Approach Archives - Page 9 of 41

Using Common Sense Problem-Solving and Worry Containment to Subdue Ruminations

Posted on July 13, 2023March 3, 2026 by Psychotherapy.net Team

The Devil of Rumination and Obsessional Thinking

I often wonder how I as a therapist can best help clients who torture themselves by overthinking and over-analysing in a cyclical manner that essentially gets them nowhere. If it is not possible to help them purge themselves of such burdensome thoughts, is it at least possible to help them make peace with the “unwelcomed devil” of rumination?

I’ll start by reframing rumination as the devil we know, which may still remain a devil, but maybe less scary than the devil we don’t know.

Rumination is a form of obsessional thinking characterized by excessive, usually unwanted, and repetitive thoughts or themes that hijack other mental activity and it is a common feature of obsessive-compulsive disorder and generalized anxiety disorder. It is also dwelling on negative feelings and distress, and their possible causes and consequences. Furthermore, the repetitive, negative aspect of rumination can contribute to the development of depression or anxiety and can worsen pre-existing conditions.

Ruminative states, even for non-depressed people, are directly associated with negative affect. In fact, the more clients ruminate, the more they are likely to throw fuel on the cognitive fire, so to speak, and become entrapped in a vicious cycle, making them feel even worse. My experience with these clients has been that they ruminate in all three time zones of their lives — past, present, and future — on events of both real significance and seeming significance.

A method for tackling rumination that I have found to be particularly useful with these clients is to use problem solving, pondering, and positive reflection. If rumination is overthinking a problem and worries related to that problem, it makes sense to take a positive stance and use problem-solving skills to find the optimal solution that rumination seems to seek, and that could put it to rest. Furthermore, problem-solving strategies can be even more effective when they actually aim to resolve the problem the rumination seeks to magically dispel.

Classic problem-solving models in organizational psychology suggest a series of stages in problem solving culminating in the implementation of action, which can help individuals to either confirm that they are moving in the right direction or think about what changes they need to make in their plans — the verification stage. I also believe that linking problem solving and positive reflection with the specific actions can help to enhance clients’ confidence and sense of efficacy and help them to break the repetitive cycle of rumination.

Applying a Solution Focus

Integrating the above perspective into Cognitive-Behavioral Therapy and Solution-Focused Therapy, I may ask my client to identify and engage in a (small and feasible) first task related to the content of their rumination and plan to complete it as soon as they realistically can. For example, if an individual ruminates about their upcoming “job performance,” they could identify one or two minor work-performance-related tasks and aim to complete them initially.

This first step would not necessarily mean that they have found all the answers to their worries, but it would help them feel that they have at least done something, even quite small, which brought them closer to the achievement of their goal (a positive job performance review in this example). Moreover, from a positive reinforcement perspective, they could also plan to reward themselves with something enjoyable that they “deserve to do” (since they will have managed to take some action, instead of overthinking or freezing).

For certain types of rumination (such as work-related stress or perfectionism), I have found this approach particularly useful as my clients find it easy to find a series of actions or tasks that help them develop a sense of moving forward — and slowly moving away from the gravitational pull of rumination. However, there are other frequent types of rumination that, by their nature and content, do not lend themselves directly to interlinked specific actions, such as “is this the right job for me or not?” or for those clients who don’t have the practical or mental resources at a given time to explore how their rumination could be translated to any specific plan.

In such cases, I invite them to “take a break” from their laborious, constant effort to find a “solution,” which would cease the seemingly incessant pressure to ruminate. This suggestion, of course, is often challenging for them as it directly opposes the very nature of rumination — the underlying implicit, irrational belief that “I need to keep analysing a specific concern, until I find an answer or a solution that I am completely happy with.”

The client’s resistance to pause their overthinking may be underpinned by another implicit belief that “there is no way I will be able to relax and find mental peace until I get everything outstanding done and dusted.” This notion is sometimes effective to help clients increase their motivation to fight procrastination and eventually solve problems and achieve their goals. Nevertheless, at other times, it will just not be possible to solve something as soon as possible, nor to even envision the solution — leaving the client feeling even more frustrated, anxious, and predisposed to continued rumination.

In these situations, the biggest trap is not that they will still have “unfinished, disturbing (pragmatic or emotional) business,” but that they will have trained their brain to believe that it is possible not to have any unfinished business, not to have any more intrusive worries and that “when there is a will, there is always a way.”

However, this otherwise helpful and motivating attitude can often just fuel further excessive worry and rumination. The curious question then becomes, “how can the normally reasonable aim to solve problems as quickly as possible become a problem on its own?”

A Pragmatic Approach to Rumination

In my experience, western culture values a proactive, problem-solving approach that rewards and encourages taking responsibility, a sense of agency, and ownership of our lives, as opposed to being passive and reactive. My aim here is not to explore this cultural notion as such (which would entail a much broader philosophical discussion), but rather to highlight its limitations and to reflect on the ways that we can contain our excessively proactive stance, and the worries and perpetuated rumination that often accompany it.

I have come to believe that as important as it is to be proactive and to take responsibility, it is equally important to fundamentally acknowledge that we only have certain emotional and pragmatic capacity at any given time to deal with our goals and our relevant worries. Thus, we may need to decide that we can only deal with just one of our concerns at a time, while we may also endeavour to teach ourselves to tolerate and bracket all other ones.

Rumination by nature “demands” immediate answers and solutions. In contrast, I encourage my clients to allow their intrusive thoughts to emerge and claim their space, while at the same time, challenge them to fight their urge to engage thoroughly with them in-the-moment (which only fuels further and futile rumination). I encourage them to slow down and allow some time to observe their worries as they emerge naturally and unfold in their mind. At the same time, I ask them to make an “appointment” with that urge a few days later, at which time they can, if they choose, respond to their demand for their attention. During that appointment, they can calmly reflect on which of their worries really matter, which ones require more time to ferment, and whether there is any proportionate course of action they can take (or not?) in response to them. When they manage to gain some distance from the urge to ruminate, or from the rumination itself, they may find out that — not surprisingly — several of their worries no longer claim much of their attention.

Of course, this is much easier said than done. Worries are unrelenting. They have their backhanded way of persevering and drawing clients into their dark, seemingly bottomless pit without offering even a glimmer of light or hope that might otherwise offer a solution that feels “good enough,” and without offering the slightest means of escaping their gravitational pull.

An additional strategy I have found useful to help my clients with rumination has been to invite them to implement an easy, positive distraction at the time when their urge to ruminate emerges. This is indeed one of the common techniques, along with other ones such as mindfulness. However, positive distractions seem to be most useful when they are combined with a “reassurance” to our worries that we will indeed come back to them at a more appropriate time, when we will be better prepared and have the mental space to deal with them.

In this context, I have had clients set an appointment with their worries and I actually encouraged them to take this appointment quite seriously. Thus, when clients actually engage in these appointments, they often find that some of these worries have been impatiently awaiting their arrival and are still adamantly demanding their attention, while others have not. At that point, and only at that allotted time, the client is better prepared to address those worries, having built the patience and mental space to do so. As therapy itself is an ongoing process as is problem resolution, clients come to appreciate that it is not necessary to respond to the siren call of worries when they first arise. Pandora’s box will always be there waiting for them in the therapy room, and they will choose when to open it or not.

Most of the above points were at play in the work I have done with one of my favorite and long-term clients. Stuart, as I will call him, was ruminating equally about “small things,” like the slight slope on the floor of his Victorian-age house; and big things, like the dilemma of whether he would ever find a more meaningful job and career. I knew that saying to Stuart something like, “don’t think about this,” would just make him think about these concerns even more.

Instead, I said to Stuart, “you can think about this as much as you want, but could you possibly give up on finding an answer to your worry in-the-moment? And maybe, as you will still be thinking about it, could you also try to do surface research online about any jobs that are out there, that could potentially be meaningful for you in the future?’’ This intervention was a combination of a positive distraction, patience, and looking forward. When Stuart came back for his next session, he told me that even though his ruminations were still there, he was much more able to contain them. Was he then able to “become friends” with them? Well, not necessarily, but by practising to sit with them, slow down, and possibly add a positive distraction in the mix, his ruminations certainly became a more familiar, less scary, and more tolerable devil.

Stuart was a willing worker, as are many of my clients. But it was as important to build a relationship of trust and hope with him as it was to help him build a sense of hope and confidence that he could eventually subdue his ruminations and live freely.

The Realm of Our Industry

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

“In the beginning, we were all psychotherapists. And it was good.”

—Bruce Minor, Minnesota Member of the MFT Community

THE TIME HAS COME to face our industry and sit with the ways the therapy system in which we work helps us, hurts us, and holds us to a standard impossible to meet. Throughout this book we have touched on many issues facing our work; now we are looking specifically at the system in which we work. No longer a collection of individual practitioners who see each other as fellow members of a therapeutic federation, our industry (therapy) has become compartmentalized, industrialized, and controlled by third-party payers.

As you begin this leg of the journey, we invite you to pause and reflect on the mentors and experiences who supported you on your quest to become a therapist. We welcome you to reflect on mentors of both the past and the present, as well as those with whom you had a challenging or even fraught relationship. Even those mentors and supervisors who we experience as awful can teach us valuable lessons (though that does not exonerate them).

When it comes to mentors and supervisors, we, the authors, have had the best and the worst. For this chapter, we reflect on some of the greats from our local MFT community: Anne Ramage, PsyD, LMFT, our graduate school professor who taught us so much more than we ever realized there was to know about Carl Whitaker; and the collective of marriage and family therapists who have sustained the Minnesota field for decades, some of whom also became our supervisors and mentors: Ginny D’Angelo, LICSW, LMFT, Bruce Minor, LMFT, Briar Miller, LMFT, and Michelle Libi, LMFT.

You blink and end your repose to find that you’re alone. It feels as if you have awoken from a dream. You rise from your resting spot and begin to walk down the winding path toward the sound of a river. As you walk, you notice the crunch of twigs underfoot and hear distant birds. Is one of them the red-winged blackbird? Neither your bird friend nor the forest yeti are anywhere in sight. Perhaps you dreamed them.

You look up at the branches of a nearby tree and notice a small silver shape clinging to a twig. Pausing, you raise up onto your tiptoes and realize that this is a cocoon, perhaps belonging to a butterfly or a moth. You gaze at the cocoon for a moment longer, noticing it shake as the small creature inside struggles with its transformation. Change is such hard work, you muse, and resume the hike. As you walk you notice that you have many aches in your body. How long were you sitting in meditation? You stretch your neck from side to side as you continue to make your way down the mountainside.

As you breathe in, the air is fragrant with the scent of dried leaves and warm earth. You wonder at the way the seasons seem to have shifted around you on your travels. As you look around the forest bordering either side of the path, you notice hints of yellow and orange in many of the leaves. The wind shifts, blowing the undersides of the leaves up, causing them to shift and sway. It reminds you of a distant memory, but as you grasp for it, the memory skitters out of reach.

The path winds down the slope, and you lean slightly backward against the tug of inertia and gravity. The sun’s rays are just the right amount of warmth, offering a radiating blanket of heat against the cooler air temperature. You look down and slightly to your left, and you see a ribbon of blue snaking through the undergrowth far below: a river. It looks like a nice place to pause and rest. You estimate that you have at least another mile to walk down the mountain before you reach the riverbank. You walk down toward it.

Therapy’s Big Brother

Once upon a time, as Bruce Minor reminds us, we were all just psychotherapists. In the very, very beginning of our industry, there were just small- to medium-sized collectives of human beings throughout the American and European continents — composed mostly of wealthy men and a few audacious women — gathering together in an attempt to suss out the nature of the human mind and heart. From these meetings, the field of psychoanalysis was born.

While these early theorists and practitioners engaged in practices that we would gasp at today — Freud psychoanalyzing his daughter, Jung sleeping with several of his patients who then became therapists-in-training — their mistakes became the foundations upon which rules like “no dual relationships” were based.

These early therapists did not have insurance agencies or managed care with which to deal. But they also tended to focus on treating the bourgeoisie — the European upper middle class who could afford to pay for things like this newfangled “talking cure,” thanks to their monopoly on industry. Neither Jung, Adler, nor Freud himself (founding psychoanalysts all) had to consider whether high-quality psychotherapy happens in increments of forty-five, sixty, or ninety minutes. We bring you this abbreviated history lesson to remind us all that our present constructs have not always existed. Not only have they not always existed, but they might not actually be the most effective structure for treatment.

When family therapy was new, co-therapy and one-way mirrors with reflection teams were the standard of the day. When Justine tells graduate students about these once-standard training practices, they are in awe. “But how did that get paid for?!” they exclaim. The short answer is that decades ago, universities, particularly public universities, had more money in the humanities and social science departments.

Insurance once reimbursed for far more therapeutic services than they do now. Then Justine will often go on to tell her students about sitting in her own graduate school classroom at Hazelden Graduate School of Addiction Studies (now Hazelden Betty Ford) and hearing her professors talk about the changing landscape of drug and alcohol treatment.

Structured limitations are necessary for high-quality therapy (recall the example of sandtray therapy and the need for a literal box within which to put the sand, from chapter 2). Certainly, the case could be made that American psychoanalysis and drug treatment of the 1970s and 1980s was in need of a bit more clinical oversight. But the evolution that followed brings us to a dystopian present where third-party payers like insurance companies are dictating the terms and conditions of treatment. They’re also dictating the amount of money that the clinician receives for the work they do based solely on their licensure, rather than on the type of work they’re doing. These payouts are often inadequate at best and paltry at worst. Because of variable reimbursement rates, the amount of time and effort needed to handle billing issues, and the hoops clinicians need to navigate to get even the small amount of money they’re paid, private-practice clinicians are increasingly opting out of the insurance model. This causes frustration for would-be clients, and for other clinicians.

Licensure Drama

Have you ever had an issue with another clinician and thought, “Well, that’s just because they’re a Ph.D.; doctorate school sucks all of the fun out of you”? Or perhaps you’ve thought, “They don’t teach master’s-level clinicians anything about diagnostics.” Third-party payers and clinicians determine their reimbursement or compensation rates based on a number of factors, including education. Hierarchical thinking dictates that the more education and experience a person has, the more they should be valued.

The main way that we express or show value is through monetary compensation. However, this very quickly leads to confusion and resentment when master’s-level clinicians and doctoral-level clinicians are working at the same practice or agency, and are performing, at least on paper, the same job functions. Disparate training and licensure requirements can lead to differences in case conceptualizations, standards of care, and clinical interventions.

Certainly, these varied perspectives can be helpful if discussed and processed through open and honest clinical dialogue. But who has time for that? We don’t say this to minimize or undermine the value of care coordination. The reality, though, is that third-party payers don’t reimburse for care coordination. Contemporary clinicians are lucky if they can connect for five or ten minutes via phone either just before the beginning (seven a.m.) or just after the end (seven p.m.) of their clinical day. Thus, it’s no surprise that confusion and even infighting across licenses and education levels abound.

Justine recalls a question from a student about this infighting: “But who is actually above the others? There has to be a hierarchy, right?” Justine responded that while it may feel as though there is a hierarchy, the reality is that we’re a community with a variety of skills. We don’t need to fight among ourselves. She said that just because someone with a doctorate has more education than someone with a master’s degree, that doesn’t make them better than or above the master’s-level clinician. This is a social construct that we get to question and challenge, because it no longer serves us.

The tangible difference between master’s-level and doctoral-level clinicians lies in the area of assessment. Folks who complete doctoral programs are schooled in the practice of psychological assessment and usually graduate with the third party-payer reimbursable skill of psychological assessment.

With gravity on your side, you make it to the bottom of the mountain faster than anticipated. The sound of the river rings in your ears as you push through the bracken toward the riverbank. The grass along the shore is a deep green and only slightly prickly as you kneel down and bend over the water, cupping your hands to take a long, cool drink. Once you have quenched your thirst, you sit back on your heels and stare out across the blue water, leaning into the rays of the sun at your back. You notice a butterfly flapping its wings and landing on a nearby flower.

App Therapy Is the New In-Home Therapy

Newly-minted therapy graduates find themselves staring down the gauntlet of the licensure process, which usually entails several examinations, hours of supervision, and even more hours of direct client care. Depending upon the state where you live and the license you’re pursuing, you may find it very difficult to get a job that pays you money while you acquire hours you can count toward licensure.

Over the past few decades, the entry-level job for graduates in this predicament was in-home family therapy. Often considered the grunt work of the therapy industry, in-home family therapy requires practitioners to work long hours and drive long distances for very minimal pay. In 2014, when Larisa was working as an in-home clinician, she didn’t even make minimum wage, so she worked another job part time as an after-hours crisis counselor.

