My dad was an avid reader, visiting the library weekly as well as purchasing new and used books. As a teenager, I spied a vintage copy of a 1957 work titled How to Live with a Neurotic: At Home and Work and snuck it into my tiny bedroom.
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A Very Brief History of Self-Help Literature
I couldn’t attain complete privacy in my room, shared with my brother, due to the 6-foot barbell we stored under the bed preventing the door from closing fully. But seriously, for the most part who needs privacy when you have weightlifting to focus on?
I discovered the book was written by Albert Ellis, a New York clinical psychologist, and I thought his ideas were monumental. I made up my mind right then and there that one day I would write my own book and interview Ellis. Indeed, many years later, when Ellis was 89 years young, I did, and the interview was much more intriguing than I ever could have imagined. But I digress.
As a graduate student, I came across his name again, only this time he had teamed up with another clinical psychologist, Robert A. Harper, to pen a 1975 edition of A New Guide to Rational Living. The word “new” was added to the title since the original version was released in 1961. The book outlined how to use Albert Ellis’ Rational Emotive Therapy or RET (now Rational Emotive Behavior Therapy or REBT) to enhance happiness in everyday life.
Simply put, I thought it was hands-down the best self-help work I had ever read. It turned out I was not alone in my opinion. The head of the publishing company, Melvin Powers, a lay hypnotist and self-made millionaire, whose picture graced the book cover along with his wife, agreed. Powers, one of the premier publishers of paperback self-help literature, said in the foreword, “it may well prove the best psychotherapy book for layman ever written.” Powers ended the foreword with, “You have my best wishes in reading a book that I think will remain the standard for years to come.” (Don’t you love it when others concur with your opinion?)
If the book had an Achilles heel, it was that the text might have been a little too complex for the average person to understand. But an answer was right around the corner.
Enter Wayne Dyer, a counselor educator at St. John’s University, who, after studying Ellis, created an easier-to-comprehend and much more popular book titled, Your Erroneous Zones in 1976. According to some estimates, 100 million copies have been sold! Behind the scenes, a controversy brewed with Ellis claiming Dyer stole his ideas and gave him no credit in Erroneous Zones. Dyer became one of the most popular lecturers and a guest on thousands of television and radio talk shows worldwide.
The bottom line is that these classic 60s and 70s bibliotherapeutic works are still a goldmine for clients in 2024 and beyond. As I often quip, “Good counseling and self-help never goes out of style.” I have often heard therapists assert that the 1960s and 1970s were the golden age of self-help.
Self-Help Guidance for the Next Generation of Therapists
A few other gems from the era you could suggest as bibliotherapy to assist your current clients could include:
The blockbuster and often provocative 1964 transactional analysis (TA) text Games People Play by the founder of the theory, former psychoanalyst Eric Berne. Or another TA flagship work, I’m OK – You’re Okay, by psychiatrist Thomas A. Harris in 1971.
Taking this theme a bit further, Muriel James and Dorothy Jongeward wrote Born to Win: Transactional Analysis and Gestalt Experiments in 1971, integrating the work of Fritz Perls into the equation. TA made psychotherapy and self-help fun using words like Parent, Adult, and Child, in place of analogous and confusing Freudian terms such as Super-ego, Ego, and Id.
As a final example, clients who wish to blend psychology with spirituality could benefit from M. Scott Peck’s 1978 The Road Less Traveled.
One unique feature of the books from the era is seemingly that they crossed the invisible line between textbooks/professional literature, and self-help or so-called pop psychology. To put it another way, these works, and many others like them, were as at home in a graduate counseling, psychology, or social work class as they were in the hands of people outside of the mental health field struggling with marital issues, addiction, depression, anxiety over public speaking, or many other challenges of everyday life.
In embracing the timeless wisdom of vintage literature, our current clients can unlock a treasure chest of insight from the past. It’s not just about self-help, it’s about tapping into a reservoir of wisdom that transcends time, offering guidance and solace to all who seek it.
Questions for Reflection and Discussion
How have you used self-help books with your own clients?
Which of the author's favorites have you used either personally or professionally?
What other newer self-help books have you found useful in your practice
Depending upon how you look at it, psychotherapy is among the oldest of professions — or one of the newest. Lacking effective active treatments, doctors always got by with some combination of supportive psychotherapy, magic, and placebo effect.
The Shaman in prehistoric times was the first psychotherapist — diagnosing and treating the mental and physical ills of tribal members by negotiating with the spirits on their behalf. In settled agricultural societies, priests assumed the same role, though the negotiation was with gods, not spirits. Then came the philosophers.
All the basic principles of CBT were laid out by the Epicurean and Stoic philosophers in ancient Greece and Rome. The Arab world, one thousand years ago, was the first to have a separate profession of psychiatry, whose practitioners developed techniques of psychotherapy quite similar to how we practice today. And Pinel substituted psychotherapy for chains in caring for the mentally ill in Paris 225 years ago.
Modern psychotherapy began with the few practitioners of psychoanalysis in Vienna 140 years ago — but psychotherapy quickly became a growth industry, both in the number of practitioners and in the wide variety of techniques they used in their practice.
One hundred years ago, there were very few people who would label themselves psychotherapists; now there are almost 200,000 in the US. About 60% hold a master’s degree, 40% are PhD’s; 70% are female; and average age is 45. Seventy percent of therapists provide mostly individual therapy; 30% also work with couples and/or families. Therapists in private practice usually see 20-25 patients a week; charge anywhere between $75-$200 for sessions that last 50 minutes; and on average, see patients for anywhere between1 and 12 sessions. The average wait time for a first appointment is several weeks.
CBT is the most popular form of treatment followed by psychodynamic approaches. Two thirds of therapists feel deep satisfaction in their work, but half report having felt burned out at times during their careers. The US Bureau of Labor Statistics estimates that the number of therapists will increase by about 20% by 2030. You can find many more interesting statistics characterizing therapists and therapies here:
My purpose in writing this piece is to provide my personal, and admittedly biased, view of the major achievements and major failures of our psychotherapy enterprise — and to provide some guesses of what likely future directions will be.
Five Major Achievements in Psychotherapy
The Therapeutic Relationship
The greatest paper in the history of psychotherapy was among the first — Saul Rosenzweig’s 1936 “Some Implicit Common Factors in Diverse Methods of Psychotherapy.” Rosenzweig correctly predicted that the most robust finding in all the later extensive psychotherapy research would be that “everybody has won, and all must have prizes.” His “Dodo Bird verdict” (borrowed from Carroll’s “Alice in Wonderland”) asserted that most comparisons of the efficacy of various forms of psychotherapy result in tie scores. Although therapies may differ greatly in theory and technique, the greatest contributors to good outcomes are the factors all have in common; the therapeutic relationship, patient and therapist positive expectations, healing rituals, catharsis, and regression to the mean with the passage of time. The success of any given form of therapy is not proof of its specific theories or practice, because so much of the variance comes from what is shared across therapies, not what is particular to each. This is not to deny that specific techniques have specific value for specific indications, but it does focus therapist attention on getting right the more general factors that cut across therapies. Rosenzweig guessed the Dodo Verdict without the benefit of any controlled studies, but many thousands of subsequent well-controlled, randomized comparison studies have proven him remarkably prescient.
Documenting The Efficacy of Psychotherapy
The most important thing I’ve ever done in my career was serving on the NIMH committee that funded the early studies of CBT and DBT during the 1980s. These were the early days in systematic psychotherapy research applying the model of clinical trials — the controlled, randomized comparison method that had already revolutionized medical research and efficacy studies of psychiatric medications.
The few million dollars that supported research documenting the efficacy of CBT and DBT have since benefited millions of patients worldwide. In contrast, NIMH has since spent many tens of billions of dollars on brain and gene research that has provided little to no benefit to patients. The research success of CBT and DBT legitimized psychotherapy and led to their widespread acceptance as reimbursable treatments worldwide. Tens of thousands of therapists have subsequently received systematic training in CBT and DBT — and both have generated extensive professional literatures and also books aimed at patient education and self-help materials, virtual and written. Psychotherapy would not be nearly so widely accepted today if it lacked this demonstration of efficacy.
Expanding The Scope of Psychotherapy and Its Specificity
Modern psychotherapy began with Freudian psychoanalysis, usually conducted several times a week, with the patient lying on a couch and free associating. Within decades, innovative pioneers developed less regressive short and long-term psychodynamically-based therapies that eventually largely replaced the original model. Almost simultaneously, behavior therapy had its origin in Pavlov’s dog conditioning experiments and was brought into clinical practice through innovations introduced by John Watson, B. F. Skinner, and Joseph Wolpe.
Cognitive therapies developed independently by Albert Ellis and Aaron Beck became popular in the 1970s and dialectical behavior therapy was developed at about the same time. In subsequent decades, at least 50 different psychotherapies have been named and defined. This profusion of different therapies is not an unmixed blessing (as we shall soon see), but it has vastly augmented the toolkit of modern therapists and increased the specificity of psychotherapy techniques for depression, panic attacks, generalized anxiety, phobias, anorexia, bulimia, addictions, sexual, and many other disorders.
