Category: Blog

Repairing Self-Neglect in Clients with Complex PTSD

Posted on by Psychotherapy.net Team

The Somatic Legacy of Complex Trauma

People who experienced complex post-traumatic stress disorder (C-PTSD) or ongoing ‘complex’ childhood trauma consisting of neglect, abuse, and invalidation, develop strategies and defenses designed to make sense of the painful truth that their caregivers failed to provide essential emotional and physical attachment needs. These protective strategies, though geared for survival, become obstacles to overall health, self-expression, healthy relationships, and fulfilling careers.

Clients who endured abuse or invalidation during childhood developed exquisite sensitivity to external cues that helped them manage chaotic or unpredictable environments. This hyper-attunement to external inputs, a kind of hypervigilant codependence, evolved while clients were simultaneously repressing internal cues like hunger, thirst, fatigue, toileting, and comfort as a result of needs repeatedly going unmet. It becomes a survival strategy to not feel or acknowledge them. By having suppressed their basic physical needs, these clients experience ongoing internal tension expressed as anxiety and depression, dysregulation, and codependent behaviors.

Growing up surrounded by reactive adults who did not provide functional emotional modeling, clients’ emotional tools are restricted. They became over-focused on external sources of validation which contribute to ongoing anxiety and reactivity. This situation fundamentally disrupts clients’ capacity for implementing self-care and other functional behaviors necessary for a healthy life.

Developing in an unsafe environment, clients’ ongoing somatic experience is of underlying danger and unpredictability. With porous boundaries and distorted perceptions, they look for confirmation of this bias in every interaction, are poised to identify danger, and experience unbearable flooding. This frequently leads to hypersensitivity to criticism and rejection along with perfectionistic tendencies as a defense against chaos.

In multiple cases, I have found that encouraging these clients to pay attention to and satisfy cues like hunger, thirst, physical discomfort, and toilet needs as a primary intervention is transformational. Providing a supportive container to address their needs evokes a crucial new experience in which to foster change.

In session, I routinely encourage clients to make themselves physically comfortable, whether we meet online or in person. My office has yoga mats, pillows, a physioball, chairs, and a long sturdy Pilates table. Throughout sessions, I cue them to check in with their sensations using direct questions with non-threatening words like, “what’s coming up for you now,” “are you still comfortable or do you need to move,” “feel free to adjust, move, or make yourself more comfortable,” “what would feel safer in this moment?” My aim is to highlight internal sensations and give explicit permission to foreground their physical needs over anything else—something that their upbringing did not allow or was not safe for them to do.

Because breathing is foundational to life, breathwork can also be a powerful tool for addressing dysregulation, though it requires careful implementation with Complex PTSD clients. Some clients may find breath-focused exercises triggering due to their trauma—for instance, one of my transgender clients rejected breathwork entirely due to traumatic experiences in a religious cult.

I begin with gentle, non-invasive approaches like observing the difference between nose and mouth breathing to help regulate anxiety. From there, I guide clients to simply notice physical sensations: the feel of air moving through their nostrils, the natural expansion and release of their lungs and abdomen. To demonstrate healthy breathing mechanics, I use a Hoberman Sphere to illustrate what I call “three-dimensional breathing”—showing how the thorax can move in all directions: length, width, and depth.

While advanced breathing techniques like those used in Kriya Yoga can create profound physiological and psychological changes through specific patterns of inhalation, exhalation, and breath retention, my primary goal with CPTSD clients is more fundamental. Simply helping them feel safe enough to take full, unrestricted breaths often begins to release long-held patterns of physical tension and armoring.

Attending to the Body in Therapy

A 23-year-old man in graduate school was recently diagnosed with bipolar disorder and had a history of physical abuse. In session he would frequently jiggle his leg. I noticed this becoming more intense when we discussed an upcoming exam. I used immediacy to bring his attention to his movement and invited him to tune into what his leg might be saying. He expressed anxiety and wanting to flee. I said, “feel free to run out of the room. I will be right here waiting for you whenever you are ready to return.”

Though surprised, he got up and left the room. A few minutes later, he came back, grinning. That completed escape and safe reception upon his return was a lynchpin to his future empowerment and ability to connect with his deepest desires. Further work around hunger ignited a passion for cooking that helped him solidify connections with friends.

During a session with a 19-year-old non-binary client, they revealed that at work they were so overburdened they didn’t urinate for up to 8 hours. When I expressed surprise and concern, they reported their boss often neglected to allow breaks. Not only due to the questionable legality of this situation, but due to this client’s habitual self-neglect, I encouraged them to insist on being allowed to take care of their bathroom needs.

In case clients don’t feel empowered to stand up for their needs, I encourage them to blame it on me, their therapist. In this way, therapy helps them repair personal boundaries caregivers often neglected to help them build. Over the course of our ensuing sessions, this client reported on the transformation they experienced because of this new awareness. Not only were they able to stand up for themselves in other interpersonal situations, they went on to become stronger advocates for animal welfare.

A 45-year-old woman was seeking therapy for chronic illness and overwhelming guilt around leaving her mother and sister, both addicted to methamphetamines. By attending to her basic physical needs, especially hunger and rest, she was able to reframe her “abandoning” of her family into the recognition that as a child, she was abandoned by them.

Paying attention to basic physical needs begins to reverse codependency dynamics of over-focusing outward and under-focusing inward. According to codependence expert Nancy L. Johnston, external focus and emotional suppression are two of the four hallmarks of codependent behavior, along with self-sacrifice and interpersonal control.

***

Helping clients become aware of biological needs is a critical first step in healing. Empowering them to satisfy these needs is the next step in helping them feel safe and grounded enough to pursue life satisfaction. Providing validation for these unmet physical needs can, at times, be challenging. As much as possible, I guide clients in session to check in with their inner experiences. I am repairing the attachment function of attending to a child’s most vital requirements.

My experience has taught me that in cases of childhood neglect and abuse, not only is there the tension of feeling needs but also accompanying grief, shame, and rage elicited by not having needs met by caregivers. Validating and normalizing having needs while providing opportunities to feel and satisfy them mitigates fears evoked by vulnerable feelings. Healing trauma through this attention can repair the split clients were forced to assume when they buried or negated crucial survival needs.

Questions for Thought and Discussion In what ways do you resonate with this author’s premise? In what ways do your PTSD clients neglect their basic bodily needs? How do you integrate these needs into your therapeutic work with these clients?

The Challenge of Therapy During War: Psychotherapy in Ukraine

Posted on by Psychotherapy.net Team

The Emotional Ravages of War

The ongoing crisis in Ukraine has placed immense psychological strain on its population, creating a heightened need for mental health support amidst war, displacement, and uncertainty. Therapists working in Ukraine face unique challenges requiring resilience, adaptability, and innovative approaches. The war has caused massive, widespread trauma with millions displaced and exposed to violence. Therapists working either face-to-face or remotely with their clients encounter acute and chronic PTSD symptoms, anxiety, depression, and grief due to loss of loved ones, homes, and stability. There is also considerable intergenerational trauma in families with histories of oppression.

