Ben Yalom on Narrative Therapy, Theater, and Writing with my Father

An Intellectual Heir to my Father?

Lawrence Rubin: I’m here today with Ben Yalom psychotherapist, theater-maker, and author. His book, Hour of the Heart, which he wrote along with his father, Irvin Yalom, explores the complexities of human relationships and personal transformation based on one-hour consultations between the senior Yalom and his clients. In addition to his therapeutic work, Ben is the founder and artistic director emeritus of fools FURY Theater Company in San Francisco, where he directed numerous acclaimed productions.

You’ve now written a book with your father, as his light is fading. I wonder if you consider yourself to be his intellectual heir.


Ben Yalom: I think I am “an” intellectual heir to my father [Irvin Yalom] to the extent that there are some things that I can do that he has done, and others that I can’t. I could never be my father’s full intellectual heir because I would have 40 or 50 years of reading to catch up on first!

But there are many things that we’ve experienced together, beginning when I was growing up. My parents were further along in their careers, and at that point, there was only one of me because my three siblings were already grown. So, I imagine that their dinner table conversations were a little different from the ones I had with my parents, which were definitely weighted towards their interests. So, almost by osmosis, I probably gathered a lot of knowledge in the humanities. I imagine my siblings did as well, but I think I probably was more exposed in many ways. That’s just in my DNA, or what might pass for my foundational upbringing.

I have done some thinking lately because I’m working on some essays and a book proposal, on what it would mean to sort of take up the mantle of some of my father’s and my mother’s intellectual work and writings. As I say, I don’t think I can ever really be my father’s heir or equal in the sense of having that deep wealth of knowledge about philosophy and therapy and the humanities that went into his writing.

But another very important aspect of his writing that resonates with therapists and students of therapy is that he’s extremely open and honest about himself and his flaws, as well as in the sharing of his ideas. And those are things I very much can do in my writing. In that regard I think I can deliver on his way of being and his way of sharing and his way of teaching.

I’ve certainly reached a place in my life which is quite relevant to the book we just completed, Hour of the Heart. I’ve reached a place in my life where I’m very willing to be quite transparent about most things in my life with my readers and with people who come to ask me for help, I am already finding that this is helpful, much in the way that my father describes in his work. One other aspect that I’m trying to bring into my work, both as a writer and a therapist, is my background in theater.

While that background and foundation does not come from mountains of books that I have not read, I do have something analogous to that in my 25 years in making theater. Particularly in doing types of theater that are deeply engaged in mining the richness of the actors’ lives, rather than the psychology of characters that comes from a script written by someone else. My experience in theater centers around working with peoples’ experiences and psychologies and stories, and in understanding how the body can be used along with the connections between the bodies and emotions in storytelling for character development.

This knowledge is quite real and substantive and can be very powerful for a lot of people. It has taken me some time to understand how to use it therapeutically. I’ve been trying to find my way to weaving these things together in a deep and compelling way to help people, and I’m now starting to see real results, which is exciting.


LR: You’re speaking of the FoolsFURY Theater Company. What was your role in it?
BY: I founded and led the company for most of its existence. I first went to the Iowa Writers Workshop for graduate school, to write fiction. But when I got out, I learned very quickly that I didn’t like sitting alone in a room writing. And all along I’d had a parallel passion which was doing theater.

But I found that I was not that interested, or satisfied, by the theater I was seeing produced. Even in a pretty interesting and experimental place like San Francisco, much of the mainstream work was very traditional American theater. That is, a script was given, people performed on a stage, and it was almost like in many ways, putting a movie on the stage. That’s a vast oversimplification, but to some extent it’s true.

I became really interested in ideas and concepts that could be expressed in metaphor and movement, and that tackled deep themes. I was much less interested in realism. What I really wanted to explore was “What could be unique about the experience of live theater?” which was completely different from trying to put realism on stage. So, I started exploring and meeting people in theater companies in the Bay area, trying to get them to hire me to direct plays. But I found quite quickly that people were interested in working with me, but nobody was going to hand over the keys of their theater company to let me create my sort of experimental vision. Finally, my mentor came to me and said, “Okay, well, I guess that means it’s time for you to start your own company.” So, I started a company to produce one play at the time, and when it came time to actually put it on stage, I was told I needed to have a company name.

You asked earlier about the name foolsFURY. I dreamt this up as a collision of fool – our absurd and comic human position in the universe – and fury at the injustices we do to one another. I meant only to do one or two plays in order to put my name on the map. Then it became a 20-year endeavor, because we got to do the things that I wanted to do artistically that nobody else was ever going to hire us to do––to raise complex questions and be deeply curious. It was a place of experimentation and research, and ultimately a place where we hosted many other companies and nurtured their creative visions, all working in this sort of space between somebody delivering a script versus the actors and the designers and the directors creating original plays.

What I wanted was people who could do powerful realist scenes but also explode the stage, do everything that was possible to create an experience that one had to be involved with live, and that could mean the type of immersive theater that we’re seeing very strongly now, 25 years later. It might mean acrobatics. It might mean dance. It might mean breaking out of realism into some sort of crazy imagination, stylized work, and then back into realism.

At the time, most of American theater, and definitely most of the mainstream theater that was happening in the Bay Area, as well as what all the major conservatories were teaching, were variations on realist acting and was psychologically driven from the top down. I had to become an expert in things that moved from the outside to enter the bottom up; start with the body, get to the mind as opposed to starting with the mind and getting to the body. So, my expertise is very much in a number of contemporary forms that are bodily-oriented, driven by impulses in the body, or understanding a feeling in the body and how that might come out, or how a certain use of the body might generate an emotion as opposed to the inverse.


Beyond Thought and Language

LR: How have you made the transition from the theater to the therapy space?
BY: I am trying to bring this “bottom up” orientation into some of my therapeutic work. This means developing ways of getting people to find or explore—if we think about Narrative Therapy—stories of self, not verbally, but through exercises that are more physically oriented. And my feeling is that one of the challenges of traditional talk therapy is that it’s so talk heavy; this works really well for some people, but not for others. The discursive, rational language that we use isn’t the easiest way for some clients to explore themselves, or to express what they find when they do. So, I’m trying to build some tools that go with narrative and existential therapies, but which help people explore and express themselves in a less language-centered way.

LR: It’s interesting that we started the conversation around the question of whether you are ‘the’ or ‘an’ intellectual heir to your parents’ careers, particularly your father’s and specifically with regard to therapy and your understanding of the human condition. But it sounds like your work in the theater, and how you’re integrating it into therapy is almost anti-intellectual or contra intellectualism.

BY: I’m not going to disagree, but I’d say it’s more a different angle than an anti-intellectual one. The first thing that comes to mind when I’m asked about my theory of change is that peoples’ living understanding of what is meaningful for them is critical. That might look like identifying their “quest in life” or their search for meaning in the universe, and then living in ways that are more aligned with those meanings or ethics. To me, that’s a very existentialist approach through which I’m saying, “What do you find truly important in your life at a deep level?” This is inherent in my father’s work, but I don’t know that all people can answer that solely through thought and language. I think meaning exists within the framework of all the other existential questions, but I don’t think that peoples’ understanding of what is meaningful for them is always easy to articulate verbally.

LR: How do you use movement or poetry or other experiential types of explorations to help your clients make sense of some of the larger existential questions?

BY: I’m doing it based on many, many years of experience with certain theatrical forms. I also have a great network of mentors that I’ve met over the decades that have guided me in explorations or exercises that allow people to go to deeper places within themselves both individually or within a group. Often, they come out with words on the other end, but the theatrical and dramatic and dance work is usually inspired by the internal work they’ve done or are doing.

Over the decades I’ve watched some of the best theater makers and dance makers I know do this kind of deep work, and I’m constantly reminded how powerful their experiences have been. My goal has been to use these highly developed skills and expertise to help therapy clients reach those deeper, meaningful places within themselves, and between themselves and others.

An Embodied, Experiential Journey

LR: Can you give me an example of a client who you helped to bridge that divide between word and experience?

BY: Right now I’m doing this work in groups. Maybe someday we’ll get to a point where I’ll bring it into individual sessions.

One person I was working with lived with a great deal of shame. She was a Middle Eastern woman battling the shaming cultural practices that came from being a woman and from her parents. Her constant pattern in life was to hide from her parents and then dig her way out and do the things that her parents then disapproved of. None of them were particularly bad things, but those things didn’t fit the culture.

Sometimes before group sessions, I will do what I call a “mission interview.” This is a format Tom Carlson, Garret Rutz, and I are working on which is basically a very short, intense, Narrative Therapy-based re-authoring exercise, in which I would say something like, “How did you decide that you wanted to become a therapist?” or, “Can you tell me a story about a moment where you made that decision by going down one path?” or, “What were the things you were fighting against in your life that then led you to take up the mantle of fighting against that?” The mission that she developed, should she become a therapist, was to provide a place where people could come to put down their shame and be treated with love, and that she would be the person to greet them with love and offer them a place of safety. So essentially, what I created in that hour for her was the opportunity to think about a story about where she came from, the practices she was up against in her life, what she was doing to combat those practices, and the solution or power or passion that she pursued to fight against those shame-inducing practices.

She understood the mission you jointly articulated for her, at which point I said something like, “We can do this verbally, or we can do it non-verbally where you can get into their body.” She picked, and we continued working together. I offered her some guidance, asking “As you reflect on what you’re really up against in your life, see what that feels like in your body? What is the power, the thing that’s driven you to keep fighting on it against this?” So, we work either way. We identify where they came from, what her big challenges in life are, and hopefully determine what are the strengths and skills or hopes and dreams that she has to fight against this.

Okay, that’s the conceptual background. Then I’ll get them into their bodies and teach them quickly what it is to make a gesture, because it’s the smallest building block of a dance. That seems to be much easier for people to instead of me saying, “go make a dance,” which can be very intimidating. For example , I can say, “Larry, make three gestures, and then let’s put them together.” You just created a little dance!

So then we’d do an exercise where they really get into a meditative space where they spend about 15 minutes just letting their body move, really articulating it and that becomes a bit of a meditation in its own right. I’ll ask them to follow one part of their body which may have begun as an impulse, and I ask them to start paying attention, trying to let their mind and body work together. At that point, I start to bring in the image of the thing that they’re up against in their life. I’ll ask, “How does that feel when you bring that into your story, into your body? Where does it go?” Usually, they’ll go on a little internal journey that’s physical and emotional.

From there, I’ll ask them to bring in the thing that they use to fight against that or to overcome that which takes the meditation in a different direction. I might ask them to just notice at some point and pull a couple of gestures that come up out of those two sides—the thing they’re up against and how they stand up to it. So here they are building a little vocabulary of movement related to their specific stories

Two more steps! They can then do something that’s called a “container exercise” where I ask them what it feels like if they’re inside a container or something that’s holding them in and feeling what that’s like. At some point I’ll say, “I want you to start finding your way out using your specific strengths and skills. And then go back into the container and force your way out again. Then I might say, “The thing that you identified as your challenge in life is that container…that’s the thing that’s forcing you when you go through that…so, how do you use your skills to get out and what does it feel like to get out?” They do it over and over again, and I ask them what they learned from that experience. (And just to note the lineage here, this is a modification of an exercise I learned from the brilliant teacher Steven Wangh, and which he in turn modified from work with the great Polish theater maker and theoretician Jerzy Grotowski.)

I ask them to focus on any gestures or thoughts or words that came out of that such as poetic or metaphorical words or sounds. Next, I might say, “I want you to start on one side of the room in your ‘up against’ state, or the place where you’re fighting against or being contained, and then to move to the other side of the room using all of these gestures that we’ve created, and while going from there to there, somewhere in the middle, there’s going to be a transition, (which in narrative terms is like an agentive turn) where you shift into taking control of this thing. Sometimes people have to go back and forth—but eventually we help them move through to this side. And so they’re getting a very embodied, experiential sense of this inner journey, This is the bottom-up process!

Writing with My Father

LR: I always considered traditional Narrative Therapy to be a very literary, intellectual type of clinical venture, but it sounds like your orientation is to the non-literary or anti-literary, sort of in the way that your divergence from your father’s work led you to an anti-intellectual, experiential place.

BY: One of the things that I saw in Narrative Therapy, at least in the readings, were ideas about ritual ceremonies. Those really caught my attention,. And now, in addition to traditional sessions, I do these experiential exercises in group format that can run six-hours long, and even multiple day intensives.

LR: So, because of your background in theater, interest in Narrative Therapy, and willingness to depart from the written word, you’re no longer committed to that traditional template of one-hour talk therapy. It’s interesting, however, that you just finished co-authoring a book with your father called, Hour of the Heart, where the explicit purpose was to highlight his commitment to continuing his therapeutic career in the shadow of some limitations by offering one-hour sessions with people around the world. Can you share what that experience was like for you?

BY: Strangely, not difficult because my understanding of therapy goes way back to my first exposure through my father’s vision, our dinner table conversations, and later his writings, particularly Love’s Executioner. I read those stories in draft and gave him feedback on those. I did the same on pretty much every book after that so I understood his thinking about therapy and his desire to make a literary form that incorporated therapy, and featured the clinician reflecting on his own thought process and the therapeutic encounter. So, my formation was not only as a therapist but as a writer.


LR: So, it was a natural progression for you?


BY: We had worked together in the past. I had edited a book called The Yalom Reader years ago which was the first big omnibus of his work. In more recent years, I had given very significant feedback on a number of his books.

I did, however, decide that it was just too demanding for both of us to work together until the mountain of stories for Hour of the Heart grew and his memory began to decay. Eventually the manuscript grew to be between 45 or 50 stories, and it was too challenging for him to put them side by side while holding onto the threads that were going on between them.

Some of the stories were sort of repetitive of one another. It’s not because he wasn’t interested in the process or fully invested in each one of those stories, but because he had forgotten what he had written. For example, story 40 may have covered some of the themes already covered in story number 12. At a certain point, we agreed that in order to help him pull it all together, he needed somebody to work with who knew him well enough, knew his way of writing well enough, felt confident enough, and had enough of his confidence to really revise and rewrite. So that’s the work that I undertook.
Embodied writing


LR: From a Narrative Therapy perspective, what do you think your dad values in you that led him to invite you into this project, even though you have a challenging history of working with him.
BY: That’s an excellent Narrative Therapy question. I can only speculate. I think we have a pretty powerful bond and it’s different for all the children. But I am the one who was most engaged in writing. As I went through grad school and after, when I wrote plays and some fiction, I certainly always shared my work with him, and we would discuss it. Likewise, he would share his work with me, and we would discuss that.

We’re certainly not the same writer, and we have different strengths. I found at some point in my 30’s by the time I had children, that it wasn’t always easy for us to collaborate because he is an anxious, and often impatient, person. And for me, working with an anxious collaborator who would often send me a draft, and then call the very next morning saying , “Do you have the edits yet? was challenging. I would come back with “I have it, I haven’t read it yet, I’m trying to get it!” I had three kids to get off to school and whatnot. While we eventually decided not to write together often, we did co-author a column for Inc. magazine for a year, and I’ve edited chapters of many of his books.

But I understood his work well enough to be able to try to write like him in a way, and not to stick things into the stories that sounded out of place. That might have come from my way of thinking but at the same time, we had spoken enough about therapy over the years that I think there was a lot of trust there as well.

It really helped that I had turned the page in my life and decided to pick up the family business and had started my education as a therapist and started seeing clients. So, the questions I was asking were really informed by some experience, as opposed to purely from the writer’s perspective. The other aspect is that I had suffered with depression back in my 20s and 30s, and we had very long talks about that. And similarly, he has had periods of anxiety, and particularly in the years since my mother died. And we had some very long talks about that. So, I think there was a certain amount of trust in one another. And for him, in my psychological acuity and compassion.


Lessons Learned

LR: In his words, “fellow travelers.” Did the nature of your collaborative efforts change from the beginning to the end of the project?

BY: Absolutely it did, and it was really interesting. At the beginning of the book, I would say my father was more concerned about me being interested in doing this, but little by little, he gave me more rope, if you will. I would bring back suggestions that he liked, and he became more and more willing to trust me as a writer. At the same time, I think there was the process of him becoming a little bit less invested in the book, or a little less interested in the book, as time went on because with his clock ticking, and realizing that he doesn’t have that much time left on the planet, there were other things he wanted to be doing and paying attention to.

Those two things allowed him to give me more and more freedom. We also moved from really looking at pages together at the beginning, to more of my doing the work and coming back to him in a Zoom session and saying, “Hey, I’ve got some questions about therapy for you.”

After a certain point, which was quite a bit later, he couldn’t even really remember the individual stories. And sometimes he would reread a story and then we’d talk about it, but often it would be me. I might say, “I’ve written the story. I feel good about it, but I’m not sure about this particular therapeutic dialog in here or this intervention here.” So, I would go back to him and say something like, “Hey, is this something you would say or does this feel right?” I might ask him to imagine he was in this situation with a client, so he didn’t have to remember all the details of the particular interaction in the story.

For instance, if one of the stories was about suicidal ideation, I would ask him how he would address that. It got to a point where what we were having was almost supervision conversations where I was saying, “Does this feel like the right therapeutic move?” and he would say, “Yeah, that that would be good,” or “Here’s a problem with that approach.”

LR: Your father has written and worked around death, dying, grief, and, of course, he lost his wife, your mother, just a few years ago, and now his memory is diminished. What have you learned as a person, as a therapist, and as an author, about death, dying, and mortality that you want to bring into your own life, as well as your therapeutic work? You know, staring at your own sun.

BY: Yeah, it’s been really powerful. Thank you for asking that. I can’t separate it from my particular stage in life. These things are definitely affecting me as a 56-year-old man with young kids. There’s been a certain awakening on my part to the time that I have left. But I’m not coming from zero because I’ve always been having these existential thoughts, because they were part of the air I breathed as a child where the idea of how we confront death was always a common topic around the table.

So, I think now it has made me look at my life, my kids, and my wife and thinking, yeah, I have X amount of time, and I really want to make the most of it. So that is helping me say “no” to things in a way that I probably didn’t before, and also say “yes” to other things and to other people and their needs, in ways that maybe I didn’t before. I think it has helped me in my mission to be a kinder person. Because we all have frailty.

It’s been difficult watching my father diminish to the extent that he has, not only because he’s my father, and that I think it’s difficult for anyone, but also because there’s this the air of the great man being diminished. Because I’m in the field, and because I’m managing his Facebook page, I’m constantly responding to people about the emotional impact on them of his decline. Everybody wants a little piece of him and wants him to know that they wish him well.

That this book itself deals with the aging question and the memory question means that these were very direct topics of conversation for us. We were often looking specifically at, “What it’s like for you to be having these memories slip away?” And “Sometimes we disagree about something that happened in your past.” But then we can’t just sort of let it go sometimes because it’s actually relevant to the story that we’re writing, so we had to stay with those things that were uncomfortable, linger over them together, and decide how to address them, both in life, and in our writing.

LR: We started the conversation around the issue of whether you are your father’s intellectual heir. But as we move to the very end of the conversation, I see you as more of the existential heir. Would this book be one that beginning clinicians could pick up?

BY: I took on the mission of making this an accessible book to a broad range of readers. I think many of his central therapeutic ideas are laid out well enough that one could pick this up as their first book during training. My guess, however, and given that most people who are beginning their journeys as therapists are much younger, is that some of the questions about aging which do make up a lot of this book, are probably not as relevant. I think picking up the Gift of Therapy or one of the books of stories is probably a better place to start. But I don’t think you would go wrong if you began with this one.

LR: I agree, Ben, and on that note, I’ll say thanks for this deep and powerful sharing, and good luck with the book.

BY: Thanks Larry. I enjoyed it as well.

©2025, Psychotherapy.net

References

Yalom, I. & Yalom, B. (2024). Hour of the heart: Connecting in the here and now. Harper Collins.

Yalom, I. (2002). The gift of therapy: An open letter to a new generation of therapists and their patients. Harper Collins.

Nancy Haug on Psychedelic-Assisted Psychotherapy

Lawrence Rubin: Hi Nancy, thanks so much for joining us today. You are a professor in the department of psychology at Palo Alto University, and an adjunct clinical professor in the department of psychiatry and behavioral sciences at Stanford University School of Medicine. You have ongoing collaborations with and a teaching role in the Stanford Psychiatry Addiction Medicine Program, where your current research interests include implementation of evidence-based practices in addiction treatment, harm reduction for substance use, cannabis vaping, and psychedelic-assisted psychotherapy. Welcome!
Nancy A. Haug: I would add to that that I do have a small private practice where I treat clients, some for addictive disorders, but I am mostly a generalist.
LR: I didn’t know that you also have a private practice. Do you practice psychedelic assisted psychotherapy?
NH: I do a little bit of that work, but it’s a very small percentage of my clients, and it’s mostly limited to the preparation and integration phases of psychedelic therapy. I’m not doing any kind of administration of psychedelics in my office or in my practice. My clients will get that elsewhere. And then I’ll help them integrate the experience into therapy. We can get more into that later.I’d like to start by acknowledging the indigenous peoples and practices, because many psychedelics are derived from sacred plant medicines that have been used for millennia by many cultures. This isn’t something new, because much of the work we’re doing with psychedelics comes from thousands of years of cultural shamanic traditions.