Today’s graduates have a new, additional option: they can become app therapists. Similar to other gig jobs like Uber Eats and Lyft, clinicians who work for therapy apps such as BetterHelp, TalkSpace, and Larkr are either populated by associate-licensed or fully licensed clinicians, and they work entirely through their company’s telehealth app interface. They tend to have very large caseloads (pitched to them as a “great opportunity to get your licensure hours”), minimal time with an assigned clinical supervisor, and demanding clinical expectations. Most therapy app jobs market their services to prospective clients with the promise of a readily available therapist, translating to the expectation that the therapist is available to the client at least via chat through most hours of the day and night.

Larisa vividly recalls many of her lectures with Dr. Anne Ramage for a number of reasons, not the least of which is that Dr. Ramage is an excellent professor and an enigmatic speaker. Among all of Larisa’s memories of Dr. Ramage’s Carl Whitaker quotes and experiential roleplays, she recalls the professor advising time and again that “in-home jobs will be waiting for you as soon as you graduate. They’re tough. You need to be ready. But they’ll give you excellent experience in working with families.” Then Dr. Ramage discussed the MFT techniques from that particular lecture that might apply to in-home work, and she explained the basic safety strategies of which in-home clinicians needed to be aware.

When Larisa graduated, she did indeed take a job as an in-home family therapist. The night before her first day, she reviewed the strategies she had learned from Dr. Ramage:

1. Arrive five minutes early and look up the homes you’ll be visiting in advance so you can plan your parking strategy. Never schedule sessions late in the evening or after dark.

2. Be ready to set clear and consistent boundaries, and for those boundaries to be tested.

3. Pack a change of clothes and hand sanitizer.

4. Review your agency’s privacy policies.

5. When you enter someone’s home, assess for safety and your own exit strategy. Although it is rare that clients will ever mean you harm, things can and do get out of hand when you are in the family’s own space. You get to protect yourself first.

This survival guide doesn’t apply to folks who are working for therapy apps, but the need for both support and coping strategies is no less acute. If you’re working for a therapy app, we, the authors, offer you deep compassion and the following tips:

1. Plan an exit strategy. What does this mean? It means a human being can’t sustain years of work at the rate demanded by therapy apps. So, it’s essential for you to decide how long you can sustain working for a therapy app before you go the way of a younger Larisa and start losing your hair and developing insomnia.

2. Find a supervisor outside the therapy app. Yes, you will probably have to pay for this supervision, and that will likely cause financial stress. However, it is crucial for you to have a guide whose sole investment is in you and who exists outside the system in which you work, to help you regain perspective and hold boundaries around things like time management and availability.

3. Remember that any symptoms of burnout (i.e., signs of physical or emotional distress) you’re experiencing are likely the cause of moral injury — harm caused by the system in which you work — rather than any fault of your own (we’ll discuss these concepts in more detail in the next section of this chapter).

4. Manage your expectations for yourself. However, you envisioned your therapy experience, it likely did not involve a smartphone application called “Better-something.” You can’t do depth psychotherapy in this kind of context; what you can do is help your clients with basic coping strategies and compassionate presence — sometimes, but not all the time. You’re not required to have 24/7 availability, no matter what your company tells you. Not even standard laptops can run constantly forever; they need to rest and update.

5. Reach out to your community. When you work in an online environment, it can be difficult to get your emotional needs met. Please remember to engage with other living beings outside your work environment who understand some of what you’re going through and who can show up for you.

Burnout and Moral Injury

The Realm of Our Work has changed in ways that we never imagined over the course of the collective traumas of the 2020s. Suddenly the norm is to work in a virtual therapy room, and some clients expect to have regular access to their therapist via text messages and video chat services. This isn’t what we thought the field would look like.

When Justine imagined her future as a therapist, she saw herself engulfed in a scarf, with a teacup in hand, sitting across from her client in an overstuffed chair near a small fire in a fireplace, surrounded by books. She envisioned herself helping people and feeling filled up by the work, then returning home to a pleasant evening all to herself — overall a very calm and steady way of life.

This is not reality. For a time, she did have the tea and the overstuffed chair, but the rest of the fantasy was just that — a fantasy. Justine now works behind a computer and sits in a rolling chair; her view is full of microphones, a ring light, and multiple monitors. For her, the change in our industry has been the death of a dream. The death of any dream is an ambiguous loss that even therapists are not always good at recognizing and finding compassion and ritual to help them move through it.

Of course, parts of what Justine imagined the life of a therapist to be all those many years ago, before she ever entered the field, were simply inaccurate. Even before teletherapy and therapy apps took over the field, the life of a therapist was rarely calm and steady. It had moments and longer periods of such calm, but the nature of therapy is to work with volatile emotions. The emotional intensity inherent to the profession impacts even the most experienced and boundaried of therapists.

Larisa’s experience differed in that she had a logical view of what life in the field would be like. She felt like she had prepared herself emotionally for the trials of holding space for people and their emotions day in and day out. She believed that this preparation would act as a shield against any future catastrophe. The sadness came when she realized that no matter how prepared she had been, the situation was worse, and far more unpredictable, than she could have imagined. She was ready for the stresses of people’s everyday lives and even for their great despair and trauma, but she was unprepared for the collective trauma of our age stepping into the therapy room and into her own life. She was totally unprepared for how political leadership would fail her and everyone else in her country during this time of great collective need.

In her younger and more impressionable years, she believed that even though power is corrosive and toxic to politicians, when they were faced with clear and present disaster, they would channel their highest selves and work to help people. Now Larisa realizes that America’s representative government has devolved into rule by the wealthy elite who use their resources to buffer themselves from the pain and the needs of their constituents. Sometimes the despair she feels is crushing. Perhaps you can relate.

As we sit with the tragedies that have befallen our profession, it is no wonder that so many therapists struggle with burnout. Burnout can be defined from many perspectives. For the sake of brevity and clarity, we offer definitions of both individualized burnout and systemic burnout. Individualized burnout occurs when a person is so emotionally exhausted that they chronically struggle with depersonalization, which is emotional, physical, and cognitive numbness that makes the person unable to feel present in their own body or life.

Systemic burnout is also known as moral injury, which is when a person experiences symptoms through no fault of their own; rather, the symptoms result from harm caused by the system in which they work. Moral injury was first defined by psychiatrist Jonathan Shay as a “betrayal of what is right by someone who holds legitimate authority in a high stakes situation.” Wendy Dean, Simon Talbot, and Austin Dean expanded upon this definition when they argued for clinician burnout to be redefined as moral injury:

Moral injury occurs when we perpetrate, bear witness to, or fail to prevent an act that transgresses our deeply held moral beliefs. In the health care context, that deeply held moral belief is the oath each of us took when embarking on our paths as health care providers: Put the needs of patients first. That oath is the lynchpin [sic] of our working lives and our guiding principle when searching for the right course of action.

But as clinicians, we are increasingly forced to consider the demands of other stakeholders — the electronic medical record (EMR), the insurers, the hospital, the health care system, even our own financial security —before the needs of our patients. Every time we are forced to make a decision that contravenes our patients’ best interests, we feel a sting of moral injustice. Over time, these repetitive insults amass into moral injury.

The article quoted above speaks solely to the experience of medical doctors, but its implications are clear for the chronic systemic burnout faced by so many in helping professions, including (but not limited to) therapists, medical technicians, nurses, and case managers. Helping professionals are increasingly placed in a double bind; that is, they’re being placed in situations from which there is no escape, and they’re being asked to perform at least two mutually exclusive actions simultaneously. They’re being asked to care for clients but also to please many other stakeholders, all without the amount or quality of support that they need. Just like all double binds, this is an untenable situation that causes distress within the clinician.

We, the authors, appreciate the distinction between burnout and moral injury. The concept of moral injury takes the onus off the individual, because there’s not enough self-care in the world to account for a system that’s set up as a no-win situation. When larger systems talk about “burnout,” that terminology allows them to let themselves off the hook for the clinician’s pain. The system can then pass the problem back to the clinician as a personal failing, rather than a systemic one. The therapy field is currently crying out for systemic change. We cannot do everything and be everything to everyone. It is impossible, and it is destroying us.

The butterfly’s orange and black wings flutter back and forth as it buries its face in a Black-eyed Susan. You contemplate the effort that it took for this butterfly to metamorphose from a caterpillar. It went through a violent transformation in the cocoon to become this creature. It’s not a pretty process. The butterfly must flap and flap and flap its wings inside the cocoon to strengthen them. It can be a difficult struggle to watch, and an onlooker often wants to help the butterfly be free from its enclosure.

But if it’s released from the cocoon early, the butterfly won’t have the strength to fly and survive. It must struggle to become strong. As you stare at the butterfly, considering its beautiful wings, you start to breathe into your own bodily awareness. You notice the many places where you’re holding tension and feeling stiff and sore. Perhaps you have also been flapping your metaphorical wings, becoming something new.

Grieving Tools — The Pain Paradox

As you might remember from chapter 2, pain can be a pivotal part of the meaning-making process. When paired with reflection time, pain can help us learn about our core values and live a life in accordance with them.

Yet because we work in a field that values sacrifice and the pain that entails, therapists are also far more susceptible to what Freud would call the martyr complex, and what we refer to as hero/savior/sacrifice syndrome. The pain paradox explores the tension between pain as both catalyst for change and a state of prolonged suffering. Particularly in helping professions, suffering for our work is often framed as positive, meaningful, or altruistic. This harmful social construct can lead clinicians to stay in harmful jobs “for the sake of the clients” and sacrifice their own health in the process.

The pain paradox invites clinicians to question their social constructs around both pain and meaning-making. In the therapy room, the pain paradox is a tool that clinicians can use to help clients who are themselves engaging in harmful behaviors for the sake of “meaningful pain.” Let us explore how you can use the tool of the pain paradox as you navigate your personal struggles outside of session, and how to use this tool with clients inside the therapy space.

Client

Pain is not the enemy, nor is it to be avoided at all costs. Sometimes what brings clients to therapy is the erroneous idea that we, their therapist, can help them learn how to disengage with their feelings entirely because these feelings are causing them pain. Of course, the reality is that we can teach them distress tolerance skills to be present with their pain and their feelings so they can learn to listen to the important messages carried by their feelings.

However, clients can sometimes mistake pain for purpose. We see this frequently with our creative clients. So often the idea of the “crazy artist” takes hold of clients. Several of Justine’s clients were terrified of feeling better. They believed that their sickness and the distress it caused fueled their art. But the reality was that after going through treatment, these clients were all able to continue making amazing art, and in fact they did so with more frequency and focus. Another part of the process of working with these folks is helping them see that they’re full human beings who are more than just the art they craft.

Many fear that if they lose the art then they lose themselves and they no longer matter. However, in our experience, part of their healing journey entails exploring areas of their life outside of art. Eventually, they come to see their art as but an aspect or a planet within the vast cosmos of their lives.

Therapist

For many of us, the desire to make meaning from our own pain drew us to the field of psychotherapy. Most therapists have experienced some type of mental distress, whether it’s childhood trauma, an eating disorder, bullying, discrimination, or an abusive relationship with chemicals. For many of us, surviving this kind of pain was only the first phase of the healing process, with the second phase being meaning-making.

The pain paradox is a gentle invitation for therapists to carefully consider ways to cultivate meaning and joy outside the therapy field. Although our work as therapists is absolutely meaningful, it is also back-breakingly painful at times. If you don’t have other avenues or ways to make meaning and find purpose, you’ll find it even more challenging to take breaks from the field, regardless of how long such a break lasts, because you struggle to see the “you” outside the office. You need not try something life altering or huge. When Larisa was recovering from a severe case of moral injury, she began making playlists, an activity she had not engaged in since her college days. This small daily activity helped her to begin to reconnect with playful and creative energies outside her clinical and professional work.

The difficult message that Justine received was that her time as a direct-care therapist was coming to a close. After over a decade of work, and so many clients helped, she began to feel that her meaning-making was now to be found in the classroom, on the stage, and on the page. She experienced a great deal of pain as a therapist during the pandemic and the social justice uprising, but the pain invited her to consider where new meaning could form. The answer was that it was time to guide the next generation of clinicians and to hold the hands of those who are still in the trenches. As of this writing, Justine is currently working on the slow transition out of direct client care.

Due North: Self of the Therapist

One of the struggles inherent in walking the dialectic between the system and the individual is despair. In the case of moral injury, which is caused by a series of broken systems subjecting clinicians to harmful double binds, it can feel like there’s little or nothing for a therapist to do beyond retiring from the field. While this certainly is an option, we offer you another one: harm reduction and intentional activism.

As you may already know, the harm-reduction model of addiction recovery focuses on making small, actionable changes that mitigate abusing behaviors, rather than prescribing total sobriety. Our intention is to invite you as a clinician to assess the harm you’re currently facing in your career and how it’s affecting you. You can’t immediately change the systems in which you practice therapy, but you can make a concerted effort to mitigate the negative impact that these systems have upon you.

Some ways that you might limit the harm you experience include limiting the number of hours you work or the types of clients or clinical presentations with which you work. Perhaps you currently work in a place with an unreliable schedule, and that causes you distress; is it possible to have a more structured schedule? If you’re not being given time for breaks or lunch, is this a conversation you can have and a boundary you can set with your site supervisor? These can be small or large changes, but any change can go a long way to help mitigate the harm you’re experiencing.

Seven Lessons for Making a Meaningful Life: A Therapist’s Guide

Posted on June 29, 2023February 11, 2026 by Psychotherapy.net Team

What makes your life meaningful? It is a question that I first asked myself in my late thirties after my partner died, and all the way through the difficult mid-life years in my forties and early fifties. I have also put the same question to over 130 other therapists, academics, and advocates for better mental health on my weekly podcast.

What I never expected was how fruitful the question would be for my own personal development or how asking it to other therapists would change my life. So, what are the seven things I have learned from other therapists that I wish I’d known years ago? And how have they changed how I look at myself, how I deal with my own problems, and how I work with my clients?

The First Four Important Lessons for a Meaningful Life

1. Therapists need therapy so much that they turn it into their profession, and in this way, can be in it full time.

When I interviewed the psychotherapist, Terry Real (the founder of an approach called Relational Life Therapy), he joked that, “therapists need therapy so much that we turn it into our profession so that we can be in therapy all the time.” We laughed but it is true. I came from a family where no one ever talked about emotions. Now, I talk about them all day with my clients and in my spare time started a podcast where I speak about, guess what, feelings! “Perhaps we should pay our clients for everything we learn from them,” Terry added.

2. Your earliest childhood memory is the key to the work.

Galit Atlas is a psychoanalyst, faculty member of the New York University Postdoctoral Program in Psychotherapy and Psychoanalysis, and author of “Emotional Inheritance.” One of her techniques is to unpack the first memory of her clients. I have yet to use the technique with a client, but I took it to my own psychoanalysis.

I have two memories from the same day. The first one is coming into my parents’ room on Christmas morning but finding that my mother was not there. My father reminded me that she had gone to hospital to collect my baby sister. I would have, therefore, been two and three-quarters years old. Later in the day, my mother came back from hospital, and I remember going to her bedroom, wanting to show her all my presents but she was too tired and turned her back to me.

So, both memories were about her being unavailable — which was a surprise because my mother was always there. I would come home for lunch from school (and so would my father) and she tried to be there when my sister and I got home, but the memories spoke to how I got my physical needs met but not my emotional ones.

A few months after taking my first memory to my analyst, I had a healing dream about my mother’s return from the hospital, but this time she pulled back the covers and invited me into bed for a cuddle.

3. Don’t take things so personally.

My witness on “The Meaningful Life” was Olivier Clerc, founder of an international programme called Circles of Forgiveness. His journey started when he translated Don Miquel Ruiz’s book “The Four Agreements.” These include the advice: Don’t take things personally.

Unfortunately, because we are at the centre of our own lives, we imagine that the actions of other people are all about us. In reality, we are often just collateral damage. Clerc got me thinking because he flew from France to Mexico to do one of Ruiz’s workshops because he wanted to meet someone who did not take things personally. I have spent a lot of time since the interview meditating on what it would be like to meet someone like that or to be like that myself. It would certainly make forgiveness easier.

I have started using one of Clerc’s forgiveness rituals. I ask my clients to look into each other’s eyes and repeat after me four sentences: “I’m sorry.” “Please forgive me.” “I love you.” “Thank you.” I have been surprised by how powerful this simple ceremony is — nearly every time one or both clients have cried. Secondly, it is not important as I imagined specifying what you are sorry about.