Research Comparing Psychotherapy with Psychiatric Medications
The ultimate test of psychotherapies is not how they do against one another (because such comparisons routinely result in tie scores (actually, CBT is usually found to be more effective than others), but rather how they do against medications (when either might be indicated) and how they do against no specific treatment (when meds are not indicated). The evidence of hundreds of studies across different therapies, different medications, and different disorders is that psychotherapy and meds are about equally effective when both might be indicated and that the combination of both may be more effective than either alone. Meds work quicker (not entirely true); psychotherapy has more enduring effects.
A useful rule of thumb is that psychotherapy alone may be indicated for most milder psychiatric problems; psychotherapy or meds, alone or in combination for moderately severe symptoms, and meds plus supportive therapy for more severe and enduring symptoms. Very mild and transient symptoms do well with watchful waiting (or, as prescribed in the UK, self-help materials or self-help groups).
Reducing Stigma
Mental illness had been more easily accepted before the urbanization that followed the industrial revolution. And in some cultures, the mentally ill had even been revered as a source of spiritual power and insight. But stigma increased dramatically when individuals with mental illness became inconvenient denizens of crowded cities. The typical expectation was that the mentally ill were all badly out of touch with reality; useless; in the way; untreatable; likely to deteriorate and become dangerous; and worthy only of warehousing in badly overcrowded, dingy, smelly, neglectful inpatient snake pits. This stigmatization of mental illness has been much dissipated with the expansion of disorder definitions according to the DSM; the inclusion in the DSM of much less severely impaired individuals; and the widespread experience of psychotherapy in the general population. Many people, especially in cities, have been in therapy or know someone who has.
Five Major Failures
Lack Of Access
In the US, most people needing psychotherapy can’t get it or wait months on waiting lists. Some of this is due to a shortage of trained therapists. Some is due to lack of parity in insurance coverage and tricky ways insurance companies have of avoiding responsibility for reimbursement. Some is due to geographical distribution of therapists — people with psychiatric symptoms live everywhere, but almost all psychotherapists live in cities.
But economic inequality is by far the greatest culprit in depriving needed psychotherapy for the very people who are experiencing the greatest psychosocial stresses. Add to this that most therapists are white, come from middle class backgrounds, and have little experience with or empathy for (or deep understanding of) people of color, with diverse cultural experiences and values, and with the economically disadvantaged. It is a great failure of public funding in rich nations that the needs of the vulnerable, most in need, are so often neglected.
Lack of access is exacerbated by the fact that most psychotherapists focus on doing the most possible for each individual patient, rather than having the public health ethos of striving to do the greatest good for the greatest number. Many psychotherapists exclusively conduct long term therapies with very ambitious goals, resulting in long waiting lists or no treatment at all for those frozen out of the system. Most patients want and need only brief treatments aimed at symptom relief. Long term therapy is valuable, but it should be the exception, not the usual first reflex.
Community mental health centers, often vastly understaffed and with therapists with less training, are expected to treat a crushing number of patients per week. And then there has been the emptying of psychiatric hospitals without needed therapeutic services, housing, and vocational support
Lack of Integration
There has been a tension during the past 50 years between the psychotherapy splitters (those who create an ever-expanding list of new psychotherapies) and the psychotherapy lumpers (those seeking to integrate psychotherapy into one coherent whole). Despite the best efforts of the lumpers (count me in here), the splitters are winning out. At last count, there are more than 50 named psychotherapies — a veritable alphabet soup. Most therapists are narrowly trained in one type of therapy and remain tribally loyal to it — applying the same techniques to all their patients rather than developing sound conceptualizations and treatment plans for each individual, integrating and flexibly applying the specific techniques most appropriate for that individual.
Most training programs are narrow in focus — locked into the techniques developed and taught by their founders, rather than teaching a wide array of the best techniques from across all models. Cognitive therapies are now by far the most prominent in the world because they have been by far the most flexible — over the past 40 years incorporating behavioral, psychodynamic, experiential, and recovery techniques and applying them flexibly to a widening range of symptoms within their theoretical framework
Losing The Battle with Drug Companies
Psych meds are essential for those with severe psych symptoms, and often necessary for those with moderate symptoms. Even though most people with milder symptoms would do better with psychotherapy or watchful waiting, a startling 20% of the general population are instead regularly taking a very often unnecessary psych medication.
There are three causes of this overuse of psych meds and accompanying/underuse of psychotherapy; 1) drug companies spent billions of dollars promoting meds; virtually nothing has been spent promoting psychotherapy; 2) 80% of psych meds are prescribed by primary care doctors with little training and great eagerness to get a satisfied patient quickly out of the office; and 3) psychotherapists are so hard to access in most communities. This overuse of meds and underuse of therapy is bad for patients, bad for therapists, bad for society — it is good only for drug companies.
Underemphasizing Supportive Therapy
The flourishing of specific techniques of therapy has obscured the fact that supportive psychotherapy is valuable and should be part of every patient encounter, whether in a medical or a psych setting. With the exception of some psychiatric residency programs, there are few training programs teaching how to do supportive therapy, and few books and papers describing it. This, despite the facts that supportive therapy is the only helpful tool most doctors have had during most of the history of medicine, that psychotherapeutic support creates hope, reverses demoralization, and counters isolation, and that supportive psychotherapy requires more skill and empathy than the use of specific techniques.
Failing To Include Evolutionary Perspectives
Darwin was the greatest psychologist who ever lived. He had three seminal insights that should vitally inform modern psychotherapy: 1) we have inherited many of our emotions and behaviors from our animal ancestors in the same way we inherited our bodily morphology; 2) we are unaware of the underlying motivations of our behaviors; and 3) many of our now maladaptive behaviors are relics of a time when they were much more adaptive.
An evolutionary perspective helps patients normalize their symptoms by better understanding where they come from and why they have them. It is normal to grieve as the price of love. It is normal to feel sad when we fail as a motivator to do better in the future. It is normal to have anxiety and phobias in response to dangers, to feel paranoid when confronted by potential enemies, to be dependent when in need of help, to overeat when delicious food is available, and so on.
Normal feelings and behaviors become problematic symptoms only when they are severe, prolonged, stereotyped, and not adapted to the current environmental contingencies. Understanding the normal roots of symptoms reduces the patient’s feeling of being uniquely damned and points the way to more adaptive responses. The valuable application of an evolutionary perspective toward psych symptoms has been described for 30 years — but most psychotherapists are woefully ignorant about it. Notably, one of Aaron Beck’s last papers did include an evolutionary perspective on depression.
Five Future Trends
Teletherapy
Telemedicine has been around for 60 years, particularly for providing services in rural areas and particularly in psychiatry. But all this was on a small scale until Covid isolation protocols temporarily made telethetherapy the predominant way for psychotherapists and patients to communicate and for young psychotherapists to be trained. States temporarily relaxed licensing restrictions that had prevented therapists from extending their reach across state jurisdictions. The results were remarkable — many therapists (and patients) preferred zoom to in-person sessions because they afforded greater scheduling convenience, eliminated travel, allowed access to a greater range of therapists, reduced waiting time for first sessions, reduced therapist overhead, and achieved surprisingly high rates of patient and therapist satisfaction.
The lifting of Covid restrictions has made teletherapy something of a geographical jumble. Different states now have very different licensing requirements, some welcoming teletherapists from other states, some tightly restricting, and many in between. But the trend is clear — more and more, psychotherapy (like so many other aspects of life) will be done remotely via screens, rather than in person.
Text Therapy
Covid isolation also resulted in the explosive growth, increasing acceptance, and commercialization of text-based therapy. The convenience and advantages of easy and expanded access, flexible scheduling, efficiency, and low cost are clear. But texting as a psychotherapy modality also has some real advantages over in-person meetings. Patients are often more open in texts than face to face, and less likely to ignore or reject therapist’s comments. Writing gives them the opportunity to think through their problems, and texts can be read and reread and considered in a way not possible with fleeting verbal communication. One exception may be CBT, where clients are encouraged to take good notes of the most important points of the session.
The disadvantages of texting are also obvious — the lack of visual appraisal and non-verbal cues can lead to incomplete evaluations and miscommunication. We can’t really trust the few generally positive studies on texting as they may be biased, but my guess is that it will play an increasing role with the advent of a new generation of patients and therapists, who have grown up using texting as one of their major forms of relatedness.
Competition From Coaching
Life coaching is a fast-growing profession with over 70,000 coaches practicing worldwide. Theoretically, coaching and psychotherapy have different goals, practitioners, and consumers. Therapists receive more extensive training, require more formal licensure, and treat psychological symptoms that are diagnosed, coded, and compensated as “mental illness.” Coaches receive much less training, have much looser licensure requirements, and provide wellness training to improve business, interpersonal, organizational, or sports performance and to enhance life satisfaction. People with more severe problems need psychotherapists; those who are generally doing well but want to do better may seek coaching. Coaching has the advantage of less stigma (no DSM disorder required); but the disadvantage of not being reimbursed by medical insurance. As coaching becomes more available and well known, it will doubtless draw many people who would otherwise have seen therapists.
Corporatization
Psychotherapy began as mostly an individual endeavor — one practitioner contracting with one patient who paid out of pocket. Soon however, and particularly after World War II, psychotherapists increasingly began working in institutional settings — hospitals, outpatient departments, community mental health clinics, the military, and VA facilities. Especially beginning with managed care in the 1990s, psychotherapists have increasingly worked as employees of increasingly larger and larger private, for-profit groups.