Psychedelics as Medicine

LR: Thank you for that acknowledgment. I think it’s important that clinicians appreciate the broader cultural and historical context of psychedelic use.So, there are practitioners of psychedelic medicine, and there are practitioners of psychedelic assisted psychotherapy—two distinct but overlapping applications.
NH: Sure. I think the medicine piece would be more in the context of something like Ketamine treatment and/or the administration of psychedelics in a more medicalized setting. Clinical trials are being conducted right now that are looking specifically at psychedelics as medications. But as a psychologist, I’m more focused on the therapy piece which I really believe is an important component. It is about the way that psychedelics can be therapeutic for psychological healing.
LR: much of the work we’re doing with psychedelics comes from thousands of years of cultural shamanic traditionsSo, you might have a client presenting with symptoms of depression or anxiety or trauma going exclusively to a medical professional and receiving one of the psychedelics, but not necessarily being referred to a mental health professional for integration into therapy?
NH: Exactly.
LR: Is there a turf battle between medical and mental health practitioners in the realm of psychedelics over who gets ownership over their use? A battle in which psychotherapy is considered a diminutive form, and the integration of psychedelics into therapy as an encroachment of sorts?
NH: I believe that a lot of the providers of Ketamine treatment would support integration into psychotherapy as part of that workIt depends on who you talk to. We can certainly get into the differences between the various psychedelics, but at this point, there are many clinics where people can receive Ketamine infusions for various conditions that don’t involve psychotherapy. But I believe that a lot of the providers of Ketamine treatment would support integration into psychotherapy as part of that work. I actually work with a psychiatrist who runs a ketamine clinic, and he is always asking me if I’m taking referrals or if I can give him referrals to other therapists. He does have some therapists built into his clinic, but there’s not enough of them to meet the patient needs. So, I think there is recognition that the therapy component is helpful and that it can improve outcomes.
LR: Which chemicals are most often used in this line of research and intervention?
NH: Ketamine was used as an anesthetic in veterinary clinics and given to soldiers in Vietnam in the 1970s as a field anesthetic. It’s also been used off-label for the treatment of refractory depression and suicidality.The classic psychedelics are LSD, psilocybin, DMT, which is dimethyltryptamine, ayahuasca, and mescaline, which comes from the peyote cactus. Of the hallucinogens that have been studied and are in current trials, I would say psilocybin has probably been looked at the most. And then we have MDMA––ecstasy or Molly, methylenedioxymethamphetamine, which is a serotonin, dopamine, or epinephrine agonist, It’s sometimes called empathogen or enactogen, which produces a heightened sense of connectedness or openness. It’s characterized by the person becoming very empathetic and compassionate. MDMA has stimulant properties, but it’s different from classic psychedelics, which affect more perception, cognition, mood, and sense of self.
LR: if someone is going to do this work, it’s very important to be familiar with the different compounds, their effects, and what conditions they’ve been applied toI would think that mental health professionals would really need to know their way around pharmacology to venture into this realm of practice.
NH: I really agree that if someone is going to do this work, it’s very important to be familiar with the different compounds, their effects, and what conditions they’ve been applied to—just knowing the research. Most training programs for therapists who are interested in integrating psychedelics into their work will include the history of psychedelics, and then there’s always a psychopharmacology piece that is addressed. I don’t really endorse one or the other training programs, but I think most of the established ones are pretty good. Psychedelics are classified as Schedule I drugs by the FDA, meaning they do not have an accepted medical use.Some states, including Oregon and Colorado, have initiatives supporting psilocybin use in therapy, but they do require therapists to go through training programs. I think they get certified or licensed somehow as being psychedelic providers, which I think is a good thing—just to put some controls around it. And this isn’t just limited to psychologists. Anyone who’s a licensed therapist can do this work and can get training. That includes licensed marriage and family therapists, and clinical counselors.
LR: Is there a national certification that is available, or is it currently a state-by-state affair?
NH: Not that I’m aware of. I think a lot of the training programs developed in the context of clinical trials, and now pharmaceutical companies that are doing drug development, like Compass Therapeutics, have developed their own kind of training protocols for doing this work, and there are a few manuals, like Deliberate Practice in Psychedelic Assisted Therapy, which is one of the volumes in APA’s Essentials of Deliberate Practice series.

Integrating Psychedelics into Psychotherapy

LR: Is there a standard definition of psychedelic assisted psychotherapy?
NH: psychedelic medicine may or may not involve therapy as it’s more focused on the administration of the psychedelic. I do have a definition of psychedelic assisted psychotherapy that I like to use which I pulled together for a presentation with one of my colleagues. Psychedelic assisted psychotherapy is a clinical intervention that combines preparation, psychedelic administration, and integration of experiences to facilitate psychological healing in the context of a therapeutic environment.All of these pieces are important components of psychedelic assisted psychotherapy. There’s also an umbrella term called psychedelic medicine, which you’ll also hear a lot, and that I simply define as applications of psychedelics or hallucinogenic drugs to the treatment of psychological conditions or psychiatric disorders. Psychedelic medicine may or may not involve therapy as it’s more focused on the administration of the psychedelic drugs. But I know you wanted to talk about the therapy piece.
LR: Am I correct in assuming that there are randomized controlled trial studies comparing psychological treatment with Ketamine alone and psychotherapy with a psychedelic?
NH: We’re still in the early stages of this work. There was a review paper that came out recently looking at the different types of therapy that have been implemented, but there’s not a gold standard at this point.
LR: if I’m going to do this work, I’m working closely with a physician or a psychiatrist who’s administering the medication in a controlled settingWould a psychologist need prescription privileges if they wanted to use psychedelics independent of a licensed physician?
NH: I don’t think that would really be part of our domain as psychologists. Our role is to provide the therapy! It’s important to work with other providers, so if I’m going to do this work, I’m working closely with a physician or a psychiatrist who’s administering the medication in a controlled setting. There is a treatment model where the patient will be prescribed sublingual Ketamine lozenges that they can take at home and then work with a psychologist or licensed clinician to do the therapy.
LR: I don’t know anything about half-lives of the various psychedelics, but must the client be in an active substance-induced state, and how do you know if they are?
NH: I think again it depends on which psychedelic medicine and on the particular model of treatment. With the IV Ketamine infusion, the person typically isn’t conscious, so you couldn’t really be doing the therapy while they’re under the influence. But you could afterwards, because there’s research suggesting that because of the brain’s plasticity after psychedelics, the patient may be more receptive to therapy within 24 to 48 hours after they’ve ingested the medication.Like I said, we really don’t have a gold standard. And I think there’s been some challenges in disentangling the effects of the psychedelic drugs from the therapy itself. Some trials have tried to incorporate evidence-based treatments like Cognitive Behavioral Therapy or Acceptance and Commitment Therapy. There is some evidence that this might promote better clinical outcomes. I think ACT specifically, and mindfulness therapies lend themselves really well as interventions because of the psychic or psychological flexibility that they target. So, combining that with the psychedelic might create synergistic effects. But again, we haven’t standardized it, so it’s really hard to even compare across studies. You asked earlier what I thought the mechanism of action was, so I did want to say that we really think that it’s a result of the interaction between the medicine, the therapeutic setting, and the mindset of the participant. People might take psychedelics like ecstasy at a rave, or mushrooms at a festival; but that doesn’t necessarily lead to them being cured of their trauma or depression. Because it’s a different setting that is not necessarily a therapeutic context, they don’t have a guide with them really exploring underlying processes. We really want to help the patient become clear about their intention, such as addressing their fixed beliefs or getting more in touch with certain emotions. The therapy can help loosen some of that up, which will allow for greater flexibility.
LR: there’s been some challenges in disentangling the effects of the psychedelic drugs from the therapy itselfWhat do you hope to tap into or capitalize on when applying psychedelic assisted psychotherapy?
NH: I think it’s different for each patient and depends on what they are coming in with. Are they coming in with an unresolved trauma? Are they coming in with existential depression? I try to determine where they’re stuck and what it is that they’re trying to get insight about. And if they have cognitive expectancies, which refers to what they expect might happen during the psychedelic experience, or their mindset. And that does require some preparation work.One of the things I would want to be clear about with my patients is what they are looking for and not overselling this therapy as a magic bullet or that they’re going to be cured of their depression. That’s not how it works, and so I would actually be hesitant to do this work with someone who came with the notion that psychedelic therapy is the end all, be all, and that they’re going to be fixed. That’s probably not going to be helpful for them. I might even want to temper those expectations by providing a more realistic picture of what could happen, which starts to get into some of the ethical issues around this, particularly with informed consent, because we don’t know what’s going to happen. How do we obtain informed consent when we can’t even explain the psychedelic experience? I can’t tell what’s going to come up, and sometimes there are even personality changes where the person becomes more open or has altered metaphysical beliefs. So, it’s important to provide a lot of education and information about what could happen, including some of the subjective effects. There are just so many possible outcomes.
LR: one of the things I would want to be clear about with my patients is what they are looking for and not overselling this therapy as a magic bulletIs there any solid research about how the brain actually changes under the influence of psychedelics that make it easier for the clinician to access conflicts, or to get through resistance, or for the clinician to more directly intervene on a particular issue? In other words, is there anything proven about what happens in the brain that allows for that?
NH: Absolutely. Psychedelics enhance neural plasticity. One model that’s been put forth is the REBUS model by Robin Carhart-Harris, which is about relaxed beliefs under psychedelics. The idea is that the psychedelics relax what they call priors, or prior beliefs, or assumptions to allow bottom-up processing in which information flows more freely, where the mind can really open. Psychedelics have also been referred to as “disruptive psychopharmacology” because they disrupt boundaries among brain networks, allowing for greater communication across the whole brain.Psychedelics are also considered nonspecific amplifiers of human experience. In other words, whatever the person is going into the experience with – their particular mindset and setting – is going to be amplified during the psychedelic-induced state of consciousness.
LR: one model that’s been put forth is the REBUS model by Robin Carhart-Harris, which is about relaxed beliefs under psychedelicsHave there been any randomized controlled trial studies involving the use of placebos?
NH: It’s really hard to come up with a placebo that is comparable to psychedelics because people usually know when they’ve been given a placebo. That’s actually been one of the most difficult pieces of doing this research is that we can’t actually blind people. I know with some of the Ketamine studies they’ve tried to use Midazolam, which is a benzodiazepine. Usually, people know the difference.
LR: Circling back a bit; you mentioned that ACT lends itself particularly well to psychedelic integration.
NH: I think that because ACT emphasizes mindfulness, anything–psychedelics in this instance– that allows for fuller contact in the present moment, can help the client more fully and deeply navigate the therapeutic experience including any states that may arise. As another example, I believe they’ve used Internal Family Systems model in the MAPS (Multidisciplinary Association for Psychedelic Studies) trainings; and while I’m not trained in IFS, some people report that it’s useful because it helps the person look at different parts of themselves that they might not otherwise.In general, I would say that the therapy that occurs while the person is under the influence of the psychedelic tends to be more nondirective. In this context, the clinician and the client can respond in the moment to what is coming up. If the clinician is using a somatic tool or some other type of cognitive reprocessing, you don’t want to try to direct them in a particular way. It is important that the client’s inner wisdom, rather than the clinician or any particular technique, be the guide.
LR: it is important that the client’s inner wisdom, rather than the clinician or any particular technique, be the guideYou describe the presence of the psychedelic drug or experience as a co-therapist; a therapeutic ally or resource. The disinhibiting or loosening helps the person to get more in touch with their somatic experience. Whatever intervention you use may be enhanced, accelerated, or deepened. So, the therapist is a facilitator or guide.
NH: Exactly! You’re a facilitator or guide. In the MDMA trials through the MAPS program, they actually have two therapists, male and female. They have various reasons for doing it that way, one of which is perhaps to facilitate projection that could take place as the client reflects on their relational experiences. But it gets very expensive to have two therapists in the room for eight hours doing this work. I’m not sure how they could scale that.
LR: we have a lot of evidence that MDMA really does work with veterans who have been in combat; but also with survivors of sexual abuse and traumaYou mentioned that Ketamine has been successfully used for clients with depression. Do you have a sense of what the mechanism of action is in this case as well as with PTSD?
NH: Typically, MDMA is going to be the psychedelic of choice for PTSD. My understanding is that it promotes emotional processing, and reprocessing of the memories in a way that the person feels safe, less threatened by the memories or the images which allows to experience a deeper contact with those emotions or memories so can work through them.We have a lot of evidence that MDMA really does work with veterans who have been in combat; but also with survivors of sexual abuse and trauma. MDMA was recently reviewed for approval by the FDA but was rejected for various reasons including lack of supportive research. It’s hard to quantify and standardize psychedelic therapy, and since the FDA is not in the business of approving therapies, more research will have to be done. I do know that this outcome was very disappointing to the psychedelic community because we’ve been working hard at this for a long time and thought there was sufficient evidence, especially with PTSD, where clients with PTSD improve more with MDMA than with other behavioral therapies.
LR: I’ve seen an acceleration in progress for those clients who try psychedelic therapiesSince you spoke earlier about the role of client expectancy in treatment outcome, I’m wondering if you’ve noticed a difference in your own therapeutic presence or expectancy when doing psychedelic assisted therapy?
NH: I think I am more optimistic because I’ve seen clients who’ve really benefited from this work. I am hopeful that they will have breakthroughs because I’ve seen an acceleration in progress for those clients who try psychedelic therapies. They kind of get to the heart of their issues and dig into the meat of where they’re stuck a lot faster than they would with regular psychotherapy. I try to go in without any expectations and just let it unfold like I have no idea what’s going to happen.
LR: There’s so much research these days comparing the efficacy of various therapies, but I wonder how much emphasis you place on the role of the relationship in therapy outcome, especially when psychedelics enter the frame? Are you a technique-oriented person or relationship-oriented person, if such a simple binary even makes sense?
NH: I think I would call myself both, but it’s a really interesting question. I recently had an expert speaker come into my class to talk about CBT for addiction. He was talking about how we have all of these branded therapies, but that all good therapy really comes down to common factors and the therapeutic alliance. We need to foster a sense of safety and trust with clients, irrespective of intervention. In using psychedelics, a lot of fear can emerge, so they really need that safe space, which is where the therapeutic relationship becomes all the more important.

A Few Challenging Issues

LR: I’d like to circle back to the beginning of our conversation where you mentioned the importance of psychedelics with indigenous cultures. I don’t know the extent to which indigenous people reach out to traditional [white] therapists, but is there research on the use of psychedelic assisted psychotherapy within specific cultures?
NH: I don’t know that we’ve done enough of this. There’s a movement to try to be more inclusive, particularly in developing our approaches by consulting with indigenous communities. MAPS was doing some training to be more inclusive of therapists and clients of color. There was a paper published suggesting there are very few therapists of color or researchers in the field who are doing this work, so there’s definitely a need for more of this. We do know that MDMA and other psychedelics can be helpful for racialized trauma. Monnica Williams has done some of this important work.I have a student who did a dissertation on this topic where she interviewed clinicians in the community who were administering psychedelic assisted therapy. She asked them about motivations and workplace values in serving diverse communities. She had therapists of color and from marginalized groups, including one indigenous therapist. It was a qualitative study, and she had some interesting findings around the values that were being incorporated into their training, their identities, and then in their work with clients, and how countertransference reactions came into play. We definitely need to do more of this kind of research and perhaps even studies that look at therapy performed by clinicians who are given the option to use psychedelics like Ketamine so they can understand what the experience is like, although there would be challenging legal parameters there, especially around some of the Schedule I psychedelics.
LR: we do know that MDMA and other psychedelics can be helpful for racialized traumaAre there any counter indications for the use of psychedelics in psychotherapy?
NH: Absolutely! I would say clients who experience depersonalization, derealization, and intense existential struggles. There can be personality changes and long-term negative effects. I think it’s a small percentage, but there’s always a risk. I would say the same risks you would have with other medications and with therapy, right? There’s a percentage of people that can be harmed in some way, or for whom it can make their symptoms worse. It’s not going to be a positive experience for everyone.I think particularly along the lines of existential struggles. Some people might even encounter a higher consciousness or spiritual or mystical experiences that they weren’t expecting which can be disturbing. A person’s outlook on the world can change or they can wind up with a totally different perspective. For some people, that can be helpful, especially around end of life anxiety, where they can begin to feel more connected and safer around their own death. But sometimes, people can feel like they’ve died when using psychedelics, and that can be very unsettling. It can take a long time to integrate these kinds of experiences and to process things they didn’t necessarily want to see.
LR: some people might even encounter a higher consciousness or spiritual or mystical experiences that they weren’t expecting which can be disturbingSort of seeing someone for good old cognitive behavioral therapy and ending up at some existential cliff, looking at an abyss that they didn’t anticipate.
NH: Exactly! There’s another model I wanted to mention called the FIBUS model, or the False Insights and Beliefs Under Psychedelics. We know that psychedelics can promote therapeutic insights, but a person may experience misleading beliefs and insights that feel like they’re profound and true but might actually not be. So, one role of a therapist would be to help guide them in distinguishing what’s helpful, what’s harmful, what’s real, and what’s not.
LR: In that vein, I can see that psychedelics might not be useful with clients experiencing dissociative disorders, delusions, or cognitive impairment where they can’t rely on their own cognitive processing.
NH: Right, right! So, this isn’t for everybody. I think the clinical trials have done a really good job screening people by using strict inclusion and exclusion criteria. But in clinical practice, we could do a better job at looking at who might and who might not benefit from this, such as a person with a history of serious mental illness like schizophrenia or bipolar disorder.
LR: Are there any particular resources that you would direct readers to if they wanted to learn more about psychedelic assisted psychotherapy.
NH: There are some professional practice guidelines for psychedelic assisted therapy, like the American Psychedelic Practitioners Association and the Ketamine Research Foundation. There was also a paper published on ethical guidelines for Ketamine clinicians. I know the VA provides Ketamine therapy for treatment resistant depression in some of the Ketamine clinics they’ve set up where they have established protocols. Yale University has a program for psychedelic science and published an article on the use of ACT with psychedelics. But, I would say the training piece is always of critical importance.
LR: many of my students come into the program really clear that they want to be psyche

From Darkness to Hope: Using Compassion-Focused Therapy

The most authentic thing about us is our capacity to create, to overcome, to transform, to love and to be greater than our suffering – Ben Okri

“It’s a head-heart disconnect,” were the words of my supervisor when I asked her why my client, who seemed to ‘know’ or agree with our cognitive reframe of their traumatic experience, didn’t feel it. I’ve repeated those words countless times since—to clients, to colleagues, even to myself when reflecting on my own processes. The head-heart disconnect, when we know something intellectually, but don’t feel it emotionally.

As a newly qualified cognitive behavioural therapist at the time, I was still grappling with the difference between cognitive change at the head level versus the deeper, felt shift that happens when change touches the heart. When I encountered that disconnect in sessions, I felt helpless and confused.

Sarah: Freedom from Shame and Guilt through Self-Compassion

Many clients stand out in my memory. This is a fictional account inspired by them, but not representing any particular person in order to protect their privacy. Sarah was in her late twenties and had been grappling with intense self-blame following a traumatic online sexual experience. She would nod in agreement when we explored the lack of control she had over the situation and when we challenged the beliefs she held about herself as “naive and pathetic.” Yet, despite these rational shifts, her emotional reality remained unchanged. “I know you’re right,” she’d say, “but I still blame myself for what happened.” It was difficult to witness how much guilt Sarah carried, as though she were the perpetrator.

In supervision, I shared my helplessness, feeling as though I were missing something essential. It seemed like no matter what we did—whether we used Socratic questions, conducted an anonymous survey of other people’s opinions, or used thought experiments about whether she would judge anyone else who had been in the situation as harshly—Sarah’s guilt persisted.

My supervisor, with the same gentle wisdom she’d shown me before, said, “is it guilt or is it also shame? I think it is shame you are dealing with, and what do we do with shame? We bring compassion to shame.”

That statement, and what it helped me to learn, changed my practice and my future research interests all at once. Up until then, I’d understood compassion as an element of the therapeutic relationship, but I had not yet worked with it as a core intervention. I began to understand how emotional change requires more than cognitive insight; it requires an internal felt sense of warmth, safety, and connection.

Shame relates to how we see ourselves through others’ eyes, or a lens through which we view ourselves. It can create a powerful urge to hide, even when there’s nothing to hide from. Compassion helps counteract this by fostering a body-mind sense of safeness, belonging, and acceptance.

In the following sessions, I introduced Sarah to the concept of her compassionate self. We practiced guided imagery, inviting her to imagine a nurturing, wise, and courageous part of herself—a part that could hold her pain without judgment. At first, she resisted. “This feels silly,” she said. “Why would I give myself compassion when I caused this?”

Together, we explored that resistance, gently uncovering her fears about compassion: that it might let her ‘off the hook’ or make her weak. Over time, she began to understand that self-compassion wasn’t about denying responsibility or making excuses. It was about recognising her suffering and meeting it with wisdom and strength.

Compassion-Focused Therapy in Action

The shift didn’t happen overnight, but gradually, Sarah started to replace feelings of numbness and the extreme discomfort of shame with the underlying pain and the caring feelings she needed to heal. As part of this process, we introduced soothing rhythm breathing—a core Compassion Focused Therapy practice that activates the parasympathetic nervous system and fosters a sense of inner safety. Sarah practiced breathing slowly, finding her own soothing rhythm that settled and calmed her. This simple, embodied exercise became an anchor for her, helping her regulate overwhelming emotions and connect to a felt sense of stability.

One day, during an imagery exercise, we identified what fuelled Sarah’s shame was the isolation she had experienced at the time of the trauma. She had hidden what had happened to her from everyone close to her, while knowing that hundreds of people, possibly more, online, were aware and might be judging her. This isolation was, in part, the source of the intense shame she carried.

Together, we created a new image. Drawing on her knowledge that her close-knit group of friends did not blame her and would have surrounded her with solidarity and love if they had been there years ago, Sarah allowed herself to develop a felt sense of protection and connection instead of ostracisation and stigma. As she did so, the head-heart disconnect dissolved.

