licensure accountability.

I would say that if you’re going to work in a college setting, you should be licensed in the same manner that you would to work in a private practice or at any other clinical facility—you need the degree and the experience that comes from practicum and internship to do this work. Unless, that is, you’re in a college where they’re calling you a counselor and you’re doing academic advising or something like that. If you’re in a college mental health counseling center, you’re doing the same kind of work anybody would be doing as a mental health professional anywhere else. The scope of your practice may be limited in that you have to do more community resource referrals. But, your knowledge and ability including understanding the DSM, various diagnoses and treatment modalities fully impacts your work every day. You need to be able to do it.

LR: Do college counselors need to like teenagers and emerging adults? Wouldn’t that be a prerequisite?

JJ: I think that you want to be able to work with that population. Three years ago, I started an internship program here at Santa Fe Communi

Deliberate Practice in Psychotherapy

Posted on January 8, 2019February 19, 2026 by Psychotherapy.net Team

Editor’s note: The following is an excerpt taken from Mastering the Inner Skills of Psychotherapy, by Tony Rousmaniere, published by Gold Lantern Books © 2018 and reprinted with permission of the author.

“Could there be a better way for therapists to acquire the inner skills of psychotherapy?” To explore this question, let’s look to other fields. Most professions have developed specific exercises that help trainees acquire the capacity necessary for professional performance. For example, musicians rehearse challenging pieces repeatedly, so they will sound effortless during the actual performance. Pilot trainees spend hours intentionally stalling their plane, so they can practice recoveries. Athletes engage in physical conditioning, so they will have improved performance in competitions. In deliberate practice, therapists use practical exercises to build their inner skills and psychological capacity to improve their psychotherapy performance.

Deliberate Practice

I lead deliberate practice workshops around the world on developing therapists’ psychological capacity. Participants who are new to the idea of psychological capacity often ask, “How can this help me be more effective with my clients?” To answer this question, let’s begin with a case example of how deliberate practice helped me with a challenging case a few years ago.

My client was a man in his early twenties. He had recently been fired from his job and was discouraged about applying for work. He struggled with depression and had started to have thoughts of suicide. His goal for our work was to improve his mood and morale so he could find new employment.

My client and I formed a good working relationship in our first few sessions. However, despite my best efforts, he did not improve. Over the following weeks his mood gradually worsened, and he became more socially isolated. The outcome monitoring software I was using indicated that he was at a high risk of deterioration and possible suicide. With the client’s consent, I recorded a video of one of our sessions and showed it to my supervisor.

When we reviewed the video together, my supervisor noticed that the client looked disassociated during our session. He said, “Notice that after you ask your client a question, his eyes glaze over and he is slow to respond? Notice how he is nodding his head but not really engaging your questions? This could be a sign that your client is experiencing so much anxiety that he is disassociating. He may be politely going along with you but not fully understanding what you are asking him or benefiting from the therapy.”

As I watched the video closely, I could see what my supervisor was pointing out. My client’s eyes were unfocused, and his speech was slow. Although he was able to follow our conversation, his comments seemed superficial or compliant, like he was going along with me rather than really expressing himself.
I was surprised that I had not seen these obvious signs of disassociation in session with my client. I had learned about disassociation years prior and had successfully helped many clients with these symptoms. “Why was I unable to help this client?”

I said, “It’s so strange that I didn’t see these symptoms in session with my client. They seem so obvious when you point them out right now.”

My supervisor replied, “I wonder if you may be having an unconscious internal reaction that is blocking your conscious awareness?”

I said, “How can I tell if I am having such a reaction?”

He replied, “They often are accompanied by thoughts, emotions, physical sensations or behavioral urges. You can look for these as signals.”

“How?” I asked.

“I’ll show you,” he replied.

Seeing in Real Time

My supervisor said, “Play the video again. Turn the volume down low so you can hear the sound of your client’s voice but not get caught up in the content of the conversation in the video.”

I did as my supervisor instructed. It felt strange to watch the video without following the content of the conversation.

He continued, “Now, try to notice any thoughts, emotions, physical sensations, or behavioral urges you may feel while watching the video.”

I tried this for a few seconds and noted that paying attention to my internal experience while simultaneously watching the video was hard. I said, “My attention keeps trying to follow what the client is saying.”