While Ukrainians have a history of resilience, the impact of intergenerational trauma and mental health stigma persists. Many of my clients attempt to minimize emotional distress or express it through physical symptoms. They have historically hesitated in seeking help, viewing it as a sign of weakness. However, online therapeutic platforms like Soul Space, the one through which I work, offer easily accessible and safe resources for support and self-help tools that empower these individuals.

The Challenge of Therapy During War

Therapists, such as myself, often face secondary traumatic stress (STS) from absorbing clients’ pain, leading to symptoms similar to PTSD. High caseloads also contribute to burnout and emotional exhaustion. Therapists often work with limited supervision, professional development opportunities, or access to private therapy spaces. Displaced populations pose additional logistical challenges to on-ground clinicians. Balancing professional neutrality with personal feelings about the war, while addressing clients’ immediate needs and maintaining a therapeutic frame, are frequent concerns that challenge clinicians under these circumstances.

While teletherapy has been invaluable to Ukraninans under seige, and has allowed me to support more clients than had I been on the ground, power outages, poor internet connections, and client inexperience with technology often impede its effectiveness. It has also been critical for me to prioritize self-care, emotional hygiene, peer support groups, and supervision to process my own emotional experiences as I serve those devastated by the war. I have also found it useful to limit daily trauma-focused sessions to prevent emotional fatigue. Techniques like grounding and meditation have helped me to maintain strength and clinical endurance.

I have learned to respect clients’ cultural coping mechanisms in order to build trust and support empowerment, resilience, and self-efficacy. I have relied on trauma-informed approaches that begin with safety and stabilization techniques such as grounding exercises and psychoeducation about trauma, while also processing with practical problem-solving to meet clients’ immediate needs. Soul Space provides psychoeducational workshops to maximize reach, provide structured, and self-guided mental health resources.

Case Example

A displaced family of four sought therapy after relocating from a war-affected region. The parents reported anxiety, irritability, and hypervigilance; while the children displayed regressive behaviors and nightmares. My approach required the establishment of safety and routine in therapy, psychoeducation to normalize trauma responses, and activities that built resilience and mutual support. Nighttime relaxation rituals helped the family with wartime-related sleeplessness, while gradually igniting bonds of trust and security due to invasive interruptions of regular routines. The parents practiced simple grounding techniques to contend with their own anxieties.

The parents learned about trauma responses in adults and children, and were increasingly able to reframe the children’s behaviors as survival mechanisms instead of simply seeing them as defiance. Several grounding exercises were also introduced to the children utilizing sensory modalities by asking them to say five things they see, hear, or touch when feeling overwhelmed.

To strengthen family bonds, I introduced therapeutic play and storytelling to allow the children to articulate issues of fear in a safe and imaginative way. The parents were given the chance to have planned conversations to foster emotional conversations and model healthy expressions for fear and grief. We also created a “Family Strengths Tree” where they could record examples of salvaged resilience to remind themselves of their survival capacities.

The family finally began processing their experiences. The children created a storybook representing their journey, necessitating a shift in the focus from fear to resilience. The parents explored their guilt and grief using cognitive processing techniques, reframing self-blame into self-compassion. Throughout the intervention with this family, and as with other wartime displaced clients, I integrated formal online training available through Soul Space with my direct face-to-face work.

During our work together, the family experienced reduced anxiety, improved communication, and renewed hope. The mother’s panic attacks became less frequent, and the father started to emotionally reconnect with his children. The daughter began socializing again, and the son had a drastic decrease in nightmares and bedwetting. Coping mechanisms and family bonds improved. Working with this family, as with others, I have come to rely upon additional training courses in trauma-informed interventions, networking, and the importance of adapting my therapeutic techniques to meet the realities of life in conflict zones, including shorter sessions or combining therapy with referral for humanitarian aid.

Questions for Thought and Discussion

Whether or not you’ve worked with clients in war-torn areas, how do you resonate with the author’s sentiments?

Which of the challenges raised by the author are similar or different from those you have experienced with traumatized clients?

What are some of the core techniques that you have found successful in working with traumatized clients?

The Art of Effective Couples Therapy: Negotiation, Compromise, and Sacrifice

Posted on by Psychotherapy.net Team

As a therapist, the language I use can shape the way clients navigate their relationships as it provides a framework where thinking and behaving can take place. In couples therapy, my main goal is to help clients cultivate, commit, and execute on their shared vision. Over the past two decades, I have found that helping clients redefine negotiation, compromise, and sacrifice is essential for fostering healthier dynamics and building a sustainable strong foundation for the future of their relationship. These are terms that are often misunderstood yet widely used and profoundly impact the quality of their relationships.

Clarifying Expectations: A Foundational Practice

In casual, low-stakes situations, many individuals tend to effectively clarify expectations. For example, hiring someone to paint a house involves clear discussions about the scope, timeline, and payment. Yet in personal relationships, particularly romantic ones, expectations are often unspoken or assumed.

Couples often bring different goals, values, and assumptions into their shared lives, which can lead to misunderstandings unless explicitly addressed. When the vision for a relationship is not clear and agreed upon, it can leave room for mismatched priorities regarding resources, which could lead to further conflict in a relationship. For instance, one partner may dream of moving to a new city, while the other wants to stay near family. Similarly, one might desire children, while the other feels uncertain or uninterested. Financial priorities can also differ, with one valuing saving for the future, while the other emphasizes enjoying life in the present. On a more conceptual level, one might define privacy and secrecy very differently than the other person.

These principles, however, extend beyond romantic relationships and can help clients navigate workplace relationships, friendships, and family connections. Making these distinctions is critical. Specifically, when working with singles or couples to carve out their shared vision, understanding these concepts is essential to fostering healthy dynamics and avoiding long-term resentment. Addressing these needs, visions and expectations thoughtfully is crucial, as they directly influence resource allocation and life priorities.

Negotiation: A Daily Practice

Negotiations are what we do daily to navigate life when we are partnering with someone (where to go for dinner, who picks up the kids, etc.). Usually the stakes are not as high depending on the sensitivities within a coupledom, and some couples might not even call it that. When I bring up the word negotiation, depending on the cultural context of the clients, they might be surprised and sometimes even offended thinking: this is not the language we use in loving relationships, and it is best to be left to the business world where transactions happen.

The way I expand on the concept of negotiation and help clients to come around, is to explain that, in any relationship, there are certain currencies involved (again, going back to the language we use, many people think that currency is only applicable to monetary entities). Based on social exchange theory, we are all looking for an exchange of some sort when we are interacting with the outside world. This might not be conscious or intentional; nonetheless, it is always present.