4. Understand your navigation principle.

When you have a difficult decision to make, how do you make your mind up? Matthew McKay, who is a clinical psychologist, couples therapist, and professor of psychology at the Wright Institute, talks about “Navigation Principles.” The most common ways of deciding “what next” include avoiding pain; going for power, control, or wealth; choosing the safe option or what other people want.

Some people try to be rational. Most of my clients have no idea what their navigation principle might be, but with a little delving, come up with answers that speak to their core beliefs. For example: growth, love, and curiosity. It helps them have confidence in their choices and when facing a blank page to know in what direction to head.

How to Mine the Unconscious Mind

5. I can ask my unconscious a question.

I can’t remember my training as a marital therapist covering the unconscious — beyond in passing. It was more focused on the argument between the couple on the couch in front of me, making certain both parties were heard, and helping negotiate change. So, the unconscious remained a shadowy presence, I never really thought I could ask mine a question until two different guests came up with two radically different techniques.

Machiel Klerk is a licensed mental health therapist, founder of the Jung Platform, and the author of “Dream Guidance: Connecting to the Soul through Dream Incubation.” Instead of waiting for a dream that might shed light on a current dilemma, he suggested putting a specific question to your dreams before going to sleep.

Meanwhile, William Pulle n, a London-based psychotherapist, suggested asking my jog (or in my case the brisk morning dog walk) for advice when I was stuck or directionless. With both techniques, the conscious mind is off-line, and the unconscious has time to work on the underlying dilemmas. I have put together four steps from their advice and my own experiences to pose to clients:

Ask open ended questions. These start with who, why, what, where, and when. For example: what might be the consequence of putting all my money into buying this apartment? Rather than a leading question, would it be a mistake to buy this apartment?

Ask one question at a time. It sounds obvious because you don’t know which one your unconscious is answering, but this is something that I have to stop my clients doing with each other all the time. Another trap, according to Machiel, is asking a plural question for example, about “limiting beliefs.” A better option would be, “what belief is limiting me the most at the moment?”

Split big questions into smaller ones. With big questions like health issues, job changes, and finding love, it is better to start with diagnostic questions and then ask about steps along the way.

Look out for answers from other places. Once you have started meditating on a well-formulated question, there are others ways beyond dreams and exercise through which your unconscious can speak to you. There is synchronicity (meaningful coincidences) and one that works for me: certain sentences in a book I’m reading or a podcast that I’m listening to seem to light up or trigger a small click in my brain. Sometimes, they don’t always make immediate sense — a bit like a dream — but I write them down and look at them. More times than not, they are a response to my question.

Being Brave Opens the Door to Insight and Change

6. Be bolder.

It is easy to get stuck in a groove with clients, using the tools that have been proven to work and not questioning your underlying beliefs. But listening to how other people work has made me think about my own practice. I will give two examples.

Back to Terry Real who highlighted failing strategies that couples use to resolve disputes. These include, “I’m right and you’re wrong.” Neither Terry nor I have ever had a couple where one partner stopped a fight and said, “You know what, I’m wrong about this.” (If they feel they are losing, they just throw in some other dispute where they might have a stronger case.) While I have allowed couples to continue an “I’m right and you’re wrong” dispute — in the hope of finding a breakthrough into a third way — Terry just calls the game out straight away and saves lots of time. I immediately thought, “I’m fed up too.” I need to be braver and speak up.

The second guest who encouraged me to be bolder was Avrum Weiss, a psychotherapist and author of “Hidden in Plain Sight: How men’s fear of women shape their intimate relationships.” When Weiss’ male clients talked about their relationship problems, he was surprised not only to discover they had not told their wives about their grievances but gave him a look that suggested he was crazy to even to suggest it.

“You don’t casually suggest to another woman that he’s afraid of a woman,” he told me. “But each time I did, I got the same response. They would get defensive, but very quickly I would see the idea go across their face and they would say how that made a lot of sense.”

When I thought about my own experiences in the therapy room, I have spent 35 years seeing couples. I have often seen the dynamic where the man would go to extraordinary lengths to avoid his wife’s anger, but I had never had the courage to call it out. But since meeting Weiss, I had been bolder and helped several men understand their fear of being controlled by their wife and why they need her so much.

Between Trigger and Reaction Lies Choice

7. Mine the golden gap.

When an idea comes up from multiple guests, it must be good. In a nutshell, the idea is that we have automatic reactions to conflict or adversity — normally learned as a child (which sort of worked). For example, we will shut down, go on the attack, people please, get defensive, distract ourselves. The list is endless. We don’t consciously choose this reaction; it is like a whistle goes off and before we know it the train has left the station. We are stuck in the same reflex action and there is no going back. As I say to my clients, when the train has left the platform, have you ever seen it reversing back?

So the golden gap is the moment between trigger and reaction. With practice, you can stretch the gap. “Take a deep breath. Where is the feeling? What is it? Please name it.” At this point, the gap has become large enough to make a choice — and therefore has turned golden. Yes, you might want to do the same old actions, but you know where that ends. What might your well-adjusted adult self (rather than your frightened child state) decide to do? How can you experiment and break the old patterns?

***

These days, and perhaps most influential among the seven lessons is the golden gap technique which I use with all my clients. The feedback is that this is one of the tools which brings the greatest reward for their relationship. I am currently working on using it in my own relationship too.

Dead Basement: Opening a Family Therapy Time Capsule

Posted on June 27, 2023February 26, 2026 by Psychotherapy.net Team

It all started sometime last year when I began a quest to clean out my basement — I’d not seen the Swedish “Death Cleaning” shows yet, so I was on my own. I mistakenly thought I could just start tossing the mounds of journals, articles, books, and conference nametags so our kids could be spared the work after I died — but then…there it was…

Family Therapy History Makers

A December 1974 — Volume 13 Number 4 issue of Family Process. A Multidisciplinary Journal of Family Study Research and Treatment, with a faded stamp from the Library of the Philadelphia Child Guidance Clinic. An article by Mara Selvini Palazzoli, Luigi Boscolo, Gian Franco Cecchin & Giuliana Prata entitled: The Treatment of Children Through Brief Therapy of Their Parents. An asterisk: “Translated by Paul Watzlawick.” I smiled remembering a dinner with them, drinking, laughing, and telling jokes. Hmm, when was that…?

As I opened the journal to page 429, something happened. It was as if I were just teleported back 49 years, now the eager graduate school student who just got out of the Army. The moment even had a soundtrack — Amy Correia’s song, “The Bike,” in which she told the story reflecting on the life of her uncle Pat, from whom she’d inherited the bike. She sang that in his youth “… life was laid before him like a platter before a king/he was young, and he was handsome/and the world was alive with meaning…”

So, I re-read the article — a treat from my younger self. It reminded me of when I was in the service and smoked heavily doing mental health reports in the stockade. Cigarettes were 26 cents a pack on post. I remembered watching the puff of the clouds as I exhaled, which evoked another song — a commentary on aging — David Bowie singing, “Time may change me, but I can’t trace time…” So, I kept the journal, for now…. only a hundred or so other journals in the “Dead Basement” — waiting for the right music.

I felt like ditching these old journals would be the academic equivalent of tossing my Beatles albums because they’re “too old,” which is to say that my “toss-to-keep” ratio is terrible. I feel like I’m one of those seniors in an Atlantic City Casino — smoking, hunched over “my” slot machine, air tank and hose to my nose, my ciggy aglow, and hoping for the Triple Cherries that may never arrive. (BTW, the RTP — “Return to Player,” averages $90.00 on $100.00 of betting if you play long enough…)

I wonder if people in other professions hoard in the same fashion. Does a doctor flip through their stack of appendix pictures and say, “Yep, this one’s a keeper…?” And how does all this play out with our respective “bucket lists?” Are therapists really cool “bucketeers,” driving through national forests in their RV’s stuffed with journals, texts, piles of Family Therapy Networkers from the ‘80s (like the one with the EST guy, Werner Earhart on the cover) and plastered with bumper stickers that have the AAMFT logo, a Forest Gump, “Shit Happens” classic, and some retired social work humor, “Social Workers Work…But Not Any More ?” And then, the Fireside Chats — hopefully fascinating and diverse, or like listening to Dwight, from The Office talking about how much he misses his Beet Farm…

Today was rough — Trash Day. I managed to get four journals out. If Gregory Bateson were here, he’d say that I’m only reaching half of the what’s necessary and what’s sufficient equation. While it’s necessary to chuck the old journals, I’m not tossing enough to make a dent in the piles. It happened again this morning. The culprit: a journal with yet another Philadelphia Child Guidance cover, this time with the library stamp for library shoplifters: “Please Do Not Remove from Library.” At that moment, past became present and I could feel it — my personal time machine: “Volume 4 Number 1 January, 1978: A Structural Approach to a Family with an Encopretic Child,” by Maurizio Andolfi and then, “Struggling with the Impotence Impasse: Absurdity and Acting-In” by David Keith and Carl Whitaker.

I hadn’t thought about Carl in years. I was very lucky. I’d worked with him after Minuchin left for New York and started the Minuchin Center for the Family. Carl and his wife, Muriel, came to PCGC “in residence twice for months at a time.” During one of those residencies, he and I were seeing a family together and one of the kids was noisily zooming around the room. I whispered, “Dr. Whitaker, shouldn’t we do something to help quiet things down?” But I said it so quietly that he didn’t hear me, so I said it again, louder — all he said was, “Not my kid.”

The father heard him, got up, and caught his son on one of his noisy rotations and then gently put him in his lap and the session went on successfully. Whitaker had worked his magic in just three words. Today, staring at the journal, I heard him again, and again, he taught me to trust our unconscious, like when ET was leaving Earth to go home, touching Elliot’s forehead and saying, “I’ll be right there,” so too will our memories — even if we don’t have the prompts.

Love is Not All You Need: A Revolutionary Approach to Parental Abuse

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

The Referral Letter

The referral from Dr. Adams, the psychiatrist, read:

13-year-old young woman took an overdose of paracetamol 3 weeks ago. Called mother who took her to Accident & Emergency. Seen and followed up over last 2 weeks. No suicide ideation. Discharged to GP. Family issues. Please can you meet with this family this week?

Session One, Part One: Overdose and Desperation

A few days later as I (Kay) walked into the waiting room at the family medical practice where I worked, I saw Becca hunched over her cell phone, radiating animosity. Her mother Jane sat on one side of her, eyes on the latest New Zealand Woman’s Weekly story, but without the eye movement of a reader. Her father, Al, resigned, stared out the window at the dripping rain. Susie, Becca’s 15-year-old sister, picked absent-mindedly at her nail polish.

My step faltered as I sensed that the meeting ahead of me might be testing but I strode in, hand outstretched: “Hi! You must be Becca. I’m Kay.”

Temporarily startled, a reluctant smile escaped her as she awoke from cyber-land. “Hi, you must be Jane. Hi, Al. Hi, you must be Susie. Would you like to come up?” I gestured toward the stairs that led to my office stairs. As I reached the first landing, I noticed Becca glancing at herself with uncertainty in the floor-to-ceiling mirror that filled the stairwell. The family awkwardly found their way to their seats. I began my usual introductory patter but didn’t get far before Al expostulated, “Look, we need to sort this out! We can’t handle it any longer.” His eyes shot towards the brooding Becca. “She hit her mother in the face the night before last and then she locked herself in the bathroom for hours. We tried to get her to come out and talk but she just shouted abuse at us.”

Jane glanced towards me as she found some words.

“Becca went very quiet, and I got really scared. We thought we had taken all the medicines out of the cabinet after the overdoses, but we couldn’t help worrying after what happened the other week. We took turns sitting outside the bathroom door just listening in. Eventually, she came out and went up to her room. It all started when Al tried to tell her she couldn’t carry on talking to me like she was.”

“Becca,” I ventured, “did you realize that your parents are feeling so scared and don’t know what to do?” My question was met by a “no” that ricocheted around the room like a bullet. “Becca, would you be willing to help me understand what has been going on in your family?”

Becca’s reply began with a fake whine which escalated to foul-mouthed accusations. “She’s always saying, ‘Honey, what’s wrong?’ What’s wrong? What’s wrong? What’s wrong? What’s wrong? What’s wrong? What’s wrong? What’s wrong is that she’s annoying me. My mum is a stupid bitch with no life. That’s what’s wrong.”

I said, “Becca, is this way of talking the kind of talking that is causing trouble in your family?”

Becca said, “This is so fucking dumb.” Susie let out a protracted sigh.

“Becca, stop talking like that. It’s not fair. Mum and Dad have had enough and what have they done to you?”

The door slammed loudly as Becca made her exit. Jane leapt out of her seat, but Al caught her by the arm.

“Let her go. You always go after her. It’s no good. You can’t keep running after her like this.”

Concerned to sidestep the impasse between them, I spoke up.

“Okay, how about I go downstairs and find out what’s happening, and we can take it from there?” Al and Jane nodded, defeated. Susie was pale.

It turned out that Becca had found the back door to the building. I caught a glimpse of her crouched down with her back against her parent’s car, head between her knees. She looked up, saw me and went to sit on the other side of the car, out of view. I asked Emma, the receptionist, to keep a discreet eye on her. When I went back to the room, Jane and Al agreed to sit it out.

Al began, “It’s good you have seen her like this. We are falling apart. We can’t do this on our own.” There was a moment’s silence. Al looked to Jane. Jane’s shoulders began to rock as if she were holding back sobs. Al continued, “Becca doesn’t treat her mother like a parent. I mean she says things to me that I would never, ever have thought of saying to my parents. You just want to slap her face, but you can’t you know?”

Jane, her body stiff, said with a look of desperation, “The other night, Becca was screaming at me that the dinner was ‘crap’ and ‘shit.’ Adam, our 4-year-old, hid under the table. It broke my heart to see him so scared of her because he loves Becca. I feel like we are losing Susie too because she can’t stand it. She is staying ‘round at her friend’s house all the time.”

Al looked towards Susie, raising his eyebrows.

“You’re no angel either, Susie, but at the moment you come a long second to Becca.”

The story unfolded. It appeared that this was a long-standing pattern which had recently escalated from initial bad-tempered-ness to dramatic, life-threatening actions. I discovered that Al and Jane considered that they were being held hostage by Becca’s threats to harm herself, both subtle and explicit. Such threats followed any insistence that she carry out some duty that she didn’t wish to fulfill such as tidying her bedroom or if Jane said “no” to her persistent demands for money or to stay out late.

Jane had begun to fear returning home from work, anticipating that she would be met with yet more demands from Becca, and find herself caught once again between holding out against them or risking further threats of self-harm. Al was also finding home life unbearable. He longed to be able to “fix things” for his family but, in the face of Becca’s threats, had no idea what to do and couldn’t find words for the mixture of frustration, fear, and anger that preyed upon him. Al had started going around to his friend Mike’s house each night for a drink until what had started as occasional visits had become habitual. He felt guilty that he was not at Jane’s side but told himself and Jane, “I no longer have a place in this family. I am sick of being abused in my own home.”

Jane and Al had no idea what to do. Becca had been “seen” by Mental Health Service several times and, after the usual assessments (in which “mental illness,” abuse, and other possible sources of distress were excluded as a cause of Becca’s behaviour), the service had come to the conclusion that the overdose and threats of self-harm could best be explained by what was referred to as “family dynamics” and suggested that Jane and Al seek family therapy. That is how they arrived at my door.

How many parents, confounded by a family life that has become dominated by teenage tantrums, threats, violence, and the dread that their daughter might respond to any challenge to their demands with an overdose or violence, would be willing to talk about how they fear living in their own homes? How many would tell family and friends? Wouldn’t it be more usual for parents in this predicament to remain silent in their humiliation that their own child is abusing them? Of those family members and friends who had some knowledge of the situation, how many of them would be too respectful to speak up about this family’s predicament without being invited to do so?

Could these tantrum overdoses and the tyrannical threat of them instigate a servicing of young people’s every want? What might these young people be led to think about themselves if their each and every whim was serviced? Where would this lead? How might this have them lead their lives? How might this affect their family life? All these questions went through my mind as we reflected on this family and their tribulations; all these questions guided us in our considerations. This is the story of a family worn down by tantrums and abuse. This is also the story of a mother who decides to revolt.