Teletherapy has recently exponentially speeded up the concentration of psychotherapist — one company has accumulated a network including tens of thousands. This has the possible advantages of improving patient access and quality control but drains money from the system and risks creating inappropriate uniformity and decreased quality.
Artificial Intelligence
I have previously written on the very real risk that computers will replace psychotherapists.
Conclusion
It is the best of times and the worst of times for psychotherapy. Best because we have so many therapists and effective therapies. We can help most patients more than medication can and no profession is more interesting or fulfilling. I am a much better person than I otherwise would have been because my patients taught me so much. Worst because the field is so unnecessarily fragmented, so poorly compensated, and so at risk of being controlled by corporate interests and/or reduced by coaching or replaced by artificial intelligence.
The best hope for the future, both for patients and practitioners, is to do our job well. We must integrate the hodgepodge alphabet soup of existing therapies by combining what works best from each within the context of a sound conceptualization. Therapists should no longer be trained in, and express fealty to, just one school of therapy. We should discuss, but rather feel comfortable applying techniques across all relevant schools, flexibly meeting the specific needs of each patient.
Psychotherapists have, since the dawn of time, provided comfort and solace to mankind. Labels change — shaman, priest, minister, doctor, psychiatrist, psychologist, social worker, counselor, nurse, occupational therapist, coach, and many more. But the essential function of explaining and healing human suffering has always, and likely always will be part of the human condition.
“Nature cocks the hammer and experience pulls the trigger,” said the presenter. Everyone nodded, in seeming understanding, that in the context of the presentation, eating disorders, too, are more complicated than learned behavior. Grinning at this clever metaphor, I slipped it into my back pocket for when the nature-nurture discussion would invariably arise in my abnormal psychology class.
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Metaphors, as figures of speech, have various conversational and literary roles. They also offer powerful therapeutic opportunities for clients that, in my experience, have ringed unconscious bells and helped them to make connections and draw important conclusions. I have always enjoyed using them in treatment, particularly those moments when a well-chosen metaphor has breathed new life into a therapeutic relationship.
Fred: Testing Therapeutic Waters
Fred was a 25-year-old graduate school student studying earth sciences. He sought therapy because, according to his girlfriend, Heather, he was “in a funk again.” Heather, who accompanied Fred to his first session, also pointed out that he never spoke to her about how he was feeling during these “funks,” which strained their relationship. Overall, the couple had a lovely relationship, but periodically, particularly when school and work stress billowed, Fred lapsed into one of these brooding episodes, which could last days.
“Fred,” I began, “I see you just listening in over there. What do you say?”
“Why should I let my crap bother other people? It’s hard to explain when that happens, anyway. I’ll deal with it,” explained Fred, providing common “logic” often exposed in couples’ work.
“God! You think keeping your stuff to yourself is protecting me somehow,” cried Heather. “I don’t know what’s going on with you when that happens, and it hurts that you’re unwilling to let me in or at least try to talk to me. Now we’re in a therapist’s office. It doesn’t help me to see you suffer.”
To test the waters, I asked Fred what it was like listening to Heather say that. He leaned on the arm of the couch with his forehead in his hand, remaining reticent. Clearly there was room for improved communication, and I had to figure out how to provide Fred with a new perspective to help the couple gain momentum.
During a subsequent session, Fred looked particularly tired and noted that he “felt like deadwood” that afternoon. Noting his “dead” reference, a metaphor that took advantage of Fred’s interest in earth sciences took shape that might illustrate the benefits of communicating emotions.
As the session took shape, I awaited an opportunity to capitalize. The metaphor goddesses were with me, for Fred commented that his classes were draining him.
“Surely,” I began, “you’ve had a class studying the world’s great bodies of water,” getting Fred’s attention.
I continued, “You know, the Dead Sea and the Red Sea are both fed by rivers teeming with life, but nothing survives in the Dead Sea. Do you know what makes the difference?” Fred sat quietly, considering the query, and shrugged. “The Dead Sea has no outlet,” I finished.
Looking up, Fred, nodding, reflected, “It isn’t flushed out, so stuff stagnates and dies.”
The bell was rung, and the message was clear. He was periodically stagnating like the Dead Sea because he was not expressing his emotions and dealing with his conflicts, contributing to his “deadwood” feelings. In the rest of the session, Fred was able to start reframing the consequences of his internalized emotions and why communicating them was important.
Beth: Metaphors to Guide Diagnostic Conversation
While I have found metaphors to be therapeutically useful in guiding patients to new understandings, sometimes patients have used a metaphor to help me understand their experience. While I would never diagnose someone based on a metaphor, I have used them to guide diagnostic conversations.
Beth was a 31-year-old professional who sought therapy because she had been feeling increasingly moody and exhausted over the preceding few months. After being checked for Lyme, low iron, thyroid complications, and other medical causes, her physician suggested Beth meet with a therapist.
“I feel like I’ve been living on an emotional rollercoaster” she described in our first meeting. While more of an analogy than metaphor, I thought there might be a way to capitalize on this poignant description.
In my clinical experience, “emotional rollercoaster” is a common way that clients, or those in close relationship with them, have described the experience of bipolar disorders or borderline personality disorders. I have had to be cautious; however, not to jump to conclusions in instances like these. Afterall, jumping from a roller coaster can be hazardous to clinical health (I couldn’t resist). “Beth,” I replied, keeping with her description, “I don’t spend much time in amusement parks, but I know there are all different sizes and intensities of coasters. If your emotional experiences were actually a roller coaster, how would you describe the one you’re on?”
Chuckling at the idea of trying to guide me along, she explained, “It’s not fast with steep hills and loops,” she began, “but sometimes I feel totally unbalanced and like I’ll fall off, like my head’s just not on straight.”
“Tell me more about that ‘head not on straight’ description.” Beth shared that she frequently just couldn’t gather her thoughts and focus well, as if “nothing wants to germinate in my mind.” It took extra time to think things through, especially at work where critical thought was involved. Beth added that, at home, she felt lazy and zoned out much of the time, even if she might want to do something. “It’s exhausting,” she signed.
“That doesn’t sound like much motion; a roller coaster moves,” I observed. “What’s the emotional ‘ride’ you initially mentioned?
Beth continued, “Well, most of the time, I feel unenthused and tired, but I get irritated so quickly and can stew on something. It could be how I hate feeling like this. It might be at a friend I’m on the phone with and they don’t silence their dog in the background. It’s so annoying and rude! I’m just mad, and that irritates me more because it doesn’t feel good, and then I’m exhausted again.” Beth detailed that it often happened daily or just a couple times per week.
It seemed her mood changes were generally reactive and short-lived, superimposed on withdrawal and malaise. After more interviewing, she failed to describe anything indicative of the moodiness ever spiking into hypomania/mania or having psychotic symptoms. The fatigue, slow cognition, lack of enthusiasm and dysphoric mood that Beth described was indicative of someone who had been depressed for months. And there it was!
***
I have come to appreciate that planting a good metaphor is like cultivating the flower instead of pulling out all the weeds.
Nothing breeds shame more than silence. If something is not spoken about or represented in our systems (e.g., family, workplace, industry), it can be considered wrong. This is why I have devoted my life to speaking out about mental health and, more recently, done so on a public stage as a psychologist who has experienced mental illness. I want to demystify the experience of mental illness in mental health professionals so they don’t suffer in silence, because we are, like the rest of the population, only human. However, it hasn’t always been that way for me.
Back in the 80s and 90s, when I was growing up, there were no representations or discussions of mental health or mental illness within the systems I was exposed to. The only thing you did hear was people being locked up because they were “crazy” or hearing the message that “you are weak if you have a mental illness.” And no one was talking about looking after their mental health, only physical health.
Struggling with Depression
So, when I struggled with my own mental health and eventually experienced clinical depression in my early 20s, I had no idea what was going on, and I didn’t dare speak up for fear of being seen as “less than.” I only received help when my partner contacted my parents for help, as he didn’t know what to do. While I did recover, I did so mostly on my own. I didn’t talk about it to others. I held a lot of shame for being depressed for many years.
Fast forward to my early 40s, early 2021. The world has changed drastically with how mental health and illness are represented and discussed, and I have about 20 years of study and working in the mental health arena under my belt. I now know differently that mental health is essential to care for, and mental illness is not a sign of weakness.
But despite all this, I once again suffered mentally, that time with a combination of burnout, vicarious trauma, and compassion fatigue. You would think that I would have reached out and spoken about my struggles this time with all that I knew and had learnt from my previous experience, but I kept quiet. I didn’t dare say anything because, once again, I felt deeply ashamed.
I felt ashamed and suffered silently for a couple of reasons. First, I believed that psychologists shouldn’t get mentally ill. I thought that, as a psychologist, I should have known better. I should have been able to prevent it. I thought that it somehow meant that I was not a capable psychologist. The other reason that compounded the first was that there was no representation or discussion of psychologists becoming mentally ill or working while managing their mental health or mental illness.