By shifting our attention away from guilt and blame toward shame and acceptance, Sarah was able to acknowledge that she had felt tricked and that it had been a painful experience. She learned to relate to her past self with wisdom, gentleness, and acceptance, replacing the internalised feelings of social danger and the urge to hide with an internalised feeling of social safeness and being deserving of care.

This experience profoundly shaped my clinical practice and research interests. I realised that, like Sarah, there may be more people who carry shame and hide because of online sexual experiences. I dedicated my doctoral research to developing a compassionate self-help programme and testing whether it might help individuals become more open to seeking support and relating to themselves in a kinder way.

There is still much work to be done in this area, but this experience taught me an essential lesson: the head-heart disconnect is not a sign of resistance or failure in therapy—it’s a sign that the heart hasn’t yet felt what the logical brain understands. Compassion is the bridge. And sometimes, we may find the work stems from the question “What would it take to feel safe enough to receive compassion?”

Transformation, creativity, love and the overcoming of suffering through compassion. This is what gives me hope in the darkness in my work at the Oak Tree Practice.

Questions for Thought and Discussion

  • Have you encountered a ‘head-heart disconnect’ with your clients? What interventions helped bridge this gap?
  • How do you distinguish between guilt and shame in your clinical work, and how might compassion help address each?
  • How might incorporating embodied practices, like soothing rhythm breathing, support clients in connecting with a felt sense of compassion?
  • Are you able to find compassion for yourself when you feel helpless at times? What helps you to do so?

A Day in the Life of a Very Old Therapist

The day had not started well. I woke at 3:00 a.m. with leg cramps that wouldn’t go away. I quietly got out of bed, careful not to disturb my wife, Marilyn, sleeping deeply next to me. To relieve the pain, I took a hot shower until it turned lukewarm, then dried myself and returned to bed. The heat had soothed my muscles, and the cramps had subsided somewhat. I tried hard to go back to sleep. But when it comes to sleep, “trying hard” is always doomed to failure. Insomnia has been my kryptonite for decades. I had been tapering down my use of sleeping pills, reluctantly, as my doctor suspected they were accelerating my memory loss. I tried some breathing exercises. Time after time I inhaled, whispering “calm,” and exhaled, whispering “ease,” a meditation practice I’d learned years ago. But it was to no avail—the slight calming brought on by the utterance of “ease” soon morphed into anxiety, another old nemesis. I shifted my attention and focused on counting my breaths. A couple of minutes later I realized I had forgotten about counting and my ever-restless mind had wandered elsewhere. A year earlier Marilyn had been diagnosed with multiple myeloma, an insidious cancer of the blood plasma. She was in the midst of a series of chemotherapy treatments, which had yet to result in any significant improvement. Her warmth and the sound of her breathing were so familiar, my beloved bedmate for many decades. But now something new had joined us, this sinister illness, doing battle within her. I was pleased to see her resting peacefully that night and gently traced the lines of her face in the dim light. We’d been together, inseparable, since middle school. Now I spent the majority of my days worrying about her and trying to enjoy the time we still had together. Nights I spent worrying about a life without her. How would I pass the time? With whom would I share my thoughts? What loneliness awaited me? Noticing that my mind had strayed so thoroughly, I gave up the idea of getting back to sleep. I checked the clock and noted, to my surprise, that it was already 6:00 a.m. Somehow, when I wasn’t paying attention, I must have nodded off for a couple of hours.

Jerry: What’s Not to Like?!

After breakfast, I looked at my schedule. I had only two appointments that day. The first was a termination, the final session with Jerry, a patient whom I’d been seeing for one year. Jerry was a successful lawyer in his 40s who had come to therapy seeking answers after his girlfriend of two years had left him, the third in a string of failed relationships. “I can’t see why,” he’d said during our first meeting. “I’ve got a great house, a great job, tons of money. What’s not to like? I mean look at me.” He’d gestured at the well-tailored, clearly expensive suit he was wearing. Jerry was not what you’d call warm or reassuring. He was demanding, and often critical. He groused about my fee, suggested I get a better gardener to tend the plants along the walkway to my office, and, once inside, disparaged the artwork on the walls. He had come to me, he told me repeatedly during our first few meetings, because he’d heard I was the best, and he deserved the best. This was soon accompanied by a look of disappointment in his eyes that I hadn’t swiftly cured him of his troubles. Clearly, that look said I wasn’t the best after all. And yet, over time, we’d had success. What had worked? We had two important factors going for us. First, Jerry was highly motivated to make change in his life. Despite his prickly exterior he realized that he was in some way contributing to his relationship problems, and he was eager to put in whatever work was needed to address this. I had to slow him down, let him breathe, and see that part of the problem was the immense demands he placed on himself and me to magically “fix” him. “Imagine being your girlfriend for a few minutes,” I suggested. “What if you weren’t ‘the best,’ if your garden path weren’t expertly tended, if you didn’t look perfect on Jerry’s arm? Would Jerry love you and support you nonetheless?” “I doubt it,” he said. “Instead he would criticize you constantly, and you’d end up feeling crappy about yourself and your relationship. And . . . ?” I left the question hanging in the air. Jerry considered for a moment. “And you probably wouldn’t stick around,” he said finally. This realization, that being demanding and often unkind severely impacted his relationships, clicked for him. He could see the role he was playing and started to change. In the weeks that followed, he set about in earnest to improve. He began to catch himself whenever he was overly critical of me and whenever he complained that others in his life were inadequate. He took more responsibility for the way people, especially potential romantic partners, responded to him. And he set about curbing his sharp tongue. Jerry’s fierce drive to change himself was essential to the progress he made, but it was not something I could control. I could influence another factor, however: the powerful relationship he and I developed. From the beginning, Jerry had tested me: Why wasn’t my taste in art better? Where was my fancy car? Why hadn’t I been able to fix him all the way yet? Through all these barbs, I’d stayed in there with him. I’d been empathetic and warm, and also willing to push back when it seemed a challenge would do him some good. Gradually he softened up and stopped competing with me. As our relationship grew, his bristles felt less like attacks and more like witty, playful jabs that I could parry or call him out on. Little by little we built a strong connection, a “therapeutic alliance” as we call it in the field. This alliance, building it and using it, is the most important factor in my therapeutic approach. In what now seem like countless lectures, and numerous writings, I’ve stated that “it is the relationship that heals.” What drives change is not a worksheet that the patient fills out, a brilliant question the therapist poses, or a behavioral change the patient must chart daily. In my approach to therapy the honest connection between the therapist and the patient is the medium through which we discover, learn, change, and heal. Jerry and I had made excellent progress using that relationship over the course of the year we had together. He became friendlier, and when he occasionally still snapped at me with a disapproving comment, I would point it out. He learned to apologize and then, bit by bit, catch himself before saying something acerbic, and often, quite endearingly, replace such comments with attempts at compliments: “The lemon trees beside the path are looking much better this week” or, “You know, that statue of Buddha on your bookshelf is actually more interesting that I thought.” I looked forward to our weekly meetings and would be sad to say goodbye when today’s session ended at 11:50. But, for reasons that will become clear, we had agreed upon a one-year time frame at the beginning of his therapy. He had certainly made the most of it, and we were both hopeful that his future relationships, romantic and otherwise, would be richer and more satisfying.

Born of Necessity: One-Session Therapy

The second session on my schedule that day would be very different. It was with a woman named Susan, whom I planned to see only once. Only once!? How could I do anything resembling effective therapy in a single session? And why would I want to try? To explain, I need to rewind my timeline a bit to provide context. About five years before this, when I was in my early eighties, I noticed that my memory was starting to fail. I had always been a bit forgetful, misplacing my appointment book, glasses, or car keys with regularity. This was something different. I began to encounter people I recognized, only to have their names elude me. Occasionally I’d stop in the middle of a sentence, stuck searching for a familiar word. And, more and more frequently, I would lose track of the characters in movies Marilyn and I were watching. As this progressed, I began to think that, perhaps, I was no longer able to offer the long-term therapy I had for nearly 60 years. Instead of open-ended therapy that sometimes lasted three or four years, I decided to set a 12-month time limit, agreed upon in advance, for all new patients, hence my agreement with Jerry. I approached this new framework with some sense of loss, as it represented a major shift in my work, one derived from necessity, not desire. But soon curiosity, and my wish to continue being helpful, won out. Ultimately, I found this to be an agreeable solution. If I chose my patients carefully, I was almost always able to offer a great deal during our year’s work together. With some patients, in fact, there was an increased sense of urgency, and thus motivation, thanks to the time limitation. This had worked well, both for me and for my patients, for the last five years. Then around the time I was 87, I started to find I was more and more reliant on the summaries I recorded after each session to remember the details of my patients and that, even with these notes in hand, their faces and problems occasionally seemed alien. I was faltering, and I began to question the value of the care I was able to provide. I felt I still had much to offer, but it was clear that I could not, in good conscience, engage in ongoing work with patients, even limited to one year. And yet, and yet . . . the thought of no longer practicing was dizzying. Sharing with my patients, aiding them through their darkest thoughts, and joining them on journeys of discovery—for the majority of my life this had been my daily work and my calling. Who would I be, if not a psychotherapist? Truth be told I was angry and deeply frightened. I was not ready to feel this old, this useless. The thought of leaving therapy behind felt like resigning myself to rapid decline, followed soon after by my inevitable death. I pondered this dilemma. I had to put my patients’ needs first, so doing long-term therapy was out. But after so many decades of practice and research, I knew I had developed levels of insight and expertise that were rare, and still potent. Plus, I felt the personal need to continue contributing in some way. How could I offer something—enough to be helpful to patients, enough to keep myself engaged in the world—while also not endangering anyone? I came up with an unconventional idea. Perhaps I could meet with people for one-time, one-hour, consultations. During that hour I would offer everything I could—insight, guidance, a warm accepting presence—and then, if appropriate, refer them to a colleague who seemed well attuned to their particular challenges for ongoing treatment. The idea of such short-course therapy was profoundly foreign to me. I have always seen therapy as a longer-term endeavor—not the endless years of old-school psychoanalysis, but often several years, long enough to help patients search for better understanding of themselves and make meaningful change in their lives. The question of how I might be effective in single sessions could be an interesting experiment, if nothing else. For some time after coming up with this idea I vacillated between skepticism—Was this just a way of forestalling my own decline rather than offering anything truly beneficial to the patients?—and excitement—I knew I had skills honed to an uncommon degree and had been helpful to many, many struggling people, which undoubtedly had some value. I took the time to stare carefully at my own feelings. It was possible my pride would resist accepting this lessened importance. And yet I knew that, at some point, I would need to accept my decline and pass the torch fully to the next generations. I honestly did not know what this experiment would yield, which itself was intriguing. Thus, I began a new adventure of short therapeutic encounters, and investigation of what might be most helpful in a far briefer time frame for creating change than I had ever before conceived as effective. I announced my retirement from ongoing therapy, and my offer of these single-hour consultations—either in person in my Palo Alto office, or online—on my Facebook page. Within hours, requests for appointments started to pour in, far more than I’d expected. They came from all over the world, English-speaking countries of course, but also many other places, too—Turkey, Greece, Israel, Germany—as Zoom had collapsed the barrier of space. And they came from people in many stages, and to some extent many walks, of life. This single-session format, I quickly realized, would allow me to work with many people I had never been able to reach otherwise, people for whom ongoing therapy with me was prohibitively expensive. It was clear this would be a very interesting shift from the relatively traditional private practice I’d led from the lovely Spanish-style cottage in our backyard over the previous 20 years, and for decades before that working in the psychiatry department at Stanford University. Would it be effective for the patients? Would it feel satisfying for me? Only time would tell. It would certainly be new, and at my age, newness was nothing to scoff at. This, then, was how I found myself on that particular morning contemplating my first single-session consultation with Susan. I was excited yet concerned. I am not always filled with second-guessing, but after a restless night spent with my darker thoughts about Marilyn’s failing body and my own weakening mind, I had my doubts. How much good would I be able to do, really, in these short encounters? I had several things going in my favor, I reminded myself. First, my particular therapeutic approach has always been heavily focused on using what I refer to as the here and now. By this I mean that the interactions the patient and I have in the moment are the essential tools of change. Whatever problematic tendencies a patient has—their insecurities, their neuroses, the things they do that get in the way of their relationships with others—these are all likely to show up in the therapy sessions, through their interactions with me. Jerry, who had to have the best therapist, is an excellent example. Even though he came to me for help, and thus presumably began our work with a positive opinion of me, he constantly criticized me in many ways. Time and again I brought his awareness to this tendency. At first, he attributed the comments to my inadequacies, that I was overly sensitive and jealous of his financial success. But little by little Jerry began to see that he behaved this way elsewhere in his life as well, and that it impacted his relationships, and his happiness. This here-and-now approach is largely ahistorical, meaning that it does not rely a great deal on patients’ personal histories. Rather than spend great amounts of time digging through patients’ backstories, time which I would not have in these single sessions, I focus on the present, tuning in closely to every word and gesture they offer, as well as those that they omit. I was confident this approach would allow us to get into the serious work quickly. It also had the great benefit of dove-tailing nicely with the limited capacities of my faltering mind: remembering the past was increasing challenging, and recalling copious details about each patient was beyond me. But being present right here and right now, I could do very well. A second thing I had going for me was that nearly all of the people who requested consultations had some knowledge of me in advance. Over six decades I have written many books, including influential textbooks for student therapists, philosophical novels, and books of stories like this one that aim to demystify the process of therapy. Through these I have had the good fortune to become a well-known figure in the field, and most of the people who had requested consultations thus far had mentioned reading at least one of my books. It was clear from most of their emails that they saw me as having some amount of wisdom and power. I took this with more than a few grains of salt, knowing that we all sometimes seek reassurance from silver-haired elders. In fact, there was a small voice inside me, adolescent and rebellious, that wanted to shout out “I’m not that old yet!” and cancel this whole undertaking. But for the most part I was happy to play the role of guru on the mountaintop, realizing that I might be able to use the wisdom with which people imbued me and leverage that power to help them change.

Susan: Trying Out My New Strategy

Such was my state of mind as I settled into the chair in my office and opened a Zoom window to speak with Susan, a 50-year-old schoolteacher from Oregon who was deeply depressed. We quickly greeted each other, and I explained that I would only be able to see her one time, as noted in the Facebook posting, and that I hoped to be as helpful as possible. It felt very strange saying all of this, and I think I was laying out the groundwork as much for myself as for her. She nodded, then launched into her tragic story. Two years ago, at about 10:00 on a Thursday night, she had opened the refrigerator and noticed that the large cherry pie she’d made was nearly gone. She had planned to serve it the following evening to close friends who were coming over for dinner, but now it was reduced to a sliver of crust oozing deep red filling. What had happened to the pie? It was no mystery: no doubt Peter, her husband, must have eaten it. It wouldn’t have been the first time. “That gluttonous slob!” she exclaimed, bursting into tears. The fate of her cherry pie was too much. The last straw. She had to be at work until 5:30 the next day, an hour before her dinner guests would arrive. She would barely have enough time to get dressed and set the table, let alone bake another pie. The disrespect! Brimming with anger, she’d stomped upstairs and confronted her husband, who was already in bed. They argued for 10 minutes. Tempers and voices rose. He told her he had always been the main support for the family (not true! she protested) and that he’d eat any pie he damn well pleased. She retorted that he was an obese hog who was going to gorge himself to death. He told her to sleep on the couch and pushed her out of the bedroom, slamming and locking the door. “Fine,” she yelled. “The last thing in the world I want to do is to share the bed with a selfish glutton.” The next morning, her hard knocks on the bedroom door and loud calls to her husband were returned with silence. Finally, she and her two daughters broke into the room to find him lifeless in bed. They called emergency services, and when the medics arrived, they declared he had been dead for several hours. When police officers arrived, they sealed off the house and searched every room. Susan and her daughters were interviewed at length—clearly the police were considering the possibility of foul play, going so far as to infer that the pie might have been some sort of weapon. “How awful,” I said. “And how much have you recovered from your husband’s death?” “I’d say zero,” Susan replied. “No recovery. None at all. Perhaps I’m getting worse. I miss him so much, and I am racked with guilt about what I said to him that last night. And I’m also mad at him for leaving me. I cry all the time and now I’m the one who can’t stop eating and I’ve gained 60 pounds. I saw a psychiatrist here recently and he said that I was, in some way, identifying with my husband. What help was that? I’ve developed terrible skin problems and I can’t stop scratching myself. I can barely sleep, and when I do, I keep dreaming of Peter. When my daughters leave for college in a month, I’ll eat by myself in restaurants and people will look at me and, I’m sure, pity the dumpy fat woman eating all alone.” She caught her breath loudly, perhaps holding back tears. “That’s it, Dr. Yalom, I’ve unloaded on you. That’s everything. I don’t know what else to say.” She slumped back in her chair. “You know, Susan, I’ve worked a lot with women who have lost their husbands and your account of what you’re going through is not unfamiliar to me. Let me ask you something. You say your husband died over two years ago. Can you compare your condition now with a year ago? Is it different? Is it less painful?” “No. Just the opposite. That’s what torments me; I think of him more and more, and when I’m alone in the house I’m terrified of being sad and lonely forever. Damnit. It’s not fair.” “Grief always lessens, but it takes time. Usually, the course of grief goes through a predictable cycle. It’s most keen the first year when you experience the first birthday, the first Christmas or New Year’s Eve, without your spouse. But then, as time passes, the pain lessens. And later, when you go through the cycle of the special days for the second time, it becomes markedly less painful. But that isn’t happening for you. Something’s blocking you and I have a hunch it’s related to your anger.” Susan nodded vigorously and I asked, “Can you put that nod into words?” “I have no words for it, but I feel you’re right. It’s confusing. I’ll be drowning in sadness and then, suddenly, all I feel is intense anger.” “Let’s focus there, on your anger,” I said. “Just let your mind go there and for just a couple of minutes please share your thoughts with me. In other words, think out loud.” She looked puzzled and shook her head. “I don’t know how to start.” “It might be easiest to start at the beginning. Think out loud about your very first encounter with anger.” “Anger . . . anger. The first time I felt anger was with my first breath—at my birth.” “Keep going, Susan.” “There was anger when I was born. My mother’s anger. I remember her saying time and time again that she wanted a boy and if I had been a boy, she would have stopped there. She just wanted one child, and it wasn’t me. She let me know about it over and over.” “So you spent some of your early childhood hearing about how your birth, your very existence, inconvenienced her?” “Oh God, yes, she made me feel it all the time. Damn her for that!” “And your father?” “Worse. Sometimes even worse. His favorite joke, which he never tired of telling, was that the nurse made a mistake when I was born and brought the family the afterbirth instead of the baby.” “Ouch. Oh, Susan, how dreadful to have your father joke you’re not a person, that you’re a placenta.” “He thought that was such a funny joke. And my mother agreed. I’ll be honest with you. I know it’s unnatural, but I hated them. Both of them. My father especially. He wouldn’t pay for my college. He wanted me to work as a secretary in his store instead. So, I left home early and had to work my way through school.” She paused, letting these deep emotions swirl through her. After a moment, while she was still in that open tender place, I pushed her to go deeper. “And the anger toward your husband? Tell me about that.” “It wasn’t like my anger toward my father. Certainly not at first. I met Peter after I left home, when I was in college. We were sweethearts and he was good to me. His parents were well off, and he always had money. Whenever I was strapped, he’d help pay my rent or buy groceries. And I’d never had that kind of help or affection before. “Peter’s father was a politician and wanted him to follow in his footprints. Peter had the charisma—he could be incredibly charming and fun. But he was lazy, a poor student who gambled whenever he could, and eventually flunked out of school. He became a guard at a local bank, a job his father got him. He never made enough to support us or, if he did, he secretly gambled it away. Either way, he made it clear that I always had to work. I never took time off, except three-month maternity leaves when I had our daughters. I could never become myself, never be the kind of mother I wanted to be for my girls. Instead, I worked, worked hard. And you know what? Just a few days before he died, he told me he’d gotten too heavy to be a bank guard, and they’d moved him to office work, which meant a pay cut. He said it wasn’t a big deal, and I got so mad at him because he didn’t even care about his health. And probably I would have to find a second job to pay our bills.” “I hear lots of anger rumbling, Susan,” I said. “A husband who never recognized all the work you did, who never valued your needs and wants. A cruel father who saw you as either a problem or a punch line. And a callous mother who never wanted you, never offered love. Now they are all gone— mother, father, husband—all gone. And a good bit of your life has gone by as well. Oh, Susan, no wonder you’re angry. Who in your situation wouldn’t be enraged? I know I would be.” She nodded as I spoke. “How does it feel to hear me say that, Susan?” “Hard. Right. But hard.” “I want to take a moment to look at all you’ve accomplished in spite of them: two loving children, a valuable teaching career, and so much more. You’ve done so well, Susan.” She swallowed, taking that in. “I haven’t really been able to talk to anyone about this,” she said. “Everyone wants to remember Peter as a good person, remember us as a good couple. No one wants to talk about the darker side.” “Thank you for sharing it with me. Your anger is only human. Yet I suspect it presents a big problem. We feel we should never speak ill of the dead, that it’s wrong or somehow disrespectful. Does this ring true for you?” She nodded, tearing up. “Well, I disagree. Anyone in your situation, with the experiences you’ve lived, would have the angry feelings you’re experiencing. You’re judging yourself far too severely.” Susan was sobbing now, and I waited for her to calm down and breathe. “I don’t know what to do, how to stop it,” she said finally. “I’d like to remember so many other things about our life together. I really did love him. But now I’m just so mad.” “I suspect that as you accept your anger, accept that it is appropriate and you have good reason for it, those other memories will return. But it will take time.” “Maybe.” She nodded. “I hope so.” Then, in my most solemn voice, I continued. “Susan, I’ve listened carefully to everything that you’ve told me, taken it all in and pondered it carefully. I want you to know that I pronounce you innocent. Please hear that: I pronounce you innocent! You deserve a good life. You’ve worked hard, you’ve been a good mother, a good wife, and you deserve some happiness now.” She smiled through her tears, and I finished the session with a keen sense of having been helpful. I gave her the name of a therapist with whom she might continue. Clearly this old man still has something to offer, I thought on reviewing our meeting! I received a follow-up email from her a couple of weeks later which confirmed this. She thanked me for helping her, writing:

I won’t forget the moment when you said something like “apparently your mother and your father were not good parents, but even so you’ve done extremely well in life . . . I admire you for that.” You gave me a warm feeling of being seen and respected and supported at the same time. Also your pronouncing me innocent. I will never forget that remark, and the smile on your face as you said it. I will keep the sound of your voice in my mind and my heart.  