Session One, Part Two: When Loving and Giving is a One-Way Street

“You know, Kay, we’ve always said, ‘love is all you need.’ It’s been our motto. I’m beginning to think we’ve made some big mistakes because I can’t understand why Becca is behaving like this. We have given them all so much love. We have always bent over backward to make sure that they are okay. It’s just so unfair. I try to listen and understand but she doesn’t want to talk to me anymore, and then she starts with her threats. I know I shouldn’t give in to them, so I try and hold my ground, but I feel like I have overreacted. Then I feel bad and give in. I know I shouldn’t. I just feel like I am stuffed!”

Jane’s voice faded into despair. As tears began to form in her eyes, she wiped them away hurriedly with the sleeve of her hoodie. Al chipped in, his voice weary with resignation.

“I just don’t know where we’ve gone wrong.”

I addressed the despairing Jane and displaced Al.

“Do you think it’s possible that all your loving and giving has become a one-way street, and that somewhere along the way your children’s wants have become confused with their needs?”

Jane swallowed hard.

“We’ve always tried to give them what they wanted. I always thought that if we respected them, they would respect us, but they don’t seem to. I just find it so hard to know what to do.”

I asked, “What do you think Al?”

Al shifted uneasily in his seat.

“What’s going to happen to them in the hard world out there?” he said wearily. I wondered if servicing their children’s needs had, contrary to their good intentions, been depriving their children of invaluable life lessons.

“Al,” I asked, “are you concerned in any way that unfairness has crept into the care of your children in that, by giving so much, your children may not have had enough opportunities to learn what they need to learn to live in the hard world out there?” Al had no trouble replying:

“Yep. I don’t think they have any respect for other people, and they don’t know how to be responsible.”

“Susie, what do you think of the idea that your parents have been unfair to you by not helping you to be ready for the hard world out there? Do you think that maybe, out of their love for you all, they need to find ways of mothering and fathering that might seem unfair to you now but may prove to be fairer to you in the long run?”

Susie stared at me, her eyes fixed in surprise, then she recovered herself. “I don’t think they’ve been unfair, but I suppose we have had it pretty easy. I don’t know, it’s getting me down too.”

“Susie, have you been worried about Becca?” Susie’s lip began to tremble. “Susie, how would it be if I carried on speaking with your mum and dad to see if we can find a way to help things be better for Becca and for you all? Would it be alright if I spoke with them without you present? I think your mum and dad need to find the way forwards on their own as your parents.”

Susie’s face softened with relief. Jane and Al agreed that the next time we met we would continue to explore how this habit of unfairness had taken root in the mothering and fathering of their children. I warned them that the road ahead might well be a rocky one and that other parents facing similar challenges are often met with intensified threats from their daughters or sons when they re-establish their parental authority. Jane and Al left our meeting, sobered by the realisation that they could go no further along the road that they had been travelling but relieved to be no longer standing paralysed at this crossroads.

Session Two: The Dif?culty of Knowing What’s Fair and What’s Unfair, What’s Unreasonable and What’s Reasonable?

Jane announced that there had been something of a turning of the tables. The day after our session she had decided that it was time the girls learned to do something for themselves. Instead of doing their clothes washing for them as she had always done, she had left their washing lying on their bedroom floors where they left it and stayed in bed herself for an extra hour. When later that day Susie asked where her clean washing was, Jane simply said, “Oh, I’ve given up doing your washing now.” Much to her surprise, Susie asked her to show her how to use the washing machine. Not surprisingly, Becca had left her dirty washing in a heap in her room.

Al, who was running late, joined us. I put him in the picture.

“We were talking about wants and needs and I was asking Jane about whether or not your parenting in the past has been about 'loving and giving?’”

“Well Susie has been getting too much until now,” Al responded. “My sister set her up with an interview as a summer lifeguard and she didn’t even bother to go. Lynette was really annoyed about it and had a real go at me. She said, ‘You two have to toughen up with those girls.’ I’ve realised she’s right.”

“What do you think you have been serving? Have you been serving her wants or her needs?”

“Her wants!”

“What do you think her needs are?”

“Her needs are to take some responsibility for herself. She hasn’t lifted a finger all holidays. She’s just sat at home emptying our fridge.”

“At what point do you think mothers and fathers should let their children know that if they as parents continue to take responsibility for them, they will be depriving them of taking responsibility for themselves?”

“Well, we do but we don’t stick to it,” Jane said.

“Yes. We lay down the law and then we give in,” Al replied.

“Looking ahead to when Susie is 40 years old, do you have any idea what she might wish you had done or said to her right now, aged 15?” I asked.

“She’d say ‘take responsibility for yourself’ wouldn’t she?” Al suggested.

“I suppose so, but we would have to make her do it and I would find that very difficult,” Jane responded.

“You said last time we met that you have a motto of ‘love is all your need.’”

“Yes, you know I have always thought that if we just loved our kids, it would all work out,” Jane said. “Last Sunday morning was a real low point. Becca started swearing at me when I got home from a late shift and was on my bed with all her friends drinking and eating. I found myself thinking ‘whatever happened to my lovely daughter?’”

“Do you think it’s possible that in the past, even though your intentions have been so very loving, love has been confused with giving in to what your children want?” I enquired.

“I guess so. I just thought they would love us if we loved them and that if we respected them, they would respect us,” she said.

“Are you coming to question how children learn love and respect for their parents and others?” I asked her.

“Yeah, I guess I haven’t made a point of them respecting me so maybe they haven’t learned it. I lose their respect for myself every time they say ‘no’ to me and I let it go,” she said.

“Al, what do you think about this? How do you think children learn to be loving and to practise respect?” I asked Al.

“Well, it’s been harder for Jane,” he said, adding, “I’ve always worked long hours and before we had Becca, we agreed that she would stay home and be a full-time Mum. We were really hanging in for Becca.”

“Yes,” Jane agreed. “You see Susie isn’t Al’s. I had Susie when I was 17 and I was a single parent until I met Al when Susie was 2. We had some problems and had IVF. Then she was preemie and we thought we were going to lose her. It was a terrible time.”

“Given you had to go through so much heartache to have her, did you ever think that Becca deserved special treatment in any way?” I suggested.

“We were just so thankful that she had survived,” Jane admitted. “Looking back now, I tried to give her the best of everything, and we doted on her.”

“Yeah, it was our one time away from her and she was all we could talk about,” Al said.

“Do you think that loving Becca so much has led you to be especially sensitive to her moods, wishes, and feelings?” I asked them.

“When I look back now, I think so,” Jane said.

“To be honest, she was very spoilt,” Al added after.

The Letter

The next day I wrote Jane and Al the following letter.

Dear Jane & Al,

It was good to meet you yesterday. As I mentioned, I often write to families after our sessions to ensure that I have adequately understood their situation and in addition to ask questions I wish I had asked during the session itself.

Sure, enough some questions came to mind whilst I was reflecting on your situation. I would be most interested to hear your answers or any thoughts you might have about these questions next time we meet. If you think that I have not described what we talked about fully or have misunderstood your situation in any way, could you also bring it to my attention next time?

Jane, before Al arrived you talked about some changes you had made. You said that a couple of days before we met, you had decided to have a ‘lie in’ and had resolved that you were no longer going to do the girls’ clothes washing. You also informed me that you felt you hadn’t had enough expectations of the children in the past and that you wished that you had started years ago. But you said that your lie-in was not as peaceful as you had hoped because you found yourself troubled, wondering whether or not your expectations of the girls were unreasonable or unfair.

Jane, do you suspect that your expectations may be having a late growth spurt but that perhaps, and very understandably, you are feeling a few growing pains? After all, have you ever noticed how overnight changes often feel as uncomfortable as a new pair of shoes to begin with?

Jane, do you have any ideas about why it was difficult for you to work out what expectations might be reasonable and fair? Do you think it may have been in part because your expectations of Becca at least, have been so shaped by the weight of your gratitude for her very existence?

Now that you have decided that your children can learn to serve themselves rather than being served, what kind of response do you think you might anticipate from them as time goes by? Do you think that they will take kindly to your new expectations which express your love for them in a way that serves their needs rather than their wants? Or do you think they might protest the changes in some way or other?

Jane and Al, towards the end of the session we talked about how separating your children’s wants from their needs had been especially hard with Becca.

Isn’t it understandable that if you have waited so long for a child and then when she is born and you are in fear for her life, you might want to treat her with especial care? Is it any wonder that your love and concern might leave you blinkered to some of her needs and sensitive to her wants?

Jane, do you think your ‘special care’ of Becca might have had a bearing on ‘giving in or setting boundaries and sticking to them?’ Thinking about it now, do you suspect that weak boundaries might be even more painful for you than for her in the long run?

You both told me that you don’t want to make your children unhappy, but then you talked about some realities that life holds. You said there was a difference between real unhappiness and tantrumming. If you always say ‘yes.’ if you’re always ‘manipulated.’ Where do your children hear ‘no’ from? What kind of lives will they lead if they never hear ‘no?’

Al and Jane, at what point do you think a mother or father should say to a young person: ‘I will not allow you to have such power over our family anymore; we are in charge, not you?’ Truth be told, what do you guess Becca would most like her parents to do right now?

I cannot believe that departing from the ways in which you have mothered and fathered your children in the past is going to be easy. In fact, would you consider that it might be one of the most difficult things you might ever take up in the course of your lives?

I look forward to meeting with you again on the 4th of March. Best wishes,

Kay Ingamells

Session Three: ‘Self Sensitivity’ 90%, Sensitivity to Others 10%

Jane came on her own to the next session. Although Al told her he was busy at work, she suspected that he had been overcome by his feelings of powerlessness and resignation. We began the session with my reading the letter aloud to Jane. Jane reported that the letter made her “realise I thought being a loving mother meant taking care of them in every way 100% of the time and this has made it difficult for them to respect me as well as for me to respect them.”

Once again, she reported some novel developments. Jane had “put her foot down” when Becca had decided at the last moment that she didn’t want to attend her surf rescue training.

“I said, ‘we are going in the car now,” Jane said. “And when we got there, she said, ‘Don’t make me go. You’re so mean, I hate you.’ I found it really difficult, but I insisted she stay. I went away feeling really upset but when I came to pick her up, she said she had enjoyed it.”

“Did you take a stand for what you knew in your mother’s heart was right only afterwards to be undermined by guilt for not responding to her wants?” I replied.

“Ummm I did.”

“How come you put your foot down even though the guilt was putting such pressure upon you to give in?”

“Well, I thought it was the best thing for her.”

“Does putting what was ‘best for her’ first rather than giving in to her wants say something about your wisdom as a mother?”

“Yes! That I know what’s right for her and it’s okay to say it and insist that she does what she says she will do.”

“Do you think guilt would have got in the way of your motherly wisdom in the past?”

“I think it would have. I wouldn’t have wanted the children to plead and cry. I wouldn’t have wanted them to be unhappy. I would have brought her home again.”

“What has enabled you to act on your motherly wisdom and use your motherly voice lately rather than be sidetracked by their pleading and crying?”

“I don’t know.”

“You’ve given me one example after another of how you have used that motherly voice very powerfully and afterwards.”

“And yet I don’t feel in control. I don’t feel in control at all.”

“Do you also think it is possible that using your motherly voice is uncomfortable because you are not that used to speaking with it yet?”

“I said to Susie when she butted in, I said, ‘I’m the mother. I’ll decide what Becca will do and what she won’t do. I don’t need input from you.’”

“Do you think that it’s possible that your children have developed over-sensitivity to themselves and to their own feelings and insensitivity to you and to your feelings?”

“Yes!”

“If you were to put that in percentages, what percentage of the time do you think they are sensitive to their feelings and what percentage of the time do you think they are sensitive to your feelings and the feelings of others?”

“They consider their own feelings 90% of the time. Al is really kind and generous and caring, but certainly he would put what he wants to do above anything or anyone else, especially me.”

“What happens to your feelings and to your needs?”

“They get forgotten.”

We talked about the effects this imbalance of sensitivity, e.g., self-sensitivity, versus other sensitivity was having in her relationships with her children and their relationships with her. Some of the questions I posed were:

“Would you be interested in restoring the balance between Becca’s over-developed sensitivity to herself and her under-developed sensitivity to others and in particular to you as her mother?”

“What kind of struggle would you expect if you were to pit your mother’s wisdom against the widespread mother guilt?”

“Overdoses as tantrums” and a big night out.

A month later, I had a call from a worker from the after hours Mental Health Crisis Team to report that Becca had taken another overdose. The overdose had followed an argument with her mother about tidying up her room in which Becca struck her mother in the face breaking her glasses. Jane had to go immediately to her optometrist as she was due to start work an hour later and could not work without them. Becca tried to stop her mother leaving the house, but Jane had no choice but to do so. Becca took the overdose as soon as Jane left. This overdose posed a greater risk than the earlier ones and it looked like she was, in a manner of speaking, “upping the ante.” Jane became concerned that Becca would take her own life and so arranged a safe haven for her at Becca’s aunt’s home for a few weeks.

Becca was seen for an urgent psychiatric review. The psychiatrist concurred that Becca’s overdoses appeared to be an extreme reaction to her parents attempting to set appropriate boundaries. A safety plan was put in place with the parents, and I met Jane and Al a couple of days later. To my surprise Al and Jane were not as shaken by the overdose as I had expected. Instead, they concluded that Becca’s extreme behaviour was her way of “testing us.”

We discussed how they had dealt with tantrums when their children were toddlers. On seeing the similarities between toddler tantrumming and Becca’s extreme form of teenage tantrumming, Jane and Al became inspired with a renewed courage and confidence. It now appeared that perhaps this was a problem that they recognised and not only had some experience in handling but could rightfully assume they might overcome. The next morning, I had a phone call from Jane. She had discovered from the mother of one of Becca’s friends that Becca was planning a big night out to a nightclub in the city with a group of teenage friends. The nightclub called Krave was in the heart of the city, an hour by bus from the suburb that Becca lived in. Jane and Al told Becca that she couldn’t go as she was underage. Becca was outraged and insisted that she would go regardless. Jane later discovered that $100 was missing out of her purse and challenged Becca who, as usual, denied taking it.

Jane and Al enlisted the help of Becca’s aunt, uncle, and elder brothers to come around that evening. Despite this, Becca made her escape out of her bedroom window.

The team hot-footed after her, combed the local mall and found her waiting at a bus stop with two friends. Al took hold of her arm and asked her to get in the car. Becca began to scream “blue murder,” shouting “you are not my parents. I don’t know you. Help someone! Help! Help!" The passers-by that had assembled called the police who arrived very quickly at the scene. The police believed Jane and Al’s version of events rather than Becca’s street theatre. Becca’s protest resulted in her being handcuffed, read her legal rights and taken down to the cells.

I asked Jane how she felt about the evening’s events.

“It’s good to be in charge at last. I have never seen Becca so demure. The police wouldn’t release her until she had promised not to harm herself.” Guilt had not had its way with Jane this time.

Session Four: Instigating the Revolution

While Jane and Al had begun to turn the tables on the habits of parenting which had flourished on their sensitivity to their children’s feelings and servicing of their wants versus their needs, I was concerned about the extreme nature of Becca’s actions and that Al and Jane’s newfound determination could be compromised in the face of them. Consulting with David in supervision, we decided that a community approach was needed to match the gravity of the situation and to provide sufficient reinforcement for Jane and Al’s fledgling initiatives. While no approach was without its risks, any alternative

Breaking the Rules: When Parroting is the Best Approach in Therapy

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

A Non-Directive Approach

Carmen is your new ten o’clock client. You are excited to be of assistance but you will soon discover that this enthusiasm is short-lived. You have decided to begin with a Rogerian person-centered approach since this is your typical modus operandi and is generally very effective in most instances.

The first rule that runs through your mind is that like virtually every other non-directive therapist, you were trained to employ paraphrasing and not parroting when responding to the client. Parroting refers to repeating back the exact words that the client has said, without any interpretation of evaluation.

After Carmen utters a few sentences, you respond. Secretly you feel greatly convinced you were hitting all the desirable keys on the Carkhuff Empathy Scale. But Carmen’s response was not even close to what you expected.

Her reply, “No that’s not what I’m saying, not at all. I believe you are missing the entire point of what I am attempting to convey.”

Okay, let’s try it again. Carmen tells you more and once again you paraphrase using fresh words only to hear, “Seriously! Are you listening to anything I am saying or am I just paying you to talk to the wall?” (Your thought, not verbalized, of course, is: Um, no, your insurance company is just paying me to talk to the wall.)

Focusing on the positive, I was convinced I would not need to spend a lot of time making Carmen more assertive.

This is déjà vu therapeutics. It immediately occurs to most helpers that on rare occasions, we have all experienced this dynamic with other clients. The dilemma is always the same: Is it truly the fact that your responses are pathetic or is Carmen (and similar clients) just the difficult, resistant clients from Hell?

