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Bruce Wampold on What Actually Makes Us Good Therapists

Posted on May 9, 2017February 11, 2026 by rezendevknowfully.com

The Zero Percent Difference

Greg Arnold: Bruce, you’ve been in the field of psychotherapy for over 30 years and have made a tremendous contribution to our understanding of psychotherapy from empirical, historical, and anthropological perspectives through what you call the “contextual model of psychotherapy.” Your fantastic book, The Great Psychotherapy Debate: The Evidence for What Makes Psychotherapy Work is in its second edition, and I highly recommend it to our readers.

I want to start right out with what I see as the most significant thing to share with our readers. In your research, you’ve found that the difference in effectiveness of various types of psychotherapy is zero percent. Is that right?

Bruce Wampold: With some qualifications. I would put the differences between various types of psychotherapy at very close to zero percent. That statistic comes from clinical trials comparing treatment A to treatment B—often CBT to another form of CBT or to a dynamic therapy, a humanistic therapy, an interpersonal therapy—and there we don’t find any differences that are consistent or very large. Sometimes they’re small differences. The other area of research, “dismantling studies,” takes out the ingredient that is supposed to be the most important element of the treatment. It turns out that treatment is just as effective without the particular ingredient.

But here’s the qualification. There are a number of trials that compare a coherent, cogent, structured treatment to what’s often called “supportive therapy,” where the patient just sits with an empathic therapist, but there’s no treatment plan, there’s no explanation to the patient about what they’re going to do in therapy to help them get better. And we know, all the way back to Jerome Frank, that we need a coherent explanation for what’s bothering the patient and a believable treatment for them—something for the patient to do so that they work hard to overcome their difficulties. Supportive therapies are a lot more effective than doing nothing, but they’re not as effective for targeted outcomes as those that have a coherent explanation and treatment plan.

As long as what they’re doing is believable, accepted, is given by a therapist who’s skilled and believes in the treatment as well, the treatment tends to go well.

So if a patient comes in with problems in interpersonal relationships, depression, anxiety, we have to come up with a cogent explanation and a believable treatment to overcome their difficulties. As long as what they’re doing is believable, accepted, is given by a therapist who’s skilled and believes in the treatment as well, the treatment tends to go well.

GA: Regardless of the treatment?

BW: That’s right. So that’s the long answer to your question about all treatments being equal. Of course, not all treatments are equal—there are harmful treatments. In my workshops, I show Bob Newhart doing “stop it” therapy.

GA: Yes, I’ve seen it. It’s hilarious.

BW: You can Google it on YouTube. He just keeps saying to the patient, “Stop it!” When we say all therapies are equally effective, we need to be clear that we are not talking about harmful or sarcastic therapy.

GA: Of course. So let’s take a case example, say someone with severe OCD. Most people think exposure with response prevention is far and away superior, its treatment rationale is better than anyone else’s treatment rationale, and that it’s the only therapy that will cure it.

BW: OCD is an interesting one to bring up.

Exposure and response prevention is pretty good, with some provisos, but it’s never been compared to another bona fide, legitimate treatment for OCD.

Exposure and response prevention is pretty good, with some provisos, but it’s never been compared to another bona fide, legitimate treatment for OCD. I would like to see a focused dynamic treatment for OCD, and I would predict it doing just as well.

The other thing about OCD is if you read the literature, outcomes are almost exclusively measured in terms of symptom reduction. There’s a failure to measure quality of life or interpersonal functioning. OCD is a terribly disturbing disorder, and the people who suffer from OCD often have a terrible quality of life—they’re isolated, they’re alienated from people, they’re not integrated into social networks because their disorder interferes, or they have other issues as well. So it’s very misleading to just measure targeted symptoms.

GA: It’s stacking the deck a little bit.

BW: I had a debate with a psychologist here in Wisconsin who has an OCD clinic, and he said the same thing: We know how to reduce symptoms. But the people are not back to work, they don’t have romantic or intimate relationships. So now we’re starting to augment the exposure and response prevention with vocational therapy and counseling for other issues. OCD is an area where we need to do more research.

The claims about CBT being superior to other treatments are not founded.

Another area where we thought CBT was the most effective treatment is panic disorder. But now Barbara Milrod and others have dynamic therapy for panic, and it’s just as effective. Social anxiety is another area. If you read the clinical trials carefully, there isn’t convincing evidence that one particular treatment is more effective. CBT folks have done some amazingly good research and have helped the field immeasurably. I don’t want to discount that, but the claims about CBT being superior to other treatments are not founded.

GA: Those claims are far and wide, deeply rooted. Given that, among the bona fide treatments, they’re all equally effective, then the medical model is not superior either, correct?

BW: Yes. In Western culture, we’re so indoctrinated by the medical model that we ignore the social factors that make psychotherapy particularly effective. Humans are evolved as social animals, and we’re influenced through verbal means. How many of us learn not to stick our fingers in electric sockets because of classical conditioning? Our parents didn’t put our fingers into the socket to learn by experience, or put their fingers in there and have us watch them writhe on the floor in pain. All the parent had to do is say, “that’s dangerous.” We have evolved in such a way that significant others have tremendous influence on us through social means. Psychotherapy very effectively does just that.

A skilled therapist makes a big difference no matter the orientation.

The medical model can have some unfortunate consequences. It leads us to think that a “cure” can come through specific “interventions,” that if a therapist follows some kind of protocol, they will have good outcomes. That’s a myth. A skilled therapist makes a big difference no matter the orientation.

GA: Which is good news, right? People are going to be happy to hear we make a difference.

BW:

Therapists Deteriorate Over Time

Yes, but it comes with responsibility. Let’s ensure that our outcomes are commendable, that they meet benchmarks, and that they improve. We just did a study where we looked at therapists over almost 20 years of practice, and the therapists did not improve. In fact, they deteriorated a bit.

GA: Sobering.

BW: It is. But it’s not surprising when you think about it. What other profession do you go into a room, do your work in privacy, aren’t really allowed to talk about it because it’s confidential, and don’t get any feedback about how you’re doing. How can we expect to get better? Would we go to hear a musician who only performed and never practiced? Do you think world class tennis players just play Wimbledon and the U.S. Open and Australian Open? No, they practice hours a day on particular skills. So becoming a better therapist takes a lot of deliberate practice.

GA: Can you talk a little bit about the therapist factors that make us better or worse that we could be working on—be it in consultation groups or in feedback informed therapy.

BW: For many years I said the fundamental unanswered question in psychotherapy was, “What characterizes an effective therapist? What do they do?” And we didn’t know. But we’re starting to get good scientific evidence about what effective therapists do, so I’ll run through it.

GA: Please do!

BW: Effective therapists are able to form a working alliance—a collaborative working relationship—with a range of patients. The motivated patients with solid attachment histories who easily form an alliance with you—those aren’t the ones that challenge us. The ones that challenge us have poor attachment styles, do not have social networks, they alienate people in their lives, they have borderline features, they’re interpersonally aggressive, they tell us we’re no good. A really effective therapist is able to form a relatively good collaborative working relationship with those types of patients. The therapist effect is larger for more severely disturbed patients, which makes sense.

Effective therapists are also verbally fluent, they can describe the disorder as well as their treatment rationale.

GA: They get the buy-in from the client.

BW: Yes, they’re persuasive as well as verbally fluent, so when they explain things, they do it in two or three sentences and it’s coherent. I have my students practice explaining what they’re going to do in therapy. It’s difficult to do and you have to practice until you can do it in three or four sentence.

An effective therapist can read the emotional state of clients even when they’re trying to hide it. And we know the patients hide what they’re feeling. It isn’t intentional; it’s part of their struggle in life. They suppress anger or they’re not allowed to express sadness. A good therapist can understand and respond to the patient affect. Good therapists also can modulate their own affect.

Can you be expressive and activated when you have a really depressed patient who just kind of sits there?

Can you be expressive and activated when you have a really depressed patient who just kind of sits there? Affect is really contagious. We know that from basic science.

On the other hand, if we have an extremely anxious patient, can we be relaxed and calm? Modulating our own affect takes some practice as well. Are we warm, understanding, and caring? You may think all therapists are warm, understanding, and caring, but it takes work. I had a student whose patient didn’t bathe, so it reeked when the patient came in. What would your facial expression be?

GA: It would be hard not to feel some disgust.

BW: Exactly. We had to practice not displaying disgust. Being warm and empathic is easy with some patients, but really hard with others.

GA: Do people lose faith when they realize that the medical model, that any model really, isn’t the X factor in therapy? Do they just throw in the towel?

BW: I wouldn’t say that. When therapists say, “My treatment is the best there is for X, Y and Z,” in a way I’m glad. I want people to believe in their treatment, as that is an element of effective therapy. But instead of thinking that treatment X is the most effective treatment, we should believe that treatment X as I deliver it to this particular patient is effective.

This is where the focus on outcomes is so helpful. Is this patient getting better? Are they reaching their goals? If so, you can have faith not in the treatment itself but in your use of the treatment with the patient who is getting better. If we’re rigidly attached to a treatment, that’s problematic. I dislike it when therapists say in the first session, “Here’s how I work. This is what we’re going to do here.” You haven’t even listened to the patient yet and understood how the patient wants to work.

You need to modify treatment for some patients, or you might have to abandon it and do something very different for particular patients. Flexibility is another characteristic of effective therapists. That doesn’t mean doing something different every week with them, which is confusing; we need to be consistent, but also flexible.

GA: Dogma gets in the way here, and you’ve shown that more fidelity to a treatment actually gives less positive outcomes.

BW:

The Sweet Spot

There’s a sweet spot. You don’t want to be so flexible that you lack coherence, as that is not effective either. We need to be kind of in that sweet spot where there’s consistency in what we’re doing so the patient feels like we’re working towards their goals with a logical treatment plan.

But there may be a crisis in a patient’s life or a dramatic event or they’re just resistant. One of the things I teach my trainees is to see the nonverbal signs of resistance—they’re not following through on activities or when we explain what we’re doing they look away. They don’t want to say, “No, that doesn’t make sense, you’ve got it wrong.” So we have to be really attuned to those signs and willing to explore them.

GA: Still, it seems like this contextual model kind of suggests that we don’t really need particular treatment models. That if we are naturally good at making alliances with all kinds of clients and verbally skilled, we don’t need to be steeped in a particular treatment model.

BW: Well that’s where coherence and clear articulation of a treatment plan come into play. You don’t have that without having some kind of approach. When we go to a doctor, we want to know what’s wrong with us and how we’re going to get better. CBT therapists are great at this. They incorporate psychoeducation into the treatment structure, so a coherent treatment plan is central to the work they do with clients.

Where CBT therapists can fall short if they don’t attend to it is the warm, empathic, understanding treatment expectation part of the contextual model.

If you administer CBT without warmth and understanding, it’s not going to be nearly as effective.

If you administer CBT without warmth and understanding, it’s not going to be nearly as effective. On the other side are the humanistic therapists who are often great at the warm, empathic part of therapy but don’t always have a coherent treatment structure. I think we all have to look at our practice and assess what we are really good at, what are the elements that seem to work well with our clients and then have a good hard look at the areas where we are falling short.

GA: Yes, for me it’s figuring out the fine line between non-directive and directionless.

BW: That a good way to put it.

GA: It sounds like we should all be multi-modal, integrative, competent in several modalities because different things are going to work with different clients. None of us should be one-trick ponies.

To what extent does this call upon us to be more educated and trained in multiple modalities? Training culture these days seems to be trending towards manualized therapies, those that have been shown to be effective with particular disorders, etc. How do you think students should be getting trained these days?

BW: That’s an interesting question. I’m a counseling psychologist, and in counseling psychology we usually start by teaching the basic interpersonal skills first. In clinical programs, they are more often these days teaching manualized treatment—CBT for panic disorder or exposure therapy for OCD. We need to integrate the basic humanistic skills that are necessary for effective treatments as well as learning treatment protocols.

I have no problem with treatment protocols. I think people should be relatively fluent in several. And we should recognize our limitations. If we’re psychodynamic and have a client who is more interested in doing CBT, or we think would be better served by a CBT therapist, we should refer them out.

We often have this belief that we can help everybody, but it’s really not true.

We often have this belief that we can help everybody, but it’s really not true.

Look at how many treatment failures there are for widely accepted medical practices. We’re not going to help every psychotherapy patient, and maybe some other therapists could do a better job with particular patients. Flexibility is called for not just within a particular therapist, but within the community of therapists.

GA: One of the elements of effective therapy you cited was being able to create a positive working alliance with a variety of patients, and difficult patients, so how do you balance that with knowing when to refer out?

BW: Well, the really effective therapists probably don’t refer out much because they’re pretty good at accommodating their treatment style to the particular patient. And we have to be careful about referrals because if it appears to the patient that they’re just being referred out because they’re difficult, that can be very wounding. I’ve heard of difficult patients saying, “I didn’t really get better, but this therapist stuck with me, and that was really helpful to me.”

Some disorders are going to take maintenance therapy to keep people out of the hospital and functioning. So even though they’re not going to approach what we would call “normal” functioning, it’s still an appropriate use of therapy. The medical model doesn’t really support this kind of treatment though. It’s looking for a specific outcome in a limited amount of time.

In the United States we’re paid by the health delivery system, which is advantageous for therapists because they’re getting paid, and advantageous for patients because there was a time when only the rich could pay out-of-pocket for therapy. Those without resources simply couldn’t afford psychotherapy and now it is available to many more people, which is a great thing. But there are some unfortunate consequences of being forced into this medical model. Limitations on sessions is probably the one that impacts therapists and clients the most.

GA: This isn’t going to change overnight. It’s deeply embedded in our culture. But in order to change the culture, we need a positive vision for the alternative. What would that look like? I think the contextual model has the potential to really change the system because not only is it scientific, it’s more scientific than the medical model.

BW: That’s a fundamental question we have to address.

We know psychotherapy is remarkably effective. It helps many people. It’s as effective as medication, and longer lasting. But we have to influence policy makers.

Many of us are working hard to influence policy, and the way to do that in my view is to present the evidence. I’ve dedicated my career to providing the evidence for the humane delivery of mental health services. We know psychotherapy is effective. It’s remarkably effective. It helps many people. It’s as effective as medication, and longer lasting. But we have to influence policy makers. There are places where we’re making progress, and there are places where it’s frustrating as hell.

GA: I bet.

BW: But we also have to be making progress as therapists. We have a responsibility to provide effective services.

GA: It’s disheartening to hear that we aren’t getting better over the course of our own professional lives.

BW:

Coming Out of Isolation

We don’t, but as we learn more through research about what makes therapists effective, we can begin to incorporate what we learn into our training and professional development. I’m involved in a start-up company, TheraVue that’s dedicated to online skill building for psychotherapists. I think technology can play an important role in making not just therapy, but consultation and training more accessible to people.

GA: That’s hopeful to hear. So many people want to be in consultation groups, but it’s much harder to make happen than you would think.

BW: This is an isolating profession. We’re sitting one-on-one or sometimes with couples or families, but essentially we’re doing our work in isolation. We have to have that peer support to help us both fight the isolation and to get better, but it’s difficult. We work six, eight hours a day with patients and at the end of the day, we don’t want to drive somewhere for a peer consultation. We want to get home to our families and friends.

GA: So given that there are these challenges, how do we get more therapists to make consultation a regular part of the practice?

BW: Psychotherapy is not the road to riches. I think most of us are in this field because we’re dedicated to helping people, so I think there’s an intrinsic motivation to get better. I don’t think there’s going to be resistance when people really understand what it takes to be a better therapist. In fact, there’s going to be eagerness to improve if it’s built-in in a way that makes it accommodating. I think it’s absurd that we don’t give CE units for actual efforts to improve other than going to workshops and doing online courses. I’m a licensed psychologist, so I do them, and some of them are really good, but is this helping me become a more effective therapist? Tomorrow are my patients going to be getting better therapy than they got before I went to this workshop? So the training and accreditation processes need to support the activities that actually help therapists get better.

GA: So we know that workshops and online courses and reading books isn’t enough. We recently did an interview with Tony Rousmaniere on deliberate practice, although we haven’t published this yet. It’s a concept he learned from Scott Miller that involves literally practicing—like tennis players do between games—the skills of therapy outside of the therapy office. Videotaping ourselves, practicing how we talk, having mentors watch our work, trying to eliminate things that aren’t helping clients—weird idiosyncrasies we wouldn’t necessarily pick up without an outside observer. Are these the kinds of practices you are talking about?

BW:

Good Therapists Are Humble

Yes, exactly. You can’t just reflect and think about your practice, just do process notes or whatever. It’s important to do those things, and certainly one of the characteristics of effective therapists is professional humility. Good therapists, the ones that get better outcomes, are the ones who say, “I’m not sure I’m helping patients. I need to get better.” But Daryl Chow and Scott Miller did a study that revealed that people who work outside of their practice to get better actually have better outcomes.

Good therapists, the ones that get better outcomes, are the ones who say, “I’m not sure I’m helping patients. I need to get better.”

The skills I’ve talked about, you have to do them over and over again with feedback from somebody. This is what we’re doing with practicum students now. Often students will go, “I’m an advanced student now; these are basic skills you’re teaching.” No, we all need to practice these things. By the end, they often say, “this was the best practice class I’ve ever had because we actually practiced the skills we use in therapy.”

GA: So we can improve our skills through practice, get unambiguous feedback from someone we respect and hopefully challenge our own confirmation bias that we’re the best therapist ever, by cultivating some humility.

Still, if the motivation to get better was intrinsic, don’t you think more therapists would be doing these things? Sell us a little more on it if you don’t mind. Like, how much am I going to improve if I implement these new strategies?

BW: That’s a great question. In my presentations I use the example of baseball. The difference between a 300 hitter and a 275 hitter is not very much. In fact, if you watch the poor hitter for two weeks, they may have more hits than the 300 hitter. But if you look over the career, the 300 hitter helps his team immensely more.

A small improvement by each therapist would have a tremendous impact and benefit to patients.

An incremental improvement doesn’t have to be dramatic, but it has a tremendous impact on the number of patients who benefit from psychotherapy. I can give you the facts and figures because I love math and statistics, but a small improvement by each therapist would have a tremendous impact and benefit to patients. It’s quite remarkable.

GA: So that’s our call to action as a profession.

BW: Yes.

GA: We know what we need to do, the gains are there for the taking, and we need to keep pushing on policy to support those efforts. None of us are going to get rich doing it, but it’s hopeful that we can really make a difference as we improve and grow.

BW: I think it is hopeful. We have the strategies and the technology for continual improvement as therapists. Let’s get better. Let’s work at it. Let’s support each other. And let’s measure outcomes so that we know how we’re doing.

GA: That’s a whole other piece we hadn’t talked about: measuring outcomes.

BW: Yes, it’s very important. What the research seems to show is that at least for cases at risk for deterioration, feedback may improve outcomes. But it’s pretty clear that just getting feedback—this patient is improving; this patient is not—doesn’t help the therapist become more skilled.

But it is important to know if you’re actually helping patients, if you’re gradually improving over time. Look and see what types of patients you’re having difficulty with.

GA: Routinely.

BW: Yes, and I would add that, in my experience, and I think the research supports this, discussing the feedback with patients is helpful. What it communicates to the patient is that you are improving and that their feedback actually matters to you. But it also makes it clear that the focus is on, “Are you getting better?” I want to know that continually. We should all be discussing with our patients how therapy is going and how we can change to more readily support their goals. That’s a tremendously powerful message when we discuss that with patients. If we’re not meeting the goals, what can we do differently? Some would call that client-informed, but all therapists are client-informed. To a large degree, we should all be discussing with our patients how therapy is going and how we can change to more readily support their goals.

GA: There’s also an indirect benefit in that it communicates care in a new way to the client, bringing them in on monitoring outcome.

BW: It’s not indirect. It’s direct. In the contextual model, we don’t minimize these things as indirect. This is deliberate.

GA: The meat and potatoes.

BW: Absolutely. The focus on patient progress is central to what we do.

GA: So we have a call to action for clinicians, one for policy makers, what about for psychotherapy researchers?

BW:

My plea to all researchers would be, if you’re going to do a clinical trial, please include a quality of life measure because I want to see that your treatment actually has a significant benefit to patients in the quality of their life. That’s why they come to treatment. I don’t want to just see targeted symptoms are reduced and therefore your model is best for a particular disorder.

GA: Any final words of wisdom you’d like to leave our readers from your years in the industry?

BW: I would say to therapists—to all of us—let’s work to get better, to continually improve over the course of our careers. It will benefit patients. It will benefit us. Our satisfaction with our work will improve as well. At this point in my career, I want to do whatever I can to help therapists do that.

GA: I am so grateful for the work you do, and I want everyone to go out and read your work so that we can all become better therapists.

BW: Thank you, Greg, it’s been such a pleasure talking to you.

Tony Rousmaniere on Deliberate Practice for Psychotherapists

Posted on March 16, 2017February 11, 2026 by rezendevknowfully.com

The Other 50%

Victor Yalom: Tony, congratulations on your new book, Deliberate Practice for Psychotherapists: A Guide to Improving Clinical Effectiveness. We’ll get to the deliberate practice part later, and find out what that means, but let’s start with clinical effectiveness, which we as therapists all certainly strive for. You’re very candid and self-revealing in this book, which I think is admirable. And it seems the thing that got you started on your quest towards improving your own clinical effectiveness was the realization early on in your training that you were only helping 50% of your clients. Can you tell us about that?

Tony Rousmaniere: When I initially started training at my first practicum, I was working with high school students and I had a number of the clients respond very quickly. They had a range of different goals and whether it was anxiety, or feeling depressed, or wanting to do better at school, and they showed what is called in the research literature, “rapid gains.”

VY: That’s always nice when that happens. It makes you feel like you know what you’re doing, or you’re doing something helpful.

TR: I went into the field feeling like I could be good at this. I’m good with people, so I was optimistic, and the initial response from clients gave me a lot of optimism. But as time went on,

I gradually realized to my disappointment that a fair amount of my clients were not improving.

I gradually realized to my disappointment that a fair amount of my clients were not improving. And when I started to try to assess overall how many that was, it was about 50%. I call that “my other 50%.” There’s some of them who responded a little, and then just plateaued. There’s some of them who deteriorated—they actually got worse during treatment—and then there are also a fair amount, at least a quarter of them, who just dropped out.

VY: Dropouts are certainly a big problem for almost all therapists. I certainly recall, especially early in my career, I had a file of dropouts that came once or twice, and it was a pretty thick file.

TR: Yeah. It’s something we don’t always like to talk about but it is pretty universal across therapists.

VY: So you took the initiative to take a frank look at this, and what did you find?

TR: Well, I spent a number of years throughout my training trying to figure out what was going wrong and then how could I improve. Specifically, how could I reach the 50% of clients that I wasn’t helping effectively? And I started going back to the traditional method of clinical supervision. I was doing the same clinical supervision that pretty much every graduate student does, where they’re meeting weekly with their supervisor for an hour or two individually, and then also with a group.

I’d often feel like I was getting better, and I was learning the theory better, so I could write better papers about psychotherapy, or I could talk in more sophisticated ways about psychotherapy, but the percentage of my clients actually improving stayed the same.

I was very fortunate that throughout my training I had really good supervisors. I know that’s not always the case, but every year of my graduate training I had supervisors who were very open, very collaborative, very encouraging. They had really good advice and understood psychotherapy theory and technique well, but I found that though I was getting all of this great advice from them and my peers in group supervision, my effectiveness was not actually improving.

I’d often feel like I was getting better, and I was learning the theory better, so I could write better papers about psychotherapy, or I could talk in more sophisticated ways about psychotherapy, but the percentage of my clients actually improving stayed the same.

VY: It sounds like one thing you did was actually track your data, which is something most of us don’t do. We rely more on the second form of feedback you described: Do we feel good about what we’re doing? Can we talk about it intelligently? Do our peers seem to respect us? But that’s not really what we’re in the field for.

TR: Our whole field suffers from a lack of outcome data at the individual therapist level. We have lots of data from randomized clinical trials which show you how therapists do in these tightly controlled circumstances. And we have some data from research collaboratives where they’ll track a large group of therapists over time. But pretty much no therapist individually tracks their own outcome data, or reports it to the public. So nobody really knows how effective they or other therapists are. We know how well we can talk about therapy, or how well we can write about therapy, or how well we can theorize about therapy, but imagine if you could never see a basketball player play, you could only hear them talk about how well they played. Or you could never hear a violinist perform, you could only hear them talk about it.

Imagine if you could never see a basketball player play, you could only hear them talk about how well they played.

This is a real problem in our field. Imagine learning to paint, but you’re never able to show your paintings to anyone. You would just describe them to someone and say, “In this painting I used a lot of green. It might have been too much. Do you think I should have used less?”

VY: When I produced my first video, and then got in the business of producing training videos, what I used to say is, imagine a dental student going to a lecture about dentistry, or about a certain technique like doing fillings, and then going off to perform the filling in a private room, and then meeting with a supervisor a week later to discuss what they did. Would you risk getting a filling from such a person? That’s the problem we’re dealing with. And that was one of the things that motivated me to start producing videos of expert therapists doing therapy.

So you were aware of this problem and used the traditional tools available for developing skills as a therapist: clinical supervision, reading, talking with colleagues.

TR: Going to workshops.

VY: But you still found that your client outcome data wasn’t getting better. How did you track your client outcome data?

TR: I was using one of the simpler outcome measures called the “Outcome Ratings Scale” that as well developed by Scott Miller and Barry Duncan and others, and is part of what’s called “Feedback Informed Treatment.” It’s very accessible—it’s free and can be downloaded from their websites. It lets therapists over time track how well each client is doing, and then if they get enough data, let’s say 30 to 50 clients, they can look at how well are they doing as a therapist overall.

VY: Once you got your data, what did you do then?

TR:

Deliberate Practice

Honestly, I just started casting about, trying everything I could get my hands on. I went to lots of different workshops, read lots of different books and got supervision from different people. I was in a supervision group with you, as you well know, where we actually used some of the methods of deliberate practice, though we didn’t call them that. In retrospect, I can see that they were, and we can talk about that later on.

But there’s one supervisor in particular I found, Jonathan Frederickson, who was trained as a classical musician, and as a musician he used the method of deliberate practice. He integrated deliberate practice into his supervision and I found that working with him, using those methods, that it really improved my effectiveness more directly.

VY: Can you define what deliberate practice is and where it came from?

TR: Sure. Did you ever learn a musical instrument?

VY: Depends what you mean by learn, but I tried. And achieved a very low level of mastery with a few instruments.

TR: What instruments?

VY: Piano. Clarinet. Banjo. Harmonica.