None of my peers, mentors, or senior psychologists ever discussed it. It was all under the radar and not out there for all to see. Outside of encouraging us to care for ourselves and seek professional help when needed, no psychologist or mental health professional I came across in training spoke of their own experiences of mental health struggles. Most likely, they didn’t feel safe to do so because nobody did for them. It wasn’t normalised or validated enough to feel safe to talk about it.
Speaking Out and Sharing Humanness
I only started speaking out about my mental health struggles as a psychologist when I began seeing a supervisor who could provide an environment where I felt safe to disclose my struggles. She was different from other supervisors I had. She was interested in my experiences and what was going on for me in the context of my work. She helped me to recognise my mental illness and take the necessary steps to recovery. She never made me feel like I was “less than,” nor did the psychologist I eventually saw for therapy.
More importantly, they both shared their humanness with me, their struggles, enough to help me debunk my belief that psychologists should be able to prevent their own mental illnesses. These experiences gave me the courage to share mine more with others, and as I did, I discovered that many psychologists and other professionals were also struggling with their mental health and changing how they worked to care for their mental health. It helped me drop the shame I had held for being a psychologist with mental illness.
Having had such a powerful experience of having my mental illness normalised by other people in my field, it became a passion of mine to pay it forward; to continue to change the culture of mental health professionals to one where we can talk freely about our mental health and what we need to take care of it; to recognise mental illness and support each other through it. I now share my mental illness story wide and far through various mediums, writing blog articles, appearing on podcasts, producing a lived-experience podcast, publishing my memoir, and providing therapy to fellow clinicians and others from different professions suffering from burnout.
I still fear sharing my story with fellow psychologists. I know this comes from being someone out on the fringe of my profession speaking out about this, but more robust than my fear is my compassion to help fellow mental health professionals drop any shame with struggling mentally. I can do that by sharing my mental illness experiences and mental health struggles. I don’t want another fellow psychologist or anyone to suffer in silence. We are only human.
An almost completely neglected topic in psychotherapy is how much patients teach their therapists — not only to become better therapists, but also to become better people. Many of the best hours of my life have been spent doing psychotherapy, and many of my favorite people were the patients I did it with.
Early in my career, I realized that I was a better person when doing psychotherapy than in my other relationships — much more empathic; much less selfish. Gradually, my work with patients helped smooth the rough spots in my personality, making me a better husband, father, grandfather, teacher, and friend. This piece is a small thank you for the great debt I owe my patients. I could not be more grateful and will now enumerate some of the many gifts I’ve received from my clinical work over the years.
Ten Ways Patients Make Us Better People
Close Relationships: Our ability to engage in close relationships derives from inborn mammalian nature interacting with early nurture — but later life experiences play a big role in enhancing or reducing our comfort with intimacy. The essence of psychotherapy is forming a therapeutic alliance, which often turns out to be therapeutic for both partners — teaching each how to become more comfortable getting closer to people.
Empathy: The ability to understand what other people feel and to see life through their eyes is also partly inborn, partly nurtured — but no profession other than psychotherapy requires and enhances it so much. Empathy muscles grow with exercise — every session is an opportunity to build and stretch our capacity to feel and express empathy.
Courage Under Fire: My patients have all had much more difficult lives than my relatively easy one. And almost uniformly, they have, more or less, lived with the hand they were dealt with a courage and grit I am not sure I could have managed. I will never complain about the challenges and disappointments in my life because I have witnessed the grace shown by my patients in facing much more difficult lives.
Emotional Honesty: Most people lie only rarely, but few people are emotionally honest most of the time, with themselves or others. It requires too much work and isn’t really necessary in everyday life. But psychotherapy is different — patients have to feel, think, and do things with a degree of honesty not normally required of them — and their honesty rubs off on us.
Resilience: One of my patients described his life as “knocked down eight times, get up nine times.” Patients get knocked down over and over again — not only by the expectable exigencies of their external lives, but also by the internal problems that are the focus of treatment. I have been amazed and inspired by how often patients get up that ninth time — how seemingly insuperable problems and hopeless situations turn out just fine because they have the guts to keep trying and never give up hope.
Good Minutes: Psychotherapy isn’t always complicated — for many patients, the goal is to maximize good minutes each day and enhance the appreciation of life’s little pleasures. This has certainly rubbed off on me.
Unselfishness: A basic precept guiding the therapist’s behavior is to always put the patient’s interests first and to never be selfish or exploitative in even the most subtle ways. This also rubbed off, if to a lesser degree, in my therapy relationships.
Humility: Working with patients taught me that what I don’t know about life and people is a lot, and that I often do and say dumb things. I also learned that patients could readily forgive and forget my errors of the mind but had trouble forgiving and forgetting my errors of the heart.
Acceptance: Sounds corny but doing psychotherapy with patients teaches you the wisdom to know what to try to change and what to accept — in them and in yourself.
Gratitude: I have had my share of failure as a psychotherapist — people who left treatment with the accurate feeling that I hadn’t helped them. But patients who did well were often very generous in their gratitude in a way that taught me to be openly grateful to them and to other people in my life.
Magic Moments in Psychotherapy
Psychotherapists are the luckiest people on earth because our profession allows us to participate in so many deeply meaningful relationships — hour after hour, each and every workday. Certainly, this makes for a demanding career, but a richly rewarding one. And psychotherapy done well never gets routine or dull. You always have to be alert to the possibility that a “magic moment” will occur — an opportunity for you to make a big difference in your patients’ lives or for them to make a big difference in yours. Patients are not your friends but may sometimes be, in a way, closer — when you are both changed through the special intimacy of the therapeutic relationship. Our patients can be our best teachers. Mine certainly have!
Questions for Thought and Discussion
What are your impressions of the author’s premise?
Who among your own patients/clients has taught you important lessons?
Might you ever express gratitude directly to a patient for a lesson taught?
We therapists are constantly asking people some version of this basic question.
What are you wanting to be different?
What are your hopes for yourself?
This difficult circumstance being what it is (and beyond your control), what do you want to be able to do in the midst of it?
This difficult person being who they are (and beyond your control), how do you want to relate to them?
What needs to happen?
What do you want?
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And people respond:
I want to feel less depressed.
I want to leave my marriage.
I want to stop drinking.
I want to feel happy.
I want to feel more connected to others.
I want to be less reactive and controlling.
Therapists Must Listen for What Clients Really Want
These answers become the guiding force that frames and energizes our work together. And as therapy progresses, and we keep asking “what do you want?” the answers and the focus of our work shift and deepen. “I want to feel happy” becomes “I want to interrupt my ingrained habit of always looking for what’s wrong.” “I want to feel more connected to others” becomes “I want to feel more connected with myself.” Or, “I want to be less reactive and controlling” becomes “I want to learn what it takes, and do what it takes, to feel safe in the world.” And beneath all these answers, beneath the “what do you want?” question itself, is one of the deepest questions of all: “What’s worth wanting?”
So, we keep asking, over and over, “What do you want?” And following our clients deeper and deeper.
Recently, a client turned the question back on me. I’d asked her some version of the question, and she’d responded with a thoughtful litany of hopes for herself and her life. But then she paused, tilted her head, and asked, “What do you want for me?”
Sometimes, of course, people ask therapists (and others) to guide and direct their lives because they lack confidence in their own inner compass. Perhaps they grew up with parents who sheltered them or micromanaged them, and they weren’t given space to grow that confidence. Or perhaps they entered adulthood trusting themselves, but a lot of things have gone wrong, and they’ve come to doubt themselves.
We therapists are careful about giving advice for lots of reasons, but this is one of the main ones: we don’t want, in an effort to help someone through a hard moment in their lives, to send a meta-message that we believe they can’t think and judge and make good choices for themselves. Quite the opposite: we want to respect and nourish people’s trust in themselves, their power to know what’s needed, and their capacity to choose and to act.
This woman, however, had demonstrated these abilities many times, in session and out. She was insightful, intuitive, and brave. So, I did not hear her question, “What do you want for me?” as a flight from responsibility: “Tell me what to do.” I heard it as healthy curiosity: “Tell me how you carry me in your heart.”
And so, I paused, took a breath, listened inside, and said to her: “I want you to be happy and powerful.”
I paused again, to see what else might be there. And I’ll pause with you, too, to say that, by “powerful,” I don’t mean CEO powerful or politician powerful. I mean the ability to gather and concentrate our energy, to plug the leaks that dilute us, and live from a strong and regulated stream of force.
I continued: “I want you to be faithful to who you are and what you know. So many people, you included, have been gaslit — by their parents, by friends, by their employer, by religion, by advertisers — and end up not able to trust themselves and their inner GPS. I want you to be a deep witness to the truth of yourself and your experience, to hear what your mind knows and, even more, what your body knows and what your intuition knows. And I want you to be able to live from all that.”
That was all. I paused and gave her space to absorb what I’d said and, if she wanted, to say how it had landed in her. She looked at me quietly, and I imagined she was doing exactly what I’d just said — listening to herself, weighing the truth of my words against the truth of her own knowing, and welcoming whatever she found trustworthy.
Then she said, “Thank you. I like that.”
And I said back, “Thank you. I like it, too.”