“That’s normal,” he replied, “just keep trying.”

I watched the video while trying to tune in to my internal experience. After a few moments, I noticed I was clenching my fists. I told my supervisor.

“Great,” he said, “what else do you notice?”

“My chest feels tense,” I replied.

“What else?” he asked.

“I’m holding my breath.”

“What else?”

“As I tuned in to my internal world, I realized that I was having many uncomfortable reactions I had previously not noticed”. “My legs are tense, my mouth is dry, and my palms are sweaty. There’s also a slight ringing in my ears.”

He said, “Great that you can see all of these reactions within you. Let the video keep playing so you can continue. Do you notice any thoughts? You don’t have to tell me the details, but it’s important for you to see them.”

I noticed I was having strong doubts about myself as a therapist. How could I be effective if I was having all these unconscious reactions? Was something wrong with me? Should I give up and leave the profession? I felt some shame and didn’t want to reveal the details of all these thoughts to my supervisor. Instead, I simply said, “I’m having negative thoughts about myself.”

My supervisor could probably tell that I was experiencing some shame. He looked at me with kind eyes and normalized my experience, saying, “Great that you can notice those thoughts. Self-doubt, shame, or other negative thoughts about yourself are a normal and very common response to reaching your own psychological capacity limits. Consider these thoughts to be like how an athlete will sweat or get out of breath during a tough workout. It’s just part of the process.”

He continued, “Do you notice any behavioral urges? Again, you don’t have to tell me the details. Just try to notice them within yourself.”

I noticed I felt the urge to stop following his instructions. I was glancing at the clock out of the corner of my eye and hoping our consultation would end soon. I was also surprised to notice that I was starting to feel frustrated with my supervisor. This felt awkward, as I liked him a lot personally and trusted his advice. I didn’t feel comfortable telling him all of this, so instead I just nodded my head.

My supervisor paused the video. “Congratulations,” he said, “you were able to observe your own experiential avoidance in real time as you had it. This is not easy! However, it is a very important skill for effective psychotherapy.”

I took some deep breaths. I felt shaken from this experience and a bit confused. “How can this help me with my client?” I asked.

He replied, “Your ability to be empathic and attuned with this client is being limited by the discomfort and experiential avoidance that he stirs up in you. To address this, we need to increase your ability to see your own experiential avoidance in real time. This will let you downregulate your emotional state, so you can be more empathic, attuned and helpful.”

He continued, “You know how to assess and treat disassociation. You could write a paper about it. You can perform it proficiently with many of your other clients. You could teach it to beginning trainees. However, we have discovered that your proficiency in this skill is conditional on your psychological state. When you have particularly strong experiential avoidance—such as with this client—you lose your ability to be helpful. We call this your psychological capacity threshold.”

“How can I increase my threshold?” I asked.

He replied, “By practicing therapy skills with stimuli that provoke your experiential avoidance. This is called state dependent learning. For example, this video will work well for practice. I’ll show you how.”

Engaging the Client

My supervisor said, “You are going to practice engaging the client with anxiety regulation techniques while simultaneously noticing your experiential avoidance. Do you remember the somatic anxiety regulation techniques we reviewed last week?”

I replied, “The technique where I ask the client where he notices his anxiety in his body?”

“Yes, we’ll use that,” he said, “Start the video again at low volume. Now, while watching the video, take a moment to notice your internal reactions. Raise your hand when you notice any experiential avoidance.”

After a few moments watching the video, I noticed my chest tightening and breath restricting. I raised my hand.

“Good,” he said, “now use the first technique we discussed last week.”

“Just say it to the video?” I asked.

“Yes,” he replied, “just say it to your client in the video.”

Looking at the video, I said, “Right now, where physically do you notice any anxiety in your body?” I felt strange talking to the video.

“Good,” said my supervisor, “now watch the video for about twenty more seconds while noticing your inner reactions.”

My supervisor used his watch to count down twenty seconds and then said, “Now use the anxiety regulation technique again.”

“The same one?” I asked.

“Yes,” he said, “you can play with the words if you like.”

Looking at the video, I said, “Right now, where do you notice any anxiety, physically in your body?”

“Good,” said my supervisor, “do this process again: twenty seconds of self-observation, followed by engaging the client.”