TR: So imagine you went to your piano teacher and you said, “I want to be really good at piano. In fact, I want to be a professional pianist. But I just don’t have time to practice. I’m hoping you can assign me some books so I can get better. We’ll meet once a week, and then in a few years I’d like to have some performances.” What do you think your piano instructor would say?

VY: If I could say that with a straight face, I’m sure I’d be laughed out of the room.

TR: Exactly. As part of learning piano you did deliberate practice. Did you ever learn a sport in school or college?

VY: Sure. I played tennis and I’m engaged in some deliberate practice of tennis these days. I have a weekly lesson and am playing during the week and trying to get better, but it’s very difficult.

TR: Well, imagine you went to your tennis coach and said, “I want to play tennis at a professional level, but I just don’t have time to practice. I mean, who has time for that? So let’s meet once a week. Give me some books I can read and I’ll make it work.” They would, again, laugh you out of the room, right?

Most people have experience with deliberate practice, they just do it in other fields. Many fields use deliberate practice as a core part of training—not just to be a professional, but to achieve basic competence, to achieve moderate expertise, and then to achieve full expertise.

VY: So what does that mean in a psychotherapy practice?

TR: Deliberate practice is a term invented by K. Anders Ericsson and colleagues in the early ‘90s. They were trying to figure out how experts achieved their expertise across a broad range of fields—musicians, athletes, chess masters, pilots, you name it—and they isolated only one variable that predicted expertise: solitary deliberate practice.

Deliberate practice is based on five principles. The first is observing your own work. So in psychotherapy that would be watching videotapes of your own work, or having an expert observe your work.

Second is getting expert feedback on the work. So that’s supervision or consultation.

The third is setting small incremental learning goals just beyond our ability. In tennis, that is turning your wrist a little to the left, or in piano it would be just working on this one note.

In psychotherapy, we talk about broad things like trying to improve the working alliance, but there are a hundred skills that fall under that broad umbrella.

In psychotherapy, we talk about broad things like trying to improve the working alliance, but there are a hundred skills that fall under that broad umbrella.

The fourth component is repetitive behavioral rehearsal of those specific skills. So when you’re playing tennis you’ve got the ball machine shooting balls at you and you’re just hitting the balls again and again and again. That’s your repetitive behavioral rehearsal. It lets you move the skills that you’re learning into behavioral memory, procedural memory, so that they can begin to happen automatically, which frees up your mind to think about more complicated parts of the game.

The fifth component of deliberate practice is continually assessing performance. That’s something we do subjectively in psychotherapy, but there’s a lot of research to show that our subjective assessments of client outcome are not terribly accurate.

VY: One thing you say in your book, which I find quite refreshing, is, “I am not a master clinician. I am not a master therapist.” Why did you write that?

TR: Well, I wanted to be very clear. This is not a book by an expert therapist and this wasn’t me imparting my wisdom about my therapy techniques. I am a beginner. I am relatively new to the field. However, I am obsessed with becoming a more effective therapist. I might not ever become an expert therapist. I might not ever become a master therapist. That’s okay. As long as I keep getting better, I feel really good about that. So I really wanted to frame this book from the very beginning as one about just trying to improve.

VY: How did you start learning about deliberate practice and then implementing it for yourself?

TR: Well, I should say that I actually found out about deliberate practice when I interviewed Scott Miller for Psychotherapy.net. In that interview, Scott Miller talked about deliberate practice for psychotherapists, and it was the first time I had ever heard of it. So he should get credit. He is the first psychologist to consider this for our field and he worked on this from the ground up.

My supervisor at the time only would supervise therapists who videotaped their work. He said the reason was that there’s so much nonverbal communication going on. A lot of it is totally unconscious. Unless we can see what’s happening in therapy, as well as hear it, we just don’t really know what’s going on. And as I showed him videotapes of my work, there were multiple instances where the transcript of the session looked like good therapy. It read like good therapy. But the nonverbal communication showed that the client wasn’t progressing at all.

VY: You give several examples of that in your book. Can you give us one now?

TR:

I found that I had a bunch of clients who were basically complying with me. They were pretending to go along with therapy.

I found that I had a bunch of clients who were basically complying with me. They were pretending to go along with therapy. They would answer my questions. They would think about themselves, but they weren’t really struggling within themselves. They were appeasing me and kind of assuming, “If I give Tony what he wants, somehow magically I’m going to feel better.”

And I was going along with this. In fact, sometimes I was even cutting them off. I was talking over them. That’s another thing you can’t see in a transcript. Sometimes my tone of voice was very strong. Theirs was very meek. You can’t catch that in a transcript. Sometimes I would be sitting forward, with a lot of intention in my seat, and they would be sitting back kind of passively. In psychodynamic therapy, we call these “transference dynamics.” Each model of therapy has a different way of discussing the relational dynamics between the client and the therapist, but I found that by watching video I was able to identify all kinds of mistakes I didn’t realize I was making.

VY: It takes courage to look at yourself and have someone else observe you.

TR: Thank you, but it felt more like desperation than courage. I got into this field because I really wanted to help people, and I had a lot of clients that I really cared about. I really wanted to help them but I wasn’t. Sometimes they’d drop out and sometimes they’d deteriorate, and that really pained me.

I could give you another example. Role-plays are another great way of getting direct observation of your work and we would do role-plays in the consultation group you and I were in together. You observed while I was role-playing with one of the other group members that my voice was kind of forced.

VY: Yes.

TR: Do you remember?

VY: I do remember it, yeah.

TR:

My voice sounded like someone trying to be a therapist rather than just being a real person.

I was trying to be a therapist. And my voice sounded like someone trying to be a therapist rather than just being a real person.

VY: Right.

TR: That would have never shown up in a transcript. What you advised me to do is to work on this specific skill. We isolated the specific skill. You said, “Just try talking naturally, Tony. Just try saying whatever you’d say naturally.” And if you remember, it was hard. It took a lot of practice for me to do that. I don’t know if I ever told you this, but I went back after that group and I watched video after video of my clients and I practiced just talking naturally to my clients in the videos.

VY: You just sat by yourself and practiced saying the words aloud?

TR: Yeah.

VY: Wow. So that’s an example of solitary deliberate practice. You were just sitting by yourself with a video and practicing speaking.

TR: Exactly. In most other fields, the bulk of the training actually occurs during solitary deliberate practice. So a professional musician might get coaching a few hours a week, but then they’re spending 20 hours a week practicing on their own. The same with an athlete. Same with a master chess player. And that is something that we do not have in our field. We spend time reading about psychotherapy a lot. But we don’t spend time practicing skills ourselves, so the skills don’t move into procedural memory, and then we’re often left floundering in session.

VY: I remember that term procedural memory from graduate school, but I don’t remember what it is. Can you refresh our readers about what it means and why it’s important?

TR: When you ride a bike you are using procedural memory. When you drive a car you’re using procedural memory. It’s when your body just remembers automatically how to do something, because you’ve done it so many hours. It’s automatic. So you can think about other things while you’re driving—like how to get to your destination—because your body knows how to make turns and yield and stop at the light.

Now, that can be a double-edged sword. My wife points out quite frequently that my driving is not always so great. But it’s in procedural memory, so I do it automatically. We want to get the skills into procedural memory, but then we want to also keep refining them throughout time, or else we stay stuck at the same plateau.

VY: Getting back to deliberate practice, so the first step is observing your own work, and one way to do it is through video. Getting expert feedback is step two, and you were getting some feedback from your supervisor about your work via video. The next step is setting small incremental learning goals just beyond your abilities. How do you do that?

TR: Ideally that’s done by the supervisor. In the group supervision we were in, you identified my voice being forced, which was something I couldn’t hear in myself. You showed me how to improve that and then let me practice it. In the group, you gave me little tweaks here and there. Try a little of this, a little of that. And then I took it home to practice on my own with the solitary deliberate practice. Ideally we’re getting that kind of corrective feedback that focuses on specific incremental skills throughout our careers. That’s how you learn pretty much any other skill.

VY: In any other field you’re getting constant feedback. If you’re a lawyer, you’re observing your senior try a case and you’re sitting next to him and maybe you’re getting up and doing some things and they’re observing you. If you’re in plumbing, you’re an apprentice plumber, you’re going to watch a master, they’re going to watch you. We’re about the only field that I can think of where that doesn’t happen on a regular basis.

TR: I think we actually work in one of the most secret fields on the planet, though not intentionally so.

I think we actually work in one of the most secret fields on the planet.

I mean, obviously there’s confidentiality rules and that kind of thing, but even CIA agents in deep cover every few years get some kind of performance review. But I could go the next 30 years without ever having anyone give a meaningful look at my work. We’re required to do continuing education units, but that’s generally about cognitive learning, which is valuable for learning new laws or new theories, but a lot of research has shown that it doesn’t translate to improved skills or effectiveness with clients.

VY: You cite a lot of evidence in your book that even years of clinical experience don’t lead to improved performance.

TR:

The Audience Can Tell the Difference

Researchers have been looking into this for decades. There’s literally decades of research and they’re trying every which way to show that experience improves performance. But except for isolated cases here and there—for example, experienced clinicians can do better with severely psychotic clients—experience is not associated with improved performance.

I think this can be possibly explained by the fact that we do not as a field engage with ongoing deliberate practice. You could take a professional basketball player and if you tell them that they’re not allowed to practice anymore, and then ask them to play 10 years later, they’re not going to be as good.

My friend plays for the symphony in Washington, DC, and she practices two hours a day, six days a week. She’s at the very top of her field and she still practices. She’s getting close to retiring. She still practices. I asked her why she still practices and she said, “If I go a day without practicing, I can tell the difference. If I go two days without practicing, my peers can tell the difference. If I go three days without practicing, the audience can tell the difference.”

VY: The evidence is compelling, but it flies in the face of what we as clinicians think. Most of us feel a lot more confident ten or twenty years into our practice. We feel like we know so much more, not only from our clinical work, but from our life experience. We can empathize with a broader range of clients because we have a broader range of experiences ourselves. We’re not so anxious in session, worrying about how clients are going to think of us, and whether they are going to see how young and inexperienced we are. So it just feels like we are much better therapists. Yet you’re saying that the evidence does not bear that out.

TR: Well, the evidence shows that there’s a lot of variability. Some therapists do improve in time. But some get worse over time. And because we’re typically not tracking our outcome data from an empirical perspective, it’s hard for us to know. We have a lot of cognitive biases, not because we’re bad people, but because it’s the way our brains were built. So it’s risky to trust your own private perception of your work over time without ever getting feedback.

Unfortunately relying on our clients’ opinions is not entirely reliable either. There’s been many studies showing that clients will routinely not tell their therapists when they’re not doing well. In fact, Matt Blanchard and Barry Farber at Columbia University did a study of over 500 clients and found that 93% of them reported having lied to their therapist. Negative reactions to therapy was one of the most common topics they lied about, including pretending to find therapy effective, and not admitting wanting to end therapy.

Now, almost every client I have in my practice has been in multiple previous therapies that they found to be marginally effective or not effective at all. They probably did not tell their previous therapist this. I can tell you, I have a lot of dropouts. I’ve had an overall 25% dropout rate across my career.

Almost none of my clients tell me that I’m not helping them before they drop out. They just leave.

Almost none of my clients tell me that I’m not helping them before they drop out. They just leave. These are the clients we need feedback from the most. Clients who are like, “Oh, this is helping so much!” are not as helpful with their feedback.

VY: Are you still using the same forms to get feedback from your clients?

TR: I use a variety of forms—the session rating scale and some others. I’m always experimenting with different ways of getting feedback from clients and also from experts—but what I do most now is record all of my sessions through video and then get expert feedback on the sessions.

VY: And when you have dropouts, if you look back on those rating forms, do you see warnings signs?

TR: Yes. There often are, but not always. Many clients feel pressure to be nice to their therapist. Look, when I’m at a restaurant and I don’t really like the food, and they come around and ask me how’s the food, I don’t often say, “It’s kind of crappy.” I usually say, “Oh, it’s fine.”

VY: So let’s get back to the final two steps of deliberate practice: engaging in repetitive behavioral rehearsal and continuously assessing performance. How have you gone about doing that?

TR:

Jazzing it Up

So the first three steps we’ve covered are usually pretty easy for therapists to understand, but I often lose them when I talk about repetitive behavioral rehearsal. They’re like, “Psychotherapy is a relational art. Every session is different. Every relationship is unique. This isn’t just playing chess and moving pieces around. It’s not football or basketball where the net is always in the same place. Our clients change their goals every session. We work in an infinitely complex field. So, how can we repetitively practice behavioral skills?”

A metaphor I like to use is jazz. Jazz is the kind of music that utilizes improvisation as an inherent part of the craft. But jazz musicians don’t just sit down and start randomly doing whatever they want on their instruments. To become a jazz musician, you actually go through very rigorous training where you’re learning standardized ways of playing your instrument. You’re learning the same notes as everyone else. You’re learning the same theory as everyone else. You’re practicing the same way as everyone else. And when all those musical skills are moved into procedural memory, you’re then able to improvise with other performers.

VY: That’s why I never got too far with clarinet, because I wanted to improvise. I just wanted to be able to improvise like jazz, but I wasn’t willing to spend the hundreds or thousands of hours playing the scales.

TR: There’s been a lot of research that shows that slavishly adhering to psychotherapy models, kind of following them cookbook style, or doing exactly what’s in the manual with every client, actually leads to worse outcomes. So that doesn’t help either.

There’s a tricky balance where on one hand you know the skills, you’ve internalized the skills, you’ve practiced the skills. But then on the other hand, you’re very adaptable and reflexive to the client.

VY: I think what you’ve pointed out is not obvious to therapists at all, because we just don’t have that in our professional culture, in our training. As you said, so much of the focus is on theory, on reading books, on writing papers, on being able to sound intelligent in class or seminars or group supervision. What are the actual skills to practice?

TR: Many people assume that since they’ve gotten lots of face-to-face hours with clients that that should count as practice. To get a degree and get licensed, typically you have to have hundreds or thousands of hours with clients.

It only counts as practice if there isn’t a real client in front of you.

Something K. Anders Ericsson and the other researchers on expertise found was that it only counts as practice if there isn’t a real client or real engagement in front of you. So a basketball player playing a game doesn’t count as practice. A musician performing doesn’t count as practice. A chess player playing a match doesn’t count as practice. That’s all considered performance. And the reason is that during performance you can’t isolate a specific skill, and you can’t repeat it again and again and again while getting feedback.

VY: I see that in tennis. I’ve spent years trying to learn a top-spin backhand, and yet when I play matches, I’m worried about winning the point. I default to hitting a slice. I don’t do what I’ve learned.

TR: Well that takes us back to procedural memory. When we’re in moments of what we call emotional arousal, your brain immediately goes to procedural memory. That is why it’s important to practice these skills behaviorally and repeat them hundreds and hundreds of times until they’re moved into procedural memory—so you can perform them in those moments of emotional arousal.

In psychotherapy, we work in states of very high emotional arousal. We help clients who are suffering intensely. And we feel that suffering while we’re sitting with them. So we will go almost immediately into procedural memory.

VY: We don’t have a lot of experience or knowledge about how to practice skills that are fundamental in the psychotherapy enterprise. How did you figure this out since there wasn’t a manual for you?

TR: Most fields have taken hundreds of years to figure out models and methods for deliberate practice. I’m hoping that we can start this. Because there wasn’t already a model or method for doing it, I focused on what’s called “facilitative interpersonal behaviors.” These are behaviors that have been shown by research to be effective in therapy across a wide range of models. You can think of them as the basics of psychotherapy. Many of them have to do with attunement with the clients in session, components of the working alliance.

A lot of research shows again and again that the quality of the working alliance in therapy contributes ten times more to outcome than the model or anything else. Bruce Wampold has written a lot about this in his books. He calls it “the contextual model for psychotherapy,” where he focuses on facilitative interpersonal behaviors. An example of that would be tone of voice. I’ve noticed that if I’m not careful I can start speaking louder than my clients. I can talk over them. I can basically overpower them with my voice. This is sometimes due to my own anxiety that goes up in session due sometimes to what they’re presenting, or my own counter-transference.

VY: How do you work on that?

TR: I sit with my own videos, especially videos of clients that I find stir up my own anxiety, and I will practice talking to the video in a level voice. I want to be engaged.

VY: You’ll literally be watching a video and just practice speaking?

TR: Yes. If someone saw me doing that, they would think I was crazy. But think of it like a basketball player shooting, practicing free throws. They’ll just sit there doing it again and again and again, and they might do a hundred a day. So I’ll spend 15 minutes just practicing speaking to videos of clients who I find I have some anxiety with when in session with them.

VY: So you’re experimenting with different tones of voice, and kind of get that into your body, into your procedural memory.

TR: Yes. Another thing I’ll do is I’ll watch videos where there’s clients who are stalled, deteriorating, something’s not going well. I’ll watch the sessions with the volume off. And I will take notes about everything I see in terms of their body language. And as I watch that, I’ll also notice my own anxiety. Does my own anxiety go up or down based on their body language?

VY: Your anxiety in the session, or your anxiety as you’re—

TR: Watching the video.

VY: Your anxiety as you’re sitting there watching the video?

TR: Yeah. I found this very surprising at first, but just watching my own videos was incredibly mobilizing of my own anxiety, my own feelings, and my own defenses. Every therapist I’ve talked with who watches videos of their own work also finds it to be quite challenging emotionally.

It’s exposing ourselves to ourselves, and in a way that we normally aren’t. And that’s one of the reasons it’s difficult to videotape and then watch your own work. So if I can sit there watching the video and noticing the body language and noticing my own anxiety, those are two different skills I’m working on. If I can do enough of that so it moves to procedural memory when I’m sitting with the real clients in front of me, it’ll be that much easier to do those skills in the background, so I can focus on something else.

VY: And what impact did that have on your work? How did you know or notice that that was actually helping you?

TR: Well, one thing I noticed is that I have a butt-load of anxiety with a lot of my clients. And I was shocked to find out. At first I was incredibly embarrassed. I didn’t want to tell anyone. And then I realized that some people could tell anyways when I talked about it with them. And then I thought, keeping it secret is not going to help anyone.

One thing I noticed is that I have a butt-load of anxiety with a lot of my clients. And I was shocked to find out.

And then I realized most therapists have some degree of emotional reaction. I’m a psychodynamic therapist; we call this “counter-transference.” But I also found that there’s a certain level of anxiety that’s kind of universal working with all of my clients. So I don’t know if it’s individual counter-transference from a certain client, or it’s just me.

Some of it might be a sympathetic reaction to what the client is bringing up. Some of it is just my own material. Some of it is wanting to do a good job. And there’s just a certain level of anxiety always going up and down within me during a session. I’m still not really good at this, but I’ve gotten better at tracking that in the background during the session. I can use it psychodiagnostically. So if a client is talking about something that really bothers them, but they’re good at hiding it in their words or even nonverbals, I can often feel their anxiety within me. A sympathetic reaction to their anxiety within me. There’s a clue there.

VY: Using yourself as a tool.

TR: Exactly. When I talk about deliberate practice, people often assume I’m talking about CBT or behavioral therapy, but that’s not accurate. The most benefit I’ve gotten from the deliberate practice methods has been with the more dynamic interpersonal/intrapersonal aspects of therapy.

VY: What do you mean by that?

TR: The more subtle, intuitive sense of myself and the transference roles being played out between me and the client, what I feel pulled to do with the client, how that might be repeating old problematic patterns from the client’s life. How my own counter-transference might be getting stirred up, and I might be guiding the client towards or away from material in ways that are unhelpful. How I might be retreating.

I’ll give you another example. A supervisor once pointed out that I was being critical of a client. I was horrified by this. Horrified. My job is to be empathic, not critical. And if you read the transcript, I was not coming across as critical. In the transcript, I was coming across as very supportive. But he said, “Listen to your voice. It’s critical right here.” I was embarrassed to admit it, but I actually had a sharp edge in my voice. And that was due to my own counter-transference.

VY: Whether you use the term counter-transference or not, or whether you work with a model that has transference or counter-transference or intersubjectivity, or as an important part of a theoretical model, those things are happening anyway.

TR: Yes.

VY: There are feelings between client and therapist that you’re feeling drawn orcompel us to do compelled with certain thing with certain clientsclients to do certain things, whether you act on them or not, whether it’s to support them, whether it’s to tell them what to do. Whether you feel detached or bored. Or whether they pull on your anxiety in one way or the other. Those types of dynamics are always occurring, whether you’re paying attention to them or not.

TR: Many of us know this from reading the theory, but we haven’t practiced actually noticing it in the moment. We practice it with real clients, but that doesn’t count as practice. So, one of the ways that I have addressed this is I’ll sit and watch videos of clients where, again, they’re stalled or deteriorating. And I will just write down what do I feel pulled to do. Do I feel pulled to save them? To criticize them? To support them? Or what role do I kind of want to be in with them?

And over time, doing this again and again, and again, I’ve built my ability to observe that as it happens in session.

VY: So the final idea in deliberate practice is continuously assessing performance. Usually we think that most of our training belongs in graduate school or early in our careers, when we’re interns or psych assistants, accumulating our hours. But you believe that if we want to achieve our maximum proficiency, we should be like other professions and keep doing whatever is necessary to get to the top of our game.

TR: In pretty much every other profession, professionals have to engage in continual deliberate practice throughout their entire career. And if they don’t, they stall, and then gradually decrease in effectiveness.

VY: Let me just challenge you on that. If you’re a professional athlete or musician, yes, you’re going to spend hours a day practicing. Most other professions, I think, you don’t do that. If you’re a surgeon, you do surgery. If you’re a lawyer, you do legal work. You’re not setting aside time to actually practice being a lawyer or a surgeon.

TR:

Competency vs. Excellence

Surgeons actually do set aside time now, and they engage in repetitive behavioral simulations. For other fields, including psychotherapy, it is possible to stay at a level of competence without deliberate practice. So I believe most therapists are competent. In fact, by the end of graduate training, most therapists are competent. Overall, the outcome data for psychotherapy is pretty good. It compares favorably to medicine in many ways. Our deterioration rate of 5 to 10% is actually not horrible. The rate of complications or side effects is very low. The rate of legal problems, people suing us, is relatively low. Overall, we perform a competent service, right? And you can stay an absolutely competent therapist your entire career without using deliberate practice.

Now if you’re an accountant, you might not need to get better. Being competent might be totally fine for your livelihood. Or if you’re a lawyer, being competent might be totally fine for your livelihood. And I’ve met musicians who don’t engage in deliberate practice. They’ve found a level of competence which works for them and they’re totally happy with that. That’s totally fine. For me, it’s not satisfying. It wasn’t satisfying. And it still isn’t satisfying. But that doesn’t mean that it has to be appropriate for everyone.

VY:

You can stay an absolutely competent therapist your entire career without using deliberate practice.

I know that for several years your wife got a job at the University of Fairbanks and you were up there with a lot of darkness. And you used that time productively by learning about deliberate practice and some of these exercises you’ve just described. For therapists that are reading this and are intrigued, and do have that desire to up their game, in addition to reading your book—which is wonderful and well-written and also very funny at times—what would you advise them to do in terms of utilizing these principles?

TR: I’d recommend a few things. One is record your work. Video is really the most effective way of doing that. Using video for consultation supervision is now becoming more and more recommended across the field, and I have advice in the book about how to start videotaping your work. I want to emphasize that this is especially true for psychodynamic therapists, who are traditionally the most resistant to reporting their work.

VY: A lot of therapists worry that their clients will be put off by that.

TR: There’s been a bunch of research on this, and they’ve found that clients in general don’t mind. The client wants to get better. That’s really what the client is thinking about. I don’t mandate recording video for all my clients. I always ask them and it’s always optional and 10 or 20 percent say they don’t want to do it. I don’t argue with them about it.

VY: So you think it’s the therapists who are more uncomfortable about it?

TR: The research shows that, absolutely. Mark Hilsenroth, a psychodynamic researcher, and colleagues did a study recently where they gave the clients questionnaires about using video, and most of the clients were like, “fine, no problem.” They just want to feel better. When I go to the doctor, I’m like “do whatever you got to do.” I want to feel better. That’s what I’m thinking about. However, they also gave the questionnaires to therapists, and they found that when the therapist was uncomfortable with video, the clients were more likely to be uncomfortable with video.

I almost got fired from one of my first supervision jobs because other supervisors were uncomfortable with me using video. Therapists can be very uncomfortable with it, which I find to be quite ironic. Because the clients don’t seem to mind much.

VY: How do you introduce it to clients?

TR: I’m very upfront with the client. I say, “ I’m a human being, I make mistakes like everyone else. And if we record the session, and I can look at the videos later, or show them to experts for consultation, I have a much higher chance of spotting my mistakes. And then we can address them and then I can help you more.”

VY: It makes so much sense. And as you say it now, I recall early in my career, maybe in my internship when we audio recorded our sessions, the idea that I might make mistakes, or that I was getting supervision or consultation, filled me with a lot of anxiety. I think that’s more reflective of the state of anxiety that many beginning therapists feel. And as you mature you realize you’re not perfect, that you don’t help everyone, that there’s always more to learn. Certainly a maxim in psychotherapy is that there is no end to what clients can learn about themselves. There’s certainly no end to what therapists can learn about themselves, including how to be a better therapist.

TR: I’ve found through watching years of my own tapes that if I work with a client for two or three sessions, I’ve already made a mistake. Honestly, I probably made a mistake in the first session, which sometimes can take two or three sessions for me to see. So if I’m not seeing my own mistakes by the third session, it means I’m missing something. And I’m okay with that.

I don’t think being an expert means never making mistakes.

I don’t think being an expert means never making mistakes. It means knowing how to spot your mistakes and correct for them in a timely way.

VY: All right. So you’d encourage therapists first to start video recording their sessions. And then what?

TR: To get expert feedback from someone that they trust. It’s got to be someone you feel good about it. A good supervisor is able to get under your skin. You were able to notice something in my voice. And that’s personal, that’s intimate. And it was okay because I trusted you. We had a good relationship. Without a relationship like that, it’s going to be hard to get the necessary feedback. Ideally it’s a long-term relationship. A lot of our trainings are these one-off weekends or series of two or three weekends, where you’re getting a big knowledge dump, but no one is looking at your work. You’re not getting individualized feedback. And then you’re not getting ongoing long-term feedback. But that’s what’s necessary for the skills to improve.

VY: I think that may be changing. Some of the approaches that we’ve just been making videos of—motivational interviewing and emotionally-focused couples therapy— actually have a lot of that integrated into their ongoing training, where you have to submit samples of your work and get feedback on it. But what you’re saying makes a lot of sense.

Research shows that most therapists think they’re well above average, which statistically is impossible. How do we then go about choosing a supervisor, a consultant, who is good?

