Approach Archives - Page 29 of 41

Dial-Up Connection

Posted on October 22, 2013February 11, 2026 by Psychotherapy.net Team

Thirty-five years ago I got my first paid therapist job as a second-string telephone counselor for an enlightened radio station in Sydney, Australia. The radio station ran a daily one-hour program called “Kid’s Careline,” and my boss was the first string counselor who fielded on air calls from the radio audience. She was so brilliant at it that she kept three of us second stringers busy 9 to 5 fielding the calls that did not make it onto the air.

It was in this job that I began to learn about the unique power of telephone counseling. Stints of supervising and fielding crisis phone calls at Suicide Prevention and Parental Stress Services in Oakland enriched my learning. These experiences eventually culminated with me adding telephone counseling to my private practice, which I have done for the last 20 years.

I have an Intersubjective/Relational approach and specialize in working with individuals whose traumatic childhoods have burdened them with Complex PTSD. I am excited by my accumulating anecdotal evidence that significant attachment repair work can be done over the telephone. I have especially noticed this with clients whose trauma is so extensive that they are incapable of handling the anxiety of face-to-face work. Some of my clients have lived reclusive lives but sought me out because my website articles explain how their childhood traumas created their attachment disorders.

Complex PTSD survivors typically operate from a deep belief that “people are dangerous,” and feel less endangered on the phone because they know that they can escape in a second if necessary. Moreover, the phone seems to offer them enough protection, that they are able to drop into authentic and vulnerable relating quite quickly with me—often more quickly than new clients in face-to-face sessions. Once again, I believe this is because phone work offers them a greater sense of safety.

Telephone therapy can foster a uniquely rapid building of trust. In best case scenarios, as with in-person work, this eventually encourages some clients to look elsewhere for similarly trustworthy relationships. More than a few of my telephone clients have experienced enough relational repair within two years of weekly sessions to venture out successfully into the world of real live relating. Often this starts with participating in online support groups, and then expands into joining in-person groups.

I believe that part of the healing dynamic in phone work is that voice contact can be as soothing and brain-changing as the eye contact that seems so fundamental to forming attachments. I wonder, in fact, if voice contact is even more fundamental than eye contact, as the soothing sound of a mother’s voice may be laying down the framework for bonding long before the baby is born. Moreover, as most seasoned therapists know, voice tone, timbre and pitch carry a great deal of emotional communication. The client’s voice can tell us a great deal about her unexpressed distress. And our voice can carry our good will, compassion and, dare I say it, love to the client.

As I write this I flash back guiltily to my adolescence and my dog, Ginger. I once unconsciously experimented with teasing her with the tone of my voice. I soothingly and sweetly told her “You are a very, very bad dog Ginger!” and her dog smile lit up her face as her wagging tale oscillated furiously. Then I switched to an angry tone: “Good dog, Ginger, Good dog!” As I vituperated she fawned nervously and her tail disappeared between her legs. Now I flash on my mother lambasting me throughout my childhood: “Of course I love you!” and 60 years later, I feel my whole body contract and imagine my ears lowering like Ginger’s.

And now let me free associate further. I think of three different friends whose parents read to them as kids, and who still love to be read to. My parents, on the other hand, frequently spoke in tones of anger and disgust, and despite a great deal of attachment recovery, I still find little pleasure in being read to. My nine-year-old son, however, drinks it up like soda. When I come home and sit on the couch he often leans into me and croons: “Read to me, Daddy!,” and lucky man that I am, I still get to read to him for hours every week. We’re on our ninth Gordon Korman book this year. (Gordon Korman is a brilliant children’s author whose books are wise, funny and replete with emotional and relational intelligence.)

Coming back to the issue of therapy, I feel I now understand why traditional psychoanalysis works so well for some clients, despite the analyst sitting out of view behind the couch, and despite the criticism some attachment therapists express about it lacking the intimacy of eye contact.

Infertility on Both Sides of the Couch

Posted on September 20, 2013February 11, 2026 by rezendevknowfully.com

Family Planning

"When are we going to start a family?" asked my husband.

I felt a boa constrictor wrapping around my throat. For months now, the topic of children had evoked tension, leaving us powerless and detached from each other. The argument had become a tradition on Saturday mornings. We would sit in the living room in an awkward silence, avoiding eye contact, until my husband pierced the hush with what he deemed a simple question about our future.

My husband was comforted by having a plan. Three years into our marriage—my second—we were in our mid-thirties, established in our careers, and financially stable. For him the next step in our lives was to start a family, but his need for a plan set off a vicious cycle. I felt ignored and disrespected in our relationship and couldn't justify bringing a child into a fractured marriage. I craved connection and love and was not willing to commit to having a child until we resolved our relationship problems. My resistance made him more insecure and unsure of his focus, and he would ask me about starting a family as a way to relieve his anxiety. Unfortunately, his persistence pushed me away, leaving me feeling trapped and controlled and leaving him stranded without resolution.

“I felt immense pressure both from him and from society to conform and have children. Gradually, I isolated myself from my husband and emotionally shut down, as my sense of self and my voice vanished.” Feeling alone with no one caring about my thoughts and feelings, I believed I was not enough for my husband and that he had married me solely for procreation. Meanwhile, I was inundated with inquiries from our family and friends about when we would be parents.

My mother-in-law often phoned my husband's siblings to convey that her children were failing her since she did not have grandchildren. While growing up, my husband's mother talked a great deal about heirlooms—each piece of jewelry or china was a link between past and future generations. Grandchildren were an essential part of keeping the family traditions alive and to not have them meant the family had failed. She made it clear that my husband was not enough, just as I felt I was not enough as his wife. My resistance to the "plan" was a clear message to him and his mother that I would not conform.

His side of the family was not the only problem. My stepfather had the impression that all couples wanted children. He frequently dropped hints about what a joy they are, pointing to his grandson and saying things like, "See, aren't these fun and not so bad?" For him, family represented connection and closeness. Initially this was endearing but it soon became annoying.

While at a party, I declined an alcoholic beverage, which ignited rumors that I might be pregnant. When I heard the gossip, a wave of heat washed through my body. How dare my friends speculate? It was as if I were starring in the reality show, "When Will Wendy Pop One Out?"

The Family System

In 2005, I started therapy with a psychotherapist who practiced from a Family Systems model, the premise of which is that the family is an emotional unit—systems of interconnected and interdependent individuals, none of whom can be understood in isolation from the system. Over the course of my therapy, I came to understand that my symptoms of sadness, loneliness, and detachment were a consequence of the recurring patterns and interactions within my family. The sense of powerlessness I experienced evolved from my marital dynamics, my family history, and the cultural expectations of a woman in her thirties.

My parents divorced when I was thirteen years old. I was an unplanned pregnancy and the reason my parents had married. It was bad enough that I was a mistake, but I resented my parents even more for their divorce, and the struggles that I encountered during my teens trying to navigate through the turmoil of their divorce played a role in my delaying the start of a family.

During my first marriage, I was enrolled in graduate school and wanted to wait until completing my program to start a family. We would have been in our early thirties by then and my ex-husband wanted to be a father sooner. He had an affair and decided to leave. This time around I wanted to make sure I was in a healthy relationship, that we were not introducing a child into a doomed family. I did not want to recreate my childhood trauma for my own children.

At Christmas in 2006, my stepsister announced over dinner that she was pregnant with her second child. I broke down sobbing at the table. A hush blanketed the room as everyone stared at me. Although embarrassed and humiliated, I could not stop crying.

Two weeks later, my stepbrother shared the news about his wife's first pregnancy. My sister-in-law had planned on not having children but had changed her mind. I was consumed with feelings of betrayal. I was my own childless island in a world that demanded parenthood. I dove deeper into despair.

Couples Therapy

My husband finally realized that our marriage was at stake and agreed to couples counseling, but I wondered whether it was too late, as by this time my rage had evolved into numbness. I recalled our minister's marriage sermon encouraging us never to throw in the towel when things were broken, but another part of me was tempted to do just that. “You don't need a man, you survived a divorce,” the voice said. "Trust me, you’ll be much happier single." I contacted therapists, but they either did not return my calls or have any openings for new patients. Was the universe telling me it was too late for my marriage? The battle inside me grew more crushing until finally after three months, I found us a therapist.

Couples therapy became our new Saturday tradition. My husband had never been to therapy, hated conflict, and had always made choices with tremendous caution, sometimes over the course of many years. Therapy for him was about finding ways to manage his stress. If he knew when we would have a baby, he could plan accordingly. Should we reserve a slot at the day care now, since there could be a waiting list for a couple of years? “Should we start putting money into a college fund? Or should we begin grieving about not having a child?”

For me, therapy was about maintaining autonomy and establishing a healthy marriage. I wanted the freedom to make choices within the marriage, but feared he would leave me if I did not have a baby. It felt like an ultimatum. And for my husband, despite his discomfort about the therapy, he began utilizing what he learned about me. He realized that asking questions about starting a family was torture to me, so he stopped asking. As a result the perceived threat of the ultimatum faded.

In my professional life, I had wanted to open a private practice. Should I be saving money for the grand opening of my business or for a divorce? The marriage had to be healed before the practice could be born.

During our treatment, I wrote my business plan. My husband was proud as a peacock and bragged to others that I was making my vision come alive. I opened my practice in mid-2007, feeling finally alive after an emotional coma. When I purchased the new office furniture, my husband questioned the size of the sofa, believing it should be larger. Prior to our therapy, this question would have offended me and I would have felt undermined in my judgment. Instead, I confidently explained that the sofa worked well in the room. Understanding his tendency to err on the side of caution, I did not personalize.

He went ahead and assembled the office desk and filing cabinet and moved the sofa into the suite. To this day, he tells others it was a good thing that I ignored his advice because the sofa barely fit into the space. This was the sexiest thing he had ever done. Life was wonderful. I was enough as a wife and my business was thriving. Without pressure to conform and have a child, I decided to go off the Pill.

For three years we did not get pregnant.

Mystery Solved

From the time I was a teenager, I had a history with difficult menses. Like clockwork I got my period every 18 days and bled for 10 days, uncertain what PMS symptoms I would experience. My blood flow would be heavy, dark and impossible to keep up with, changing my tampons and pads every four hours and during the night bleeding onto my bed sheets. At times to get through my school day, I took over-the-counter pain pills for heavy cramps, lower back pain, or headaches. For my peers and teachers I maintained a pleasant façade, but what I wanted was to retreat into a corner and savagely eat raw meat and growl or be in my bed weeping and eating salty chocolate. I applied copious amounts of zit cream to my face attempting to fight a hopeless battle with breakouts. My bra and pants would restrict my breathing because I was bloated. During my annual exams, a range of doctors had explained these symptoms were stress-induced by my parent’s divorce, my divorce, and graduate school, and had prescribed birth control pills.

Now while off the pill, my life was good and I had no stress on which to blame the problem. I was receiving holistic care and yet was still physically and mentally suffering. Why was I having the same problems I had as a teenager?

I made an appointment with an OB/GYN specialist with little faith that I would find answers, but for the first time, a medical doctor was eager to learn what was going on with my body. He believed my symptoms were pathological and not related to stress and ordered blood work and an ultrasound.

A month later, the OB/GYN nurse escorted my husband and me to the doctor's office for my consultation. He was perusing my test results with a look of concern on his face when we walked in. Gazing up at us, he said, “I am unsure where to begin.” The blood work was perfect. The ultrasound, however, revealed why I’d suffered for decades and had not become pregnant during the past three years. Both of my ovaries were smothered in various types of growths (some were thyroid tissue), my fallopian tubes had blood, my uterus had polyps and was malformed, and as a result I was unable to carry a pregnancy. The doctor recommended a full hysterectomy.

My symptoms were not stress related. They were not my fault. A sense of calm flowed over me; my eyes welled up with tears. My husband took my hand and asked questions while I continued to absorb the news.

Judging Claire

Meanwhile, my professional life was evolving beautifully. I had the satisfaction of seeing my vision coming to life, and I loved owning my own business. For several years I had been seeing Claire*, a married and successful professional in her mid-thirties with a significant history of depression and anxiety. She had a warm sense of humor and loved to learn about herself. During the first couple of years working together, she feared her future children would be genetically predisposed to suffer from similar aliments and struggled between the desire to feel a child growing inside of her and her desire to adopt.

During the course of our therapy, Claire forgave herself for having a diagnosable mental illness; she realized the illness did not define who she was. She began to consider that she had plentiful and warm offerings as a mother and decided to conceive naturally. After a year of not getting pregnant—this was around the same time I went off the pill—Claire was diagnosed with infertility.

By then I was secure in my marriage and waiting to see if I got pregnant, but I struggled to maintain my alliance with Claire. Still vulnerable with my own triggers, I had my own opinion about the infertility treatment process and our sessions evoked strong emotions for me.

One in ten couples struggle with infertility issues. According to the medical model, infertility is a disease of the reproductive organs, and usually the first option in treatment is a daily injection of medication to stimulate the ovaries to develop eggs in the follicles (the structure in the ovaries that contain developing eggs). The side effects can include bloating, weight gain, headaches, and nausea. If this is unsuccessful, IVF (in vitro fertilization) begins, in which eggs are surgically removed from the ovaries and combined with sperm. Weekly ultrasounds and estrogen blood levels drawn twice a week assist the doctors in determining the best time to retrieve the eggs. The last resort for infertility treatment is the egg donor cycle, where an embryo formed from another woman's egg is transferred to the uterus of the woman trying to conceive. More coordination and time is involved since two women are being monitored for transfer.

As I witnessed Claire’s physical and emotional agony and the suffering in her marriage it caused, I began to judge her harshly. “How could she brutalize her body from treatments and spend so much money to conceive and carry?” I hated her for choosing to participate in the infertility treatment process and holding faith in the medical model. I felt lonely and betrayed that she conformed to society's pressure to attempt pregnancy at all costs. I wanted her to join me in rejecting this awful and debilitating process and to redirect her energies toward adopting a child.

Though I had every intention of becoming a mother, once I realized I was infertile, I never considered infertility treatment or adoption. Both seemed too unpredictable and a setup for repetitive grief and loss. It was disturbing to have such an intensely negative reaction to a client, so I began to repress these feelings and thoughts in an attempt to protect both of us. In the process, however, I became increasingly disconnected from Claire.

What was happening between us put strains on my belief in the humanistic approach, which emphasizes that we are in control of our destiny, our choices, and the discovery of meaning for our life’s narrative, and makes use of the relationship created between the therapist and patient as a catalyst for exploration and change. A safe arena was vital for Claire to share her narrative and to discover the meaning of her experiences—the energy in the room could then provide an atmosphere conducive for healing. Regardless of my opinions and beliefs, I wanted to support her in her destiny and choices. But did I have the freedom to accomplish this?

As a therapist, I participate in a weekly supervision group. While disclosing the pain of my challenges with Claire, I shared about my sensitivity to the fertility topic and my beliefs about the infertility treatment process. My peers validated me and understood why I felt threatened, but also challenged me about my countertransference and helped me to work through it. Other colleagues were offended by the infertility treatment process and called my patient "greedy." A few of them had been adopted, and were exasperated that it wasn't Claire's first choice. Others were sympathetic with her plight and could relate to her need to biologically conceive a child. Through the group process, I was able to witness all the different parts of myself being voiced through my peers, and I felt safe enough and free enough to get to some of my own core fears and doubts about infertility. Ultimately this freed me up to be much more present with Claire in the coming months.

Working Through and Joining With

During a subsequent session, Claire tearfully shared how painful it was to have no control during the infertility treatment process. My inner voice whispered, Ask her if she feels she has the choice to stop the infertility process. Before working through countertransference with my supervision group, I would have suppressed this voice, believing it was my own “stuff" and would not be helpful to Claire. Now my heart pounded; I couldn't help but speak up: “Who says you need to continue to fail with the pregnancy attempts?” Something in the room shifted. After a pause, Claire affirmed, "I could stop." I exhaled. We had finally found a moment of empowerment and connection.

Claire continued to participate in the infertility treatment process, and I joined the emotional roller coaster with her. This freed up much more space to explore her process and mine.

Therapy is not immune to the disruption of the infertility treatment process. “The scheduling of appointments revolved around Claire's menstrual cycle and she cancelled appointments due to the side effects of medications and clinic appointments.” We had lapses between appointments while waiting for the doctors to contact her for the next treatment cycle. All of this meant that I needed to figure out what would take care of me during her infertility series. That involved answering questions such as: How do I cope with my anger? How do I keep from getting stuck in her holding pattern of waiting? Do I charge for missed appointments?

With the ongoing support of my supervision group, I continued to explore my emotional reactions. Claire and I collaborated about payment for missed appointments—she willingly paid and the joint conversation made her an active participant in an otherwise helpless period. The medical doctors had no clear diagnosis about why she didn't get pregnant for three years and she suffered continuously from a sense of loss. She had always dreamed of being a mom and having a family and now she had to face the fact that it might not happen.

Claire tried to detach from her emotional turmoil and did her best to function at work, but the clock ruled her while she anticipated lab results. Her job performance began to suffer and the cost was guilt, shame, and embarrassment. Work became heavy and dreadful. Her depression ignited, leaving her brooding in isolation and sleeping for 17 hours or more every day. Her “should” cognitions were in overdrive and kept her paralyzed.

The Breakthrough

"I'm afraid you're mad at me for the last minute cancellation last week," she said. "I'm failing at everything." In fact I was angry about the appointment. Missed appointments touch on my vulnerability around not being recognized as valuable. But our agreement for her to pay for missed sessions, combined with my own awareness of the reasons behind my countertransference, made it possible for me to process my response outside of session and bring my full attention to figuring out what she was enacting and what it meant for her. I responded, "You think you should be able to manage life better. But things are dropping all around you: your relationship with your husband, your work, your friendships, and especially not getting pregnant. You're feeling so alone." I watched her reach for a tissue, look down at her lap, and wipe her tears. "What are the tears saying right now?”

In her soft voice, Claire answered, “I'm afraid my husband will be angry at me for not controlling my emotions. My anxiety is through the roof. I want to be in my bedroom with the covers over my head. It's unfair to expect my colleagues to do my work. I want to be with my friends but it hurts too much because they have babies or are pregnant.” She believed she needed to be perfect and worried about disappointing everyone around her, including me.

But this conversation about failure and disappointment positioned Claire to begin healing her marriage and bring her husband, family, and friends back into her life. Through addressing her loneliness, Claire articulated her envy about her friends being pregnant or having newborns. “She felt conflicted about whether to maintain her connections or isolate herself because it was too painful to be subjected to swollen bellies and to the innocent scent of newborns.” She also acknowledged she pushed her husband away because she did not want to be perceived as a "burden." He had a demanding job that made him unhappy, but it provided them with medical insurance to pay for the infertility treatment. She secretly fantasized about him attending medical appointments with her and being readily available to abruptly leave work to provide comfort when she received bad news. I encouraged her to share her emotional burdens with her husband, to let him feel her burden, as that is part of what it means to be intimate with another person. She began to feel less guilty and apologetic about her struggles and to share the craziness of the process with him. They became closer and her sex life began to thrive again.

Over the two-year period of her IVF treatments, Claire's visits to the reproductive health center would evoke a sense of helplessness and lack of emotional safety. She often felt rushed because she didn't get satisfactory information to her questions, and the clinic became increasingly more uncomfortable and sterile. As our work progressed, she was more assertive and less apologetic about demanding the attention of the nurses and doctors until she was satisfied with the gathered information. To increase her comfort at appointments, she brought her own pillow and blankets.

Unfortunately, Claire was given a lot of unhelpful advice from her own support system of family and friends, even medical doctors. She was told, for example, to "just relax" because her stress could be interfering with the infertility process. In the therapy sessions, we worked on how to handle unwanted and sometime hurtful advice and not absorb the harmful implications. When she deemed it appropriate, she informed people about what would be helpful or harmful.

Different Kinds of Pregnant

When the IVF failed, Claire opted for the final remaining option: an egg donor. Our sessions were spent with her describing how a donor was selected and the various reasons they donated their eggs. It was a surprisingly fun process for both of us.

After her second cycle with the egg donor, she curled up on the sofa in my office, hugging a pillow with a distant look in her eyes. Her lip trembling, she said, "For four days, I was pregnant. Now, I am pissed off.” Her rage demonstrated no guilt. She did everything right but was unable to carry her first pregnancy.

The following month, her third attempt was successful.

One day, well into her second trimester and beaming with life, Claire effused, “My boobs are huge!” She shared her ultrasound pictures of her healthy son and we talked through her stress about finances with the arrival of her baby. In her desire to save money and prepare for the baby's arrival, she requested a break from therapy. I encouraged her to go and create a loving home for her son. Tearing up, she said, “I can’t believe I can hear ‘my son’ after all of this.” Claire would soon be a mother.

Through quite a journey, Claire and I mirrored each other for a couple of years. My marriage and business were at last breathing life. I scheduled my hysterectomy, knowing my body would be cured. I learned a valuable lesson: Psychotherapy is a fertile process.

* Claire's name had been changed to respect confidentiality.

George Silberschatz on Psychotherapy Research and Its Discontents

Posted on August 23, 2013February 11, 2026 by rezendevknowfully.com

What is Empirically Known About Psychotherapy?

David Bullard: Let’s start with a little background information about your work. I first met you through the San Francisco Psychotherapy Research Group—can you talk about your involvement there?

George Silberschatz: Certainly. It was originally called the "Mt. Zion Psychotherapy Research Group,” founded by Joe Weiss who was joined by Hal Sampson, both psychoanalysts, in 1971. They were just starting to publish some research papers and were very active teachers at Mt. Zion Hospital when I began working with them in 1975. Their work together formed the basis of what is now known as Control Mastery Theory.