I watched the video for twenty seconds while noticing my inner reactions and then said, “Do you notice any anxiety physically in your body right now?”

“Good,” my supervisor said, “again.”

I repeated the process.
“Again,” he said.

As I repeated the process, I noticed I had conflicting feelings toward my supervisor: I was simultaneously frustrated at him and appreciative of his help.
“Again,” he said.

I repeated the process and noticed I was starting to feel fatigued.

“Okay, pause,” he said. “What did you notice while repeating the exercise?”

“It got easier,” I replied.

“Great!” he said. “”You are building your psychological capacity to engage the client” while you have experiential avoidance.”
I asked, “Why does this client provoke such a strong reaction in me?”

He replied, “We don’t know yet. I’ll give you some deliberate practice exercises to do as homework, and maybe you’ll find out.”

Doing the Homework

My supervisor said, “Between now and our next supervision session, try to do an hour of the same deliberate practice exercise we just did together. Doing these exercises on your own may be more challenging than it was here with me, so try to be patient and self-compassionate. Remember that the goal is just to notice your reactions and practice engaging the video. Do not try to change or ‘fix’ any of your reactions.”

Over the following week I did the deliberate practice homework in three sessions of twenty minutes each. Doing it myself was much harder than it had been with my supervisor. I had to fight strong urges to avoid it. I scheduled practice in the morning but put it off until the afternoon. When I sat down to practice in the afternoon, I felt tired and decided to do it the following morning. The next morning, I was tempted to put it off yet again. However, I summoned the willpower and did the exercise.

When I started the video, I noticed a general tension throughout my body and fogginess in my mind. I kept losing track of time, so I set my phone to count down in twenty second intervals. I found it hard to say the anxiety regulation words out loud to the video. I felt awkward and had strong thoughts of shame and self-doubt. When I stopped after about twenty minutes, I felt discouraged by how much harder it had felt doing the exercise on my own rather than with my supervisor.

Two days later I did the exercise for a second time. Like my first practice session, this took considerable willpower. However, this time I had less fogginess and noticed more distinct internal experiences, including dry mouth, sweaty palms, and ringing in my ears. I felt clearer when saying the anxiety regulation words out loud. My shame and self-doubt were less pronounced. I ended the practice after about twenty minutes feeling more optimistic.

Three days later I did the exercise again. This time felt very different. As I watched the video, I noticed strong waves of tension rising from my stomach through my chest to my throat. I almost choked as I said the anxiety regulation words. The waves increased in intensity as I repeated the exercise. With surprise, I noticed tears forming in my eyes. “I felt a sharp spike in my shame and self-doubt and a strong urge to end the exercise”. However, I gathered my willpower and persisted. As I watched the video, I realized my client reminded me of times as a teenage boy when I had felt anxious and disassociated. I remembered the pain of those days, along with the social isolation and confusion. As I spoke the words of anxiety regulation to the video, I pictured saying them to myself as a teenager. I started crying out of sadness for my younger self as my shame melted into self-compassion. Resisting the temptation to stop the video, I continued with the exercise. I cried throughout the last ten minutes of the practice session.

Deliberate Practice Helped

This experience helped in multiple ways. First, my effectiveness as a therapist improved dramatically. I felt less tense and foggy sitting with the depressed young client whom I had videotaped. I was better able to help him see his own disassociation and use anxiety regulation techniques to reduce his anxiety. Over time, his mood improved, and he became more socially engaged. My effectiveness with other clients improved similarly.

Second, my morale and confidence as a therapist improved. I experienced less shame and self-doubt in my work. I felt optimistic about resolving other clinical impasses I was encountering and enthusiastic to practice more.

Third, the effects of the practice carried over to my personal life. I grew more open and engaged with my friends and family. I felt like I had further healed an old wound.

“The impact of deliberate practice on my personal life has been surprising”. I had previously done years of my own therapy, in which I had talked extensively about my teenage years. I assumed I had finished processing these old wounds. However, empathizing with this client stirred up painful memories that I had not recalled in my own therapy. Deliberate practice with my session videos helped me process those memories. After having many similar experiences myself and hearing of many from my trainees, I have come to see that deliberate practice with session videos can be a valuable tool for therapists’ personal growth. Deliberate practice helped me build my psychological capacity to be more effective with this client—and with my other clients.

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Deliberate Practice Helped