Unfortunately, without running a complete battery of tests, consulting a string of experts, perusing a host of journal articles, and watching a video of the session again, it is next to impossible to know for sure. And yes, your own negative self-talk haunts you as you recall the sage advice of your uncle George who often quipped during your grueling time in graduate school, “Forget about this counseling and therapy graduate school stuff. Become a plumber like me.”

In essence, you really have no way to be 100% certain whether your therapy skills are a bit rusty, your uncle George was on to something, or if Carmen is just the resistant client your professors warned you about.

And surely you would never turn to parroting since your graduate faculty depicted the horrors of this evil technique. Moreover, every book, article, and mentor in the field insisted parroting was negative as well. In fact, it had to be true, since I have mentioned the dangers of parroting in my own books.

Even the ultimate expert Chat GPT AI says, “Parroting can be seen as invalidating and unhelpful for clients. Chat continues, “Parroting is condescending and dismissive to the client and does not allow the helper to add interpretation or elaboration.”

Does Therapeutic Parroting Work?

Having said that, ironically, I am going to suggest that the solution to your predicament with clients like Carmen lies in using a fool-proof intervention that can help you diagnose the situation virtually every time: parroting. Yes, parroting, the concept your professors warned you to avoid like the plague.

Your answer will become crystal clear when the client responds to your intentional parroting. Hence, if Carmen says, “I hate my mother,” and you violate the advice of your graduate faculty, and virtually all texts on the subject and say, “You hate your mother,” and Carmen replies, “No you really aren’t getting this, are you?” We can begin to suspect that her combative or perhaps clueless behavior is fueling the discord.

Assume Carmen’s next response was, “I had a terrible childhood,” and you come back without a shred of creativity with, “So you had a terrible childhood” only to see Carmen roll her eyes and say, “Where did that come from? I mean, really. No, I never said that. Are you really trained to perform therapy?”

Now you know Carmen has some issues and most likely your psychotherapeutic skills, although they may not be ideal, do not need a complete overhaul.

At this point, you can choose to confront Carmen either now or later or implement whatever strategy you deem appropriate, but at least you will have convinced yourself the issue is within the client and not you.

You may be asking if I have just invalidated a long-standing tradition in treatment. Well, not really. My guess is that in perhaps 99% of your interactions with clients, your graduate faculty got it oh-so-right when they recommended you refrain from parroting. Parroting is used for the 1% when a client has put your paraphrasing, summarizing, and reflective listening skills in a double bind.

I must disclose that I have a slight advantage over most therapists. On rare occasions when I need a little encouragement, I have my two pet African Grey parrots in the next room ready to help if I can provide a small treat.

Questions for Thought and Discussion

How effective has parroting been in your own therapeutic work?

What techniques do you find most effective in demonstrating that you are listening?

Are there particular clients with whom parroting is more effective? Less effective?

Satya Byock on the Search for Meaning and Stability in Quarterlife

Posted on May 31, 2023February 11, 2026 by Psychotherapy.net Team

The Journey of Quarterlife

Lawrence Rubin: Thanks for joining me, Satya. You're a psychotherapist in private practice and founding director of the Salome Institute of Jungian Studies in Portland, Oregon. Your newly released book, Quarterlife: The Search for Self in Early Adulthood, deals with the developmental and clinical challenges of people in this phase of life. What about this phase of life is important for clinicians to appreciate?

Satya Doyle Byock:

my interest in this time of life coincided with my desire to be a therapist, which is to say when I was in my early 20s

My interest in this time of life coincided with my desire to be a therapist, which is to say when I was in my early 20s. I could not find anything in the psychological literature to help me understand what was happening in my life. Developmental psychology has historically focused on childhood and the teenage years, and then there's a big jump to midlife and the midlife crisis, and increasingly into the older years of adulthood.

But whether you're a clinician or a person going through this time of life, those years of the first part of adulthood are historically synonymous with normalcy. With just being an adult, with just getting your life together and buying a house, getting married, and having kids. And so, it was very disorienting for me to be so confused and to experience anxiety, depression, and existential questions. I truly felt as though there was a vacuum of information that would either help me get oriented or make me feel better. So, my journey really came out of my own anguish in those years, my journey to be a clinician.

LR: Is there such a thing as “normal” when referring to the quarterlife passage?

SB:

what I'm trying to get away from is the idea that there is one single picture of what “normal” looks like in adulthood,

It's a great question. In my book, I lay out two extremely broad types of quarterlifers, who I define as “stability” types and “meaning” types. What I'm trying to get away from is the idea that there is one single picture of what “normal” looks like in adulthood, which is to say that historically, that has primarily emphasized gaining stability. But that’s a very externally oriented goal. And so “normal” quarterlifers have been those who don't cause a fuss in quarterlife, those who are pretty comfortable adhering to economic goals and expectations of dominant culture, as well as to what are considered heteronormative gender roles. The expectations of a man to get a job, or a woman maybe increasingly to have a job and have finished college, but to be moving towards marriage and children.

And for a lot of folks, those normal goals have never worked, and they are increasingly feeling unsafe and uncomfortable. So rather than defining “normal,” I'm trying to define a broad spectrum where we can see our quarterlife clients, and quarterlifers can see themselves so they can better understand how to obtain a sense of balance, and how to get to an experience of wholeness in quarterlife, versus trying to be normal and just adhere to social expectations.

LR: “Normal” is such a moving target. Is it possible that a client could arrive at quarterlife stable, ducks in a row — house, job, relationships — but still be hurting because the meaning part is not yet in place?

SB: Absolutely, that's what I talk about in my book. The stability types may feel quite secure in the external world and in doing what society has asked of them, but at some point, they are going to ask, what else is there? Is this all there is? And theirs becomes the search for meaning in some way. Of course, that shows up differently for every individual, but that inner longing for something more tends to come for all of us.

but the so-called midlife crisis has always really been about people who I refer to as stability types — checking all the boxes, reaching midlife, and then saying, wait a second. is this all there is?

And so, I speak about stability types starting a journey towards meaning, as happening more often in quarterlife than it used to. But the so-called midlife crisis has always really been about people who I refer to as stability types — checking all the boxes, reaching midlife, and then saying, “Wait a second. Is this all there is?”

LR: Peggy Lee couldn’t have said it better. Some might wonder if dividing quarterlifers into these two camps — stability types and meaning types — might be overly-reductionist. I think society is sort of plagued by binaries, anyway. Are you comfortable with the binary?

SB: Well, no, I'm not comfortable with binary. To write a book and to speak about any kind of theory we need to be as clear cut as we can be, but I try to indicate in the book that while I am doing my best to assert a theory and a system of working with folks — and a system in which quarterlifers can see themselves — I am not trying to introduce a strict binary. That was never the point.

So, I really try to emphasize in the book that the goal is wholeness. The goal is a unification of these opposites. It is a journey towards having stability and meaning. But clinically what frequently happens is that our understanding of quarterlife is reduced to a search for stability. When meaning types walk into our office — and you can see this in other books about this period of life — the focus just gets to be about how to get them stable. How to get them moving towards the normative goals. And very frequently they crumble as a result.

Meanwhile, if those are the goals for clinicians in quarterlife, and a stability type comes in, there's very little to explain what's going on with them, and they frequently leave clinicians’ offices with less understanding or with minimal understanding about why it is that they're suffering, because they “should” have everything and be happy with what they have.

I attempt to bring this spectrum of types into our discussion to say that the more we can locate ourselves on this sliding spectrum, between stability and meaning, the more we can understand what we are longing for, what our shadow is, and what our longings are about, and as a result get oriented.

Province of the Privileged

LR: I imagine that the quest for stability and/or meaning are neither linear nor sequential. How does this show up in therapy with the quarterlifer?

SB: }That’s exactly right, and so that's the whole discussion, right? That is to say that both of these goals are part of quarterlife. It’s not just that stability is quarterlife and meaning is midlife. That's been the developmental psychological framework; whether we have spoken about it explicitly or not, that's what it's been. What I'm expressing is that the journey of quarterlife is like two strands of DNA; these two elements are what we are trying to weave together all through adulthood. And we need to speak about that up front, and orient quarterlifers to the fact that they are going to have existential questions, especially on a planet with so much overlapping crisis all the time. We can't just keep emphasizing trying to get them back to stability and normalcy.

LR: With so much of our society in crisis, isn’t the pursuit of meaning the province of the privileged?

SB: No, we all seek meaning. We all seek meaning on this planet, whether you are a quarterlifer in a refugee camp, or a quarterlifer who has inherited millions of dollars. There are questions about why you are alive and in the circumstances you're in that you want answers to. And privilege is absolutely a part of what is possible for those two groups, there is no question about that. And I try to open that up much more in the conclusion of my book where I talk about the systemic issues and social issues that that can make a fulfilling journey of existence nearly impossible for, frankly, billions of quarterlifers. I don't know the literal numbers, but enormous numbers of quarterlifers around the world don't have their basic needs met.

refugees arguably are predominantly made up of quarterlifers — people who are trying to pursue their journey of existence and find a better life, a better adulthood

I don’t think that the search for meaning is something that only exists for the privileged. I think it's actually infantilizing, in the end, for us to say as much, because people in every circumstance want to know how to feel better and have the best, most enriching life they can have. Which is why, in fact, refugees arguably are predominantly made up of quarterlifers — people who are trying to pursue their journey of existence and find a better life, a better adulthood.

LR: Irrespective of possessions or stability, this reminds me of the work of Viktor Frankl and how nothing is really stable about the life of refugees, of political prisoners, of prisoners and the oppressed or marginalized.

SB: That's right. Well, they're overlapping — this need for survival, this need for safety and comfort, and this longing for a sense of purpose in the world. If we really see it as the physical needs for safety and comfort, and the emotional and existential and mental needs, they're just overlapping all the time no matter who we are.

Clinical Work with Quarterlifers

LR: Are there particular symptoms or diagnoses that quarterlifers will bring to you?

SB:

we have wanted to reduce the quarterlife population to the complaints of millennials, say, or to social media issues, or to dating, or something

I think like any demographic, quarterlifers come into therapy with a wide, wide range of issues, complaints, and anguish. And so, I'm asked this question a lot, but I struggled to answer it, because I find that we have wanted to reduce the quarterlife population to the complaints of millennials, say, or to social media issues, or to dating, or something, that we want it to be concise. In fact, quarterlifers are having a human journey. And on that journey, there is grief. People lose parents, they’re sorting through adoption issues, they're simultaneously thinking about pregnancy and parenting, they're dating, they're seeking partnership, they're trying to understand their sexuality and sexual orientation, their gender, and they're making sense of their race and ethnicity. Sometimes they're dealing with immigration issues, and on, and on, and on. People, however, may very well call and say, “I’m depressed, and I don't know why. I'm extremely anxious. I'm having panic attacks. I’m having difficulties with my father. I'm having confusion with my mother.” There may be some initial presenting issues, just like any client who walks through the door, but of course we know the story grows from there once they get into our office.

I will also say that most people don't identify as quarterlifers. I'm really trying to introduce this term, because I find the other terms to historically be very pejorative and misleading. The idea is young adulthood versus a stage of adulthood, for instance, in which we need to see a whole person, not just a young person tripping and falling.

LR: Does your therapeutic approach, technique, or techniques differ if you're working with a client who presents with, say, anxiety, and is really at a deeper level struggling with meaning? Or a client who is depressed and is seemingly struggling with issues of stability? I don't mean to be so reductionist.

SB:

stability types often really benefit from a more imaginal body, artistic approach, even though they resist it

Well, yeah, it's a good question. I will say, I think my techniques certainly are, well — let me start over and say — I approach each individual differently, certainly. But if we want to speak about broad strokes, I might say that stability types often really benefit from a more imaginal body, artistic approach, even though they resist it. That's what's in their shadow. That's very often what they are seeking, but don't know how to get there, to a more right-brained approach. And meaning types can very often benefit from a little bit more of the cognitive-behavioral approach, a little more of the left-brain structure.

Neither can be forced on them, and neither can be imposed on them. But while stability types need to deepen into a sense of meaning and kind of a holistic experience of the world, it's helpful for clinicians to give them a taste of what that feels like. And similarly, as meaning types are often kind of floundering with executive functioning and external world stuff, it can be helpful for clinicians to be gently introducing structure in that way within therapy.

LR: As you were talking, it almost seemed antithetical to me. My first impulse is to think that stability types, as I understand them, would benefit from a more concrete approach, because they're anchored more in the world, in the present, and in the zone of achievement and acquisition. Whereas the meaning types might be ready for or open to more existential, right-brain, artistic, creative. Initially, I think CBT and all that stuff might be more applicable, but you're saying it's the opposite.

SB: Well, it's really a question of what they are missing and where they're headed, right? So, there's no question. I think stability types are much more comfortable with more of a CBT approach, typically, than an imaginal body, art therapy approach. And yet my experience is, they ultimately feel quite unsatisfied if they don't experience in therapy a sense of what it is that they're looking for.

If they come to therapy over a period of four or five weeks and then leave without a feeling of expansion or a feeling of that inner anguish being witnessed and being met, they're unlikely to continue coming back. And so, while they think what they want is structure and just a couple of checklists for what they can do at home, it's not ultimately solving the larger issue. Which is that there's a deep question of dissatisfaction happening in their souls, and that needs to be met. It's not just about typically — I mean, sometimes it is — but often it's not just about anxiety or depression on a surface level.

LR: In this context, but on a side note, I think we diminish children when we fail to consider that children have existential needs.

SB:

we're born with questions. that's our birthright, and it's sort of irrelevant what age you are, really

No, but that's exactly right. And I would say again, similarly, of people in lower socioeconomic circumstances or people in other parts of the world, it's the same thing. We're born with questions. That's our birthright, and it's sort of irrelevant what age you are, really. But you're absolutely right. We have been discounting that for decades. I mean, we discount that in most decades of life until people reach midlife or the elderly years, when we kind of sanction the search.

LR: I’ll jump from childhood to later life for a moment. I read an essay by social gerontologist William Randall, whose idea is that we can help the elderly by helping them re-narrate their story, rather than one of decrepitude and impending demise, to one of expanding and growing. So right here in the middle is this emerging adulthood.

SB: That’s right. And I will say again, just for the transcript really, I don't use the term “emerging adulthood.” That's a Jeffrey Jensen Arnett term, and I'm trying to get away a little bit from that as well. Because again, I think this isn't so much about emerging anything, as a stage unto itself.

LR: As a quick aside, did the pandemic alter the trajectory of your quarterlife clients in particular ways? Or did you notice how the how the pandemic left its imprint on quarterlifers?

SB: Sure, but again, it wasn't a singular experience. For some of my clients it was a huge blessing, in that for the first time they had adequate unemployment money coming in and weren’t feeling the pressure to hustle from one place to another all day long and feeling exhausted and feeling depleted and depressed. So, some of my clients finally addressed emotional or childhood issues that we couldn't find space for before. Or they were able to deepen into intimate relationships they didn't have space for previously. There were many blessings in that respect. Ironically, of course, the opposite was also true, which is that for many quarterlifers it was extremely isolating. Their symptoms of depression and anxiety increased. It absolutely had an impact, as it did on all our lives, right? But it wasn't a unilateral, monolithic experience.

The Real is What Works

LR: Nothing is singular and monolithic. It's such a nice fantasy to think that things can be reduced. How does your own approach to therapy jive or not with the predominant contemporary quest for evidence-based treatment?

SB:

to quote Carl Jung, the real is what works

You'd have to ask the evidence-based people, I guess. To quote Carl Jung, “the real is what works.” And so, I am working all the time, in every session, to stay present with my clients and be in a deep relationship with them, to understand, is this working? Is what we are doing affecting your life? Is it having a healing effect? Is it having an enlivening effect? And if the answers to both of those questions are “no” or “maybe,” I want to do a deep check-in of what we're doing and how to reorient. Because for me, the real is what works. And that must be on an individual level, not statistically. That's not the work I do.

LR: Can you give me an example from your clinical work?

SB: In other words, what works is what works, you know? And so, for me, it's not the statistics of any given approach, because in any statistical analysis there's people for whom it's not working. And so, as clinicians, our work has to be exceedingly individual, as individual as it gets. So, if my techniques, if my approach is not working for one of my clients, that's an issue. That either means I need to reorient, or I need to refer them to somebody who is going to be able to support them. Because they're not statistics, right? What works is what works, and that's where I try to stay present.