DB: You’ve been in private practice about thirty-five years and are a clinical professor at UCSF with a multitude of research papers on psychotherapy process and outcome.

GS: My book Transformative Relationships (Routledge, 2005) is on Control Mastery Theory, and my papers are almost evenly divided between research and clinical work, because they are so intertwined and I go from one to the other very easily.

DB: You are currently the president of the international Society for Psychotherapy Research, which includes chapters in North America, Europe, Latin America, and Australia. Would you talk a bit about the concepts “empirically-validated” and “empirically-supported therapies.” What are your thoughts about what is truly empirically known from psychotherapy research?

GS: Well, I have very mixed feelings about all of it because I don’t think it’s fundamentally based on scientific evidence.

I believe that the term “empirically-validated” is largely used when people are trying to market their specific brand of therapy.

I believe that the term “empirically-validated” is largely used when people are trying to market their specific brand of therapy. You know, “Our empirically-validated therapy is better than everything and everyone else, so if you need therapy, come see us!"

It seems a bit overdone and over-hyped. A lot of people have started saying “evidence-based therapy” instead of “empirically-based,” but what counts as evidence and how is the evidence portrayed? There’s a great deal of subjectivity in that process.

DB: In the early mention of “empirically-validated treatment,” researchers made another distinction between efficacy and effectiveness. Is there such a distinction in the real world versus laboratory research?

GS: It’s a big controversy. The term “efficacy” is used by people who believe that empirical evidence can only come from randomized clinical trials, i.e. in the lab. It has its roots in both medicine and pharmacology in the way drugs are tested and, basically, the proponents of this research paradigm feel that anything else isn’t empirical, isn’t evidence.

Manuals are essentially useless for practicing clinicians.

I wrote an article about this for the Journal of Consulting and Clinical Psychology called “Are results of randomized controlled trials useful to psychotherapists?” It was basically a debate between myself and my co-author, Jackie Persons, who is a cognitive behavioral therapist. She took the position that people should only be practicing empirically validated therapies—by which she meant Random Control Trial-Based Therapies or RCTS—and that it might even be unethical to do anything other than that.

DB: Which implies following a manual that such studies usually use so that the treatment condition is uniform across therapists?

GS: It does often imply following a manual. They punted on this a little bit and said there was some wiggle room for therapists to stray from the manual, but what’s a manual? I took the position that manuals are essentially useless for practicing clinicians.

DB: That’s refreshing and helpful to hear.

GS: There’s a lot of variability among clinicians, you know? There are a lot of very thoughtful people who think like Jackie, but there are also people that see the limitations of that as a model, especially for psychotherapy.

There is no support for the idea of one therapy being better than another.

The current—and I would say balanced and intelligent—position of the American Psychological Association is that when you really look at the evidence carefully, as they’ve done, there is no support for the idea of one therapy being better than another. But a lot of the proponents of the Randomized Control Trial for psychotherapy use their results to say, “Our results show that our method is better than yours.” That’s led to a rash of people trying to do trials on their new model of therapy. Every time there’s a new therapy, somebody has to do a trial showing that their new therapy is as good or better than some other one. That hasn’t been very productive, in my opinion.

Psychotherapy Works

DB: Overall, what would you say has been shown? For example, Consumer Reports did their research on their readers’ reactions to psychotherapy in 1995.

GS: That was a very large survey of psychotherapy effectiveness. I think it had a very useful purpose because it was actually asking the people who were using the service what they thought of it. It was pretty impressive.

DB: So there have to be quite a substantial number of technical issues within the field of psychotherapy research that we won’t go into today, but I heard Daniel Kahneman, who won a Nobel Prize for Behavioral Economics research, state in a recent interview that the most relevant, reliable outcome measures for a person’s happiness should be based on the report of the person’s friends. In other words, their evaluation would be more valid than anyone else’s. What would you say is the most useful outcome measure for psychotherapy?

GS: Certainly not the therapist’s!

DB: No!

GS: It turns out to be a very complex problem. I respect Kahneman's work very much. He’s a brilliant man. But I’m not sure that I would necessarily agree with him that a friend or significant other in a person’s life would have the best perspective. This is something that has troubled psychotherapy researchers for a long time: How do you measure outcome? Whose perspective do you rely on? There are plenty of people who feel the therapist has the best position. There are other people who feel that the patient is in the best position. There are yet other people who—

DB: How about the patient’s mother?

GS: She may not be in the best position either! Because someone like a mother or a spouse may have a particular vested interest. But it’s a very thorny problem in psychotherapy research and I don’t think anyone’s come up with a definitive answer yet. I think we tend to use multiple perspectives now but that creates its own particular difficulties as well.

DB: You have studied both outcome and process-oriented research. Overall, hasn’t it been shown through meta analyses of lots and lots of studies that psychotherapy works for the vast majority of people who undertake it?

GS: Yes.

DB: And other studies of process show the elements that seemed to have the most impact within a psychotherapy relationship.

GS: Well, you’re quite right that there’s evidence available now that shows unequivocally that psychotherapy works. There should be no more questions about that in anyone’s mind.

Evidence available now shows unequivocally that psychotherapy works. There should be no more questions about that in anyone’s mind….The issue of what it is about therapy that is causing it to work is still up for a lot of debate.

It definitely does work. What that means, concretely, is that a person who is having any one of a variety of psychological, emotional or behavioral kinds of problems will do far better getting psychotherapy than not. The issue of what it is about therapy that is causing it to work is still up for a lot of debate. And, of course, every school of psychotherapy, every brand, has their own particular perspective on that.

One thing that people do generally agree upon is that the therapeutic relationship, the nature of that relationship that some people call the “therapeutic alliance,” is a critical factor. Other people say the relationship is a necessary, but not sufficient, condition, but what is it about the relationship? If you’re a clinician, and you’re about to meet a new patient, the research doesn’t really tell you what you might do to enhance that relationship. What are the things that are involved? What are the steps involved in creating these productive therapeutic relationships?

DB: Versus looking up in the manual to find out which antibiotic to give for which infection?

GS: Yes, but even with antibiotics, it turns out that a lot more of that is art and trial-and-error than we are led to believe. It’s not quite as cut-and-dried and as narrowly evidence-based. People try one thing and that may work on half the patients. But it doesn’t work on the other half, and then you have to start experimenting with tweaking it.

DB: I guess we’d like to pretend that we live in a world of certainty.

GS: Yes. There is something inherently reassuring about that. But it’s also quite elusive, in my opinion.

DB: I’m reminded of an old saying: “There is no Zen, only Zen teachers.” In a way, there is no “psychotherapy.” It’s only each unique interaction between two people (or three people if it’s couples therapy).

GS: I think that framing it this way goes back to a very old argument in psychology. The controversy about nomothetic versus idiographic principles. Ideographic being very individualized kind of principles, and nomothetic applying to large general populations. And in psychotherapy, my own view of it, both clinically and per research, is that it is very individualized.

So what’s going to work well for one person is not going to necessarily work well for another.

Therapy has to be tailored to the particular needs and goals of the patient we’re working with.

Therapy has to be tailored to the particular needs and goals of the patient we’re working with. But, having said that, I also think that there are some general principles, and here is a good example of one: If therapy is tailored to the needs of a particular person, all other things being equal, it will be more effective and more successful.

DB: Your background and your extensive work with Control-Mastery Theory, developed by Joe Weiss and Hal Sampson, is all about that.

GS: Yes. Very much so. It’s one of the things that really drew me to their work. It really takes into account the particulars of a person, the nature of their particular problems, what their particular history is, and how the therapy can address that in a very individualized way.

"We Forgot to Ask the Patient!"

DB: What’s your opinion on getting regular feedback from clients? The research that I’ve seen, both for individual therapy and couples therapy, seems to be clear that having clients give written feedback after every session improved either the alliance or the outcome. Should therapists be encouraged to incorporate that more into their clinical work?

GS: It’s a very good question, and it’s an area that is really taking off like wildfire right now, not just in psychotherapy, but in the field of healthcare generally. One of the biggest initiatives in many, many years, at the National Institutes of Health, is what they call “Patient-Centered Outcomes Research.” A lot of research in healthcare, for decades actually, was really just based on what lab tests showed, or what a physician concluded. Nobody bothered to get the patient’s perspective, and suddenly people are saying, “Oh, my God, we forgot to ask the patient!”

So now there’s this huge catch-up game going on in terms of trying to get the patient’s point of view. In psychotherapy research, we’ve certainly taken the patient’s view into account a lot, but what is newer in psychotherapy is this point that you’re raising about feedback, and getting patients’ feedback after every session. People have tended to use symptom-based measures, so patients fill out a form at the end of each session to see how they rate the severity of various symptom profiles.

I think that getting the patient’s feedback is very useful, but I’m not particularly impressed with symptomatic measures. I think there are probably more important things that one could find out from the patient after a session. What did they find useful? How did they feel the therapist was responding to them? That’s useful information for therapists to know, and historically we just relied on our own impressions to get that kind of information.

Sometimes we’re right; sometimes we’re wrong, and we often don’t know which is which.

Sometimes we’re right; sometimes we’re wrong, and we often don’t know which is which. Having the patient be the arbiter of that information is very valuable.

Even without written feedback, one would hope that an experienced practitioner would draw out the patient’s feelings and perceptions if he’s seeing some kind of transference to what a therapist has said or done. We hope that that would be an integral part of the work.

DB: Sure.

GS: Some therapists, of course, explicitly ask patients at the end of or at some point in the session, “Well, how do you feel things are going today?” Or, “How do you feel you’re doing?” Or, “How are things with us?” That’s a useful thing to do, but the people that are more into systematic feedback would say that you may get more reliable data if the patient is outside of the session, sitting, thinking about the influence of the therapist. You may get a more complete picture of the patient’s experience that way, instead of—what’s that old term in research?—the “socially desirable” answer.

"What Exactly Does 'Cured' Mean, Anyway?"

DB: Let’s switch back to the marketing aspect of “evidence-based therapies.” I recently came across a practitioner’s website where he claimed that his particular brand of marital therapy has proven to be effective with 90% of his couples and 70% were “cured.” What are your thoughts about that?

GS: It strikes me as primarily marketing. It’s hard for me to wrap my mind around numbers like that. What exactly does “cured” mean, anyway?

DB: Talk about the medical model! As if the people came in limping and left skipping merrily along.

GS: There’s plenty of evidence that therapy, including couples therapy, is effective. It works. But there’s no evidence whatsoever to support the idea that one particular brand is systematically better than another. There just isn’t evidence for that. People make all kinds of claims, but it just isn’t supported when you look at it on the broadest possible level.

DB: I found a couple of articles through the American Psychologist with tables about empirically validated therapies. One broad grouping is “well-established treatments.” And then they have “probably efficacious treatments.” I’m sure you’ve seen all of that.

GS: Yeah, absolutely.

DB: And someone cited 420 different defined psychotherapies. Do you think those are also marketing attempts to differentiate themselves from the rest?

GS: Yes, I think it is primarily marketing. I mean, there just can’t be 420 fundamentally different ways of doing this work. It flies in the face of common sense. I see it as what somebody called the “narcissism of small differences.” People have variations on cognitive therapy, to take a few examples. Albert Ellis, “Rational-Emotive Therapy.” You have Aaron Beck’s “Cognitive Therapy.” You have Jeff Young’s “Schema Therapy.”

There just can’t be 420 fundamentally different ways of doing this work. It flies in the face of common sense. I see it as what somebody called the “narcissism of small differences.”

And then there are probably 20 other variations of it. Well, are they really all that different? I don’t think so. I think it’s just people wanting to create a brand rather than looking for commonalities. They’re looking for, “this is my way,” so that they can develop empires and training institutes and all that.

DB: I’ve talked to a number of colleagues, a few of whom I guess may be possibly nearing retirement, and they look back over the years and wonder, “How did I do? How did it all go?” Arnold Lazarus, years ago, did some follow-up with as many of his patients as he could. Could you comment on how he did that, or your knowledge of that?

GS: I don’t know the specifics of Lazarus’ work on that, but I do know therapists who do this routinely. I’ve always had a lot of fascination and admiration for it, where a therapist will, after a number of years, get in touch with their patients and ask them to come back and to check in and to see how they’re doing. This is, obviously, without charging a fee. It’s just the therapist wanting feedback. Lou Breger wrote a book recently called Psychotherapy: Lives Intersecting in which he describes his experience contacting a lot of his former patients, and asking them how they’ve done. I think more of us should do it, probably.

DB: There are ways to do it, obviously, that ensure ethical reconnection with past patients.

GS: Yes. One has to be sensitive to respect their privacy. I mean Lou Breger got permission from all of his patients and any identifying data were disguised in his book. But even if one isn’t writing about it, just for one’s own edification, systematically getting a patient’s point of view several years after the end of therapy—what they felt about it, whether it was helpful or not helpful—could help sharpen us as clinicians.

We Are All Skinner's Pigeons

DB: Do you feel your clinical work with people is impacted by research results and, if so, to what degree? Or are you more impacted by what has happened in the session? One person pointed out to me quite a while ago, that in a sense, we therapists may be similar to Skinner’s pigeons—we get reinforced to do the things that work for us with our individual clients or couples. Research and theory can, perhaps, clarify and codify what we are doing or should do, but meanwhile, we’ve been getting these experiences with people about what works and doesn’t work. Do you have a sense of whether your own direct experience of doing therapy is most influential, versus reading research results?

GS: I’d say that my own work has been more influenced by my patients’ feedback and from teaching and observing what other therapists are doing in their work and how that’s going. In that case, I have the luxury of not being in the room at that point so I can think more broadly about what’s happening or not happening. I would say that those experiences, along with my own supervision—I’ve had therapy supervision for many, many years by really good people—have probably shaped my work the most.

There are some things from research that have also affected me. In my early training, which was largely psychoanalytic in the 70’s, the role of interpretation, particularly transference interpretation, as a primary mutative factor, was thought to be the primary effective ingredient of psychotherapy. My colleagues and I did some research on that and found, along with others, that there was no evidence that transference interpretations were especially powerful.

My colleagues and I did some research … and found, along with others, that there was no evidence that transference interpretations were especially powerful.

So that certainly led me to rethink everything. I thought, “Wait a minute. All the stuff that we’ve been learning from very senior psychoanalysts—there isn’t really any evidence supporting it other than the fact that they say so?” That really led me to question the role of interpretation in psychotherapy.

DB: Is that close to the idea that information—insight—can be imparted that will change people versus people having an experience that changes them?

GS: That’s exactly right. There’s a very gifted psychoanalyst, Frieda Fromm-Reichman, who said patients don’t come for insight; they come for experience. So this view has been around for a while, particularly in the so-called interpersonal school of psychoanalysis. I think that more often than not, people do learn from their experiences.

Having said that, I also want to say that in terms of my commitment to individualizing psychotherapy, it is true that there clearly are people who do learn a lot from new information, so I don’t privilege one or another. I don’t privilege the idea that there’s a particular technique that is across the board better than others. We might even say that for some people, having a new insight, a new thought about themselves or their lives or their childhood or current process, gives them a new experience.

DB: Yes, it can.

GS: Maybe more compassion for themselves.

DB: It could work both ways. It can work that the insight gives them new experiences. It can also work that new experiences opens them up to new insights.

GS: I would say it really does work both ways. And there’s no way to know in advance which it’s going to be for any given individual.

DB: What are your thoughts more generally about the role of research in a practitioner’s life?

GS:

Unfortunately research hasn’t given clinicians and practitioners a lot that they can use.

Unfortunately research hasn’t given clinicians and practitioners a lot that they can use. That is changing and will continue to change in a positive way, but the whole emphasis on the Randomized-Control Trials and so on has not helped clinicians much in my opinion. Other people have different views about this, obviously.

I think what can begin to help clinicians more is the very consistent research finding that “therapist effects” trump treatment effects. In other words, if there are therapists doing a trial of three different therapies, it turns out that there are particular therapists in all three of those conditions who are actually better than their peers.

DB: Those must include what some have referred to as “non-specific treatment effects.”

GS: And those effects are bigger than the particulars of the therapy that’s being practiced. To me, that’s a really interesting finding. And the question that it begs is, well, what are those therapists doing? Let’s figure that out. And, if we can figure out more about that, we could try to train other people to do that or try to incorporate more of that in our own work.

"He Was a Wise Dude, That Buddha"

DB: The final area I’d like to discuss with you is your own interest and involvement in Buddhist concepts. You’ve done very well-received seminars and workshops with Steve Weintraub, a Zen priest and psychotherapist, on Buddhism and psychotherapy. Is there anything that you would like to say about that?

GS: Overall, Buddhism, for me, as well as just the experience doing psychotherapy, has taught me that much in human life seems to get better when you can have more self-compassion. I’ve been interested in Buddhist thought for a very, very long time. My interest in it probably dates back to when I was studying psychology as an undergraduate. I was really interested in Freud. I was interested in Carl Rogers. I was interested in the Human Potential Movement.

Then I had this kind of—I don’t know what to call it—like an insight. I thought, “Wait a minute. People have been thinking about these things way before Freud, way before Rogers or Maslow; there’s a history to this. And it’s a very, very old and long one.” I would say that

Buddhist thinkers have been paying attention to the nature of mind and suffering for longer than just about anybody else.

Buddhist thinkers have been paying attention to the nature of mind and suffering for longer than just about anybody else. They’ve had a lot of valuable insights into what causes people to suffer, and how people’s suffering can be alleviated and reduced and so on. So at that broad level, I think Buddhism has a lot to teach us about just basic human psychology, and particularly the nature of suffering and what causes people’s suffering.

It’s different, in my opinion, from organized religions, in the sense that it doesn’t say one’s salvation will come through this or that route. I would say it’s a very broad model. It allows people to apply the teachings in their own lives in their own way. It doesn’t really require going to church or synagogue every week or every month or that kind of thing. But it does give certain tools that people can use in a very reliable and useful way.

DB: I’ve seen a commentary attributed to the Buddha, where he sounded like an empirically-based fellow. He essentially said, “Don’t believe anything I’ve told you. Try these things out for yourself. And if they work for you, great. If they don’t, go onto something else.”

GS: Yeah. I think that’s one of the things that has contributed to Buddhism gaining enormous popularity in the West right now. We have something that fits very well with the kind of individualized and democratic mindset that we can learn things by seeing what works for us. There is a lot of wisdom in that. He was a wise dude, that Buddha.

DB: They’ve updated it. I’ve run across some people who are espousing “Open-Sourced Buddhism,” that we are free to choose from those schools of Buddhist thought, from the very cognitive-based wisdom of Tibetan Buddhism to the no-thought idea of Zen.

GS: I love the idea, and would love to see more of that open-source thinking applied to psychotherapy. One of the things that we have right now in therapy is the equivalent of proprietary systems, where people develop one of those 420 brands of therapy, and then you just have to get in and do it that way. As opposed to an open-source model, which is people getting in there and using it for their own purposes and contributing to it, growing it in their ways—which is what’s happened to Buddhism. People are growing in all kinds of ways in the West, and I’d love to see more of that actually happen in psychotherapy.

DB: Supposedly a graduate student went to Jung one time and asked, “How do I become the best therapist I possibly can?” And he replied, “Go to the library, read everything good that’s been written about the art and science of psychotherapy, and then forget it all before you peer into the human soul.”

Well, thank you. I really, really appreciate having had this time with you.

GS: Thank you.

Technology and Psychotherapy

Posted on August 20, 2013February 11, 2026 by Psychotherapy.net Team

A recent article on a study from the University of Zurich offered the headline, "Psychotherapy Via Internet as Good as If Not Better Than Face-To-Face Consultations." It does not surprise me when I think about many of my clients’ everyday lives in the Bay Area: technology tends to be seen for the most part as a fun, useful and normal part of life. It also makes sense when I think about the ways that technology, if wielded strategically, can sometimes make things simpler and more immediate. Grandkids and grandparents all over the world would agree (thanks Skype!), as would families with service members deployed in far-off countries.

Here's a quote from the article in Science Daily about the online psychotherapy study, "In the case of online therapy, the patients tended to use the therapy contacts and subsequent homework very intensively to progress personally. For instance, they indicated that they had re-read the correspondence with their therapist from time to time. ‘In the medium term, online psychotherapy even yields better results. Our study is evidence that psychotherapeutic services on the internet are an effective supplement to therapeutic care,’ concludes Maercker [one of the study’s authors].”

Skype therapy could improve outcomes while it lowered the barrier to accessing therapy. In one way of thinking about it, what was once a trip across town and a 2-hour commitment is now 50 minutes at one’s desk.

But I notice a conservatism and even a bit of prejudice against technology use among therapists: Skype, texting, online scheduling, and other things can be treated as if they are volatile substances when in fact they are more and more a part of everyday life, used by lots of people to great effect. Therapists can benefit from remembering the wisdom that often what seems unstable and jarring to an older generation is soon enough just “the telephone”—utterly banal and safe.

A few years ago a former Supervisor warned me against texting with clients about appointments and scheduling shifts. When I questioned him further, however, he admitted that email was ok for this, and that he emailed with clients about appointment times, though not clinical material. Most therapists under forty who I ask about texting with clients say it is the same thing—just a quicker form of email. I have even heard a client assert, “It’s rude to call someone on the phone now. You interrupt their day and make them say ‘how are you?’ Texting is more polite, faster, and doesn’t require needless formalities.”

I think that the obvious insight here, that technology changes and what seems outlandish today will soon be normal, can go one step further. What if therapists could harness the excitement and convenience of technology to improve our usefulness to clients and to improve our ability to help clients change their lives?