Thinking about it later that night, I felt this was one of my best therapy hours ever. I resolved to keep offering these unusual one-hour sessions, to see whom I could help and to glean as much as I could from the process. Equally important, I would share what I learned. Earlier, speaking of my desire to help patients, I left out the other major aspect of my professional life, that of teacher. Most of my work as a writer has been in the service of teaching young therapists and others practicing, or entering, therapy. Furthermore, many of my thoughts have gone against the grain, countering major trends in the field. While psychiatry has increasingly pushed medication as the solution to mental illness, I have championed human connection; while psychotherapists have increasingly been taught approaches that aim at symptom reduction, like cognitive behavioral therapy or solution-focused therapy, I have embraced curiosity and deep personal exploration. This dedication to sharing what I’ve learned has always been a powerful force driving me forward, and I began to feel that impulse again when thinking of Susan and imagining many rich brief encounters ahead of me. I would undertake this project not only to help those who seek consultation and to remain engaged myself, but also to pass on what I learn. Full book available here. From the book HOUR OF THE HEART by Irvin D. Yalom and Benjamin Yalom. Published on December 10, 2024 by Harper, an imprint of HarperCollins Publishers. Reprinted with permission.

Nothing Left to Give: A Psychologist’s Path Back from Burnout

Journal 1: Warning Signs-15 January 2021

I have nothing left to give anymore. I thought the break over Christmas may have helped, but it hasn’t. I am still exhausted, more than ever, and I can’t believe I am saying this, but I feel like I am just going through the motions of caring, that I am “pretending to care,” which is so horrific to say. I do care for my clients; I’m just finding it hard to do this work.

It gets worse. I had a session today with a client. A client with multiple current crises and past traumas still left unprocessed, a presentation making up most of my caseload. This session has floored me.

I am ashamed to admit that my mind was almost completely disconnected from the client throughout the session. My mind was all over the place:

I don’t know if I can help this client anymore.

I wish this client would do what will help instead of just talking about it all the time.

I feel so out of my depth.

I don’t know if I can keep doing this kind of work.

I can’t leave; so many people depend on me.

I feel so trapped.

I need to focus on my client right now. It’s not okay that I’m caught up in my shit.

It is one crisis to the next for this client.

It will never end.

I don’t have anything more to give to this person.

I feel like I’m on autopilot. I’m here, but I’m not here.

It’s hard to know that this client will be safe.

This client deserves a psychologist that can help.

I want this session to end.

I have never been that detached before, and I know I have let her down. A thought popped into my head soon after her session with me ended – you are this client!

I was immediately taken aback as, on paper; we are nothing alike, and we don’t share similar pasts, current life situations, personalities, traumas, or even approaches to life. Despite my immediate disagreement with this thought, it repeated itself. . . you are this client!  

Right here, right now, while reflecting on this session, I still find myself rejecting this thought, this knowing. I’m not this client. My mind is saying:

This client’s experiences, past and present, are a lot more complex than mine.

This client has experienced multiple traumas, depression, and work-life stressors.

I don’t even have half of that…but maybe the similarities lie in how the suffering presents, not the causal events.

Now, this has made me stand up and listen. Despite our notable differences, our suffering does have similarities. We are both going around in circles, staying stuck in situations that are not healthy for us. We both have lost pleasure in our lives in what we do. We withdraw, keep busy or turn to substances (food for me) to cope. We both continue to push ourselves to do better and be better both professionally and personally. We both find it hard to talk about our problems to others. We keep it hidden. We are constantly irritable and exhausted. We both have very high standards and expectations of ourselves. Our worth is caught up in what we do for a living or who we are for other people. We are profoundly insecure and, at the same time, desire safe and supportive connections. We both feel disconnected from who we are. We both suffer from bouts of depression and anxiety. We both dream of escaping, breaking free from our suffering. And we are both beyond burnt out and have no more fucks to give. We are both feeling trapped in our lives.

Shit! We are alike.

Well, what do I do with that now?

I know what I have advised the client to do, and if our sufferings are similar, I need to either step back from my career as a clinical psychologist or make some significant changes to how I’m doing things right now. I need to prioritise care for myself.

But am I that bad?

Maybe this is all just in my head.

It’s just too much even to fathom right now.

Too many people need my help; I need to keep pushing through.

I need to focus on doing what is best for the clients.

Wellness Practice

Don’t shove down any insights you may be experiencing. Don’t question it. Sit with it. Pay attention. You can do so with a daily check-in.

Daily Check-in

Answer the following questions to help you check in with yourself: What is happening for me right now? What am I feeling? What is on my mind? How is my body feeling? Do this regularly to help you gain self-awareness and be in a better position to respond to any difficulties. You can even start a journal to capture these daily check-in insights.

Journal

Start a journal to record your wellness practices throughout this book. The writing process in and of itself can offer therapeutic qualities, and it helps us slow down, pay attention, look in, engage with ourselves, and process our experiences.

Journal 3: Severely Burnt Out-3 March 2021

Since my last journal entry, I have left my job and career behind. I feel deeply ashamed and guilty for leaving my job as I did. It happened so suddenly, so quickly; no one saw it coming. In some ways, even I didn’t, although I had thought about it quite a bit. A week ago, on February 25, 2021, my mind and body spoke for me—“I can’t do it anymore.”

You are not well enough to take care of others right now. Leave this for those who can. Your job is to take care of yourself, and leaving your work is caring for yourself and others.

On that day, I showed up to work at the psychology practice where I had been working for almost five years, Zest Infusion. Like many preceding days, I felt completely and utterly exhausted, emotionally, mentally, and physically. Along with this feeling, I felt a sense of dread, hopelessness, fear, anxiety, self-doubt, and a lack of care to give to anyone.

I had set up a meeting to talk to the practice director, Dr Ilze Grobler regarding the need to change my schedule to support my well-being. I was still struggling with what I wanted to do. Reducing my client load or leaving meant that clients would suffer, but if I kept working the way I was, I would suffer. Both decisions involved suffering; no one would win. I remember feeling very anxious to talk with Ilze about it all, not because of what she’d say (she’d always been compassionate) but my fears of what this meant for everyone—for clients, me, and Ilze’s business.

My heart was heavy, and my mind was too. I knew I wasn’t okay, and something needed to change, but I was battling my need to care for others and myself. I didn’t realise how bad my health was until I was in front of Ilze, letting her know what was going on. Ilze’s compassion made me feel safe enough to connect with the depths of my suffering and listen to what I needed. She mentioned that she knew of a psychologist in a similar position who needed to take time away from the profession to care for herself. At that moment, I admitted I couldn’t do it anymore. I couldn’t push. I couldn’t be present for my clients. I couldn’t adequately put my pain aside and be present; worse, doing so would create more suffering for everyone. I had to stop, and I had to stop then. Ilze’s compassion helped me to find what I needed at that moment and to express it.

I recognise that my awakening to the depths of the pain and suffering I am experiencing has happened because of two compassionate women in my life, Dr Ilze Grobler and Dr Hayley D. Quinn. Without these women, I wouldn’t have been able to take the steps I have made so far. It was Hayley and Ilze who told me…

You are not well enough to take care of others right now. Leave this for those who can. Your job is to take care of yourself, and leaving your work is caring for yourself and others. 

Maybe I can believe, in time, that it is okay to take care of me.

Wellness Practice

Surround yourself with empathic, non-judgmental, warm, kind and empowering people. If you haven’t got them, find them. You will know you’ve found one when you can be yourself around them. If there is not someone in your immediate environment (friends or family), seek out a professional. A mental health professional (e.g., psychologist, counsellor) is trained to provide a safe, secure and supportive environment, so you can be free to be yourself, to share your pain and suffering.

It will depend where you are in the world with how you go about this and what professional to see. In Australia, it can be helpful to see your doctor first, a doctor who specialises in mental health, who can do an assessment and assist with referrals to appropriately trained professionals. You can also visit the following link https://www.healthdirect.gov.au/mental-health-where-to-get-help. This page will help guide Australian readers on the next steps to link with a professional.

If you find this whole process daunting, that’s okay, it is. Bring a friend, someone you trust, so they can support you through the process. They don’t need to know what to do; you can find out together. This way, you don’t have to be alone.

Journal 4: Letting People Down-10 March 2021

I see my burning out and inability to work as being pushed off the side of a cliff, free-falling into the space below with microscopic moments of being lifted, flying to somewhere unknown, feeling scared and free simultaneously.

The past couple of weeks have been extremely challenging. I have spiraled in and out of feeling relief, quickly followed by crippling fear, guilt, and shame. I constantly think that I have let others down (Ryan, colleagues, and former clients) and that I’m selfish for prioritising my care over others. The fear, guilt, and shame are currently overtaking any feelings of relief.

The feelings of fear, guilt, and shame were most substantial when people I care about started to find out I was sick and no longer working. The day the email to my clients and colleagues went out to let them know I had left was particularly gut-wrenching. At first, I couldn’t look at the emails from clients and colleagues. The shame and fear I felt then wouldn’t allow me to read them. I feared they would hate me. I feared harm would come to them; I believed I failed them.

Further, I felt guilty for the position I put them in—not having regular, familiar, and reliable psychological care. I feared they would be angry with me, hurt, and that they’d believe I abandoned them. Or I felt like I had abandoned them. I can’t shake these feelings and thoughts; they are constant companions.

Despite how I feel or think, I must confront this fallout in a way that supports both myself and those affected. I don’t want to hide. I’ve done that before. In my late teens and early 20s, I was experiencing what I later came to recognise as clinical depression. During this time, I worked at a local restaurant fulfilling both waitressing and administrative roles. One day, I upped and left and never returned. I didn’t speak to anyone from work, friends, or family. Those close to me at the time knew something was up, but I didn’t talk; I didn’t know how back then. I felt deeply ashamed for being sick; I believed I had no reason to be. The shame kept me silent. I’ve learnt a lot since then. I’ve learnt to speak up, front up, and recognise that anyone can become mentally unwell and that there is no shame in being mentally ill. I’m thankful for the experience of clinical depression for this learning experience.

This time I want to be the person who fronts up to the fallout, speaks up, and honours the responses from colleagues and clients for my abrupt departure, doing what I couldn’t do all those years before. With this intent, I told Ryan and my family that I was sick and started reading emails from clients and colleagues.

Reading my former clients’ email responses has been particularly tough. I have felt many emotions—grief, loss, gratitude, support, compassion, kindness, and despair. Most of the responses were compassionate, demonstrating concern for me, sadness for not receiving psychological care from me anymore, and non-judgmental support; very few clients responded with what I feared (i.e., feeling abandoned, angry, and let down by me). I wasn’t mad at those who felt this way; I was glad they could express their feelings. It was a difficult time for all.

Despite the overwhelmingly compassionate responses from everyone, right at this moment, I still feel weighed down by it all. I still believe I have let my former clients down; I should be capable enough to support them and hold up my end of the relationship. I want it all to be over. I want to crawl into bed and not deal with it. I still worry about the potential harm that may come to my former clients due to not having a psychologist until they secure a new one. I worry about the workload now on the Zest Infusion team, and I feel bad for no longer financially providing for my family. I feel overwhelmingly responsible for everyone’s pain and suffering at the hands of my actions. I feel like I’m drowning. It’s like it will never end.

What keeps my head above water is the continual support from those who genuinely love and care for me—Ryan, Jayd, Hayley, and Ilze. I love when a message pops up from Hayley or Ilze to check in to see how I am going and knowing I can speak with Ryan and Jayd when I am having a bad moment. I am fortunate to have their support. It gives me the strength to continue putting my needs first, back away from being the carer for others, and allow others to care for me. It helps me to acknowledge that I’m sick and not in a position to care for anyone right now, and it would be wrong for me to do so. They are helping me focus on my choice to care for myself while also doing what is needed to finalise work. For example, setting and sticking to a workable schedule for doing the background work necessary to assist clients in being seen by another psychologist (i.e., writing reports to their doctors, handovers to new psychologists, and answering client emails) and scheduling an appointment for myself as soon as possible with a psychologist. I’m focusing on what is necessary to finalise the care for others whilst also taking care of myself.

I’m in awe of the overwhelming support from former clients for my health and well-being. Many of them have said in their messages to me something to the effect of “if there is anything you have taught me, Shannon, it is the need to prioritise care for self.” I’m so happy they have learned this from me; it helps me to know that they have learned a valuable healthcare strategy, care for themselves. More than this, everyone’s responses (including the clients) showed me that even when what you have to do affects them, it doesn’t mean they will hate you. They may express their hurt but also offer care and kindness. I’m grateful to have been surrounded by such wonderful human beings. The free-falling stopped in these moments, and I felt lifted and supported in this place of the great unknown.

Wellness Practice

You can’t change what has happened. Your illness will impact others. This doesn’t mean you are a “bad” person; it means you are human.

Acknowledge and show compassion for any undue impact on others. For example, “I’m sorry for the impact leaving work has had on you.” Don’t sacrifice your needs to take care of others right now. You will only do further harm to yourself and to the very people you don’t want to hurt.

Turn your attention to your recovery. Do the work so that this doesn’t happen again. What is one small step you can take today in service of your recovery? For example, make an appointment with your doctor to discuss a referral to see a mental health professional, prioritise rest, make time to catch up with a trusted friend, or spend time in nature.

Journal 5: Uncertainty-16 March 2021

At some point recently, I lost that lift and started to free fall again, and this time I was aware I had no place to land. I was fucking freaked out. I was staring into the abyss, and there was nothing. I have never jumped off a cliff; I always have a destination. I’m a planner; I always have a plan.

The free-falling recommenced when I was wrapping up the last bit of administrative work I had to do for my former job. This work has taken a few weeks, working full-time hours to complete, and it has filled my days and kept me from seeing the naked abyss of my life, a protector in some ways.

So, of course, I started to look for work frantically. Honestly, I have been looking for work on and off before then. If you were a fly on the wall for the past few weeks, you would have seen me sitting at my desk, editing my resume, signing up to major job sites, and applying for jobs after finishing a full day of client report writing. You would have heard a few thoughts about what I should do inside my mind. One of them was to do something within my expertise. Another was to do something entirely different with little to no responsibilities. I even thought about not working. My favourite idea was to take off in a van around Australia. At some point, I recognised that my mind and body were busy finding a place to land (i.e., a plan).

I talked about this with Ryan just the other day. I promised to talk more with him, especially when I get caught up in my head about something and take actions that are not helpful to me. Talking with him helps. I know he cares for me and has no qualms about being honest with me if what I do is not in service of that. I wouldn’t share with him or anyone in the past, and I would end up with a messy yarn of irrational thoughts, beliefs, and behaviours that only made me sicker. Talking it out with him helps untangle some of that yarn and keeps me from losing my shit. This time was no different.

On one of our daily walks with our puppy Hana, I shared with him what was happening in my mind and that I had been frantically looking for work, feeling the pressure to earn a living and pull my weight. Just voicing what was going on in my head helped. His words of encouragement, love, and support to do whatever helps me be healthy and happy have helped untangle some of this story and guided me to the firm decision to take 12 months off from working in the mental health field, stepping away from a caring role. I’m very thankful I decided to talk with him about my current messy thoughts; it has led to a critical decision.

This decision felt so good. A weight was lifted from my shoulders. My gap year began. A gap year with a stark difference; one focused on getting better and doing what is necessary to heal.

Gap Year Rule

To engage in activities that meet my needs. Care for self without engaging in work involving providing mental health care to others for at least 12 months.

While this decision and Ryan’s support have helped significantly, I realised I still didn’t have any place to land; I didn’t have a plan. I was still free falling into the unknown, uncertain where I might land. The view was cloudy, messy, unclear, scary, and foreign.

At some point (not sure when), the clouds cleared. I don’t know why; maybe a combination of journaling, talking with Ryan, and time. Whatever the reason, it became clear that I was pushing myself to find land (i.e., a work plan) because I believed doing so would help me feel safe, secure, and in control. I was looking for certainty. However, pushing myself to find a work plan only created more suffering. I needed to stop pushing myself to have a plan and instead let go, be present in the sky, this place of uncertainty, the great unknown. If I remain still, present in this place, I believe the answers will come at some point, and the plan will unfold. A plan that will likely be healthier and much wiser than the one made from pushing.

So, the plan is to be still and ignore the urge to push; to focus on caring for myself— meditating, spending time in nature, hanging with loved ones, stand-up paddle boarding, hiking, and stretching, whatever supports me at that moment.

Wellness Practice

When everything stops, it can be unnerving. Sending you into a tailspin of complicated feelings, thoughts and body sensations, often unexpectedly, especially if you are a high achiever.

Uncertainty is a tough place to be in, and reaching certainty in a moment isn’t always possible.

Instead of dealing with this all alone, talk about it with trusted friends, family or a professional. Speak it out loud. When we voice what is going on, it supports processing our experiences.

Have you ever talked something out with someone, and they haven’t said anything particular back to you, just sat there and listened, and afterwards, you have felt better, maybe even knew what to do next?

Talk with someone. If you don’t have someone, talk it out with a therapist, or write it in your journal.

***

As the sole rights holder and author of Nothing Left to Give: A Psychologist’s Path Back from Burnout, I Shannon Swales hereby grant permission to Psychotherapy.net to reprint the journal entries dated 1/15/21, 3/3/21, 3/10/21, and 3/16/21.   

Can You See Me? Arab Immigrants’ Quests for Identity and Belonging

The multifaceted and emotional aspects of working with Arab immigrants—a community to which I belong—is something I have learned to navigate more effectively through writing. This medium allows me to articulate the ineffable and share my thoughts more sincerely and deeply.

In the coming few paragraphs, I will describe my work with American adolescents of Arab origin, some of which can be found here; my own experience of immigration and mourning; and my experience with an analyst, where the consulting room became a microcosm of world affairs. We both were lost in our own traumas, and our work could not progress. Finally, I will share my present experience in my psychoanalytic treatment in the hopes that these stories can help you better understand Arab clients.  

Between Homelands: Arab Identity and Resilience in the Face of Stereotyping and Discrimination

Although American families of Arab origin come from 22 countries with diverse cultures and backgrounds, it’s important to note that not every Arab is Muslim, and not every Muslim is Arab. Despite these differences, many face common challenges such as acculturation stress, stereotyping, and discrimination. These difficulties have been magnified by the aftermath of September 11, ongoing wars on terror, Islamophobia, pervasive anti-Arab and anti-Palestinian rhetoric, and of the war on Gaza, which has been described by the International Court of Justice as a plausible case of genocide.

The insights I share here are based on anecdotal evidence and are not everyone’s experience. While not every Arab immigrant might relate to my narrative, immigrants from other ethnicities might find similarities.

For first-generation Arab immigrants, acknowledging the profound loss of their homeland and the deep mourning that follows is essential. Furthermore, when we come as refugees, our grief is intensified by the pain, and injustice of being forcibly displaced. Additionally, issues of racism and othering often become more pronounced in their new country.

In addition to mourning and grief, Arab immigrants must balance their love for their adopted land with the awareness that they are often rejected, misjudged, and even disdained. Employing Frantz Fanon’s concept, among the White majority, we become the “phobogenic subject”—a target of racial hatred and anxiety. Imagine, as you hold your children, looking into their eyes filled with dreams and innocence, knowing that in some places, they are not seen for who they truly are but are feared and misunderstood because of these labels. In your heart, they are cherished beyond measure, yet to others, they might only represent fear and prejudice.

In our adopted societies, and even on global and international stages, we Arabs often represent Carol Adams’ “absent referent.” This term, coined by Adams—a vegetarian feminist—illustrates how subjects of oppression are discussed as if they are not present. For animals, it means the pig becomes pork, the cow becomes beef, and the chicken becomes poultry, making our meat consumption more palatable. Similarly, the identity of the Arab is reduced to labels like Muslim, backward, and potential terrorist, as a result the killing of men, women and children, and the leveling of cities becomes acceptable. Arabs are frequently this absent referent, discussed and debated without their actual representation, their narrative or voice, rendering their perspectives and humanity invisible.

It would be wholly insufficient to explore the Arab immigrant experience without delving into Palestine and the relentless war on Gaza. I realize this is a topic that often creates anger and polarization, but it cannot be avoided in this context. Since 1948, Gaza and Palestine have been etched deeply into the Arab psyche, the significance of this tragedy has intensified since October 2023. In my practice, the impact of the war on Gaza is palpable and is a replicated experience of many, if not all, clients who are against the slaughter in Gaza.

For many, if not most of us Arabs, Palestinians and racialized people of color, Gaza looms persistently in our thoughts. The plight of the children, women, and men of the Gaza strip has shattered any remaining veneers of hope, belief, and promises for Arabs and non-Arabs alike: we have come to recognize that racialized colonization is the norm. The so-called universal values of justice and human rights have conspicuously failed us.