What I liked was twofold. It was, firstly, the experience of connecting with her, which I found deeply nourishing. And secondly, it was the sense I had that, spontaneously and concisely, I’d just articulated my view of what I hope happens for people who talk with me in therapy. I’m hoping they will grow in consciousness and in power. I want to help people witness the truth of their life — their outer life and their inner life — and, based on what they witness, to exercise agency, freedom, and choice.
I’ll close by asking you, therapist or whoever else you are, when it comes to the people you care for, what do you want for them?
Why do coping strategies help to resolve psychological symptoms? I once assumed that this question had a simple answer, but I have found over the years that the answer is much more complicated. There is a hidden depth to this question that is both mysterious and life-altering.
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As a therapist, I regularly offer an assortment of coping strategies to help my clients cultivate symptom reduction. The empirically grounded strategies that I most commonly provide include breathing exercises, grounding techniques, mindfulness practices, and/or distress tolerance skills. My clients typically report these techniques to be effective physically and psychologically. Despite their positive impact, I often wonder how exactly these coping strategies work — beyond the obvious, that is!
How Coping Strategies Work
The apparent reason for the success or failure of any coping strategy is its potential to effect visible or discernable change in behavior, thought, and/or feeling. However, I have often found both in my personal life and clinical work, that there is a deeper symbolic process contributing to these outcomes.
For example, I love to run simply because it makes me feel better. While the science suggests that running promotes neural growth, creates a reduction in inflammation, stimulates new activity patterns in the brain, and releases endorphins which help to regulate mood, sleep and energy levels, these are not the reason why I run.
I run because it “carries me to a new place,” beyond the literal, that is. Symbolically, this seemingly simple, mechanical activity “opens me” to new paths and possibilities within my own internal experience. It reorients and centers those parts of myself that have gone astray. I return to who I truly am when I’m running, and I am never the same once finished. If, once I begin running, I’m angry, my feet can stomp out my frustration. If I’m anxious, my body can unwind, working through its tension. Beyond the positive, physical outcome, these symbolic gains are what keep me going, so to speak.
Along similar symbolic lines, I often de-clutter my home when my thoughts feel cluttered or chaotic. Sometimes, however, I forget to attend to this symbolic process, getting lost in the physicality of de-cluttering. In those moments when I should be focused on the symbolic, I feel too distracted by the misguided pressure of the physical act. In instances like this, and in retrospect, I often wonder how much more benefit I would gain if I were to better recognize and then enter more intentionally into these symbolic processes.
Transforming Act into Symbol
In a similar way, I often wonder if my clients are missing out on the full benefits of their coping strategies by not paying attention to their symbolic healing potential. For example, one of my client’s daily practice of journaling became much more effective when he began to intentionally symbolize the words he wrote as thoughts that were finally “leaving his mind.”
This particular client initially presented with “stress” related primarily to his inability to let go of the future-oriented worries that regularly “pulled at” his attention. These thoughts typically intensified in the quiet of the night as he obsessed over the demands and possibilities of the next day. These thoughts made it impossible for him to fall asleep, which left him fatigued and even more worried the next day. Over time, this cycle solidified into a holding pattern that dominated his life, making it impossible to freely move forward.
I asked him to write down his worrisome thoughts before bedtime to externalize them. Initially, he found it difficult to banish these thoughts to paper, so he stopped trying. The action didn’t seem powerful enough to help. The full benefits of writing down his worries made sense only when he intentionally embraced the symbolic process by truly experiencing his worries leaving him through the embodied process of writing.
He also expressed the need to add a symbolic ending to the process by crumbling and tossing away the worry-laden paper into a small trash can that he set up in his nearby hallway. While he considered other symbolic acts including storing the paper in a designated box, shredding it, or setting it on fire, the act of tossing it away made the most sense to him. Over time, the journaling practice extended beyond the original act and into his everyday activities so he could experience a more complete sense of separation from the worries that had previously dominated his life.
Bridging the Gap Between the Physical and Symbolic
My clients and I find that the physical and symbolic need to be explicitly paired in order for the coping strategy to work most effectively. For example, I had another client who was struggling to experience the full advantages of diaphragmatic breathing. Despite the research suggesting the many neurophysiological benefits of this activity, she wasn’t experiencing them.
As it turns out, this client had struggled with anxiety for most of her life, incessantly shopping for and trying on coping strategies in search of “the one” that would finally “fit” and bring her relief — hobbies, relationships, etc. Over time, we realized together that the “real” cause of her unrelenting distress was the fear that she would not be able to endure “standing still” and being in the moment. Searching for, trying on, and then discarding technique after technique was an illusory quest, denying her peace in the moment.
Together, we discussed this disconnect, and I suggested that she take a small step towards stillness by intentionally pairing a pleasant feeling (one she wanted to bring into herself) with every inbreath, and an unpleasant feeling (one she wanted to release from herself) with every outbreath. She chose to breathe in peace and breathe out anxiety. She came to the following appointment excitedly celebrating the positive effects of this modification to her breathing practice. The simplicity of the assignment, and her willingness to literally and symbolically “breath into it,” helped to override her deeper fears of being fully present, reduced her anxiety, and freed her to more fully and deeply engage with life.
Both clients provide striking examples of the transformative power of symbolic acts for enhancing the efficacy of otherwise traditional and mechanical coping strategies. One of the major benefits of the symbolic process is how easily accessible it can be for clients. The benefits await clients willing to engage with the limitless possibilities that symbolism provides.
For example, taking a shower may help me to wash away the shame that is held in the body. Pulling weeds can help to eradicate negative thoughts that keep “popping up.” Simply locking the front door to one’s house is a symbolic gesture that offers a sense of safety. Every moment, every act, every thought contains the possibility of actualization. The quest for symbolism, whether in or outside of clinical space, is an endless call to adventure.
This call is also a call to more fully enter into the mystery of this human experience, and to participate in the world with a fuller sense of awareness and being. Personally, these symbolic processes enrich and transform me on my own personal journey to feeling fully human. They help me to not only cope with my own day-to-day challenges, but more importantly, they pull me into a much deeper participation of healing that continually restores my own love and appreciation for life.
Professionally, I remain eager to deepen my engagement with the symbolic so that I can help guide my clients toward transformative experiences, regardless of the troubles they present. Whether they “write out” their distressing thoughts or “breath away” their anxiety, I admire their willingness to entertain and benefit from venturing into the symbolic with me. I am also amazed by and find beauty in their commitment to do so. I am fully committed to offering all my clients these symbolic pathways they can use in and outside of my office and consider this a fundamental aspect of the therapeutic process.
Questions for Thought and Discussion
What are your reactions to the author’s premise of the importance of symbolism in healing?
How have you used this process with your own clients?
Which clients with whom you currently work might benefit from this strategy?
How have, or might you use this symbolic process in your own personal life?
Lawrence Rubin: Hello, Makungu. I first became aware of your work through conversations with Drs. David Epston and Travis Heath, both of whom have worked clinically and written within the Narrative Therapy sphere. However, they've also made me aware of different approaches to narrative storytelling, including the oral tradition of West Africa, and your work. And that led me to an interest in Testimony Therapy. With that said, what is testimony therapy and what is testifying?
Testifying and Testimony Therapy
Makungu Akinyela: Testimony Therapy is a discursive therapy, related to Solution-Focused Narrative Therapy, and any of those therapies that we think about that focus on privileging people's stories about their lives. I tell people that testimony is a narrative therapy with a small “n” because testimony and testifying come from my tradition — the Black cultural tradition, to testify. The way Black folk use it is to tell your story but also to tell the story that you want told about you, to give your testimony. It has some roots in the Black church experience. Folks who are from the South or have been to the South and maybe to a Black church, might have witnessed a testimony service or folks testifying in church where they get up and tell a story. There are parts to testifying it. Usually, a testimony starts out with what I call a doom-and-gloom story. For folks who are into Narrative Therapy, Michael White and David Epston used to call it a thin telling of the story.
testimony therapy is a discursive therapy, related to Solution-Focused Narrative Therapy, and any of those therapies that we think about that focus on privileging people's stories about their lives
So, it starts off with this real doom-and-gloom narrative that goes something like, “Well, I woke up, and the doctors told me that I had cancer and I was going to die. And I've been sick ever since and in bed and I couldn’t get up. And that’s what my life is about.” That's the doom-and-gloom telling. But then usually a testimony begins to sound like, “But if it had not been for my friend or my neighbor, who came to give me support and help…” The important thing about that testifying process — the dialogue — is in Black orality, which is that orality that we are grounded in, the oral telling of stories.
And that call and response becomes a community telling of the story. It's not just the storyteller telling the story
There's also call-and-response. As the “testifier” begins to tell that doom-and-gloom story, there is a response to the call. The “witnesses” let them know that they're listening. “Wow! Really? Well, okay. Amen. I get you.” And that call and response becomes a community telling of the story. It's not just the storyteller telling the story. The witness to the story, by engaging with the story, also helps to shape where the story goes. The testifying usually goes from doom-and-gloom to the call-and-response, and then all in the “community” begin to identify what I call the “victorious moments” in the story.
Narrative Therapy might say those victorious moments contradict the thin telling of the story. And as you get to those victorious moments — if it were in a church ceremony, as people begin to give that feedback, that response to the call — they begin to say things like, “Yeah, it wasn't so bad. It was good.” And then people might start seeing the blessings in their lives in the middle of the doom-and-gloom.