I've been thinking a lot about therapists and technology lately, as I have been part of a group testing out a new mood-tracking app called Senti. With Senti, users answer a few relevant questions about mood and emotion throughout the day and Senti keeps track of how they seem to be doing. The questions both track useful information (“Thursday tend to be a rough day for me”) and also function as a mini-intervention, just as if someone had texted you to say, "hey, put your feet on the floor, take a deep breath, and tell me how you're really feeling right now."

But when I described the app to another therapist she was skeptical. "It sounds great," she said, “but therapists are late adopters. You'll never get them to use it with clients." Similarly, The New York Times recently ran an article by therapist Lori Gottlieb with the headline, "What Brand is Your Therapist?" In it, she ponders whether therapy as we know it is a think of the past. "I hate to think that therapy is an outdated idea, too slow and too private to satisfy a population that has come to expect immediate responses and constant gratification."

I see people each day needing help coping with divorce, eating disorders, anxiety, depression, and other problems that cannot be repressed and forgotten and that need attention. There is a great need for inner work and for the relief of human suffering. Rather than thinking technology is a barrier to connection, we can ask what Darren Kuropatwa asks in his presentations about technology and learning: “What can I do now that I could not do before?”

What if instead of a necessary evil, technology could facilitate a different kind of depth—the depth of a therapy that can be held by a client in their hand; where self-support, self-inquiry, and a therapist at the other end of the wi-fi connection make transformative work more possible? After all, there is nothing about Skype or about an email exchange that is inherently glib or false. What matters is the content and the material and the depth to which the client can face themselves, with the powerful support of another person trained to be of use. Whether the therapist is on Facetime or tweeting reminders to followers to pause and breathe when angry feelings erupt, what matters is that people get better and the world gets better. And for that project we need every tool we can get.

Charles Mansueto on Obsessive Compulsive Disorder

Posted on July 22, 2013March 13, 2026 by rezendevknowfully.com

OCD and Its Misconceptions

Victor Yalom: We can assume that our readers who are therapists and students of therapy or counseling or social work know something about obsessive compulsive disorder, but may not have a great deal of expertise. So what are a couple of things that therapists don’t know or may misunderstand about OCD?

Charles Mansueto: Well, the first misconception is that it’s amenable to a broad range of psychotherapeutic interventions. It’s not. It appears that that the treatment that’s clearly effective and has been well tested is cognitive behavior therapy. The second kind of treatment that is available is pharmacological treatment that typically impacts the serotonin system.

The first misconception is that it’s amenable to a broad range of psychotherapeutic interventions. It’s not.

Because it’s widely thought of as a brain-based or biological disorder having a biological substrate, one misconception is that it needs a biological solution, that a person must be treated with medications to correct whatever anomalous conditions exist when OCD is present. That’s not the case. The learning-based treatment, Cognitive Behavior Therapy (CBT), has been established and continues to be emphasized as the treatment of choice in the vast majority of cases.

VY: We hear that about so many conditions now that they are biologically based, and I think many therapists are skeptical. What’s the evidence for OCD being biologically based?

CM: The evidence comes from basic studies of brain scans. Some early research, for example, identified the activity in the brain that occurs when OCD is present as identifiably abnormal. I participated in a study with Judith Rapoport using Pet Scan imaging. We found that when the cortex, the thinking brain, perceives a danger of some sort, it transmits a signal down to deeper structures of the brain. In people with OCD, the caudate nucleus seems to not be able to regulate these worrying signals. But when OCD has been treated successfully, either by the serotonergic drugs or by cognitive behavior therapy, there’s a degree of normalization of brain function. There’s a lessening of that repetitive activity within the communicative structures in the brain.

VY: So with brain studies, there’s some clear differences between people with OCD and the “normal population,” and there’s a difference between pre-treatment and post-treatment OCD. Is that what you’re saying?

CM: Exactly.

VY: But I’m sure looking at the brain you could find brain differences in many groups of people. That doesn’t prove that it’s a neurologically-based. That’s correlation. So what other type of evidence is there?

CM: Well, there’s the family studies that show a greater-than-chance-alone incidence of OCD within families. So there’s a suggestion that there’s a genetic element to the transmission of OCD. There are other possibilities, of course—cultural transmission, social transmission—but there’s strong evidence for some genetic linkage.

VY: And then there’s some more intriguing evidence of OCD being related to Tourette’s syndrome, which I know you have done a lot of research on.

CM: Those of us who treat OCD frequently often come across the co-existence of OCD and tics and Tourette’s syndrome, most often in children. There is often great difficulty in distinguishing between complex tics in adolescents, for example, and compulsions. So the question comes up often: Is this is a tic? Or is it a compulsion? Now those have important treatment implications because we have different sets of tools for OCD versus Tourette’s. But there are a lot of close similarities and an intriguing connection between the two that hasn’t been well-clarified in the literature.]

Strep Throat and OCD

VY: I recall hearing in the past that there was some potential linkage between Tourette’s syndrome and strep throat. Is that true?

CM: Yeah. It’s called “PANDAS,” Pediatric Autoimmune Neurologic Disorder Associated with Strep. Cute name but not a very cute disorder. Sue Swedo and others have pointed out that there seems to be a link between rapid onset in childhood strep infections and, in some case, the emergence of OCD-like symptoms, tic symptoms, and an array of other presumed neurological symptoms, like hyperactivity.

There seems to be a link between rapid onset in childhood strep infections and, in some case, the emergence of OCD-like symptoms, tic symptoms, and an array of other presumed neurological symptoms, like hyperactivity.

More recently, there’s been speculation that other diseases, such as Lyme Disease, might also be able to initiate or exacerbate symptoms of OCD and some of these other related kinds of problems. Now that it’s been identified as such, we’re seeing more and more children who are presumed to have a biological-based onset—or infection-based onset—of OCD and these related problems.

VY: So there are multiple ways that this might manifest, in terms of symptomatology—a lot of complexities there.

CM: Well it adds the possibility of environmental causes. So it’s not just that a traumatic incident or a biological vulnerability are the only causes, but relatively common infections may also be implicated in the etiology of OCD.

VY: Has the traditional psychoanalytic/psychodynamic explanation for it been totally discredited?

CM: Well, it’s certainly very interesting and compelling, but it’s very hard to prove in research, as you might guess. But more importantly, treatments based upon psychoanalytic and psychodynamic presumptions do not seem to have a significant impact on OCD, at least in the cases that have been researched.

OCD and Obsessive Compulsive Personality Disorder

VY: Is there any correlation at all between what we think of as obsessive compulsive personality disorder and OCD? Or are those two really quite distinct things?

CM: Well, they are distinct, but again they’re curiously related. We do distinguish the disorders, putting them in two different parts of the DSM and they’re differentiated relatively easily from diagnostic criteria. However, my own view is that we’re talking often about how ego-dystonic versus syntonic it is. In other words, how much does a person who is extremely orderly and very concerned about germs and cleanliness— how much do they value that? Do they see that as part of themselves, the way they are? Their own characteristics as opposed to something that happened to them that they would like to get rid of?

Treatments based upon psychoanalytic and psychodynamic presumptions do not seem to have a significant impact on OCD.

With OC personality disorder, one distinction that’s made is that the behavior is ego-syntonic. The person doesn’t necessarily want to give up this part of themselves because it’s well-integrated into their overall functioning, their value system, their dispositions to action and their history. With OCD it’s more dystonic. It’s something that happens to me and I want to get it out of me at all costs.

But we do see a continuum here. We see individuals who are more or less committed to maintaining their particular approach to life, their perfectionistic tendencies, their extreme cleanliness, their methodical orderliness, to the point where they are doing more organizing than they are working; it becomes very dysfunctional. So I’m not convinced that we are talking about two totally different populations. But that’s the way we think diagnostically.

VY: Let’s talk about the course of the disorder. Let’s say someone has classic OCD—hand washing, door checking, those types of behaviors. When does this typically start and if left untreated, does it tend to go throughout the course of their life?

CM: Well, we don’t have perfect information on this because we only see people who are in trouble, when things haven’t resolved. So there may be people out there who experience significant OCD that then resolves, but we don’t see those individuals very often. But typically, OCD occurs in children around age eight, nine, ten or there is another onset cluster in late puberty/early adulthood. Whether they’re identical is up for some debate. There do seem to be differences in many of the childhood cases we see. Some of the work I’ve done with what I’ve come to call “Tourettic OCD” tends to appear more typically in childhood.

Whether a person gets it early or later, it seems to be chronic when left untreated.

But whether a person gets it early or later, it seems to be chronic when left untreated. It does wax and wane though. There probably are many individuals who are able to adapt and continue to live reasonably productive and happy lives. But for many individuals it becomes a true disorder, in the sense that it substantially decreases their ability to be happy and satisfied with the quality of their lives.

VY: Right, you said that obsessive organizing behaviors interfere with work, but I imagine it can also interfere with relationships.

CM: Very much so. We work with a lot of families, and a whole family’s life can revolve around the OCD of one individual within that family.

Treating the Family

VY: Does an example come to mind?

CM: Let’s say an older adolescent or a young adult continues to live with the family, with the parents, and the parents realize that the person is impaired, and very dependent on them. Well, as parents often do, they try to keep the person as comfortable as possible, as comforted as possible, and that means they begin to adapt their life to the needs of that individual. Those needs can often be excessive and very bizarre. It may involve cleaning and separating dirty things from clean things. It may involve strange eating patterns. But the family becomes more and more inclined to revolve and have their home life dominated by those requirements. In that case, we have to often treat the entire family.Now that’s more typical of children and adolescents, obviously, but we see people who are up there in age and they worry that their child cannot exist without them and their time is limited. Those individuals often reach out in desperation even though their loved one is unwilling to get treatment and just simply wants everyone to continue to cater to their unique and idiosyncratic needs.

VY: It becomes a kind of codependent situation where their attempts to comply or adapt to the OCD sufferer probably reinforces it.

CM: It’s a big problem. At the OC conferences, we often have rooms full of parents who are there because their children—usually adolescents or young adults— wouldn’t come. They’re trying to figure out how to get their children to agree to participate in treatment.

VY: Let’s delve into treatment. You mentioned that cognitive behavioral therapy is the treatment of choice?

CM: Yes. The expert consensus guidelines were developed in the late 90’s, 1990’s, and haven’t been modified since because, except for the addition of a few medications into the treatment approach, the guidelines are still very solid. About 70 or so treatment experts from around the world were asked to put together the guidelines for those who are not experts at treatment.I think just under two-thirds were medical people, MD’s, and across the board, CBT was recommended for individuals with OCD, sometimes in combination with medication for more severe cases. But medication alone was seen to be a second best treatment, except in the case of more severe adults. Essentially CBT is the treatment of choice, and we do biofeedback, relaxation training, assertiveness training, all under the umbrella of CBT.

The Experts Agree: The Solution is CBT

VY: We’re a field that doesn’t always easily come to a consensus about what to do when you’re sitting with another human being in the room to help them with their malaise, but it sounds like at least for the treatment of OCD, there is a higher consensus than we typically find.Let’s get into the specifics of CBT treatment. Let’s take a prototypal case—a hand washer or a checker who’s checking the locks or checking to make sure that the stoves are turned off. Let’s say this is someone who is coming voluntarily to your office and wants to get some help. How do you start out?

CM: Education first. There are things to know about OCD.

It can feel very mysterious and just because someone has it doesn’t mean they understand it.

It can feel very mysterious and just because someone has it doesn’t mean they understand it. So the first step is to help explain that there are understandable relationships between symptoms and elements within OCD. It’s important to explain this because it suggests that there are proper lines for treatment.

VY: I assume you have to do some kind of assessment on what type of OCD they have, what’s the severity, what they’ve tried so far.

CM: Most people have received some treatment when they first come to our treatment center, but not proper treatment—not CBT and often not even the appropriate medications.The letters themselves tell something about the problem. First there are the obsessions—whether it’s about germs and contamination, or locks and safety from marauders, or fear of displeasing God—whatever the nature of the obsession, there’s typically a belief in a threat that must be avoided at all cost. These obsessions have a negative emotional impact; there’s often a great deal of anxiety and shame that accompanies them.Next we have compulsions. There are two ways of being compulsive. One way of being compulsive is to avoid any circumstance that arouses those ideas and fears associated with the obsession. So I might try to avoid thoughts that are negative towards other people if I fear that God is displeased by that, or lascivious thoughts. Or I might try to avoid touching doorknobs or coming in contact with people’s hands because I fear that I may pick up some disease.

VY: So those are the avoidance type of compulsions.

CM: Yes, those are avoidance compulsions. The other type of compulsions are the rituals, which are used when certain things can’t be avoided. So pleading with God for forgiveness for having improper thoughts, praying over and over in certain ways to ensure that God realizes that I wish to be forgiven and am unhappy with my behavior.Or the washing that’s done in order to get rid of the possibility that there are germs on me, and the obsessive scrubbing and showering and cleansing of clothes and so forth. Or the checking of locks over and over because maybe I missed the lock or I accidentally unlocked it instead of locking it. Or that just looking at it isn’t enough. I have to check it physically or ask others to reassure me that the lock is, in fact, well secured.

VY: Listening to this, I’m imagining psychodynamic-oriented people finding these behaviors rife with potential meaning, but you don’t go there in your approach, right? You don’t put too much effort into figuring out what the meaning of these things are?

CM: Well, there are situations where some traumatic or highly stressful experiences of the individual might have preceded certain kinds of problems. But that’s not critical. The origins of the problem don’t seem at all essential to a successful treatment of the problem. Nor does insight necessarily produce the kind of improvements that one would hope for. So we think of insight into the origin of the problem, or understanding the meaning of it and so forth, as somewhat autonomous from the alleviation of the problem itself.

Avoidance and Its Discontents

VY: So getting back to treatment—once you’ve done some sort of assessment and have a sense of what the obsessions or the compulsions are and how severely they’re impacting that person’s life, then what do you do?

CM: Next you point out the way these behaviors often worsen the condition. Let’s take a common example: A child wants to avoid sleeping in the dark, but the parents insist that they stay in the dark, and maybe give them a little nightlight or open the door a crack. If they scream loud enough, will their parents leave the light on? No. Parents will say, “No, we’re going to turn off the light. You know you have to get back to sleep.” Avoidance is a way of maintaining fears.

VY: So if they cave in to the child’s demands and leave the light on, that’s going to reinforce the child’s fear.

CM: Right. It’s like not swimming in deep water isn’t going to help you get confident in your swimming ability in deep water. Not taking the training wheels off the bike isn’t going to make you a confident two-wheel bike rider. What we need is exposure to the experiences that cause us fear so that we can actually gain confidence and overcome our fear.

The origins of the problem don’t seem at all essential to a successful treatment of the problem. Nor does insight necessarily produce the kind of improvements that one would hope for.

Similarly with OCD, what we do is provide methodical and manageable levels of exposure to the feared elements, with the assumption—and borne out by our experiences—that the person will eventually become less fearful; and when the fear is lessened or extinguished, they have no longer have to perform rituals or compulsively avoid the original cause of their fear.

VY: You’re talking about exposure and response prevention.

CM: Mental exposure to things that cause us unwarranted fear, and then response prevention: encouraging the person to forego any abrupt reductions or eliminations of their fear, because the nervous system needs time to adapt. With repeated exposures, and saying, “Yes I know you’re anxious, but don’t wash your hands. Let’s let your nervous system get used to the fact that you have a great deal of nervousness and fear about this”—over time, what we typically see is a person becoming more comfortable with higher levels of fear-invoking distress.

VY: So how do you actually do that? These people are very invested in their symptoms so it can’t be easy. What are the steps? What do you do in the first session, the second session?

CM:

We have to come across as knowledgeable experts in order to instill confidence in them to allow us to lead them into the belly of the beast.

In orthodox, standard treatment, there’s the cognitive therapy component, where there’s a great deal of education about the way these things work—why their efforts to remain comfortable are thwarting their wishes to overcome their OCD. This educational component is key and we have to come across as knowledgeable experts in order to instill confidence in them to allow us to lead them into the belly of the beast. We have to do it in a way that allows them to experience some of these corrective measures, so that they can say, “Whoa. I’m much more comfortable doing this than I ever imagined I could be.” That’s the first step out of the pit.

VY: So you start by explaining how the treatment’s going to work and establishing yourself as an expert so that they’ll do what you tell them to do.

CM: And the proof’s in the pudding.

VY: So with the hand washer, will you give them some homework in the first week?

CM: Yes.

“Do You Know Somebody Who Got AIDS from Touching a Doorknob?”

VY: Do you tell them to go cold turkey?

CM: Not usually, because these fears are heavily entrenched and have been reinforced over a lifetime. So there has to be a great deal of preparation, cognitive therapy, correcting of misconceptions and identification of distorted thinking to help prepare the person for more experiencing and tolerating of their discomfort.

VY: So how do you do that? If these people have a very strong belief, bordering on delusional, that they’ll get AIDS from touching a door knob, for example, how do you get them to start touching door knobs? Clearly just presenting them with their distorted thinking isn’t going to be enough, right?

CM: Well, you start with simple observations like, “Other people seem to be touching doorknob quite regularly. Are your friends who touch doorknobs dropping like flies from AIDS? Do you know somebody who got AIDS from touching the doorknob? Have you ever heard an expert who understands disease processes suggest that we should all avoid touching doorknobs because AIDS or some other deadly diseases can easily be transmitted?” You start point out flaws in the thinking process.

VY: So having a logical discourse can be effective?

CM: It helps. It establishes a foundation of looking at things differently. These people are not crazy; they’re very intellectually competent, in fact, so they’ll begin to take notice of the many inconsistencies in the way they address these things. They might have a magical way of ensuring that they don’t get a disease—for example rubbing their hands on their pants six times.

We might ask, “What scientific principle suggests that rubbing it six times makes you safe, while rubbing it seven times or five times doesn’t?”

So we might ask, “What scientific principle suggests that rubbing it six times makes you safe, while rubbing it seven times or five times doesn’t?” And they’ll go, “Wow. Yeah, now that you mention it, it sounds kind of silly.” We begin to undermine their notion that this makes sense.

Nobody wants to live life like this. They’re just so afraid of giving it up. So they really want to believe you when you say that they can get over it, because life can be such hell for them otherwise.

VY: So cognitive preparation can be helpful. What do you give them as homework the first week?

CM: Well, homework might be to monitor. The chunks of useful information for setting up treatment are the many things they avoid. Why? Because avoidance exposure is the opposite of avoidance. Anything they avoid doing is potential fodder for the exposure experiences. So they don’t touch doorknobs; they won’t eat off a fork that hasn’t been rubbed with a disinfectant wipe; they won’t shake hands with people; they won’t use public restrooms or touch any surfaces in a public restroom. All of the things they avoid doing become useful information to develop the exposure experiences. And on the other side of the coin, all of their compulsive behaviors—their washing, their separating clean things from dirty things, their asking for reassurance from others—all of those become the elements for response prevention. Those are the easy escapes, and we can’t have that during the course of the treatment, in order for it to be successful. So in the early stages of treatment, our goal is to get a wide array of potential exposure treatments, those things that they tend to avoid that ordinary folks don’t.

VY: So in the early stages of treatment, you first want them to be more aware of what they’re doing. And then you’re giving them some alternatives?

CM: You’re gathering information to become a collaborator in treatment. You’re saying, “You’re going to hate exposure. You’re probably a little nervous about it. But I’m going to help you understand why avoidance has been so detrimental to your life. You’ve worked so hard, but you’re more afraid than you’ve ever been about these things.”Originally they see the compulsions as the solution. “I’m going to avoid touching things that make me feel dirty. I’m going to do things that make me feel clean.” But soon they’re doing those things for hours and they feel more scared than ever.

VY: Okay. So the first week or two, what do you specifically give them to do as homework? Or tell them to do?

CM: There’s no one formula for how you start, how fast you move, and so forth. In fact, individually gearing it to the person, to their readiness, to the level of preparation they need and how much help they need with the exposures—these are all very important elements to ascertain before moving ahead with the treatment. And this is where the expertise of the practitioner comes in.We might do a more traditional once-a-week treatment, or an accelerated treatment where people come more than once a week. There may be in vivo components in or outside the office where they’re getting exposure to the stressor. We can have intensive treatment, where over a shorter period of time, let’s say a month, people are getting very intensive daily hours of treatment.

But the general thrust of early treatment is to gather the correct information to build a road map for the treatment. And that involves the patterns of avoidance, the patterns of rituals that are used, and so forth. Then we develop a hierarchy, which is the essential part of the roadmap. Which things produce very little discomfort, which things seem outrageously anxiety producing, etc. Then we bring them through the different stages. So as they learn at each stage that they won’t meet their demise, we lead them through increasingly more difficult exposures.

Hierarchy for a Hand Washer

VY: What would be a hierarchy for a hand washer?

CM: Early on I’d try to find something relatively easy to work with. So if a client feels safe in their bedroom but not safe touching the bedposts because her mom touches them when she changes the sheet, I’d ask her to rate her discomfort on a scale of 1 to 100. The name of the scale we use is “SUDS,” Subjective Units of Distress. So I’d ask how anxious the bedposts make her and she’d say, “just a little bit.”

Our job is to titrate the exposures so that they are manageable and doable, and to ensure that the person is gaining confidence that the powerful emotional response and the belief in the catastrophic consequences that they fear are both diminishing.

So I would ask, “Would you be willing to just come in contact with that bedpost, and see what the emotional experience is like? Is it going to be awful? Is it going to be reasonable? Can you forego the washing? If so, for how long?” We try to probe into how people actually react. Sometimes it worse than they think, and sometimes it’s easier than they think.