Therapeutic Insight: Negotiation provides clients with a sense of agency, it helps individuals learn how to take accountability over what they desire in life, show up for it, and articulate it with their partner. Otherwise, we all have seen cases that one went along with the other only to find out somewhere along the way that “this is not what I wanted,” while the other person didn’t have a clue. As a therapist, I can coach clients to approach these conversations as opportunities for collaboration, encouraging them to listen deeply, receive what is offered, and then formulate their responses in a thoughtful and authentic manner.

Compromise: Balancing Individual and Shared Needs

Compromise often involves ensuring both partners feel their needs are valued. This step helps partners identify areas of alignment and divergence, usually without resorting to defensiveness or rigidity. It requires mutual give-and-take and intentionality to avoid one-sided concessions. It is not always meeting in the middle as it is believed to be, because healthy relationships are not based on equality or 50/50 as many of us working with couples would agree. They are based on equity where everyone involved is satisfied in their own ways.

Therapeutic Insight: It’s crucial to remind clients that compromise doesn’t always mean equality in the moment—it’s about creating equity over time. I encourage them to assess whether the “currencies” being exchanged feel worthwhile and sustainable.

Sacrifice: When It Becomes Unhealthy

Sacrifice often involves one partner giving up something significant, which can lead to resentment if done without open communication or equitable acknowledgment. For instance, one relocates for her partner’s job, leaving behind her career and community while not having a chance to assess her own needs in short and long term and without continued communication as things evolve with this move. Without mutual appreciation and a plan to address her needs, resentment may develop, impacting the relationship’s health.

Therapeutic Insight: Help clients reflect on whether a potential sacrifice aligns with their values and long-term goals. Sacrifice should be a conscious, collaborative decision rather than an expectation.

Cultural Context and Relational Dynamics

When I’m talking about relational dynamics, I am also talking about what defines them for individuals and couples. Cultural, religious, and gendered expectations often influence how clients perceive negotiation, compromise, and sacrifice. For one couple, sacrifice might be the way to go (and might even be expected of a good wife) and for another, it might just be a figure of speech while in reality the description of the dynamic resembles a negotiation pattern for the therapist.

I have found that exploring these factors is essential to helping clients identify patterns that may unconsciously shape their behavior. Meet them where they are and empower clients to define their relational values and vision, rather than defaulting to inherited scripts.

Some Practical Applications for Psychotherapy

These are some practical ways I have incorporated the above strategies into my clinical work with couples:

With singles, I encourage clients to clarify their non-negotiables and flexible areas before entering relationships. This self-awareness equips them to negotiate and compromise effectively when building connections.

With couples, I guide each to regularly revisit their shared vision—perhaps at the start of a new year or on anniversaries. This practice ensures their goals evolve alongside their individual and collective growth.

In the broader context, I try to apply these principles to familial and professional relationships, helping clients navigate complex dynamics with greater intentionality and respect.

Case Application

Rory and their kids loved skiing, while Hunter despised it—not just the sport but the cold and all the logistics involved. Before they had kids, this wasn’t an issue. They simply did their own things in winter, and no one thought much of it. However, once their kids reached skiing age, the dynamic shifted. Rory planned to spend every winter weekend skiing with the kids, and Hunter realized what this would mean for him.

In the first year of ski school, Hunter found himself waking up at six in the morning to help pack lunches, wrangle the kids’ gear, and drive 80 miles to the mountain. Rory and the kids thrived on this, but Hunter was miserable. He felt he had no options: staying home without a car wasn’t fulfilling, and joining in was even worse. To Hunter, it all felt like an unwelcome sacrifice.

Entering the second year, Hunter and Rory recognized that their dynamic wasn’t sustainable. They began to negotiate in earnest. Rory explained her perspective:

I grew up skiing; it’s my passion. It’s really important to me to pass that on to the kids because they love it too. I hardly get to see them during the week, and bonding with them over skiing feels really meaningful. I don’t want to give this up, but I also don’t like feeling guilty all the time. I know this isn’t working for you. Is there a way we can make this work for both of us?

Hunter shared his struggles and feelings of resentment, and through multiple conversations and creative problem-solving, they found a solution that worked for both of them. Rory took over 90% of the labor involved in ski school, including handling all the gear and logistics. Hunter agreed to pack lunches and have dinner ready when they returned. Rory bought a second car, so Hunter had options on weekends. Hunter decided he would join them for a few ski trips each season for family bonding, but otherwise enjoyed rare, unstructured time to himself—a precious commodity as a stay-at-home dad.

This arrangement worked beautifully. Rory was able to share her love of skiing with the kids, which was incredibly meaningful to her, while Hunter gained much-needed personal time and no longer felt trapped in a situation he despised. Hunter and Rory’s story illustrates how healthy compromises work; neither partner “won” nor “lost.” Instead, they both gave a little and got a little. Through negotiation and compromise, they reached a solution that felt equitable and allowed them to move forward with confidence and mutual respect.

***

Negotiation, compromise, and sacrifice are integral to shaping a life together. By teaching clients to differentiate these concepts, I hope to empower them to engage in relationships as active participants rather than passive followers. Healthy relationships require adaptability, mutual respect, and clear communication. Whether clients are building a life with a partner, strengthening family bonds, or deciding on a career path, these tools equip them to foster meaningful, sustainable connections. As a therapist, my role is to guide clients in creating these shared visions with intention, ensuring their relational choices align with their values and aspirations.

Questions for Thought and Discussion

  • How does the author’s work resonate with your own couples therapy?
  • Which of the three elements of change do you use in your clinical work with couples?
  • What additional or different interventions do you use with couples?
  • How would you have worked differently with Hunter and Rory?

Teaching Clients Active Listening Skills to Improve their Relationships

Posted on by Psychotherapy.net Team

One of the most common questions I am asked when people learn that I am a therapist is, “How can you listen to all those people?” What prompts that question is a fundamental misunderstanding of what it actually means to listen to another person. In my work, I strive to make my patients better listeners, not just better at self-expression.

It is imperative that we challenge the assumptions people make about what it means to listen. Truly listening to another person so that they feel heard improves the quality of conversation and enhances the opportunity for understanding. It does not guarantee agreement, nor does it necessarily entail problem solving or changing anyone’s mind. Unfortunately, it seems that these days, people are far more interested in talking than listening, even if no one is listening to them.

As one patient said to me, “Once we stopped caring about facts, I was at a loss about what to say. Why bother to listen if the loudest person in the room always wins?” This can lead to what feels like a forced choice between joining the argument or leaving the conversation. Given the cacophony of disinformation and vitriol infecting our lives, strong listening skills are more critical than ever if we want to strengthen our connections.

It takes effort to be a good listener, but with practice the results can be truly life changing. Learning how is a teachable skill and foundational to good mental and physical health. There are five foundational components of active listening.