LR: One of my dear friends and mentor used to say, “people are not evidence-based.”

SB: I'm not a dogmatist. My clients don't have to buy anything. We're working together for their benefit.

LR: Do you use art, and mandalas?

SB: I’m not an art therapist. I have a strong Jungian background. My tool is largely — certainly, my training and my theories are useful — is me. It's my relationship with them, my presence with them, my understanding of them, and then the techniques, whether it's trauma-informed care, dreamwork, or any number of things that we might do together. That's sort of secondary to the deep relationship that we have.

LR: Does the course of your work tend to be longer or shorter?

SB:

I am allergic to stagnation

Well, I have a lot of very long-term clients. And for me, again, the goal is always to stay present with whether we are continuing to have value in their lives. I am allergic to stagnation, so if things are stagnant and uncomfortable, I try to adjust that. And if things are stagnant and comfortable, I suggest the possibility of ending our work together, so they can move out into the world and kind of shift our dynamic and relationship. But generally, my work tends to be longer-term than shorter-term.

LR: Can you give an example of a client where stagnation had entered the therapeutic work, and something you did to “de-stagnate?”

SB: Well, I think there's a lot of ways in which busyness, but also dissociation, trauma, and the freeze state, are reflections of stagnation. There are different ways in which we can kind of get stuck as clients, and that clinicians can inadvertently perceive that as being done with therapy. There are ways in which stagnation and stickiness are defense mechanisms, you know? There are other ways in which stagnation can be manifest in compulsions or addictions, where the clinician is unable to have any kind of effect until the client chooses, really in some significant way, to shift their relationship with that compulsion.

I terminated with clients because I couldn’t find a way to motivate them to battle with those inner demons, at which time it felt like termination was the best intervention I could offer. And there have been other times when clients reached what they were seeking and felt done, and that was a cause for celebration. That felt less like stagnation to me than a genuine completion of therapy.

LR: A rarity for many therapists, especially when there's issues of insurance and accountability to an external payor. Have you worked with suicidal quarterlifers?

SB: I think most clinicians have suicidal clients at some point or another, and I think there are more of our clients who are suicidal in some respect than we always know. But there's certainly clients who have been hospitalized, or who have been significantly suicidal, who I'm glad to say have felt significantly better and gotten to a place of thriving in my practice. And that's absolutely a goal for me, of course.

LR: I imagine if a client was acutely suicidal, that might present different challenges for you given your orientation.

SB: Of course, but again, presence, care, relationship, and me modeling that life can be beautiful. all have a significant impact.

Unique Quarterlife Issues

LR: For those folks who are no longer able to see that life is beautiful or meaning is possible, it sounds like you're journeying with them. Have you found unique challenges around gender identity issues in quarterlifers that may be different from gender identity issues in adolescents or later life?

SB:

I think gender identity has always been a huge component of the quarterlife years

Well, I don't know that they're different at different stages of life, per se. I mean, I work with quarterlifers. Let me start there. You can scratch the first part. I work with quarterlifers, right? So, I think gender identity has always been a huge component of the quarterlife years, in that we have been historically trained towards extremely heteronormative gender roles in quarterlife, almost specifically. You know, we might jump from gender reveal parties to, okay, now you're a 25-year-old. Are you going to have babies, women? Are you going to get a big important career, men?

In other words, we've been trained towards these gender roles in these adulthood years with remarkable ferocity, and that's what so many quarterlifers are rejecting, and have been rejecting, from Sylvia Plath's The Bell Jar and the entire feminist movement to a lot of what we're seeing around the exploration of gender and attempting to break out of the gender binary now.

The question for clinicians in these years is to stay really present with that, in an utterly nonjudgmental way in a deeply curious way and invite and encourage our clients to explore whatever they need to explore around gender. Because it's a sticky and complicated issue of self-identity with a lot of social implications.

I have a number of trans clients. I have clients who identify as nonbinary. I have clients for whom gender has never really posed that much of a question, but it might be something we talk about as well. It’s critical and it's an especially important part of the quarterlife years. I will also say, the question of the masculine and feminine is core to Carl Jung's psychology, and that search for wholeness is core to Carl Jung's psychology, and that that really does also inform the stability type versus meaning type spectrum that I lay out in which, on some level, it's also still the question of masculine goals versus feminine goals, in extremely broad terms, but it's a search to have all these things. The extroversion and introversion, the masculine and the feminine, the stability and the meaning.

LR: And I would imagine that there are trans clients who have made the, if you will, full transition to the gender that they desire and still seek meaning, who still feel perhaps that something is missing.

SB: I would say, of course that the human experience of the search for meaning is endless.

LR: Endless. What are some of the challenges when working with quarterlifers and their elder parents? Have you noticed anything unique or challenging there?

SB:

we’re walking, moving, and separating bit by bit from our parents in that way, but that continues in a significant way in quarterlife

Chapter six of my book specifically emphasizes this, although it's part of the entire journey. But I talk about four pillars of growth in quarterlife. These are nonlinear pillars, just like stability types and meaning types are a non-strict binary. But I talk about the first pillar being that of separation, and a very, very significant developmental step of quarterlife — which goes on for frankly decades, but certainly needs to be emphasized in these years — which is understanding who we are as separate from our parents. Both in terms of physical space, financially, but also in terms of values, belief systems, anxiety and depression, all the ways in which we find ourselves tied to our parents. And working on shifting those and separating that sense of self from our parents. It’s a continuation of the work we start when we were toddlers. We’re walking, moving, and separating bit by bit from our parents in that way, but that continues in a significant way in quarterlife.

And I do think clinicians would better serve all our quarterlife clients to understand the nuances of that, because we've really kind of emphasized that separation is a midlife thing. When our parents die, we do these layers of separation. And I think we're all better off the more we're consciously working on doing that decades prior.

LR: That developmental task of separation appears in the beginning and end of life, both for the quarterlife and their elder parents. What about quarterlifers and their kids? Any unique challenges?

SB: Well, most quarterlifers don't have adult children. They'd be mid-lifers then. So quarterlifers, historically, barring teenage and child pregnancies, the horror of young pregnancies — most parents are quarterlifers. Most are parents of young children.

When we talk about young parents, we’re talking about quarterlifers typically. And this is also a core tenet of these years. Often, they have historically really been viewed as the years of reproduction, which is why they became sort of so fixed in notions of just stability and kind of biological requirements — marriage, children — that the work of quarterlife has really been seen as being parenting. Make money, buy a house, raise the next generation, then search for meaning. That's been the kind of framework.

So, I can't say there's unique challenges for quarterlifers. Again, most people who have kindergarteners, fifth graders, or whatnot, are often in their quarterlife years. Less and less, I mean, as parents get older when they first have their first child. But I will also say that a huge challenge for this age group is socioeconomics and utter lack of support for parents and society, that we don't have universal preschool or child income support for low-income parents. There are countless issues quarterli

How to Use Inner Processes in Play Therapy to Help Traumatized Children

Posted on May 30, 2023February 11, 2026 by Psychotherapy.net Team

I am a Safe and Sound Protocol provider (SSP.) In my clinical experience with the protocol, I have worked with children who have experienced severe trauma including physical abuse, sexual abuse, neglect, disruptive behaviors, dysregulation, and the disparities accompanying rural living. I have also worked with individual/family needs associated with neurodivergence.

In this work, I have relied heavily upon Stephen Porges’ Polyvagal Theory because I have found that looking at behavior through this particular lens provides a framework that depathologizes clients and emphasizes safe relationships. This lens also promotes an understanding from within the client and between the systems in which the client is embedded. James is one such client.

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A Tale of Therapeutic Attunement

Seven-year-old James (a fictitious name) was referred for his disruptive and aggressive behaviors. James was being raised by his paternal grandparents as his father died by suicide when James was young, and his mother was unable to care for him due to her complications with mental illness. James’ behavior with me was often the exact opposite of what the adults in his life reported.

Outwardly, he appeared calm, engaging, sociable, and playful. What, I wondered, was going on with this seemingly cherubic child to provoke him to rage and violence against his grandmother? What might be happening within the family system — within him?

James had experienced significant losses, so anger made sense. But, in spite of his placid and seemingly sociable demeanor, he was also quite emotionally disconnected; a protective strategy that helped him to feel safe and secure amidst all of the changes and losses he experienced. For many years, it was safer for James to simply not feel the pain of all these stressors. Not until we started play therapy, that is. James and I played together almost every week for many months.

Being a client-centered therapist and a play therapist, I allowed James to guide me in and out of his world, in his own time, with his own stories, items, and creativity. I noticed how he would go into a deeper part of himself, but only after many months of building emotional safety, and then it was only for a brief “nugget” of time. As I began to learn about James’ story, his past and his present, I learned to go with and trust the “ebb and flow” of the process that unfolded for him and between us in the playroom.

I recognized the importance of matching my pace to his, which can be difficult because there is a temptation to more immediately address the disruptive behaviors. I knew how vital it was for me to regulate myself so that both he and I could “dive deep” together into that private inner world he so fiercely protected.

As I worked with James, I often calmly and patiently reflected on what he was showing me through his chosen play activities which included Sandtray-world-making, art therapy, or even video games. Over the course of a few particular sessions, I noticed what is referred to in Polyvagal theory as Polyvagal countertransference — my own physiological response to the process between myself and James as we played together.

James might, for example, briefly create a sparse scene in the sand before abruptly bouncing to another activity. As this pattern continued, I patiently tracked him, monitoring my own internal physiological state so as not to become dysregulated or distracted by the rapidity of his changing play. In one particular session, a shift occurred. He created an elaborate, deep and lengthy sandtray scene, replete with a wide variety of miniatures.

I noticed myself becoming very excited, mirroring his own physiological state, and thought, “he is finally going to ‘let out’ a large piece of his trauma story.” For a brief moment, my own inner experience bordered on fight-or-flight, not as much because I felt fear or that I was scared, but because I was excited with and for James. I recall also sensing danger arising from his play, likely a mirroring of his own fear as the trauma story became revealed.

Fully connected and engaged in that amazing moment, our nervous systems met. He brought all of him, I brought all of me. If only for a moment, it was in that sliver of spacetime that healing was happening. In that space I could say to James, I see you. I see your pain, I see your loss. I see this anger, confusion. I see all of it in this story that you just told me. I see how this big storm came and wiped out the entire town, and how your mom was swept away. How you tried to save her, and how you still want to save her.

In that magnificent moment, all of James’ heavy and painful feelings finally surfaced. I was able to contain those emotions for James because my own nervous system was responding to his. And that level of attunement was not shown with words but through and with a shared energy. The within and between.

Questions for Discussion and Thought

How have you used the work of Stephen Porges in your clinical work with children? With adults?

What about the way the therapist worked with James do you appreciate? Why?

How might you have worked differently with James?

Do Clients Really Read Session Notes? The Truth Might Surprise You

Posted on May 25, 2023February 11, 2026 by Psychotherapy.net Team

“I’m old school, my job is to focus on what my client brings to me,” said my friend and colleague Joan, a social worker of over 35 years.

Having worked for decades in the public school system with some of the most challenging clients, many of whom were entangled in the state’s labyrinthine bureaucracy, Joan was familiar with the multiple levels and layers of accountability, and the importance of writing notes and sharing records. She also knew that there would always be eyes watching — eyes without faces, and faces without names, all looking to make sure that her T’s were crossed and her I's dotted.

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Joan also appreciated the necessity of assigning an accurate diagnosis, and that doing so in a clinically and ethically correct manner meant taking time to get to know the client, their personal challenges, and their system of support. But Joan had also always believed that “my notes have never been problem-oriented,” and that “I want my notes to be about more than a diagnosis; something that actually helps my client.” Joan made it her policy to not be the one to initiate conversations with her clients about diagnostic impressions or diagnoses, current or past. For her, a diagnostic note was a clinical tool, much like mental status data, clinical impressions, or assessment results — and not within her clinical province to “bring up.” Doing so, she believed, would invariably shift the focus from what the client needed to what she needed to do as part of her job.

Discussing Diagnoses and Clinical Notes with Clients

So, it came as a resounding shock to Joan — now a teletherapist — when, at the start of their second online session together, her client proclaimed, “I read the document about my diagnosis of ‘adjustment disorder with mixed emotional features’ and it was right on!” Joan recalled thinking, “what the hell?!” She vaguely recalled the contract she signed with the teletherapy company specifying that clients could review their notes at any time. But after reviewing the contract following the revelation by her client, she could not find anything that specified the mechanism through which clients were alerted to the location of their notes on the platform, or whether they received some kind of alert when a new note was uploaded by the therapist, or if the actual diagnosis was available to them. She added, “Had I known that the company was sending an alert of some sort, especially about the notes from the initial session with the diagnosis I was mandated to provide for insurance purposes, I would have introduced and explained the process and my diagnosis with the client.” It was soon after that Joan wondered if her previous one-session-only clients never made it back for a second visit because they received her notes from that first meeting with a diagnosis or diagnostic impression that didn’t sit well with them.

It’s not that Joan was worried about how her notes — which were written in SOAP form — or even her diagnostic impression would be received, but that for those clients who read their notes and never addressed them in session, her observations and diagnosis would be the elephant in the room, and perhaps her responsibility to address if the client did not.

For Joan, it was always important that her clients “have someone who likes them, someone who finds them interesting, someone who can look beyond a diagnosis, someone who is willing to see their daily struggles and who could see them as a human being either caught in a moment of distress or battling demons that left them feeling ‘less than, unlikeable, unliked.’” She was concerned that by turning the conversation to one of diagnosis and notes that she would “no longer be talking with them, but about them.”

Toward the end of our conversation, I asked Joan how this scenario might impact her work with clients moving forward, particularly around discussions around notes and diagnoses. She reiterated that, “I am old school…I simply don’t want, nor do I feel it is important to ‘bring it up’ with clients.” But she added that she would give it some thought.

***

Joan later recalled a client with whom she worked for only one session and gave a diagnosis that included anxiety and depression. That client, through some mechanism unknown to her, then saw a psychiatrist who worked for the same teletherapy company as Joan did. She found out that the client had been subsequently diagnosed her with borderline personality disorder and prescribed medication after one visit.

Joan promised me that she would share her impressions of that scenario in a later conversation.

How To Map the Toxic Impact of Social Media on Families in Therapy

Posted on May 4, 2023February 24, 2026 by Psychotherapy.net Team

Learn how to see. Realize that everything connects to everything else

— Leonardo Da Vinci

The internet in the late 1990s was exciting because you could research topics including sports, education, and entertainment and stay in contact with old friends. In retrospect, however, when working with adolescents at a local PHP and IOP, I/we ignored the impact of Myspace and other social media websites that encouraged cutting and suicide. We attributed the increase in behavior to peer influence and the impact of dysfunctional family relationships.

Today, social media’s algorithms and influencers have more of an impact on the family than we are willing to acknowledge. It has been argued that social media’s algorithms entice family members who use social media to spend more time on the app than with their own family or friends. As a clinician who works with families in private practice and schools, it has become increasingly clear to me that social media’s algorithms and influencers often occupy the “empty chair” in the family sessions.

The “Therapeutic” Power of Influencers on Family Systems of Care

It was evident to me while watching the hearings in Washington, DC a year ago that social media companies will not change their algorithms and will not share them for everyone to understand. The Netflix documentary The Social Dilemma had many former social media employees expressing eye-opening concerns. The film revealed how tech companies hire psychologists to make a persuasive algorithm to increase the appeal and use of their apps.

Unfortunately, Congress appears powerless, unwilling, or both, to make changes due to the powerful lobbying groups. Some have said that Congress is waiting for the UK’s Parliament to take the lead in regulating this industry.

Social media makes money by showing images or comments that their algorithms “say” are interesting and encourage consumers to “like,” “comment,” or “share.” Social media companies have also learned the more divisive and inflammatory the post, the more views and money there is to be made.

Well-designed apps continually boost the user’s connection by showing information, comments, or images that they have discovered are of interest. Showing an opposing view or people from a different “virtual tribe” will decrease the views/time spent on the platform and decrease money for the makers of the app. The app creates a virtually closed system that does not allow any “disliked” information or contradictory views.

If different members of a family “like” different apps, or different posts on the same app, each member of the family may conceivably align with a virtual presence against their actual brick-and-mortar kin or friend. As a result, algorithms have the power and potential to intensify the already-present pattern of conflicts within a family system or relational circle. Disconnection, chaos, conflict, and exacerbation of individual and/or family pathology may follow.