Our job is then to titrate the exposures so that they are manageable and doable, and to ensure that the person is gaining confidence that the powerful emotional response and the belief in the catastrophic consequences that they fear are both diminishing. That’s the only reason why a person would move forward and give up all their safety mechanisms and participate in treatment.

VY: Alright. So in the hierarchy, the bedpost might be relatively low. The refrigerator door might be higher and the faucet in a public restroom might be a lot higher than that.

CM: Right, and typically we start with some exposures in the office, where it’s a safer environment and they don’t have a history of a great deal of compulsivity. The therapist becomes kind of a guide and a confidante and a trusted companion on the journey.As we go, we learn more about how the nervous system reacts and what’s going on in the mind of the individual, and then we can apply cognitive therapy and wait for the habituation as the nervous system reaches it’s kind of asymptote, and then begins to decline. It’s a very interesting and powerful experience for individuals. “Wow. I don’t feel as nervous now. When I think about it, it kicks up a bit, but somehow it doesn’t bother me as much as it did before.”

We emphasize the techniques, but so much of it is the importance of the relationship—the confidence of the patient in their therapist and the therapist’s sure hand on the tiller.

So there’s a lot going on, as you can see. We emphasize the techniques, the exposure response information, but so much of it is the importance of the relationship—the confidence of the patient in their therapist and the therapist’s sure hand on the tiller.Just knowing that whatever comes up, we’re going to know how to deal with it. That’s why the experience and the special training helps. At some point along the way, we’ll touch on how a person might go about getting that additional training that enables them to be confident at whatever their previous kinds of approach to therapy might have been.

No Reassurance Allowed

VY: Let’s carry this through a little further. So in an ideal scenario, you graduate, move up the hierarchy. They may have a feared response but, if all goes well, they’ll find that if they wait a bit and, with repetition, and with reassurance and—

CM: Well, not reassurance so much. Reassurance is an escape mechanism. We might even say, “Who knows? You might get AIDS. I can’t promise you won’t. You know, things happen.” So we can’t reassure them too much in the process, or it can become a type of ritual in itself. We have to allow them to address the uncertainty of their situation.

Reassurance is one of those subtle kinds of variables in therapy for OCD that can easily be mishandled by a therapist who is unaware of the importance of facing uncertainty.

It’s a balancing act. In a certain way, preparing them cognitively is also reassuring them that we know what we’re doing, that they can overcome their problem. But we have to watch out for specific reassurance when their anxiety is up that is designed to reduce it. You see? It feels important to distinguish this because reassurance is one of those subtle kinds of variables in therapy for OCD that can easily be mishandled by a therapist who is unaware of the importance of facing uncertainty. We often reassure our patients in treatment, but with OCD, you have to be particularly careful or you’re just colluding in the compulsivity of that individual.

VY: Coinciding with the publication of this interview, we’re releasing two videos with Reid Wilson, whom you know, and he even takes it a little further than what you’re saying. His approach really emphasizes the lack of certainty—not only do they have to tolerate the uncertainty, but to welcome and invite it.

CM: Yeah. And that’s very important, dealing with uncertainty, because we don’t know everything about this world. Our patients often come to our office on the beltway. They know people die on the beltway. Are they certain that they’ll make it? That they’ll go home? That they’ll be alive when they get home? The answer is no, they’re not certain. I’m not certain. The reality of the world is that uncertainty is part of the picture.We don’t know what happens after we die. We don’t know if there’s a God that is so vindictive that one false move and we’re forever tortured in hell. We don’t know that for a fact. We have to help people live with realistic uncertainty. With kids, you have to be a little more careful. If a kid believes the number 3 is a bad number and if they eat three M&M’s their parents may die, you have to be a little careful about saying, “Your parents may die, we can’t know for sure.” How that’s handled is extremely important. There are certain people who are going to be much more ready to deal with that part early on, and others who have to be handled very carefully along the way.

But Reid and others of us who work in this way realize that reassurance is a way to help people feel safe, and we can’t do that. We have to expose them to the idea that it may not be safe, but that we have to live our life as if it were safe, the same way we do when we go on the highway, or we eat unknown food. The food may send our body into some convulsive shock, but we eat it because we are willing to accept some uncertainty.

VY: So, following the roadmap that you’ve laid out, they would progressively move towards behaviors that are higher on the hierarchy, and in a good case scenario, they would experience some anxiety, but over time it would diminish or eventually even go away entirely.

CM: In most cases, there are some remnants of OCD symptoms. However, it’s like a person who was once a drinker and now is abstaining—they have to be a little cautious, recognize the danger signs, know what to do. An alcoholic wouldn’t go hang out at a bar; somebody who used to be very overweight doesn’t go shopping when they’re hungry or keep Halloween candy around the house for weeks before Halloween. We teach people how to recognize OCD, how it works, and essentially how to become their own therapist.

We don’t have a lot of repeat customers with an OCD treatment. People go out there and, if properly treated, they should have skills that enable them to live a reasonable life.

We don’t have a lot of repeat customers with an OCD treatment. People go out there and, if properly treated, they should have skills that enable them to live a reasonable life. It is important to understand that there is a potential for people to totally overcome their OCD and live a life that’s free of those problems, but realistically speaking, we have to prepare people for the likelihood that they have to remain vigilant to a certain extent, and have to retain the skills necessary to remain functional and symptom-free as possible.

“You Actually Do That?”

VY: With all therapies, there are usually stumbles and hitches along the way—setbacks, relapses. What are some typical challenges therapists and clients face along the way of navigating that hierarchy?

CM: Well, sometimes people cut corners. They cheat a bit. They may succumb to their compulsion and end up washing and separating at some point during the week. So compliance is extremely important. And because we’re dealing with a very anxious group—and rightly so, they’ve lived a life that’s been drastically altered by their fears and beliefs—we have to prepare them for the importance of compliance with the therapy. So that’s one challenge: people who aren’t quite doing what they tell you they’re doing.

Therapy can be a bit odd. We ask people to do things that ordinary folks don’t do—you know, putting a cookie on a public restroom toilet and eating the cookie…

The other, as I mentioned earlier, is people’s families. Families can be a problem themselves. We have kids who we’re trying to wean from hand washings, and Grandma says, “You’re not coming to the table without washing your hands, are you? Go right over there and wash them and be sure and use soap.” Well, that’s a bit of a problem. That’s why it’s important to educate the family about what we’re up to and why we’re doing it. Because therapy can be a bit odd. We ask people to do things that ordinary folks don’t do—you know, putting a cookie on a public restroom toilet and eating the cookie. We don’t think it’s really going to kill us, but it’s a yucky, you know?

VY: You actually do that?

CM: Sure. Because we’re asking people to go far with this, so that when they leave treatment, it goes back to normal. If you just bring them up to almost normal, there’s a tendency to backslide. So we want to take them to some rather “notable experiences,” I’ll call them, “memorable experiences,” where they say, “Wow, I did that, and I survived. So I’m willing to live my life in a more ordinary way.”So we tell them along the way, “This is yucky. I don’t like doing this. I don’t like reaching into a dumpster and rubbing my face with garbage.” But part of the training is to understand that our own sensitivities mustn’t interfere with therapy. It’s important to get experience and training in this so that we really understand what we’re up against, what people are up against.

The stress of life can also undermine treatment. Whatever we’re trying to do—whether it’s exercise more or get along better with our co-workers—when we’re under stress, it’s easy to slip back into old behaviors. That’s why so much preparation goes into relapse prevention. The latter part of treatment is mostly about preparing people to be their own therapist, and creating a plan that they can follow through on for different expected moments of weakness or the recurrence of some feelings that were perhaps attenuated for a while but, for reasons unknown, come back with a vengeance.

VY: So what might be an example of a relapse prevention plan?

CM: Self-managed exposure and response prevention would be one example. Let’s say I have a fear of dust and dirt and I’ve been doing a lot better after treatment, but one day I notice dust on me and I start to worry. I think, “What would my therapist say? Well, he’d say, ‘Hey, it’s just dust. It’s probably not radioactive material!”

VY: It’s not anthrax.

CM: “So now what do I do? I go and intentionally take a little of that dust and perhaps put it on me, put it on my shirt, so that it makes me feel uncomfortable. It’s kind of foolish to do. No normal person would do that, but I understand I have to use the most powerful tools that anybody knows about to fight back against OCD. ERP—exposure response prevention.” So they do those kinds of things. Self-managed exposure response prevention. It’s very important.But if they’re having trouble, they may need to call up their therapist and say, “I need a booster session. I just took a step backward, I tried to handle it on my own, but I think I may need some help.” So we’ll plan a little systematic approach and a little mini-therapy session. Relapse prevention is preparation for the inevitable human failings, setbacks, weaknesses, and so forth.

VY: So even though it’s a fairly structured form of therapy and there is a lot of technique involved—a roadmap—there’s a lot of creativity involved as well.

CM: Absolutely. We learn from every patient. There are always new twists. The OCD is a product of the person’s own imagination and creativity, so everyone has their own twists and turns.

Training for Therapists

VY: From what I can gather, therapists who don’t have specific training in treating this and just kind of incorporate it into traditional talk therapy are unlikely to have effective results.

CM: Well, it depends on the case. Some cases are relatively simple and a highly motivated individual with a therapist who grasps things well enough not to make some of the common mistakes in treatment can do quite well. So it is possible to pick up a book about it—there are some good manuals out there that tell therapists how to do this as well as some good self-help books that therapists can use. It’s possible to be effective in some cases without extensive training.On the other hand, more difficult cases are challenging even to the most experienced therapists. There are going to be cases that are difficult to treat under any circumstances and that’s where more experience, more heads in on the treatment make a difference. Creativity and troubleshooting problems can be essential to moving smoothly through treatment. It rarely goes according to the cookbook, you know?

VY: If someone reading this interview wants to get more in-depth training, where would you suggest they go?

CM: An excellent place to get that is through the International Obsessive Compulsive Foundation’s Behavior Therapy Institute. It’s a wonderful three-day certificate program. It’s been developed over almost two decades, and provides excellent preparation for individuals who may never have had much experience, or any experience, with OCD. After the training there is follow-up guidance, supervision by phone—people can get really a huge jump in competence in treating OCD.It’s so important to develop more practitioners. As it is, there aren’t enough trained competent practitioners to deal with the large numbers of individuals with OCD. There are whole states where there are very few places to get competent treatment. Not only is it important from the standpoint of the sufferer, but for practitioners. This is an extremely rewarding area to work in.

We do get those Hollywood endings where people just shed their symptoms, hug the therapist, and walk out into a whole different kind of life.

We do get those Hollywood endings where people just shed their symptoms, hug the therapist, and walk out into a whole different kind of life. That isn’t so common with some of the problems we treat.

Just the fact that we’re there and we know what we’re doing ensures that we’re going to get lots of love from our patients, because they’ve often been through some harrowing times when they didn’t understand what was going on, when they got misguided advice from professionals; so when they finally feel that they’re getting competent treatment, there is very often a great deal of positive emotion generated by that alone.

And they pay their bills. The OCD persons are often achieving, smart, and conventional in many ways. So it’s very rewarding. Those of us who specialize in OCD treatment never get tired of it. I have almost 20 people in our center who love to treat OCD and get very excited about new cases that, while challenging, are teaching us new things every day.

VY: Do you treat other conditions as well?

CM: Well, once you treat OCD, you’re going to also be treating things under the broader OCD umbrella. There are many disorders that are now considered OC spectrum disorders—things like body dysmorphic disorder, where people perceive ugliness in themselves and are often very depressed and very distraught. Also hypochondriasis or health preoccupations—the person believes that every ache and pain is some deadly disease and bug their doctors to death, or do doctor shopping, looking for someone who will take them seriously.I already mentioned that we see a great deal of commonalities in Tourette’s and OCD. We also treat trichotillomania, hair pulling disorder, and excoriation disorder, skin picking and the picking of acne or the picking of skin around the body, fingers, toes, legs, scabs, mosquito bites. That just made it into the DSM-5, by the way.

VY: I understand there were some other changes in the DSM-V in terms of classifying some of these related disorders?

CM: Tic-related disorders are pulled into the mix. There’s now an identification for a subtype where tics and OCD appear within the same individual. We’ve conceptualized something called “Tourettic OCD” that’s very similar, but we don’t believe that its necessary for tics to be present for it to be Tourettic. It’s more that certain kinds of OCD are really discomfort-driven, rather than anxiety-driven, and therefore it’s similar in many ways to the experience of Tourette’s.Even Asperger’s syndrome, or what the DSM-V now calls Autism spectrum disorders— very often people are referred to us who say they have Asperger’s or they have pervasive developmental disabilities, but they also have OCD. Well, they may or may not. They may fit a sort of OCD configuration, but they may not be exactly OCD. They may have stereotypies, or they may have hyper-interests, where they just love everything about Pokemon or something. But it’s not OCD. These are more repetitively driven things. They’re not driven to do stuff because they feel very uncomfortable and frightened unless they do them. They do things because they just love to do those things.

VY: That’s an important distinction.

CM: It is, because a lot of things we call compulsive—some people love to shop or love to gamble or love to act out sexually—that doesn’t mean they’re obsessive compulsive. They’re exhibiting repetitive patterns of behavior, but the treatment’s quite different. If you treat OCD and identify it as treating OCD, you’ll eventually learn how to distinguish them from each other, and when it’s best to refer them out, in the case of something like internet addiction. People call up all the time saying, “My son is obsessed with the Internet. He plays videogames all the time. I understand you treat OCD.”“Well, yeah, we treat OCD, but that’s not OCD.” The importance of expertise is to be able to distinguish the subtle differences among some of the repetitive patterns of behavior that are often clumped and misidentified as OCD.

VY: Well I want to thank you for taking the time to share your wisdom and experience with us. You’ve gone into a lot of depth and, as is typically the case, though I’ve been in this field for quite a while, there’s always more to learn. I think our readers will have a similarly enriching experience and will be intrigued and interested in getting further training and expertise in treating OCD.

CM: I hope so. And I thank you for inviting me to participate here.

Our Hungry Selves: Women, Eating and Identity

Posted on June 13, 2013February 11, 2026 by rezendevknowfully.com

The Tyranny of Slenderness

In the early eighties I wrote several books about eating disorders; one of them became a national best seller. In the first book: The Obsession, Reflections on the Tyranny of Slenderness, I researched the way our culture's fear of women was directed against women's bodies and, in particular, against a large woman's body. I felt that the cultural preference for very slender women revealed a wish to see women reduce themselves as women and relinquish their power.

Here’s how I reasoned back then: “The body holds meaning. A woman obsessed with the size of her body, wishing to make her breasts and thighs and hips and belly smaller and less apparent, may be expressing the fact that she feels uncomfortable being female in this culture. A woman obsessed with the size of her appetite, wishing to control her hungers and urges, may be expressing the fact that she has been taught to regard her emotional life, her passions and 'appetites,' as dangerous, requiring control and careful monitoring. “A woman obsessed with the reduction of her flesh may be revealing the fact that she is alienated from a natural source of female power and has not been allowed to develop a reverential feeling for her body.””

The second book, The Hungry Self: Women, Eating and Identity, studied the way a woman's hunger for self-development, creative expression and liberation might express itself if it was not recognized as a hunger for food. I was curious about the emotion and conflict and turbulence that might be disguised as a craving for food, and especially “forbidden” foods like carbohydrates and sweets. “In [this] book I extend [my] analysis to include the mother/daughter bond and the issue of failed female development….We cannot heal ourselves until we understand the hidden struggle for self-development that eating disorders bring to expression in a covert way. We cannot indeed even begin to think of self-healing until we stop using the words “eating disorders” to hide from ourselves the formidable struggle for a self in which every woman suffering in her relationship to food is secretly engaged.”

In the third book, Reinventing Eve: Modern Woman in Search of a Self, I issued a call to women to step up and re-invent ourselves, freeing ourselves from the pressures and constraints of a society that feared women. I saw Eve as a radical, the first woman who was forbidden to eat food and who broke the taboo. “Women speaking intimately about their lives are usually, whether they know it or name it, on the far side of outworn ideas…We [have had] to start with the assumption that we knew little, had been lied to a great deal, that secrets had been kept from us, we were setting out as pioneers together, groping to find a suitable language for our experience….”

The Tyranny of Obesity

Thirty years later these ideas are still meaningful to me but my vision of possibility has been checked. “Fat is Beautiful,” a movement I greatly admired, has now become, thirty years later, a group of aging, obese women with serious health problems. I used to refer women who wanted to lose weight to other clinicians; I explained that my work offered them a chance to make peace with their body, not to change it. I now look back and think that I was rather close-minded, as if I knew what should matter to every woman who came to me for help.

Over these thirty years I've counseled countless women, discussed these issues with them, found them open to these ideas, yet progressively we have realized that it was no easy task to overcome the predominant dislike for big, fat or obese women. This overcoming of cultural dictates is a task suitable for some of us, not for everyone, and why should it be? Many women would rather work towards the body our culture admires than analyze the reasons they dislike their body as it is.

When I began to speak these ideas publicly, women who had read my earlier books were shocked; they felt that I had abandoned them in their quest to accept their body and their appetites. This new orientation seemed a betrayal, a renunciation of my earlier thinking with its cultural and psychological understandings. But I myself had begun to feel that my earlier ideas were hardening into an absolute, as if what was right for some women had to be right for all women, another once-size-fits-all approach to women and food.

I’ve had to explain that these days more and more women have to lose weight for the sake of their health, and that my clients and I had found a way to transform dieting from a self-defeating, frustrating, futile exercise into a useful therapeutic tool. A diet is—or can be—a way of becoming conscious of why one eats or feels driven to eat. Paradoxically, limiting what we eat is often the most direct way to uncover the feelings that drive us into self-destructive eating. Earlier, I had been opposed to the very idea of dieting, now I was willing to offer women help if they chose to diet. I left the decision to them, offering them both possibilities of work—towards body acceptance, weight loss, or sometimes the two together.

But there is more. There are other changes during the last thirty years that I have come to take very seriously. Following Michael Pollan, I began to study the food we are given to eat, so much of which has been degraded. The additives in it actively cause weight gain, and it is offered up in mega portions we tend to accept because there they are on the plate in front of us. As Michael Pollan writes: "Researchers have found that people (and animals) presented with large portions will eat up to 30 percent more than they would otherwise." Some of the weight we unhappily carry around with us is not really ours, it isn't natural, we haven't chosen it. Much of it has come upon us in surreptitious ways, through mysteriously named presences in our food, like high fructose corn syrup and its near-relations—aspartamine, glucose, dextrose, maltodextrin, maltose—which most people do not recognize as sweeteners. Even when reading a label and consciously hoping to avoid sugar, we end up with sweetening agents we don't want.

The Tyranny of American Culture

Thirty years ago I was asked to help people suffering from anorexia, bulimia and compulsive eating; these days women are calling me because, over the years, they have gained so much weight their doctors are alarmed for them. It was short-sighted to send them to someone else when I was a person who had dieted on and off for most of my life, at times winning, at times losing, the battle against our culture’s standards. And wasn’t I now, just as then, responding to a cry for help from our culture? After all, three of every five Americans are overweight. Obesity is an epidemic.

And so too is a woman's unhappy preoccupation with the size and shape of her body, or some part of her body, or some new diet that promises to change her body. I know this, not only from my clients, but far more intimately from myself. “I am a feminist, I care about women's self-development and the cultural and psychological obstacles that inhibit it, yet I have struggled, since the age of seventeen, to be at home in a body that has never been overweight but still has not been acceptable to me.” In spite of my three books about women and food, and all the lectures I have given, and the deep conversations in which I've been engaged; even in spite of the fact that I never any longer eat compulsively, a preoccupation with food and body size is still hanging around in my life. As a result, I can no longer underestimate the power of this conflict, as I observe it listing towards a feminist understanding about a woman's right to make decisions about her body, free of cultural pressures, and then spinning off in the opposite direction towards the next miracle diet that comes along, promising a body that conforms to our culture's punishing ideals. Weight and body size present us with a problem for which we don’t have an adequate solution.

Taken together, these are good reasons to change one’s point of view. I have changed mine in an effort to supplement—not replace—my earlier work. I intend to help people find the right diet and support them while they are losing weight, an emotionally demanding task whatever the nature of the diet. But losing weight is only part of it; we have to learn to eat in a way that often contradicts everything we’ve been taught about healthy nutrition. Not three meals a day but a small meal every couple of hours; not avoiding water because it may produce weight gain but drinking quarts of it; eating at night, before bed, because the body even in sleep requires 500 calories to keep itself going. Eating fat because we feel nourished by it, learning what are desirable portions, eating local produce because the food contains more of what food should contain and will therefore nourish us in smaller amounts. There is no one diet that is suitable for everyone—creating the right diet has elements of a quest for identity, a coming to know and be able to choose what is good for one. If this isn’t meaningful therapeutic work I don’t know what is.

Catherine's Story

A client of many years returned to work with me. Her doctor had just told her she had to lose between 25 and 40 pounds because her medical condition was severe. She came full of despair, wondering how we could approach this assignment since we had always discussed body-acceptance and appreciation for big and voluptuous women, which she was. Beautiful, certainly; but perhaps not healthy?