TR: This is tricky because I don’t know any supervisor who tracks their outcome data or reports it to people who are approaching them for supervision. At this point all we can really go off of is our gut sense, and occasionally we can watch videos of our supervisor’s work. I found you because I met you and had a good feeling about you. And then as we did supervision together I found it was helpful. But ideally we’ll have a more empirically rigorous way of assessing that in the future.

VY: I tell therapy clients to meet with a therapist a few times. If it doesn’t feel helpful, you may want to discuss with them what feels good, what doesn’t feel good, and see if they’re open and receptive to hearing that. If they’re not, or the therapy doesn’t feel helpful, try someone else. It’s too important not to.

So get a coach, supervisor, a consultant. And then what?

TR:

Track Your Outcomes!

Another thing I recommend doing is tracking your own outcomes, and then using some kind of empirical measure to do that. The outcome ratings scale is a great measure to use. It’s free. It’s easy to use. There are dozens of other measures available. There’s the Outcome Questionnaire. There’s the Behavioral Health Measure. There’s measures made for different settings, like universities, or working with children. And accumulate your own outcome data over time. And over years you’ll start to get a picture of how effective your practice is.

One of the reasons I started doing this is I had a supervisor look at my work and she thought I was doing horrible work. In fact, she said, “You want to kill your clients.” I was shocked. I knew I had made mistakes but I didn’t think I was that bad. But I didn’t have any data; it was just one opinion versus another. This is one of the reasons I doubled down on collecting my outcome data. After a year I had enough outcome data to look at my practice and see that overall I was helping the majority of my clients.

I definitely still have dropouts and deteriorations, but it helped my self-assessment be more level. Before then, there were some weeks I felt like Superman. I felt like everyone was getting better. And then some weeks where it seemed like everyone was getting worse. Of course, neither was ever true.

VY: But we certainly have days like that. If you’re in private practice and you have a few dropouts, or a few no-shows, it’s hard not to feel like something is wrong with you. So getting long-term outcome data is kind of a buffer for that.

TR: I found that my outcomes at my private practice in San Francisco were pretty good. The outcomes at the university counseling center in Alaska were not as good.

The outcome data never looks all good. And it never looks all bad.

Maybe that was due to the setting, the clients, maybe it was due to the darkness. Maybe it was because I was on the edge of being depressed because I was in the middle of Alaska. I mean, it could have been any number of things. Back here in Seattle, the outcome data is looking a little better. But importantly the outcome data never looks all good. And it never looks all bad.

VY: So it’s not so bad that you think you should hang up your shingle. And it’s not so good that you think, “I nailed this. I can coast.”

TR: Yes. Correct.

VY: So people start recording their sessions, getting a consultant in a long-term relationship, but the rubber meets the road with deliberate practice. What would you recommend to help people get over the initial hurdle, because I imagine it’s a big hurdle to actually sit down and do some of these solo exercises that you recommend.

TR:

“It’s the thing I look forward to least in my day”

It is a big hurdle. It’s the thing I look forward to the least in my day. It’s the thing I put off the first in my day. I would rather go to the gym, pay my taxes. In the recent election I was making get out the vote phone calls, which is a very stressful thing to do, and I found that I would do that before my deliberate practice. So it is very, very stressful. And unfortunately in our field it’s not recognized. It’s not rewarded. You’re not compensated for it. Your clients don’t know you’re doing it. Your peers don’t know you’re doing it, or don’t care. A licensure that never asks, or doesn’t care if you do it.

VY: Your spouse may prefer that you go wash the dishes, rather than sit and talk to yourself on video.

TR: Exactly. And to add to that burden is the fact that there are not immediate payoffs. They call deliberate practice short-term effort for long-term gain. So here’s what I do: I think of the therapists who are really, really good who I want to be like. And I know from talking with them that they got that good by engaging in hundreds or thousands of hours of watching their own videos. I’m not smarter than them. I’m not more talented than them. If I ever want to be that good, I’m going to have to put in that time.

The same way that if I wanted to be a really good basketball player, or a really good anything else. It might not make me as good as they are, but it will definitely move me in that direction. I have a reminder that pops up on my computer every day that says, “How good do you want to be in five years?” Now, if that day I don’t really care how good I am in five years, I won’t do it. And that might be fine. I might feel like I’m good enough, and that’s totally fine. But as of today, I still want to be that much better in five years.

VY: Well, I admire what you’re doing. And I’m gratified that I was able to impart some wisdom that was useful to you. It’s lovely to have this conversation and to have been able to read your book and have the tables turned and to be able to learn some very valuable things from you, Tony.

TR: Oh, thank you. To be interviewed by you for your website, it’s a great honor.

VY: I would encourage anyone who finds these ideas interesting to go out and grab your book and read it. Although it is chock full of research citations to back up what you’re saying, it’s not just idle theory. It’s also chock full of funny stories, humorous anecdotes, and I guess I’d like to just leave our audience with one of them. Can you tell the story about the job at the university?

TR:

Professional Identity Politics

Sure. My wife was applying for a job at a university in the West that really wanted to hire her. It was a very small town, and it was full of therapists, so I didn’t think I could just start a private practice there. She’s a wildlife biologist and the ecology department at that university that wanted to hire her were trying to arrange what’s called a “spousal hire,” which is something traditionally done in academic circles when they want to hire a person and there’s a spouse. They call it the “two body problem.” So they went to the university counseling center and they said, “We will give you money, we will pay for the salary if you hire Tony for three years. Part-time. Just so we can get his wife. We don’t care about Tony, but we want his wife, and Tony comes with the wife.” In other words they could have had me as a part-time therapist for three years for free.

We’re more like religions than any kind of public healthcare service.

They asked me to submit videos of my work as part of the application process and I thought, “This is great. I’ve been videotaping my work for years now.” So I sent in some videos and went in for the interview and they were horrified by my work. The style of therapy that I do is short-term psychodynamic psychotherapy. It’s a bit more active and engaged and I work actively with the client’s feelings and defenses. They were doing a more traditional long-term, reflective approach of psychodynamic therapy. When we were watching the video they kept asking, “Do you think this is appropriate for the client?” I kept saying to them, “Why don’t we look at the client outcome data. Why don’t we look at how the client responded?”

It’s like we were having two different conversations. They weren’t really concerned with how the client was responding. They were concerned with the model of therapy I was using. It made me realize that we’re more like religion than any kind of public healthcare service.

VY: You wrote in your book that they weren’t interested in your outcome data any more than a church would want to see how many meals a Buddhist monk had provided to the poor!

TR: Exactly. If we don’t collect our outcome data, if we don’t look at our work, we get unmoored from the outcomes, and we get stuck in professional identity politics where have all these debates about obscure theory because we don’t have actual outcome data to look at. They actually liked me as a person. They said, “You’re such a nice guy. It’s a shame it’s not going to work out.” But they didn’t accept me, and so we couldn’t move there, she didn’t take the job.

VY: The interesting thing is you were both in the general rubric of psychodynamic therapy where oftentimes the clashes are most intense.

TR: Yes.

VY: I had a college roommate who was a Leninist and he would go to some Communist convention. Probably less than a very, very small percentage of the population consider themselves Communist. And instead of coming back with a Kumbaya feeling, he would come back and report to me the big clashes between the Stalinists and the Leninists.

And even now with this emphasis on evidence-based treatments, or so-called evidence-based treatments, there’s a clash often between modalities, not taking into account that the data finds that modalities and theories do not explain outcome.

TR: If anyone ever talks to you about evidence-based treatment, ask them whose evidence. If it’s someone else’s evidence, it is not correlated with your personal outcomes as a therapist. There’s been study after study after study showing that though the models are proven very effective in clinical trials, when taught to therapists they don’t improve the outcomes of individual therapists.

Until evidence means our individual evidence, we’re not really doing evidence-based therapy.

Until evidence means our individual evidence, we’re not really doing evidence-based therapy. We’re working from someone else’s evidence.

VY: Well thank you so much for taking the time to share your journey and your expertise with our readers. Even though you humbly claim not to be an expert therapist, you certainly have accumulated a great deal of expertise on how to become an expert or master therapist.

TR: Yeah, I am learning a lot about how to become one. And thank you for having me. It’s been wonderful.

Note: Tony’s latest article, "What Your Therapist Doesn’t Know," has been been published in The Atlantic.

Why Clients Choose Online Therapy

Posted on February 9, 2017February 11, 2026 by Psychotherapy.net Team

When I think about why clients choose online therapy, the first intuitive answer that comes to mind is about convenience: the comfort of being in your own office or home, no travel necessary, the time saved, and the possibility to have sessions during a work trip or a holiday.

For many of my clients online therapy was the only practical option. For example, I have worked with refugees or expats unable to find a therapist speaking their language within reachable distance. I have other clients who are constantly on the move, and don’t stay in one place long enough to engage in a stable therapeutic relationship (their peripatetic existence may indeed be a topic to explore in the therapy). I also work with women from some very conservative parts of the Middle East, for whom a therapist outside their country is the only way they are willing to open up and explore their religious beliefs, or their experience of oppression, without the risk of being judged or possibly persecuted.

In other, less dramatic cases, online therapy becomes the best choice for certain deeper psychological reasons. One such underlying reason is shame.

A feeling of extreme shame, of not being enough, freezes us, and makes reaching out for therapy nearly impossible. When the potential support is just one click away, and there is no physical exposure involved, we can take that step more easily. There is always the option to keep the camera off, which already reveals a lot to the online therapist.

Tim, a policeman from Ireland, had always suffered from shyness. He had grown up in a narcissistic family, which had left him with a deep sense of not being good enough. His father openly referred to him as a “failure” and the “biggest disappointment of his life.” He had sought traditional face-to-face therapy before, whilst struggling with drinking and depression, but hadn’t trusted the therapist enough to open up and expose himself to his potential judgment. He felt that his parents never really saw him, and any close emotional or physical contact seemed unbearable for him. Bound by shame, he had retreated into loneliness, which was his only safe space.

In the early sessions he would talk “at” me, and seek little input. His camera would easily get wobbly, focusing on a far corner of the room, avoiding his face: it seemed to enact his hidden desire to flee.

Later on, we explored the deeper reasons for his choice of online therapy with a foreign therapist. Tim reckoned that he felt safer this way: the distance between us and the differences in our cultural backgrounds made him feel more relaxed, allowing him to grade his exposure.

Another case, which comes up often with expats, is their tendency to develop extreme self-reliance.

As for Lucy, a Canadian aid worker based in Rwanda, she felt disillusioned by traditional face-to-face therapy. She had never been able to trust any of her therapists. All her previous attempts to get some support had only confirmed her belief that she could only “make it on her own.” This time, in the middle of an extremely unsafe environment, rigged with the weight of huge responsibilities, added to loneliness, she decided to give it another try and reach out to an online therapist.

At times, Lucy’s extreme self-reliance and difficulty in trusting others made our work challenging for both of us. But she gave it a chance. Letting a face on her screen slowly become a person, she allowed our therapeutic relationship to develop. She eventually learned how to trust again and receive external support. Paradoxically, a virtual online therapist facilitates the development of trust, especially when it seems nearly impossible. Turning potential obstacles into advantages is one of the creative challenges of online therapy.

In the same way as our clients do, therapists may display the avoidant attachment style and be uncomfortable with too much intimacy. Carl Rogers admitted that the intimacy he was able to develop with his clients in the therapy room "without risking too much of his person" compensated for his inability to take such risks in his personal life. I guess he would have become a keen online therapist…

The requirement for therapists to have an experience of personal therapy is an important one. I argue that any therapist offering his services online should go for an online therapy himself, experiencing the process “from the other side of the screen.”

My own personal therapy online helped me enormously to offer a better service to my online clients. The sensitivity and generosity of my “virtual” therapist also has continuously guided my work.

My choice for online therapy must have been influenced by my own displacement, and I often recognize in my clients who have left their country of origin, a familiar self-reliance.

Therapy is also about letting somebody else give you a hand.

Giving people who experience shame or extreme self-reliance the option of a seemingly easier way into therapy is not a trick; it is a gift to those who may otherwise never take the hand that is there to help them work on improving their lives.

If You Kill Yourself, Don’t Make a Mess: Paradoxical Intention with a Suicidal Client

Posted on January 24, 2017February 19, 2026 by rezendevknowfully.com

"Maybe I was happy for like a day or two”

Marcus once told me he has no memory of what it feels like to not suffer. You’re exaggerating, I told him. He insisted he wasn’t. You are, I fought back. Everyone has such a memory, at least one. Marcus concedes little.

“Well, maybe I was happy for like a day or two.”

“That’s it?”

I’m visiting Marcus in a psychiatric stabilization unit. My task this morning is straightforward but not easy: confirm that he won’t harm himself when he leaves this place, and that he’ll take his medication. “You mean, not think about it?” he blubbers, in response to my direct question whether he’ll kill himself once he’s released. “I think about it all the time.” Coughs. “It don’t mean I will. And it don’t mean I won’t. So that’s that.”

Marcus is rotund and bald, with a noticeable stoop when he stands and a limp when he walks, as if he were an octogenarian trudging through the day under the invincible weight of his age. But he’s not yet even forty.

I walk over to the large window and open the blinds. “Is this okay?” I ask.

So thorough is Marcus’s lethargy that it would take supreme effort to imagine him at any point in his life gamboling joyously while soaking in the sunshine. The way he slouches, the way he mumbles and mutters, the way the sagging flesh on his face seems to collect around his neck, the way his drooping eyes make him look like a human bloodhound, the way he wears his bedraggled clothing, draped tent-like over his fatness—all of it, from his unlaced Converse sneakers to the labor of his breathing, speaks to the torments inflicted upon him as a child and the torments he inflicts upon himself ever since because that past is no mere residue of memory but instead exists within the corpuscles playing bumper cars in his veins. Marcus’s past is vastly alive inside him.

“Knock yourself out,” Marcus says. “I like it dark but it’s fine.”

I can see it more clearly now, with the sunlight drenching the room. The discolored bandage on his neck, the one that covers the stitched-up gash. It is puffy and loose. Like a cloud stained by urine. I ask if I can see the wound.

“For what?”

“For fun,” I say, winking.

Marcus tugs gently on the urine-cloud bandage. All the while he is mute, tongue sliding through soft lips, not unlike a narcotized snake. His tai-chi pull reveals the inch-long railroad track a little off-center on his pink, fleshy neck, the entire slow-motion divulgence giving the unveiling the feel that something ceremonial—no, something intimate—is happening.

The Real Nature of Suffering

Intimacy is what good talk therapists hope to achieve through this special encounter—which is why I strongly hold the view that talk therapy is a kind of artistry, for all art stems from an encounter between the artist and the subject, wherein the two become entwined in an intimate collaboration. What I mean by intimacy in this context is that a special kind of healing can occur when facades fade away, when neither person sees the other as potentially useful, which is to say the other is not a means to an end, the other is not expected to perform a function in one’s own advantage-seeking scheme, where the other is not to be used in some way (subtle or otherwise) to get some wanted outcome.

So talk therapy is something entirely different from having a rap session. An hour of heartfelt exchange without a handheld computer vitiating the experience—that right there makes it sadly unique. We might think of lovers sharing an intimate moment, but when there is the subtle (or not-so-subtle) underlying quest to keep the other close because the other serves the useful function of bringing about an inner experience that we have become attached to (meaning, we love the other’s presence because of the ability that the other has in bringing about a certain feeling within us), the intimacy is tainted thereby. Healing intimacy, I mean to suggest, and the face-to-face encounter that gives rise to it, is untainted. And it is this sort of intimacy that creates opportunities for the therapist to connect with the real nature of suffering.

The real nature of suffering—what is that? Well, I’m looking at it as I look at Marcus’s sagging face, with his eyes barely visible and his lips now sucked into his mouth. I hear it in his mumbling, the gravel, scratchy vocalizations that evoke a sense of futility about life. “No matter what Marcus says, the way he says it conveys his attitude that the whole enterprise of living is fruitless and cruel.” To Marcus’s way of thinking, life consists of events that happen to you; events are rarely neutral and they surely are not participatory; events by and large inflict suffering and there isn’t much to be done to exert control over them. All that is to be done is to take cover.

The existentialist philosopher Martin Heidegger and Doors singer Jim Morrison speak of our being “thrown into” the world, which is to say we have had no say (unless you believe in karmic reincarnation) in what our fundamental life circumstances will be. Will we be born in an affluent country or a war-ravaged one? Will our parents be wealthy or will they be drug addicts? Will they be skilled in the art of parenting or will they mutilate the child’s soul through mental torments or physical deprivations? A pile of shit or a basket of rose petals, or something in between—you don’t get to choose which you get thrown into. I’m sure Marcus has never read a word of Heidegger and I doubt he has ever grasped Morrison’s reference to “thrown-ness” when he sings, “into this world we’re thrown.” But Marcus understands thrown-ness in a way that few do. His understanding is purely experiential, and thus utterly non-conceptual. And that is why it is pointless to talk with him right now about choice and responsibility and meaning—all core concepts in my therapeutic repertoire, but useless at this moment.

His is an attitude of hopelessness, a recalcitrant, immutable belief that his emotional pain is permanent. But there is much more to it, as I see it through my own existentialist lens. Depression might be a clinical description of how Marcus experiences his life, but to restrict ourselves to that misses the deeper truth. Being depressed is, for him, a strategy, in the same way that the fox’s “sour grapes” in Aesop’s fable is a strategy, an emotion experienced to deflect something more painful. Depression is his cover. He has learned to use it—learned helplessness, one might say—to announce to the world that he is not responsible for his choices, that he cannot be blamed or held to account for his many self-sabotaging acts. In effect, helplessness and dysphoria serve as protection against the rigors of transcending his life circumstances. Depression protects him from any demands that he relate to his own life as a process of creation and the living of it as a kind of artistic endeavor.

"I'm Surprised You Used a Knife"

“Does it still hurt?” I ask.

Marcus taps on the wound with two fingers, as if to test it. “Nah,” he says. “Not if I don’t turn my head.”

“I’m surprised you used a knife,” I say.

Marcus had told me early on, repeating it often, that he envisioned himself going into the woods and shooting himself in the head. A fantasy perhaps, some aesthetic end to his particular decrepit story, as if a gun-blast obliterating the cranium in a quiet forest is the quintessential response to an ugly and alienated existence. A worthy denouement to a life of unmentionable sorrow that, though silent to the rest of us, now screams inside his head. A knife? No, I’m sure of it—he’s never mentioned that that would be a suitable instrument to effectuate his escape from the tribulations of his life. And bleed himself out on his mother’s kitchen floor like a slaughtered pig? Not the Marcus I had come to know. He had told me a gun-blast to the head in a secluded area of the woods, a spot he had already designated in his death-welcoming mind, would not leave a mess for others, as if his remains would be shoveled and disposed of with no more ceremonial fuss than the discarding of road kill.

He’s a complete mess inside and yet he has this concern for the mess he might leave when his inner mess becomes too intolerable.

Marcus and I have talked of suicide and death from day one. “Day one,” and many days thereafter, was in his a squalid single-room occupancy hotel. Existential therapy in a paint-peeling, cigarette-smelling room with a mattress on the floor, a small knee-high table abutting it—so much easier to roll cigarettes that way—and an always-on large flat-screen television five feet away. “I think about it all the time, every day, it’s how my life is.” Usually in the morning: such thoughts to be considered before he heaves himself off of the mattress to endure more inconsequential suffering. Not one session ends without him mentioning suicide.

I always make it a point to demonstrate that I’m unafraid of the subject. We’ve even laughed together over how naïve so many are to think that our so-called “survival instinct,” our presumed “will to live,” ineluctably trumps our desire for self-destruction. Self-destruction, alongside myriad habits of self-numbing, is so omnipresent in our world that it seems absurd to think that we humans actually do treasure the gift of living.

If we treasure life, really treasure it rather than just give lip-service to it, then why so much squandering of it?

“What does anyone know about living?” Marcus had said to me once. He wasn’t really asking me a question. He was declaring his own wisdom, his own hard-earned wisdom, the only kind of wisdom that’s worth a damn.

His remark reminded me of the scene in the Vietnam movie Platoon where Sgt. Barnes, the dark character competing for the soul of the Charlie Sheen character says to a group of young soldiers who are smoking pot: “Death? What y’all know about death?” Sgt. Barnes, with his scar-chiseled face and pain-knowing eyes, has undoubtedly peered into some abyss and thus has little patience for the young soldiers who seek escape and avert their eyes from the abyss through petty distractions. I don’t recall how I answered Marcus. But I do remember being impressed by the fact that he understood so well the interdependence of life and death, that to understand life one has to understand death. Not that Marcus spoke from a place of understanding death—far from it. He never spoke with any particularity about how contemplating death might bear on the artistry of living.

“I became an altar boy when I was 12,” he continued. “Did that for a few years. Father Lewis didn’t know nothin’ about living. I’ve seen psychs, therapists, energy doctors, fuckin’ you name it, and none of’em knows a goddamned thing about living.”

Not much to argue with there. I told Marcus that hardly anyone knows anything meaningful about how to live. How pathetic we are, I told him, the vast majority of us in the land of plenty, in the art of living. How can we know? After all, we lack a vocabulary for it. In this money-making, status-seeking, distraction-obsessed culture, we’ve lost the capacity to talk about it; we’ve lost the tools to even think about it in any serious way. Marcus lit a cigarette, offered me one, and as I waved him off I realized I had lapsed into preacher mode. I’ve been prone to do that.

I always refrain from talking Marcus out of suicide. He has commented on that fact a few times, usually to express gratitude for not doing what other health-care providers do—tell him that it would be best to forge ahead (best for whom?), that things will get better (how the fuck do you know things will get better?), that killing himself would only leave a legacy of pain (oh, I get it, I should suffer through life out of obligation). I never take that approach, for two reasons.

First, I think it is useful to look upon the urge to kill yourself as arising from a “self” that wants to manage the pain (which includes vanquishing it entirely). That managerial “self” must exist against another “self” that generates and experiences the pain. There is thus a polarity within the suicidal human organism: the managerial “self” who can’t stand the pain polarized against the pain-experiencing “self” who just won’t stay sequestered in some psychic locker tucked away among all the other toys in the attic. To preach at the managerial “self” about the folly of suicide, to guilt-trip the managerial “self” or appeal to that “self’s” sense of obligation, only leads to an intensified desire to commit suicide because it ignores completely the interplay of the polarities within the human organism. The polarity itself needs to be addressed.

Second, I don’t believe in the notion that living is an obligation and I don’t think it is truly therapeutic to signal such a notion to others, including those in despair. It’s an implicit mental model that generates ripples of more pain and suffering. I’m not one to promote to a desperately suffering person the brightly lit news of how wonderfully magical life can be, if only you just hang on. I do the opposite: I go towards the darkness, the pain, even the madness itself; I climb down into the pit of despair and sit with the person and ask questions like What’s holding you back now? What’s held you back in the past? Why haven’t you’ve given up already? Usually that sort of questioning arouses a spirited discussion, led by the client (a crucial fact), about what makes living worthwhile. It can often take a while to get there, but I have found that it almost always happens.

"If I Had a Gun"

I ask him again to tell me about his choice of killing implement, this time with a forward-leaning posture and a hand-slicing gesture, using my body in the way I used to do in my former life as a courtroom lawyer cross-examining witnesses. “I would have used a gun,” Marcus explains. Silence, for two beats, and then he adds, “If I had a gun.” He taps the wound again. “All I had at the moment was a knife. So I. . . .” He falters in his speech, as he often does.

“So you used it,” I say to complete Marcus’s sentence. He nods. “Small wound,” I add. “Scary, but small.” He shrugs. He tells me he doesn’t want to talk about it anymore and I tell him sure, no problem.

Do It Day

A week passes and I visit Marcus again, this time to prepare him for discharge. But first I have to make a judgment—can Marcus leave this place?

“Look, Marcus, you keep talking about killing yourself and sometimes you do stuff like—hell, you know, you cut your throat, for Christ’s sake.”

Marcus interrupts me. “Yeah, and I wouldn’t be here right now if I had a gun around. I woulda killed myself a long time ago. I woulda killed myself a lot of times.”

“Yeah,” I say, holding back a laugh. I guess I’m not too successful because Marcus asks me, with a stupefied look, what’s so funny? And I tell him nothing and he insists that he wants to know so I tell him it’s just the shit you say, Marcus, and he asks me what shit? and I tell him you just say funny shit sometimes and the fact that you don’t know that it’s funny just makes it funnier. Marcus shrugs and he smiles wanly. That’s my cue to push forward and quit the banter.

“Anyway,” I say in a low register, “I get that you always think about it. But let’s talk about doing this whole thing right.” Marcus perks up. His lips separate and form an oval. “First off, let’s set a date. No messing around. Let’s write it in your calendar.” Marcus has a paper calendar taped on the wall near his bed. We go back and forth about a suitable day to “do it” and Marcus keeps saying this is ridiculous, it’s fucking ridiculous and I keep countering no it isn’t, we need to do this right, and then he says stop messing around, Dan, and I tell him I’m very serious right now. It’s early April and we discuss Memorial Day as “Do It Day.” Marcus keeps repeating this is ridiculous, fucking ridiculous, and then—

Paradoxical Intention

Paradoxical intention is what Victor Frankl called it in his book, Man’s Search for Meaning. The fundamental idea is that of going towards, rather than away from, the peril, the darkness, the pain. Resistance and evasion prolong and intensify suffering; healing is predicated on overcoming. Still, ushering a client towards the distress is frightening, which is probably why Frankl’s paradoxical intention is most often restricted to treating garden-variety phobias. I don’t use Frankl’s technique in any formalistic way. I use it more by happenstance because it accords well with my Zen training, which in turn harmonizes with my therapeutic orientation towards existentialism. That probably explains why I am not frightened to use it with Marcus. My time in a Zen monastery was replete with exercises in paradoxical intentionality, largely invoked to lighten the practitioner’s attachment to “self.”

He relents.

“What difference does it make?” he says, clearly exhausted by the rapid banter. “Let’s make it Memorial Day then.”

I ponder that date, staring at the calendar. It’s a free calendar with a Walgreens logo and a photo of two youthful faces, white male and black female, bearing happy smiles, the cliché image of human joy and social progress. “No, not then,” I say.

“Why not?” Marcus asks.

““You should have one more summer before you call it quits. It’d be stupid to waste a summer, get what I’m saying?””

“No, I don’t.” He starts to rise off the bed. “C’mon, let’s get me signed outta here. That’s that, huh?”

“Summer! Dontcha want one more summer?”

Marcus considers my expression. I feel exuberant, like I’m proposing something wild and fun, maybe even sinister. “Yeah, you’re right,” he says gamely.