Five Foundational Components of Active Listening

First, an active listener must have a genuine interest in the other person, a curiosity to hear what they have to say. Too often we think we know what the other person will say before they speak, so we spend our time preparing our comeback rather than listening to what the speaker says. Or we write people off as soon as we learn one thing we don’t like about them, and refuse to listen to anything else they have to say. Consequently, our world gets smaller, and we have less intimacy.

Feeling trapped in this dynamic is a common complaint about familial interactions. For example, one patient shared, “Before I’ve even taken off my coat, my father will tell me that I must be so happy with my job. It’s because he is happy that I went into law like him. I brace myself before I get there for his greeting.” After many failed attempts to have a more nuanced conversation, she no longer tries to dissuade him of his belief but is saddened by how superficial their relationship has become.

Second, active listeners understand that agreeing to listen does not assure agreement. This needs to be recognized by both the speaker and the listener. If my goal as a speaker is agreement, I must make that clear up front. When a patient tells me about a fight they had with their spouse, I use my words to express understanding of their hurt feelings, not to say they were right and their spouse was wrong. Whenever we frame a conversation as having a winner and a loser, the quality of the relationship suffers.

Third, active listening is actually hearing what the speaker has to say and trying to understand their needs. Too often people attempt to show they are listening by trying to solve a problem. This often feels patronizing and may devolve into an argument. For example, a patient of mine reports, “When I come home from a bad day at work, all I want is for my wife to listen, not tell me what I could do differently. Tomorrow, when I am rested and have some distance from the situation, I might be ready to listen to suggestions for how to do things differently, but at that moment I just want understanding. Is that too much to ask?”

One strategy that can be helpful in these situations is for the listener to ask, “Do you want to be hugged, heard, or helped?” By clarifying the unstated need of the speaker, the listener knows the desired outcome for the interaction and what will feel like effective listening to the speaker.

Fourth, active listening involves acknowledging feelings as well as facts, without conflating the two. There is a truism in psychology that anxious people can’t listen, to which I might add, neither can enraged people. Communicating that I understand the depth of a person’s emotional state is a necessary precursor to understanding what has upset them so much.

Recently, a patient called to share that she’d been diagnosed with breast cancer. Before I asked her the stage of her cancer or what her treatment protocol would be, we discussed how she felt hearing that she has cancer. Asking about her feelings was essential to providing care for her. Later we would brainstorm how she could get the best medical care possible, but until she felt heard she couldn’t process the onslaught of medical information her physicians were sharing with her.

Finally, active listening requires listening to ourselves as well as others. By setting a time limit or voicing discomfort if someone is using offensive language or yelling, allows us to take care of ourselves as listeners and increases the likelihood we will be willing and able to engage in active listening. When being a better listener, we will hopefully find ourselves in more meaningful conversations that will enrich our lives.

***

Active listening can make us feel vulnerable. Sometimes the divide is too great and ending the conversation or ultimately the relationship is the right decision. But, hopefully, more often our efforts to listen will increase our understanding of one another and bring us closer. In our fragile world we need to honor the power of listening.

Questions for Thought and Discussion

How important is it for you to “teach” your clients to listen effectively?

Which of the author’s five components of active listening is most resonant with you?

Can you think of one of your clients who would benefit from improved active listening skills?

Becoming an Accidental DBT Therapist

Posted on by Psychotherapy.net Team

A Curious Professional Journey

I did not set out to become a therapist who utilized Dialectical Behavior Therapy (DBT). When I was in graduate school, I had hoped to become a therapist who worked mainly with married couples and families, which is where I put much of the focus of my training. I had taken a class that referenced DBT and had also heard what a nightmare clients with borderline personality disorder (BPD) were to work with. But since that was never going to be me (ha!), what did I have to worry about?

Turns out, quite a bit.

For my predoctoral internship I was matched with a clinic that specialized in working with families going through oversea adoptions. Often families who had successful adoptions would later discover that the children had attachment disorder. While at this clinic, I worked with various licensed therapists and families in a variety of modalities, including: individual work, EMDR, support groups, skills groups for the children and developmental assessments.

Attachment disorder is difficult to treat and the burnout rate among therapists who do this important work is high. The clinicians I worked with, and under, were passionate and gifted. I still bear a scar on my left arm from where a child who had become dysregulated bit me. In a conversation with my supervisor, he explained to me that many of these children with attachment disorder will grow up to be clients with BPD. This is not a population for the faint of heart, and while the success rate is not exactly through the roof, it was an important part of my development.

Fast forwarding to the end of my internship, I was out pounding the pavement, trying to find a job in the field without much success. A former classmate and friend of mine had recently interviewed for a job at a community mental health center. They were looking for an already-licensed therapist to train in DBT who was willing to work with BDP clients. My friend told me, “this job doesn’t pay for shit, so I’m taking a pass. Thought that you might be interested instead.” Funny right?

Despite the glowing recommendation from my friend, I applied. During the interview, the interviewer (correctly) noted my lack of experience with BPD. I remembered what my supervisor told me and responded that I had experience, I just worked with them earlier in the process when it was still seen as Attachment Disorder.

I never received feedback to know for certain if that’s what sealed the deal, but I had gotten the job. My friend had been right when he said it didn’t pay very much, but what it did offer me was training in DBT and that changed my life forever.

My Challenging Work with Sarah

For those not familiar with DBT, it is a skills-based modality with regularly assigned homework that incorporates concepts and practices drawn from mindfulness, Buddhism, Hegel, and basic methods of therapeutic validation. Many of these concepts are abstract, and often difficult for clients to fully grasp and embrace. It can be especially tough for those with developmental challenges typically associated with attachment and personality disorders.

For me to be able to explain them to these clients in ways that they could understand and implement in their daily lives, as well as during times of crisis, I really had to learn these concepts backwards and forwards, breaking each down to its essence.

One of my earliest clients, whom I shall call “Sarah,” was very hesitant to embrace these concepts. Partly, because they were difficult to understand, but Sarah had also been through a LOT of therapy before arriving at DBT. (DBT is rarely the first stop on a client’s therapy journey and as we say, “nobody gets to DBT by accident.”)

Therapy had yet to help her in any way she could appreciate. Her arms were covered in scars from many attempts at suicide and self-injury. Estranged from most of her family, she lived with her grandparents because no group home or assisted living facility wanted the liability risk. At the time, she proved unable to hold down a job of any kind. As such, Sarah’s world was small, and her human contact was limited to intermittent conversations with her grandparents, therapists, medical personnel, and DBT Group members during her frequent hospital stays.

During one session, we were talking about suicide and self-harm when Sarah stated that she was likely to die from suicide at some point, because what was the point of living if this was all there was to life? What would happen to her after her grandparents passed away? I replied that those were excellent questions. Her life as it was currently constructed was about survival and little more. Why would any therapist expect her to embrace such a life? For Sarah, being told that “things could always be worse,” was of little consolation. What was the point of staying alive when things could get worse?