For many of us Arabs and other people of color, the situation in Gaza, which has been described by the Israeli historian, Raz Segal, as a textbook case of genocide, has deepened our intolerance for mediocrity and double standards. One cannot advocate for the conservation of sea turtles while remaining silent about genocide, nor can one campaign against global warming without addressing the killing of tens of thousands of civilians. In my practice I increasingly see how Gaza is compelling many of us to reevaluate our actions, career choices, and investments critically: Are they promoting justice and equality for oppressed nations worldwide or merely bolstering oppressors and enriching the affluent?

I vividly recall the dismay when the U.S. persistently ignored calls for a ceasefire and blocked international attempts at halting the carnage. We were not asking for statehood or the start of negotiations—it was a desperate call for the cessation of the killing of children who could be our children, mothers, fathers, brothers, and sisters, who could be us. It was about the basic human plea to halt the slaughter. That such calls did not spur those in power to take decisive action against the atrocities—children maimed, orphaned, and slain in the most brutal manners—was beyond comprehension.

This epiphany has deepened my insight, revealing a painful truth: despite being a mother, a psychoanalyst, a well-established middle-class member of society, and a devoted New Yorker who has served this country for decades, I am perceived differently. Standing beside my White and non-Arab friends and colleagues, a stark realization dawns: “I am not like you.” It is profoundly disconcerting to suddenly see oneself through this lens, to grasp that in the eyes of others, you are not entirely human.

Against this backdrop, immigrant Arab children and families try to adapt. Children and adolescents from American families of Arab descent, especially newly arrived immigrants, tend to excel academically. However, because of this success, they often remain overlooked by research and policy. These young individuals face the challenge of defining their identity in a society that may not fully recognize or understand their history, religion, or customs.

Moreover, adolescence is typically a period marked by separation-individuation—a second phase where the youth begin to distance themselves from their parents, as described by the psychoanalyst Peter Blos. This process can be particularly tumultuous for immigrants, as it may be compounded by their cultural displacement. Such disruptions can cause difficulties in managing emotions and lead to identity confusion, issues that could be alleviated through peer support and opportunities for identity exploration.

Studies have shown that adolescent immigrants often undergo what is termed in the literature as “double mourning,” defined as grieving not only their passage from childhood but also the loss of their homeland and cultural values. This dual loss raises complex questions about loyalty in their new cultural contexts. Additionally, the literature points to significant emotional stress among immigrant adolescents stemming from discrimination, microaggressions, and acculturative stress. These factors adversely affect their social and psychological well-being. Studies focusing on Latino adolescents in North America have highlighted family conflicts and perceived discrimination as major sources of depression and acculturative stress. The role of school environments, including their ethnic makeup and the sense of belonging they foster, is crucial for the mental health of adolescents.   

Literature suggests that immigrant adolescents are prone to emotional stress, exacerbated by discrimination, microaggressions, and stereotyping. Studies highlight that these experiences can lead to a decline in social functioning and an increase psychological distress. Further studies in the United States identify parent-adolescent conflict and perceived discrimination as key cultural risk factors for stress and depression among Latino adolescents. The educational environment, particularly the racial and ethnic composition of schools and students’ perceptions of belonging, also significantly impacts emotional and behavioral issues, indicating potential areas for targeted interventions.

In addition to these challenges, Arab American adolescents face unique pressures such as Islamophobia and negative media portrayals, which can intensify feelings of alienation and cultural dissonance. A study of Arab high school students demonstrated a strong link between perceived discrimination and mental health issues, suggesting a heightened vulnerability among this group.

The Shadow of the Phobogenic Self: Interpellation of An Arab Immigrant

In my work with middle-school-aged boys and girls who, like me, are Arab immigrants, I encountered a reflection of my own “phobogenic” self—an aspect of my identity that, due to its roots in history and heritage, attracts phobic hatred and anxiety. This was not just my experience but also that of my young clients. This recognition brought to light the process of interpellation, a term revived by French Marxist philosopher, Louis Althusser, through which I became identified as the “Arab Immigrant.”

In this role of Arab Immigrant, my subjectivity was shaped not just by personal experience but also significantly by the state and security apparatuses in the United States. These external forces crafted a version of myself that diverged sharply from the person I had been before immigrating to New York. This realization highlighted the profound impact of socio-political contexts on personal identity, particularly for immigrants like myself and my clients, whose selves are constructed at the intersection of past heritage and present circumstances. To understand what I am trying to convey here, consider the image that will come up for you right after I say, “an Arab Immigrant woman.” Other than her image, how do see her life and how she conducts herself in the world?

A Vignette with the Boys: I Am You
For a three-year period, I worked with a group of middle-school-aged Arab immigrant boys. The goal of the group was to help the students adjust to life in the United States. It was the first time I had worked with my own people in a clinical setting and the first time I had worked in my mother tongue. I thought that having lived for so long in the West, I could help the boys in their transition. Instead, they helped me see a part of me I wasn’t aware of.

Early in the treatment, I dreaded the advent of each session. God forbid one of the boys should want to enter the room before the beginning of our meeting, I would eat him with my eyes. I brushed my feelings off as a reaction to the anxiety in the room. I thought the sessions were so difficult that it was understandable that I wouldn’t look forward to meeting the boys. 

The boys, although they came to the sessions willingly, could barely sit still. They fought with each other and with whoever poked his head into the room. It felt impossible to contain them and alleviate their anxiety and mine. For me, they were interpellated Arab immigrant boys in the post-September 11 era. I could only see them through a political lens. My goals for the treatment felt superficial and inauthentic. The anxiety was palpable.

Even to this day, I vividly remember how much it weighed on my chest. I was at a loss. I wished for a manual with clear steps for conducting the treatment. Or perhaps a curriculum of sorts to contain me and the group. Have you ever had a dream where you went to the exam unprepared or perhaps to class in your pajamas? Well, this is how I felt during each session: vulnerable, unprepared, and exposed. For them, I was the White teacher: Although I ran the sessions in Arabic, a language they used among themselves, they spoke to me only in English. In addition, they took liberties that I am certain they wouldn’t have taken with an Arab woman. I conducted the treatment through artwork. If they were not drawing the flag of their country of origin, they would build clay structures that resembled erect penises with testicles or would throw food at each other and make sexually tinged jokes.

My feelings towards the boys and the treatment didn’t change until I presented my work at a case conference, where I was the only Arab and the only immigrant and where I began to experience what W.E.B. De Bois called a “double consciousness” feeling: this sense of always looking at myself through the eyes of others. The audience had only positive statements to offer. Nonetheless, I couldn’t escape my feeling of being an Other.

I couldn’t overlook the fact that we spoke a different language, literally and figuratively. I realized that I did not fool my audience with my Western-looking appearance. I am different. This early feeling of disconnection and alienation came back in full force. I felt as if I had just gotten off the boat. I appreciated that it would be hard for my audience to see through the social, cultural, and political layers between us. But I felt as if the boys and I were specimens for study. We couldn’t be understood intuitively. We needed to be dissected and examined. Something felt so sterile, disconnected, and uncomfortably clean.   

Following the case conference, my feelings for and experience of the boys shifted. I could no longer hide behind the fact that I could pass for a non-Arab. I could no longer project on the boys’ disavowed aspects of my identity. I realized that I had dreaded the sessions because they were making my interpellated self intelligible to me. I had to concede that escaping this self was as impossible as escaping my own skin. The alien feeling I had at the case conference reminded me of how things were when I first landed in New York: scared, alone, and vulnerable. This memory helped me hold the boys in mind (1). I could feel their sense of alienation, experience the lack of warmth they might have felt; taste the dread of living in a land as alien as Mars, and feel heartbroken by seemingly endless losses.

My work with the group was no longer only about the participants’ transition and integration but also about my second chance to connect with my origins. It allowed me to create something of value. From then on, I felt a connection to the boys that could only bring warmth, understanding, and patience to the room. I wish I could tell you that with a magic spell I was able to contain their anxiety and work with them. But no such luck. Our work together had to take its course. I accepted my interpellated self and accepted their stigma and mine.  

A Vignette with Girls: Colonization of the Unconscious Mind
A few years ago, I worked with a group of Arab girls. Most of them wore the hijab, which is a headscarf that covers the hair and exposes the face. Some women who wear the hijab also wear a neutrally colored, loosely fitting long coat, while others only cover their hair and neck and wear Western modest attire.

I showed videos of pertinent issues to engage the students in a dialogue. One such video was a documentary of interviews with five teenagers who immigrated to the United States from various parts of the world. Two of the five interviewees were girls, one wearing the hijab. One of the girls in the group I was working with, whom I will call Houda, shared her reaction to the video. Houda, who wore the hijab, had immigrated to the United States just a year earlier. She was helpful, engaged, and engaging. A group leader’s gift. Houda was clearly upset and deeply touched by the experience of the girl in the video with the head scarf. She told us how the kids in her class often teased her. She said that once, and without warning someone pulled her scarf off. The other girls in the group gasped and looked frozen.  

When she gathered herself again, Houda continued. One day a fellow student asked why she dressed the way she did. Houda explained that she was Muslim, and that Muslims believed that God wanted them to dress like that. The student who had asked her retorted dismissively: “What kind of God is this God that would force you to dress like this?!” Houda related the story with gut-wrenching distress. She was choking, half crying and half laughing, swaying side to side, as if not knowing what to do with the pain. In Arabic, she said, “I wished I could have told her that our God is better than yours. You are idol worshipers.”

I realized then how blinded I had been by the prevailing culture’s values. I thought all along that the hijab was a liability. Following the session, I decided to do an experiment. I wanted to wear the hijab to know how I would feel to carry something so dear, something that sets me apart from most around me. By the way, I want to stress that I come from a secular Christian family. I never wore the hijab growing up, nor was I expected to do so.

That summer was the first time I tried the hijab on. I was taken aback to see myself looking like a conservative Muslim woman. I had a dream after I saw myself in the hijab. To present the dream in context, I need to share a feature of Jordanian society where I grew up: pockets of culture and tradition made of the same substance that, paradoxically, do not seem to link. Although Christians and conservative Muslims live, work together, and have warm a respectful relationship, in Jordan, they don’t always cross paths socially. In fact, it is quite unlikely for my Jordanian family to have close or intimate relations with a conservative Muslim family: in a sense, they just do not speak the same language.  

I was taken aback, therefore, when I had the following dream. I dreamt that I was back in Jordan. It was winter and the weather was rainy and dreary. Streets flooded, mud everywhere. The kind of day that makes you not want to leave the house except in emergency.

The apartment was boisterous and alive with the sounds of children, blasting radio and the cling-clang of some culinary project in the kitchen. Freshly washed laundry was spread out on every open piece of furniture. The humidity and the aroma of home-cooked food sapped every bit of fresh air. The place felt uncomfortable and tedious. Nothing was going on except chores. No playdates to relieve you from the screeches of your quarreling children, or the hope of a lighthearted adult conversation.  

The bell rang. A middle-aged woman was at the door. She was wearing a conservative Muslim dress, head scarf, and long neutral-colored coat. She was softly walking towards me. She brought with her the hope of a pleasant chat and her three children, who would entertain mine and give me peace and quiet. My sister and brother were there. They greeted her as if they knew her. I felt I should have known who she was. I felt I was expected to greet her warmly. After all, she made the extra effort on a bad day and dragged her children along to greet me and welcome me back to Jordan.

When I woke up, I realized that this woman was no one else but me. She is my interpellated Arab immigrant self. I might believe that I am an Arab Christian or think that this made any difference in my social encounters. Christian, Muslim, white, brown, or green, my internalized sense of myself is that of a Muslim woman with a headscarf, and long neutral-colored coat. I am that woman in the mirror, shackled with tradition, fighting for recognition, gasping to rise above the stigma of her heritage. I felt sad and ashamed. Ashamed that I had dismissed and rebuffed her. I denied her existence. On which peg in my New York life does she fit? Among my American welcoming friends, she could be terribly misunderstood. I thought that no matter how hard I might have tried to explain her, tried to bring her into focus, her image will always be blurred and unclear.  

From that moment onward, I began to see how my thinking was colonized. In my article Through the Trump Looking Glass into Alice’s Wander Land: on meeting the House Palestinian I use Malcolm X’s analogy of the House vs. Field Negro to describe how I was the House Palestinian I noticed how often in my work with my people, my thinking and ways of functioning come from a colonized mind. I delivered a keynote address at the National Institute for Psychotherapies annual conference. In a 16-page essay, I repeat the word Christian seven times. I repeat it as if it were an important part of my life when I rarely, if ever, visit a church, and my connection to Christianity is mostly through Christmas gifts and Easter eggs. But on some unconscious level, I felt I needed to claim this religion, perhaps to identify with my aggressor, to tell them that “I am like you,” or, tragically, to disidentify from my own people: to the hijab, a liability is in itself colonial thinking.  

At this point in my life, I refuse to refer to myself other than a Palestinian or an Arab. I believe religion began to be used to fragment our societies because bonding together and our collective power can be formidable.

Immigrant’s Mourning: Peter Pan’s Neverland

I have wanted for a long time to claim that Arab immigrants and refugees have a unique position in terms of our struggle to adapt to life in the United States, especially regarding the history of Arab-West relations and the political issues I outlined above. I yearned to claim that the Arabs had it worse than anyone else, that our pain was more chronic, our longing more tender, our losses irretrievable, and our weeping inconsolable. But I couldn’t. Alas, the DSM-5-TR does not come with a diagnosis a la carte; there is no such thing as Arab Generalized Anxiety Disorder, Russian Paranoid Schizophrenia, or Character Disorder Français. The symptoms are the same, but the causes are different. To paraphrase Tolstoy, every happy immigrant is the same, but every unhappy immigrant is unhappy in their own way. Nonetheless, we are a particularly racialized and demonized minority. We are indeed the phobogenic subject.

Arabs might arrive in the United States as refugees escaping a war-torn homeland or an oppressive regime oppression, such as Palestine, Syria, Yemen, Sudan, and Iraq. Usually, their trip to the US is difficult: in addition to having to uproot themselves and abruptly and without permission, leave family and loved ones behind, they have to find a safe passage to their adopted homeland. When they arrive, they have to adjust to a strange land, language, smells, and faces. In addition, often they have to contend with below-the-poverty-line lives: someone who might have been a well-established office manager in his home country, because of language restrictions, would end up washing dishes for three dollars an hour, barely making ends meet.

In addition to the anguish, sadness, and hardship, they must be in a society that judges them, sees them in one light, and often disrespects them and their heritage. Considering that most of us Arabs are of the Muslim faith, Islamophobia and misrepresentation of the Islamic teachings tarnish a treasure Muslim immigrants hold dearly. A faith built on surrender and respect is misperceived and manipulated and misrepresented by politicians and mainstream media. Consequently, something you hold dearly, a book that is your blueprint for good and patient living, wrongly becomes deformed and ugly. The Arab Muslim immigrant is left heartbroken and dissociated from a logic that does not make sense.

The experience of immigrants, in general, tends to include periods of mourning. I once felt that immigration was like a never-ending funeral—an infinite procession of losses—relationships interrupted, events not attended, words left unsaid, memories that cannot be recaptured… A world and life are gone forever, but they are undying in my mind. I likened this experience to Peter Pan and his Neverland (2). Peter was an immigrant; he left his home in Kensington Gardens in search of a better life.

He told Wendy that one night, when he was still in the crib, “father and mother [were] talking about what [he] was to be when [he] became a man. …” He rejected their plans and left the crib and ran to Kensington Gardens, where he lived for a “long, long time among the fairies.” But, one day, Peter Pan dreamt that his mother was crying, and he knew exactly what she was missing—a hug from her “splendid Peter would quickly make her smile.” He felt sure of it, and so eager was he to be “nestling in her arms that this time he flew straight to the window, which was always open for him.” But the window was closed, and “there were iron bars.” He had to fly back, sobbing, to the Gardens, and “he never saw his dear mother again” (3).

Peter lives on the Island of Neverland, which is make-believe, and everything that happens there is also make-believe—time moves in circles, no one ages, and most of the events are pretend. He comes across as a superhero, an invincible boy who does not want to grow up. Peter likes to portray himself as independent and self-sufficient. He claims he “had not the slightest desire” to have a mother, because he thought mothers “over-rated.” The lost boys were only allowed to talk about mothers in his absence, because the subject had been forbidden by Peter as silly. When he is away, the boys express their love—and longing—for their mothers: “[All] I remember about my mother,” Nibs, one of the lost boys, said, “is that she often said to father, ‘Oh, how I wish I had a chequebook of my own!’ I don’t know what a ‘chequebook’ is, but I should just love to give my mother one.”

Despite his claims of self-sufficiency, however, Peter longed for a mother. Every night, he snuck into Wendy’s house to listen to her mother’s bedtime stories, which he would relay to the lost boys in Neverland.

Part of the immigrant’s psyche, like Peter Pan, lives in a “Neverland,” a make-believe imaginary space. There, relatives do not age, his mother still expects him for Sunday lunch, the dog waits for him at the door, and his friends look for him on the weekends. It is where he is understood without explanations, where he does not need to spell out his name or pronounce it, where his actions and reactions are just the way they should be, where everyone looks familiar, and where he safely blends into the background. Like Peter, the immigrant does not want to grow out of his Neverland, nor accept that his country, as he knew it, is no longer there. He does not want to mourn, for doing so means losing home forever.   

The immigrant is unaware that the interpersonal scene back in his home country is not the same. Time did not stand still: his friends aged, and their roles changed; parents, siblings, and cousins moved on, and the space that he once occupied is now filled with someone or something else (there is already “another little boy sleeping in [the] bed,” to use Peter’s metaphor). The immigrant is left suspended, never landing—a spectator to the events behind barred windows and painfully aware that even if he wanted to go back, he could not.

For the immigrant, visits to his home of origin become a harsh reminder of his mortality and insignificance in the schema of life. The memories he has of himself back then, of the person he developed into—the one who “came from nothing, progressed from a primitive and physical state of being to a symbolic one” (4)—do not exist and there is no proof that he ever existed. He left no traces behind. The memories and emotional experiences he holds are nowhere to be found.

In my experience, the immigrant’s trajectory entails an effort to assuage the pain of leaving “no traces … behind” by creating something that can be productive in the new land and applauded in the old one. It has to be successful enough to make an impact back home, so he won’t be forgotten, valuable enough to mend the rupture (real or perceived) created by his departure, and desired by others enough to give him a sense of still being needed.

Just as Nibs wanted to get his mother a “chequebook,” the immigrant wants to bring back proof that the losses were worthwhile and his love for his homeland is unrelenting. Thus, to view the pain and longing as pathological and to attempt to heal it before the immigrant is ready feels to him like murder—as if separation will kill the person he once was. It is to deny that he ever belonged to a group. To move quickly past the wound robs the immigrant of the energy that propels him to harvest the fruits of severing his ties.

Just as Peter and the lost boys left their mothers behind, the immigrant leaves his mother figure—their motherland and all its symbols—behind. In the New World, they struggle with the loss of psychological existence as a member of the larger group with whom they share a permanent sense of continuity in terms of the past, the present, and the future. Accepted ways of self-expression and old adaptation mechanisms must be shed: they are, at worst, dangerous and threatening; at best, they are unique or exotic.

Freud wrote that one mourns his lost object by separating from it, “bit by bit.” At times, the immigrant’s “bit by bit” mourning of his homeland is seemingly perpetual. For all intents and purposes, his love object is not dead: the country is still there, his parents call regularly, his friends stay in touch, and he can reach his siblings anytime. But he mourns the loss of his country on every significant occasion that takes place there. He might rejoice in a sibling’s wedding, but he will not know the little stories and many encounters that kindled the couple’s love; he might be sad that an uncle died, but he cannot and will not miss the uncle the same way others will. His presence at the funeral or his letter of condolence is that of an outsider; he is the undesignated mourner, unable to soothe or be soothed.

When the immigrant arrives in the new world, he spends much of his psychic energy adjusting and adapting. Unconsciously, he survives on the mistaken belief that his “secure base” is stable, and he can “refuel” anytime.

Speaking of my personal experience, my emotional connection to my country was like Peter Pan’s Neverland—a make-believe space where people never age, and time goes round in circles. My house is just as I left it the day, I moved out more than 40 years ago—as if my teenage siblings are still waving goodbye, as if my friends look for me every weekend, my mother waits for me for Sunday coffee, and my father is no older than I am now. But my sister and brother are parents now, my father passed away, and my friends are busy with new commitments. I am only a spectator behind the barred windows to events that move me, but I can’t touch. To use Peter’s metaphor, there is another baby in my bed.

For many, especially Palestinians, returning home can be a jarring experience, a stark revelation in black and white of all that has been lost, how life has irrevocably changed through no fault of their own. Your home is occupied by someone else, the streets you walked on as a child are barred for you, your neighborhood and your streets have been renamed, and the shop down the corner is now a supermarket that has been built on top of the ruins of most of your neighborhood. “I’m trying to understand why the sight of my son standing near the gate of the house, on a bench stretching to catch a closer glimpse of the garden, shattered my heart”

Recently, my son and I visited Palestine. One winter morning, we went to see my mother’s home in West Jerusalem—the home she lost in 1948. I arrived to find everything as she had described: the big stone construction, the arched balcony, the two staircases, and the lemon tree. It was all there. I longed to nestle under the tree, climb the stairs, or perhaps stand on the balcony. Of course, I could not; this was no longer my home. To this day, I’m trying to understand why the sight of my son standing near the gate of the house, on a bench stretching to catch a closer glimpse of the garden, shattered my heart. Perhaps it felt like he, too, was mourning, dreaming, and wondering what could have been. Or perhaps it was the sense of powerlessness to protect my son’s rights, his dreams, and his wishes.