“That’s the spirit. Live it up and then do it on Labor Day.” I reach over and pull the calendar off of the wall. I find September and I write “The End” in the little box for Labor Day. Marcus is looking at me with electric eyes. “But here’s the deal, Marcus. I’m serious about this, so listen to me.” I pause, wait for the emotional gravity of the moment to hit. “You can’t back out of this. If you are feeling then what you are feeling now and like you’ve felt in the past, then you have to make Labor Day the last day of your life.”

He nods but I can tell he’s puzzled and yet interested in this therapist-led madness. I tell him we are going to designate a place for The End but that we’re not going to do that now because it’s worth thinking hard about since it’ll be a really important event and we need to treat it as such. I insist that he promise me that he will not harm himself in any way before Labor Day.

“Understand, Marcus? You need to promise me that.” I get him to promise. “But there’s one more thing, Marcus.” I say this solemnly.

“What’s that?”

“This is crucial. This is the key to the whole deal.”

“Fucking what?” Marcus is no longer slouching. He stopped slouching several minutes ago but I’m noticing it now.

“You only get to do it—it’s only The End—if you live it up this summer. You have to go to the beach, like, every day. You have to ask women out and not give a rats-ass if they say no. You have to . . . you know . . .”

“Get laid?”

“If that makes you happy. And I want you to go to the library and go on the Internet and make a reservation for a campsite in August.”
“I love camping,” he says.

“I know, Marcus. You’ve told me that before. That’s why I’m telling you now—I’m telling you, you hear?—to reserve a campsite.”

“Willya come out? To the campsite, I mean.”

“Sure,” I say hastily. I grab his knees, squeeze them together. “Listen to me, man. You have to live it up this summer and then you can do it on Labor Day. You must do it on Labor Day.” I let go of his knees and lean back in my chair. “Unless, of course, you aren’t depressed anymore like you are now.” Marcus picks up the calendar from the floor where I dropped it. He studies it. “Deal?” I say.

“Deal,” he says.

We shake on it. Then I leave the room and return with a legal pad. Marcus asks me what I’m writing and I tell him I’m writing an “Odysseus agreement.”

“What’s that?”

“It’s a thing you sign. It’s your signed promise not to harm yourself, and if you do feel like you’ll harm yourself, you’re promising here that you won’t, that instead you’ll call nine-one-one or somehow, someway, get yourself to the hospital.”
“What’d you call it?” he asks

“An Odysseus agreement is what it’s called.”

“A what?”

“Hey, Marcus, what does it matter? Let me write this and you sign it. Okay?”

“Yeah, okay. So that’s that. But what’s with the name?”

“Marcus, lemme write this,” I protest. “Sooner we do this, sooner we get you signed outta here. That’s what you want, right?”

“Yeah, but what’s this Odys thing? Never heard of that word.”

“O—dyss—e—us,” I say, as I put the pad and pen on the floor. I explain to Marcus, because he really wants to know, a bit about the Homeric poem, The Odyssey—about the gore and blood-thirsty violence, about vengeance and honor, and I tell him that back then, in ancient Greece, they valued things differently than we do nowadays. Heroism, courage, unflinching acceptance of death. “Back then, to be respected and to have self-respect, you had to have conquered your fear of death.”

“Sounds like The Gladiator,” Marcus says, referring to the Russell Crowe movie.

“Yeah,” I say, “the Greeks influenced the Romans.”

“So why is this thing you’re writing called what it’s called?”

Odysseus, the hero in Homer’s classic, requested to be tied down to the ship’s mast because he couldn’t trust his ability to withstand the call of the Sirens. I explain the whole scene to Marcus and he gets it.

“Oh. So, signing this piece of paper, that’s like you tying me down to a pole on the ship.”

“Exactly.”

He laughs. Not a chuckle, but a real laugh. “Go on, then. Write it and I’ll sign it. That’s that.”

Postscript

Marcus is still alive. He discovered that “living it up” isn’t as easy as one might think. Working with Marcus reminds me how difficult being easy-going actually is. Giving oneself permission to live life with ease, free from attachments to our dramas, is something that requires patience and practice. Permission-giving has been the therapeutic project preoccupying me and Marcus, once the Labor Day moment passed, with Marcus telling me, “I’m game to keep going.” Physical challenges continue to get him down—structural damage to one knee, a bad back—but he has become more resilient, largely because he takes fewer things personally. The sessions following those described in the essay—sessions where he was encouraged to “live it up” before following through on his determination to “end it all”—led him to a realization that treating life as an obligation only intensifies suffering. Our slogan these days: Nothing matters, but everything is honored.

William Richards on Psychedelic-Assisted Psychotherapy and Mystical Experiences

Posted on January 24, 2017February 11, 2026 by rezendevknowfully.com

Psychedelic Healing and Research

David Bullard: I’ve enjoyed our several conversations, Bill, heard several of your talks, seen you interact with students and colleagues, and have learned deeply from your recent book, Sacred Knowledge: Psychedelics and Religious Experiences; it filled so many gaps for me in how we see consciousness and psychotherapy. Plus, this has all been augmented with your articles in tribute to Abraham Maslow and on psychedelic psychotherapy published online in September 2016 in the Journal of Humanistic Psychology.

But even more recently, the December 2016 issue of the Journal of Psychopharmacology published the results of your study at Johns Hopkins and of the similar research reported by the NYU team, showing very impressive results in the use of psilocybin for the treatment of people with cancer who were experiencing existential anxiety and depression. These two studies have been described as “the most rigorous controlled trials of psilocybin to date.” The issue also includes penetrating commentaries from ten notable psychiatrists and neurologists. As stated by the issue editor:

“All agree we are now in an exciting new phase of psychedelic psychopharmacology that needs to be encouraged not impeded.”

The re-emerging study of psychedelic research really hit home for many with the beautifully written article in The New Yorker by Michael Pollan, “The Trip Treatment,” giving a historical perspective on the resurgence of research and the therapeutic role of psychedelic medicines. I was astonished at how positive it was for such a mainstream publication. Pollan quoted you in it, concerning whether people get an illusory or “real” experience of mystical consciousness. Citing William James, you suggested “that we judge the mystical experience not by its veracity, which is unknowable, but by its fruits: does it turn someone’s life in a positive direction?”

Can you talk a bit about your research on psychedelic-assisted psychotherapy and the potential entheogens have to accelerate treatment and facilitate transcendental spiritual experiences?

William A. Richards: Well, I’ve been at Johns Hopkins School of Medicine doing research and clinical work for the past 17 years, but I started out in college intending to be a minister. I studied philosophy, psychology and sociology, then completed a first year of graduate studies at Yale Divinity School, followed by a year of studies in both theology and psychiatry at the University of Göttingen. There I naively volunteered to be a research subject and received a drug I had never heard about called psilocybin for the very first time, having heard that it might provide some insights into early childhood. That triggered an awesome and amazing transcendental experience that I wrote about in my recent book.

I then returned to the States, completed the degree at Yale, studied the psychology of religion with Walter Houston Clark at the Andover-Newton Theological School, and then became a research assistant to Abraham Maslow at Brandeis. After that, I accepted a job at the Maryland Psychiatric Research Center doing psychotherapy research with a variety of psychedelics including LSD, DPT, MDA and psilocybin. To further that work I continued my graduate studies at Catholic University to obtain my doctorate and become licensed as a clinical psychologist.

In 2006 our team at Johns Hopkins published our first psilocybin study, utilizing normal volunteers who had no prior experience with psychedelic substances, and the results were impressive.

We found that 58% of the 36 volunteers rated the experience of the psilocybin session as among the five most personally meaningful experiences of their lives.

We found that 58% of the 36 volunteers rated the experience of the psilocybin session as among the five most personally meaningful experiences of their lives, and 67% rated it among the five most spiritually significant experiences of their lives, with 11% and 17%, respectively indicating that it was the single most meaningful experience, and the single most spiritually significant experience. A follow-up study, published in 2008, indicated that attitudinal and behavioral changes were sustained.

Most recently, our study with cancer patients showed psilocybin produced large and significant decreases in clinician-rated and self-rated measures of depression, anxiety or mood disturbance, and increases in measures of quality of life, life meaning, death acceptance, and optimism. These effects were sustained at 6 months. The study at NYU showed similarly robust results.

So what comes to mind is a growing awareness that this field may really become mainstream. In mid-October I was at a conference in Victoria, British Columbia, with 150 really bright, young mental health professionals and boy they are serious about what needs to be done practically to change the laws in Canada so therapists who are properly trained can use psilocybin and other entheogens in their practices. They’re not thinking 50 years from now, they’re thinking five years or sooner. And why not?

And then in early December in San Francisco, you observed the ceremony for 41 therapists and medical personnel who completed an exciting new eight-month training program, the “Certificate in Psychedelic-Assisted Therapies and Research,” directed by Janis Phelps at the California Institute for Integral Studies (CIIS), where I consult and teach as well.

The program is groundbreaking and so important, since multicenter, phase 3 clinical trials are about to be funded for the use of psychotherapy using psilocybin for end-of-life issues and with MDMA for PTSD. Research also continues with psychedelic substances for treatment-resistant depression, alcohol, cocaine, narcotic and nicotine addictions and social anxiety. The CIIS certificate program will provide wonderfully aware and trained personnel to participate as the guides in this important research, both in the US and in other countries.

DB: I greatly enjoyed witnessing the passion and dedication of the students and faculty at the graduation; it was a beautiful ceremony.

WA: One participant in the program, Dr. Robert Grant, is a physician and a full professor at UCSF who has pursued research with AIDS/HIV and, among other things, is very interested in AIDS survivor syndrome—people who aren’t dying from AIDS now but are often chronically depressed and living with the threat of death over their heads all the time if they don’t take their medication.

There are some very well established clinicians who decided to become students in that program in order to obtain this certificate in case it helps open doors to initiate or contribute to research down the road.

DB: You’ve used a wonderful metaphor of music to describe this profusion of recent events.

WA: Ah, yes! Well, when recently asked how I felt about psychedelic research and clinical work from my historical perspective, I replied, “Most of the time I have music going through my head—and right at the moment it’s the Prelude and ‘Liebestod’ or ‘love death’ from Wagner’s Tristan und Isolde.”

It’s very expressive, romantic, soaring music. And then, as the end of the Prelude approaches, it dies down and gets quieter and quieter. And then there's dead silence. I think there are just a couple plucks of strings, and more silence. And then the theme comes back, very softly at first, and it builds, and it builds, and it builds. And it gets bigger than it ever was in the beginning. It returns even more magnificently than before.

My response was to a question about the way the research has developed: when it started to expand in the 1960s, it was a theme with incredible promise for helping to relieve suffering, and then it became very quiet because of the 1970 legal prohibition and all, and now the research is coming back quite strongly. That music is a metaphor for where the research and the field have been and, following a dormant period of 22 years, where they are right now.

DB: And you’ve even created a playlist for psychedelic studies. It looks like a wonderful compilation to listen to, even without psilocybin!

WA: My son Brian and I had a delightful time putting it together. It is based on many years of experience with an impressive variety of people.

DB: Going back to the just-published psilocybin research: The results are extraordinary for any therapeutic intervention, let alone one that consists of just a few meetings pre and post, and one active psychedelic session with very vulnerable people.

The journal issue includes some excellent supportive commentary on your research that I found very helpful, such as one by Stanford psychiatrist David Spiegel, “Psilocybin-assisted psychotherapy for dying cancer patients—aiding the final trip."

WA: We were very gratified by his and the other commentators’ contributions. It is certainly another milestone in demonstrating the gifts that these experiences facilitated by the skilled use of psychedelics can bring. Everyone involved in this work is dedicated and appreciates how profoundly meaningful these experiences can be for many people.

DB: Do you know how many centers they’re going to need for phase 3 clinical trials to build upon your psilocybin research? Definitions of phase 3 that I’ve seen range from 300 to 3,000 subjects.

WA: We don’t have those numbers yet. We expect to discuss this with colleagues at the FDA soon. But there are countless other research projects that can be done as more and more universities start coming on board. Hopkins may be the beginning, the Mecca, but things are happening far beyond Hopkins.

DB: Including at UC San Francisco; I know that Brian Anderson, MD, had a proposal recently funded to utilize psychedelics in a group therapy format for HIV/AIDS patients.

WA: We keep doing the best-designed research studies we can come up with and it’s spreading. All of a sudden it’s socially respectable to do psychedelic research again, when not long ago many people wouldn’t dare touch it for fear of ruining their careers. Now it’s becoming mainstream and being applied to different populations of patients including “well” people, for that matter. Bob Jesse, who helped to facilitate the initiation of psilocybin research at Johns Hopkins 17 years ago, talks about the use of entheogens in promoting “the betterment of well people.” It looks like these drugs really are fundamentally safe for most people when they’re used responsibly with good preparation and when skilled guidance is provided to facilitate the initial integration of the insights that occur during the period of drug action.

And since it can accelerate and deepen psychotherapy for many people, why should this not be a tool available to the profession? It’s a bit like asking, “Should we allow astronomers to use telescopes or microbiologists to use microscopes?” Well, for the mental health world and perhaps the religious world too, here’s an incredibly effective, powerful tool. And sure, we have to use it skillfully and wisely but why shouldn’t it be legally accessible?

Awe and Transcendence

DB: You go beyond the psychotherapeutic goal of symptom reduction and restoring someone to a culturally defined “normal” state of mental health. This therapy can increase the capacity for awe and a deeper sense of interpersonal connection, transcendence and feeling at home in the world.

WA:

Normal for some might be drinking beer and watching television. As human beings, it’s not necessarily all that wonderful to only aspire to that.

I suppose that was inevitable after studying with Maslow. He took me on as his research assistant when a dean at Brandeis got cold feet about accepting me as a graduate student with research interests in psychedelics. It was a great opportunity to learn from him. I remember him saying that the early stages of self-acceptance involve coming to terms with grief, guilt and anger, and relationships with parents and siblings and so on. And that’s important, of course.

But that’s kind of the kindergarten. And then you move to coming to terms with your capacity to love, your creativity, your tolerance of different ideas and perspectives on the world—the whole process of self-actualization rather than adjusting to whatever “normal” is. Normal for some might be drinking beer and watching television. As human beings, it’s not necessarily all that wonderful to only aspire to that.

DB: Maslow was even talking about transcending “self actualization.” These are pretty immense subjects to tackle in this brief interview, but you’ve written about Unitive Consciousness and about space and time in the book.

WA: I wrote about transcending time and space as part of the experience of mystical consciousness. It is always a tall order to capture the Divine in language. Immanuel Kant pondered the mysteries of time and space long and hard back in the eighteenth century. Many others, including Huston Smith, have written eloquently about this.

When in some sort of altered state that we describe as mystical or transcendental, what is perplexing is that people often claim not only that they were distracted or unaware of the passing of time, but that the state of consciousness they were experiencing was intuitively felt to be “outside of time.”

Many of our research subjects have reported such experiences, and I’ve explored it in the book over several chapters. These are all extremely exciting and vital topics to pursue.

Skeptics

DB: You’ve probably had plenty of experience in discussing these issues with skeptics and probably studied the ancient skeptics who classically have been attacked on their major thesis that knowledge is not possible—a rather self-refuting assertion!—but when anyone discusses or writes about mystical experiences, they might be seen as being on pretty thin ice by the more empirical rationalists among us. How do you answer these critiques?

WA: Well, I write extensively about this in the book, but in this discussion I can say that these experiences entail more than emotion—however exalted and elevated the feelings may be. Mystical experiences explored in both the literature of each world religion and in modern psychedelic research, are also claimed to include knowledge.

William James, the Harvard psychologist who published The Varieties of Religious Experience, described it as “beholding truth.” In contrast, Freud had trouble comprehending this aspect of mental functioning and called it “the oceanic feeling,” a term for mystical consciousness that had been coined by a French novelist, poet, and mystic, Romain Rolland.

Freud himself devalued the import of the experience and interpreted it as a memory of union with the mother’s breast before the individual self or ego developed. Yet even he acknowledged “there may be something else behind this, but for the present it is wrapped in obscurity.”

In spite of the apparent efficacy of some visionary and mystical experiences in psychotherapy, I also want to stress that there is also the potential efficacy of psychedelic substances in accelerating psychotherapy within the realm of the ego, often with dosage too low to provide access to mystical forms of consciousness. These experiences are important in their own right, though they may not be described as transcendental, religious or spiritual. In the 1960s a number of European therapists were using psychedelics to accelerate more conventional psychoanalytically-oriented therapy, often administering psychedelics on several occasions during each week of treatment.

Maslow was very interested in my psilocybin experience in Germany as a research subject, but he had a cardiac problem that kept him from pursuing this personally. As noted earlier, I wrote about my time with him in that recent issue of the Journal of Humanistic Psychology. It was a kind of tribute to him and a joy to write and recollect. I’m so grateful for the mentors and other people I’ve been able to know and work with: Huston Smith, Walter Houston Clark, Hanscarl Leuner, Charles Savage, Walter Pahnke, Stanislav Grof, and many others with whom I currently get to interact. Sadly, I just received word that Huston “fully woke up” this morning. I will miss him and find myself grieving—a rich combination of gratitude and sorrow. He was the last of my living mentors. Now we (and an increasingly robust community of other pioneers) are standing on the top of the mountain.

DB: I count 74 colleagues, friends and others who’ve inspired you in the “Acknowledgments” section of your book. So you have found a very meaningful life exploring these understandings with others.

WA: That’s why I can’t retire; it’s too much fun; it’s too meaningful; it’s joyful. And when I look back on my life, I think there were many times when I was wandering academically through sociology and psychology and music and philosophy and comparative religions. People probably looked at me and thought I was just one lost kid. Like, would I ever make a decision of what to commit to?

DB: Yeah, “why don’t you settle down?”

WA: When I look back on it, it was ideal training for becoming a psychedelic therapist or researcher, but I didn’t even know the word “psychedelic” back then. Music really wasn’t a detour at all; it was central to what I was doing. The study of comparative religions was central to it as was the study of depth psychology and it’s like I knew what I was doing unconsciously.

Psilocybin and Cancer

DB: Back to your point about the old worry that having clinical and research interests in psychedelic medicines could threaten one’s career: Ninety researchers and clinicians from UCSF, UC Berkeley, Stanford, and the California Institute for Integral Studies showed up to hear your talk about psychedelics a few months ago and also for another earlier discussion with Françoise Bourzat, a therapist who’s been doing this work for about 30 years. She takes people to Mexico outside of Oaxaca where she works with a Mazatec elder. She creates therapeutic support and integration for the people, and together with her Mazatec teacher, guides them through the ancient ritual of sacred mushrooms.

But for greater acceptance and legality, there will have to be empirical studies following up yours further validating their safety and efficacy.

WA: Yes. The results of our recent research show some profound effects from the use of psilocybin for a selected group of cancer patients who were experiencing existential anxiety. After several therapy sessions for them to become comfortable with the co-therapy team, they had one session with psilocybin in adequate dosage, followed up by some appointments devoted to the integration of whatever new perspectives they had acquired.

DB: Can you brief us on the research design of your group?

WA: Both Hopkins and NYU utilized double-blind, placebo-controlled crossover designs. At Hopkins the control substance was a very low, placebo-like, dose of psilocybin; at NYU nicotinic acid was administered.

DB: So, were there any particular new perspectives that were commonly attained and helpful across subjects?

WA: Though every person’s experience is unique, many reported new understandings of a religious or philosophical nature as well as helpful insights into their own lives and interpersonal relationships.

Those who encountered mystical forms of consciousness frequently claimed not only reductions in depression and anxiety, but also loss of the fear of death, coupled with increased openness and curiosity about life.

And there’s work going on in Europe to move towards the legal use of psychedelics, especially in palliative and hospice care. Very bright researchers were recently collaborating at the European Medicines Agency—it’s their equivalent of our FDA—working together to determine which data are needed in order to make a drug like psilocybin accessible. And what training do you need to enable therapists to use it safely and responsibly. They’re involved in very practical considerations. So, things are moving out there.

DB: Definitely. I met recently with a visiting Zen teacher, Vanya Palmers, who helped with a recent University of Zürich double-blind study where, on the 4th day of a 6-day retreat, participants who were long-term meditators got either psilocybin or placebo. Each subject had fMRI imaging before and after and completed follow-up questionnaires. Results haven’t been published yet but are bound to be fascinating.

WA: Here in the States, of course, Dr. Rick Doblin’s group MAPS (Multidisciplinary Association for Psychedelic Studies) has since the mid 1980s been funding research and education in this area with the hope that some of these medicines, like MDMA, might be approved so that medical professionals could prescribe them as early as 2021.

Enhancing Psychotherapy

DB: Given the apparent effectiveness of a single or just a few of these entheogen sessions in a psychotherapeutic context, how do you see psychotherapy changing to utilize them?

WA: Basically I would say—with no apology—that psychotherapy is an art as well as a science and the being of the therapist is very important as well as the collection of techniques and procedures he or she has memorized and internalized. You can’t do psychotherapy to someone; it’s a process that unfolds in the context of a trust-filled, courageous, committed human relationship; that is, if you want to really accomplish something significant in terms of personality growth or development.

For the clinical use of these medicines, ideally we would have eight hours of preparation. That may be a little more than some people need and a little less than others. But, if in those eight hours you can’t establish an intuitive sense of interpersonal grounding and trust, then I wouldn’t give someone a psychedelic. There’s an intuitive judgement that there’s enough trust here and I’m committed enough to be with this person for the period of drug action whether I’m needed or not. But I can be in a mental space that is completely dedicated, completely accessible, and completely available to that person, especially during the onset for the intense period of drug action.

If the person’s anxious I’m here to provide support; if they just need freedom and privacy and respect I can provide that instead. I’ll make sure they don’t injure themselves physically if they’re off balance and they have to go to the bathroom or something—very practical things. I’ll provide the best supportive music and periods of silence now and then that may be indicated and just let it unfold. It requires evoking and providing the conditions in which the person’s own mind can manifest and heal itself.

And even if there are periods of anxiety or fear to navigate through, we welcome those as well. “In and through, in and through” is the mantra. If an inner dragon, boogeyman, or monster should reveal itself then we go right straight towards it as rapidly as possible and say, “Well, hello. Aren’t you big and scary! What can I learn from you?”

And so instead of running away and getting into panic and paranoia and confusion and even perhaps needing to go to a psychiatric emergency room, you look it straight in the eye and say, “Boy, you’re an ugly part of me but what are you made of?” And when you go towards it, inevitably there’s insight. As you know from psychotherapy in general, the monster turns into the alcoholic father in the middle of the night, or turns into the person who sexually abused you, or turns into some personification of your own guilt or unresolved grief or fears, or deep, dark sources of shame or whatever it is.

But when you go towards it there’s always healing, and insight, and resolution. And what you wanted to run from one moment you can laugh at minutes later. Like, “How could I ever have been afraid of that??!! That was only my drunk father in the middle of the night when I was a little boy,” or whatever it is.

What Devils Hate the Most is Being Embraced

DB: Well, it’s reassuring to know that voyagers like yourself who have been there with people going through it so many times can, with complete confidence and clarity, make that statement that you can face these demons.

WA: In some psychoanalytic circles there’s this tradition of being afraid of revealing too much too soon. Such that you have to precede very, very slowly and gingerly, four days a week, sometimes for seven years!

But I’m convinced these medicines can be used safely and effectively—having had these clinical research opportunities for decades now, working with several hundred different people—and hardly any of them have been so-called “hippies.” They’re just normal people: cancer patients, or alcoholics, or narcotic addicts, or depressed people, or anxious people, or they have personality disorders. Some have been mental health or religious professionals in an educational context. Generally, they’re people who never would have been interested in psychedelics if the opportunity to receive one hadn’t been offered as part of medical treatment, education or research. Some were eighty-year-olds from the inner city dying of cancer; not the hippie type—not the stereotype of the psychedelic user at all. And I have to say just about all these people have benefited.

I’ve come to believe that if there’s anything they’re not ready to deal with yet it won’t even come up, not even in a psychedelic session.

And if it comes into consciousness, to me that says they’re ready to deal with it—that this is an invitation and if it comes to you, greet it. It may be the uninvited guest but it’s the guest. And you meet it. I always say what devils hate most is being embraced. They’re like kids in Halloween masks—but then the game is up, and you realize the false front of the terror.

When you go towards the fear there’s growth and insight and resolution. But you need to be grounded in a good relationship with a therapist or someone you really trust, or in the depths of your mind perhaps if you’re spiritually developed enough. There’s this courage, there’s this intention to greet, to welcome, to embrace whatever comes into consciousness. And with that there’s a willingness to suffer.

It doesn’t have to be a “good trip,” you know, especially if “good” just means getting high and laughing and feeling that everything’s cool.

It doesn’t have to be a “good trip,” you know, especially if “good” just means getting high and laughing and feeling that everything’s cool. Personal growth is sometimes hard work, and spiritual development takes you through the dark night of the soul sometimes. But with that intention to welcome whatever comes into your field of consciousness and accept it, and wrestle with it, and go through it, people invariably emerge with a feeling of inner strength and confidence, and significantly decreased anxiety at the end of the day.

DB: One mentor of mine, the psychoanalyst and Control Mastery Theory co-developer Hal Sampson, would often say that you can reassure people who have articulated something like, “I’m so ashamed about x, y z, that I’ve never told anyone before,” that their being able to say it out loud to you absolutely means that it’s not as powerful as it was before they could even utter it.

But, you’re taking it a step beyond that by your reassurance that anything that comes up even in a psychedelic session—from your experience—is something that means it’s ready to be dealt with. That’s very useful.

I’m remembering a time with my son when he was 7 years old, and in response to his worrying, I said, “well, whatever goes on in your brain is never going to hurt anybody else and whatever you see or imagine…” He said, “What?? Say it again!” I said it again and he suddenly physically relaxed and went, “Ahhhhhhhhhhhh.”

It’s similar to when I hear you affirming that whatever can come up can be dealt with. And it helped me understand too how we’re used to thinking of traumatic memories coming up and then people being engulfed in them, what some colleagues call a “trauma suck,” but with psychedelics it’s a kaleidoscope, things are going to be shifting and changing.

WA: You triggered a wonderful memory with one of my own sons. On Halloween we were at an amusement park and in one of these rides where you get in a boat and you slowly move through this dimly lit river with dry ice where everything is setup to look spooky. And, as we were going around a curve, there was this girl in a witch’s costume, her back against the wall, just waiting for the moment to jump out and try to frighten us. And Brian must have been six years old and he just jumped up and scared the witch a split second before the witch did her thing. And the poor girl almost fell in the water. But that’s the principle, you know: “If you can scare the witch you’ve got it made!”