One of DBT’s core concepts is referred to as “A Life Worth Living.” In essence, it asks the client what would have to change about their life so ideations like self-harm or trying to commit suicide would organically come off the table? Of course, we must survive before we can thrive, but what did thriving look like to Sarah?

Sarah said she wanted to be able to live on her own (or with occasional assistance that would come when needed), to have a job and her own money, and MAYBE (some pie in the sky stuff here) even have some friends! To her, that would be “A Life Worth Living.” I told her it was possible to have those things, but it is going to take work. DBT, like life, is like playing a sport. It requires clients to consider making choices that someone who could live on their own, hold down a job, and had friends would make. I challenged Sarah by asking, “are you making any of those choices right now?”

She reluctantly conceded that she was not. She could not fault her grandparents for not having faith she could live on her own; the paramedics were at their house at least once a month, if not weekly due to Sarah’s self-harm and suicide attempts. Her time in and out of the hospital and subsequent therapy appointments throughout the week, made it hard for her to hold a job.

I asked Sarah what she saw as the biggest obstacle to getting to her “Life Worth Living?”

“The cutting,” she said.

I agreed. If we could find other more skillful and adaptive ways to tolerate distress, the idea of her living on her own and being able to stay out of the hospital (and therefore able to work), seemed more plausible. That session was when Sarah committed to taking self-harm off the table.

This was no small commitment. Sarah used self-harm weekly for over ten years. Neither she nor I had any illusions that it would be easy for her. In a paradoxical way, self-injury had kept her alive as a coping skill on more than one occasion. She had a concept of how to resolve physical pain, while emotional pain seemed too overwhelming. In order for her to make this work, it was a matter of buying into DBT and its skills. Would the skills be as effective as a coping mechanism for her while keeping her safe? It was a leap of faith I was asking her to make – to put her trust in DBT and our therapeutic relationship. We were off.

Sarah’s Rocky Progress Forward

Gradually the ambulances stopped coming to Sarah’s grandparents’ house and while she never went to the hospital again, it was not a smooth, upward trajectory. There were setbacks, but one day without self-harm became a week which became a month, and then we were at her quarterly review. With her grandparents present, they attended many of Sarah’s appointments and reviews, Sarah proudly told them she had gone three months without hurting herself. She had been practicing her DBT skills (Distract, Self Soothe, Opposite to Emotion, Pros and Cons) and she had plans to share!

Sarah told them about wanting to live on her own and have a job. Her grandparents were pleased, surprised, and anxious all at the same time. These were big steps to take. While they praised Sarah for her efforts and progress it didn’t stop them from worrying. Sarah wasn’t derailed and instead offered to negotiate with them: if she could keep up this progress for nine more months and graduate from Stage 1 of DBT, would they support her? First in getting a job and second in finding a place to live?

As her therapist, I jumped in explaining that this seemed like a good Wise Mind (middle path between reason and emotions) compromise. Assuming she succeeded it would be a new experience with new kinds of stress and new opportunities for her to use her skills. If she could navigate holding down a job while using what she had been practicing, it would stand to reason she could do the same living on her own.

Her grandparents agreed to the plan – the smile it brought to Sarah’s face was one I hadn’t seen before. I wasn’t sure who was more excited at that moment, me or her! Being able to observe her having faith in herself and her future remains one of the most powerful experiences I have shared with a client. I did not know then what the future held, but I knew that DBT worked, and I could not turn my back on something that worked. From that moment on, I was a DBT therapist.

***

It’s been almost 25 years, throughout which I have worked with thousands of clients on achieving their “lives worth living.” I have seen clients who went from thinking about suicide almost every day to taking it completely off the table. Many were clients who now have healthy relationships and rewarding careers, just like Sarah. The work is challenging, and I am thankful for the support of a great team. The pride I take in seeing how hard these clients work on themselves is impossible to describe. They continue to make me a better therapist and I would not have it any other way.

Questions for Thought and Discussion

  • What serendipitous experiences have you had over the years that have opened interesting clinical doors for you?
  • In what ways are the core premises of Dialectical Behavior Therapy consistent with your orientation to therapy?
  • What are some of the limitations you have experienced or anticipate in the application of DBT principles and techniques?

Lessons in Tough Compassion and Male Resistance to Therapy

Posted on by Psychotherapy.net Team

As a counselor and educator, I often find myself reflecting on representations of therapy in popular culture. One film that has stayed with me over the years is Good Will Hunting. While the movie is celebrated for its exploration of genius, trauma, and relationships, what stands out most to me is the character of Sean Maguire, the therapist played by Robin Williams. Sean’s approach to therapy, particularly with a resistant male client like Will Hunting, is a masterclass in what I call “tough compassion.”

The Unsung Hero

Sean Maguire is a humble community college professor and clinician. He is a quick-witted, grounded therapist who connects with Will person-to-person. His approach is in sharp contrast to the two other high-profile therapists Will is forced to see, who never get on Will’s level. Sean is the kind of professional whose impact might never make headlines but is deeply felt by the individuals he helps. How the film represents Sean’s work really resonates with me as a counselor. While we may not gain the accolades of more visible professions, or write noteworthy, high impact therapy texts, get featured on TV shows, and so forth, our work of helping individuals confront their pain, realize their potential, and find healing—is no less meaningful.

Sean’s humility and commitment remind me why I chose this path in the first place. The scene where Sean and Will end their time together with a hug speaks volumes of the positive impact that Sean had on Will, that Will can’t even begin to articulate. And Sean knows it. The two men say so much without saying anything; the impact the relationship had on both men on such a deep level is clear. While this particular element of the movie inspires me, it is the way in which the movie demonstrated male resistance to therapy, and Sean’s tough but compassionate approach with Will that I love.

Male Resistance to Therapy

We can see in Will’s interactions with the other two therapists that he made outrageous comments and disingenuous intimate disclosure meant to derail the session and throw the counselor off his game. But with Sean, he is able to roll with the resistance (in a very Milleresque manner). He doesn’t get offended or distracted by the resistance, but continues to redirect with humor and direct questions back to Will (except for when Sean choked Will out on their first session, we’ll ignore that for now). This approach, over time, with some vulnerable disclosures from Sean about his life, losses, and relationships, eventually get through to Will.

Will starts opening up and letting Sean into his inner world. He begins to trust Sean. Will’s reluctance to engage with Sean reflects a broader societal issue, and one that I have often noticed in my practice: men struggle to open up about their emotions or seek help. Cultural expectations of toughness and self-reliance can make vulnerability feel like weakness. Sean understands this resistance, and rather than forcing Will to conform to a traditional therapeutic model, he meets Will where he is—both emotionally and relationally.