I began to work with Catherine in 1995. She was 26 at the time, a graduate from an Ivy League school, a women’s studies major who sought me out because she had read my books. She came from a small town on the East Coast, from a family active in their Episcopal church. For her to leave home, move to the West Coast, live with a man to whom she was not married, give up all religious affiliation and develop an interest in feminism while her two sisters and one brother remained close to home, was daring. She had graduated with honors and gone out into the world eager to make the most of herself. But this promising development had stalled. She was working as a secretary at a job she hated, was preoccupied with compulsive eating and her body’s size, found life meaningless and disappointing, described herself as depressed and despairing and at times suicidal. I was then in training with Otto Will, who had trained with Harry Stack Sullivan, who had worked with Freda Fromm Reichman. I was following their interpersonal approach with a dose of object relations mixed in, supplemented by an analytic interest in childhood memories.

Catherine found it almost impossible to cook for herself, although she had no trouble cooking on the night assigned to her by her collective. She didn’t plan for her meals but grazed throughout the day, almost entirely on cookies, candies and anything sweet. She ate in secret, disliked herself for doing so, was afraid that I was judging her, and suffered from guilt and remorse. Together, we observed the nuances of our relationship as it developed over many years, curious about the fact that she always stopped for food before her session and immediately went out afterwards for a piece of cake. She suggested that she was filling herself up so as not to bring a ferocious desire to eat into the room with me, evidently afraid that she would gobble me up. The cake that came after the session was to restore the energy that she felt had been depleted in thinking about these issues. She discovered that she refused to cook for herself because she wanted her mother to cook for her and would rather not eat than have to provide food for herself. Although she had voluntarily left the family for a larger life, she missed the closeness and safety of the small town, their church and especially her mother’s devotion to feeding the family. She was brilliant and analytic and good at interpreting symptoms; her childhood memories grew richer and more plentiful over the years, as did her ability to piece together a plausible narrative of her childhood. “Catherine ate in secret, disliked herself for doing so, was afraid that I was judging her, and suffered from guilt and remorse.”

She was the youngest in her family, and by the time she arrived her mother was exhausted and depleted. She hadn’t wanted another child, her milk dried up when Catherine was a few weeks old, and the care of the infant was largely handed over to her elder sister. Nevertheless, on the surface they were a happy, close-knit family, admired in their church and appreciated for their good works. Mother spent the day cooking for them, trying out new menus and culinary ideas, seemingly satisfied with her life but with an undercurrent of bitterness only Catherine seemed to recognize. Although well fed by her mother as she was growing up, Catherine began to wonder if she’d ever been nourished. Even her desire to have mother cook for her now that she was an adult began to seem a poignant wish that mother’s care and even her cooking had contained more authentic nourishment. The family dinners, which she’d always remembered as happy occasions, began to reveal their seams of stress—her older sister resenting her for the care she’d given her, her brother, two years older, in fierce competition for attention, her father absent, the second sister gentle and meek, as if she’d early decided that life was not going to offer her much, mother tyrannical when it came to the family’s enjoyment of her cooking. Dinner table conversation was lively but largely restricted to comments and conversation about food.

Catherine’s life changed dramatically through our work. She left her job, started a not-for-profit organization that became very successful, developed a strong interest in psychology, got an M.A. in counseling, worked out an honest and passionate relationship with her boyfriend, bought a house with several friends and lived collectively. When she got pregnant she decided to stop her work with me, owing both to financial concerns and to a general feeling that we had accomplished much and that she wasn’t capable at that time of going further. She still ate compulsively, giving us both the impression there was a lot more to understand.

I present this story in order to muse about the fact that excellent psychological work can be done that nevertheless does not reach a troubling emotional core. This did not surprise me. In my decades of work with eating disorders I have found that the underlying reasons a person eats compulsively, or eats more than they want, or far less than they ought, are hard to experience as direct, unmediated emotional events. The symptoms of a troubled relationship to food are so powerful and so deeply ingrained in the way one soothes and rewards oneself, hides from loneliness, expresses outrage and sorrow and in general shuts off consciousness, that it is hard to get beneath symptom into the raw emotion that is giving rise to it. She sensed that there was more to her emotional life than we'd yet explored; nevertheless, that is where we left it until, six years later, she came to speak with me about her doctor’s insistence that she lose weight.

Catherine's Diary

I have permission to quote from the diary she kept during the first three weeks of the diet. My comments follow her diary entries. This is not a description of the way Catherine and I worked together but an account of her process of uncovering meaning in what earlier had been unconscious, compulsive acts.

Catherine: I have a strange sensation—I am not really that hungry, though I can feel an underlying pull in my stomach now that's it's been a few hours since my breakfast. I am sad and irritable. My mind brightly goes to "treat" several times an hour, for myself, and socially ("like, oh I should take the girls out for burritos for lunch!" "I want a latte and a scone!"). Then I am disappointed in some deep way when I remember, but it's not exactly about being hungry. Fascinating. What is it about?

I am interested in the fact that from the first day of dieting hunger is put under suspicion. It can’t be taken at face value. This is an insight Catherine has not had before.

Catherine: Today, the glutton, the sensualist in me rebels. I can feel a sense of victimization mounting. "I hate restriction, I don't want to do this."

Here, as we can see, the issue has now become one of dislike for restriction. Insight is developing: this is a character trait, not an eating behavior. Catherine has not previously named in herself this rebellion against limitation. Indeed, it would be hard to recognize when there is a lifetime pattern of instant self-gratification.

Catherine: “OK, this is bearable, I am OK. But the sense of comfort I am missing—I am working so hard, I am so tired and worn out from childcare. How will I replace food as comfort? How? How? So far there is no replacement and I’m not sure there ever could be one. I am working so hard.

An additional meaning has been attributed to food. It is now recognized not only as a comfort but also as a reward for having had a hard time. This is a steady growth in the capacity to think symbolically. Hunger is no longer simply hunger and food is no longer simply food.

Catherine: It’s not hunger that’s hard. What I have to know about myself is what’s hard. I’d rather not know.

The progression of self-awareness has moved on into the striking discovery that the struggle with food has been a drama about self-knowledge. Or rather, about refusing self-knowledge. This is a lot of insight to achieve in a week.

Catherine: Last night at the party someone said I seemed like a happy person and I felt so embarrassed I almost cried. "I am having a terrible time, I'm filled with jealousy and poison," I thought. "Why does she think I'm happy?

Catherine has always had the capacity to seem happy, well-adjusted and cheerful, traits that were required by her family. They’ve been a second skin and only now are being viewed as alien. Although these traits have served as a protective covering, they have also been misleading as to who she really is. As she comes to know herself authentically, a wish to be authentically known begins to emerge.

Catherine: The depressive, dark, roiling, murky, angry, resentful, revengeful part of me is so present now when I am alone and I never show it in public—Who is this? I can see why she’s been out of sight. I don’t want her. I feel suffocated by these feelings and their bare truth. I can't push this part of me away and "think positive." I must integrate, integrate, integrate. I wish I could cry, but I feel so bottled up. Maybe I will cry today. Would crying be more satisfying than a burrito?

I thought of this as an important breakthrough. A subterranean world of feeling, now present in her awareness, has brought in the crucial thought that an ability to feel, to cry, or even to want to feel might be more satisfying than eating.

Catherine: It's very hard for me. These feelings are hard for me. I didn’t know I was filled with so much poison. Feeling these feelings is what’s hard for me. I don’t like who I am. But I do like myself for knowing all this.

The capacity to know and name herself is making the emergence of difficult self-knowledge bearable. We know how crucial this particular exchange is in psychological work. Not liking who one is but liking oneself for the ability to know it. The supposed safety of not-knowing is falling away before the power of insight.

Catherine: Last night I dreamed I was trying to warn a school full of small children (preschool) and teachers that a huge tidal wave was coming. Everyone was very busy and distracted and could not focus. Then I was in a meeting where someone was presenting us with his new beautiful chocolate bar. I raised my hand and asked, "What was your aesthetic inspiration for making this chocolate?"

I often dream about tidal waves: massive, blind destruction. But I never thought they were about what I was feeling. Or not feeling.

I think they represent my dread and fear and the sense of overwhelm I have about things. And the chocolate is so funny! That’s what I’ve found in my life, a chocolate bar to keep me safe against a tidal wave.

This is a curious insight because in fact the chocolate bar and its sister-sweets have served to protect her from the tidal wave of feelings that she fears. They’ve worked; they’ve captured her consciousness and shut it off. That’s why chocolate and muffins and brownies have been so hard to give up. Nevertheless, they are now seen for what they are and have become ludicrous.

Catherine: Any choice about my size, about losing weight, is astonishing to me. It lifts a lifetime of discouragement. How do I comfort and reward myself if not with food? (I want to replace compulsive eating with compulsive writing!) My shoulders ache, my eyes are heavy with un-slept sleep. I want to lie down right now in this library and cry.

Wonderful, this wish to replace compulsive eating with compulsive writing. She is in fact a very good writer and will, in a few months, discover that when she sits down to write, the inner turbulence she feels will subside. Not every time, not completely, but often enough to make her aware she has a choice between chocolate and self-expression.

Catherine: It's getting somewhat easier for me. Still many fantasies of treats, but it is balanced out by feelings of excitement and accomplishment. After all, it wasn’t hunger that was the problem. But all this poison inside me. So, now that I know it’s here? Now what? Can I just live with it? I don’t think so. But that’s what I’ve been doing, isn’t it?

The sense that these feelings are unbearable has not gone away, but there is the simultaneous discovery that after all they have been borne. The unbearable has become bearable. If this happens once, it can happen again: “I can’t live with it, but paradoxically I’ve just discovered that I have been living with it.”

Catherine: Clothes that were a bit too tight feel good and are fitting. Joy. Joy. JOY. Having these intense, florid cravings a few times a day. They stop me in my tracks. Today it was my childhood birthday cakes—"bakery cakes" we called them—white cake and frosting with clusters of pink frosting roses, they were even better slightly stale. Everyone wanted a rose on their slice—a mouthful of pure frosting. I practically moaned aloud as I pictured this. Bizarre. I could eat a truckload of that soft, fragrant, sweet white cake and frosting. Yesterday had a craving about thick ice cream shakes full of candy. Amazing that this is there, so deeply. Much much more than a memory. I can right now taste that pink frosting. Like those frosting roses were going to make up for everything that wasn’t so great in our childhood?

I still find it extraordinary that this transformational journey is taking place simply because Catherine isn’t eating in the way she ordinarily would. Through this precise memory, this sensually present image of the pink frosting roses, she has understood the full power of the emotions that she is engaging.

Catherine: I am starkly alone with all these bad feelings. I am hungry and I want to eat. I am sad and I want a treat and a reward. The only thing I can think of is going to bed, not so much as a reward but as a way to live through this. I am going to live through this. I have to live through this.

I admire this knowledge, this clear seeing of these very difficult feelings and the search for something other than food to see her through. Above all I am taken with this resolution: “I am going to live through this. I have to live through this.” It has some of the quality of a hero’s, or more precisely, a heroine’s journey.

Catherine: It gets easier. I am living with medium to mild cravings and longings; not much hunger; and a mounting pleasure in what I have done. It has been so hard and it’s not about hunger. I have been wrestling with an angel and trying to find my meaning in it all. The feelings are so intense: jealousy, grief, rage, cruelty, indifference, helplessness, mad cravings and feeling crushed. It's like living through a hurricane at times. I’m thinking again this is the hardest thing I’ve ever done in my life. But somehow I’m doing it.

I take this testimony seriously; this probably is the hardest thing she’s ever done in her life, harder than giving birth or separating from her family. The newly discovered feelings write the emotional narrative that had been driven out of awareness but was always lurking, lurking, driving the compulsion to eat.

Catherine: I am at my desired weight. I am really pleased. It's amazing. On the feelings front, I am in lots of turmoil. My temper is short, I am touchy and sad. This is the perfect moment to "assault eat." And I will not. I want to be able to handle my feelings and not use food to soothe them, but will I be able to do that for the rest of my life? Maybe if I ever am told I have 3 months to live I promise myself I will eat only ice cream.

I love the way she can simply say, after a lifetime of struggle with eating: I will not. She has acquired choice where she previously experienced compulsion. This transformation of compulsion into choice may be the single most crucial accomplishment in anyone’s therapeutic work.

Catherine: I want support from you and from my man but I feel vulnerable and raw when I think about sharing all this. But maybe it will be better if I talk to him? Maybe I will feel more recognized for how hard this is for me? I am not sure.

Food has so many purposes, meanings and uses; no wonder it’s so hard to work them all out. You give up food as comfort then it shows up as reward; you recognize it as a consolation, then it appears as an interpersonal shield.

Catherine: I spoke to you on the phone about how I'm feeling today. I'm noticing this kind or foundational feeling (that's the word I keep finding)—as if I have more of a right to be here. I think it has to do with feeling proud of myself for doing the hardest thing I can do. Working on my relationship to food is the oldest, toughest, most entrenched part of me. As we said today—it's not likely for me to find something harder. With my clients, I feel a new sense of balance, of rootedness. If I can deal with this for myself, I can ask them to do the hard things they need to do for themselves too. I can support them to do those things. This makes me feel transparent, more authentic. Like I am not a fraud.

This is a beautiful piece of psychological work. Catherine has discovered that experiences and moods she took at face value are actually the expression of emotions and conflicts. I love to recall that resounding phase: “I will not.” She has been able to substitute choice for compulsion. She has gained a great deal of self-respect by succeeding at something she found really difficult. She feels more confident in the work she does with her clients. She understands the meaning of her dreams, she sees life-patterns emerging, she has achieved much more self-knowledge than she’s had before. I like to think of this as the deconstruction of eating in favor of meaning. To this day, after some thirty years of work with these issues, I’m still astonished that something as seemingly mundane, concrete and literal as eating and food can have this crucial importance. Maybe it’s not surprising if we remind ourselves that our first act after birth and taking our first breath is a reaching out for food.

The Journey Continues

Successfully losing weight is not the end of the story, far from it.

Weight-loss faces anyone who has accomplished it with a number of immediate dilemmas. The body has changed but intimacy is still frightening; being dressed in size 8 clothes doesn’t necessarily secure a job; if one was shy before very likely one is still shy. A lot more social attention may be directed towards a woman who has changed her body’s size but cat calls, whistles, crude remarks, are not necessarily the attention she desires. The magic that weight-loss was supposed to produce as it solved all of life’s problems gets tarnished very fast. And there we still are, the same self in a different body, unless the dieting has helped us to change that self.

There’s still a long, hard road ahead. Learning to eat properly, sticking to the new habits one has acquired, shifting from the food of immediate gratification to food that supports health, these are going to present an ongoing struggle.

Catherine’s is not a typical story. Most people who lose weight on any kind of diet do not make a transformational journey. Nevertheless, many do. My intention in writing this article is to suggest that, as clinicians, we are going to be faced increasingly with the problem of obesity and its effect on health. If we learn to use dieting as a therapeutic tool, as a way of uncovering unconscious impulses and compulsions, weight-loss may be easier to accomplish, and certainly will be more rewarding, as knowledge of the self is acquired at the same time.

In closing, I would like to point out that I am not just speaking about dieting here. Any close examination of one’s eating habits and behaviors can yield the same consciousness of deep feelings, memories and life-patterns. As clinicians, I have the impression that we tend to be overly interested in people’s sexual experience and fantasy, and far less concerned than we ought to be in what food and eating have meant to them. In that sense, there is no contradiction between my work of thirty years ago and my work now: whether an individual chooses to diet or to become conscious of the ways she eats, the shared goal can be self-knowledge. Eating behaviors, as I wrote many years ago, can be the royal road to the unconscious as much as, or maybe even more than dreams, Freud’s favorite candidates for that distinction.

Steven Hayes on Acceptance and Commitment Therapy (ACT)

Posted on June 9, 2013February 11, 2026 by rezendevknowfully.com

Why ACT?

Tony Rousmaniere: In your experience, why do seasoned therapists who may already be proficient in other therapeutic modalities choose to learn ACT? What does ACT offer them that’s different?

Steven Hayes: I think there are a few main things that ACT offers. One is you can deal with deeper clinical issues, but inside of a model that feels progressive, so when you’re pushing into new territory, you have a road map that actually feels coherent. Another piece is that it’s personally relevant to people when they’re facing issues of their own. It’s kind of critical that we do work that does not feel false or hollow in some way, and almost all the ACT practitioners I know feel uplifted by the work when they’re struggling in their personal lives. They see the relevance.

I was giving a talk in England a few years ago and there was a person there from England’s evidence-based treatment program who asked that same question of the audience. Many of them shared that it’s fun to be part of a community that doesn’t speak down to you and that engages your intellectual interests in a number of different ways. People are able to integrate their interests in philosophy, evolutionary biology, social change and transformation, stigma and prejudice into their ACT work, which is unusual.

I think a lot of our psychotherapies have gotten way too focused on DSM disorders and things of that kind, especially the more evidence-based ones, and less interested in the broad application of behavioral science to all kinds of issues around human behavior. There’s a surprising number of people, for example, who are interested in Relational Frame Theory. It’s difficult material, very geeky, and doesn’t seem like something clinicians would be interested in. In fact, they’re not initially interested in it but as the work speaks to them, they become interested in it. Why is language like this? Why are our minds like this? Why does this model work? There’s also a community of scientists in ACT who are coming to conferences and presenting their work. It’s just kind of fun to be part of a group that has that aspect to it.

TR: How about therapists coming from CBT or just a purely behavioral angle? Is it challenging for them to move towards the philosophical side of things?

SH: Part of what’s interesting about ACT is, when you go to an Association for Contextual Behavioral Science conference, which is the ACT community, there’s kind of a fruit-nut-seed mix of people there. There’s people from the gestalt, existential and humanistic side of things as well as behavioral and CBT folks. Because ACT sort of emerged out of behavior analysis, it includes some pretty hardcore Capital B behavioral people. Of the various groups, though, I think it’s hardest for traditional CBT folks because we’ve waved people off of some popular CBT methods that we just don’t think are very important or produce good outcomes. Especially detecting, challenging, disputing and changing cognitions—it’s just not something that we do very much at all. It can be hard for them to let go of these methods and can take some time to adjust.

We may do psycho education and cognitive reappraisal, but it’s just too dangerous and too close to things that are going to be too hard to do and that clients are going to sometimes misuse. You would think that the behavioral folks would really hate the philosophical aspect of ACT, but actually they like it a lot because they can see the connection to their tradition. And having a way to deal seriously with cognition that isn’t dismissive or reductionistic is kind of a relief to them.

TR: ACT is considered an evidence-based treatment?

SH: Yes, ACT and many others. I mean, Motivational Interviewing is really Rogerian thinking scaled up into evidenced-based care. People are increasingly required in agency after agency and state after state to show that their practices are evidence-based, and that’s probably even more true worldwide. There are some parts of Europe where you basically can’t practice unless you are doing things that are on a list of evidence-based treatments.

Motivational Interviewing is really Rogerian thinking scaled up into evidenced-based care.

ACT processes and procedures allow you to fit what you’re doing to the needs of an individual and create things on the fly and do things that make sense to you clinically, and yet know that you’re practicing inside an evidence-based care framework. It’s nice to not have to check your mind at the door and leave behind some of the deeper clinical issues that interest you. You don’t have to minimize or dismiss the complexity of human beings in order to make it on the list of evidence-based treatments.

If You're Note Busy Being Born, You're Busy Dying

TR: You mentioned that ACT is a progressive model. Can you give a concrete example of what that means or how that would appear in the work of therapy?

SH: There’s a tendency for us as therapists to get into a groove clinically speaking, with our personal style and our knowledge, and settle into it. It’s not a bad thing, but there will always be curve balls thrown by cases that we can’t reach, patients we don’t know how or what to do with, complexities that don’t yield to our methods. And if you’re not busy being born, you’re busy dying, to quote a Dylan song. So the kind of progressivity I’m talking about is the sense that we as individuals and as a field are getting better and better and more and more able to deal with what is complex and difficult, while not having to check what you already know works at the door.

So many of our evidence-based approaches basically ask people to buy in whole cloth to everything that some founder came up with. I don’t think that’s necessary, healthy or even reasonable frankly. I like to say to people when they get interested in ACT, “You’re going to find your own work inside this work. There’s a reason why you’re here, and if that’s not true then you should walk away from it.” Once you see that connection you can build on it. You can do new things and the entire community will support you.

I think our communitarian approach is one of the reasons ACT has developed so much over the years.

I think our communitarian approach is one of the reasons ACT has developed so much over the years. People bring these different ideas in and we keep adding things, subtracting things, modifying things, and extending things so there’s the sense that we’re doing more and doing better and that we’re all part of it. That’s the sort of progressivity I’m talking about.

Being part of a knowledge-development community is an exciting thing. If you look at the people who are active in the ACT world, we’re out there as trainers and writers, scientists and researchers and really sophisticated clinicians. We’re moving forward in a way that’s networked. I call it a reticulated model, meaning a web or a network where each little node has their part of the task of getting better as we move forward.

The DSM Kool-Aid

TR: ACT has much less of a focus on psychiatric symptoms and diagnoses than many or most other modalities. Can you talk about that and also your thoughts about the changes to the new DSM-5?

SH: We never did drink the Kool-Aid that was offered from the DSM-III onward. Not that it’s not of some use, of course, to have some sort of terminology or nosology, but it got way overextended. We don’t have any functional entities inside these syndromes. No diseases—none—have emerged. And that’s the whole point of that syndromal game—to lead you to an etiology so you can respond with proper treatment. An honest examination of it points to it being a billion dollar failure.

We never did drink the Kool-Aid that was offered from the DSM-III onward….ACT work is based more on the psychology of the normal.