Radioactive Identifications and the Psychoanalytic Frame

The psychoanalyst Wilfred Bion recommended that we approach treatment without “memory, understanding, desire, or expectation” (5). Is that possible when the intersubjective space is flooded with trauma, hurt, grief, and rage—when it is drenched with sociopolitical forces beyond the control of the clinical couple? Can we hold the psychoanalytic situation when the power differential is not only between expert and client, but also between colonizer and colonized, terrorist and terrorized?

In such circumstances, any communication between the clinical dyad, even silence, Bion argued, is liable to create “an emotional storm.” To sail safely through this storm, the analyst needs to maintain clear thinking. But if the situation becomes too unpleasant, the clinician might opt for other forms of escape, such as sleeping or becoming unconscious. I would argue, based on the personal experience I describe in an article I wrote a few years ago, entitled “Where the Holocaust and Al-Nakba Met: Radioactive Identifications and the Psychoanalytic Frame,” that under circumstances such as those above, it is nearly impossible to do anything more than make “the best of a bad job,” as Bion noted.

In my article mentioned above, I delved into the intersection of historical trauma, psychoanalytic treatment, and sociopolitical influences through my personal experience. As someone of Palestinian heritage, I engaged in therapy with a Jewish analyst, the descendant of Holocaust survivors. Our interactions became deeply influenced by the respective historical traumas associated with our backgrounds—mine with the Palestinian displacement known as Al-Nakba and his with the Holocaust.

The concept of “radioactive identifications,” first introduced by Yolanda Gampel, is central to understanding the dynamics within our therapeutic sessions. These identifications refer to psychic remnants from memories of extreme social violence that remain potent and disruptive. In our therapy, these identifications manifested through various interactions, complicating the therapeutic process.

I worked for a little over two years with an analyst whom, in a paper published, I call Dr. Shamone. I chose Dr. Shamone, a queer Jewish analyst opposed to the American Psychological Association’s complicity in torture, hoping he would understand the experience of being an Other. I was unaware of his anti-Palestinian beliefs at the time. Our early sessions were promising; I felt comforted and believed he was genuinely interested in my well-being.

However, a few months into our sessions, Dr. Shamone accused me of vandalizing his air-conditioner with graffiti. He believed the scribble, which looked like a combination of our names, was my doing, likening it to the act of “teenage lovers.” I could not believe what I was hearing. I sat in utter shock and dismay. I felt my heart shatter into a million pieces. I could not speak. My eyes were welling up. I felt overwhelmed with sadness, disbelief, and powerlessness. Who am I to this man? I wondered. How does he see me? Which part of me comes across as an irresponsible, immature woman who acts like an adolescent? Which part of me seems like a potential vandal and someone who would break the law so nonchalantly?

I spent the time between this session and the next researching the graffiti. Could it be an artist who scribbled on people’s air-conditioners? What could this word be? At the next session, I told him I thought the word on the air-conditioner could have been “Lakshmana,” which is part of the name of an organization called LifeChange. Dr. Shamone acknowledged that a week before the session, someone researching this organization visited him while writing a critical piece on the organization, accusing it of harming those who join it. It didn’t occur to me to ask him why it was that he accused me instead of wondering whether the researcher or someone belonging to that organization was responsible.

I am a Palestinian, but not a Terrorist

I entered psychoanalytic treatment with Dr. Shamone about 13 years after the September 11 tragedy. At the time, I thought the difficulties I faced had more to do with being an Arab from the Muslim world in an environment that demonized and feared people like me. On a conscious level, I was, of course, aware of my heritage but did not realize the extent to which radioactive identifications with intergenerational trauma and global events could affect the treatment. In the consulting room of Dr. Shamone, such identifications seeped between us — formless, odorless, and deadly.

Dr. Shamone began to struggle to keep himself awake during the sessions. Halfway into our meetings, he would become drowsy, his eyes would close, and his head would hang over his chest. At first, I felt as if I needed to protect him. I did not want to embarrass him. When I saw him dozing off, I would look away, pretending I had not noticed. One day, I came in with a bunch of chocolate bars. He wondered if I had a crush on him; perhaps chocolate was a sign of love. I said, ‘‘No, it is just that chocolate contains caffeine.’’ He responded, “You know, you are right, I gave up coffee a while ago.” I smiled and thanked him for accepting my gift. I thought then that his sleepiness was perhaps nothing personal, but caffeine withdrawal symptoms.

During this period, persisting to the end of our treatment, our relationship seemed to oscillate between a waltz, a judo fight, and an extended Amy Goodman interview. Dr. Shamone was only able to remain engaged and present when the discussion centered around Middle East politics. But when issues of everyday life took the place of politics, and topics such as my boyfriend, children, or work took center stage, he would feel drowsy and doze off. It was as if this monster between us was too much to bear if it wasn’t being continuously addressed. The monster had to be front and center; when it was hidden, the atmosphere became heavy and pregnant with unuttered statements. This dynamic continued for over a year.

Finally, I began to take his sleepiness personally. I felt this way because it was then that I began sharing my childhood trauma. I told him that I would feel hurt when he fell asleep and did not know what to do with that. Other times I would tease him; as soon as I entered his office, I would ask, “Are you going to doze off today?” This question usually worked, and he would stay awake.

Dr. Shamone felt certain that I was bringing something to the room that was making it hard for him to stay awake. He said at times what I was saying felt confusing, which made him lose concentration. But his conclusion shed no light on anything useful. Now I wonder if his sleepiness was a way to evade the reality of our dynamic, a flight from his feelings about me, or a way to escape from a traumatic memory that was being triggered by me.

Perhaps it was I who held unbearable trauma that he sensed and could not handle. Maybe he could not bear feeling responsible, at least in some way, for the trauma that led to my damaged mother. Or, perhaps, this was a parallel process to what Palestinians experience their predicament unrecognizable, their lives ungrievable, and seemingly on the road to annihilation. At the same time, the world dozes off on the sidelines.

During that period, I began to censor myself with Dr. Shamone. The analysis stopped being about my internal process and growth, but about how to keep Dr. Shamone engaged, about what material to bring in so he would remain present.

As I considered ending our work together, Dr. Shamone suggested, “Make sure your next analyst is not Jewish.” When I expressed my hurt, he added that I might harbor murderous intentions and come to the session with a weapon. This statement was a final blow, making me feel utterly alienated and unsafe.

In one of our last sessions, I told him about the fictitious traits I endowed him with when I approached him for treatment. I said, “I thought you would not be supportive of the Israeli government. I imagined that you were pro-Palestine.”

“Of course, I would be supportive of Israel! If things get tough for me here, I could always move there and be accepted.” I responded with a heavy heart. “Will you be living in my grandmother’s house?”

With a confused look on his face, he was quiet for a moment. Then he said in a thoughtful tone, “Sometimes we hurt each other.”

Back to the Present: My Journey with My Current Jewish Analyst

About two years ago, I began working with a supervisor to enhance my skills as a couple’s counselor. The supervisor was incredibly thoughtful, kind, and down-to-earth, with no pretenses, just analytic love and acceptance. Our connection transcended a mere supervisory relationship, embodying profound care and hope for my well-being on this life’s journey. Consequently, I decided to engage in personal analysis instead. While we sometimes focus on supervision, our interactions are primarily a therapeutic dyad.

Having previously worked with Dr. Shamone and had this painful experience, with my present analyst, I immediately brought up Palestine after expressing my desire to become his analysand. He reflected, “If you had asked me 20 years ago, my response would have been different. Now, I understand the situation on a much deeper level.” I have been with my current analyst for over two years now, experiencing significant personal growth and feeling deeply grateful for his attentiveness and presence. When the war on Gaza began, he would check in on me regularly, even outside our sessions, to ensure nothing was overlooked and to express his concern during those difficult times.

Contrary to Dr. Shamone’s advice, my current Jewish analyst has become one of the most important and healing people in my life. I continue to work with him because he is an honest and caring witness to my life and genuinely cares about me. Each session enriches my understanding of how to live authentically and trust myself as a therapist. Like my analyst, I strive to be authentic, helpful, and deeply caring with my clients.

Reflecting on my experience now, several years following the termination of treatment with Dr. Shamone and having this analytic experience with my present analyst, I find it insufficient and too generous to attribute my ex-analyst’s action solely to radioactive identifications. I have come to believe that my ex-analyst’s behavior was not just professionally unethical but overtly racist. His demeanor and actions towards me perpetuated a narrative that cast me in the role of a terrorist, devoid of an unconscious—my words came with subtitles I did not write.

Can You See Me?

Remember the experiment I mentioned earlier about wearing the hijab myself? On several occasions, I would wear the hijab and go about New York streets, watching for reactions. On my first trip, I discovered that there was a social network hidden in plain sight. Women wearing the hijab and men who seemed to be Middle Eastern or South Asian acknowledged my existence. They greeted me with a look, a gentle nod or some gesture, as if to say: I am here for you. I see you. I am like you. I realized how much I had been missing. That I have brothers, sisters, and a family I never tapped into. On other occasions, and for no apparent reason, my projections left me anxious and feeling in danger. I was worried someone would intentionally push me or pretend to be tripping and bump into me, or that I might be lynched in plain sight.

One summer, I had foot surgery and had to use crutches. During those times, when I traveled around New York in Western dress, I felt taken care of by many. For example, I never lacked a seat on the subway. Riders would rush to give me theirs. Dressed like a Muslim woman, I felt as if they looked right through me. As if I didn’t exist. Crutches or no crutches, they didn’t know what to do with me. I did not feel discriminated against per se, I just felt invisible.

A feeling of sadness and loneliness took me over. My Palestinian or Arab self is a charged topic. I, therefore, often enter my social encounters edging to be seen, but opting to hide.

I realized that there is a point that my dear psychoanalyst cannot enter;

I wish I could let him in. Perhaps I can hum a tune of a song he’d remember.

I wish he could smell the air of my land, see the beauty in desert roads, rundown houses, and joyfully running barefoot children with smudged clothes.

I wish he could taste the food I miss and know my teenage friends who are grandparents.

I wish I could mention the name of a neighborhood and he’d tell me about the streetlamp that stood there.

I wish he could laugh at my Arabic jokes, know a poem or two, or remember a public holiday.
But I don’t want to share my misunderstood traditions—I don’t want to find out how peculiar they seem to him.

I don’t want to introduce him to my beloved Palestine, I am afraid I might find out that he can’t understand the endless heartbreak I experience daily.

I don’t want to share my wish to remain in Neverland, where time goes round in circles, where no one ages, and where my siblings are still waving goodbye. I don’t want him to tell me that no such land exists.

I don’t want to uncover my inner world and end up being a specimen—dissected by his skilled psychoanalytic blade and disjointedly reassembled.

I really don’t want him to see me, all of me. I just want him to sit with me, hold my pain, blow on my wounds, and just answer “yes” when I ask him:

Can you see me!?

References

(1) Allen, J. G., Fonagy, P., & Bateman, A. W. (2008). Mentalizing in clinical practice. American Psychiatric Publishing, Inc.

(2) Barrie, J. (1911). Peter Pan. Barnes & Noble Classics.

(3) Kelley-Laine, K. (2004). The metaphors we live by. In J. Szekacs-Weisz & I. Ward (Eds.), Lost Childhood and the Language of Exile (pp. 89-103). Karnac Books.

(4) Becker, E. (1973). The Denial of Death. Free Press.

(5) Bion, W. (1970) Attention and Interpretation. Tavistock.

 

©2024, Psychotherapy.net

When Symptoms Overshadow a Diagnosis: Psychotherapy as Archeology

When a prospective client makes an appointment to “work on my anger,” I can never be sure what other, deeper issues might lie beneath that common presenting concern. In my clinical experience, anger rarely exists in a vacuum, leaving me to wonder if it is driven, for instance, by personality pathology, trauma reactivity, or rooted in a specific mood disorder that will also need addressing. The person might hyperbolize or downplay their anger problem details during the phone screening. I have also come to wonder if their anger could fuel hair-trigger sensitivity and reactivity, which might add an element of danger to the therapeutic relationship.

Early in my career, I worked in a jail where I intervened with many acutely angry individuals. I knew my way around potentially dangerous people. While their anger required more immediate address, often with solution-oriented methods, what had always interested me more deeply was discovering the person beneath the anger. However, given the nature of corrections, inmates frequently moved for programmatic and security reasons, so my time with them was short, and my interventions were symptom- and situation-focused.

An existentialist at heart, I always wondered about peoples’ internalized experiences. What kind of meaning do they assign to phenomena? What defenses are at play? How does that all affect the clinical picture and what kind of material is in there to work with for better gains? Thus, what I later came to appreciate about working in private practice rather than institutional settings was spending more time with people and really getting to know them. I was better able to contextualize and understand symptom functions and help clients learn about themselves and to relate more effectively with others — especially when anger entered the clinical frame.

Robbie Needs Anger Management

When Robbie’s mother, Jane, called for an appointment for him, I was expecting him to be a child, perhaps even a teen as opposed to being in his early 20s. “He lives with me and is doing OK, but he’s been diagnosed with ADHD for years and can get rageful. He’s got to clean this up and stop living in the fast lane if he hopes to hold a job,” she shared.

I learned that at one time Robbie was on ADHD medication, but discontinued it after he completed high school, and had no interest in restarting it. Jane shared that it was questionable whether the stimulant medication had much of an effect, anyway. She was hoping that meeting with a male therapist, someone he might relate to, who encouraged exploring his emotions and aspirations, would prove more effective.

For his first appointment, Robbie arrived with Jane. They sat next to each on the couch across from me and seemed to interact amicably, something that didn’t always happen when family members arrived together. Robbie nodded along to Jane’s historical details about his development and family matters. He sometimes reminded her of a detail or filled in a blank with his personalized recollection. While Robbie was fidgety at times, he did not exude a hyperkinetic or inattentive vibe. Throughout, he maintained a bit of brightness, as if there were some contained excitement, but it was too early to explore deeply.

At first glance, I considered the possibility of ADHD. Clients I’ve worked with who have been diagnosed with ADHD have low frustration tolerance that often led to angry outbursts. Further, like the prototypical class clown who has that ever-present grin, Robbie had an ongoing light smile of sorts, and he could be a little interruptive and fidgety. “Perhaps, if he indeed has ADHD, he’s just learned to manage well,” I thought as the interview went on.

Therapy with Robbie Begins

On the day of our first therapy appointment, I heard a motorcycle pull up out front, and a second later, in walked Robbie with his helmet. “What a day for riding,” he beamed, taking off his jacket and making himself comfortable on the couch. “What do you enjoy most about being on your motorcycle?” I asked.

“It’s the thrill,” replied Robbie. “King of the road! Just taking off and maneuvering. It’s harder for a cop to get you, too!” he laughed.

Settling into the session, I said, “I wanted to ask, how was it for you last week when we met for the first time with your mom here?” “It’s all good,” said Robbie. “We have a great relationship. She told you everything.”

“She gave me a lot of information, for sure. Given it’s your time to meet with me, I was hoping to hear more of your thoughts about what you’d like to get out of coming here.” Robbie admitted he wasn’t sure.

He explained he knew he was directionless, watching friends finish college or settle into long-term relationships and jobs. Nonetheless, he said he felt free and like he was having a good time and that it would all work out. “Maybe I’m a ‘live fast, die young’ kind of guy. My mother always tells me I can’t last if I don’t get some direction,” he finished, rolling his eyes.

Clasping his hands behind his head and looking about the room, Robbie circled back to my question. He wondered out loud what one does in therapy. “I mean, I do get frustrated easily, and bored quickly. Those medications I took way back didn’t do much. Maybe I focused a little more in school, which was cool, but, you know, this is me. Why do people get frustrated with me if I get frustrated or want to do something? That’s ADHD, right?” he grumbled.

“What can you tell me about people getting frustrated with you for getting frustrated?” I asked.

“People can get under my skin. It’s not just my mom about ‘getting direction.’ She just wants me to be successful. I’m not too irritated with her. I get it. But other people, it’s like they can’t keep up with me or something. I’ve had girlfriends say it, and when I get people together for ski trips or rock climbing, they can’t keep up. If I want to have fun, it seems it’s got to be on my own. I get pissed off. I don’t want to, but people come with me, know I go all out, then complain I’m wearing them out when we’re skiing at first light until dusk. I don’t want to waste time, you know? Make use of time on that vacation!”

“What exactly happens?” I asked.

“Err, I got really pissed one time last year and smashed my GoPro camera as I let my friend know what I thought about his whining,” Robbie said, irritably. “I mean, c’mon, you come on a ski trip and don’t want to ski? Then I’m like, ‘f*&k it, I’m still gonna have a good time,’ and skied off.”

Robbie quickly lit back into a bright expression.

“Are you still friends?” I continued.

“Yeah, he knows it’s just me. He’s seen it before. I guess I’m an acquired taste,” laughed Robbie.

Throughout, Robbie could veer off course, getting distracted by a topic that seemingly popped into his head. It never seemed he had much attachment to the discussion.

Over time, I learned more about other relationships, such as when Robbie told me that dating was tough. It wasn’t because of aggression, but rather he felt he burned out girlfriends. “I’ll find a girl who I really vibe with, and we’re climbing and stuff, and hanging out a lot at the start. A lot of energy, you know? But then, like this one girl, she wanted to do more chill stuff like typical dates to movies and dinner and family events. I really tried to accommodate. I liked her a lot. I tried to have my cake and eat it too by getting together during the week for after work cycling or going to the climbing gym. She told me she just couldn’t handle that activity load. We’re still friends though.” Robbie’s brightness flattened.

I replied, “I can’t help but notice your expression changed, Robbie.”

“Hell, I do get lonely,” he admitted. “I want someone to do stuff with! I like sex and all, but I can get that on demand with girls I’ve known over the years. Chicks dig me, haha! But those girls don’t have to deal with me like a relationship girl would, I guess.”

“What more can you tell me about this loneliness?” I followed.

Robbie explained that he never quite felt “full.” On one occasion when he seemed dull compared to his usual energized self, I acknowledged that I noticed he did not seem the usual Robbie. He said it was one of the “not full periods.” Robbie was able to liken it to a silo that gets filled with grain but has a leak, emptying it again, then hearing an echo within. After some exploration, it seemed that Robbie’s activity level was the grain, keeping him feeling full, but even that had its limits when he couldn’t keep up with it.

“What happens on the occasions you encounter the echoing silo? What’s it like? How long might it stay empty?” I inquired.

“Dang,” began Robbie, looking away. “I lose my excitement vibe, you know?” He continued that he force feeds himself activity to try and get back the momentum and fill the silo, but it’s a trudge. He might have days of feeling apathetic and stuck in his head, thinking too much. He described how he can get to belittling himself for probably being a disappointment to his mom, who had it tough and had dreams for him. “It’s all kind of exhausting,” he finished. With half of his usual energy, he grinned and said, “But I’ve learned to accept myself.”

It sounded to me that Robbie was prone to crashes into depression and that he had a polarized self-concept.

Between sessions, I found myself realizing Robbie’s restlessness and impulsivity weren’t so ADHD-like afterall. When I combined this with how Jane denied any clear early history of typical ADHD symptoms in Robbie, and that she denied having any perinatal ADHD risk factors, I began drawing a different conclusion.

A Hypomanic Personality Dynamic

Robbie was clearly a depressed young man, and it seemed he had a sort of “keep active” or “moving target defense.” He was living a duality—a depressed inner world that he kept suppressed with a hypomanic defense. Perhaps the ultimate denial!

I didn’t realize it at the time, but Robbie was exhibiting what some have called a hypomanic personality, sometimes referred to as a hyperthymic temperament. While not included in the DSM or ICD, the hypomanic or hyperthymic personality are nothing new, and, in fact, have remained of interest to various personality experts (see references).

Millon provided descriptions of this personality style from historical giants. Kraepalin, for instance, said that these are patients who, “…throughout their entire lives display a ‘hypomanic personality’ pattern without severe pathogenic developments [i.e., crashes into full affective disorder episodes].” Schneider wrote, “hyperthymic personalities are cheerful, kindly-disposed, active, equable, and great optimists. Often, however, they are shallow, uncritical, happy-go-lucky, cocksure, hasty in the decision, and not very dependable.” McWilliams, perhaps the modern authority on this personality 100 years later, provides similar descriptions.

A movie character fitting a hypomanic personality that readers may be familiar with is Paul Mclean, played by Brad Pitt, in A River Runs Through It. Also, the portrayal of Scott Scurlock, an infamous 1990s bank robber, featured in the recent Netflix show called How to Rob a Bank, exemplifies a more intense case in that Scurlock’s personality also entailed sociopathic characteristics.

In time, I learned that those with what could be considered a hypomanic/exuberant personality may feel more alive chasing rainbows than the idea of long-term success, for this would require a type of settling, and thus, stagnation in their eyes. This is dangerous because they depend on being a moving target, lest their depressive ghosts catch up with them. Unfortunately, while an immediate salve, this perpetual motion encourages the cycle, for lack of success engenders a sense of failure, feeding depression, which the hyperthymic activity defends against.

Their solution to troubling emotions is the problem. As described by McWilliams, living this energized, unstable existence can become exhausting. Thus, the defense becomes weakened enough that the suppressed internal depressive experience crashes the gate until the energized state reconstitutes and corrals the depressive escapee back to the sidelines where it can only shout insults, which the guard ignores via enthusiastic distraction once again.

The Therapeutic Work with Robbie Deepens

After spending numerous sessions learning about Robbie and encouraging him to engage in sharing/self-revelation, we began more pointed work.

“Robbie,” I began, “from what you shared, correct me if I’m wrong, but it seems like that ‘being active’ protects you from having to deal with that hollow feeling?”