DB: There are some therapists and researchers who espouse “exposure and response prevention” and “prolonged exposure” in the treatment of trauma and anxiety. A friend of mine is involved in researching this for the Departments of Defense and Veterans Affairs. But a couple of people I knew just couldn’t tolerate the protocol that they had and so they dropped out, but I have a new appreciation for it in a way by what you’re talking about—of going into it.

The key must be to make sure they have all the tools to make it safe enough—and I think that’s it—an experienced guide who knows it’s safe to go into these psychedelic shifts within consciousness.

WA: I agree. If the relationship is solid and the dosage is adequate so you can tap into what we call transpersonal realms of the mind, beyond the everyday self and at the border between the everyday self and transcendence. One thing we keep discovering, and it’s awesomely beautiful really, is that within the psyche there is wisdom about the way traumas or conflicts are presented to the ego for resolution.

Within the psyche there is wisdom about the way traumas or conflicts are presented to the ego for resolution.

It’s not that it’s just sitting there. But the very way it comes up and presents itself—when you interact with it—the way the mind depicts the process of resolution, it’s like a great novelist writing a very moving and effective story.

And we find these very creative resources within the human body but beyond the ego if you will, perhaps deep within our DNA somewhere. And if you go into the mind with courage, trust, openness, and interpersonal grounding, the experiences that emerge tend to be infinitely more effectively and more artistically designed than anything you could have planned in advance. If you think, “Oh, what this patient needs is to regress to age seven and address her relationship with her father,” you are being unnecessarily controlling and underestimating the resources within your patient. If you just go in with openness and trust, what emerges and what the person writes down after the drug wears off is awesomely effective for many and I suspect most people.

You don’t have to have a doctorate in English Literature, you know; it happens to very ordinary people. And the richness of the imagery and the storylines are very impressive.

DB: And I hear also what you’re saying about the importance of trust by both the person undergoing the experience and the facilitator or therapist, the trust that that’s there.

WA: We’re potentially saying,

“You may feel like you’re dying in this moment and go ahead, let yourself die; you’re going to be okay.”

“You may feel like you’re dying in this moment and go ahead, let yourself die; you’re going to be okay.” Or, “you may feel like you’re going crazy; that’s okay, go ahead, go crazy, we’re going to take good care of you; you’ll be okay.” That certainly takes a lot of trust because when you get into those deep states of consciousness they feel incredibly real, incredibly powerful.

Transpersonal Psychology

DB: But in everyday life we seldom if ever hear those very powerful, positive, loving, supportive messages that whatever occurs in our own psyche, we’ll be OK.

WA: Right. We’ve got to talk more about these transcendental or mystical states of consciousness. When they occur they seem to be the most powerful factor in attitudinal and behavioral change. They literally change the self-concept. They change who you think you are, who you feel other people are, what you feel the nature of reality is, what the nature of the world is, and your sense of values may shift. That’s powerful stuff, you know? And we’re not used to talking about that; we leave that for the theologians. There’s still this whole reticence in psychology to even acknowledge what we call “transpersonal psychology.” I like to think of “trans” as meaning both “above and beyond” but also “between.” There’s a vertical and horizontal dimension of transpersonal psychology, but they’re both there and they’re both incredibly powerful and important.

DB: That’s something you articulate in the book so well—the sense of oneness, wonder and connectedness. I’ve seen something similar in couples therapy—when they think they’re angry at the other person it’s kind of an illusion because they’ve helped to create the other person who’s there, who is reacting to them as they are reacting to the other. When they see what a system they are in the accusations and guilt can greatly diminish. Many Buddhist concepts come to mind in what you’re talking about also.

Jinpa Thupten, a scholar and the long-time English translator for His Holiness the Dalai Lama, wrote his first book for the general public last year. And when he thought about the numerous Tibetan Buddhist teachings that he had learned, he decided to write about compassion as his main topic. And to me that’s a major part of the whole experience of growing spiritually—developing self- and other- compassion—whether it’s therapy or through transcendental states or other psychedelic experiences or some combination. All of these things merge into self-compassion and compassion for others—and then awe and joy of just being alive.

WA: Yes, and after the great mystical experience, however you want to try to put that into words, you come back to earth and the memory needs to be integrated. You chop wood and carry water. And you try to see the divine in your boss, in your spouse, in your kids, and in the people you disagree with. It’s a lifelong process.

DB: We’ve touched on this a little bit before but I think this thing called “psychotherapy,” at moments joining and looking into all these other human lives, is a counterpoint to meditation that involves looking into your own consciousness and beyond. And I know we’re both grateful we’ve been able to do that. You and I are both celebrating our 40th year of private practice—another synchronicity I enjoyed finding out about, as well as your sense of humor.

WA: I sometimes think of how the Jews, Christians, and Muslims who tend to be excessively serious and somber could benefit from the Hindu appreciation for lila, known as divine playfulness.

DB: Anything you’d like to say more about lila? We could use some of that appreciation for life after this terribly difficult election season.

WA: I’m having trouble myself imagining it. I picture this great beast coming out of the ocean and ask how do we confront it and care for it, and love it, and tame it, and appreciate the energy in it, you know, and not just run in terror.

DB: So, you’re saying that, similar to seeing something terrifying during a psilocybin session, when you would encourage the person to, that great term, embrace the demon who hates to be hugged, we have to find a way to deal with our political realities.

WA:

How do you respectfully stay centered and go towards what we label as bad, evil, or unpredictable, or scary?

How do you respectfully stay centered and go towards what we label as bad, evil, or unpredictable, or scary? It’s a real challenge and an art, I think, and maybe what religions are all about.

DB: And your background in comparative religions and the psychology of religion really informs your writing about the psychotherapeutic experience; it really is the culmination of your whole life’s work.

WA: It is, yeah. The book kind of wrote itself really. Hardly any rewriting, it just kind of flowed out during one year and there it was. Also, I’m more aware that I have a different verbal vocabulary than my written vocabulary. Sometimes I write words that I never say and speak words I never write. It’s just interesting, you know; like another part of the brain is in charge.

DB: So now I’m wondering about your sense of the experience of successfully working with trauma through psychedelic-assisted therapy compared to how we understand either prolonged exposure and response prevention or EMDR and somatic approaches. Any thoughts you’ve got about what happens to a person with trauma when they are in the entheogenic state?

WA: I suspect whenever therapy works there’s stuff in common among these different approaches. It may be labeled differently and be conceptualized differently, but there’s something very important about the courage to confront in a grounded relationship without running away and without panicking and just seeing it for what it is.

And perhaps coupling the intention to trust and confront with some breathing exercises or eye movements or whatever may be helpful. But it would seem to me the main theme is this confidence that in this relationship we call therapy there’s nothing we can’t deal with. You’re not helpless and this can be meaningfully resolved, not just vanquished. And in the big picture the flow of experiences might even enrich your life in some way.

DB: I see the distinction you just made between vanquished versus meaningfully resolved. It’s close to the difference between symptom removal and this transpersonal and even mystical experience that you believe can be or should be a part of psychotherapy for some persons.

WA: That’s right. I mean, you can hide under the bed and you won’t see the tornado coming, but I’m not sure that that’s curative. And it goes deep philosophically. Suffering and tragedy has its place; it’s an integral part of living. The image of the dancing Shiva that’s both destroying and creating comes to mind.

Transformation is not just getting rid of pain but finding meaning in pain.

Transformation is not just getting rid of pain but finding meaning in pain. That’s heavy stuff but it’s profound and it’s intrinsic to being human the way I see it.

DB: Maybe the short version from the Buddha is: out of suffering comes wisdom and out of wisdom comes compassion for yourself and for others.

WA: That’s right.

Beyond Death Anxiety

DB: Another aspect of all of what we are discussing is the neurobiological studies of the brain with fMRI’s and other sophisticated scanning instruments. A 2014 study in London found that a dose of MDMA occasioned a drop in activity in the limbic system resulting in less fear. Other such exciting work found a quieting of the regions of the brain involved with the sense of self, especially the so-called “default mode network.” It is easy to be very curious about where all that is going. You’ve noted that correlation is not necessarily causation, and that the nature of consciousness still remains a tantalizing enigma.

Is there anything more right now that you think is helpful for the person who clearly has benefited from the depth of their insights, who feels that they have seen a more real reality and then have come back here? Anything you want to say about those experiences?

WA: Just how incredible are the therapeutic and spiritual outcomes for the diverse people who were terminally ill that I’ve given psychedelics to in our research. I recall people who considered themselves agnostics, or atheists, or Jewish or Christian, or those who never went to church or synagogue, or those who were piously there all the time. With all of them when they have this mystical type of experience there’s a change. Instead of fearing death they report something akin to curiosity about it. As in, “this is a new experience I’m going to have that everyone who’s ever been born has eventually had.”

The perceiver and the perceived somehow interact on a subatomic level and everything is perceived as energy and there’s this ultimate insight that we’re all ultimately the same.

Maybe it’ll be, as this one patient of mine expected, “just like a light bulb going out,” you know, or maybe I’ll encounter my ancestors and maybe I’ll visit hell, or purgatory, or heaven or all three. But there’s this kind of almost innocent openness replacing the anxiety. Essentially they say, “something’s going to happen and I wish I could come back and report, but it doesn’t work that way.” And beyond that is this intuitive conviction for those who encounter mystical types of consciousness that it’s not an issue of personal immortality—whether my little ego is going to continue to survive or not. Instead, an intuitive conviction is often expressed that there’s something incredibly magnificent and eternal and trustworthy that’s not going to go away.

DB: It’s so beyond the personal ego.

WA: Yes.

DB: “I don’t have to worry about my little self, there’s this fantastic, beautiful thing out all around us, in us, outside of us.”

WA: “…that is in control. I don’t have to be in control.”

DB: I recently was thinking that when I die, my own personal experiences of joy, awe, excitement will be gone but these human feelings will still be being experienced by others: by my children, and then by their children.” Excitement itself will still continue. It was very comforting.

WA: Yes, especially in Judaism, what we call social immortality is often emphasized: that whatever your contributions are, whatever you stand for in life, it flows on and continues in your children and your children’s children. It’s a beautiful thought, but it doesn’t rule out the energy of consciousness itself being indestructible.

DB: In the book you distinguish between internal and external unity—could you clarify it here?

WA: In the literature and the psychology of religion and in the study of mysticism scholars talk about two different ways to approach unitive consciousness. One, called “internal unity” entails going deeper and deeper through various dimensions of being until finally the ego vanishes, dies or dissolves, like the drop of rainwater in Hinduism that merges with the ocean of Brahman, and all of a sudden there’s awareness of this great oneness.

And then the other approach, called “external unity,” occurs in interaction with the world, often visually through the natural world, a kind of resonating with visual perception to this point where the best way I’ve been able to describe it is—which I think Alfred North Whitehead was trying to state—the perceiver and the perceived somehow interact on a subatomic level and everything is perceived as energy and there’s this ultimate insight that we’re all ultimately the same. There is a great oneness. It boils down to one approach occurring with closed eyes, if you will, and one occurring with open eyes.

But that the same person in the same culture can experience both approaches to unitive consciousness is what the new discovery is. And so this isn’t culturally bound or indicative of different nervous systems, but it appears to be different ways of approaching the same unitive experience. Whether or not it’s the same unity can be debated forever. How many different unities can there be? But, you know, intuitively it feels like it’s ultimate.

Is it the same galaxy or a different galaxy? It’s mighty big and impressive whatever it is.

DB: My own experience with LSD, a few months before hearing a talk by Timothy Leary in the late 1960s, and just before it was made illegal by Federal law, was a strong glimpse into the awareness that I was not just these identifications I carried around with me then: “21 years old,” “college senior,” “English major,” “Middle class,” “Ann Arborite,” “son,” “brother,” or even “male.” These labels all fell off like articles of clothing and what was left of me was pure energy or light—part of a bigger quantity of the Something. Trying to articulate that the next day in an English Literature seminar was not too successful and didn't generate much further class discussion at the time, as I recall!

The descriptions about your own psychedelic experiences and those of the research subjects you’ve heard from are helpful and clarifying in the book. They added a lot for me as a reader.
I also enjoyed the quote in your book from Thomas Roberts about the 500-year blizzard of words triggered by the invention of the printing press. You have written very “illuminatingly” about our limitations in describing and articulating deeper realities using words and concepts. My favorite bumper sticker is “Don't believe everything you think!”

But, back to using your words, can you comment on the impact of faith and religion in these psychedelic studies?

WA: In our first study at Hopkins, published in 2006, the double-blind study with Ritalin and psilocybin demonstrated that psilocybin really does do something; it’s not all suggestion and wishful thinking. For that study we selected people who were religiously inclined, i.e. they went to church or synagogue, or they belonged to a meditation group, sang in a church choir or something. But people who read that study sometimes think it’s only because they were religiously inclined that they had their spiritual experiences. Clearly we know from other studies that people who consider themselves total agnostics also have profound mystical experiences. Perhaps some may even find it easier to allow the occurrence of mystical experiences than those who have studied and practiced specific forms of religion or spirituality.

When there’s a radical openness and they’re not trying to prove anything, mystical and non-ordinary states of consciousness that are claimed to be beneficial seem more likely to occur. People who might have trouble during a psilocybin session would be either the self-defined atheist who wants to prove that there’s no ultimate meaning—

DB: —or the rigid fundamentalist?

WA: If he or she thought that there’s no way except finding Jesus through the Fourteenth Baptist church, he or she might have trouble. But anyone who’s open and willing to explore consciousness and collect new experiences is likely to encounter these really magnificent states.

Is It Safe?

DB: I wonder if you could again address here what is so well delineated in the book, about the issue of safety?

WA: Gladly. Both my book and the article that Matt Johnson, Roland Griffiths and I published really systematically address it comprehensively. Given the pure drug and the right dose with adequate preparation, the major psychedelics are fundamentally safe for most people. Physiologically they’re safe; psychologically you have to know something about how to navigate well in the internal worlds to benefit. And I make the parallel in my book with learning to ski. It helps to have a few lessons before you do it. And it’s pretty stupid to just throw the drug in your mouth and see what happens, or strap on skis for the first time and jump off the ski lift at a black diamond run.

But given preparation they really are safe for most people. They’re nontoxic and non addictive. They’re not for everyone. For example, persons with psychotic histories, genetic tendencies towards severe mental illness, brain tumors, acute cardiac or renal conditions or dependence on certain medications would incur greater risk and would be screened out of most current research projects with psychedelics. Some persons simply may not be interested in personal or spiritual development, or may prefer other modes of exploration.

Given the pure drug and the right dose with adequate preparation, the major psychedelics are fundamentally safe for most people.

In many studies researchers find that volunteers report little desire to repeat the psychedelic experiences in the near future, even though the therapeutic intervention may be highly valued. One cannot predict the specific phenomenology that’s going to occur, but if you respond to the opportunity of consciousness opening up in an interpersonally grounded style with an intention to accept whatever emerges and explore it, the probability of the experience being beneficial is high. It is not dangerous if it’s handled competently.

Also with psychedelic therapy we’re right up front with volunteers or patients by saying there may be episodes that are scary and painful. One may have to tumble through some grief, guilt, fear or transient somatic discomfort. One may encounter “the dark night of the soul” as part of the spiritual journey, but that’s all good, and it leads towards resolution and transcendence.

DB: In other words, you won’t get stuck in it like the endless dark night…it will turn into daylight.

WA: That’s right, because, whatever comes into consciousness—you can meet it; dive right into it like diving into a swimming pool, and we’re here with you and there’s nothing from which you need to run away. And as we talked about earlier: the principle is that if it arises in consciousness that means you’re ready to deal with it and we’re here with you; let’s meet it.

DB: So, does that imply that it’s necessary for a person who’s a therapist doing psychedelic-assisted therapy to have had the experience?

WA: You have to be comfortable with non-ordinary states of consciousness.

DB: Okay, and you can say that you get there—

WA: Whether with psychedelics or not—

DB: —for example with Stan Grof’s holotropic breathwork.

WA: Yes, or meditation, for some sensory isolation or flooding; then you’re not going to panic if the person expresses something that you might ordinarily label psychotic or fear that the person’s going to get out of control, because that fear can easily become contagious. So, the therapist has to stay centered. “I’m with you and there’s no demon we can’t look straight in the eye.”

“Whether we like it or not the time is coming when we have to put up with being unconditionally loved.”

In a section of my book titled “Movement into the Future,” I wrote that if we take mystical consciousness seriously and accept that it appears to be a potential state of awareness that ultimately awaits all of us, then eventually we may all have to accept that we are spiritual beings, that there is indeed something of god within us, and that “whether we like it or not the time is coming when we have to put up with being unconditionally loved.”

Cosmic Laughter

DB: Well, I’ll be happy to put up with that! And how much, in your experience, do people in these sessions or journeys get into periods of cosmic laughter?

WA: Quite commonly, you know. And it’s usually after approaching something that feels very heavy and onerous. All of a sudden the belly laugh comes out, and god laughs and the universe goes on.

And humor aside, I wish we could offer safe psychedelic journeys here in the United States, both for persons who may benefit from psychotherapeutic treatment and also for people interested in personal or professional development. I write about the centers for research and retreat that I envisage in the book. And I think that day is coming.

It’s ridiculous that people who want legally to receive psychedelics often have to go to South America and take ayahuasca with sometimes questionable entrepreneurs.

It’s ridiculous that people who want legally to receive psychedelics often have to go to South America and take ayahuasca with sometimes questionable entrepreneurs. That may work out well and it may not work out well. Sometimes there is minimal assistance in facilitating the integration of experiences and not much preparation or thought that goes into the construction of the group.

So why should you have to go to South America to have a legal experience, when we are in the land of the free and the home of the brave? Come on USA, get with it!

DB: We ought to have a Constitutional amendment. We have freedom of speech, why not freedom of consciousness?

WA: Many of us will vote for that!

DB: What would you say to people who are considering doing a journey like this because they have treatment resistant depression, or they have been feeling terribly stuck? You’ve said it many different times, but here is one more opportunity.

WA: It’s tricky because I don’t want to encourage people to break laws and there are dangers of ingesting substances with unknown purity and dosage.

I talk primarily in terms of fostering research, and someday the laws will change. Sometimes I go online to Amazon.com and I read some of the reviews that people have written of my book, and one of them is from a guy who claims to have used drugs and psychedelics in the past but never used them right, and since my book essentially taught him how to use them correctly and safely, he had a marvelous curative experience and he’s deeply thankful for learning how to use psychedelics wisely. And that wasn’t my intent in writing the book, you know, but if it makes for healthier sessions and less trips to the emergency room for the people who choose to use the drug illegally; I can’t regret that.

DB: That’s beautiful.

WA: But it certainly wasn’t my plan in writing the book. Yet, since there are an awful lot of people who are choosing to use psychedelics, if the book helps them learn how to do it safely and wisely, maybe that’s a constructive step.

DB: So as we wrap up this conversation, it might be fun to acknowledge some recent literal “big” news: Astrophysicists reported calculations last month indicating that the universe is from two to ten times as big as was previously thought: they now think there may be up to two trillion galaxies, each with hundreds of billions of stars!

WA: There are no limits to awe! But you can only open your mouth so wide, you know?

DB: And Tibetan Buddhist scholar Robert Thurman suggests that the metaphor of Indra’s Net points toward human consciousness being at least as vast as the universe, if not countless times greater. So it looks like there is still plenty of territory to explore

I want to thank you again for the complete pleasure of our conversations.

WA: Well, good being in the world with you. Enjoy and take care.

DB: Namaste.

*For a full list of all articles cited, please email david@drbullard.com.

Tea with Freud: An Imaginary Conversation About How Psychotherapy Really Works

Posted on October 4, 2016February 11, 2026 by Psychotherapy.net Team

Following is an adapted excerpt from Tea with Freud: An Imaginary Conversation about How Psychotherapy Really Works by Steven B. Sandler. Segments from each of the first three chapters are reprinted here with the author's permission.

I. Where Did the Roses Go?

By the time I reach the apartment building at Berggasse 19, it is nearly two in the afternoon. The sky over Vienna is increasingly cloudy, and the first drops of rain are starting to fall. A young couple walking arm in arm look up at the sky in unison and pick up their pace a bit. Given my destination, it would be fitting to have strident discharges of lightning and thunder, signifying an elemental conflict between earth and sky. Mother Nature is not so inclined today. This is merely a soft spring rain, and I have arrived just in time to avoid getting too wet. I enter by the main door of the building and walk up a long flight of stairs bordered by a wrought iron banister. At the top of the stairs, the door to the apartment suite has his name on it in bold lettering. The door opens, and I am greeted by a maid, a petite young woman who smiles politely but says nothing. I assume that she speaks no English, and I have never studied German. She shyly motions to me to follow her into a waiting room. When we get to a closed set of double doors, she knocks softly and disappears without a word.

“ Good afternoon, please come in.” I am not sure what I was expecting, but I am immediately surprised that he is not taller. After all, this is Sigmund Freud. I am standing before one of the intellectual giants of the Western world, and I am not prepared to meet a man of rather average height. He is very handsomely dressed, of course; his three-piece suit is accompanied by a bowtie that is partly hidden, tucked beneath the collar of a clean white shirt. His whole demeanor is professional and confident, but his unremarkable height is not what I have anticipated. I suppose I have traveled to Vienna with some sort of childlike notion of a man who is larger than life, a father figure staring down at me—at all of us—from an Olympian peak. Instead, I find myself eye to eye with Freud, a man no bigger than myself.

“It is an honor to meet you, Professor Freud. Thank you so much for agreeing to speak with me. I know how busy you must be.”

“It is my pleasure.” He is just the age at which I always imagine him. He is neither the forty-year-old with the thick, dark beard and relentless ambition, nor the frail eighty-year-old who is struggling with oral cancer and packing his belongings to escape the Nazis. Someplace in his late fifties, perhaps sixty or so, this is the Freud who has clearly established himself as a major thinker. He is still strong and healthy, and still capable of producing more important work.

I am at least twenty years his junior, still in my thirties; curiously, I feel even younger standing before him. For a brief moment, I glimpse a memory of myself sitting in the library of the Capital District Psychiatric Center in Albany. I can see myself as a psychiatry resident, sitting at a small desk with a volume of Freud’s work open in front of me. There was something in those pages that confirmed for me that my decision to switch from pediatrics into psychiatry was the right move. Freud was trying to go beyond the classification of symptoms and diseases, beyond the typical treatments of his day (water baths, massage, and rest cures), beyond giving the patient suggestions under hypnosis—You can move your arm!—to arrive at an understanding of the root of the problem. He wanted to comprehend the mysteries of the psyche. I remember sitting in that library, paging through his book, feeling like I was being initiated into a very selective secret society whose membership was limited to intrepid explorers of the mind.

Now I am standing before him, and he looks at me directly for a long moment, as if he is already engaged in a psychological calculus of my character. Naturally, I am taking a measure of him as well, trying to read what I can in his eyes. Although he is a man of ordinary height, there is nothing ordinary about his gaze. He looks at me with the eyes of someone with an immense capacity for concentrating on one object at a time, and presently that object is me. There is obvious intelligence in those eyes, of course, and a look of relentless curiosity. Here is a man who can ponder a question for years: What is anxiety? He can wrestle with such a question tirelessly, and he can continually revise his understanding of it. He has a very direct gaze, a look of someone who is neither afraid to see nor afraid to be seen. For a brief moment, I think back and puzzle over something I once read about him. In one of his books, he wrote that he sat to the side of the couch, out of the patient’s view, because he could not stand to have people staring at him all day long. After one long moment of meeting his gaze, I have trouble believing this.

I can imagine that his eyes might be unnerving to some people, but there is warmth in them, too, and it would not be hard to imagine him breaking into laughter and making a joke. I find myself wondering why the photographs of him always show such a stern expression. He is not smiling or laughing at the moment, but there is nothing severe about his gaze. Something in his look makes me feel welcomed as well as analyzed. I wonder for a moment what I convey to my own patients when I look at them sitting across from me in my office back in Albany.

“Come take a seat, and we will have a nice chat. You have traveled far. New York State, yes?” His English is quite good. Accented, but good. My first impression of his consulting room is that it reminds me of a museum, or perhaps the back office of the museum curator—a cigar-smoking curator, to be sure, as the air is permeated with the smell of cigar smoke. The walls are crowded with framed artwork depicting ancient civilizations and their myths. To my left, there is a painting of Pan, the half-man and half-goat of Greek mythology who caused panic in mortals when they encountered him in the forest. In addition to the paintings, there is Freud’s famous collection of miniature antique statues, sitting on a ledge, on a desk, in glass display cases, or wherever there is a bit of space. These are the little artifacts from around the world that he had acquired over time, and there are legions of them. On one table, I see Egyptian figures standing erect, a large camel, and a couple of sitting Buddha figures among rows of other assorted pieces. One would think, judging by the cluttered profusion of antiquities, that the resident of this place is someone who is far more interested in archeology than psychology.

There are bookshelves, of course, filled with hardcover volumes. On one of the shelves, I notice a photo of a woman. She has a penetrating gaze the equal of his. Surrounded by the collections of weighty books and dead little statues, the woman in the photo looks intensely alive and alert. One of his relatives, perhaps? A sister? But he had several sisters, so it would make no sense to have a photo of only one of them.

“Yes, I live in Albany.” The couch is directly in front of me as I enter, and to the left of the couch, there is a wide green upholstered chair for him to sit in while listening to the “associations” of his patients. Why do I keep looking at the couch? In order to answer my own question, I look once more, and then I allow myself the visceral reaction taking shape within me: “This is it! I am looking at Sigmund Freud’s couch! This is the couch that has symbolized, for well over a century, a guided journey into the center of the human psyche.” This couch was the epicenter of some of the greatest psychological discoveries my profession has ever known. I have to take in every detail of it. There is a large Oriental rug thrown over it, a second rug hanging on the wall behind it, and a third larger one beneath our feet. Of the many colors in the rugs, the reddish browns stand out most to me, giving a very warm feeling to the room. There are large pillows on the couch for the patients to use, as well as a blanket in case of cold drafts in the room. I can barely believe my good fortune at being here.

II. The Root of the Problem

My office at Albany Medical Center is a small, boxy allotment of space, but it is sufficient for the necessities of psychotherapy: a desk, an old oak file cabinet (my attempt to bring a little character into the room), several chairs, and a small bookshelf. On top of the bookshelf sits a small plastic figure of Freud, holding his trademark cigar. The room easily accommodates me, Freud, and the friendly young woman sitting across from me. There is also space for a small video camera sitting on a tripod to the left of my seat. The young woman has agreed to let me videotape our sessions and use the tapes for my teaching.