Influencers have always been present in our society. For many years, our influencers were teachers, family members, neighbors, friends, supervisors, actors, news anchors, and other people in our community. We would ask our immediate community personal and embarrassing questions. Many times, adolescents and young adults would get personal and difficult questions answered by building up the courage to approach someone face-to-face in their community.

Building up the courage to ask questions taught us how to manage our fear and anxiety. Navigating face-to-face relationships also teaches us how to manage embarrassment, frustration, anger, resentment, and rejection which is an important step in our development. Non-virtual relationships also allow us to feel emotional and physical closeness that is missing in social media/virtual relationships.

Today, our society is teaching the belief that anxiety is a bad thing that needs to be kept at bay. We in the field know that anxiety is not the problem. Arguably, anxiety is a result of the person’s core belief and/or what is going on in a relationship that will not change for the better. Because of this, adolescents and young adults are narrowing their non-virtual relationships because it is the path with the least amount of risk.

When asking intimate or difficult questions face to face, we learn how to manage proximity and closeness in our family and friend groups. We learn who in our family and friend groups has earned the privilege to be asked these intimate questions. We learn who can keep our personal life private and who may have the better answer, which builds friendships and family relationships.

Social media triangulates family and friends to find the immediate answer and connects people to a tribe that challenges them the least. Many believe decreasing their non-virtual relationship decreases their anxiety, but it actually increases their isolation from their community and increases their anxiety when meeting someone face-to-face. Also, virtual relationships give the illusion that all of these important ingredients are present on social media.

Family members are turning to influencers as if they are therapists/experts with answers (good therapy doesn’t give answers.) Or they are turning to politicians that they must blindly follow (good politicians allow debate.) We know the politicians who are at the extreme right or left posting inflammatory statements get the most views.

These influencers are making statements encouraging family members or friends to pick sides, skipping the process of face-to-face discussion with follow-up questions or reflection that occurs in non-virtual relationships. When a person stops exchanging ideas with their family members or friends, it creates a dangerous virtual closed system.

During my training at the Minuchin Center for the Family, I was always asked, “Whose shoulders is the adolescent standing on?” One year, a family I was working with agreed to meet with Dr. Minuchin for a consultation. Dr. Minuchin said to me after the consultation, “You will fail because the system of care erodes the boundaries of the family.” It became evident that each of the six members of the family relied on their own individual therapists to reinforce their view of how everyone else in the family was toxic.

This taught me the importance of understanding the family map in addition to evaluating if different family members were in coalitions with other therapists, social workers, and/or even agencies. It was an important step to understanding the map and identifying where the coalition(s) across generational boundaries occurred with the family and larger system.

In many of the sessions, other families were able to overcome their symptoms once they began to work on their relationships and change their relationships with the systems of care. It was exciting to see when the system of care noticed their triangulation with the family. Other times it was sad to see how systems of care did not see how they were triangulated against family members.

Today, influencers are present in the family session as seen by the virtual coalitions that the member(s) must maintain as if they were their closest friends in order to be a part of their tribe/team.

The Impact of Social Media on Family Relationships

Families are always ahead of the researchers and therapists, but do we listen to the pieces together as therapists? The following are the themes/symptoms families have discussed in my own family therapy sessions as well as those of colleagues in the wider clinical world. Each of these impacts adolescents, and, in turn, how they impact the adults in their home. On both sides of the relational equation, social media has a powerful impact, and not always for the good of individual and shared relationships.

When one or more family members are engaging in excess screen time from two to sometimes more than six hours a day on social media, the research shows there is an increase in symptoms of depression and/or anxiety. If someone has this much daily screentime, they are displacing healthier activities or hobbies such as walking, sleeping, drawing, painting, mindfulness, and gardening, to name but a few. And this displacement impacts the interactions in the family and community by isolating them.

Algorithms encourage constant social competition and comparison, and as such function as social currency between peers and family members. Adolescents typically feel that they are on stage competing to increase their position in the “hierarchy” with peers and/or parents. They continually compare themselves to peers at school and other families.

The algorithms that draw them in make it difficult for them to turn off the social app and get away from the stresses of adolescence. Jockeying for competition and comparing their lives to others may at times backfire, leaving them feeling poignantly and painfully alone. Again, this constant competition and comparison mirrors similar interactions in the family that can contribute to increased anxiety and depression.

The adolescents I’ve worked with discussed how they feel lonely and alone. They feel lonely when they are not supported or perceive they are not supported by family or friends, and feel alone when they have little face-to-face contact with peers like we all experienced during COVID.

The two-dimensional views people experience when using Zoom as the primary source of connection do not “feed the soul.” There is no substitute for good eye contact and close physical proximity. The irony is social media was created to decrease feeling lonely and alone but actually amplifies it. In family sessions, many, if not all, talk about how they feel lonely and hoped that social media would fill this void but were unsuccessful.

Adolescents typically think they are invisible or always on stage. These polar positions can occur on the same day for any adolescent. They think they are invisible when they are spending more time on their phones not getting enough likes and/or views, whatever that means to them.

This causes them to work harder on their online stories and identities, decreasing the proximity with their non-virtual friends. Many adolescents begin to look for the “genuine” or “real” friends, determining they are only present in social media and not in their own hometown or within the family walls. In the family, these themes are very common when there is already a pattern of disengagement (invisible) or enmeshment (always on stage).

The adolescent also thinks their peers are waiting for them to make a mistake so it can be posted online. This position makes them feel as though they are always walking into the cafeteria for the first time as a freshman in high school. Adolescents are supposed to make mistakes, struggle, learn about relationships with typical external distractions (friends, family, media, work, and politics). But does social media fill the lonely times when the adolescent and young adult are reflective and recoup?

Being invisible or always on stage prevents the adolescent from developing close connections with peers, teachers, coaches, or other family members. This results in adolescents seeking temporary relief from asking a “person” and instead getting information from social media.

Information on the app is monitored by the algorithm and is not as embarrassing or stressful as asking a family member, friend, or teacher. This is where social media begins to enter the family, impacting the adolescent development and challenging their family’s belief system.

The algorithm also motivates the adolescent to seek select information that aligns with their narrow/closed view about politics, friendship, religion, sexual identity, sexuality, gun laws, suicide, mental health, or any other hot topic.

The Atlantic, 60 Minutes, Pew Research, the New York Times, and the Wall Street Journal have done a great job discussing all the different ways social media has triangulated members of our families. The New York Times article on suicide, “Where the Despairing Log On and Learn Ways to Die,” by Megan Twohey, or The Wall Street Journal essay, “TikTok Diagnosis Videos Leave Some Teens Thinking They Have Rare Mental Disorders,” by July Jargon are exemplars.

Social media focuses on the “person” and navigating them to topics they are interested in and picking what tribe to belong to. The information is flowing into one part of the family system and not to the whole family which triangulates family members against virtual friends or influencers. This occurs if the family is already in a state of constant conflict or conflict avoidance. A recent 60 Minute piece discussed how China does not allow TikTok to bring up divisive topics to their children or adolescents.

For the adolescent to decrease feelings of anxiety and depression, they must work for the “likes” and “views.” They will be trying to affirm their sense of self, but many times they will be accused of bragging and will feel they are not good enough when comparing or competing with others.

Body image and feeling unattractive are especially amplified by social media’s filtering app. Many plastic surgeons are reporting an increase in adolescents wanting to get surgery to look like their filtered self. Current data shows that 55% of surgeons report seeing patients who request surgery to improve their appearances in selfies, up from 42% in 2015. They want fuller lips, bigger eyes, and smaller noses. “This is an alarming trend because those filtered selfies often present an unattainable look and are blurring the lines of reality and fantasy.” (1)

When I’ve met with families and these themes come up, I have encouraged them to discuss these themes which have allowed me to see the systematic position of each family member, system of care and the influencer/algorithm.

Every family has its struggles and at times feels out of control when it goes through a stage of what Monica McGoldrick calls its family life cycle. I have seen this especially when a family enters my office as it is attempting to (re)adjust to the needs of their childhood, adolescent, or young adult. Now add the influence of social media to one or all members of the family, the spiraling becomes more intense.

Crisis of Voluntary Play for Children

The importance of free and voluntary play with children to teach them how to give and take has been well documented. There is no substitute for non-virtual relationships in the early stages of childhood. Antithetical to this, algorithms require constant attention, taking the time away from connecting with others face-to-face.

Whether it is the child who requests to go on the smartphone or the parent who gives the child a cell phone in social situations (i.e., play dates, restaurants, long car rides, it decreases the opportunity to negotiate, argue, entertain themselves, compromise, and resolve conflict. This “tech choice” leads to delaying the development of the family and prevents them from moving to the next stage of a family with an adolescent.

Children Entering Adolescence Have Not Learned to Play

There comes a point in families when adolescents are told they are no longer a child, yet neither are adults. For some adolescents, not knowing the initial stages of voluntary and free play puts them into limbo looking for answers. The adolescent and family know on some level they are missing the tools for non-virtual relationships.

First, this is where the social media’s algorithm and influencers potentially intensify the family’s struggle. When the adolescent looks to social media for the answers, this intensifies conflict. Naturally, the adolescent wants to grow away from the family. They want to connect more with peers.

The adolescent in families with intense enmeshment/disengagement and different forms of coalitions struggle the most. This is where social media’s algorithms direct the adolescent to find a group. The algorithm pulls the adolescent in to spend more time on their app, resulting in the app making money and the adolescent searching for connections separate from the family.

However, virtual connections encourage the same patterns of enmeshment/disengagement and the different forms of virtual coalitions. These intense virtual connections are sometimes in opposition to the non-virtual relationships of the family and/or community.

Secondly, this social media generation has grown up learning to communicate more virtually and less in person, especially during COVID. Many adolescents have decided that they would rather communicate virtually. It is hard for some adolescents to look into someone’s eyes, read body language, and feel the energy of being in proximity because it makes them anxious. Look at any lunchroom at any local high school. If the school allows students to be on their phones during lunch, adolescents prefer to spend time on their phones working to maintain a social virtual hierarchy.

Social media offers a prime context for navigating these tasks in new, increasingly complex ways: peers are constantly available, personal information is displayed publicly and permanently, and quantifiable peers’ feedback is instantaneously provided in forms of ”likes” and ”views.” (2). Many of us who grew up before social media can only imagine if our mistakes were on a permanent record and followed us around for the rest of our lives, never allowing us to move forward.

Thirdly, the family does not have a chance to limit the adolescent’s time on the apps because the social media’s algorithm encourages constant attention, reinforces isolation from family and non-virtual friends.

Many parents have approached me saying, “The phone is their lifeline to manage their anxiety,” or, “The phone is the only way they connect with their friends.” During these moments, I have found it useful to explore how the whole family has come to the belief that the social app has become a way to maintain the homeostasis of the family.

A Non-Virtual Family Map

I often ask families about their virtual and nonvirtual family maps. I think it is important that we ask the family about their social media involvement to understand the virtual map of the family. Do families understand the impact of the social media algorithm? Do families know how to get out of the social media web? Do we ask each member of the family who they talk to virtually or non-virtually when they are struggling?

In initial evaluations, I often explore if the family is aware of how many hours they are spending on the social media apps. It is important to assess if the family is aware of how much social media raising/influencing is involved in the marriage, parenting, and sibling subsystem. Some providers want to focus on social media addiction, but the algorithm is not like any other “addiction.”

The algorithm allows many of the family members to covertly — and sometimes overtly — bring influencers into conflict with different members in the family. These virtual relationships amplify the family’s symptoms, and unfortunately today’s therapists use the medical model to diagnose the adolescent symptoms, further pathologizing and pushing the relationships in the wrong direction. This narrow view further sets the enactments, reinforcing the enmeshment, disengagement, and coalition patterns.

Non-Virtual Family Map

It is hard to shift our medical model training from a focus on the individual’s (child, parents, siblings) deficits to one that acknowledges strengths and competencies within individuals and the family system. When individual therapy does not make significant change, families often turn to family therapy as a last resort.

After experiencing this different approach, they often express frustration that they were never given the opportunity to move forward together, instead deferring to the experts for the correct intervention and diagnosis.

Structural Family Therapy was so different in the 1970s and 1980s; it was transcendent. While many new theories of family intervention have reached the mainstream, so too have many reverted to focusing on the individual. When starting individual therapy with the adolescent, I have found it important to ask the adolescent to overcome the algorithm on their own without their parents’ involvement. As family practitioners, we need systemic thinking more now than ever to approach the intense cultural impact of algorithms and influencers.

Below is a “traditional” family map that does not consider social media. It represents a compilation of families I’ve seen in therapy, rather than any one family. The symptoms include those typically seen in family practice — poor school performance, school avoidance, vaping, drinking, and using drugs.

From a system’s orientation, the symptoms are a result of the functional and dysfunctional interactions within the family system.

It’s hard for me to understand how therapists begin assessment and treatment without considering or involving the whole family. Some clinicians might say the conflict is too high, and it would only impact the adolescent negatively. Others might assume from the start that one or both parents are not willing to work or are too busy. Some might even be unaware of the importance of beginning from the position that families do not have the strength to make change.

Sometimes therapists and school staff buy into and reinforce the belief that the child or teen is the problem. In the case of this particular map, Mom “reportedly” goes to her private therapist while the son sees his own therapist. Mom and son separately complain about dad to their respective therapists and to the school staff. When mom and son voice frustration about dad and each other in the individual therapy session, disengagement with dad is reinforced. Mom and son are trying to get the type of connections from the system of care that they cannot get with Dad.

While this disengagement takes place, the son turns to his peers, attempting to pull away from mom’s enmeshment, activating her to pursue more. At home, Dad complains that his wife and son always bring up their therapist who agrees that he is unavailable and/or flawed. When this occurs, Dad becomes more distant and angrier, feeling like he is the odd person out.

When Mom gets angry at dad, she turns to her son and vents to him which activates him to challenge his father about money, drinking, and the way he treats her. At other times, the son may jump into the conversation when the parents interact about money, drinking, or the way he treats Mom.

When I attended graduate school, the common exercise was to map the triangles in the family system. Based on the above map, there are at least 24 triangles that are activated in the family-school-mental health system. The 24 triangles are:

The mom, son, and dad
The mom, son, and school social worker
The mom, son, and principal
The mom, dad, and school social worker
The mom, dad, and principal
The mom, dad, and school social worker
The mom, dad, and school principal
The mom, son, and mom’s friends
The mom, dad, and mom’s friends
The mother, dad, and dad’s friends
The mom, son, and son’s friends
The mom, son, and son’s therapist
The mom, son, and son’s psychiatrist
The mom, dad, and son’s psychiatrist
The mom, son’s therapist, and psychiatrist
The mom, dad, and son’s therapist
The mom, school social worker, and mom’s therapist
The dad, son, and son’s therapist
The dad, son, and son’s friends
The mom, son, and mom’s therapist
The mom, dad, and mom’s therapist
The son, son’s therapist, and school social worker
The son, son’s therapist, and psychiatrist
The son, school social worker, and principal

These 24 triangles are at the same time difficult for adults in the family to appreciate, even harder for an adolescent, and deeply challenging for the clinician to manage. In those triangles within the family where cross generational coalitions are activated, the symptoms in the family increase. I have often been challenged whether to discuss the impact of all these cross generational interactions with the family and whether it is important to differentiate the healthy, less healthy, and unhealthy ones from each other

On top of the above complexity, other questions arise like “where did the boundaries go?” The therapist must keep in mind how the boundary between the family and the outside world becomes invisible and the symptoms become more intense, to the point more professionals are recruited to “fix the dysfunction.”

I have also had to maintain awareness of how managed care’s enforcement and reinforcement of the medical model has influenced me and other members of the community of care, including other therapists, psychiatrists, physicians, and schools. This reinforcement has an impact on the family’s interaction with the son focusing only on his diagnosis and the correct medication, while failing to address the family relationships.

As mom turns to the school and the system of care for answers, things are not changing. She reports that her son is getting worse. Mom blames dad’s aloofness and dad blames mom’s overindulgence. Mom increases calls to the psychiatrist. The psychiatrist adjusts the medications frequently. The frequency of crises increases and the boundaries between the family and the outside world are dissolving due to the interaction between the family and the system of care.

The number of alliances increases between different family members and different professionals as more professionals/agencies are pulled into the drama. Professionals unintentionally begin to write/rewrite the individual’s and/or family’s stories, especially when utilizing the medical model.

With more stories, there are more opposing interests for each family member. This phenomenon between families and agencies is a result of a collision when both parties collaborate to uphold sociocultural trends. The goal is not only to interrupt multiple unhealthy alliances with existing professionals/agencies, but to also prevent new transactions from developing. (3)

This phenomenon was usually seen when the system of care worked with economically challenged families. We now see this also occurring with families of significant means because they can afford an individual therapist for each family member and psychiatrist(s) if needed.