He agreed that it’s the pattern. “It seems like, if you really look at it, life has become a defensive act against feeling that hollowness,” I continued.

“I’m curious,” I began again, “have you ever thought about what life would look like when it’s really going your way?”

“Yeah, not having this moody stuff. Finishing things.”

I asked, “When can you recall that you weren’t moody?”

“I’m not sure. Maybe when I was pretty little. I remember playing and being happy with my dad and brother, the whole family.” Robbie had shared that his father eventually cheated on his mother and left, and she had to work, so wasn’t around as much. Eventually she got a divorce settlement and was able to stay at home more.

It became clear that Robbie harbored a lot of feelings of rejection and subsequent sadness; he was living two sides of the same coin with the ever-present sadness being defended against by an exuberant denial.

In order to stop this rollercoaster, since the hypomanic defense was a product of his bleak internal world, therapy would need to resolve his feelings of rejection that encourage the sadness.

“Like I said, I want a steady girlfriend,” explained Robbie.

“You’d like a meaningful relationship, some real intimacy?”

“Of course.”

“Strictly romantically, or?”

“I don’t want to have arguments with people like what happened with my friend, either.”

As if Jokey Smurf entered the room, Robbie laughed about breaking the Go-Pro camera and the horrified look on his friend’s face. “It’s crazy! I’m like some f**ked up movie character sometimes. But that’s being human, right?”

“Humans can act f**cked up sometimes, for sure, but I recall you saying you really didn’t want it to keep happening for you. I’m curious about what’s behind the laugh about it,” I inquired.

“Man, you therapists find stuff under every rock, don’t you?” asked Robbie, trying to evade my question.

“Hey, you told me you want to learn to make some changes, so it’s my job to notice things that might get in the way. To me, if someone has a contradictory response, it tells me they could be struggling to be real with themselves. Make sense?”

“So, what, I can’t laugh at myself?” he followed.

"Not taking oneself too seriously can ease the pain, can’t it?” I continued.

“It’s the best medicine!” Robbie added.

“Robbie, what are you medicating?”

With that, Robbie said he can’t escape some frustrations so laughs about them. Upon examination, his frustrations were rooted in painful ruminations, coupled with the exhaustion inherent in not being able to stop running if he is to “deal” with them. Distraction was corroding him, but admitting he had little steam left made Robbie feel vulnerable. He would often run on fumes, only to discover some psychological alchemy that provided fuel for the escape rides, which, over time, we saw were getting shorter, almost episodic. Whether this was the result of something therapeutic, such as feeling there was someone to help him manage what lay beneath, incrementally lowering his defenses, or a natural dip in childish energy that occurs as one eases into adulthood, it is hard to say. Regardless, Robbie’s more frequent low points were taken advantage of, where he would become more revealing of his years-long festering conflicts.

Effecting Deeper Therapeutic Changes

In months that followed, Robbie continued with an almost cyclothymic presentation. But the nature of the moods changed. There were peeks at more vulnerable parts of him. He kept up an energetic cheerfulness, but it wasn’t so charged. There were often peeks at actual lamentation and sadness that accented what was left of the hypomanic demeanor. At times, it was more of a reactive, temperamental mood. This seemed corollary to being more in touch with the depressive foundation; making contact with painful memories can be anger-provoking, and great therapy material.

There was still restlessness at times, but not in the old hypomanic sense. It was rather a more nebulous anxiety as Robbie edged into being more self-revealing and exposing his internal landscape. We seemed to be contacting bedrock issues, which, like in geology, would seem like stable turf, but if there are nearby fault lines, that could all change.

But Robbie learned more about the language of emotions and being real with himself. He realized that under it all, he hoped someday to discover it all never happened, but eventually accepted the idea he can’t somehow have a better best. With the disintegration of the denial, the smoke screen of exuberance he made for himself continued to lift. Relationships improved. When he felt more in them, he related better, leading to people being able to have more constructive, stable relationships with him and his fear of rejection no longer had a leg to stand on.

Over this two-year span of meeting with Robbie, I was never sure of how tenuous progress was. Would his psychological fault lines quake? He was invested, rarely missing an appointment, and had made strides in reducing the initial concerns and being more real. It often felt like skiing in avalanche country where anything could upset the delicate structure of snowfall and off it goes, taking everything established in its path with it.

As we wrestled with his long-simmering conflicts and learning to better understand himself and relate to others, Robbie began taking non-matriculated college classes to see what school was like. This was good grist for the therapy mill. Productive, real-world structure. In the meantime, Robbie still enjoyed his interests. Along came a part time job, then a girlfriend. Then the end of our sessions. Sometime after, Robbie left a voicemail asking for a letter about his having been in therapy and if he was ever a danger to anyone. Apparently, he was moving in with his girlfriend, who had a child whose father was contentious and heard Robbie had been in mental health care for being explosive in the past.

Postscript

I can’t help but feel that Robbie wouldn’t have reached this stage if his encounter with mental health care continued to see him as having ADHD, or as having problems with anger control. Some people say diagnoses don’t matter, that “we treat symptoms and not diagnoses,” which has the implication that symptoms can always be treated similarly. This can be a specious and dangerous outlook. Symptoms may occur across diagnoses, but that doesn’t mean they’re treated similarly. This diagnostic consideration of hypomanic personality, despite the debates about its legitimacy, allowed me to contextualize the nature of Robbie’s symptoms, which guided my approach to intervening with him. If merely addressing symptoms was sufficient, it wouldn’t have mattered if Robbie’s presentation was chalked up to ADHD or a hypomanic personality. The ADHD medications in theory would’ve fixed him.

We generally never know how our patients fare in the long term. Robbie’s hypomanic presentation was deconstructed, and an honesty about his life settled in. Consistent structure followed, highlighted with the activities he’d escape through, but now in more moderation. A semblance of a well-balanced interaction with himself and the world took form. Chances are, spot-reducing symptoms wouldn’t have allowed such a rich experience. Symptom reduction is great, but how does the person now live with their newfound experience? Does it have stability?

Personality is important, whether it’s pointedly treating personality disorders or helping someone integrate updated parts of existence into their being and work that into the world around them. Hopefully, Robbie is a reminder about the intricacies of therapy. It certainly was to me! It’s more than what’s observable, and what’s observable isn’t always what it seems.

References

Akiskal, H., Placidi, G., Maremmani, I., Signoretta, S., Liguori, A., Gervasi, R., Mallya, G., &Puzantian V.R. (1998). TEMPS-I: Delineating the most discriminating traits of the cyclothymic, depressive, hyperthymic and irritable temperaments in a nonpatient population. Journal of Affective Disorders (51),1, 7-19.

Jamison, K. (2005). Exuberance: The passion for life. Vintage.

McWilliams, N. (2011). Psychoanalytic diagnosis: Understanding personality structure in the clinical process. Guilford Press.

Millon, T. (2011). Disorders of personality (3rd ed). Wiley.

Oser, D. (2019) Hyperthymic temperament. Psychiatric Times, 36(9). https://www.psychiatrictimes.com/view/hyperthymic-temperament  

Navigating Client Loneliness in the Digital Age with Therapy

I’ve noticed a striking paradox in today’s digitally connected world: loneliness persists despite the abundance of online connections. Many of my clients grapple with profound feelings of isolation, shedding light on the intricate relationship between technology and loneliness. As digital interactions increasingly shape our social landscape, it has become important for me to delve into the possible underlying connection between loneliness and digital habits of my clients. By examining this paradox, I have been better able to support them in navigating the challenges of modern connectivity while fostering their interpersonal connections and well-being.

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Nurturing Non-Digital Relationships through Therapy

Social media and messaging platforms often create a superficial sense of connectivity, where likes and comments substitute for meaningful face-to-face interactions. Moreover, the pressure to maintain a curated online presence can amplify feelings of inadequacy and isolation. Excessive screen time and reliance on digital communication can hinder the development of deep, authentic relationships, ultimately contributing to a sense of loneliness and isolation. Understanding these detrimental effects of hyper-connectivity on social well-being has been crucial for me as a clinician working with clients who have been impacted in this way.

I’ve come to realize that while virtual communities offer a semblance of connection and support, they often pale in comparison to the richness of genuine, in-person relationships. Online interactions lack the depth and intimacy of face-to-face encounters, leading to a sense of emotional emptiness. Additionally, the curated nature of online personas can create a distorted perception of others, fostering feelings of inadequacy and isolation. Excessive reliance on virtual interactions can thus contribute to anxiety and depression.

In my clinical work, I’ve witnessed the pervasive influence of the fear of missing out (FOMO). This hyperconnected lifestyle often leads to a sense of emptiness and disconnection from the world around them. However, amidst the frenzy of digital connectivity, the concept of the joy of missing out (JOMO) offers a refreshing perspective. By consciously choosing to disconnect from digital distractions, my clients can potentially create spaces for meaningful real-life and interpersonal experiences. I have strived to promote awareness of these concepts and to empower my clients to prioritize meaningful off-screen/offline connections.

Case Applications

I recall working with Sarah, a 32-year-old marketing executive, who presented with profound loneliness despite her extensive online network. Spending hours each day immersed in social media and messaging apps, Sarah sought validation through digital interactions. However, despite the illusion of constant connection, she felt increasingly isolated from genuine human interaction. Through therapy, I remember supporting Sarah as she acknowledged the detrimental effects of hyper-connectivity on her social well-being.

Sarah’s treatment plan focused on dismantling her curated online presence, moderating her excessive screen time, and reducing her reliance on digital communication. Together, we explored alternative ways for her to nurture meaningful relationships offline. I emphasized the importance of face-to-face encounters and encouraged Sarah to connect with a limited group of friends in real-life settings.

In a similar manner, I supported Michael, a 28-year-old Latino construction worker, who experienced feelings of emptiness and isolation despite his active participation in online communities. Raised in a tight-knit community, Michael valued deep, meaningful relationships rooted in face-to-face interactions. However, his demanding work schedule limited his social opportunities, leading him to seek connection through virtual means. In therapy, I recall reflecting on Michael’s cultural values and exploring strategies for fostering authentic relationships offline.

Recognizing the importance of developing culturally relevant social skills to navigate interpersonal interactions, I suggested incorporating extended family members into Michael’s treatment plan. We discussed the idea of using role-playing exercises with his relatives to simulate real-life scenarios and practice social interactions within a familiar cultural context. By engaging with his extended family in these role-playing sessions, Michael gained confidence in initiating conversations and building rapport with others while staying true to his cultural heritage. These sessions provided Michael with valuable opportunities to develop his social skills in culturally relevant contexts, ultimately empowering him to forge deeper connections within his community.  

***

Technology presents a double-edged sword in the fight against loneliness. While it offers innovative solutions for connection, it also poses challenges, contributing to the erosion of traditional social structures. By promoting digital interventions that prioritize authentic connection and well-being, I hope fellow clinicians can empower their clients to navigate the complexities of loneliness in this complex digital age.

Questions for Reflection and Discussion

What is your opinion on the author’s view of technology and loneliness?

What has your clinical experience been with clients who have chosen digital over live connection?

In what ways does the author’s position resonate with you personally?  

The Disconnection of Depression: How to Restore Attachment Using Cognitive Interventions

“Despair is an ultimate or ‘boundary-line’ situation. One cannot go beyond it.” – Paul Tillich

“I don’t want to be a burden,” she told me. It’s a phrase that I’d heard many times, and it often came from my aging or depressed clients. Her words came from a selfless place. She didn’t want to hurt others with her pain. She didn’t notice that withholding her suffering meant she was introducing disconnection within her relationships. Or maybe she did. As she pulled away from the people in her life, her silent march towards death’s absolute disconnection had begun. It was an incremental, self-inflicted dying.

In the last entry, I shared how clients can experience the moral dimension of suicide. It’s important for me to notice when my clients feel like a burden, because suicide can appear like a strategy to protect others from themselves. In this context, I wanted to explore what my clients have taught me about how to avoid this trap, and how they were able to eventually reconnect to those they desired to protect.

Blended Truths: A Cognitive Intervention

When my clients have talked with me about being a burden, they usually point to a mountain of supporting evidence. They tell me they’re no longer able to work, that their spouse is earning the only income, and the kids are visibly confused. To make matters worse, they aren’t helping around the house. They tried to vacuum, but “the chord got tangled.” Then they tried to cook dinner, but they became “overwhelmed by the existential absurdity of shredding carrots.” So, back to bed they go. In their absence, their loved ones are suddenly forced to do it all, and they’re sure it’s their fault.

When clients present this way, I try to help by asking them to reconsider this belief. At first glance, the conviction that they’re a burden appears to have some merit. The people in their life are struggling to compensate for the consequences of their depression. That’s usually true. But one of the hidden mechanisms found within depressed thinking is the presence of blended truths.

Blended truths are thoughts that contain some amount of truth, but they also contain some amount of falsehood. Facts and fiction co-mingle. The problem with these blended truths is because they hold some amount of merit, they initially seem persuasive. Unable to argue with the apparent validities, clients are simultaneously baited into swallowing their inconspicuous falsehoods. The good goes down with the bad. Blended truths operate like a worm-hidden hook — or an Almond Joy.

But it’s true that their loved ones are affected by their depression. That’s the first part of the blended truth that’s factual. This is an unavoidable part of being a social animal, and it’s the cost of admission when we’re meaningfully connected to each other. But I’ve noticed that my clients believe something more than this. If they simply believed their loved ones were having trouble, this would create feelings of worry, but it wouldn’t create feelings of guilt. So where does the guilt come from? It comes from the second part of the blended truth. It comes from the belief that it’s their fault. This is the hidden falsehood within the blended truth. It’s the sharp hook. Or the chalky almond. This is where I try to help clients address their sense of burdenhood, and if I’m having a good day, it might sound something like this:

Therapist: You mentioned feeling like a burden, can you tell me more about that?

Client: Well, everyone is working to pick up my slack. My wife is exhausted. She’s working and doing the parenting while I watch reruns and avoid phone calls. I hate what I’m doing, but I can’t seem to get myself right.

Therapist: You hate that your family is affected by the depression. I mean, how could you not? It sounds like everybody is really struggling. I’m sorry to hear things have been so difficult.

My first step to untangle a blended truth is to validate the part that’s true. In the past I tried to reassure my clients that their loved ones couldn’t be struggling too badly. That was a mistake. It was a mistake because my clients knew I didn’t know their loved one’s experience, and when I feigned that I could, this made me less credible. My false consolations had led to lost credibility, and my lost credibility led to damaged rapport. What was intended to be a supportive sentiment, ended in a damaged therapeutic relationship. But despite the punishing grind and slothful speed that is my learning curve, I eventually learned that if I could acknowledge the part of my client’s blended truth that was true, I could earn credibility and tighten our rapport. Then with the relationship standing on firmer ground, I could initiate the second step of addressing these blended truths. I could invalidate the part that’s false:

Client: Yeah, so that’s what I mean by being a burden.

Therapist: I gotcha. Would you mind if I picked a friendly fight?

Client: Go for it.

Therapist: So, I don’t doubt that your family is struggling. That sounds undeniable. You make a difference in your family, and so your absence is going to be felt by them. But I’m not sure considering yourself a burden is completely fair.

Client: Well, it’s my fault that they’re struggling and so that’s what I mean by being a burden.

Therapist: Hm, that’s hard. Would you mind if I keep pushing?

Client: Fine.

Therapist: I think worrying about your family makes sense because it sounds like they’re having a hard time. There’s no getting around that. But the second part of what you’re saying — that it’s your fault – this sounds to me like it could be depression talking. So, with the risk of sounding obtuse, let me ask you directly. Are you choosing to be depressed?

Client: What? No, I’m not.

Therapist: Of course not. If you were choosing to be depressed, you could simply choose not to be. But that’s not exactly the nature of what we’re dealing with, is it?

There are a couple things I try to make happen in these moments. The first is I ask to pick a friendly fight. If I can characterize the impending disagreement as friendly, I can emphasize that challenging my client will occur between the cushions of our existing rapport. If I can get their permission to proceed, I can then introduce the idea that part of their thinking might be depression-inspired (“this sounds to me like it could be the depression talking”). This invites the client to depersonalize their thinking about being at fault, and if they can separate their authentic thoughts from the depressed ones, this can make challenging their depressed thinking more realistic. In whatever form it takes, “Is this really you, or is this the depression?” is a question I can’t do without.

This second step of invalidating what’s false is concluded by plainly asking the client if they’re choosing to be depressed. This is a ridiculous question. It’s like asking, “How many inches is the temperature outside?” But the ridiculousness is the point. This makes the implicit falsehood within the blended truth explicit, and it invites the client to sign on depression’s dotted line. When the falsehood within the blended truth is no longer hidden, my clients have a better chance to avoid digesting it.

Divide By Two: A Behavioral Intervention

Untangling blended truths is one way to explore the mental dimensions of the depression, but in some cases, I’ve found that the cognitive strategies don’t work. Sometimes my clients are overcome by their despair, and they lose any interest in thinking abstractly. In these cases, I think it’s better to start with the behavioral interventions.

I’ve found it can be useful to begin by identifying the behavior that’s connected to the client’s belief that they’re a burden. I’ll call this burden-behavior. Burden-behavior seems to present similarly across differing cases. Clients withdraw from their life in order to protect their loved ones from themselves. They hide out in bedrooms, run the fans on high, and bundle themselves in blankets. The judgmental Netflix algorithm keeps prompting them, “Are you still watching?” (What does it take to get some unconditional-positive-regard algorithms around here?)

But as each day passes, life becomes more difficult to reenter. When these determined clients make the choice to re-enter their lives, they quickly run into problems. They plan to go for a walk, but the front door appears miles away. They schedule time to meet with friends, but they immediately find reasons to cancel. As quickly as plans are made, they’re unmade, and their return to isolation occurs. Reentering life feels more like mountain climbing, and each attempt upward is followed by a slide back to the bottom.

In these situations, I try to show my clients that their plans are divisible. When they determine their plans are too difficult, instead of returning to the bedroom, they can learn to divide their plans. My aim is to interrupt the status quo of complete inactivity and to encourage them to find the outer rim of what they can handle. Then eventually, they can widen the circumference of their experience. To provide a sense of how this can work, and to show how much division can be done, here’s an example of how Divide by Two can sound:

Client: So, I tried to go for a walk around the neighborhood, but honestly my body just felt incredibly heavy, and I stayed home.

Therapist: That’s sound really uncomfortable. What did you do, instead?

Client: I just stayed in bed. I’ve been watching reruns of Cupcake Wars.

Therapist: Cupcake Wars? Yeesh. Things are worse than I thought.

Client: Tell me about it.

Therapist: On a serious note, it’s really difficult to feel cemented the way you do. Would you be open to a suggestion that might not apply?

Client: Sure.

Therapist: In these situations, I often suggest dividing by two. Here’s what I mean. If you plan to take a walk, but it becomes too difficult — divide by two — try going to the mailbox. This way you won’t find yourself trapped behind your bedroom door, beating yourself up for the plans you didn’t implement.

Client: This is going to sound pathetic, but the mailbox feels pretty far away, too.

Therapist: I bet it does. I’m glad you said that. The useful thing about this technique is that it’s flexible. You can always divide by two again. If the mailbox is too far away, determine if you can make it to the living room. If that’s too far, divide by two again, discover if you can make it to the nearest bathroom.

Client: If the bathroom is too far?

Therapist: It might be. Depression can be that way sometimes. But the trick is to do more division. Determine if you can put your feet next to your bed. If that’s too much, you guessed it — divide by two — practice a progressive muscle relaxation exercise while in bed. Too much? Start thinking about what it might be like to practice progressive muscle relaxation. The idea is to divide your plans until you find the outer range of what you can handle. Anyway, I’m sorry for preaching. Tell me about where this might not fit your situation.

With this behavioral intervention, I can invite my client to consider how to reenter their life after forfeiting their plans, and this can prevent them from sliding back to the base of the mountain. Instead of returning to complete inactivity, they can ask themselves what half-measures they can handle, and this can boomerang them back to the outer edge of engagement in their life.

The Five G’s: An Affective Intervention

Exploring the cognitive and behavioral parts of my client’s experience of being a burden is important, but so is discussing their emotional experience. This means exploring the emotion of guilt. Guilt has always carried a negative connotation for me. It makes me think about childhood religious guilt or being prompted to donate to sick puppies at the grocery store register. No thanks. Those puppies had it coming. I’m too familiar with the internal wincing that’s created by guilt. It’s an emotion that pinches the heart.

But my clients have taught me how to help them with their guilt. And in order to explore guilt’s excesses, I had to learn about its purposes. There’s a version of guilt that’s deeply important to wellbeing, and once I understood this, guilt’s surpluses became clear. What I learned is that guilt is an emotion that requires training. It’s an unbroken colt teeming with raw force. Nature doesn’t provide guilt with a safe level of calibration.

Without the right technique, it’s dangerous to the rider. This is the reason my perspective on guilt had previously been negative. I experienced guilt’s force, and it led to injury. The only colt that I had ever known had bucked me to the ground, and from the dirt I cussed and condemned it. I didn’t know it needed to be trained. I didn’t understand that before guilt could teach me anything, it needed to be taught by me. More on this in a moment.

I also used to think that guilt was an emotion that was only relevant to my past behavior. When I behaved in ways that were misaligned with my values, my guilt pain came after. Then I’d get stuck there. I’ve since come to understand that this fixation with the past is characteristic of untrained guilt. It can lead to injury. But when guilt is well-trained, it’s not only an emotion related to past regret, but it protects me from future regret, too.