Her name is Carla, and she is twenty-six years old. She has an Italian last name, which agrees quite nicely with her dark hair and dark eyes. She works at our hospital as an x-ray technician. Because this is her day off, she arrives in T-shirt and jeans rather than hospital garb. Even on a casual day off, she obviously takes some pride in her appearance; the bright, clean T-shirt is a colorful promotion for the New York Yankees, and the jeans look new. She is pretty, and she smiles the easy smile of someone who is used to having other people respond kindly to her features. She knows that she makes a good impression.

She looks directly at me, and she seems comfortable sitting here, or at least as comfortable as anyone can feel in her first psychotherapy appointment. She wastes no time in announcing her agenda for our first meeting. She reports that she is chronically nervous, and she finds it difficult to relax. (In today’s terms, she has a generalized anxiety disorder; Freud would have called it a neurosis.) She has a second problem that is even more disturbing to her than the anxiety. She gets angry at her fiancé and says mean things to him, words that he does not deserve. She just cannot control what she says when she gets angry. She has no idea why she is so nasty to him, but she knows that it bothers her, and she fears that her behavior will end the relationship before the wedding date ever arrives. She knows that she needs to get help with this.

So she has anxiety and she has a relationship problem. These are not the root of her problems, of course; they are the symptoms at the surface. Still, it is a good sign that she can state these problems clearly and succinctly. Some people come to therapy and they cannot even articulate a clearly defined problem. They come to the office because a friend or a spouse urged them to make an appointment. They have “a lot of issues,” but they cannot name a single one. They describe all kinds of difficult events they have experienced in life, but they cannot tell me how those past events are still affecting them now and why they are seeking therapy.

I also notice that she is describing problems about herself, rather than blaming others. She could have said that she is mean to her boyfriend because he is a terrible person who makes her feel irritable. Instead, she seems able to take responsibility for her own behavior. She has an intrapsychic focus, a focus on something about herself and her own psyche that she wants to work on. She does not externalize the problem and blame her environment. So far, so good. Now I need to get some details.

“How much of the time are you nervous and tense?” I ask.

“A lot. I’d say, half of the day.”

“Half of each day, typically?”

“Yeah.” Then she sighs. She takes a big breath, as if she is now feeling some anxiety that has tightened up the intercostal muscles of her chest and limited her to short, shallow breaths. She looks like she needs more air; she needs to get free of the tension and breathe more deeply.

“You sighed?”

“Yeah,” she says. “It just seems like I’m always rushed. I always have a million things to do. I never sit still, you know. I mean, that’s kind of my personality. I go, go, go. But last night, we just got a movie and sat on the couch, and it feels so good just to relax. I feel like I’m never relaxed.”

I explore this a bit more, and I run through a mental checklist of anxiety symptoms with her. I learn that she has no panic attacks, no obsessive-compulsive behaviors, no social phobia, and so on.

“And you say that you get angry and you have trouble controlling what you say. Can you give me an example of that?”

“I sometimes hold things in, and then—with Jimmy, my boyfriend—I get irritated about something. Or when he’s driving, you know. I tell him I’m going to punch him in his face because I get so mad.”

“You actually say those words?” I ask.

“Yeah, I do.”

I notice that she is doing something with her mouth, perhaps putting her tongue against her cheek. Maybe she is chewing on the inside of her cheek. Yes, I think that’s it. She is chewing the inside of her lip and cheek. She must be getting more anxious as we talk about her anger at Jimmy. Perhaps there is something about this anger that makes her more tense and anxious. It is a perfect example of what Freud said in one of his theories of anxiety: the ego can send out a signal of anxiety because the patient is coming too close to an impulse or emotion that is dangerous or unacceptable. Signal anxiety is the label he gave it. This chewing might be a clue to me that she is getting anxious about troubling feelings lurking beneath the surface.

“I’m not really going to punch him in the face, but … He’ll say something to get me going. He knows how to get under my skin, and I’ll say, ‘Oh, shut the … heck up. I’m gonna punch you in the face if you do that.’”

Clearly, she did not say ‘heck’ to him. She is cleaning up her language a bit as she tells her story. I suspect that she uses pretty rough language when she is mad at him. I would not have guessed this just by looking at her. Her whole appearance gives the impression of someone who is sweet and even-tempered.

“What might he say that would make you angry?”

“That he’s going to show me how, um . . .” She has been starting to smile, and now she breaks out with a small laugh. “Let’s see, what happened the other day?” She laughs more openly now. We are getting closer to something. As long as she could keep the topic general, she was managing fairly well, just a little tense. Now that I ask for a specific example, the tension rises and she starts to laugh.

The nervous laugh. It is such an interesting phenomenon. She gets anxious and the chest muscles contract and she sighs, trying to get more air. When the tension increases further, Mother Nature provides an escape valve with the nervous laugh, which suddenly loosens up those chest muscles, and she automatically takes bigger breaths of air to support the next burst of laughter. At the same time, the laughing turns a difficult situation into a funny one, so it also functions as a defense mechanism against feelings that are threatening or painful. What a marvelous invention, this nervous laugh! No wonder we all make such liberal use of it. It is a very pleasant social invention, as well. I could easily join her in the laughing.

“I don’t even remember what he said to me,” she continues, “but it was just the whole situation.”

“So you were really angry.”

“Oh, yeah!”

“And how do you feel right now, talking about it?” I ask.

“Just aggravated.” She’s laughing again. “Because I’m thinking about it, and I just can’t get him to …” Suddenly she brings her hands up, fingers spread wide and slightly flexed, as if she would like to grab him and shake him. “She presents me with such an interesting mixed message: her hands are energized with anger, but her face says it is all just a funny story.”

“You laugh, I notice.”

“Yeah, I can’t . . . it’s funny, because it’s like . . . I think about it now and it’s almost funny.”

“But the laugh doesn’t match the emotion of the moment, does it?”

“No.” She is laughing freely now, and she looks like she is really enjoying it.

“But I wonder if the laugh covers up the anger,” I say.

“It could.” She is still smiling, but the laughing stops. “Yeah, it could.”

Good. I made my first attempt at pointing out a defense mechanism.

I told her that the laugh does not match the anger she describes.

III. Inspired

“This is not psychoanalysis!” That is his entire response, a merciless verdict delivered by a stern judge in a terse four-word sentence. I have just spent the better part of an hour describing the case of Carla in some detail. He has listened, but as I proceeded, I could see his expression growing more distant, more cautious. At first, he looked interested and asked a few questions, but he gradually became silent and aloof. Now he stands up and walks over to get one of his cigars. Is this a sign that the discussion is over? Should I just get up and leave? Outside on the streets of Vienna, it is a beautiful sunny day in May. Perhaps I should abandon my hopes for a dialogue with Freud and go sightseeing.

He stands by the bookcase near a photo I noticed during my first visit, a photo of a woman with very intense eyes. As he examines his choice of cigars, I find myself attracted to the photo. I see intelligence in her eyes, or at least I imagine that I do, and perhaps a tendency to be passionate about things that interest her. What I cannot discern is the nature of the emotion in those eyes. One could read a heavy sadness in them, but maybe she just looks serious. I can imagine her eyes becoming angry, but she is not passionately angry at the moment of the photo shoot. Maybe it is not anger at all. Is she trying to contain some kind of distress, some inner turmoil, her eyes warning the photographer not to come too close? She looks at me with a direct, engaging look, but she will not let me know what lies within. But why am I so absorbed by a photograph on a bookshelf? I suppose I would like to enlist her help in getting him to listen to me. Would she help? Who is she, anyway? And why does her photograph deserve a special place on Sigmund Freud’s bookshelf?

He has yet to light the cigar, after some fiddling with matches and an ashtray; he comes back to his chair and sits down with his pleasure still unlit. I still have a chance to make my case, although I can see that the odds of success are diminishing with each passing minute.

“But Professor, this is a direct offshoot of your psychoanalysis. It’s just a newer version of your original ideas.”

“You have no couch, correct?”

“That’s correct. The patient and I sit facing each other in chairs.”

“You do not ask her to tell you her associations as they occur to her. Correct?”

“That’s true. I don’t tell her to just say whatever comes to mind. This is a more directive approach to treatment.”

“No couch. No free association. This is not psychoanalysis!” He stands up again, and now he paces back and forth. He not only disagrees with what I have presented; he is clearly angry. In fact, he looks insulted, as if I have personally attacked him. I am stunned that a man of his stature can be so easily offended. I have read about this aspect of his character, to be sure. No matter how much positive attention he received in the world, he was prone to misinterpreting even the most balanced critique as a vicious attempt to destroy him and his theories. Friendships fell apart because someone dared to disagree with him. I must have been dreaming to think that I could interest him in a reasonable discussion about modern changes to his original technique. Still, I feel that I might as well try to finish my argument, as long as I have come all this way.

“But if you look at my case, perhaps you might agree that this is a variant of psychoanalysis. Just look at my use of defense mechanisms in the session. At first, Carla laughs when she talks about her anger at her fiancé. A nervous laugh, of course, but the laugh also functions as a defense against facing her rage at him. I point it out to her, and she agrees that the laugh might be masking other emotions.”

Freud stops pacing and nods, almost reluctantly. His concept of defense mechanisms was one of the most original ideas in his voluminous work. He must be stopping to consider whether I am honoring his concept by using it wisely or defaming it by blatant misuse. I decide to continue.

“Later in the interview, I ask her how she feels and she again employs defenses. She says, ‘It seems like forever ago.’ She separates her emotions from the story. ‘It doesn’t seem real to me.’” Freud is listening now, and I can hear myself becoming more hopeful as I try to sell my argument to him. “By pointing out these defenses, I am educating her about the workings of her psyche. At the same time, I am trying to turn her against the defenses, so she will face the unacceptable ideas and emotions that she has refused to face until now.” At this point, I reach for the book that I brought with me, as a lawyer reaches for the critical piece of evidence that will prove his client is innocent. “May I read something to you?” I ask.

“Certainly,” he says, still looking quite skeptical.

“These patients whom I analyzed had enjoyed good mental health up to the moment at which an occurrence of incompatibility took place in their ideational life—that is to say, until their ego was faced with an experience, an idea or a feeling which aroused such a distressing affect that the subject decided to forget about it.”

I look up from the book to make sure he is listening. “From your paper, ‘The Neuro-Psychoses of Defense,’ written in 1894. One of your earliest papers. As a child, Carla was faced with terrible, frightening events, events that she would rather forget about. We are now using your concepts and challenging the defenses to get to the disturbing ‘experience, idea or feeling.’ For this patient, she has never really faced the painful reality of what happened in her childhood home. And you can see what happens by the end of the session. She experiences a breakthrough of emotion and begins to realize the magnitude of the situation she endured as a child. She remembers with emotion, just as you and Breuer prescribed in your book, Studies on Hysteria.”

Freud is standing in one spot now. He no longer looks agitated, and he seems to be considering my line of thought. He takes his chair again, much to my surprise. He is thinking, and he takes his time before offering a thought.

“So you are using my concept of defenses as a direct technical intervention with the patient. You actually tell her about her defenses as they arise.”

“Exactly,” I say.

“And by pointing them out to her, you are trying to weaken their hold on her, so that the repressed contents of the mind can emerge.”

“Exactly! The thoughts and memories can emerge, and she can open up with her feelings. She can emotionally expand again.” Freud looks puzzled by my last comment. I want so much to talk with him about Reich’s concept of expansion and contraction. I want to tell him: You cannot be open and closed at the same time. Carla started the session in a state of emotional contraction, and later she was able to re-expand emotionally. But this might be too much to lay on the table so soon. And who knows how he might react to the topic of Reich and his revolutionary ideas? I need to stay focused and talk about short-term dynamic psychotherapy. “Yes, the contents of her mind can come forth. That’s exactly what I am trying to accomplish. If I can loosen the grip of her defenses, then we can dig down beneath the surface and find out what lies buried. Like an archeological dig.” I know that Freud loved to compare psychoanalysis to archeology. He would sometimes point to his vast collection of miniature antiquities to make the metaphor to his patients. I worry for a moment that I am trying too hard to ingratiate myself to him, but he nods his approval at the comment. At this moment, Gretchen opens the door to his office holding a tray with tea. Freud waves her off, apparently not wanting to be distracted now.

He sits pondering what I have said. Here, in the last couple of minutes, I have seen the two sides of Sigmund Freud as I have read about him. On the one hand, he could be remarkably thin-skinned. He was always determined to make a name for himself, and his ambition could sometimes lead him to be competitive, distrustful, and vindictive. To use the psychoanalytic term, his narcissism got in his way. True, he had his detractors, and he endured some unwarranted hostility from colleagues, but he sometimes took an honest disagreement as a narcissistic injury, a blow to his basic self-esteem. On the other hand, he had a quick mind and an intense love of ideas. When he was immersed in the world of ideas and theories, without feeling threatened, he could be a kindly mentor, a committed analyst, and a devoted friend. One could easily see how two people could come away from him with two diametrically opposed impressions of the man.

At the moment, his intense curiosity has overtaken his bellicose instinct to protect his intellectual territory. He asks more questions about how I use defense mechanisms in therapy. Which defenses do I see most often? Are certain defenses associated with particular symptoms? How do I proceed if the defenses do not yield to this approach? As he talks, he sits back and lights his cigar. Now that he is engaged, I make my next move.

“Here is another point I would like to make, with your permission. Just look at your concept of anxiety and how I used it in the session, and you will see why I say that this is still psychoanalytic work. You remember that I noticed how she was biting her lip and the inside of her cheek? This happened early in the session, and it became more obvious as she began to tell the story of her violent, chaotic family life.”

Freud nods, puffing on the cigar.

“And you recall that I pointed this out to her as a possible physical manifestation of anxiety. The anxiety was triggered by the difficult topic at hand. It was your signal anxiety: anxiety that gets triggered by some unacceptable thought or emotion within the person. In your terms, the ego sends out a signal of anxiety because there are uncomfortable feelings lurking beneath the surface. In plain English, she is afraid of her own emotions.”

Freud nods again.

“In Carla’s case,” I continue, “the anxiety was prompted by the stirring of hidden grief over her childhood. Her anxiety, which caused her to chew her lip, alerted me to the presence of unacceptable thoughts, feelings, and memories. When I asked her about the significance of the chewing, she realized that she was anxious, and she was anxious because she was starting to talk about the trauma. Soon after that point, her sadness began to emerge.”

“So you are using my signal anxiety as a marker in the therapy,” he says. “Once you see it, this biting of the lip, you know that the emotions are not far behind.”

“Yes. Exactly! And it can be any sign of anxiety: fidgeting of the hands, gripping the chair, tapping the feet. Any of this might mean signal anxiety, and then I start to suspect that buried feelings are closer to the surface.”

Again, he asks questions. How do I know when the anxiety is not due to buried thoughts or feelings within, but due to a real threat—financial problems, illness, and so on—in the immediate environment? Not all anxiety is signal anxiety, he cautions me. What do I do if the patient’s anxiety gets too overwhelming? How soon do I address the anxiety in a session? He calls for Gretchen, and we drink tea and talk for quite a while about defense mechanisms and anxiety, until he has satisfied himself that he understands the approach I am describing. For the moment, at least, the struggle to get him to listen is over, and the battle is mine.

Margo Maine on the Eating Disorder Epidemic Among Middle-Aged Women

Posted on October 4, 2016February 27, 2026 by rezendevknowfully.com

The Equal Opportunity Disease

Deb Kory: Margo Maine, you are a clinical psychologist who has specialized in eating disorders and related issues for over 30 years, and you’ve authored several books about eating disorders, including: Pursuing Perfection: Eating Disorders, Body Myths, and Women at Midlife and Beyond, Treatment of Eating Disorders: Bridging the Research-Practice Gap, and Father Hunger: Fathers, Daughters and the Pursuit of Thinness and you’ve also edited and written for several books about clinical treatment of eating disorders. You’re the senior editor of Eating Disorders: The Journal of Treatment and Prevention and in addition to serving as a psychologist both in private practice and at Connecticut Children’s Medical Center, you’ve done advocacy work to address federal policy related to eating disorders.Having just read your book, Pursuing Perfection, I now know that eating disorders for women in mid-life are a kind of silent epidemic. Can you talk about your work in this area and why you feel it’s so important to dispel the myth that eating disorders are primarily experienced by wealthy, white teenagers?

Margo Maine: It is certainly an equal opportunity disease. I’ve been treating eating disorders for about 35 years now, starting in graduate school working at the local children’s hospital. I ended up doing my dissertation on them and then started up a program for treating adolescent eating disorders that included the parents in treatment as well. Many of the moms admitted to a little bit of dieting. Nobody admitted to an eating disorder, but in many cases, you knew there was something more there. So that was in the background of my mind.And then probably about 20 years ago, a couple of the moms of daughters I had treated called me, and now that their daughters were better and kind of launched, they came back to talk about themselves and their own eating disorders. That was a real eye opener for me.

DK: Did most of the teens have mothers with eating disorders?

MM: I wouldn’t say most of them did, but I would say at least a third. But nobody was talking about it. The kids were the identified patients and the moms wouldn’t mention hiding M&M’s in the closet or laxatives in the glove compartment. We’d ask questions about the mothers’ eating habits but they were all “just fine.”So my interest blossomed out of this early work and I started to see more adult women as the years went by. But the case that made me decide that I needed to bring this out of the shadows was a woman who came to me about 12 or 13 years ago. She had an eating disorder most of her life, and it was very much a family created eating disorder. She went through a normal weight gain in pre-adolescence, but that didn’t sit well with her family. They didn’t like her looking a little bit pudgy, and at the age of 12 they started bringing her to Weight Watchers.

When she went off to college and developed anorexia and came home having lost so much weight, nobody said or did anything. In fact, they were happy with her weight loss. She ended up getting better on her own, graduated from college, went on to have many successes in life, but the disordered eating was always there as a coping mechanism. She had two pregnancies, and after the second pregnancy she wasn’t able to lose all of her weight, and that just launched the eating disorder, which had been subclinical for a while, into full gear with purging, restriction, and over-exercising.

DK: So, it came back with a vengeance.

MM: Yes, though not all at once. She started with one thing, and then that didn’t get her to lose enough weight, and then she added another, and then the symptoms were really out of control by the time she came to me.

DK: How old was she by then?

MM: She was in her early 40s and was very scared. She didn’t really know what was wrong with her and she didn’t know where to go for help. She certainly couldn’t go to anybody in her family, so she decided to make an appointment with her OB/GYN. She’d had two successful pregnancies and she trusted him.She had lost 25 pounds in the previous year between medical visits, and she was a small person to begin with. In terms of the standard BMI [Body Mass Index], she wasn’t off the charts, but for her she was. All the nurses said she looked great and how did she lose the weight, etc., and she’d been prepared for that. But then she was sitting in the examining room waiting for the doctor to come in, and he walks in and says to her, “So how does your husband like your new body?”

DK: Seriously? That’s horrifying on so many levels.

MM: It was devastating to her. Here she was, so scared of what she was doing to herself, and she’d come to him for help. She wasn’t sure if she had an eating disorder, or if she was just kind of “crazy,” but she knew she was out of control, and then that comment made her very, very depressed. She wouldn’t talk to him and left feeling almost suicidal and just kind of closed the book on it. But within a week or two, got on the internet, started researching and found my name. I was only a few towns away, so she came in for treatment and did really well in treatment. But that case really brought to the forefront for me how pervasive eating disorders can be in a woman’s life. This was a very high-functioning woman, she had two masters degrees, she was very respected in her profession, very active in her community—

DK: Somebody with a voice.

MM: Yes, and yet she’d had an untreated eating disorder on and off for her entire life, and for the decade before she came to see me, was very out of control and physically at risk and in need of medical help.

“I used to be a mess, but now I’m a high-functioning mess”

DK: And it sounds like her attempt to get help was met with total failure.

MM: Absolutely. The other thing about a lot of the women I treat, they tend to be very high-functioning. A new fifty-something patient of mine who’s had an eating disorder since she was a teenager said to me, “I used to be a mess, but now I’m a high-functioning mess.”That’s how a lot of these adult women are. No one has a clue that anything is going on because they’re so good at functioning well and taking care of everybody else, but the despair they have about their bodies, what they’re doing to their bodies, is really astounding.

DK: In truth, I know very few women who don’t have some kind of body dysmorphia at the very least. Those who don’t have usually done a lot of work around it, including therapy, to get to a place of body self-love. And I’d say that most women I know had a period of disordered eating at some point in their lives—be it anorexia, orthorexia, binge eating or over exercising. I know that your clients probably self-select based on your specialty, but would you say that pretty much all the women who come through your door have body image issues and/or disordered eating?

MM: Oh, yes. I’m always amazed when I do presentations to clinicians about eating disorders and I hear people say, “Oh, I don’t treat eating disorders.” Really, you don’t treat eating disorders? Thirteen percent of women over 50 have eating disorders.

DK: Thirteen percent? Really?

MM: Yes.

DK: Wow.

MM: But they believe they don’t treat eating disorders.

DK: This was one of the reasons I sought you out for this interview. It seems like many clinicians are missing the boat here because we ourselves are immersed in a disordered culture. Many women therapists have struggled with body dysmorphia and disordered eating, which is pretty much the norm in American society, so if we aren’t actively fighting against the culture of dieting and the worship of thinness, we are likely not only to miss this in our clients, but to in some ways feed the problem. It seems to me that you’d have to assume that every woman who comes into therapy has a relationship to food and to her body that needs to be explored.

MM: I completely agree with you that all mental health clinicians need to be bringing it up, as do medical providers. They need to ask a few questions, just a few, to open the subject. Clients may not be ready to talk about it yet, but they will know that it’s a safe place to talk about it.

DK: What are those questions that clinicians should be asking?

MM: I have five questions that I suggest clinicians—and particularly physicians—include into their assessments. 1. “Has your weight fluctuated during your adult life?” 2. “Are you trying to manage your weight? 3. If so, how?” 4. “What did you eat yesterday?” You don’t ask them if they are on a diet, you ask them what they ate yesterday. Or if it’s later in the day you might ask them what they’ve eaten today. Otherwise people may say they aren’t on a diet, but then when you specifically ask them, “What have you eaten today?” and it’s 3 o’clock in the afternoon, and they haven’t had anything to eat, then you know there is a problem with their eating.And 5. “How much do you think or worry about weight, shape, and food?” I often ask people to quantify it in a percentage, as in “What is the percentage of your daily thoughts that are about weight, shape, and food?” Some women will answer that it’s the first thing they think of when they wake up in the morning. They think about what they’re not going to eat, when and how they’re going to exercise, how they’re going to exercise to get rid of what they eat. It’s a powerful part of their lives, but if you don’t ask the questions, you’ll never find out. It’s kind of like what the American College of OB/GYNs has done with domestic violence—it’s a topic that all OB/GYNs are supposed to ask about at every visit.

DK: And what about with men? Are these questions that you would suggest people ask men as well?

MM: I do. There are a lot of men struggling with body image—more so than ever before, and the numbers are compelling. There are some studies that suggest that as many as 25 percent of men have some disordered eating going on.

DK: Wow. Again these statistics are pretty startling.

MM: In my personal experience, it doesn’t seem like it’s 25 percent, but there are a couple of really good studies that suggest it’s that high.Overall, 10 percent of people suffering from eating disorders are men, and certainly men are getting much more pressure today around body image and appearance. They have a lot of pressure to not look old because of discrimination against older men in the workplace, so there is a greater emphasis on looking young and powerful. Increasing numbers of men are doing cosmetic surgery, but I think the difference for men is that it tends to be about power and influence whereas with women it’s more about appearance—that’s our “power and influence.”

You Can’t Tell by the Body

DK: Why do you think eating disorders so often go undetected? Do clinicians and physicians think that if you can’t “see” the eating disorder—as with someone who is severely anorexic—that it’s not problematic?

MM: With physicians and medical providers, the only eating disorders they think of are the extremely emaciated anorexics that they may have seen in their ICU or the morbidly obese person who comes in who they’re convinced has an eating disorder when they may not. With eating disorders, you can’t tell by the body.Eating disorders come in every shape and size. That’s why the BMI is not a very sensitive instrument by which to assess somebody’s health status. You can be basically anorexic at a high weight because you started at a high weight, your body might have been meant to be at a high weight because of your genetic background, but you’re undereating or perhaps taking medication that has caused weight gain. There are all kinds of factors that influence weight gain, but we know that at least half of the influences on adult weight maintenance are biogenetic, so that’s kind of programmed in, and then behavioral factors are added to that.

So some people go to the doctor and are at a higher weight, and they are put on diets when in fact they’ve already been severely dieting, they’re already undernourished, which is why sometimes they binge, but they’re not necessarily binge eaters, they’re more anorexic.

It’s important for clinicians to know that anorexia is in fact the least frequent of the eating disorders in the general population as well as in adult women, but it’s the one that’s easiest to identify because there is a marked weight loss. Bulimia is the next least frequent, but it’s hard to identify because of the secretiveness of bulimia. People with bulimia are often deeply ashamed of what they’re doing to their bodies and they don’t want anyone to know, so they are good at covering their tracks and are often symptomatic for decades without anyone knowing.

The mother of a former patient of mine called me to get help for her bulimia. She was in her early 50s and said that she’d been bulimic since she was about 20. She’d had two marriages and three children and relationships with physicians over the years and no one had a clue.

DK: What about dentists?

MM: Dentists have some opportunity to assess that, but not everyone with bulimia ends up with dental problems, or sometimes it happens very late in the process. Dentists are trying to step up though. I know when I go to my dentist they have you fill out a form, and it specifically asks you about eating disorders, and I’m so proud of them. I don’t think all dentists do that.

OSFED

DK: So what are the more common eating disorders?

MM: The most frequent disorder is OSFED—otherwise specified feeding or eating disorders—which is basically variations of anorexia or bulimia or combinations of the two or binge eating disorder. Again, weight is not going to necessarily tell you that much about whether someone has binge eating disorder or OSFED. What I’ve noticed in my clients, and there’s also some research recently that showed this, is that adult women tend to morph in their symptoms over time; that they might have started out anorexic or bulimic earlier, but they get a little bit better from that, and then the symptoms kind of merge into what would be OSFED, a combination, or subclinical disorders.

DK: My experience is that subclinical disorders are so prevalent. I’ve had so many women clients come in and say, “I was anorexic in my teens, but I’m fine now.” But “fine” often means, “I’ve learned how to control it in such a way that nobody thinks that I have a problem with eating, but I’m on a permanent diet and cannot cope if I don’t exercise every day.” Do you know what I mean?

MM: I agree with you completely. That’s exactly what it is—they have learned how to keep themselves in check so that they’re hopefully not binging and if they do binge, know how to get through it, know how to restrict for a few days to get themselves out of that trouble, but they’re really not out of the eating disorder.