Tough Compassion in Action

Sean’s approach is what makes him so effective. He doesn’t back down when Will tests his boundaries. In their first session, Will mocks Sean’s deceased wife, pushing him to the edge. Rather than retaliate or shut down, in a manner of speaking, Sean asserts his boundaries with firmness (although I don’t endorse choking out your client). “You ever disrespect my wife again, I will end you,” he says. This moment is not about anger or dominance; it’s about authenticity. Ultimately, it is what earns Sean respect and credibility in Will’s eyes.

Sean’s tough compassion also shines in his willingness to challenge Will. He sees through Will’s intellectual defenses and calls him out on his fear of vulnerability. In another memorable scene, Sean tells Will, “you’re terrified of what you might say. Your move, chief.” This balance of empathy and accountability is a cornerstone of effective therapy, especially with male clients who may be guarded or skeptical of the process.

The Impact of Authentic Connection

The turning point in the film—and in Will’s therapy—comes when Sean shares his own vulnerabilities. By revealing his grief, regrets, and imperfections, Sean shows Will that strength and vulnerability can coexist. This authenticity creates a safe space for Will to confront his own pain and begin to heal. For me, this aspect of Sean’s character underscores the importance of being real with male clients. Therapy is not about having all the answers or maintaining a perfect façade. It’s about creating a relationship grounded in trust, respect, and genuine care—a relationship that can serve as a foundation for growth — and being willing to change up one’s approach to therapy with male clients, using a tough technique that’s counterbalanced by compassionate.

Lessons for Counselors

As I reflect on Good Will Hunting, I’m reminded of several key lessons for working with male clients:

  • Meet Clients Where They Are: Understand their resistance and adapt your approach accordingly. Resistance to therapy among males is not the end of the road, but a bump. So, roll with the resistance, and redirect back to the client with honesty, empathy, directness, and humor.
  • Balance Empathy and Accountability: Build trust through compassion while challenging clients to confront their fears and defenses.
  • Be Authentic: Share enough of yourself to foster connection without overshadowing the client’s journey.
  • Value the Quiet Impact: Recognize that our work, though often unseen, can change lives in profound ways.

Sean Maguire may not have had the fame of his academic peers, but his influence on Will Hunting’s life was transformative. As counselors, we may not always see the ripple effects of our work, but Good Will Hunting reminds us that our presence, compassion, and persistence can make all the difference.

Good Will Hunting is more than just a story about genius and redemption; it’s a testament to the power of connection in therapy. Sean Maguire’s approach—grounded in tough compassion and authenticity—offers a blueprint for counselors striving to make a meaningful impact, particularly with male clients. The film is a poignant reminder that while we may not always receive recognition, the relationships we build with our clients can be life changing.

If you’ve ever wondered about the quiet yet profound impact of counseling, Good Will Hunting is a must-watch, and if you’re a counselor, it’s a call to embrace authenticity, persistence, and the transformative power of tough compassion.

Questions for Thought and Discussion

  • In what ways do or don’t you connect with the therapeutic concept of “tough compassion?”
  • What movie featuring a therapist has inspired you, and why?
  • What emphasis do you place on connection in your therapeutic encounters, particularly with male clients?

When Clients Don’t Want to Talk about Their Feelings

Posted on by Psychotherapy.net Team

“My husband does these little things that get under my skin,” Naomi lamented as she sat across from me. “Like he chews his ice.” She scrunched up her freckled nose and clenched her fists. “I ask him not to. I ask him really nicely to please not chew his ice.” She shared some other things her husband did to annoy her. “Like, whenever I ask him a question, he’ll answer with a question. I’ll ask what he wants for dinner, and he’ll shrug and be like, ‘What do you want for dinner?’ I know I’m overreacting, but that makes me furious.”

Helping Clients to Put Feelings into Words is not Always Easy

“You feel furious,” I said. “I can’t stand that. I want to scream at him.” “What do you think it is about that question that makes you furious?” “I don’t care.” Her arms crossed; she was now tapping her foot against the carpet. “I don’t care why I feel like that. I just want to not feel like that. I want to stop being so pissed off at him.” This was not the first time Naomi and I had had this kind of impasse: me attempting to better understand her and her dismissing my attempt as a pointless intrusion. She wanted “tools” to change her feelings, specifically to help her feel less angry with her husband. “I get that you want tools to help you feel less upset,” I said, “and we can definitely talk about tools, but I think that in order to change your feelings, it’s important to first understand them.” “I don’t get that logic.” She straightened her posture. “No offense. I’m sure you help many people, but I’m not your typical client. I don’t want to sit here for 50 minutes whining about my problems. I don’t need a sounding board. I need tools to change my situation.” Over the weeks that followed, I obliged Naomi’s request to talk about tools, and we identified coping skills that had worked for her in other situations. All the while, I kept nudging her to further explore her feelings, my belief being that clients like Naomi ultimately benefit from developing greater emotional insight. Following one of my nudges, she indicated that her reluctance to talk about her feelings was based on her fear of becoming helpless. “I don’t want to turn into one of these whiners you see on TikTok. You know, these helpless women who can’t handle the slightest adversity and always complain about being victims.” “Well, goodness,” I said with playfulness, “I wouldn’t want to turn you into one of those women either.” She looked at me as I spoke these words, and we both laughed. This marked a turning point in our work together. I better understood her fear of becoming helpless, and she understood that that would never be my intention. Naomi started to more fully open up, and I began to sense that her anger over her husband was more complicated than she’d assumed. When she told me one afternoon how he had continued answering her questions with questions, I asked that standard therapist question: “How did that make you feel?” “Really pissed off,” she answered. “Beneath that feeling of being pissed off, what else did you feel?” “I don’t know.” She looked away and slowly shook her head. “I guess I felt like a monster.” “You felt like a monster?” I emphasized. “It’s like he’s afraid to disagree with me. I think he’s afraid that if he disagrees with me, I’m going to bite his head off. But I’m not like that. I’m really not so horrible.” “That must really hurt, to believe your husband thinks you’re this monster.” “It sucks.” Her energy had changed, her body now still, her head slumped forward. It now seemed clear that she had initially resisted exploring her feelings because what lay beneath her anger—what we would later describe as “shame”—was far more painful to accept than mere anger. The two of us sat in silence for several seconds. “I wonder if your husband knows that’s how you feel,” I finally said. “I don’t know. Probably not.” She looked up at me. “We should probably talk about it.” Naomi’s initial desire to learn new tools was not wholly misguided. Tools, or coping skills, are a necessary component of psychological health. However, coping skills often mitigate symptoms without bringing about lasting change. Sometimes simply adding more gasoline to a sputtering car doesn’t do the trick. Sometimes we need to look under the hood and figure out what’s going on. Naomi reported back the following week that she had had a heart-to-heart with her husband, the first such conversation they’d had in a long time. “We’re better. We’re not perfect. No relationship is perfect. But it’s good that we talked.” Questions for Thought and Discussion In what ways do you resonate with the author’s premise regarding feeling exploration? How do you work with clients who resist exploration of their feelings? In what ways might you have worked differently with a client like Naomi?