As we look back at the map, it is now easier to understand that because the family has already identified what they think is the problem, it really needs to address the triangle between mom, dad, and son. It doesn’t really matter where to begin. A clinician can enter through mother-son enmeshment and coalition, father-son disengagement, or parental/marital disengagement.

It might also be useful to address the system of care coalitions between the therapist and school with the mom and son. Having the family identify how to change the interaction between the whole system allows them to move forward. It may be a challenge because getting directives from an expert, rather than looking within their own system, is what they have come to expect.

Using a Virtual Family Map to Identify Issues in Families

Before talking about the influence of social media on the family, it is important to acknowledge some of the “players” in social media. The system of social media has many parts. Social media success is dependent on an algorithm, which encourages frequent interactions by virtual and non-virtual friends.

The frequent interactions result in the shareholders receiving monetary return on their investment, the employees maintaining their jobs and bonuses, and the advertisers increasing the visibility of their product resulting in increased sales. The influencers are dependent on social media to reach as many people as possible to receive income from the app. There is a lot of pressure to have an effective algorithm to support social media.

As you next look at a map depicting the interactive nature of the family and social media, it is important to keep in mind that the 24 triangles from the non-virtual map are still present, and the family boundary is already disintegrating with the school workers, friends, and therapists to seek help with the identified patient.

Now in addition to these non-virtual professionals and friends, the family is inviting social media’s virtual friends and influencers to seek help with the identified patient. Clients (and non-clients) often turn to virtual friends and influencers to provide the same connection as non-virtual friends, but these connections are void of physical closeness. Children and adolescents believe a virtual relationship can replace a non-virtual relationship. But all virtual relationships are void of physical closeness in which touch, eye contact, and a warm smile can feed the soul.

The family can turn on a social media app at any time of the day or night and the outside world is invited into the family, increasing the number of triangles exponentially. From the clinical perspective, it is critical to examine what actions (social competition, social comparison, loneliness, etc.) in the family trigger a member(s) to invite social media into the family. The therapist must also discuss how social media algorithms are activating/triggering the member(s) of the family to turn to an app to surf or post an event. This increases the time spent on the smartphone to maintain these virtual friends, non-virtual friends, and influencer relationships.

At times, social media decreases connection with non-virtual relationships and increases the connection with virtual friends and influencers. In the therapy session with this particular family, some members discuss how they rely on virtual friends and influencers more because “they understand me more than the friends in my own town/school.”

The adolescent believes these virtual figures want to listen to them more than family and non-virtual friends. It is important to ask the family what influencers and virtual friends provide that their own family members or non-virtual friends cannot. This allows the clinician to address the patterns and interactions in the family.

In the map below, I do not draw the number of different social media apps, influencers and virtual friends who are involved with the family. However, I do recommend when meeting with families, to draw each app, virtual friend, and influencer to show the number of triangles the family is managing or attempting to manage. For simplicity’s sake, I use one (black) box to represent all the social media apps and one box for all influencers and separated mom and son’s virtual friends.

Husband, Wife, and Social Media Triangle

What is the impact of social media on marriage? The wife turns to social media and influencers to figure out how to “fix” her marriage. The wife tries to talk to her husband about what she has learned about marriage on social media. The husband discounts the wife’s attempts to “educate him about marriage.” She eventually gives up on the marriage and “wants to focus more” on her son. She also tries to connect with previous friends and boyfriends from past life because she feels lonely and alone “looking for a connection.”

What you will see in this triangle, and all the triangles which involve social media, is a substitution of a virtual relationship for a non-virtual relationship whose connections are full of conflict or conflict avoidance. The virtual relationships convey an illusion of meaningful connection, but the person(s) feels alone and lonely because it lacks the important ingredients for a fulfilling relationship.

Mother, Father, and Social Media Triangle

Now the wife stops working on the marriage and focuses on parenting. The husband is not aware of this decision, focusing on “making money to provide food, clothing and shelter.” The father continues to feel alienated, disconnected, and disempowered, becoming angry towards the mother and son. The mother turns to school staff, therapists, non-virtual friends, virtual friends, and influencers for ways to “fix her son.”

This fosters more of an enmeshment with son, and disengagement with Dad. The son turns to school staff, his therapist, non-virtual friends, virtual friends, and influencers. Each family member describes a feeling of disconnectedness trying to overcome the feelings of being lonely/alone. Dad voices his frustration, complaining that he is “old school,” and they are “hypnotized by that damn phone.”

Mother, School, and, Social Media Triangle

In this triangle, mom calls the teachers and guidance department for support. She has frequent phone calls with the guidance counselor because the guidance counselor “is an expert with adolescents.” As you can see, dad is left out of the interactions with the school.

After a few months, her son’s behavior is not changing, and mom is frustrated with how the school is not helping her son. Mom begins to turn to social media looking for answers. Mom spends hours on the app talking to non-virtual friends, virtual friends and reading/commenting on influencer’s posts. Mom displaces healthier activities with time spent on social media. Mom begins to complain that the school is not meeting the goals set out by the Individualized Education Plan (IEP). Mom cites information from influencers from social media and the internet. The tension rises between the school and mom.

Schools today are under tremendous pressure to perform. Schools are understaffed, and do not have the mental health training or support to bring in a countercultural systemic approach into the schools despite the money being put into schools after COVID-19.

Parents, Son, and Social Media Triangle

Mom is spending hours on social media looking for answers to why her son is struggling. She also spends time looking for connections. The son also spends hours on the app interacting with non-virtual friends, virtual friends and reading influencers’ posts.

Mom pursues the son, but he only is aligned with her to challenge dad’s limit setting. When the parents attempt to be aligned, the son acts out more. We see the son increase his conflict with parents, who struggle due to their enactment/conflict avoidance with each other on how to help their son. This results in the father leaving and the mother turning to social media to find answers or overcome feelings of loneliness.

When the family interactions are in intense conflict or conflict avoidance, many children, adolescents, and young adults get most of their answers from non-virtual friends, virtual friends and influencer’s posts. The son is seeking temporary relief by getting information and trying to affirm a sense of self.

The non virtual, virtual relationships, and influencers introduce beliefs that are the opposite of the family’s beliefs and further impact the self-esteem of the adolescent. The son discusses what he learns from social media of what “real parents are like.” The decrease in face-to-face communication with family increases his anxiety, depression, irritability, and intrusive thoughts. This also confuses the family of how their family member can “think so differently.”

Son, Non-Virtual Friends, and Social Media Triangle

The son in the session discusses constant social competition/comparison, working for social currency, and thinking he at times is invisible to his non-virtual friends. The son gradually believes his non-virtual friends “don’t understand.” He believes he cannot turn to his parents because “What do they know?!”

The son begins to engage in the same interactions with his peers as his parents and avoids turning to his peers for support. The son begins to spend more time on social media with virtual friends and influencers to seek select information that matches a narrow/closed view, hoping to avoid conflict/interaction. The son then turns more to virtual friends and influencers for answers. Again, this increases his time on his smartphone and increases the family’s sense of not being good enough for each other.

Remember, the son believes there is “less stress” getting information from a stranger, pop culture icon, or a virtual friend than an enmeshed mom, disengaged father, or face-to-face with a peer(s). However, the decrease in face-to-face communication with family and non-virtual friends increases his anxiety, depression, irritability, and intrusive thoughts.

Despite the time spent on social media, the son feels alone/lonely, looking for emotional, face-to-face and physical connection, but does not have the words to express these thoughts to each other.

Mom, Therapist(s), and Social Media Triangle

Dad continues to be absent from the triangle that involves the therapist. The mother attends her own therapy and attends her son’s sessions to discuss what new information she has seen on social media.

She reviews with both therapists what she has learned on social media about new treatment, new medication, and new diagnoses. She advocates with all providers that her son is incorrectly diagnosed, hoping that would help him with his symptoms. The quality of training of the therapist determines their response to entertaining or challenging mom’s research. This may result in mom seeing a new therapist.

The individual therapists and psychiatrists are not looking at how the parents avoid “getting on the same page.” They are reacting to reports by mom about the son’s behavior. Mom and dad are unable to interact differently because they have not figured out how to work together to decrease their son’s phone usage to increase his time with non-virtual friends. The professionals are avoiding addressing the parent’s avoidance!

Mom, Psychiatrist, and Social Media Triangle

Dad is absent from the triangle that involves the psychiatrist. Mom becomes disgruntled with the psychiatrist. She begins to challenge the psychiatrist’s diagnosis and medication recommendation. The psychiatrist recommends if mom is not satisfied with his assessment, she seek a second opinion. Mom begins to look for a psychiatrist who agrees with what she has read on social media.

Son, System of Care, and Social Media

The son is seeing his individual therapist 1-2 times a week and his psychiatrist once a month. He is also spending 2-8 hours on his social app each day. The therapist has not assessed the hours the son is spending on his phone. The app is only showing views/opinions/likes/images that interest him.

The son begins to complain that the therapist does not understand him and challenges his therapist saying, “This doesn’t help.” When the therapist explores the son’s statement, he begins to discuss information from “reliable sources” from social media and influencers. He too begins to diagnose himself and discusses medication that can help. When the system of care discusses reliable sources such as universities and professional journals, the son becomes irritated saying “I don’t want to read them.”

Son, School Staff, and Social Media

Not only does the system of care increase their sessions, but the school staff increase their time with the students. The number of triangles with the son in the school increases between the child study team, teachers, and administration.

The teachers are pursuing him to get his work done — offering to meet him before school, lunchtime, and after school to complete his work. He never shows. The son is seen in class on his phone. Some teachers ignore him, and others nag him. When a teacher challenges the time he is on his phone, he tells the teacher other instructors let him do it.

The social worker is calling him down to discuss his avoidance of work and disruptive behavior in the classroom. Only when the son becomes overwhelmed, he discusses with the school social worker his home life and that medication is not working. The vice principal is meeting with him to give him detentions. The son feels frustrated with the school stating, “They are only doing this because it is their job.”

Son, Non-virtual Friend #1, Non-virtual Friend#2 with Social Media

The son leaves school to go home to continue to work on his non-virtual relationships on social media. It becomes evident that in social media apps, the same social stressors occur online like in school. It is exhausting to navigate being included and avoid being excluded at school and online. The son and non-virtual friends are jockeying for social currency and social position, never getting time off to charge their own social battery.

The son and non-virtual friends stress about the images they post. They are anxious about what the image means to them and others. The son is trying to understand the unspoken rules for posting and the reaction by his peers regarding the image. The son worries if the image appears “authentic” and will help him maintain his position inside the social media group or if a new group be formed without them.

Son, Non-virtual Friend(s), and Virtual Friends

The son struggles connecting with his non-virtual peers. He is not getting feedback from his non-virtual friends about his art and his physical appearance and finds out they have different chat rooms that do not include him. (Remember, he does not want feedback from an overly involved mom or detached father.)

He begins to look for feedback about his art and physical appearance from virtual friends. When looking for connection outside the non-virtual friend group, he states he is looking for virtual friends who are nonjudgmental.

But as time went on, it began to mirror the non-virtual group. Some of his virtual friends on social media become competitive and attempt to increase their social currency on this platform. They do this by making fun of his physical features and his art. This mirrors some of his non-virtual friends’ behavior. The son frantically searches for another virtual peer group that he believes will not activate anxiety by not challenging his views, providing a stress-free venue.

As the son increases his time searching for virtual peers and influencers over non-virtual friends — reinforcing a closed system, increasing isolation at school, and decreasing time to sleep at home. His virtual relationships are now more important — increasing time spent on the app and continuing to strive for more likes and views.

Lack of face-to-face contact with family and non-virtual friends fosters more of a virtual enmeshment with virtual friends. He describes them as “nonjudgmental” and “more accepting.” This further increases his self-doubt and increases his feelings of loneliness and creates a virtually closed system (Virtual Enmeshment).

Son, Virtual Friends, and Influencers

The virtual group is important to maintain when avoiding contact with his parents and non-virtual friends. The son describes his virtual friends as more “authentic” and describes his non-virtual friends as “fake” and “not genuine.” However, some of his virtual friends on social media become competitive and attempt to increase their social currency.

The son frantically looks for another group that is an anxiety and stress-free venue. This further increases his self-doubt and increases his feelings of loneliness. This increases the symptoms of anxiety and depression when waiting for approval from virtual friends saying, “They are the only ones who understand me.”

As the son looks for new virtual friends, he and his virtual (and non-virtual) friends look to influencers for answers on how to portray themselves. Influencers work hard to establish and maintain their position in their virtual community. The influencers are working hard to make money and increase their viewership. The influencers often ask adolescents to agree with their beliefs and recommend products they are selling. The influencers work hard to appear on the “right side” of an issue.

As the son tries to replicate the beliefs of his preferred influencers, he looks for fellow virtual friends that have done the same “research.” They notice the more they make comments in opposition to a belief, it increases their views and likes.

As the symptoms in the family increase in intensity, the members increasingly must decide who to align themselves with in the virtual and non-virtual triangle. The therapist highlights this and encourages the family to discuss and identify the boundaries of virtual and non-virtual triangles that maintain these alliances/symptoms. This allows a family to discuss non-virtual triangles that are underutilized, which reinforce healthy boundaries that benefit the family.

Using Exploring Questions to Make Circular Statements

Much has been written about joining, unbalancing, and mapping in SFT. One of the beautiful ways Structural Family Therapy (SFT) uses language is by employing circular statements to connect the family member’s behavior in the system. When SFT enters the family, the systems therapist uses the family’s own observations to connect their interactions.

It is important today to make a circular statement to widen the lens in which the family sees how all virtual and non-virtual relationships impact the relationship in the family. Below are some examples of circular statements using the words used by each family member.

I agree with you, Mom, that as long as you do not have a voice with Dad and work together, your son will not stop posting explicit images on Snapchat

Dad, as long as you sound like a drill sergeant, Mom will not find her voice as a woman and work with you as a wife and mother of your son who will continue to believe he must mirror images on Instagram

Mom, I agree that the harder you work, the less Dad helps you with parenting your daughter— your daughter will have to turn to influencers about how a woman should look and act

Peter (son), as long as your mom is worried about the frontstage appearance, she will fight with your father who is more concerned about your backstage struggles with you and your mother

What do your virtual friends give you that you cannot get from Mom, Dad, or your non-virtual friends?

Conclusion

Many are worried about the continued increase in suicide, suicide attempts, and mental health issues in the family and how Congress is powerless to challenge these companies. Many providers are not looking at what has changed in our lives in the past 25 years.

Relationships are becoming more complicated than ever. Many families and therapists are unaware of the impact of the system of care and less aware of the impact of the ubiquitous “algorithm.” It is hard to understand how the algorithm works because it is important for these companies to keep the algorithm secret for fear of losing profit.

We must also remember that each influencer, virtual friend, and nonvirtual friend has their own family map. Just as many professionals do, influencers understand how their stories, views, and images echo in the family.

Are families aware of the alliances that occur with virtual and non-virtual friends and influencers? Are we aware that when more virtual influencers and friends enter the family, more alliances increase establishing social hierarchy, increasing social competition and social currency? Are we, the clinicians, aware that influencers and virtual friends unintentionally/intentionally begin to write/rewrite stories in the family and permanently on the internet?

We must begin to understand that with more stories, there are more opposing interests for each family member. This phenomenon between families, virtual friends, nonvirtual friends, and influencers (social media) is a result of collusion when all parties collaborate to uphold their preferred sociocultural trend.

The goal is not only to highlight and interrupt the multi-alliances with existing social media but to highlight the transactional pattern in the home that maintains this pattern. Remember, a virtually closed system impacts all family members, whether one or all are using these platforms excessively.

References

(1) Susruthi, R., Myara, Maymone, B. C. & Vashi, N. Selfies-Living in the era of filtered photographs. JAMA Facial Plastic Surgery. 2018 20:6, 443-444.

(2) Nesi, J. (2022) The impact of social media on youth mental health: Challenges and opportunities. North Carolina Medical Journal, 81(2), 116-121.

(3) Colapinto, J. (1995) Dilution of family process in social services: Implications for treatment of neglectful families. Family Process. 34:59-74.

Questions for Reflections and Discussion

How has social media influenced your personal and family life?

How does the author’s premise resonate with you and the way you practice family therapy?

How have you integrated social media and app use into family therapy?

In what ways do you agree or disagree with the role of social media in family systems?

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