The subclinical women were as impaired psychologically and bothered by what was going on in their lives as the ones who were full-blown eating disordered.

There was an interesting study done in Austria a couple of years ago that found in one sample of women over 60, four percent of them met the clinical criteria for full-blown eating disorders, another four percent met the criteria for subclinical, but when they asked them questions about mood and anxiety and depression, they were the same. In other words, the subclinical women were as impaired psychologically and bothered by what was going on in their lives as the ones who were full-blown eating disordered. That says a lot, and is an important take-home message because a lot of people, when they have subclinical cases or OSFED, don’t see themselves as being as seriously impaired as people with anorexia and bulimia, but they often are. Another study showed that the medical side effects of OSFED might even be more severe than anorexia and bulimia.

DK: Why would that be?

MM: My theory around that is that OSFED people are less likely to be identified, either self-identified or identified by their caregivers, so the symptoms last a lot longer, they’re probably impaired longer, and that cumulative impact can be devastating. That’s my guess.

DK: So they’re not getting their nutritional needs, but they’re also maybe not getting the kind of emotional support that they need because they’re not recognizing they have a problem?

MM: Right.

DK: I wonder if it’s also that so many people are struggling with this that they don’t actually know what healthy eating and body image even looks like? I know you probably can’t really answer this, but how much of the population would you guess is struggling with subclinical eating disorders?

MM: I’d guess that it’s about 70 percentish.

DK: Wow.

MM:

I think it’s safe to say that in our culture at least 70 percent of women are struggling with subclinical body image issues and disordered eating,

There’s a study of women 25 to 45 years that found that 75 percent of those women were unhappy with their bodies and were dieting much of the time. Seventy-five percent. Another study looked at women over 50 and they found that 80 percent of those women had a tendency to base their self-worth on their weight, on dieting, and some were seriously bulimic. So I think it’s safe to say that in our culture at least 70 percent of women are struggling with subclinical body image issues and disordered eating, but as you said, it is so accepted that nobody talks about it and, therefore, nobody gets help.

DK: In Pursuing Perfection you point out, very poignantly I thought, that if you’re a drug addict, people look down on you when you’re engaged in your addiction, or they at least know that it isn’t healthy; but if have an eating disorder that causes you to lose weight, you get widespread acclaim from all around—even by doctors—for engaging in unhealthy behaviors that make you miserable. Unlike with drug addiction, the world really conspires to keep you in disordered eating.

MM: Exactly. No one wants to call it out because then they would have to out themselves, too. It is really incredibly sad. I mean, how often when you go out with a group of women does anybody just order off the menu? Instead it’s, “could you please hold this and that? Salad dressing on the side,” etc. That’s become normal.

DK: That’s so true.

MM: I don’t go to gyms anymore because I don’t want to hear all of the body-self-loathing and dieting talk that goes on there

Feminism & Rebellion

DK: That brings me to another aspect of your work, which is the use of feminist theory. I know these days that the medical model is definitely a big part of treating anorexia—people need to find their way back to a healthy weight and be monitored and checked out for medical problems. But in my mind, it’s hard to imagine actually getting better from an eating disorder and body dysmorphia without really understanding the objectification and abuse of women’s bodies in this culture. And it’s something that can be better understood through the feminist lens and reading history and seeing how, over time, women’s bodies have literally morphed in shape to fit cultural ideals. When you understand it in that context, it’s easier to actively fight against it. I think you said somewhere in your book that only a rebellious woman can look at herself in a mirror and love her body.

MM: It’s an act of rebellion. A true act of rebellion.

DK: And it’s a daily practice because, again, from the gym locker room to the workplace to the checkout line at the grocery store, the world really does conspire to keep women hating their bodies. So, I’m wondering if you could talk a little bit about both the benefits and limits of the medical model and whether it is possible to get better without feminist theory?

MM: Well, first of all, eating disorders are tricky because there is a necessary medical component to treatment. People have to get medical evaluations, we have to ensure that people are medically safe, and that can take a lot of time, a lot of finesse from clinicians like you and me to help a patient navigate that.Sometimes when I meet with an adult woman for the first time, she hasn’t been to the doctor in years because she fears what she’s going to hear about her body, and she doesn’t want to get on the scale. So, one of the early conversations I have during the intake is, “I want you to be able to get a medical assessment. If you don’t have a doctor, let’s try to find you one. If you do have a doctor, I am happy to call them and tell them that we have started working together and that they should not be weighing you.” That is such a relief to them. They don’t have to go through that process of being weighed, often out in the hallway, with people commenting on their weight. But we do have to find ways to intersect with the medical community, and it takes a lot of time and energy, most of which is uncompensated. I think that’s part of the reason why there aren’t as many people treating eating disorders. We have to do a lot of stuff that we don’t get paid for.

DK: There’s a great deal of collateral work with doctors and nutritionists and sometimes treatment centers.

MM: I spend a lot of time deprogramming with clients after medical appointments. It’s just something you have to add into the treatment, helping them understand that the physicians don’t know much about eating disorders, and they can’t guide them through the recovery process. They can help gauge whether there are medical problems or a Vitamin D3 deficiency, but they are only one part of treatment.CBT is the one treatment that insurance companies see as the standard, and it’s the most readily reimbursed, but with CBT and other manualized therapies, you have six or 12 sessions and you’re supposed to be cured. Or three months of DBT and you’ll be all better. The insurance reimbursement stops then because ostensibly that’s when a cure should be achieved. In that way CBT has adopted a medicalized framework of treatment and cure, but it’s not a medical therapy. Most of the studies show that only about 35 to a maximum 40 percent of people get better with CBT. If you or I were to go to a physician who told us they had a cure for us that had a 35-40 percent chance of cure, we’d probably want something else.

Eating disorders are much more complex than any 3-month manualized treatment can tackle and often require long-term treatment with many systems of care. We work in partnership not only with the client in determining appropriate treatment, but with the other clinicians brought into the treatment.

DK: Is CBT the standardized treatment for eating disorders in medical facilities?

MM: CBT and family-based treatment (FBT), which is a particular model that conceptualizes the eating disorder as primarily a behavioral issue, and prescribes that parents learn to manage their child’s eating.

DK: Is that the Maudsley Approach?

MM: It’s a variation of Maudsley, generically called FBT now, and it has some genuine strengths in that it gives parents some practical things to do, but it isn’t an appropriate model for everybody. It’s a power-oriented treatment where the parents tell the kids what to do, and there isn’t any talk about emotional issues or problems in the family—it’s more like the eating disorder has sprung up and needs to be dealt with.But I and many of my colleagues treat families sometimes who have had emotional, physical and even sexual abuse, or families where the parents are eating disordered—in these cases this approach is often inappropriate. In families like these everyone needs help and the eating disorder is very much a family-created illness.

DK: Isn’t that so often the case, though?

MM: Well, I have seen eating disorders develop in very, very healthy families where there isn’t a lot to do other than to help them learn how to get their kid through the eating disorder. But sometimes it’s extremely complex and the medical model doesn’t really allow for that kind of openness and discussion. Instead it can very objectifying—the patient is a puzzle to be solved through various medicalized interventions.

DK: And how does that differ from the feminist model?

MM: Within the feminist model, it is a collaboration and a partnership—it’s really about “we.” It’s about us together, and it’s very empowering. But to get back to your question about whether people get better in a non-feminist treatment approach, I think people can get symptomatically better. I don’t think they can get better and stay better unless they’re really, really lucky. And some of them will be lucky because the disorder wasn’t that horrible to begin with, and they get treatment, and they kind of get past it.But for most people, to really recover, they need to understand why this happened for them, and they need to grapple with a lot of gray issues in their lives, and that isn’t something that happens in the medical model, which is based on symptom control and weight management.

When I was doing my dissertation back in the ‘80s, I interviewed women who had recovered from eating disorders and, needless to say, the treatment wasn’t very advanced at the time. The definition of recovery was whether a woman had gotten her period back, whether she had weight restored, and whether she was married.

DK: Whether she was married?!!

MM: Well, I’ve been married a long time and I don’t necessarily see it as a sign of good health, you know? It does say that a person has the potential to have a relationship, but that’s no guarantee that it’s a healthy relationship.

DK: I guess I shouldn’t really be that surprised. There is still a widely held, and largely unchallenged belief in our field, and in our culture at large, that people can only find true happiness through coupling and, ultimately, marriage.

MM: Yes, we’re not much further along thirty years later. Weight is still a primary measure of patient health, even though for many of our patients, weight is not the primary factor in their illness or recovery. In the feminist model we work collaboratively with the patient to decide what the signs of recovery and relapse are.

“We’ve Just been drinking the Kool-Aid longer”

DK: It’s my understanding that a big part of eating disorder recovery is abstaining from toxic pop culture. Avoiding women’s magazines, health magazines, celebrity news, things that are likely to trigger body dysmorphia. Or, like you were saying, avoiding locker room chatter where women are picking apart their bodies and discussing diets.

MM: Yes, absolutely. I think we’ve done a pretty good job of understanding how the media and the culture affect young teenagers around body image and self-esteem and all that. Well, guess what? We adults aren’t any different. We’ve Just been drinking the Kool-Aid longer.

DK: So part of your treatment is educating patients about the cultural and media influences that contribute to their eating disorder?

MM: Yes, and I tell them they’ve been drinking the Kool-Aid. These are smart people—I don’t want to in any way diminish them—but they have bought in hook, line, and sinker to a culture that tells us that we as women have to be a certain way and look a certain way, and it’s very disempowering. So I help them understand that while they think they’ve been making active choices, they’ve actually been acting out the script that is given to women. Over time it’s very empowering.That kind of critical perspective, understanding the impact of culture, is very much a feminist discussion and it’s what keeps women strong. They see that they have to stand up against this culture that tells them to be less than who they—both literally and figuratively.

DK: Are teens open to the feminist perspective?

MM: They’re usually not at the beginning, but after a certain point, once they’re really engaged in their recovery, they become more receptive. Feminism is still the F word, and a lot of girls who do not want to associate with feminism think it’s for women who don’t shave under their arms and hate men. They don’t think of it as sexual and reproductive rights, equal pay, the right not to be sexually harassed in the workplace and so many other struggles the feminist movement has fought. I’ve had a number of young women in their 20s say to me that they want equal pay, but they’re not feminists.

DK: What do you think that’s about?

MM: Well, I think some people don’t really understand sexism until it affects them directly. I had an interesting experience a few years ago where three women who were probably all in their early 30s independently found out that male counterparts were getting paid more than they were for similar jobs. And the meaning they each made of it was that they were inadequate because they weren’t thin enough.

DK: Right, because it couldn’t have been a structural issue. They must have brought it on themselves.

MM: Yes. So I did a lot of educational work with them around what really happens in the workplace around salaries, the inequality in both pay and power, the many double standards and unrealistic expectations that are built into the very fabric of work life. When a woman realizes that a man is valued more in the workplace, it’s not uncommon for her to try to make it right by losing weight, which then can fuel an eating disorder.

Weight is the Politically Correct Form of Prejudice

DK: Particularly for middle aged women who might have put on some weight during menopause, who might not be as quick with words and numbers, who might be having hot flashes all day and drastic mood swings because of all the changing hormonal activity.Let’s talk about obesity for a second. I treated a client who was between 300-400lbs at any given point, and had yo-yoed up and down for much of her life. The way she was treated any time she went to the doctor for any ailment—it literally didn’t matter—was appalling. Nobody could see past her weight and they attributed it to all of her problems. She went in for her knee? Lose weight. For a flu? Lose weight. For pain of any sort anywhere? Lose weight. As if she wasn’t constantly being reminded of this in every interaction she had out in the world. People on the street felt like it was OK to yell insults at her. She had a hard time maintaining a job because of discrimination.

I was scrambling to find ways to be an advocate and counter this awful treatment, and then I read Health at Every Size, which turned out to be kind of a mind-blowing book.

MM: A bible.

DK: It deconstructed a lot of the myths about obesity and shed so much light on the fat hysteria in our culture. And it made me question the whole role that many therapists play in trying to help people lose weight.

MM: It’s a complicated subject, but I don’t think that people with our skills should be employed in helping people lose weight. I think we should be employed in helping people understand their relationship to food and to their bodies and we should help them learn to care for themselves in positive and healthy and sane ways, but that doesn’t necessarily translate into weight loss.Even the people who do the bariatric surgeries and the most intense kind of work in obesity find that a good outcome is a very modest weight loss—10-15 percent of body weight is considered a good outcome. That is not very impressive. People go through that intense and often traumatic experience just to lose 20-25 pounds.

It’s been interesting to watch this bariatric surgery surge. Insurance companies often won’t pay for eating disorder treatment, but they pay for expensive surgeries and the long-term outcome doesn’t seem to be that good, but we don’t get the long-term statistics. We get the statistics up to about a year and a half, but it’s between 18 and 24 months when folks tend to start regaining their weight and having more difficulty with their symptoms. And people who are really struggling don’t go for any of the outcome follow-up because they feel so bad and so ashamed.

DK: So they’re not participating in the research.

MM: Right. I honestly think we have to be very careful about being sucked into the war on obesity. Obesity is associated with some health problems, but we don’t know that those health problems are the result of obesity or if obesity is a result of a health problem. It’s correlational and not causation. People can really improve their health parameters—cholesterol, blood sugar, cardiac status, etc.—by eating better, by getting some exercise. But for people who are big, it can be hard to move their bodies, and they’re often very ashamed, so they won’t necessarily go to a yoga class at a local studio. As you said about your client, people are astonishingly judgmental and even rude to big people, which can isolate them from taking part in the kinds of classes that many people rely on for their exercise. As I said in one of my earlier books, weight is the politically correct form of prejudice.

DK: That is devastatingly true.

MM: When I have patient who is obese and needs to see a physician, I always offer to call their doctor and introduce myself and let them know, “What she needs from you is a good medical assessment, but she doesn’t need to be told to lose weight. She already is embarrassed about coming to you and feels deeply ashamed about her body, and there isn’t anything you can say that’s going to be helpful to her about that. Leave that to me.” If you say it clearly, lots of doctors really get it and are happy to partner with you.The anti-obesity movement really feeds a lot of eating disorders. The whole BMI craziness—the BMI has nothing to do with individual health. It’s a population statistic.

DK: Do you think it should just be abolished?

MM: I think it should be abolished. Pediatricians are supposed to monitor it at every visit and talk to parents about putting their kids on diets. These are kids who are going through normal uneven development. Most kids don’t develop perfectly— they get fat before they get tall, they get tall before they get fat, or they have a long neck for a while or big feet for a while.

DK: I see a lot of teens in my practice and all of them struggle in one way or another with their changing bodies and many of them flirt with eating disorders. How do you intervene there to try to help them get through that?

MM: That is a very normal process for kids, getting used to their bodies and living in this culture where other kids are going to be talking negatively about their bodies. I think some education around these changes and the normal course of development, talking with them about their fears and worries, and working with them on self-soothing. So often people turn to eating disorders because they have no clue how to self-soothe, and starvation feels soothing to them, or the calm after bingeing and purging.

DK: Teaching them self-soothing techniques at that age could head off a lifetime habit of disordered eating.

MM: Yes, and learning how to express your emotions directly and knowing that it’s okay to have emotions. It’s important to help them figure out what helps them feel good, what helps them get calm, and to develop some tolerance for their big emotions. If kids knew how to self-soothe, you’d have far fewer eating disorders, drug issues, substance abuse, self-harm, all of that.

Can People Fully Recover?

DK: Can people fully recover from eating disorders in a sustained way, and what is the best approach therapeutically for doing that that?

MM: I do believe that people can get fully better, and in my practice over the years, we’ve seen a lot of people get fully, fully better. They may still have issues to deal with, but it doesn’t turn against them in the same old way. It doesn’t become, “I can’t eat, I hate myself.” Rather it’s a signal that they have to put their recovery to work and perhaps reach out for some extra help, come back into therapy for a bit, etc. But it’s not that they’re coming back into therapy because of their eating disorder, it’s that they’re having life struggles that could trigger disordered eating if they don’t get help.To the question of what’s the best therapeutic approach, that really is different for each person, and it may change over time. It can’t be quick.

There’s no such thing as a quick fix. It has to be different interventions at different times. One of the limitations in treatment outcome research is that it assumes that everybody goes to one kind of treatment for a particular length of time and that’s it.

But most people with serious eating disorders have a little bit of treatment early on which may or may not help, and then they have some other treatment over here, and then maybe they go to a partial hospitalization program or residential treatment, and then maybe they end up in outpatient treatment, maybe they do some group therapy. It’s a tapestry that blends together into what is right for them, and it’s not a one size fits all. Of course the medical model wants it to be one size fits all, wants it to be CBT or DBT or FBT and that’s it, but the reality is that treatment needs to be varied, long-term, and is different for everyone at different stages of life.

DK: Does it usually take more than just individual psychotherapy?

MM: Yes, more often than not it takes more than individual therapy. Certainly there are people who get what they need and recovery with individual therapy, but if it’s a serious eating disorder, they might need a dietician, they will certainly need a doctor, they will benefit from things like art therapy, creative therapies.

DK: Art therapy is especially helpful?

MM: Yes, nonverbal work is really helpful for them. And family therapy, medication— a whole range of treatments.But the keystone for most people is the individual therapy, and their own trusting relationship with somebody that they can feel safe with and be honest with about what is really happening. Someone to guide them through the process and stay with them and help them break out of their shame.

The driving force that creates and sustains eating disorders is shame. So therapy is all about what do we do about that shame.

DK: Well it’s been so interesting and informative to talk with you about your work. Thank you for taking the time to share it with our readers.

MM: It’s a pleasure, thank you.

Dreamwork in Stereo

Posted on September 15, 2016February 11, 2026 by Psychotherapy.net Team

Have you ever struggled to share your dream with somebody in the morning? What seemed most vivid and realistic just a moment ago, when verbalized, turns into senseless gibberish, doesn’t it?

What about adding another difficulty to recounting a dream, namely telling it in a foreign language? Which of their languages to use is a dilemma faced by many of my multilingual clients in therapy. It may also open doors that neither they nor I would have dreamt of.

Francesca was Italian, living in Paris. When looking for a therapist, she had reached out to me because we shared common emigrants’ background, and three languages: Italian, French, and English. She was going through a double transition: recently married, she was settling into her new role as a wife when she was laid off by her employer. As a result, Francesca felt anxious, stuck at a crossroads between countries, lost in her professional life, and unfit for her new married life.

She had chosen to communicate with me in English, as Italian felt “boring and obsolete” to her. Having left her country in her early twenties to pursue artistic studies in the US, she was now living in Paris, working as a designer for a large fashion house. Her adopted English was her language for “creativity and self-growth”, as she put it.

For the first time in the two months of her therapy, Francesca arrived early. She rushed into telling me her nightmare:

She was late for her own wedding and stood naked in the middle of her bedroom. Her groom Alain was waiting at the church; she needed to dress quickly, but was unable to find her white-laced wedding gown.

The clock on the wall was ticking, adding to her growing panic. She pulled the door of a huge cabinet. Inside, a dirty pig was smiling at her, insolently.

Terrified, she pulled a rope hanging alongside the pig, hoping to make the beast disappear. But as a result, a shower of vomit dropped from the ceiling, full of disgusting noodles.

A strong smell of vomit had woken her up.

Now, sitting in front of me, she looked sick indeed.

Going through the dream again, with me as a witness, had been sufficient for Francesca to make some sense of it: she realized that the ticking clock could be her biological clock (time for children), time passing on the job hunt, time to go back to Italy…

But, listening to her, I felt that something was missing: usually very much in touch with her emotions, this time Francesca was slipping into a very cognitive, fruitless field. Her storytelling made sense, but I wanted us to go further into exploring it. Two objects actually echoed in Italian in my mind: “the ticking clock” (orologio) and “the noodles” (spaghetti).

This “stereo effect” triggered my curiosity and I asked Francesca to tell her dream again, this time in her mother tongue.

She did, and as she started describing her anxiety, and the feeling of urgency at not being ready for her wedding, we both felt how the flow of emotions had finally penetrated the room. Francesca’s voice had changed. The immediacy of the emotional experience gave me goosebumps.

Francesca admitted that she had “felt much more emotional” when recounting her dream in Italian. If in English her mother’s not being there had not seemed to provoke any particular feeling (she had died when Francesca was a child); in the Italian version, her mother’s absence stood as a painful void. The sense of loss and solitude had become almost tangible, and I could see how much Francesca was missing her again at this stage of her adult life, when she may herself become a mother soon.

Listening to her Italian fluid words, I finally connected with the little Francesca, who, like any other young girl, had idealized marriage. In that ideal representation, maintained by a rich cultural imagery, she was to wear white and her parents would be there. The reality was different, her parents had been long gone, the white wedding dress was not compulsory, having a first child at her age was nothing abnormal in today’s world.

Now the vomit image made sense as well. She associated it with the pregnancy nausea, and her anxiety about not being able to be a good mum (or even not to be able to bear a child at all).

As she was sharing her fears with me, Francesca felt slightly nauseous. She recognized this very sensation in her throat as something she had been experiencing lately. She had been repressing it successfully, but could now understand the reason for it.

Finally, I asked Francesca to go back to her dream and replay it all over again. Playing with its own imagery seemed like an opening for re-writing Francesca’s story about herself at this stage of her life. This time, she decided to stop looking for the white wedding gown, as she realized that it was more important for her at this point to get to the church, where Alain may start to worry.

In this refabricated new dream, as she ran through the fields towards the church, dressed in her old jeans and a jumper, she reported feeling young and liberated; excitement replaced anxiety.

Compartmentalization is a psychological strategy, naturally adopted by emigrants. Francesca’s world was divided into two well-separated realms: her childhood and life in Italy before her expatriation, and her “new”, more independent, life in the US and then France.

Up until that session, using mainly English, we had been engaging with the latter; the young Italian girl had been left behind. This feeling was a familiar one: after all, she felt abandoned by her mother who had gone too suddenly and too soon. Sticking to English, I may have re-enforced this narrative, leaving the little Francesca to a lonely and sad past. On the other hand, had Francesca told me her dream in Italian only, we would have done a good job eventually; possibly an easier one. But having access to both “parts” of her through telling her dream in both languages had enriched our work.

Working with dreams in therapy is a deeply relational activity. We don’t just recount our dreams (as we do by writing in a dream journal), but we let somebody else enter its realm, and re-experience it with us. This is also why the language we use for it has a meaning. This unique experience had not only allowed me to see Francesca more fully, but our therapeutic relationship had deepened, with her younger and more vulnerable self now invited to the therapy room as well rather than waiting behind a closed door.

Dreamwork is a great opportunity to move forward the therapeutic work, especially with highly cognitive clients. The multilinguistic perspective goes one step further restoring a missing stereo effect to the music heard by the therapist.

The Gloria Films: Candid answers to questions therapists ask most

Posted on August 16, 2016February 11, 2026 by Psychotherapy.net Team

When I penned an article and a book chapter on the classic Gloria Films some years ago I never dreamed these pieces would continue to bring me a seemingly endless string of correspondence. Indeed, this classic video influenced the psychotherapy training and subsequent practice strategies for thousands and thousands of helpers.

To this day the battle rages on about whether this work of art was the savior of psychotherapy, or psychotherapy’s worst nightmare.

Recently a graduate student contacted me with a string of seriously good questions. In this blog I shall share those questions with my answers to shed a tad more light on this major artifact of the 20th century counseling and psychotherapy movement. Okay, let’s do this!

Question: Is the Gloria Film the actual name of the training video? I couldn't find an official reference for it?

Answer: No, the actual title was Three Approaches to Psychotherapy I, II, and III, but folks dubbed it the Gloria Films.

Question: Is the work really as old as it looks? I mean it comes across as ancient.

Answer: That’s because it is ancient. The actual filming took place in 1964 and the movie was released in 1965. In 1964 the Beatles made their first appearance on the Ed Sullivan Show and in 1965, "The Sound of Music" was a big hit at the box office, and the mini-skirt was just released.

Question: Who came up with the idea for the project?

Answer: The mastermind (aka the producer and director) behind the flick was a California psychologist and psychotherapist of note, Everett.L. Shostrom. He created some self-actualization inventories and two years after the Gloria films he authored a successful book, Man the Manipulator.

Question: Why do you think Dr. Shostrum got involved in this project?

Answer: At that time a shroud of secrecy had permeated professional psychotherapeutic helping. The books gave mountains of information about theories, but there was very little literature about what therapists actually said to clients. In 1950 Shostrom recorded the late, great Carl Ransom Rogers with a client on a magnetic wire (yes, go ahead and laugh, this predated digital, cassettes, reel to reel, and eight-track recordings). But: It was not to be. The recording was lost forever when the head of the history department recorded his own presentation of Adam and Eve on the wire recorder! I mean seriously, could I make that up?

Question: Why did Dr. Shostrom choose Albert Ellis, Carl Rogers, and Frederick (Fritz) Perls as the therapists?

Answer: Well, quite frankly, it was an all-star line-up. A lot of folks in the field felt these three helpers were the dream team . . . the best in the world, if you will. Perls created gestalt therapy; Ellis pioneered RET or rational emotive therapy (abbreviated RT at the time of the filming); while Rogers was the father of nondirective counseling which in today’s world is often called person-centered counseling.

Question: Why do my professors always call the approach by Ellis REBT? Is that the same thing as RET?

Answer: Late in his career Ellis added the “B” to stand for behavior based on the longstanding recommendation of a well-known psychologist and psychotherapy book author Raymond J. Corsini.

Question: Had Gloria met Perls, Rogers, and Ellis prior to the filming and what did she know about them?

Answer: No. She just knew they were prominent therapists and would each have approximately 15 or 20 minutes to cure her of what ailed her.

Question: Was Gloria a real client or merely an actress pretending to be a client?

Answer: Oh definitely, a real client. In 1963 Shostrom put together a film titled "Introduction to Psychotherapy." The film featured an actress who was pretending to be a real client. Shostrom was not happy with the movie, nor the acting, hence a real client, Gloria, was cast for 1965 project.

Question: I thought Perls acted like a jerk during his session. Do you have any evidence that Perls was aware of how he was coming across? I am totally sure my current internship supervisor would never allow me to treat a client in such a mean manner.

Answer: I can say with great certainty that Perls was aware of his actions. At one point in the session he quips, "Well, Gloria, can you sense one thing? We had a good fight?"

Question: So how do experts who practice gestalt therapy defend the practice of this theory?