The story begins to become a little stronger and a little more positive. By the time the story finishes and all have experienced victorious moments, transformation has happened, and the testimony becomes, “This is the story that I want people to have of me. This is the story that I want.” It uses narrative ideas, and for folks who are familiar with Narrative Therapy, the preferred outcomes have replaced the doom-and-gloom, thin story.
the critique that testimony gives to narrative therapy is that all storytelling and all ways of telling stories are not grounded in the metaphor of literacy
The important thing about testimony therapy is that it is a discursive therapy. I consider it a narrative therapy in the sense that it's a storytelling therapy. I agree with the narrative therapist, that people use stories to constitute their lives, to describe and explain the meaning of their lives. The critique that testimony gives to narrative therapy is that all storytelling and all ways of telling stories are not grounded in the metaphor of literacy. Narrative therapy, the therapy that was developed by Michael White, David Epston, and that is contributed to so strongly by all those other great people — you know, Steve Madigan, Jill Combs, and Gene Freedman – all those ways of doing narrative therapy are particularly grounded in the metaphor of literacy.
LR: Storytelling in a linear kind of way.
Oral Culture: A Different Kind of Listening
MA: Exactly, in very linear ways, even the metaphors that are used such as “Turning over a new page, re-authoring our lives.” So, the metaphors reflect the culture that it comes out of, which is primarily a culture whose consciousness is developed through literacy. What testimony therapy says is, “What about those people who come from cultures that are predominantly oral cultures, grounded in orality?” Like the culture of Africans from West Africa, where my folk come from, the culture of so-called African Americans who, basically, trace our lineage and heritage back to West Africa?
Our cultures are primarily oral. So, the thing that shapes our thinking, the way we talk about and think about relationships is grounded in that orality. Storytelling will look different, and the meaning that's given to the story is different. And so, within testimony therapy, rather than being grounded in the metaphor of literacy, I ground it in the metaphor of orality and musicality. Does that make sense?
LR: As a narrative therapist but also as a client-centered therapist, I would be validating. I would be using nonverbal gestures. I'd be highlighting unique outcomes. I would be listening to elements of the client’s story, which are doom-and-gloom-centered, and asking for counter-stories. What would I be doing differently if you were my therapist in this interaction and coming from that oral tradition? Now, what would we be adding as therapists in this moment?
MA:
I'm paying attention to the rhythm and the beat of a conversation
I'm paying attention to the rhythm and the beat of a conversation. So, it's not just the words of a conversation that are important, right? It's not just listening to the words that are coming out of your mouth. It's how the words are coming out of your mouth. I'm paying particular attention to things like the relationship between bodily space and the words, the rhythm that's created through bodily space. I'm paying attention to things like the expression on your face because those are all things that also begin to define orality.
In other words, people from oral cultures don't just use the words out of their mouth. It's the tone of the word. You know, where there might be three or four ways that I can use the same word, depending on the tone, it means something different. Also, it might be even the way I might use my body. You know, sometimes people make jokes about Black women. You know, if a Black woman is talking to you and she starts snaking her neck…what's the meaning of that? So, no matter what the words are that she's using, that body motion, the way she takes up space, begins to define the rhythm of the conversation –
LR: So, what feedback would you be giving me in the moment?
MA: I would be getting in rhythm with you, right?
LR: You would be mirroring?
MA: I might be mirroring, or I might be thinking, “Wow, he's really agitated here. And I might even slow down my rhythm, and I might begin to speak more slowly. And I might even become a little more reserved, again, because I'm believing that the rhythm and the beat of our conversation is just as important as what you're saying. I might be taking note of and become curious about what the emotional content of your speech might be at that moment, and I’d bring that out.
I'm a testimony therapist whoever I'm working with, just like narrative therapists
I was talking to a couple just the other day. Now, this couple happened to be White, but I'm a testimony therapist whoever I'm working with, just like narrative therapists. A narrative therapist, whoever they work with, they're simply using their cultural understanding to engage the work. And that's what I talk about with this. I don't believe that “techniques” in themselves fix things or do things.
But with that couple, there was a conversation going on. In this case, it's a heterosexual couple. The husband listened to the wife say something, and it felt as if she was saying he was the problem. But he was his usual calm demeanor, almost a flat effect. But he began to describe how he was resentful that she was making him into the problem. Sometimes, not always but sometimes therapists are really afraid to engage emotion, particularly “negative” emotion, right?
LR: I'm on the edge of my seat. So, how did you manage yourself with that White couple?
MA:
one of the things I point out is that oftentimes, particularly for Black people, we're encouraged to suppress our emotions
First of all, I validated what he had to say. And then I said, “You know — ” Let's call him George. Not his name. “George, I get the feeling that you are real pissed off about right now. And I'm really appreciating that. I'm really glad that you got pissed off enough to say that.” In other words, rather than running away from the emotion, to name the emotion — because I also believe that all our emotions are important. You may have read one of my articles, and one of the things I point out is that oftentimes, particularly for Black people, we're encouraged to suppress our emotions.
LR: Especially anger. Especially anger.
MA: Right, especially anger! You're not supposed to do that. I believe that my work as a therapist is creating a space where all emotions are safe, and all emotions can be validated and understood and experienced. Because one of the things that I'm trying to do when I'm working with my clients is — and again, these are my philosophical understanding of this work — that, under conditions of oppression or suppression, people are alienated from their emotions.
A lot of the ideas that I work with come from the psychiatrist, Frantz Fanon. And Fanon talks about alienation, which comes with colonization. And when people are alienated from their emotions, they don't feel their emotions. They don't experience their emotions. So, the emotions control them rather than them being in control of their lives. And so, a lot of the work that I do is about helping people to feel their feelings, to experience their feelings, and to dis-alienate themselves from that.
LR: So, going back to George and his wife, you highlighted what you surmised to be George's emotional reaction, his alienation from his emotions. And you helped encourage a conversation around that. How is that different from what a good Rogerian therapist or a linear narrative therapist might do?
MA:
one of the big complaints that I often get if I am referred a Black client, who maybe has previously had a White therapist, is the cultural uncomfortability that they felt in those relationships
That's a good question. And one of the emphases that I make is that this is not about trying to find something that on the front looks like a radically different practice. It's about worldview and understanding. One of the big complaints that I often get if I am referred a Black client, who maybe has previously had a White therapist, is the cultural uncomfortability that they felt in those relationships. It's like that person just didn't seem to get them. They say, “Well, they just sat there and listened. They didn't say anything.” You know, they didn't say anything.” Sometimes they'll even say, “They didn't tell me what to do.” And I'll say, “Well, you know, I'm not going to tell you what to do either.”
But again, it's just that interaction, that responding in those conversations in oral ways as opposed to this kind of a linear conversation. I ask you a question, and then I quietly wait for a response. And then I assess that response. “Okay.” And then I ask another question. And then I wait for a response. That's that linear conversation. Even when I'm doing supervision, I don't want therapists to try to be like me. In this field, that's what a lot of people do, particularly from our generation. You know, we used to go to those demonstrations, and we would be mesmerized by the experts.
LR: Nobody could be Albert Ellis, regardless of how hard they tried.
MA: Yeah. But, again, when I talk about Testimony Therapy, I'm talking about a conceptualization of the work that we're doing, which is grounded in a philosophy. In a very similar way, when Michael and David began to develop Narrative Therapy, for the most part, they were grounding their therapeutic work in the philosophies of Michel Foucault, in other words, a conceptualization of the meaning of the word. Does that make sense, what I'm saying?
So, you know, human interaction is human interaction whatever the culture, but there are conceptualizations that define the meaning of the interaction. There's a difference between people who come from oral cultures and, again, how stories get told and the meaning of those stories, and people who come from literary cultures.
LR: What about when you're working with a Black client, a Black couple, a Black family who don't identify with their ancestral roots, who have no connection to the oral tradition of West Africa? Does that make a difference?
MA:
I believe that when Black people say, “Hey, I know I'm Black. I'm Black,” that's not about having some deep sense of West African culture, because culture doesn't work like that. You see, the culture of African American people is African, I believe
I think you're asking a philosophical question. Just off the top, I say, okay, probably that couple that you're describing in that way wouldn't even be coming to see me, right? But also, I think this is about a perception of what culture is and what culture means. I believe that when Black people say, “Hey, I know I'm Black. I'm Black,” that's not about having some deep sense of West African culture, because culture doesn't work like that. You see, the culture of African American people is African, I believe.
It's African in the context of 300 years of colonization, but it's still African. And that doesn't mean that people go around every day thinking, “I'm African. I'm African.” They just are. They're being what they're being. Using Frantz Fanon once again, he once said, “A tiger doesn't have to proclaim its tiger-tude. It just is what it is.”
I described the whole idea of a Black church testimony service, right? That's African. Those are African ways of engaging. People don't name it that, but that's what it is. You know, the way that we talk, right? When we talk about Black ways of speech that we call Ebonics. I guess the more professional way is AAVE, African American Vernacular English. I'm speaking to you right now in pretty standard English. But if it wasn't you and it was somewhere else, I would be talking in Ebonics. But the thing about the way that I speak — I call it my grandmother's language — is that it’s grounded in a mixture of African and English vocabulary, but primarily West African syntax and grammar. It comes from there.