ACT work is based more on the psychology of the normal. I think we have every reason to believe that most of the things that people struggle with are based on the failure to bring out normal psychological processes. Not that there aren’t abnormal processes, of course there are. But if you take, for example, our tremendously useful human capacity to problem-solve, analyze, categorize, predict and evaluate things—this process, when applied to the world within, can become very toxic. It turns your life into a problem to be solved. Once you start focusing on your sadness or your anxiety or your urges, your problem-solving processes are going to be anywhere between unhelpful and pathological. They’re going to increase your focus on things that are just a small part of what’s going on and create these kind of self-amplifying loops—like, the more you try not to think of things, the more you actually think of them.

If you focus on the psychology of the normal as we have, we think that experiential avoidance accounts for about 25 percent of the variance in almost all of the major syndromes. But it also accounts for whether or not you can learn a new software program or are comfortable in your relationships and so on. We have to dig down and see what these processes are and how can we rein them in, because it isn’t possible—nor would we even want to—eliminate them.

Problem solving, for example, is just too darned useful for us to check at the door, but we need to learn how to respectfully decline our mind’s invitation to use our problem-solving repertoire for our normal flow of emotional and cognitive events. That’s very hard to do, but people can learn to do that. The mindfulness folks have learned a number of methods for doing it and we’ve found some additional tools that people can integrate into their lives pretty easily. Using these tools people can become more psychologically flexible, more able to shift their attention from fear and avoidance to what they most deeply care about and want from their lives.

We need to learn how to respectfully decline our mind’s invitation to use our problem-solving repertoire for our normal flow of emotional and cognitive events.

So our approach—instead of the DSM medicalization of human suffering—is to try to dig into the processes that narrow human lives or expand them, and to learn how to measure them so that we can begin to train people to use them to evolve forward. People don’t go into therapy when life is moving forward at a reasonable clip; they go in when life is stuck or going backwards. And it’s not that they get cured or fixed, because humans are not broken, they don’t need to be fixed. They need to be supported in a way that allows them to grow and do a better job over time with the things that they really care about—their kids, their work, their intimate relationships, their sense of participation and connection with the world around them. That’s just not going to be found inside a syndromal model. It doesn’t mean you can’t draw on genetics, epigenetics, physiology and neuroscience in formulating your treatment, but not with the mindset that we’re discovering abnormal processes.

What we’re actually discovering is the richness of human experience and what moves you forward and moves you back and how can we get evidence-based processes linked to evidence-based procedures that can be used creatively by competent clinicians. Not to fix you but to get you over that hump. From there we have a kind of family dentist model—if you run into problems again, if you find yourself in a cul-de-sac, come on back in. Part of what’s exciting about ACT work is that anybody who responds to it is likely to respond even faster the next time around because the same basic processes show up over and over again. Often just reminding people of the progress that they’ve made in the past by learning to be more open, more aware, and more actively engaged in their values is enough to get them over the new barrier that they’ve run into in their life.

Treating Addiction with ACT

TR: I’ve seen a bunch of literature recently on using ACT with addictions. What’s the ACT approach to addictions?

SH: It’s an exciting area. There are about 10 or 12 controlled studies on ACT with addictions—several very powerful ones on smoking and now some in other areas of addictive behavior. In a recent study we published in The Journal of Consulting and Clinical Psychology titled, “Reducing Shame in Addictions: Slow and Steady Wins the Race,” we showed that you can focus ACT methods on reducing shame and self-stigma. We did a randomized trial at an inpatient unit comparing it to 12-step oriented inpatient care, and ACT interventions resulted in fewer days of substance use and higher treatment attendance at follow up.

When dealing with severe substance abuse, working with shame is critical because people have done a lot of damage, not just to themselves but to their families, their children, their work, to the things they care most about. You don’t get into a 28-day inpatient program in the modern era—at least, not in Nevada where it’s cowboy conservatives—without creating some real wreckage. You’ve probably lost your job and all the rest, and most likely someone else is footing the bill for your treatment.

Guilt actually predicts positive outcomes in substance abuse, but shame does not.

Guilt actually predicts positive outcomes in substance abuse, but shame does not. When you’ve done things that are harmful to others, guilt is a perfectly appropriate emotion; it’s something to have and experience and it can help reorient you toward what’s important in your life and what you can do to clean up the mess you have made. What shame adds on is the “I’m bad” piece—the kind of fused conceptualization of oneself as a broken organism. That’s toxic and it predicts bad outcomes.

The normal, reasonable way that a human mind tries to resolve this problem is to talk itself out of shame. The Stuart Smalley solution: “Gosh darn it, I’m good enough and people love me.” But that’s a form of suppression and it can blow up like a house of cards when people leave treatment because it’s not grounded in a deeper set of values.

What we did initially in our groups was to slow things down, to learn to just watch the mind, watch all the chatter and finger wagging and shame and blame coming up, and then dig into the part that’s useful and let go of what’s not. It sobers people up in a way.

There’s kind of a humbling that takes place when you inhale into the pain of your own history and your own addiction and then make that leap of openness.

There’s kind of a humbling that takes place when you inhale into the pain of your own history and your own addiction and then make that leap of openness. You know, “I’m willing to take a leap of faith that I’m big enough to have this feeling,” and then the intentional flexibility inside a more mindful place to now shift my attention towards what I deeply care about. Then one step at a time, one day at a time—how am I going to get there? This resonates with some of the deeper parts of the Twelve-Step tradition. There’s nothing in the Twelve-Step program, or at least what I see in the Big Book version of it, that contradicts ACT, but these principles are not always what’s being applied in treatment facilities.

For the folks participating in our ACT groups, their shame levels actually went down more slowly, but they continued to go down after treatment and their outcome rates were better. For those not in our groups, their shame levels went down more quickly while they were in treatment, but their recidivism rates were higher after treatment.

TR: So mindfulness work is really essential to ACT and specifically to this process of decreasing shame?

SH: Very much so. What’s true about any mindfulness work is that, if you’re going to open up, you’re going to see dark places. You can’t hide from yourself like you used to. Hiding from yourself created problems, but opening your eyes and being with yourself and watching your emotions rise and fall, being more honest about what you’re feeling, sensing, remembering, thinking—that’s also going to be difficult. I don’t think it’s by accident that mindfulness-based cognitive therapy works pretty well for people who have had depression three or more times, but is arguably inert for people who’ve only had a single depressive episode. Because if you’re going to open the door to the basement and go walking down into the basement you’re going to see stuff down there that’s not for the faint of heart.

If you’re going to do this kind of work you’re going to find pain within you and without; you’re going to see injustice, you’re going to see suffering around you. You’re going to walk into the grocery store and you’re going to see people who don’t have enough money to buy the groceries they need. You’re going to see people walking by you who have a hard time taking a next step because they’re old and in physical pain. You start opening up to a more varied kind of perspective on yourself and others that I think is more honest.

But we dare not take these Eastern traditions and simply throw them into our Western minds with the idea that we’re going to relax and walk around with a big smiley face all the time. It’s a richer soup than the kind that our western commercial culture is giving us and our children, but it’s a hard path. This study we did with shame and addiction sort of shows that giving people a healthy way to walk that path is slower, but it’s more surefooted. So we’re bringing something new, I think, to the addiction field that as it becomes more known will be helpful to people working with addictions.

“It’s Not a Happy-Happy, Joy-Joy Bliss Trip”

TR: It’s interesting what you say about mindfulness opening your eyes to some of the darker things in the world. Sometimes when I hear therapists or others talking about mindfulness and meditation it seems like they’re talking about a pleasure cruise to bliss land or this image of the Buddha looking all happy. It sounds like that’s not what you mean in ACT.

SH: It isn’t and frankly it’s a distortion of those traditions. Taking a compassionate approach to yourself and others only really makes sense if you know how hard that is. If it’s not connected to the pain for which compassion is useful, then it’s just another suppressive, self-delusional trip. It’s a sort of psychological tranquilizer that is undermining what it’s there for and what I think we need right now.

Science and technology are creating such a challenge for us now that we can instantly see all the horrific things happening in the world on our screens. Those destroyed homes left in the wake of the Oklahoma tornado, the Boston Marathon bombings, the faces of the Newtown victims—your children are seeing it on their screens and you can’t throw out enough televisions and iPhones and all the rest to protect them from it.

The amount of pain that we’re exposed to now is a magnitude higher than anything we evolved to face. Your great-grandparents didn’t see anything near the flow of horrific images and judgmental words and painful events that we do now. So we need modern minds for this modern world, but it’s not a happy-happy, joy-joy, bliss trip to the beach kind of thing. It’s much more serious and sober. Not serious in the sense that it’s not fun and joyful to be alive and connected, but in the sense that it does justice to the richness of human life. And it’s right in there from an ACT point of view.

We have a saying: “In your pain you find your values and in your values you find your pain.” When you connect with things that you deeply care about that lift you up, you’ve just connected yourself into places where you can and have been hurt. If love is important to you, what are you going to do with your history of betrayals? If the joy of connecting to others is important to you, what are you going to do with the pain of being misunderstood or failing to understand others? The acceptance and mindfulness work doesn’t self-soothe and makes all of that easy; instead it gives us the openness and grounding and consciousness to be able to move our attention in a non-suppressive way towards what we care about. It empowers us to take that leap of faith that we can care, that we can have values and nobody can stop us. Like Viktor Frankl wrote about, you can take away all of my external freedoms but you can’t take away my capacity to choose to love and care about others. You just can’t do it.

With meditation, the artificial anxiety that we pump into our lives sometimes recedes very quickly, and that’s fine. But people sometimes make the mistake of becoming mindfulness junkies. That’s the psychological equivalent of a tranquilizer and it’s an abuse of the traditions. Yet I worry that many therapists use it in just this way. It’s important to have the added dimension of values and caring and compassion and participation and making a difference.

TR: Speaking of making a difference, there’s a social justice component of ACT that I haven’t heard of in very many other therapeutic modalities. Can you describe this a bit more and also maybe some specific examples of how it’s being utilized to help people?

SH: I think that’s kind of a natural extension of ACT. The same cognitive processes that allow us to have a sense of transcendence or oneness or consciousness—the I-here-nowness of consciousness itself—are based upon the ability to see the world through other people’s eyes. So it isn’t just “I,” it’s “I/You.” There’s a social extension of consciousness that happens right in the process of becoming more aware of your own processes in which you begin, suddenly, to become aware of the fact that people around you are suffering. We can model this in the lab, actually. We use Relational Frame Theory methods with kids who don’t have a sense of self, and very soon empathy begins to emerge. When I see from my eyes, it happens at the same moment that you see from yours. When I learn to feel my feelings as feelings, it happens at the same moment that I see that you have feelings—that you’re feeling, too.

The natural extension of that process then is, if I’m going to be more accepting of my emotions and try to walk with them in a values-based way, what about the difficult emotions that other people are experiencing because of things that have happened to them? This is not a kind of mindfulness work that’s alone and cut off and sort of in the corner; it extends across time, place, and persons.

Objectification, dehumanization and prejudice naturally connect to things like self-stigma. I mentioned that we’ve done that kind of work with addicts, but we’ve also done it with LGBT populations, with victims of racial and religious prejudice. It’s the natural, reasonable, sensible thing to take the next step toward reining in the parts of the mind that lead us to objectify and dehumanize others.

Can we bring a more compassionate and values-based world into existence, starting with ourselves and then extending it out?

Can we bring a more compassionate and values-based world into existence, starting with ourselves and then extending it out?

In our research on experiential avoidance, we’ve found that part of the problem with people who are prejudiced towards others is that they are unable to take in the perspective of others. They get overwhelmed by seeing the pain of others and would rather objectify and dehumanize them than feel what they would have to feel to know what it’s like to be them. We’ve shown the same thing with social anhedonia; you don’t care about being around others unless you have the big trio of good perspective-taking, empathy towards others and not running away from pain. So you can see how the model naturally leads us to a concern for issues of social justice. In a way it’s one and the same.

I can’t cut myself off from others and objectify and dehumanize others except by attacking the processes that allow me to be more open and accepting of myself.

I can’t cut myself off from others and objectify and dehumanize others except by attacking the processes that allow me to be more open and accepting of myself.

And that gives us a way in because nobody goes into therapy saying, “Gee, I’m a bigot. What can you do for me?” But they do come in saying, “I feel distressed. I feel disconnected. I feel far away.” And it turns out that objectification and dehumanization of others produces those results for the individual.

This happens with us, too, as clinicians. You know the kind of dark humor that happens in the staff room—“Oh, Sally the Borderline has shown up.” “Oh, God! Not Sally.” I understand why people do it and don’t mean to wag my finger, but it comes very close to objectifying clients, dehumanizing them as a defense against the pain of not being able to reach them. These kinds of attitudes predict burnout and ultimately minimize your ability to make a difference with others.

TR: It’s so interesting to think of therapists as social change agents. Have you done research in this area too?

SH: Our very first randomized trial in the modern era—because we had a few in the ‘80s, then we went dark for 15 years while we worked out the basic model and the theory of cognition and the measures for fear—was done by a guy named Frank Bond at the University of London. He did research with people who were working in call centers in banks—a very tough job, a lot of pressure and very little pay. He compared ACT to a program that was encouraging people to take charge of the stressors in their environment and make changes so that their environment was more supportive. ACT was a more psychological model, obviously, and when people got more open and accepting and values-based, they started demanding work changes of their foremen. The thing that was keeping people small and keeping them in a box was fear—“What will my boss think if I raise this issue?’”

The values piece activated people and I’m proud of the fact that when you do the kind of work that we’re doing, you empower people who are downtrodden or on the short end of the stick. We’ve shown this in several studies, that If you are more open to your feelings, more conscious, more aware, more mindful, and more linked to your values, you will be more empowered to step up. We’re doing that now with racial minorities, ethnic minorities, religious minorities and also with a message for those who are in a majority status but who care about these issues.

Psychotherapists have a role to play not just in the area of mental health, but in social justice as well.

Psychotherapists have a role to play not just in the area of mental health, but in social justice as well.

There’s a richer journey there and I think a lot of therapists are frustrated just dealing one person at a time at a time with the results of a society that just doesn’t know how to support people in being more fully human. You can be in your therapist role but also be part of a social change effort that is linked directly to the clinical work that you’re doing.

Running Towards Values

TR: It seems like you’re working to shift the focus away from symptom avoidance and towards values. Does that sound right?

SH: Exactly. A whole person running towards values—not in a suppressive or avoidant way in order to feel less of anything. There’s no delete button. In the language of mathematics, this is addition and multiplication, not subtraction and division. If people can learn how to add and multiply and open up, it’s deeply empowering.

TR: I saw on your website that you’re doing a study looking at the training effects of consultation groups. Is that right?

SH: Yes. People have begun to apply some of these very same processes of openness, mindfulness and values to training itself and we have now several studies showing that we can apply these methods to therapists and they will do a better job of learning. Psychological flexibility is important to us as learners and we’re looking carefully at training and studying it—not only how we train in ACT methods themselves, but also how we use ACT to train in a variety of psychotherapy and other processes that are helpful to us in our professional roles. It’s not simply a matter of learning a clinical technology; instead, we’re trying to create a knowledge development community that takes these processes and procedures wherever they can be of use to people.

TR: Thank you so much for taking the time to share your work with us here at psychotherapy.net.

SH: It’s been a pleasure.

Embracing Your Demons: An Overview of Acceptance and Commitment Therapy

Posted on June 8, 2013February 11, 2026 by rezendevknowfully.com

Imagine a therapy that makes no attempt to reduce symptoms, but gets symptom reduction as a by-product. A therapy firmly based in the tradition of empirical science, yet has a major emphasis on values, forgiveness, acceptance, compassion, living in the present moment, and accessing a transcendent sense of self. A therapy so hard to classify that it has been described as an “existential humanistic cognitive behavioral therapy.”

Acceptance and Commitment Therapy, known as “ACT” (pronounced as the word “act”) is a mindfulness-based behavioral therapy that challenges the ground rules of most Western psychology. It utilizes an eclectic mix of metaphor, paradox, and mindfulness skills, along with a wide range of experiential exercises and values-guided behavioral interventions. ACT has proven effective with a diverse range of clinical conditions: depression, OCD, workplace stress, chronic pain, the stress of terminal cancer, anxiety, PTSD, anorexia, heroin abuse, marijuana abuse, and even schizophrenia.¹ A study by Bach & Hayes² showed that with only four hours of ACT, hospital re-admission rates for schizophrenic patients dropped by 50% over the next six months.

The Goal of ACT

The goal of ACT is to create a rich and meaningful life, while accepting the pain that inevitably goes with it. “ACT” is a good abbreviation, because this therapy is about taking effective action guided by our deepest values and in which we are fully present and engaged. It is only through mindful action that we can create a meaningful life. Of course, as we attempt to create such a life, we will encounter all sorts of barriers, in the form of unpleasant and unwanted "private experiences" (thoughts, images, feelings, sensations, urges, and memories.) ACT teaches mindfulness skills as an effective way to handle these private experiences.

What is Mindfulness?

When I discuss mindfulness with clients, I define it as: “Consciously bringing awareness to your here-and-now experience with openness, interest and receptiveness. There are many facets to mindfulness, including living in the present moment; engaging fully in what you are doing rather than “getting lost” in your thoughts; and allowing your feelings to be as they are, letting them come and go rather than trying to control them. When we observe our private experiences with openness and receptiveness, even the most painful thoughts, feelings, sensations and memories can seem less threatening or unbearable. In this way mindfulness can help us to transform our relationship with painful thoughts and feelings in a way that reduces their impact and influence over our life.

How Does ACT Differ from Other Mindfulness-based Approaches?

ACT is one of the so-called “third wave” of behavioral therapies—along with Dialectical Behavior Therapy (DBT), Mindfulness-Based Cognitive Therapy (MBCT) and Mindfulness-Based Stress Reduction (MBSR)—all of which place a major emphasis on the development of mindfulness skills.

Created in 1986 by Steve Hayes, ACT was the first of these "third wave” therapies, and currently has a considerable body of empirical data to support its effectiveness. The “first wave” of behavioral therapies, in the fifties and sixties, focused on overt behavioral change and utilized techniques linked to operant and classical conditioning principles. The “second wave” in the seventies included cognitive interventions as a key strategy. Cognitive-behavior therapy (CBT) eventually came to dominate this “second wave”

ACT differs from DBT, MBCT, and MBSR in many ways. For a start, MBSR and MBCT are essentially manualized treatment protocols, designed for use with groups for treatment of stress and depression. DBT is typically a combination of group skills training and individual therapy, designed primarily for group treatment of Borderline Personality Disorder. In contrast, ACT can be used with individuals, couples and groups, both as brief therapy or long term therapy, in a wide range of clinical populations. Furthermore, rather than following a manualized protocol, ACT allows the therapist to create and individualize their own mindfulness techniques, or even to co-create them with clients.

Another primary difference is that ACT sees formal mindfulness meditation as only one way of many to teach mindfulness skills. Mindfulness skills are “divided” into four subsets:

Acceptance
Cognitive defusion
Contact with the present moment
The Observing Self

The range of ACT interventions to develop these skills is vast and continues to grow, ranging from traditional meditations on the breath through to cognitive defusion techniques.

What is Unique to Act?

ACT is the only Western psychotherapy developed in conjunction with its own basic research program into human language and cognition—Relational Frame Theory (RFT). It is beyond the scope of this article to go into RFT in detail, however, for more information see https://contextualscience.org/rft

In stark contrast to most Western psychotherapy, “ACT does not have symptom reduction as a goal.” This is based on the view that the ongoing attempt to get rid of “symptoms” actually creates a clinical disorder in the first place. As soon as a private experience is labeled a “symptom,” a struggle with the “symptom” is created. A “symptom” is by definition something “pathological” and something we should try to get rid of. In ACT, the aim is to transform our relationship with our difficult thoughts and feelings, so that we no longer perceive them as “symptoms.” Instead, we learn to perceive them as harmless, even if uncomfortable, transient psychological events. Ironically, it is through this process that ACT actually achieves symptom reduction—but as a by-product and not the goal.

Healthy Normality

Another way in which ACT is unique, is that it doesn't rest on the assumption of “healthy normality.” Western psychology is founded on the assumption of healthy normality: that by their nature, humans are psychologically healthy, and given a healthy environment, lifestyle, and social context (with opportunities for “self-actualization”), humans will naturally be happy and content. From this perspective, psychological suffering is seen as abnormal; a disease or syndrome driven by unusual pathological processes.

Why does ACT suspect this assumption to be false? If we examine the statistics we find that in any year almost 30 percent or the adult population will suffer from a recognized psychiatric disorder.³ “The World Health Organization estimates that depression is currently the fourth biggest, most costly, and most debilitating disease in the world, and by the year 2020 it will be the second biggest.” In any week, one-tenth of the adult population is suffering from clinical depression, and one in five people will suffer from it at some point in their lifetime?. Furthermore, one in four adults, at some stage in their lifetime, will suffer from drug or alcohol addiction. There are now over twenty million alcoholics in the United States alone.?

More startling and sobering is the finding that almost one in two people will go through a stage in life when they consider suicide seriously, and will struggle with it for a period of two weeks or more. Scarier still, one in ten people at some point attempt to kill themselves?.

In addition, consider the many forms of psychological suffering that do not constitute “clinical disorders”—loneliness, boredom, alienation, meaninglessness, low self-esteem, existential angst, and pain associated with issues such as racism, bullying, sexism, domestic violence, and divorce. Clearly, even though our standard of living is higher than ever before in recorded history, psychological suffering is all around us.