Navigating the Landscape of Spiritual Experience in Therapy

Posted on by Psychotherapy.net Team

A Discipline Founded in Spirituality

One of my favorite literary quotes is from Shakespeare’s play Hamlet: “There are more things in heaven and earth, Horatio, than are dreamt of in your philosophy.” It implies that there are mysteries and experiences beyond our understanding of the world. Hamlet says this after encountering his father’s ghost, which is considered a strange and supernatural event.

The Swiss psychiatrist, Carl Jung had many paranormal experiences including near-death ones and a series of visions. He wrote and painted extensively about these experiences. Though committed to practicing practical psychology, he pioneered a way of incorporating mysticism, like astrology and divination, in psychological work.

The American philosopher and psychologist, William James was one of the founders of psychology as a discipline. He identified four characteristics of mystical experience: ineffable, noetic, transient and passive.

All this to say that spiritual encounters are foundational human experiences.

The ACA’s Code of Ethics emphasizes a client-centered approach, meaning whether or not to discuss spirituality is ultimately decided by the client. The counselor should only explore this topic if it is relevant to the client’s concerns and with their consent, and counselors must acknowledge and respect the diverse spiritual beliefs of their clients, including those who may not identify with any particular religion.

I come from a culture with spiritual traditions ranging from Jewish to Pagan to Christian, often blending them. My family’s stories include tales of mysterious visitations (when her beloved grandfather died, my mother said he came to her in the middle the of the night) as well as rituals like baptisms, seances, lighting candles, and making offerings to saints. We also have a Freemason or two among my ancestors. I have engaged in a lifelong exploration of spiritual practices and traditions including Catholicism, Reformed Judaism, Taoism, Tantra Shaivism, and Dzogchen Buddhism so when it comes to spirituality, I’m open to whatever shows up.

Valuing the Client’s Spirituality

A non-binary client in their late thirties was facing a 4-year battle with malignant terminal cancer. They shared that their experience using psychedelics felt initially terrible and filled with suffering, but that when they were able to surrender, they experienced a sense of wholeness and bliss. I suggested we could use this psychedelic vision as a map for their journey going forward with illness and death, something they had not considered nor shared with their previous counselor.

Another client shared that traveling abroad enabled her to soften the edges of her identity and boundaries, allowing her to experience the world and other people with a sense of greater connection and ease. She strongly felt that travel was a spiritual experience for her that aligned with her Jewish roots.

A client who had struggled with intergenerational trauma and loss, practiced self-administering psilocybin alone and shared with me her insights. She described a mixture of experiences, from the more mundane to a profound connection through a vision of an ancestor whom she felt she actually embodied during a mushroom journey. This enabled her to connect with feelings of forgiveness for the suffering she endured.

Perhaps one of my most challenged clients identifies as a Christian. He struggles with an understandable dilemma: if God is good, why does evil exist? And why does God allow women he falls in love with to stay in abusive situations? Though I do not subscribe to his beliefs, I feel strongly that his questions are profound and worth exploring. It is, at times, difficult for me to refrain from remedying his dilemma through my more Eastern spiritual beliefs. Instead, I shared Anthony de Mello’s little gem of a book entitled The Way to Love. de Mello was a Jesuit who lived in India most of his life and wrote bracingly about God, Reality, and Love.

Clients who identify as Pagan or Wiccan, will often discuss their Tarot readings with me. I feel thankful for my familiarity with this tradition and genre of symbology that allows me to explore their concerns using a rich metaphorical language.

These are some of the questions I use when approaching clients’ spiritual experiences:

  • What do you feel or think this dream/vision is telling you?
  • Is there a message here that feels relevant to your life?
  • What troubles or reassures you about this experience?
  • If this experience was “your marching orders” as it were, what would those be?

When clients talk about noetic experiences, I listen closely for clues to discover and incorporate meaning in their experiences. The terrain of spiritual experience is as complex and multifaceted as human consciousness itself. Our therapeutic approach must honor this complexity—recognizing that spiritual encounters are deeply personal, often ineffable, and profoundly transformative. Just as Carl Jung and William James understood, these experiences transcend simple categorization, challenging our conventional understanding of reality and self.

My key therapeutic considerations include:

  • Embracing radical openness to clients’ spiritual narratives
  • Maintaining ethical boundaries while creating space for profound exploration
  • Recognizing spirituality as a potential source of meaning, resilience, and healing
  • Understanding that spiritual experiences are as unique as the individuals who encounter them

As counselor, my role is not to validate or invalidate spiritual experiences, but to provide a compassionate, non-judgmental container for understanding. Whether these experiences emerge through dreams, meditation, near-death encounters, or altered states of consciousness, they represent critical moments of potential insight and personal growth.

Critically, my approach must be rooted in the ACA’s ethical framework: client-centered, consensual, and fundamentally respectful of individual spiritual diversity. I listen not to interpret, but to understand—creating a therapeutic relationship where clients feel safe exploring the most intimate dimensions of their inner landscape.

Just as my own journey has woven through diverse spiritual traditions—from Judaism to Buddhism, from mystical practices to academic inquiry—so too must my therapeutic practice remain flexible, curious, and deeply attuned to the nuanced ways humans make meaning of their existential experiences.

Our relationship(s) with the invisible and numinous (meaning, suggesting the presence of divinity, or just Presence) is as individual and unique as fingerprints, yet has common features. These experiences may elicit awe, offer reassurance, incite action, and clarify issues. I have found the Mystical Experience Questionnaire (MEQ) to be very useful in this regard. It was developed in the 1960’s to assess mystical experiences caused by hallucinogens. It covers dimensions such as unity, sacredness, and ineffability. The Revised Mystical Experience Questionnaire (MEQ-30) is a 30-item version of the MEQ that is used in clinical research & measures four dimensions of spirituality: belief in God, mindfulness, search for meaning, and feeling of security. It can be downloaded here: https://psychology-tools.com/test/meq-30.

***

Ultimately, spirituality in counseling is about creating a sacred space of genuine human connection—where the mysterious, the ineffable, and the profoundly personal can be witnessed with compassion, wisdom, and profound respect.

Questions for Thought and Discussion

Which of the cases the author discussed resonated with you the most? In what ways?

How do you incorporate spirituality into your own clinical practice?

How do you integrate your own spirituality into your clinical work?