And this gets far beyond therapy, but we've got tons of research that shows the continuities, the continuations, the relationships between the cultures of African people in the western hemisphere, who are here because of enslavement and other things, and Africans on the west coast of Africa. So, when I'm talking about culture, I'm not talking about something that's this kind of mechanical thing that is easily identifiable. I'm talking about what we understand about the nature of culture, which is constantly moving, changing, and growing. Does that make sense?
Double Consciousness
LR: It does. Is there an implicit assumption or a presumption that an African American client, a Black client, has experienced or has internalized colonization and is living a story that really is one of adapting to those colonializing practices, whether or not they acknowledge it or feel it or resent White people?
MA:
every Black person has two souls in one dark body, an American soul, meaning White, and a Negro soul. And they're constantly fighting and struggling against each other
Absolutely. And, again, I ground my ideas in, like I said, Frantz Fanon and W. E. B. Du Bois, who was probably one of the greatest minds of the 20th Century — from the whole 20th Century because he wrote his first book in 1903, and he died in 1964. But he wrote a book called The Souls of Black Folk. In there, he defines this idea that's called double consciousness. Basically, he calls us Negros, but he says every Black person has two souls in one dark body, an American soul, meaning White, and a Negro soul. And they're constantly fighting and struggling against each other.
That's something that I could never explain probably to you because you've never been through that. But to be a Black person who is constantly doubting their Blackness but also affirming their Blackness at the same time, right? If I told you, as a little boy — we're about the same age — one of my favorite shows used to be Dennis the Menace. Remember Dennis the Menace?
LR: I remember Dennis the Menace.
MA: And wanting to be Dennis the Menace but also saying, “Wow. I wish I had hair like Dennis,” or, you know, “Wow. How come my mom doesn't stay home and bake cookies all the time? My mom is up working,” right? You know, “My dad doesn't wear a tie except on Sundays,” right? But it's also giving meaning to that. Or growing up — again, we're in the same age group – remember Tarzan on Sunday afternoon, the Tarzan movies?
LR: I do. Johnny Weissmuller, yep.
MA: – and identifying with Tarzan more than the so-called natives? And, as a matter of fact, not wanting to be the native. That's the double consciousness that Du Bois talks about. Fanon calls it the zone of nonbeing.
LR: The zone of nonbeing?
MA: And Fanon, going from Hegel's master-slave hypothesis. I don't know if you're familiar with that.
LR: Familiar only by name.
MA: Fanon says that's about the idea of recognition and consciousness, that we become conscious of ourselves by being recognized by others. Now, that's fine, but Fanon says, in a colonial situation, the colonizer never recognizes the colonized as human, right?
LR: And the colonized don't recognize necessarily that they have been colonized.
MA:
In the colonized relationship, the third person is always in the middle of the relationship
Sometimes. Exactly. But also, what he says, in the zone of nonbeing, the colonized is never able to have a “normal” relationship.” Because a normal relationship is this, Larry: I and thou. I see you. You see me. We recognize each other. We are conscious of each other. In the colonized relationship, the third person is always in the middle of the relationship.
So, in describing another person, and this is using me hypothetically, I might say, “You know that guy over there? He's dark-skinned, but he's handsome.” So, in other words, there's another measuring stick to that person to help me describe that person. “You know that guy? He is really dumb for light-skinned dude.” So, there's always these relationships that are in the middle of our relationships. These are the things that affect relationships.
I'm a family therapist, right? These are the things that begin to affect relationships even when they're unspoken. And if you're not aware of the nature of those things, that's what testimony therapy brings to the forefront, that these are also things that are important to think about in these situations. When I've got a husband and wife come in, it's not just the problems they have. It's the problems they have that have been exasperated (sic) in the everyday lived experience of just being a Black person growing up in America.
LR: Is there a presumption that all Blacks, all African Americans have this double consciousness whether they're aware of it or not?
MA: Absolutely. Can you be Black in America and not always have this small voice in the back of your head? For Black women, the decisions about how they fix their hair is a political decision and not just a daily decision. The choice. How they do that. Decisions about how we speak and how we are heard, right? If we speak and our speech sounds too Black, or if we speak and our speech sounds too White, right?
LR: Or not white enough.
MA: The clothes that we might choose to wear. All of those are decisions which are grounded in, “How will I be perceived?” And it's not just how I will be perceived. Also, I'm concerned about how other Black people are perceived because I'm afraid that how they're perceived also may have some effect on how I'm perceived.
LR: So, the Black person is always being evaluated. And if they're not receiving overt criticism, there is this other consciousness in which they're either comparing themselves unfavorably to other Blacks or unfavorably to Whites. So, your clients, to the one, your Black clients experience oppression whether they are conscious of it?
MA: Even if it is not named that. There's always this question of… For instance, I was at a conference last week. And my wife and I were about to open our hotel door. I was kind of casually dressed, had a nice little jacket on. You know, my wife is super colorful and flamboyant. So, she had some colorful clothes on. There was a White family about three doors down, and I think they were locked out of their space. And we went to our door, and we opened it up, and one of the women said, “Oh, it's down here." She's telling us, “It's down here.” And we kind of looked confused. And she says, “Oh, never mind.” [laughs]
LR: They thought you were the help opening –
MA: They thought we were the help. [laughs] You know, I wasn't dressed in any kind of uniform or anything like that. And so, now, the part of that is, you know, my wife kind of got a little… She's like, "Argh.” I said, “Look.” As I thought about it, I was like, “Wow. Why?” What was that about? Why would they assume that I was the help? What is there about me that looked like the help? I wasn't dressed like the help or anything else. But there was that quick assumption. That's what the young people call everyday microaggressions. It's like those things that make you wonder. Now, you're not quite sure, but it's, again, to always have those thoughts. It is not an unusual thing for me to have conversations with my clients, and in some way experiences like that come up in the conversation. Or ideas like that come up. And, again, this is not about people being hyper-politicized or understanding. This is the everydayness of life.
LR: Black life.
MA: What testimony therapy is about is about having a framework to understand that and to understand the meanings of that and a framework that allows us to engage those conversations in ways that feel safe and also are not committed to having you just basically fit in. You know, our traditional training as therapists is to help people fit in. Do we really want people to fit in to that experience of life, or do we want to give them ways of challenging that and seeing themselves in more powerful ways?
Therapy Embraces Culture
LR: Is psychotherapy with Blacks/African Americans diminished if the therapist does not take a testimony-oriented approach or that does not focus on that double consciousness?
MA:
I don't get into the wars about what approach to therapy is best
No. The reason I'm not going to say that is because I don't think just taking a testimony approach, even though I think that the things that I talk about are valid and should be dealt with, is critical because I don't get into the wars about what approach to therapy is best. But I do think that the dominant Eurocentric approaches to therapy are oppressive in that they try to force people to fit into a cultural context that is not their home. That is the subject of the book that I'm working on which is about decolonizing therapy, and that idea of decolonizing and dis-alienating the work that we do away from that kind of therapy which basically assumes Western ideas and cultural values. Eurocentric ideas are the norm and, in that context, the best way to help people's mental health is to help them better be able to fit into those norms. And so, we use those Eurocentric approaches to fit people in.
LR: I appreciate this and am very excited by this conversation, and I see how animated you’ve become — your gestures, your tone, your body movements. And I guess, if I was doing a testimony-type therapy, we would be talking about this experience between the two of us.
MA: This is what I do in my therapy room.
LR: So, if you believe that all Black America has double consciousness, is therapy with Black folks less than good enough therapy if we don't touch on the issues of double consciousness and colonialization? Is it incomplete therapy by definition?
MA: If we are not aware of that reality, yes! I believe that the reality of double consciousness, the zone of nonbeing, as Fanon calls it. But there has to be a consciousness of the lived experience of Blackness in the West.
LR: Living in a Black body.
MA: – and how, as a family therapist and systemic therapist, that impacts relationships. That's always the undercurrent of relationships. Even when it's not spoken, even when it's not something that people are consciously aware of in sophisticated ways, it's impacting the way they think.
There's always this comparison. When we talk about Black male and female gender relationships, there's always that under thing. You know, it's always racialized. When you have Black men who don't like Black women, they say specifically, “Black women ain't shit.” Black women may be thinking, “You know what? I can't stand Black men. I'm thinking about dating out of my race because these men…”
It's all of them, right? And the thing that defines them is their Blackness. That's what makes them Black. So, it defines those relationships. When people are afraid of how their kids look. “I don't want you braiding your hair like that. People are going to think you're a gangbanger or something.”
LR: Or have “the talk” with them.
MA: So, this lived experience shapes relationships. And, again, so th
Psychotherapy and coaching may seem like they are worlds apart — as close to the uninformed as medicine and cheerleading. They are not only similar but are in many ways identical. As a retired therapist and an active creativity coach, I have some ideas about how this has come to be. On the one hand, psychotherapy, at least to me, never quite became the science it had hoped or promised to be. No theory of psychotherapy has ever been proven sufficiently rigorous or singular to win the title of “the best” or “the most effective.” And therapeutic techniques that flow directly from DSM diagnoses have similarly fallen short.