Destructive Normality

ACT assumes that the psychological processes of a normal human mind are often destructive, and create psychological suffering for us all, sooner or later. Furthermore, ACT postulates that the root of this suffering is human language itself. Human language is a highly complex system of symbols, which includes words, images, sounds, facial expressions and physical gestures. We use this language in two domains: public and private. The public use of language includes speaking, talking, miming, gesturing, writing, painting, singing, dancing and so on. The private use of language includes thinking, imagining, daydreaming, planning, visualizing and so on. A more technical term for the private use of language is “cognition.”

Now clearly the mind is not a “thing” or an “object.” Rather, it is a complex set of cognitive processes—such as analyzing, comparing, evaluating, planning, remembering, visualizing—and all of these processes rely on human language. Thus in ACT, the word “mind” is used as a metaphor for human language itself.

Unfortunately, human language is a double-edged sword. On the positive it helps us make maps and models of the world; predict and plan for the future; share knowledge; learn from the past; imagine things that have never existed, and go on to create them; develop rules that guide our behavior effectively, and help us to thrive as a community; communicate with people who are far away; and learn from people who are no longer alive.

The dark side of language is that we use it to lie, manipulate and deceive; to spread libel, slander and ignorance; to incite hatred, prejudice and violence; to make weapons of mass destruction, and industries of mass pollution; to dwell on and “relive” painful events from the past; to scare ourselves by imagining unpleasant futures; to compare, judge, criticize and condemn both ourselves and others; and to create rules for ourselves that can often be life-constricting or destructive.

Experiential Avoidance

ACT rests on the assumption that human language naturally creates psychological suffering for us all. One way it does this is through setting us up for a struggle with our own thoughts and feelings, through a process called experiential avoidance.

Probably the single biggest evolutionary advantage of human language was the ability to anticipate and solve problems. It has enabled us not only to change the face of the planet, but to travel outside it. The essence of problem-solving is this:

Problem = something we don't want.
Solution = figure out how to get rid of it, or avoid it.

This approach obviously works well in the material world. A wolf outside your door? Get rid of it. Throw rocks at it, or spears, or shoot it. Snow, rain, hail? Well, you can't get rid of those things, but you can avoid them by hiding in a cave, or building a shelter. Dry, arid ground? You can get rid of it by irrigation and fertilization, or you can avoid it by moving to a better location. Problem solving strategies are therefore highly adaptive for us as humans (and indeed, teaching such skills has proven to be effective in the treatment of depression.) Given this problem-solving approach works well in the outside world, it's only natural that we would tend to apply it to our interior world; the psychological world of thoughts, feelings, memories, sensations, and urges. Unfortunately, all too often when we try to avoid or get rid of unwanted private experiences, we simply create extra suffering for ourselves. For example, virtually every addiction known to mankind begins as an attempt to avoid or get rid of unwanted thoughts and feelings, such as boredom, loneliness, anxiety, depression and so on. The addictive behavior then becomes self-sustaining, because it provides a quick and easy way to get rid of cravings or withdrawal symptoms.

The more time and energy we spend trying to avoid or get rid of unwanted private experiences, the more we are likely to suffer psychologically in the long term. Anxiety disorders provide a good example. It is not the presence of anxiety that comprises the essence of an anxiety disorder. After all, anxiety is a normal human emotion that we all experience. At the core of any anxiety disorder lies a major preoccupation with trying to avoid or get rid of anxiety. OCD provides a florid example; l never cease to be amazed by the elaborate rituals that OCD sufferers devise, in vain attempts to get rid or anxiety-provoking thoughts and images. Sadly, the more importance we place on avoiding anxiety, the more we develop anxiety about our anxiety—thereby exacerbating it. It's a vicious cycle found at the center of any anxiety disorder. (What is a panic attack if not anxiety about anxiety?)

A large body of research shows that higher experiential avoidance is associated with anxiety disorders, depression, poorer work performance, higher levels of substance abuse, lower quality of life, high-risk sexual behavior, borderline personality disorder, greater severity of PTSD, long-term disability and alexithymia.

Of course, not all forms of experiential avoidance are unhealthy. For example, drinking a glass of wine to unwind at night is experiential avoidance, but it's not likely to be harmful. However, drinking an entire bottle of wine a night is likely to be extremely harmful in the long term. ACT targets experiential avoidance strategies only when client use them to such a degree that they become costly, life-distorting, or harmful. ACT calls these “emotional control strategies,” because they are attempts to directly control how we feel. Many of the emotional control strategies that clients use to try to feel good (or to feel “less bad”) may work in the short term, but frequently they are costly and self-destructive in the long term. For example, depressed clients often withdraw from socializing in order to avoid uncomfortable thoughts—“I’m a burden,” “I have nothing to say,” “I won’t enjoy myself”—and unpleasant feelings such as anxiety, fatigue and fear of rejection. In the short term, canceling a social engagement may give rise to a short-lived sense of relief, but in the long term, the increasing social isolation makes them more depressed.

Therapeutic Interventions

ACT offers clients an alternative to experiential avoidance through a variety of therapeutic interventions. In general, clients come to therapy with an agenda of emotional control. They want to get rid of their depression, anxiety, urges to drink, traumatic memories, low self-esteem, fear of rejection, anger, grief and so on. In ACT, there is no attempt to try to reduce, change, avoid, suppress or control these private experiences. Instead, clients learn to reduce the impact and influence of unwanted thoughts and feelings through the effective use of mindfulness. Clients learn to stop fighting with their private experiences—to open up to them, make room for them, and allow them to come and go without a struggle. The time, energy, and money that they wasted previously on trying to control how they feel is then invested in taking effective action (guided by their values) to change their life for the better.

The ACT interventions focus around two main processes:

Developing acceptance of unwanted private experiences which are out of personal control.
Commitment and action toward living a valued life.

What follows is a brief summary of some core ACT interventions, illustrated with vignettes of clinical work with a client called “Michael.”

Confronting the Agenda

In this step, the client's agenda of emotional control is gently and respectfully undermined through a process similar to motivational interviewing. Clients identify the ways they have tried to get rid of or avoid unwanted private experiences. They are then asked to assess for each method: “Did this reduce your symptoms in the long term? What did this strategy cost you in terms of time, energy, health, vitality, relationships? Did it bring you closer to the life you want?”

Michael was a 35-year-old accountant who suffered from significant social anxiety, and had seen a number of therapists to no avail. In the first session we ran through the many strategies he had used to avoid or get rid of his social anxiety. They included: drinking alcohol, taking Valium, being a “good listener” (asking lots of questions, but sharing little of himself), arriving late, leaving early, avoiding social events altogether, deep breathing, relaxation techniques, using positive affirmations, disputing negative thoughts, analyzing his childhood, blaming his parents (who were both socially avoidant), telling himself to “get over it,” self-hypnosis and so on. Michael realized that none of these strategies had reduced his anxiety in the long term. Although strategies such as taking Valium, drinking alcohol, and avoiding social events had reduced his anxiety in the short term, they had created significant costs to his quality of life. His “homework” was to notice and write down other emotional control strategies, and to assess their long-term effectiveness and costs to his quality of life.

Control is the Problem, Not the Solution

In this phase, we increase clients' awareness that emotional control strategies are largely responsible for their problems; that as long as they're fixated on trying to control how they feel, they're trapped in a vicious cycle of increasing suffering. Useful metaphors here include “quicksand,” “the struggle switch,” and the concepts of “clean discomfort” and “dirty discomfort.” We might deliver these metaphors like this:

Remember those old movies where the bad guy falls into a pool of quicksand, and the more he struggles, the faster it sucks him under? In quicksand, struggling is the worst thing you can possibly do. The way to survive is to lie back, spread out your arms, and float on the surface. It's tricky, because every instinct tells you to struggle; but if you do so, you'll drown.

The same principle applies to difficult feelings: the more we try to fight them, the more they overwhelm us. Imagine that at the back of our mind is a “struggle switch.” When it's switched on, it means we're going to struggle against any physical or emotional pain that comes our way; whatever discomfort experienced, we'll try our best to get rid of it or avoid it.

Suppose the emotion that shows up is anxiety. If our struggle switch is ON, then that feeling is completely unacceptable. This means we could end up with anger about our anxiety: “How dare they make me feel like this?” Or sadness about our anxiety: “Not again. Why do I always feel like this?” Or anxiety about our anxiety: “What's wrong with me? What's this doing to my body?” Or a mixture of all these feelings. These secondary emotions are useless, unpleasant, and unhelpful, and a drain upon our vitality. In response we get angry, anxious or guilty. Spot the vicious cycle?

But what if our struggle switch is OFF? Whatever emotion shows up, no matter how unpleasant, we don't struggle with it. So if anxiety shows up, it's not a problem. Sure, it's unpleasant. We don't like it, or want it, but at the same time, it's nothing terrible. With the struggle switch OFF, our anxiety levels are free to rise and fall as the situation dictates. Sometimes they'll be high, sometimes low and sometimes there will be no anxiety at all. Far more importantly, we're not wasting our time and energy struggling with it.

“Without struggle, we get a natural level of physical and emotional discomfort, depending on who we are and the situation we're in. In ACT, we call this “clean discomfort.”” There’s no avoiding “clean discomfort.” Life serves it up to all of us in one way or another. However, once we start struggling with it, our discomfort levels increase rapidly. This additional suffering we call “dirty discomfort.” Our struggle switch is like an emotional amplifier—switch it on, and we can have anger about our anxiety, anxiety about our anger, depression about our depression, or guilt about our guilt.

Obviously, these metaphors are tailored to the particular feelings the client struggles with. With the struggle switch ON, not only do we get emotionally distressed by our own feelings, we also do whatever we can to avoid or get rid of them, regardless of the long term costs. We draw clients' attention to the many ways they've tried to do this—through more obvious strategies such as drugs, alcohol, food, TV, gambling, smoking, sex, surfing the net—to less obvious emotional control strategies such as ruminating, chastising themselves, blaming others and so on. (As mentioned earlier, many control strategies are not an issue, as long as they are used in moderation.)

Michael was able to connect with these metaphors readily, especially the idea of the struggle switch. We were able to refer back to this in subsequent sessions whenever he experienced anxiety. “Okay, right now, you're feeling anxious. Is the struggle switch on or off?”

Six Core Principles of ACT

Once the emotional control agenda is undermined, we then introduce the six core principles of ACT. ACT uses six core principles to help clients develop psychological flexibility:

Defusion
Acceptance
Contact with the present moment
The Observing Self
Values
Committed action

Each principle has its own specific methodology, exercises, homework and metaphors. Take defusion, for example. In a state of cognitive defusion we are caught up in language. Our thoughts seem to be the literal truth, or rules that must be obeyed, or important events that require our full attention, or threatening events that we must get rid or. In other words, when we fuse with our thoughts, they have enormous in influence over our behavior.

“Cognitive defusion means we are able to “step back” and observe language, without being caught up in it. We can recognize that our thoughts are nothing more or less than transient private events—an ever-changing stream of words, sounds and pictures. As we defuse our thoughts, they have much less impact and influence.”

If you look through the wide variety of writings on ACT, you will find over a hundred different cognitive defusion techniques. For example, to deal with an unpleasant thought, we might simply observe it with detachment; or repeat it over and over, out aloud, until it just becomes a meaningless sound; or imagine it in the voice of a cartoon character; or sing it to the tune of “Happy Birthday”; or silently say “Thanks, mind” in gratitude for such an interesting thought. There is endless room for creativity. In contrast to CBT, not one of these cognitive defusion techniques involves evaluating or disputing unwanted thoughts.

Here’s a simple exercise in cognitive defusion for yourself:

Step 1: Bring to mind an upsetting and recurring negative self-judgment that takes the form “I am X” such as “I am incompetent,” or “I’m stupid.” Hold that thought in your mind for several seconds and believe it as much as you can. Now notice how it affects you.

Step 2: Now take the thought “I am X” and insert this phrase in front of it: “I’m having the thought that….” 'Now run that thought again, this time with the new phrase. Notice what happens.

In step 2, most people notice a “distance” from the thought, such that it has much less impact. Notice there has been no effort to get rid of the thought, nor to change it. Instead the relationship with the thought has changed—it can be seen as just words.

There now follows a brief description or the six core principles, with reference to the case or Michael.

1. Cognitive Defusion: learning to perceive thoughts, images, memories and other cognitions as what they are—nothing more than bits of language, words and pictures—as opposed to what they can appear to be—threatening events, rules that must be obeyed, objective truths and facts.

In session two, Michael said he experienced frequent distress from thoughts such as “I'm boring,” “I have nothing to say,” “No one likes me,” and “I'm a loser.” As the session continued, I had Michael interact with these thoughts in a number or different ways, until they began to lose their impact. For example, I had him bring to mind the thought “I'm a loser,” then close his eyes and notice where it seemed to be located in space. He sensed it was in front of him. I asked him to observe the thought as if he was a curious scientist, and to notice the form of it: whether it was more like something he could see, or something he could hear. He said it was like words that he could see, and he noticed that as he “looked” at it, it became less distressing. “I asked him to imagine the thought as words on a Karaoke screen; then change the font; then change the color; then imagine a bouncing ball jumping from word to word.” By this stage, Michael was chuckling at the very same thought that only a few minutes earlier had brought him to tears. “Homework” included practicing several different defusion techniques with distressing thoughts—not to get rid of them, but simply to learn how to step back and see them for what they are—just “bits of language” passing through.

2. Acceptance: making room for unpleasant feelings, sensations, urges, and other private experiences; allowing them to come and go without struggling with them, running from them, or giving them undue attention.

In session three, I asked Michael to make himself anxious by imagining himself at a forthcoming office party. When I asked him to scan his body and notice where he felt the anxiety most intensely he reported a “huge knot” in his stomach. I asked him to observe this sensation as if he was a curious scientist who had never seen anything like it before; to notice the edges of it, the shape of it, the vibration, weight, temperature, pulsation, and the myriad of other sensations within the sensation. I had him breathe into the sensation, and “make room for it”; to allow it to be there even though he did not like it or want it. Michael soon reported a sense of calmness; a sense of being at ease with his anxiety even though he didn't like it. “Homework” included practicing this technique with his recurrent feelings of anxiety—not to get rid of them, but simply to learn how to let them come and go without a struggle.

3. Contact with the present moment: bringing full awareness to your here-and-now experience, with openness, interest, and receptiveness; focusing on, and engaging fully in whatever you are doing.

In session four, I took Michael through a simple mindfulness exercise, focused on the experience of eating. I gave him a sultana, and asked him to eat it “in slow motion,” with a total focus on the taste and texture of the fruit, and the sounds, sensations and movements inside his mouth. I told him, “While you're doing this, all sorts of distracting thoughts and feelings may arise. The aim is simply to let your thoughts come and go, and allow your feelings to be there, and keep your attention focused on eating the sultana.”

Afterwards, Michael said he was amazed that there was so much flavor in one single sultana. I was then able to use this experience to draw an analogy with social situations, where Michael would he so caught up in his thoughts and feelings that he wasn't able to engage fully in conversation, and missed out on the “richness.” “Homework” included practicing full engagement with all the five senses in a number of daily routines (having a shower, brushing his teeth, and washing the dishes) as well as continuing to practice his defusion and acceptance techniques. He agreed also to practice mindful engagement in conversations; i.e. keeping his attention on the other person, rather than on his own thoughts and feelings.

4. The Observing Self: accessing a transcendent sense of self; a continuity of consciousness that is unchanging, ever-present, and impervious to harm. From this perspective, it is possible to experience directly that you are not your thoughts, feelings, memories, urges, sensations, images, roles, or physical body. These phenomena change constantly and are peripheral aspects of you, but they are not the essence of who you are.

In session five, I took Michael through a mindfulness exercise designed to have him access this transcendent self. First, I asked him to close his eyes and observe his thoughts: the form they rook, their apparent location in space, the speed with which they were moving. Then I asked him: “Be aware of what you are noticing. There are your thoughts, and there you are noticing them. So there are two processes going on—a process of thinking, and a process of observing that thinking.” Again and again, I drew his attention to the distinction between the thoughts that arise, and the self who observes those thoughts. From the perspective of the Observing Self, no thought is dangerous, threatening, or controlling.

5. Values: clarifying what is most important, deep in your heart; what sort of person you want to be; what is significant and meaningful to you; and what you want to stand for in this life.

In session six, Michael identified important values around connecting with others, building meaningful friendships, developing intimacy, and being authentic and genuine. We discussed the concept of willingness. The willingness to feel anxiety doesn't mean you like or want it. Instead it means you allow it to be there in order to do something you value. I asked Michael, “If taking your life in the direction of these values means you need to make room for feelings of anxiety, are you willing to do that?” His reply was, “Yes.”

6. Committed Action: setting goals, guided by your values, and taking effective action to achieve them.

Continuing session six, we moved to setting goals in line with Michael's values. Initially, he set the goal of going for lunch with a work colleague every day, and sharing some personal information on each occasion. In subsequent sessions, he set increasingly challenging social goals, and continued to practice mindfulness skills to handle the anxious thoughts and feelings that inevitably arose. At the end of ten sessions, Michael reported that he was socializing a lot more, and more importantly, he was enjoying it. Thoughts of being “a loser” or “boring” or “unlikeable” still occurred, but usually he did not take them seriously or pay them any attention. Likewise, feelings of anxiety still occurred in many social situations, but no longer bothered him or distracted him. Overall, his anxiety levels had diminished considerably. This reduction in anxiety was not the goal of therapy, but was a pleasant by-product.

This illustrates how ACT can result in good symptom reduction without ever aiming for it. First, a lot of exposure took place, as Michael engaged in increasingly challenging social situations. It is well known that exposure frequently can lead to reduced anxiety. Second, the more accepting Michael became of his unwanted thoughts and feelings, the less anxiety he had about those thoughts and feelings. Indeed, practicing mindfulness of unwanted thoughts and feelings is a form of exposure in itself.

The ACT Therapeutic Relationship

ACT training helps therapists to develop the essential qualities of compassion, acceptance, empathy, respect, and the ability to stay psychologically present even in the midst of strong emotions. Furthermore, ACT teaches therapists that, thanks to human language, they are in the same boat as their clients—so they don't need to be enlightened beings or to “have it all together.” In fact, they might say to their clients something like: “I don't want you to think I've got my life completely in order. It's more as if you're climbing your mountain over there and I'm climbing my mountain over here. It's not as if I've reached the top and I'm having a rest. It's just that from where I am on my mountain, I can see obstacles on your mountain that you can’t see. So I can point those out to you, and maybe show you some alternative routes around them.”

Conclusion

The experience of doing therapy becomes vastly different with ACT. It is no longer about getting rid of bad feelings or getting over old trauma. Instead it is about creating a rich, full and meaningful life. This is confirmed by the findings of Strosahl, Hayes, Bergan and Romano? who showed that ACT increases therapist effectiveness, and Hayes et al (2004) who showed that it reduces burnout. If I had to summarize ACT on a t-shirt, it would read: “Embrace your demons, and follow your heart.”

References

Bond, F. W. & Bunce, D. (2000). Mediators of change in emotion-focused and problem-focused worksite stress management interventions. Journal of Occupational Health Psychology, 5, 156-163; Branstetter. A. D., Wilson, K. G., Hildebrandt, M., & Mutch, D. (2004). Improving psychological adjustment among cancer patients: ACT and CBT. Paper presented at the Association for Advancement of Behavior Therapy, New Orleans; Dahl, J., Wilson, K. G., & Nilsson, A. (2004). Acceptance and commitment therapy and the treatment of persons at risk for long-term disability resulting from stress and pain symptoms: A preliminary randomized trial. Behavior Therapy, 35, 785-802; Twohig, M. P., Hayes, S. C., Masuda, A. (2006). Increasing willingness to experience obsessions: Acceptance and Commitment Therapy as a treatment for obsessive compulsive disorder. Behavior Therapy, 37:1. 3-13; Zettle, R. D., & Raines, J. C. (1989). Group cognitive and contextual therapies in treatment of depression. Journal of Clinical Psychology, 45, 438-445.
Bach, P. & Hayes, Steven C. (2002). The use of Acceptance and Commitment Therapy to prevent the rehospitalisation of psychotic patients: a randomized controlled trial. Journal of Consulting and Clinical Psychology, 70, 1129-1139.
Kessler, R.C ., McGonagle, K.A., Zhao, S., Nelson, C.B., Hughes, M., Eshleman, S., Wittchen, H.U., and Kendler, K.S. (1994). Lifetime and 12-month Prevalence of DSM-111-R Psychiatric Disorders in the United States. Archives of General Psychiatry, 51 (Jan 1994): 8-19.
Davies, T. (1997), ABC of Mental Health, British Medical Journal, 314, 27.5.97: 1536-39.
Kessler, R.C ., McGonagle, K.A., Zhao, S., Nelson, C.B., Hughes, M., Eshleman, S., Wittchen, H.U., and Kendler, K.S. (1994). Lifetime and 12-month Prevalence of DSM-111-R Psychiatric Disorders in the United States. Archives of General Psychiatry, 51 (Jan 1994): 8-19.
Chiles J., and Strosahl, K. (1995), The Suicidal Patient: Principles Of Assessment, Treatment, and Case Management, American Psychiatric Press, Washington, DC.
Strosahl, K. D., Hayes, S. C., Bergan, J., & Romano, P. (1998). Does field based training in behavior therapy improve clinical effectiveness? Evidence from the Acceptance and Commitment Therapy training project. Behavior Therapy, 29, 35-64; Hayes, S. C., Bissett, R., Roget, N., Padilla, M., Kohlenberg, B. S., Fisher, G., et al. (2004). The impact of acceptance and commitment training on stigmatizing attitudes and professional burnout of substance abuse counselors. Behavior Therapy, 35, 821-836.