When to Use Unexpected Techniques with Emotionally Overwhelmed Adults

Posted on by Psychotherapy.net Team

“Name it to tame it” has become a popular phrase among parents and those working with children. It denotes the principle that we can help emotionally overwhelmed children feel better by helping them put their feelings into words. Daniel Siegel provides an example of this principle. Bella, a nine-year-old girl, watched the toilet overflow after flushing it, “and the experience of watching the water rise and pour onto the floor left her unwilling (and practically unable) to flush the toilet afterward.” Her father later sat down with her and encouraged her to tell the story, allowing “her to tell as much of the story as she could,” and helping her “to fill in the details, including the lingering fear she had felt about flushing since that experience. After recalling the story several times, Bella’s tears lessened and eventually went away.” Putting these experiences into words, Siegel writes, “allows us to understand ourselves and our world by using both our left and right hemispheres together. To tell a story that makes sense, the left brain must put things in order, using words and logic. The right brain contributes to bodily sensations, raw emotions, and personal memories, so we can see the whole picture and communicate our experience.”

Putting Theory into Action in Therapy

I repeatedly experienced the power of this principle during the six years I worked with children in an elementary school. After I transitioned to working with adults, I would sometimes forget the principle. I can remember a session with Mary, a 55-year-old woman who could not bring herself to leave Harlan, her emotionally abusive husband of 30 years. She had entered therapy to find the resolve to leave, something her friends and even her grown children had long encouraged her to do. I spent the better part of the session encouraging Mary to give voice to that part of her that wanted change. She followed my lead and asserted her rights and needs. After speaking with passion for several minutes, she suddenly stopped talking and looked off into space. “I know everyone thinks I should leave Harlan, and I know their hearts are in the right place.” Her eyes fell to the ground, all the energy that had animated her just moments before now gone. “We were basically kids when we got together. We grew up together. There’s something about Harlan and me that others just don’t understand. There’s something that I just can’t put into words.” There was a heaviness to her words. She seemed to be saying, ‘Yes, on paper there are good reasons for leaving him, but these other reasons possess a power that ensures that things can never change.’ I had given Mary the space to share her story, but she was now telling me that part of her story could not be shared. She was suggesting that this part of her story, perhaps because of its ineffability, exerted a hold over her from which she could not escape. Consequently, she felt she could not move toward the goal that had motivated her to start therapy. As the session ended, her despair seemed contagious, and I too felt that she would never be able to articulate that part of her story. I thought about our session over the next week and couldn’t avoid feeling that I had failed her. Yes, I had empathized with her, and I think she felt that, but I had failed to give her hope. I shared my feelings with my own therapist, and she said something that reminded me of another popular principle among parents, one often described as, “the power of yet.” I hadn’t helped Mary put words to her feelings —yet! She and I would again talk about Harlan, and she would again say that there was something about their relationship that others didn’t understand, something she just couldn’t put into words. I would add that simple, powerful word. “There’s something you can’t put into words—yet.” Not unlike a parent, my job as a therapist is to sometimes help others find words for their experiences. Helping them find their words is not the answer to every problem, and indeed words cannot fully and adequately describe the depth of many important experiences. Yet. Helping clients put words to their most difficult experiences can be profoundly helpful. Mary could not describe a crucial part of her relationship with Harlan—yet. My work was to help her find those words. I thought back to my clinical supervisor’s statement that, when his clients struggled to describe their inner experience, he would ask if an image or even a color came to mind. The goal was not for them to provide a precise, granular description of their feelings at first, but to try to take steps in that direction, little by little, one word at a time. I now had hope, and I knew I would be able to share my hope with Mary. It might take time to get there, but with my encouragement, she would vocalize that aspect of her relationship that had never before been vocalized. And when she did so, she would feel less isolated and more empowered. I did not know what she would feel empowered to do, and neither did she. Yet. Questions for Thought and Discussion In what ways does the author’s message resonate with you? Not resonate with you? Based on the readings, do you agree that the author initially “failed” with Mary? How might you have addressed Mary’s decision to remain with Harlan?

The Silent Therapist: Teddy Bear Therapy with Adults

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Alex is a tall, thin, 86-year-old former psychotherapist now living in a nursing home, and walking with a walker. He experiences mild anxiety and depression associated with adjustment to his advanced stage of life development, and he experiences mild cognitive issues. I meet with him for life review therapy.

The Importance of Everyday Objects

Alex loves music and theater, and he wrote and performed in plays, in addition to practicing and teaching psychotherapy. He had studied in a Catholic Seminary yet decided against becoming a priest. He has a teddy bear named TJ in his room with a scarf around its neck knitted by his daughter. Alex was given TJ many years earlier, and for 30 years TJ served as his co-therapist. “I gave presentations at maybe 75 conferences with at least 75 participants each time, and I always brought TJ with me,” Alex said. “I would approach the podium and introduce myself. The audience members were probably wondering what was going on with this guy holding a teddy bear. ‘This is my partner TJ. He doesn’t have a lot to say, but he would be glad to meet some of you while I am speaking.’ Always, someone would raise their hand and ask to hold TJ. “While I was speaking, I would notice one person tap the shoulder of the one holding TJ, and pretty soon he would be handed along, person to person. When I was wrapping up and asking if there were any questions, one or more hands would shoot up, and someone would say, ‘We haven’t had a chance yet to hold TJ.’ The experience of TJ being at the meeting would create a warm sense of camaraderie, and people always spoke to me afterwards to remark on the special experience it had been for them,” Alex said. In his private practice, Alex had TJ placed in a chair next to his in the office. “Clients would walk in and say, ‘What’s up with the bear?’ ‘Oh, this is TJ. He just likes to listen; he doesn’t say too much; you can hold him if you’d like to get to know him better.’ Some who scoffed at TJ the first time, might return the next time and just pick him up and hold him without saying anything. “TJ was like a doorway to feelings and thoughts that clients might not get to for a long while if I had only used language. It was always remarkable to me the things that people remembered and talked about because they were holding TJ,” said Alex. He added; “With my students or clients, they look at me, and they see their projection on me. But when they look at TJ, they see into themselves; a part of their self they have not been in touch with, or for a long time, and they sometimes don’t know what to do with it.” “TJ helped me have a tangible connection to the child in me, and helped me evoke that in others,” Alex said. He added, “TJ represents innocence, and there are not so many ways in therapy, or in society, for an adult to access their innocence — and I don’t only mean childhood innocence, but a sort of opening to wonder and mystery and spirit — because if those things aren’t present in therapy, what are we doing,” Alex asked?

***

Teddy bear therapy has been around for many decades, yet mostly used in work with children. Alex found clever and effective ways to incorporate TJ into his teaching and therapy practice. At a time when he feels saddened by the need to adapt to a slower and less productive period, life review therapy validates Alex’s notable accomplishments and restores his positive sense of self-worth and makes room for his mischievous and warm-hearted sense of fun, which is where TJ comes into play. Questions for Reflection and Discussion What are your personal and professional impressions of the author’s work with this patient? How might you have addressed the patient’s relationship with TJ’s similarly? Differently? How have you made use of inanimate objects in your clinical work?