In contrast, coaching has evolved into a helping discipline unencumbered by the burden of calling itself scientifically minded or medically based. It asserts instead that helping requires an orientation away from the pathological to the normal, as well as the psychological, social, and contextual.
As a coach, I have never placed much emphasis on pathology and diagnosis. I always consider instead my client’s nature, which includes elements of despair, hope, fearfulness, addictive tendencies, and both personality strengths and shortfalls. I’ve been very careful in this role to avoid robotically co-creating goals and assigning homework — core “clinical” tools. I always saw the same all-too-human person sitting across from me as when practicing psychotherapy.
Over the years, I’ve come to appreciate how the two seemingly disparate professions have converged in their core orientations and approaches. They are both helping professions that rely on certain and specific strategies that are surprisingly simple to articulate: both helpers listen; both use themselves and what they know and feel; both empathize and, maybe sometimes in rather different ways, support their clients and cheerlead for them. And both are keenly aware that a human being with a formed personality and two feet planted in real-world circumstances is sitting across from them.
Psychotherapy may balk at this characterization and conclude that coaching is “merely” helping and not doing anything like science or medicine. But it can’t really justify any fancier claims. The arguments against the legitimacy of the DSM, its “mental disorder” paradigm, and its checklist mentality should persuade any open-minded therapist that “diagnosing” is for insurance and prestige purposes only. To announce to someone who is in despair that she has “the mental disorder of clinical depression” is a linguistic gambit, not a medical diagnosis. Therapists know this.
In my experience as a therapist and current work as a coach, I know that in both roles, I am carefully and compassionately listening to another human being and responding according to their understanding of human nature. If a client announces that he hates his job, a right-minded therapist is hopefully not going to impose some pseudo-medical interpretation of despair. She is going to believe that her client means exactly what he says. She may investigate to make sure that he is indeed saying what he means and not fibbing or fooling himself, but centrally and crucially both coach and therapist are going to formulate the same internal question: “What does meeting in the middle look like?”
The Limits of Coaching
Consider a client of mine whom we’ll call Jane. Jane is a middle-aged writer who has had some successes but who craves better sales and more recognition. She isn’t particularly interested in achieving another “middle list” success — it’s the prestige of a bestseller that she craves. What’s standing in the way of her pursuit of greater achievement? As it turns out, the answer is, ‘many of the sorts of things that both creativity coaches and therapists would expect to see.’
Jane isn’t sure that she has a bestseller in her. She feels resistant to talking the matter over with her literary agent and is resistant to writing. As a result, her mood has plummeted. Taking care of her husband, who is ill and who requires many medical appointments, further drains her, reduces her available writing time, and lowers her mood. Dealing with a lack of enthusiasm from recent readers has put her in an extra-deep slump. She feels generally anxious and has difficulty concentrating on her writing or on much of anything. Her sleep isn’t good, her eating habits disappoint her, and when she does manage to get to her desk, she finds herself procrastinating and distracting herself, sometimes for hours.
Both therapist and coach understand that this is what real life looks like. The therapist might find herself wending her way to a depression diagnosis, an anxiety diagnosis, an attention-deficit diagnosis, or some other pathological label. But in session, both would likely proceed in quite similar ways. They would listen; they would ask questions; they would ask follow-up questions. They would help Jane prioritize which of these issues she wanted to focus on. They might reflect on Jane’s language, maybe wondering aloud if, when Jane says, “I’m probably over the hill,” or “I don’t think I can come up with an idea for a bestseller,” such thoughts are really serving her. They might, with Jane, co-create a new sleeping regimen or help her acquire a useful anxiety management tool or two. They might “use themselves” by role-playing a Jane-literary agent interaction, with the therapist or coach playing the agent. They might point out a pattern, say, the way that reader criticism seems to overly affect her, or wonder aloud about Jane getting some support in her role as caretaker of her husband.
In this scenario, has the coach overstepped? I don’t believe so. And if a therapist had operated this way, would she have been operating exactly according to her mandate, if that mandate was to “diagnose and treat mental disorders?” Maybe not. But she would have operated completely in line with her implicit mandate to help a person in distress. Neither would be practicing medicine or following a version of the scientific method. Both would be attempting to be supportive, humane, helpful, and wise. Each might come to session with a different set of tactics and techniques, but both would be doing essentially the same sort of work and hoping for the same sort of positive results.
At the same time, both would expect Jane, and clients with similar narratives to be defensive and resistant. Neither would be surprised if the client were to take two steps backward for every half-step forward. Both would nod in understanding if the client found it hard to change, hard to keep to a program, hard to come to a session, hard to put everything on the table. Both coaches and therapists know these sorts of things.
I think that this is very good news for both professions. Therapists can own that they are not doing medicine, are not at the beck-and-call of pharmaceutical companies, psychiatry, the DSM, the ICD, or any other tentacle of the medical/mental disorder apparatus. At the same time, they can own that they are a useful class of helpers who are good at listening, understanding, and responding. They can feel more human (and more humane) and less white-coat-ish. Freed of these burdens, coaches, for their part, can step even more fully into helping — they can become better helpers by deepening their understanding of human nature and by bringing that increased wisdom to their sessions. Aren’t those excellent outcomes for both?
Do coaches need to know more than they currently know to meet this ideal of helping? Yes, absolutely. But most therapists do as well. Both groups of helpers need to rely less on their standard tactics — goal-setting and goal-monitoring for coaches and a single theoretical orientation like cognitive-behavioral therapy for therapists. Both are well-positioned to provide more wisdom and wide-ranging understanding than most in either group can currently muster. Each group can point to the shortcomings of the other group, but in this movement toward the middle, where coaches become more psychologically minded and therapists become less attached to the medical model and pseudo-scientific notions, perhaps the outline of a new wave of superior helping will emerge. I hope it will arrive soon.
Questions for Thought and Discussion
How do you resonate with this debate between coaching and psychotherapy?
In what ways do you see the two disciplines converge? Diverge?
How would psychotherapy and coaching look different with a client like Jane?
The other day, I attended a case consultation webinar with Psychotherapy.net’s founder, Victor Yalom, who demonstrated, and then discussed, supervision with a beginning therapist. As he was addressing the importance of creating a therapeutic atmosphere in which both client and clinician are fully engaged, he described the intricacies of learning table tennis. Almost as an aside, he suggested that, like his time on the table tennis mat with his instructor, therapy — good therapy — is a “full-body contact body sport.” Currently trying to learn the torturous game of golf with the assistance of my own instructor, I fully resonated with his aside.
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Body and Mind
Whether on the table tennis mat or golf course, the student must not only integrate their own mind and body, but must also be fully open to the instructor, who is doing the same within their own skin — as they mold, model, and instruct their student. So, a good “lesson” involves a balanced and delicate dance between student and teacher, where both simultaneously merge self-awareness with an awareness of the other. Full-body contact sport!
You probably knew where this essay was going. To therapy, of course! And first to Carl Rogers, who understood that effective therapy was built on a relationship between client and clinician in which congruence, or full presence, was a prerequisite. The person-centered clinician asks the client to be open to — and willing to share — their most intimate thoughts and feelings in search of unity between their “real” and “ideal” self. Similarly, the clinician, to provide a space in which the client is willing to take this step, must be congruent — fully present, self-aware, and open to the client’s experience. Fully-embodied contact!
Existential psychotherapist Irvin Yalom teaches us that for a client to venture into the realm of challenges and concerns that define their humanity and allow them to relate healthily to others, the clinician must help them focus on the here-and-now. This notion, while simply said, is not always easy to achieve with a client who comes to therapy in distress, deeply conflicted, and struggling to meaningfully connect with others. The clinician encourages the client to take the risk to be fully present — body and mind — in the therapeutic relationship while also making the same demand of themselves. The in-the-moment therapeutic relationship becomes the table tennis mat, or golf course, on which clinician and client move together towards healing and growth. Full contact!
Few have illustrated this notion of full body contact better than Peter Levine, developer of Somatic Experiencing. For Levine, who is doubly credentialled in psychology and biophysics, clients who have been traumatized benefit from learning how to control the flow of energy through their body. The goal of effective intervention with them — and with others struggling to self-regulate — is to learn how to stay centered, calm, and present within themselves. To help their client to achieve these goals, the therapist must travel down a similar path, listening to cues within their own bodies that resonate with, or are triggered by, those of the client. Full body to full body contact. Co-regulation if you will!
Isn’t this co-regulation, full-body contact, embodied connection, or whatever you choose to call it, also part and parcel of effective countertransference management — a state of delicate full-bodied self-awareness in response to that of another. A moment of reciprocal “I-Thou-ness."
So, perhaps the next time you sit with a client, or trainee, or supervisee, and wonder if you have made a deep and meaningful connection in the service of healing and/or learning, do a full-bodied self-check-in as you encourage your client to do the same. And as in any “sport,” whether it be golf, table tennis, or some other, give yourself permission to evolve as you practice, and the consolation that in this sport of psychotherapy, practice will never make perfect. But you’ll get better at it.
Questions for Thought and Discussion
What does the notion of therapy as a full body contact sport mean to you?
With which kind of clients do you find it easier to work in this full-body contact way? Which are more difficult for you?
What techniques do you use in and out of therapy to be in full-body contact with yourself? With others?