Verbal Ventilation: The highway to intimacy and the key process of therapy

Posted on May 14, 2013February 11, 2026 by Psychotherapy.net Team

I was standing in the waiting room before my first session with a new therapist some twenty years ago, when I perused a cartoon that she had displayed on her bulletin board. In panel 1 of the wordless cartoon, a woman with a dark cloud over her head is talking to a friend who has a shining sun over hers. In panel 2, as the first woman gestures in a way that indicates complaining, the cloud covers her friend’s sun. In panel 3, the cloud emits a bolt of lightning, she angrily catharts, and her friend glowers along with her. In panel 4, the cloud rains on them as they embrace, commiserating in the rain of their own tears. In panel 5, relief spreads on their faces as the cloud moves away from the sun. In panel 6, the sun shines over both of them, as they smile and slip into pleasant conversation.

I have come to call this process verbal ventilation, and I believe it is a key healing process in therapy and a key bonding process in intimacy. Verbal ventilation occurs when an attunement to our feelings guides us in choosing what we say—a powerful enactment of Jung's dictum that feelings tell us what is important to us.

In therapy, verbal ventilation is the penultimate metabolizer of emotional pain. It is speaking or writing in a manner that airs out and releases painful feelings. When we let our words spring from what we feel, language is imbued with emotion, and pain can be released through what we say or write.
When my wife and I join each other on the couch after one of us has put our son to bed, we often reconnect via some version of this process. Spontaneously taking turns checking in with our feelings to use them to tell us what is most important right now, we share and process the ups and downs of our day.

Many times like my clients, what seems to arise in each of us is the need to share about what was most difficult, before the lighter stuff naturally arises to the forefront of our consciousness. Perhaps this is a reflection of a reality that the novelist David Mitchell describes thusly: “Good moods are as fragile as eggs, bad ones as fragile as bricks.” I once had an ex-priest client who called verbal ventilating traveling through the catacombs to get to the cathedrals.

I specialize in working with clients who were extensively traumatized in their childhood families. Many of them present as developmentally arrested in their ability to relationally regulate their emotional stress through verbal ventilation. Their parents routinely attacked, shamed or abandoned them for emotional expression. Now, whenever they have the urge to verbally ventilate, the critic steps in and slaughters their self-expression with self-contempt.

Neuroscience research increasingly suggests, perhaps through the vehicle of mirror neurons, that human interaction is a powerful process for helping us work through states of hyperarousal and intensely dysphoric emotion.

A key therapy task for my traumatized clients is the practice of verbal ventilation. While the client vents, we work together to deconstruct her critic. It seems that as I compassionately respond to her painful disclosures, we are engaged in a process of co-regulating her emotional pain. Perhaps mirror neurons are also the circuitry behind the process of modeling.

The cartoon described above also reminds me of my archetypal, favorite session, which fortunately occurs increasingly with my clients. Here is an example of it: A well-practiced client begins his session lost in an emotional flashback to his painful past. He verbally ventilates about it. He is the regressed hurt child, feeling bad, and part of him is sad and part of him is mad. He has lost the experience of feeling whole and integrated, and this loss is like a death that responds well to grieving.
As he cries and angers out his pain from his right brain, he is welcomed by my right brain commiserating with his grief. Our dialog also helps him to connect his feelings with an integrating, left-brain understanding. Typically, during the hour he moves back from the past to the knowing and integration he normally has when he is not regressed or in a flashback.

And typically, this is accompanied by an authentic return of his sense of humor (Duchenne laughter*), not the sarcastic, bullying, non-Duchenne* humor of his critic, with which he prefaced the session. He laughs with the surprised relief of having been released from what moments ago felt like interminable suffering.

Finally, I also notice that in the most successful therapies, my clients move on when they have formed a primary relationship in which reciprocal verbal ventilation is well established.

*See Judith Kay Nelson’s excellent book, What Made Freud Laugh, for an excellent exploration on these two types of laughter.

Diana Fosha on Accelerated Experiential-Dynamic Psychotherapy (AEDP)

Posted on April 19, 2013February 11, 2026 by rezendevknowfully.com

“What You Think is Impossible, You're Actually Already Doing”

Polly Ely: Diana, welcome. As a devotee and student of Accelerated Experiential-Dynamic Psychotherapy (AEDP), I’m so happy to have this opportunity to interview you. Because AEDP is still pretty new to the world of psychotherapy, could you begin by explaining a bit about it?

Diana Fosha: Well, to begin with, unlike most models of psychotherapy that proceed from psychopathology—that start from what’s wrong and very reasonably want to go about fixing and healing it—one of the core characteristics of AEDP is that it assumes healing is already there to access from the first contact with the patient, including the most traumatized person that we encounter. It proceeds from the assumption of healing as a process and healing as a phenomenon—something to be entrained and engaged.

And we’re an experiential treatment, so whether we’re working with healing or attachment or emotion or what have you, we’re not so much interested in the narrative or people’s stories about it as much we’re interested in helping people drop down as much as we can into their experience and exploring the experience.

PE: In terms of “dropping down,” are there particular components or interventions that feel most relevant to AEDP that allow for that to occur?

DF: One of the things that’s characteristic of AEDP is to make the most of what’s there before trying to work with what’s not there or what’s maladaptive. So even when dropping down, if we see little glimmers of greater contact with the body, we would try to focus in on that little glimmer and enlarge it. I think more than anything else the stance is, “You’re already doing it so let’s just do more of it.”

PE: So you’re trying to amplify it, stretch it out, do more.

DF: Make you aware that what you think is impossible you’re actually already doing.

“I Don’t Have Any Feelings”

PE: So when you talk about greater contact with the body, how might you proceed with bringing something to life by making contact with the body in some way that traditional psychotherapists or eclectic psychotherapists might not feel as comfortable doing?

DF: Well, I’ll just say what we would do in AEDP and let other people judge whether it’s what they do or don’t do. For instance, the last person that I worked with was a man with a huge trauma history and a lot of disassociation. He walks in and he is telling me about some severe illness in a parent, and I ask him how he feels about it, and he says, “I don’t have any feelings.” So my question to him is, “What are you aware of?” And he becomes aware of a kind of subtle sensation in his chest—and that becomes our entry point. So we stay with that and I ask, “What does it feel like?”

“Well, it’s tense and it’s sort of a little dense.”

“Is it pleasant? Is it unpleasant?”

Over the course of a period of time, we really stay with what’s in his chest, which turns out to have all sorts of qualities of heaviness and pain—it’s a painful sensation. So before you know it, here I am with this incredibly intellectualized, supposedly in-his-head patient, talking completely in the language of sensation.

We’re no longer talking content. We’re no longer talking narrative. We’re speaking this kind of right-brain language.

We’re no longer talking content. We’re no longer talking narrative. We’re speaking this kind of right-brain language. He’s touching his chest with his hand as he’s palpating the spot where he’s experiencing this, and he’s starting to notice all these shifts and fluctuations, which are very much occurring in the moment. So within a few minutes, we had sort of “dropped down.”

PE: Dropped down and undone some belief about him not having any feelings?

DF: Right. Or that he’s all in his head or that he has an impossible time accessing his feelings.

PE: I see. So you’re developing capabilities and his belief in those capabilities, too.

DF: Over time, yes, absolutely

PE: So when I think about that—what’s happening in the body—how do we tie that to either the intellect or the story that they’re coming in with about whatever their perceived problem is? How might that be an inroad to the problem?

DF: Oh good question, because, of course, he’s not coming in because he has this subtle sensation in his chest; he’s coming in for a variety of issues and we’re just using it as an example. But really as we’re able to get more body-based and right-brained as a way of speaking about these kinds of phenomena, he and I are also having an interaction and we’re noticing what goes smoothly and flows and what’s difficult; what brings him closer and what makes him more distant?

And as we’re evoking what the pain is about or the sensation and what happens when I empathize, associations start to come up. “Did you ever have this kind of feeling? What comes to your mind about what this feeling may be telling you?” That becomes a way in, a much deeper way than telling the story or narrative. And eventually, the goal is to bring it all together—to bring it to a place where we can integrate experience with narrative, with understanding, with some sense of how his experience is linked to whatever issues he was having in his past.

PE: Sounds almost like you’re bypassing the thinking mind by calling on associations from that place in the chest that you’re talking about.

DF: I think that’s very much the case; or we’re trying to do that in the earlier part of the process, where we want to get experiential, construct something from the bottom up. In other words, not with preset preconceptions, beliefs, narrative coherence, but to let the story emerge from the kinds of experiences that are getting generated in the therapy. And then once we’ve worked with that, then we’re putting together basically a new narrative.

The Origins of AEDP

PE: What are the origins of AEDP? Did it spring forth from another model or did it come from your own curiosities about psychotherapy and what works?

DF: That’s an excellent question. I think the easiest way to answer that question is to tell you a little bit about my personal trajectory. My own training and development as a clinician was very psychoanalytic, psychodynamic and also developmental.

At the time I felt uncomfortable with the length of traditional psychoanalysis and its relatively cavalier attitude towards effectiveness and results.

At the time I felt uncomfortable with the length of traditional psychoanalysis and its relatively cavalier attitude towards effectiveness and results. So when I came across short-term dynamic psychotherapy in the work of David Malan and others, I was very excited because it seemed to be a way of working that preserved some of the depth. The analytic way of working, but at the same time, it was short-term, it was intensive. And the effectiveness of the treatment was one of the measures.

So I trained in a particular form of short-term dynamic psychotherapy developed by a clinician named Habib Davanloo, who developed a very intensive and very confrontational model of short-term dynamic psychotherapy. That was my early training and the first exposure I had to viscerally-based, deep feelings and emotions being systematically accessed in a relatively short period of time.

However, that way of working was confrontational; there’s a fair amount of stuff around aggression, which was not ideally suited to my personality or my way of understanding what’s needed in treatment. So from that point forth it became my personal goal to access the phenomena that I witnessed and learned in short-term dynamic psychotherapy and have things that are as visceral and as powerful and as transformative, but proceed from a place of being with the patient, rather than from a place of confrontation.

My other goal was to have a coherent theory for these amazing transformative phenomena. And I thought psychoanalysis, as marvelous as it is, didn’t have a good explanation of why the hell these phenomena were transformative in the moment.

You know, you start a session, you access this experiential phenomena, and 15 minutes later or half an hour later you’re in a, very different, transformed place. So it became important for me to try to have a theory that really reflected the phenomena of experiential psychotherapy. And over time AEDP, with both its theory and its practice, started to develop.

Resistance vs. Transformance

PE: You talk a lot of about transformation and for me, as a student, transformation is a word that was fairly new to me in the context of psychotherapy until I came upon AEDP. It just wasn’t a term that I ran across in my own training. I’m thinking about the word “transformance,” which is a term that you coined. It’s an important term and concept in the language of AEDP. Would you be willing to share a bit about its meaning?

DF: Well, it’s this idea of healing from the get-go—of healing not just being an outcome but a process that exists within each person that emerges in conditions of safety. That idea is not new to AEDP; it exists in spiritual traditions; it exists in humanistic therapies; it exists in some other existential therapies.

Whereas resistance is the conservative force in the psyche that causes us to resist changes or challenges, transformance is the force in the psyche that’s moving towards growth and expansion and transformation.

But still, our language tends to be very psychopathology-based, so that it seemed to me that a term was needed in our therapeutic lexicon to capture this notion of healing from within that we’re trying to tap. I coined the word “transformance” to capture that force and to have it be in counterpoint with resistance. So, whereas resistance is the conservative force in the psyche that causes us to resist changes or challenges, transformance is the force in the psyche that’s moving towards growth and expansion and transformation.

PE: I know for myself that one of the key elements of being an AEDP therapist is videotaping our work. What feels most important to you about that? It has some obvious teaching potential but I wonder if there’s more to it that you believe contributes to the process?

DF: I think it’s very much this emphasis on experience and phenomena and being able to witness firsthand the actual, live interaction. When a student comes to me for supervision, I’m not hearing his or her rendition of what happened. We’re having an experience together, witnessing what happened on video. It’s a huge help for the therapist because there’s no way that one can, in the moment, have access to the multiplicity of things that are happening in any given moment. So there’s this component of being able, after the fact, to look and look again and again and again, which is a beautiful way of learning about the richness that’s there.

Meta Processing

PE: Going back and looking at my work has been a huge place of growth for me as a therapist, and layers of new understanding emerge each time I watch a session. As I become more sophisticated in my understanding of what I’m doing, I’m able to notice more about the experience in the moment with my patients.

One area that is very key to AEDP that has been a struggle for me and where I’ve stretched a lot is around the idea of doing meta processing with the patient. Could you talk some about how you define meta processing and its value and why we, as therapists, may want to consider doing meta processing with our patients?

DF: Meta processing is huge and I think it’s one of the more important contributions that AEDP has made to the field of psychotherapy. I can explain it best by using a scenario. Let’s take somebody who comes in with depression and is feeling sort of sluggish or hopeless or whatever aspect of depression they have. And as a result of doing a piece of work—maybe it involves mourning—30 minutes later the depression lifts. They have a somewhat new perspective. They start to have a little bit of confidence in their own capacity to be effective in the world, right?

PE: Okay.

DF: So the depression lifts and the person starts to feel some efficacy. Well, at that point for us, what we want to do is process

PE: In that session.

DF: Right there in that session. What happened that allowed them to come in feeling lousy and now, half an hour later, they’re feeling more energized or more effective? So we then go through the experience.

The reason it’s called meta processing is that we’re processing the experience of what’s therapeutic about therapy. So—meta therapy. We might start to explore with the patient, “So you’re saying that you’re feeling better. And you have a sense that maybe you can be more effective. What’s that like? What does that feel like?” In the same way that we would explore what the sadness felt like or what grief feels like or what heaviness feels like. Now we’re beginning to explore what does energy feel like? What does vitality feel like? What’s it like that you and I, through talking together and doing this piece of work together, ended up here when we started back there? So that all these experiences that are quite implicit start to become more explicit, and then we’re doing another round of experiential exploration.

PE: So the next round is kind of concretizing what was learned in those first 40 minutes?

DF: Yeah. That’s a beautiful way of saying it. Concretizing, solidifying, increasing awareness, and consolidating it.

PE: And is that something that you expect your therapists to do every session?

DF: Well, we think about it in the following way: we have “Big-M” meta processing and “Small-M” meta processing. And “Big-M” meta processing is when you’ve had an experience like the one we’ve talked about—a very definite change for the better as a result of doing a piece of psychotherapeutic work. Whereas “Small M” meta processing is when there is a tiny little shift. The patient says something, you make a remark, and maybe tears come to their eyes because they feel understood. It’s not that you’ve worked for half an hour and you’ve done a whole process; it’s been one little exchange. “When I said that, it seemed to have moved you. What’s that like for you? What happened?” That’s a little meta processing. But it doesn’t have to be positive. It can be negative. Let’s say you say something and you see the patient sort of turn away or advert their eyes. So there’s been a very specific moment, a little change. We want to zero in on that and not have preconceived ideas about what it means. It doesn’t matter. The point is for the therapist to really get inside the patient’s experience, in a precise way.

So that’s how we use the meta processing and it’s probably accurate to say that rarely does an AEDP session go by without several instances of either “Small-M” or “Big-M” meta processing.

Existing in the Heart and Mind of Another

PE: I’ve been asked a few times if there’s any research that supports the accelerated outcomes of AEDP. How do you answer that question?

DF: That’s a very good question. There are about five research projects that are currently in the works on various aspects of AEDP—on outcome, meta processing, the nature of the changes that people experience as a result of AEDP training—but there are many, many components of AEDP that have been researched in the context of other experiential models. So while we have no research on meta processing or on dyadic affect regulation—because nobody else has done it—there’s infancy research that shows that mother/baby dyads where there’s effective affect regulation are the dyads that produce the most resilient babies. We have developmental research that shows that working with the feeling of existing in the heart and mind of another, which is a phrase we use that relates to attachment, is a huge aspects of resilience in the face of trauma.

There’s a lot of experiential research in the field of trauma that shows that processing previously unbearable emotions through to completion in a safe environment is one of the factors that leads patients to both stay in treatment and have better outcomes on some of the interpersonal measures. So many pieces of AEDP have quite strong empirical validation. The last piece comes from what AEDP shares with short-term dynamic psychotherapy, which shows that when you get past defenses and when patients and therapists are in close contact with core emotions, that contributes significantly to good outcomes. There’s a whole literature on that.

PE: You mentioned a few minutes ago how therapists report being impacted by working with this model. Can you say more about how their lives changed or their own personal processes changed?

DF: That’s a beautiful question. I would actually love to turn it back around and hear what your experience has been.

PE: Well, it has sort of paralleled my own deepening and ability to understand myself and where my defenses lie and where breakthroughs occur for me. It’s such a big question because, as I deepen in my understanding of AEDP, I see a natural transformation in who I am as a human being with other people; how I do in relationships with other people. How much vitality and life I feel within myself on a moment-to-moment basis and just how well I recover and how resilient I become. Without sounding like I’m proselytizing, I feel pretty transformed by it, to be perfectly honest.

DF: I appreciate your saying that. It’s a beautiful answer and people often speak of the parallel process in terms of their own transformation and deepening. I think that one of the other aspects is the gratitude that people experience at the generosity of the community. In the same way that we do therapy with affirmation and empathy and focusing on what people already do, the AEDP community is a very affirming, supportive community.

Especially for people who have had a lot of experience having to steel themselves against criticisms. You can certainly learn with a lot of harsh feedback, but I think the sense of learning through deepening, while being held and being in resonance with others; learning to pay attention to what gives you energy and vitality and what saps your energy and vitality and bringing that into the work—these are things that people are profoundly grateful for.

People have often said that they have a sense of coming home, which is very moving to me.

Way before they became professionals trained in fancy models and systems of interventions, there was just some intuitive sense of wanting to be with people and help them—some sense of hope and generativity that very often gets trained out of people in graduate school. People learn techniques and learn models and become very competent, but lose contact with some of that kind of naïve but very core sense of what it takes to heal in the presence of another. There’s something about AEDP that really draws on those innate processes by which we connect and heal and need to be with one another that lets people feel more alive.

PE: The word that comes to mind for me is “sustainable.”

DF: Yes, something about it allows you to sustain rather than burn out, and feel actually fed by it.

Men Get a Bum Rap

PE: I know recently you did some work around the differences between working with men and women and I’m wondering if there’s anything about that you’re excited about and would like to share.

DF: You know, I’ve really felt that men, to be perfectly honest, were getting sort of a bum rap in the world of emotion focused therapy. I have a colleague who sees couples and the typical set up was that the woman dragged their male partners in and they came because they didn’t want to lose the relationship. But they would always be revealed in the therapy as cut off from their emotions and not therefore able to use the couple’s therapy, so my colleague would send the men to me for individual therapy. These men would come in with their tails between their legs and feeling sort of sheepish or defensive or alienated. And when, in AEDP fashion, I’d look for the glimmer of what’s resilient or what’s healing or what’s transformance based and reflect back to them sensitivity or care or empathy, it was such a mind-blowing experience because they were so used to being told everything that they do wrong.

It was in that kind of informal way that I got interested in what happens to men in psychotherapy, especially in emotion- or relationally-based psychotherapy, because AEDP is so attachment- and emotion-based. So I actually went to do some neuroscience research and there’s a tremendous amount of the neuroscience research on sex difference and affect regulation.

And surprise, surprise, all the stuff that standup comics and guys in bars and girlfriends speaking to each other talk about—you know, everybody’s so-called stereotypes of the other gender—have some bearing in neuroscience.

PE: Which ones stand out to you?

DF: Well there are some real differences in how male and female brains process emotion. One of the main characteristics of male brains is that they’re actually more emotional—counter to stereotype—and have more right-brain activation than women, but that more visceral, raw sense of emotion is not as linked with language, so that modulation of emotion is much more problematic in men. Whereas connectivity in the brains of women is much more evenly distributed in the left and right brain, so that everything is much more connected for women. Under extreme emotional activation, language sort of goes off screen for men.

So it’s not that men don’t have feelings; they have tremendous, tremendous emotion, but the capacity to articulate is different.

So it’s not that men don’t have feelings; they have tremendous, tremendous emotion, but the capacity to articulate is different. And then there’s all this backlash in terms of shame and feeling inadequate for not being able to have an emotional conversation.

PE: That’s such an empathic way to be with men who are experiencing some trouble with expressing themselves.

DF: Yes, and I’ll tell you one other fascinating one, which has to do with face recognition. There’s an area in the brain that’s devoted to face recognition and women are superior to men in face recognition in all conditions, across the board. Under stress, women’s face recognition gets better and men’s face recognition gets worse. In stress-based literature they say that under stress, men’s sympathetic nervous system—the fight-flight response—is activated. For women, what’s activated under the same kind of threatening conditions is the limbic system and what’s been called the “tend and befriend.”

We women reach out, seek, and offer care. Reaching out to others means better face recognition, right? Presumably, evolutionarily speaking, the more you can recognize a face, you can recognize friend, foe, nurturer, etc. Whereas under stress, men sort of go inside, get strong, get into fight or flight, and are more isolated. It’s like the focus is on action and the face recognition drops off. So those are two things that seemed to me to bear very directly on our work, whether we’re working with individuals or couples.

PE: What are your suggestions for people who are interested in learning about or getting involved in AEDP?

DF: The first thing would be to visit the website, www.AEDPinstitute.com which is a focal point for the community and a way to just find out something about the model. We’ve got videos, presentations, downloadable articles, and trainings with different members of the faculty. You can also find out where trainings in various parts of the country are.

PE: Thank you so much for taking the time to discuss your work.

DF: Thank you.

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