Answer: Well, generally speaking, they say something like, "You don't need to do therapy exactly like Perls to be a gestalt therapist." To be fair, I have heard top practitioners say precisely the same thing about Ellis, though to be sure they are not talking the way Ellis came across in this movie. If you ever witnessed a therapy session or workshop conducted by Ellis he was often prone to use a little off color language, and that's putting it mildly!

Question: Okay, well here is my biggest question and the one I really want to know the answer to. In the movie, Rogers comes across in a very warm moving way. Ellis, is seemingly a tad less empathic, but not bad, while Perls is flat out mean to her. After Gloria experiences therapy sessions with all of them she is asked which therapist she would most like to continue therapy with and she chooses Dr. Perls. I was shocked. I mean, I just thought Rogers was the hands down winner. What in the world was going on here?

Answer: You were surprised, I was surprised, my entire graduate class at the time we viewed the films was surprised, and seemingly countless others who viewed the sessions were in shock and awe. There was just something not quite right about her choice of Perls. I didn’t buy into it then and I sure don’t buy it now. In fact, it was her strange choice of Perls which piqued my interest in researching the movie.

Personally, I thought it was the strangest response (from a client who was not psychotic) I had come across in the entire field of psychotherapy, and that's saying a lot!

Question: Did you find it difficult to research this film?

Answer: Do birds fly? Absolutely. Lots of people were trying to piece this puzzle together with very little success. Perhaps the most remarkable was a fellow I corresponded with in another country who was actually offering small rewards for information. Seemingly folks with connections to the film just were not talking. On one occasion a person who actually knew Shostrom told me he insisted I share anything I came up with him before I had it published! He wanted to approve or disapprove of what I was going to write. What? (Excuse me, but when did America stop being a free country? Just asking.) He also refused to give me any information and told me it wasn't relevant why Gloria chose Perls. This made me even more suspicious and made me want to research this even more!

Question: Did Gloria ever see Perls after the interview and if so what transpired? I hope the transaction was more cordial than the therapy session.

Answer: Yes they saw each other, but no it wasn't pleasant! According to Gloria, after the cameras stopped rolling and the experts and movie crew were preparing to depart, Perls used Gloria as a human ash tray (not a misprint). He motioned for her to hold her hands cupped with her palms facing up. He then flicked his cigarette ashes into her hand.

Question: Geez, that's downright abusive, wouldn't you agree?

Answer: Yeah! At the very, very least I could safely say it is behavior that was unbecoming of the father of a major psychotherapy modality.

Question: Lots of folks on the web accuse Gloria of having an affair with Rogers or Ellis. Some even suggest she married one of them. Any truth to the rumors?

Answer: Totally false. Junk science. Not a shred of evidence to support these claims. In fact, to the contrary, Gloria became very close to Rogers and his wife.

Question: Okay, so I can't wait another moment. Why did Gloria pick Perls as her favorite? Rogers came across so empathic. Wasn't he surprised when Gloria did not choose him? I have heard therapists say that Perls was chosen because she realized she needed a tough helper and he would not allow her to remain disturbed.

Answer: Rogers did admit he was baffled. In my mind Rogers gave a flawless performance. I'd give him five stars. Six if I could. As the session began to wind down Gloria says, "Gee, I'd like you for my father." Rogers replies, "You look to me like a pretty nice daughter." As you remarked earlier, it was very moving and Rogers came across as an ideal billboard advertisement for his own theory. Moments after the session with Rogers Gloria announced that, "All in all I feel good about this interview."

Three years before he passed away, Ellis told me that Gloria hated Perls for the rest of her life. Ellis revealed that the movie was "a fake" in the sense that, prior to the filming Gloria had seen Shostrom for four years of psychotherapy. When the film was produced Rogers didn't know this either. At the time, Shostrom was a supporter of Perls. To quote Ellis, "He [Shostrom] got her to say it was Perls who helped her, when he actually didn't." Was Gloria experiencing positive transference toward Shostrom? Was it just that she didn't want to disappoint her therapist? Could it have been that she was petrified of Perls? I don't have the definitive answer, but I think all of the aforementioned issues most likely entered into this. Just for the record Ellis felt he tried to cover too much in his own session with Gloria, and thus while his intervention was not horrific, he was clearly not at the top of his own psychotherapeutic game.

Question: So what is the take-away message you think counselors and therapists need to know?

Answer: Well, first let me be 100% crystal clear that there are occasions when a helper must be direct and use confrontation. No argument about that. Not now, not ever. However, after watching the movie, countless generations of therapists came away with the false notion that a sarcastic, up in your face, card carrying mental judo therapist (in this instance Perls) will walk away with the grand prize. Over the years I routinely heard therapists, supervisors, and my own students brag, "I got right up in the client's face and came across like Perls in the movie," thinking that was the best approach. According to Gloria's daughter (referred to as Pammy, just a fifth-grader at the time of the film), who authored Living with the 'Gloria Films': A daughter's memory in 2013, these Perls wannabes got it oh so wrong. After perusing her book it is safe to say the brief session with Perls negatively impacted her for the rest of her life.

Question: Is Gloria still alive?

Answer: Sadly, Gloria passed away in her mid-forties after a battle with cancer. I believe Gloria said it best herself as she was fond of saying, "Believe half of what you see and none of what you hear." Every aspiring and practicing therapist who wants to complete the emerging gestalt should see this film.

Louis Cozolino on the Integration of Neuroscience into Psychotherapy—and its Limitations

Posted on May 31, 2016February 26, 2026 by rezendevknowfully.com

Neuroscience or Neuro-psychobabble?

Sudhanva Rajagopal: Lou Cozolino, you are a psychologist and professor of psychology at Pepperdine University, where you were a teacher of mine. You’re a prolific writer and researcher on topics ranging from schizophrenia, child abuse, the long-term effects of stress, and, more recently, neuroscience in psychotherapy and the brain as a social organ.As a clinician in training, it seems like there is a lot of neuroscience talk out there in our field, and it gets used to legitimize anything from specific interventions to whole theoretical orientations. My first question to you is, for the clinician in training, how do you recommend that we see through the noise of all that to what is actually helpful in the room with a client? How does knowledge of neuroscience play out in the room and what is actually important for the clinician to know?

Louis Cozolino: There are two main realms where neuroscience can aid clinicians. One is case conceptualization and the other is for clients who aren’t really open to a psychotherapeutic framework or an emotional framework. For them a neuroscientific explanation or conceptualization of their problem is often something they can grasp while they can’t or won’t grasp other things.

People who learn a half a dozen words about neuroscience think they’re neuroscience literate.

But there’s so much psychobabble and neuro-psychobabble out there, and the thing is if you say something is the amygdala as opposed to saying it’s anxiety or fear-based, you haven’t really upgraded the quality of the discourse. You just substituted one word for another. So the risk is that people who learn a half a dozen words about neuroscience think they’re neuroscience literate.

Learning neuroscience takes dedication. It takes work to get beyond the cocktail level of conversation and clichés. It took me ten years to feel like I had any sense of what was going on and I studied it pretty intensively. So I think we all have to be careful, but even more importantly, just because you know some neuroscience doesn’t mean you know anything more than the therapist who doesn’t. It’s really about how you use that information to upgrade the quality of the work you’re doing.

SR: In your book, Why Therapy Works: Using Your Mind to Change Your Brain, you say that science in many ways is just another metaphor. Do you think there are dangers to people using neuroscience to legitimize their work?

LC: Well, sure. There’s a fellow, Daniel Amen, who does these SPECT scans of people and he’s been selling them for thousands of dollars for probably 20 years now. It’s hard to know whether any of his data has any meaning. All we know is he’s made a hell of a lot of money doing them. The danger is in selling things before you know that they have any legitimacy, so you have to watch out for snake oil salesmen just like you do when you’re buying carpets and used cars.

SR: So how do you recommend that someone like me goes about finding and learning about neuroscience in a way that’s helpful? How do I avoid the snake oil salesmen?

LC: It’s important to realize that knowing neuroscience doesn’t make you a good clinician—in fact it doesn’t make you any kind of clinician at all. So I would say for beginning therapists, it’s probably best not to pay too much attention to neuroscience.Learn a few things about it but focus on getting the best supervision you can in a recognized form of psychotherapy—psychodynamic, cognitive, behavioral, family systems, etc. And avoid the passing fancy of all of the new therapies; every day there’s a new therapy with a new set of letters in front of it.

SR: Yeah there are so many different kinds of therapies these days.

LC: Try to learn something that isn’t just a fad, because the fads—I’ve watched hundreds of them come and go over my years. But if you cleave to psychodynamic training and cleave to cognitive behavioral, Gestalt, family systems training—those are the things that you can hang your hat on. Then you can learn the fads to add to your tool box. The fads are very sexy and they create the illusion of understanding because they’ve got fancy terms and nice workbooks and such, but really you’re not a thinker when you’re doing those things, you’re more of a mechanic.Now neuroscience is sort of like a sidecar to conceptualization, but you’ve got to remember the motorcycle is the real tried and true way of thinking about clients. You know, what is a particular problem? What is mental distress or mental illness? Where does it come from developmentally and what are the tried and true ways of approaching it and treating it?

Every Therapy is Embedded in Culture

SR: Speaking of tried and true ways of thinking, you say in your book, “Psychotherapy is not a modern invention, but a relationship-based learning environment grounded in the history of our social brains. Thus the roots of psychotherapy go back to mother-child bonding, attachment to family and friends, and the guidance of wise elders.” My question is, where do you think psychotherapy fits in to the context of healing traditions that have been around for millennia?

LC: Well, I think one thing that seems to be different over the last hundred years in psychotherapy is a kind of structured recognition of the fact that the therapist is imperfect and contributes in a lot of different ways to the problems. The tradition of wise elders was one of an authoritarian stance: This is the truth and I’ll take you on this journey with me to change you into my likeness. To whatever degree psychotherapy has evolved past that has to do with the self-analysis of the therapist and the recognition that whatever pathology exists in the relationship between client and therapist, some—hopefully not the majority, but some—pathology in the relationship comes from the therapist.That type of recognition is a step forward. There are probably some steps backward too. Often psychotherapy is ahistorical and acultural—or at least tries to be—but every therapy is embedded in culture. There is a kind of pretense about an objective scientific stance that is just a fantasy. So in some ways, wise elders in a tribal context with a long history are probably advantageous for some people as compared to psychotherapy.

SR: I was flipping through the index of your book and noticed the word “culture” appears exactly once, though you do talk about the wisdom of the ancients, about Buddhism and Confucianism and some of the Indian traditions. Seems to me that once we start relying on these kind of generalized, evolutionary, and biological forces as explanations for things, there’s a risk of painting people’s lived experience with a pretty broad brush. What’s your take on the importance of culture as it relates to neuroscience and psychotherapy?

LC: From an evolutionary perspective, a basic principle is biodiversity, and culture is too blunt an instrument to understand people because there are so many differences within culture. I think in terms of every individual being an experiment of nature. Every family is a culture in and of itself, and the more different someone’s cultural background is from mine, the more there is for me to learn. I think that culture needs to be interwoven into every sentence of every book, not just included in some special chapter of a book.

SR: From my point of view, many of these older cultural practices have been repackaged and rebranded as psychotherapy theories and techniques. The “mindfulness revolution” and transcendental meditation are based on ancient cultural traditions, but they are marketed as if they are especially effective because they are “new” and “evidence-based.” What is your stance on that?

LC: Having studied religion and philosophy and Sanskrit starting back when I was in college in the 70s, the self-awareness of meditation has been part my worldview since long before it became a cottage industry. But even back then there was the Maharishi Mahesh Yogi and the Beatles, and it was coming into the cultural context. Now people have figured out how to package it as a way to sell more therapy, which isn’t all bad, but runs the risk of becoming “the answer.”

I think we’re in a race between global destruction and global consciousness, so we’ll see who gets to the finish line first.

What I’ve been hoping for since I first discovered Buddhism in the 1960s, is that as the world gets smaller and as people from different cultures communicate more, the wisdom of the ancient Eastern philosophies will be interwoven with Western technology and we’ll come to some higher level synthesis of understanding and consciousness. I think we’re in a race between global destruction and global consciousness, so we’ll see who gets to the finish line first.

SR: Can you say more about that?

LC: Well, it’s a slow evolutionary process for the types of awareness that people four or five thousand years ago discovered in India and Tibet, in China, in Japan, to penetrate Western culture. The Western world view is so different—for so many people it’s almost impossible to conceptualize an internal world; everything is external. Everything is about creation, growth, and, in a more destructive sense, conquering and genocide.So there are forces of destruction—of each other and of the planet—on the one hand and then there are the forces of consciousness and wholeness and a sense of oneness of the species on the other. So will we understand that we’re all brothers and sisters on a spaceship before we destroy the spaceship?

“There only needs to be a piece of you that’s a psychologist”

SR: How can psychotherapy play a positive role in this race you’re talking about? Or psychotherapy as we know it in the Western world?

LC: Well, one of the problems with psychotherapy as I see it is that psychotherapists tend to be sort of passive—they retreat from the world of leadership and create very insulated relationships in their consulting rooms. But for the field of psychotherapy to have any impact, it has to be expressed politically and socially. The types of ideas and theories that we’ve researched and studied, like the importance of early child rearing, self-awareness, authoritarian personalities, positive psychology and so much else, need to become part of political discourse both to elevate it and also have an impact on how resources are distributed.

One of the problems with psychotherapy as I see it is that psychotherapists tend to be sort of passive—they retreat from the world of leadership and create very insulated relationships in their consulting rooms.

Evolution is a slow, meandering process. All you have to do is watch the Republican debates to see that. It reminds me of junior high school in the Bronx in New York where we used to engage in chop fights, which was all about humiliating the manhood of other guys just to get a one-up. It doesn’t make me optimistic about the evolution of consciousness, but we’ll see what happens.

SR: I want to move onto something you said in your preface that I liked a lot: “Like monks and soldiers, therapists of all denominations assume that God is on their side.” What do you think are the limitations of psychotherapy and where does it come up short against the human condition, cultural walls or seemingly immovable, systemic injustice? In other words, when do we have to admit that psychotherapy is just not helpful or effective?

LC: The risk with psychology and psychotherapy is that it can lean too much in the direction of helping people tolerate rather than fight against oppression. Self-awareness and self-compassion are crucial experiences and skills that we foster as psychotherapists, but there needs to be a balance there. You can’t become too much of a psychologist. There only needs to be a piece of you that’s a psychologist and there’s another piece of you that has to be willing to go out and fight for systemic change.

As I said before, psychologists tend to watch from the sidelines, and that’s why as a field it has relatively little impact. In fact, the profession gets a lot of bad press because there are plenty of famous psychologists who do staggeringly immoral and unethical things. They are the basis of the cartoon version of the therapist nodding their head and going, “uh huh.”

SR: You talk about psychology as being an essentially solitary profession. Are there people you can think of who aren’t standing on the sidelines?

LC: Psychologists you mean?

SR: Yeah, psychologists.

LC: No. Can you?

SR: Not off the top of my head.

LC: Psychologists are really good at telling other people they should do something. It’s sort of like life by proxy.

SR: Indeed.

LC: Another problem in psychotherapy is a lack of appreciation or respect for anger; anger is always something you’re supposed to manage. Or you’re supposed to learn how to behave appropriately in society, but that’s not always an appropriate response, especially if you’re a member of an oppressed group. It’s really important sometimes to go on picket lines and carry bricks and defend yourself and make a lot of noise.I very much respect the Black Lives Matter movement and I watch them in these Trump rallies, and they’re getting pushed around. It breaks my heart because it reminds me of a lot of bad memories from childhood during the Civil Rights Movement. And I’m sure you’ve seen pictures too of what happened in India with the British, of people being hosed and slaughtered. There’s a tendency in human behavior to objectify differences and we really need to fight against and not tolerate that. I’m hoping that, given that Trump is consolidating and activating the anger of people in this culture against immigrants and foreigners and God knows what else, that it also energizes the liberal base and brings out a new progressive movement as well.

SR: Absolutely, but this idea of psychologists carrying bricks and taking up arms seems really at odds to me with this image we have of psychologists as dispassionate observers, people who are sitting in their therapy chairs saying, “uh huh.”My interests lie in political action as well and I do remember, at least from my dad’s generation and my grandfather’s generation, thinking about British rule and the independence movement in India and the idea of people really taking a stand. But that doesn’t seem like something psychologists really do. Even in the room with a client, we’re not taught to take a stance on things, you know?

LC: In fact it’s the opposite. Everything that we believe is interpreted as countertransference and non-neutral. It creates a real rift in people. It’s hard to imagine that a lot of younger psychologists with any sort of a political drive would be attracted to psychology. It will continue to attract people who want to stay on the sidelines in the world or avoid the conflict.

SR: How is that going to change?

LC: In truth I don’t know. In the 60s we had something called community psychology, which was very radical at the time and which still exists, but it’s not prominent at all anymore. One of the main focuses of community psychology was to identify those people in the community or in the tribe that other people went to for assistance—people like hairdressers and bartenders and cab drivers. These are the people that folks in trouble tended to talk to, so community psychology emphasized educating people in the community that were sort of hubs of interaction. The field has gotten so much more insular since then.

Transitioning From a Beta to an Alpha

SR: I want to go back to something you said about anger that intrigued me. I’m just thinking back to discussions and supervision I’ve had in training, and whenever anger comes up, you’re told there’s something “behind” the anger. You know, there’s shame behind the anger, or sadness behind the anger. How do you feel about anger as just a primary kind of emotion? And do you think it has value both for the therapist and for the client?

LC: If you’re going to become empowered, if you’re going to transition from a beta to an alpha in your life, you really need to be able to get back in touch with your anger because it can be very propulsive, very helpful in life. It evolved along with caretaking and nurturing because it’s not just necessary to feed and nurture babies, but to protect them.Anger is the only left-hemisphere emotion that we consider negative, but anger is a social emotion, unlike rage. It can be engaging, relational, constructive. In order to combat the social programming that leads to shame, we have to get at least somewhat angry—at both the voices in our head and out in the world that shame us, disempower us, keep us from speaking up.

When I think of somebody like Gandhi or Martin Luther King, Jr., I think of the courage it took to walk into angry crowds. It’s so moving to me and such a powerful act. We can’t just be passive about these voices in our head and in society. We have to get angry because our anger and our assertiveness and our power are all interconnected. If you give up your anger, you give up your power.

SR: Agreed. Tell me a little bit about your idea of the social synapse.

LC: The more I studied different physiologies, social psychologies, organisms, the more I realized that there is a very complex highway of information that connects us via pupil dilation and facial expression and body posture and tone of voice, and probably a hundred things that we haven’t even discovered yet.What we’re doing in psychotherapy, and in any relationship where we’re trying to be soothing and supportive and nurturant, is connecting across the synapse between you and someone else. You’re trying to create a synergy between the two of you and have an effect on their internal biochemistry that enhances their physical health, their brain development, their learning. If you’ve ever been with a really good teacher, you know that in part because you feel a lot smarter because you’re connecting with someone who’s stimulating your brain to work better. If you’re with a bad teacher, you feel dumber, and you get pissed off and angry. And there are not a lot of good teachers out there so you’ve got to cleave to the good ones.

But also there’s a different chemistry between different people. Someone who’s a good teacher for one person may not be a good one for another. Same thing with therapists. Every therapeutic relationship creates a new organism—a dyadic field— and sometimes it works and sometimes it doesn’t. The chemistry part we often don’t have any control over.

SR: Going back to the brain and neuroscience, where do you think we are in right now in the field and where are we headed?

LC: Well, we’re all over the place in brain science, but there is a great deal of focus right now on genetics. In other words, looking at the relationship between experience and interactions and how the molecular level of the brain gets constructed and changes over time in relation to the others and the environment. I think that the translation of parenting and relationships in psychotherapy into actual protein synthesis and brain building is an incredibly complicated but very important paradigm shift that is going to be playing out probably over the next century at least as we uncover those things.Another shift in neuroscience is getting past the phrenology of looking at individual brain regions related to specific tasks and starting to look at these new technologies that measure brain connectivity. In other words, how do different areas connect to regulate each other and synergize? The next step will be figuring out how two or more brains interact and stimulate each other.

I don’t know where the technology to research that is going to come from but I think it’s on the horizon. We’ve got to get beyond thinking about brains as individual organs and think about how they weave into relational matrices so we can understand human connection and have a scientific view for the types of things that Buddhists and Hindu meditators and Tibetan scholars have been thinking about for the last several thousand years or so.

Why Does Neuroscience Matter?

SR: How would you explain to an existential psychotherapist why these advances in technology and in brain science are at all important to what they do?

LC: I don’t know if they are important to what they do. I don’t think neuroscience is more important than Buddhism—it’s basically just another narrative.

SR: Interesting.

LC: It’s just another way of looking at things. Think about when you’re at a museum looking at an exhibit and you’re walking around it trying to experience it and appreciate it from a number of different angles.That’s pretty much what reality is. We walk around it and we have these different ways of thinking about it and explaining it that are partially satisfying and partially unsatisfying. Buddhism is incredibly satisfying a lot of the time and very unsatisfying some of the time. So when you get bored with one way of looking, you want to look at something in a different way. For me it’s interesting to combine and integrate different perspectives but I don’t think that you have to subjugate one to the other.

In the 1950s Carl Rogers was talking about how to create a healing relationship. Fast forward 65 years and now neuroscience is discovering pretty much what Rogers was talking about. Am I better off talking about it from that perspective than listening to Carl Rogers? I don’t know. But it makes me appreciate what Rogers says even more and in a deeper way when I can see it from this scientific perspective.

SR: That makes sense.

LC: If Buddha were alive, he’d say, “Of course,” right? “There’s 5,000 research studies you did, but all you needed to do was read the Sutra and you would have figured it out.”But I think it’s interesting to just keep learning about life from as many points of view as possible. When have your read enough novels?

Each novel you read is a new way of capturing the universe, and they’re entertaining and stimulating and make you feel human. I feel the same way about the sciences, which is why I love reading E.O. Wilson’s work on ants, because I learn a lot about humans by reading about ants. So many things we do are very ant-like. Plus, ants are interesting.

Nobody Has the Answer

SR: Ants are very interesting. That’s a great way to look at it and I completely agree. Moving away from neuroscience for a moment, I’m curious about how your clinical work has changed over the years.

LC: It’s changed constantly. When I started as a student of pastoral counseling at the Harvard Divinity School, Carl Rogers was one of my teachers, so my first real training was Rogerian. The reason I got interested in counseling in the first place was reading Fritz Perls’ Gestalt Therapy. Then when I ended up at UCLA I realized you have to learn cognitive behavioral therapy whether you like it or not. So I was trained in that. I did a couple of years at a family therapy institute in Westwood in L.A. My supervisors were psychodynamic and my therapist at the time was a Jungian, and then I had a couple of other therapists who were psychodynamic and Gestalt.I was working with people who had been severely traumatized as kids, so I got interested in neuroscience through a study of memory, trying to figure out what the heck was going with the memories of people who’d suffered severe trauma.

Since then, my heart is more in the object relations world, I think mostly because it matches my personality and the type of relationships I like to create with people. But I’ve woven in neuroscience, attachment theory, a bit of EMDR, some meditation and self-awareness exercises. It’s a hodgepodge of all the different things that I’ve learned, but I don’t really feel like I’ve got a hammer and everybody who comes in is a nail. It’s more like I’ve got a toolbox of 30 or 40 years of things that I’ve been collecting and I try to figure out how to match as best I can to the needs and the interests of the client.

SR: Is there a certain population or certain pathologies that you’ve been working with more lately or that you’re more interested in?

LC: Not really. My practice is pretty general and I like to keep it that way. I don’t really like to see the same problem over and over again. I always think of psychotherapy as kind of like a collaborative research project. People come in and we work together to figure out what’s going on—how did it arise? Is there any hope of making it better? I really like having problems I haven’t dealt with before.

SR: What do you wish you’d known as a beginning clinician?

LC: When I started, I was looking for an answer and I wanted to know who had the answer. So

I tried to become a disciple of one person or another person. It took me quite a while to realize nobody has the answer. Everybody has a little piece of it.

And what I’ve got to do is just learn the best I can and then sacrifice and move on. This is a very ancient Rig Veda philosophy—every day you wake up, you sacrifice the day before, you move on, you create a new reality.

Had I understood this, I would have spent a lot less time worrying about finding the truth and being acceptable to whatever godhead I happened to run into at the moment. I think idolatry is the problem. Idolatry and objectification.

SR: It’s hard to avoid being exposed to that as a student. At least in my experience, in every new class you’re exposed to something people think is the answer, the best way to look at things.

LC: In my experience, the degree to which someone is enthusiastic and adamant about having “the answer” usually reflects the degree of insecurity they have and their lack of ability to tolerate their own ignorance. If we’ve learned anything, especially when it comes to diversity, it’s that we have to embrace our ignorance and be curious as opposed to leading with certainty.Jacob Bronowski was a physicist who died about 20 years ago, but he did this wonderful documentary about visiting Auschwitz, where his whole family was slaughtered. He waded into the mud behind the crematory and grabbed a handful of mud, realizing that his ancestors were part of this soil, and said, “This is what happens when we’re certain.”

Certainty leads to ideological beliefs that supersede humanity. At a less dramatic level, we get so enamored with our philosophies and our therapeutic beliefs that we miss our clients because we’re so convinced that we’ve got to convince them we’re right about the things we believe should be true.

SR: So last question here; where do you think the field as a whole is going?

LC: Well, I don’t think mental distress is going anywhere. I think that more and more people are going to be having psychological problems as society and civilization become increasingly crazy. No matter how many therapists the schools pump out, the world is creating plenty of suffering, so there will always be a need for therapy.And though there will always be therapists trying to create revolutionary new therapies with great acronyms, I think that the tried and true methods will remain strong and stay strong because they’re tapping into fundamental constructs in human experience—the need to connect with other people, to be able to leverage our thinking to modify our brains, to ask questions about ultimate meaning and existence.

Where the field is going to have to upgrade its sophistication and quality is in the areas of like pharmacology, epigenetics, psychoneuroimmunology, diet. All of the actual mechanisms that create and sustain our brains will have to become part of the dialogue about how we help people sustain and maintain health. This might just be my Eastern philosophy bias, but we’ll probably be moving in the direction of more holistic, integrated thinking and treatment—not just combining East and West, but integrating scientific discoveries into our case conceptualizations and treatments.

Finally, I hope that psychology becomes more integrated with education. I have a book series that I’m editing for W.W. Norton which is on the social neuroscience of education, and we’re pushing to have psychologists, neurologists, neuroscientists and educators communicate more so that the things we’re learning can be integrated into each field.

SR: Well that seems like a great place to end. Thank you so much for taking the time to share a bit about your work and your life with the readers of psychotherapy.net.

LC: It was a pleasure, thank you.

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