The purpose of guilt isn’t to create suffering for the mistakes I made yesterday, but to prevent more suffering in my tomorrows. This guilt might take a moment to evaluate my mistakes in the past, but its additional purpose is to create fulfillment in the future. It seems that when guilt is well-trained, it’s equal parts retrospective and prospective.

This also seemed true with my clients. When my clients held unbroken eye contact with their past, they lost the ability to move forward. Focusing on their mistakes this way could lead to self-hatred, and this self-hatred would foment the conviction that others must be protected from themselves. When the retrospective was dominant and the prospective was absent, these clients would become convinced they were a force for harm in the world. But in order to join them in these difficult moments, I will try to introduce the 5 G’s. With it bit of luck, it can sound something like this:

Client: I don’t know, I’m just the worst.

Therapist: That seems harsh, and only one of us has that opinion of you, but what brings that forward?

Client: Same stuff. I just feel awful that I can’t get back to work. I tried to contact HR to figure out the process, but I started crying while I was drafting the email. My wife deserves better.

Therapist: It sounds like there’s a lot of guilt going on in there.

Client: Yeah, and I deserve it.

Therapist: Can we explore this guilt a little more? I have a few ideas.

Clients: That’s fine.

Therapist: I don’t believe guilt is harmful in every case, but in this one, I’m not so sure. Can I share a strategy to help you determine whether your guilt is useful or not?

Client: Go for it.

Therapist: So, I think we can assess guilt by using the 5 G’s. This stands for Good Guilt Gives Good Guidance. Yes, the alliteration is excessive but here’s what it means. When guilt teaches us something about how to succeed in the future, then I think it can be helpful. But when guilt doesn’t provide guidance, or if the guidance that it provides isn’t particularly wise, then the guilt is working in service to the depression. It creates an emotional environment where the depression can make itself more comfortable. But tell me what I might be overlooking.

Client: Well, I hate myself for being stuck, but my guilt is also telling me to go back to work. How is that not good guidance?

Therapist: Right. I think you’re close to identifying what your guilt is saying, but I think you might be missing two words. Tell me where this doesn’t fit, but is it possible your guilt is telling you to return to work right now?

Client: Okay, right.

Therapist: I’m wondering if you think that’s good guidance. What do you imagine would happen if you returned to work after lunch today?

Client: It would be a nightmare.

Therapist: We can probably agree it wouldn’t go so well. So, how might we update this guidance to make it more useful to you?

Client: I don’t know. Maybe I should tell myself to return to work eventually? But that doesn’t feel urgent enough.

Therapist: Hm. I can see how that might feel too open-ended. Can I submit a rough draft for your editing?

Client: Go for it.

Therapist: What about something like, “Do everything that’s possible to feel better today, because this will get me back to work as quickly as possible.” But take out your red pen, where should we make edits?”

This framework can help me to extract the wisdom within my client’s guilt. If I can ask them to evaluate their guilt along the lines of its guidance, this can nudge them away from looking backward and towards looking ahead. The client can travel towards their feeling of guilt, but for the purpose of returning with a new direction. This can bring the retrospective to the prospective, the colt to its bridle, and the feeling of guilt to its belated resolution. Once it’s well-trained, their guilt is a guide.

***

Working with clients who consider themselves a burden has been rewarding work. These clients have taught me that when they unravel their Blended Truths, Divide-by-Two, and implement the 5 G’s, they can release themselves from this conviction. Once their sense of being a burden is broken apart, disconnection from others can be incrementally reduced, and attachment to those they wanted to protect can occur once again.

[Editor’s Note: In the next and final installment in this five-part series, the author will address the challenges of balancing empathy and burnout]   

Donald Meichenbaum on Coping with Loss and Traumatic Bereavement

Lawrence Rubin: Hi, Don. Thanks so much for joining me today. You are most widely known for your foundational work in developing CBT but it is equally important that our readers know that for these last 35 years, you have been the director of research at the Melissa Institute for Violence Prevention and Treatment in Miami, Florida.
Donald Meichenbaum: (DM) Thank you for the invitation.
LR: You had previously requested that my first question be about the tragic and unexpected death of your wife, Marianne?

The Irony of a Trauma Specialist’s Tragic Loss

DM: We were married 58 years. My wife and I were vacationing in Clearwater, Florida, escaping the snows of Buffalo, where our permanent home is. My wife was tragically hit by a car at a pedestrian crossing. You know they have flashing lights, and this is sort of a warning sign. She was hypervigilant about not trusting people to stop, so obviously she would not have stepped off the curb if the vehicle had not stopped. But for whatever reason, the vehicle continued on and hit her. And in fact, she was lifted by a helicopter from Clearwater down to the trauma center in Saint Pete.I had called her on her cell phone thinking that she was late because she had a Zoom yoga meeting that she usually attended. I got a male voice, and he indicated that she had been hit and taken by helicopter down to the trauma center, but they would provide me with a police car to drive to the trauma center. I got there and the trauma physician indicated that she had already died. I asked to see her, went in and she was covered by a sheet. I pulled down the sheet, and she was pretty messed up from the accident.

I’ve worked with head injured, so I’ve been involved in seeing such incidents. Remarkably, her hand was still warm when I caressed it. There was a chaplain sitting next to us and I asked her to take a picture of me holding her hand. I actually sent that picture to my daughter-in-law who made it into a pillow. So, it was a traumatic bereavement kind of situation.

The irony is that morning I was giving a Zoom lecture for therapists in China on how to cope with traumatic bereavement and prolonged and complicated grief. And by four o’clock that afternoon, I was living my lecture. So, one of the interesting aspects of all this, and I’d be happy to discuss it with you, is what is the immediate and more long-term impact on an individual such as myself, who is in some sense is an expert on the area of interventions — having developed cognitive behavioral techniques.

Interestingly, there are hundreds of these kinds of accidents, many in Florida, of people — for whatever reason, where the driver is not complying with the pedestrian crossing. And there are multiple accidents and deaths in this particular way. So, the issue of traumatic bereavement as compared to a kind of prolonged complicated grief is an issue that I have been preoccupied with. And moreover, I’ll just add this final note before we open it up for your further questions. There are two aspects that are really quite fascinating in the aftermath of such traumatic bereavement.

One has to do with dealing with the grief. And the other aspect that is not readily discussed by clinicians is the sequelae that follow the sudden death of a loved one. And I will give both you and the readers to this presentation, a keyword that will change your life forever. This is the most important thing you should take away from our discussion. And the one word that you need, Larry, that will change your life if you do not already have it in your repertoire, is “passwords.” If you do not have the password of your significant other who died in a traumatic fashion, you are screwed.

LR: You’ll lose access to everything.
DM: Yeah, right. So, at a moment of intimate repose for your listener, they should lean over to their loved one and say, “I love you, but do you know our passwords and how to retrieve them?” So, you know I can fill you in and turn this into a kind of therapy session? And tell you the kind of trauma events, both dealing with the aftermath of the loss of my wife, but also the police reports, the autopsy reports, the life insurance, the banking, all of the credit cards — everything that goes with it.And the interesting thing is, if you are a clinician, one of the things you do in helping me is assessing, what is the lingering impact of this, what was the aftermath like? But it’s unlikely that you would have done that and asked does your social life change, and then a whole bunch of other questions that I’ve put together. In fact, the lecture that I was giving that morning to Chinese therapists, that entire 80-page handout that I provided them with is available to your listeners.

So, if they go to Google – Meichenbaum, Donald, Melissa, Institute – they will be able to download my 80-page tool plus other items on how to treat individuals who have traumatic bereavement and prolonged and complicated grief. So, if there’s anything I say that might be of help, I’m glad for that. And moreover, if there are people who want to contact me, they could do so through the Institute.

LR: I’m fascinated by the one word that you said clinicians, spouses, partners, family members should know, which is “password.” What’s the significance of imparting that piece of wisdom of knowing your partner’s password? And how did it play out in your journey?

DM: To access a number of accounts, my life was such that my wife Marianne was a wonderful wife, a very competent person. She was an actress, and she was a June Taylor dancer. She looked after all of our finances. I’m not a very competent person other than psychology. I’m a really good psychologist. I know a lot.

But when it comes to life, she was what I would characterize as my surrogate frontal lobe. And therefore, I never knew how to run appliances or bank machines or any of these kinds of things, and she looked after it. So, to gain access to that information, you really need the passwords. Fortunately, I have four wonderful children who are competent and loving and supportive, and that helped a great deal. So, we were able to, over a lengthy period of time — trust me, it took more than an entire year — to settle accounts related to adaptive functioning and financial issues and the like.

I won’t trouble you and your audience, but to highlight how unfriendly, how totally unfriendly the system is, to the 1,000,000 people who lost loved ones due to COVID. You know, the 20,000 individuals who died by interpersonal violence. You know, the incidence of mass shootings and all the other kinds of episodes, you know, the 48,000 who have to survive the suicidal death of a loved one. So, this discussion is absolutely remarkably timely, let alone the loss of natural disasters. I mean, just think of all the people at Maui whose lives are just upturned, and the many wars and the like. So, dealing with loss, grieving, traumatic bereavement, and mourning has to be on the top agenda of every clinician.

Difficult Therapeutic Conversations

LR: Working with adult children of elderly parents, clinicians have to enter conversations about what their plans are with and for them. And it seems to really behoove clinicians to engage these clients about the possibility of traumatic loss and unanticipated loss without pre-traumatizing them. How can we do that?

DM: We have to remind ourselves that what makes us effective therapists is the quality and nature of the therapeutic alliance that we establish, maintain, and monitor with our clients. So, to answer your question, I would advise clinicians to not enter that discussion without the permission of their clients. If I were in that situation, I would say something like, “I recently had a personal loss and I had a lot of lessons that I learned. And I was wondering if you would be interested or willing for me to share those.” So, my notion of being a good therapist is always to solicit permission from my clients, no matter what it is I want to ask. The third thing I would do is to say that, “you should feel free if this is not a good time or this is what we want to do, to put you in charge.” Remember that we, as therapists, need to be person-centered rather than protocol driven.

So, it sounds like, Larry, you had a whole bunch of to-do tasks that you think this elderly client or loved one should go through, right? You said you don’t want to traumatize them. Well, I agree totally. You know, so treat them with the same respect that you would want.

LR: How do we have conversations with our clients who may not even have elderly parents, but who are aware that they live in a world where there are dangers around every corner. How do you help clients prepare for the unpredictable without pre-traumatizing them?
DM: I have a kind of style of therapy, and I’ve actually highlighted this. I just put together a legacy course on what makes people expert therapists. As it turns out, 25 percent of therapists get 50 percent better results and have 50 percent fewer dropouts. So, my legacy course is, what characterizes those 25 percent of people and how can I elevate clinicians to that level? I have a kind of interpersonal style of respectful curiosity. And I really want to convey that to the client and wonder if they’re curious as well.I might say things like, we live in — how should I describe it — precarious times. With the COVID epidemic, with unpredictable violence, with multiple disasters and I must confess that I personally wondered to myself, and I wondered if you wondered to yourself about, given the unpredictability of life ever occurring, are we and our loved ones prepared for that? I mean, that’s my style of interacting. So, what I’m doing in that is actually sharing the rationale, and I’m extending an invitation.

My client might choose to take that invitation or not. And moreover, if I am going to see that person again in the future, all I want to do is plant the seed, then I will be able to follow up. I would say maybe this isn’t the right time or I’m not the right person. But as I look around, I think it might be advisable. And even something as simple as knowing the password of your loved one might be a good starting point. So that’s my way of engaging people.

LR: As simple as that. Simple, but complete.
DM: The key, or perhaps the challenge, is to deal with difficult issues in a non-traumatic engendering fashion.

Lessons on Grieving through Personal Loss

LR: In what ways, looking back, has your own clinical work and research helped you in your journey of grieving?
DM: Now that I’ve talked about the sequalae, let me take a moment and talk about the grieving thing. One of the things that’s really important for your audience to know — and there’s good research by George Bonanno and others that in the aftermath of loss — is that whether it’s due to traumatic, violent episodes like this, or whether it’s due to more prolonged, complicated grief as a result of having someone who’s been ill for a long period of time; there’s an expectation and different kinds of deaths have different kinds of impact.The bottom line is you need to recognize that most people are highly resilient. If you look at the data, most people don’t develop prolonged and complicated grief. So, the key aspect is, what distinguishes those who do versus those who don’t? And I even wrote a book called Roadmap to Resilience, that examines this and deals with it. In fact, your audience is welcome, in honor of my wife’s death, to view this and also my legacy course in her memory. So that’s one way of transforming pain into something good that will come of it.

And in fact, the Roadmap to Resilience has been downloaded for free on the Internet by 45,000 people in 138 countries. So now, let’s get to the heart of your question. In fact, George Bonanno wrote a really nice book called The Other Side of Sadness, which I recommend. It’s a nice little extrapolation on the kind of resilience engendering behavior. Therese Rando has also developed a concept that I’d like to comment on, that she calls “STUGs,” Sudden Temporary Upsurges in Grief.”

And in monitoring my own behavior, since I’m a psychologist and good observer, I’ve tracked my own STUGs. These kind of substantial or sudden kinds of upsurges of grief. And there are two kinds of STUGs in my life that I’ve discovered that have important clinical implications. The first STUGs are sort of sudden and unexpected. A song comes up, an invitation comes up to go to dinner with someone who doesn’t know about my wife’s loss. A couple walks by holding hands and lovingly convey their intimate connection.

And that hits me in an unexpected way. I’m moved to tears, and I have a sense of loss and the like. And there’s nothing wrong with that. In fact, I’ve come to believe that each tear that I experience in loss is not only a reflection of the loss and the grief and how much I miss her and the like, but it’s also a tear of appreciation. Of how lucky I was and grateful to have her in my life all these years. And then, I would have never had this career and all that without her. I’m a cognitive behavior therapist, so the whole thing is not that you cry, not that you feel losses.

It’s what is the story you tell yourself and others about that emotion? Each of us, each of your readers of this interview are not only Homo Sapiens, but they’re Homo Narrans. That we’re actually all storytellers. And the nature of the story we tell will determine — I’m going to suggest — whether you fall into the 20 percent who develop prolonged and complicated grief, or you’re part of the 70 to 80 percent who, in spite of the loss, everlasting loss, your STUG is this kind of sudden reminder.

LR: Unexpected!
DM: I sort of expect them, but they come out of the blue, right? The other kind of STUG which is interesting is something that’s a reflection of a prolonged type of routine or activity that we would have engaged in. So, I’m in Cape Cod, one of the things we would do is go down and have our sunset drink on the beach. A saxophone player would often be playing in the background from their beach house, you know, some Cape Cod song that we would have toasted to, kind of thing.Or we have our favorite restaurant, or our favorite hike or something like that. And I’m now doing those activities on my own. There’s another really interesting aspect to this, and that is, is the person who’s surviving the death, male or female? Okay, so most of my social contacts here in Cape Cod, and in other places, are a derivative of my being a partner of Marianne. So, she had a remarkable social network. She was just lovable and likable. There wasn’t anyone who didn’t fall in love with my wife.

And when she died, those social contacts sort of evaporated. People sort of give you occasional email and a “how are you doing?” But you don’t get invited to the same social occasions or dinners or other kinds of activities, so your network is really an important issue. And the important predictor here, especially among men, is loneliness. Okay, and there’s a higher incidence of husbands dying soon after the death of their wife, about 30 percent and so forth, and having other kinds of physical ailments than the other way around.

And then you need to distinguish between loneliness and isolation. Some people choose to isolate — they like being alone and so forth. Loneliness is yearning for this. And so first of all, in the aftermath of both traumatic bereavement and in terms of the mourning process, that becomes important. The other thing that your readers should take away is that there are no stages of grieving. So Kubler-Ross and Ron Kessler’s stuff about going through stages has no scientific basis for it.

And not only do you not have the five stages, but the expectation on the part of the clinician that people need to go through stages, and the failure to do so is a sign of pathology, is indeed problematic and possibly stress-engendering. So, when people don’t get angry, okay, then it’s deniable or they can’t handle their emotions. And I had a pretty good cause to be angry. This happened in Florida, okay? So, the guy who killed my wife got fined 160 dollars and lost his license for three months.

That was the total consequence. Not only that, in Florida — this is a wonderful state to live in if you’re going to retire — you don’t have to have liability insurance on your car. Okay? All you need to do is pay insurance up to 10,000 dollars. The helicopter cost of taking my wife from Clearwater to the trauma center was 68,000 dollars. So not only do I have, look, how much time do we have? You want me to go on and on? So, what am I going to do? And anger we know, gets in the way of processing trauma memories. Of all the emotions, that’s the one you don’t want to give up to. And that’s the one that clinicians should ask about in the aftermath.

So, if you go to the handout that I have, I have put together the most important diagnostic questions that clinicians should ask. Yeah, I give workshops on grief, and I actually bring my pillow and tell people. And I ask, if I’m your client, Larry, what questions do you think you should ask me? You’re a gifted clinician. What do you think are the most important questions you should ask me to see whether I’m going to develop prolonged grief disorders? Because there are now effective treatments. Shearer and others have created really good cognitive behavioral interventions, when I go on and on and review all the literature. So, I can make this a two-way street. I could ask you, what question do you think you should ask me first?

LR: What comes to mind is, how has your life changed?
DM: Wrong question!
LR: Okay, I could probably guess 20 times wrong.
DM: No, no. The first thing you should ask is, “how long ago has this occurred.” Okay, if this happened like last week or last month, that’s different than if it occurred a year ago. Okay? You know, and then there’s a whole set of questions you could ask about the circumstances, like you did at the outset. Okay, so getting to the notion of how you handle this has a kind of implied judgment on your part that I should be handling it.So, am I going to tell you how bad off I am or am I going to say oh, it’s not that bad, right? So, you have to establish a good therapeutic alliance with me, where I’m going to be open and honest. You know, I have trust engendering things, so I don’t know what your agenda is. Anyway, go to my handout.

LR: I will. I will.
DM: Please, I didn’t mean to put you on the spot.

LR: It’s refreshing and intimidating at the same time. What other guidance are you offering to clinicians who maybe are sheepish about asking the questions, or will not openly receive or seek out clients who have experienced loss? 

DM: The first thing — over and above the comment on stages — is that the field of psychotherapy is absolutely filled with bullshit. I wrote an article with Scott Lilienfeld called, How to Spot Hype in the Field of Psychotherapy. The next thing for therapists to understand is that the various therapeutic procedures are equivalent in outcome, and that there are no winners in the race. So that’s the next thing, just don’t believe the hype in these workshops where these people are saying that, “X, Y, and Z works better.”That traumatic bereavement is a common response, will lead to grief and mourning that leads to deteriorating performance is just not the case. So, the second thing that’s really important is that you need to ascertain from the client how to do therapy in a culturally and religiously, and gender-related kind of fashion. You need to ask the person — in my case, whether I’ve had other losses besides Marianne. You need to make me a consultant to you. Okay. And then you need to probe. How did I handle those? And is there anything I learned from them? So, you need to see me as a client as a resource person rather than someone you’re going to treat because you went to some workshop. Okay!

And apropos of the loss and transition website by Neimeyer and colleagues, they have a lot of techniques. Some of them are expressive. Some of these are customary activities that people engage in. So, you, the clinician, need to honor the way in which I want to cope with grief. Okay? And I recently went to a workshop by Mary Francis O’Connor who wrote a book on the grieving brain. And you need to recognize that some of the losses that people experience are natural and a reflection of love.

So don’t pathologize people’s grief or their coping techniques. If I want to avoid certain activities, I don’t go and get rid of the clothing and so forth. And there was a movie that Tom Hanks made that his wife produced called, A Man Called Otto. It’s a bit of a Hollywood version, but they did a really good job on talking at the gravesite. And doing the thing on the clothes. Here’s a wonderful thing that happens. When I cleaned out my wife’s closet, I found out that for the five years that we courted each other, we had written letters. And mind you, that was 1961. She saved all those letters. In 1961, a stamp was four cents. I read those letters as if she was present, each night I take out a couple. I’m now up to 1963, you know that stamps now cost $0.08 in 1963? Her presence, my storytelling, my doing this interview, my reading the letters, are all my own personal ways to honor her memory. The fact that I put the Roadmap to Resilience online for free in her memory.

If you go to the Melissa Institute website, if you’re interested, if you like this interview, go there and make a donation in my wife’s name. We’ve already raised 25,000 dollars for the Institute against violence prevention for her. I’m now in the midst of having done this legacy course of ten one-hour lectures on what makes someone an expert therapist, and then how to take those core principles and the transtheoretical behavior change principles and apply them to a whole host of diverse problems like grief and PTSD and anger and the like.

Each of those courses is only going to cost 150 dollars. Okay, that’s 15 dollars per CEU. All that money is going to go to the Institute in memory of Marianne. So, if you want more of what we’re talking about, track down this legacy course. If you do, there’s the likelihood you’ll be in the 25 percent group and you’ll be able to honor my wife’s memory. You get CEU’s for cheap.

The Role of Resilience in Healing through Grief

LR: You mentioned something earlier on, Don, about resilience as one of the really powerful predictors of how someone will move through their grief journey. Can you say a little bit about what a resilient griever looks like?
DM: In the aftermath of trauma or victimization, and with regard to whatever form it takes, resilience has been equivalated with notions of the ability to bounce back and with dealing with ongoing adversities. And it deals with the notion of personal growth. Margaret Stroebe and her colleagues have an interesting distinction within which people oscillate. That is, they have a variety of coping responses that are loss-oriented or restorative, and future-oriented. One of the things that’s interesting is that people can deal with it as a kind of Viktor Frankl type of observation.That people could deal with any kind of how in their life, as long as they have a kind of why in their life. Some sense of meaning, making purpose. This fits into my constructive narrative perspective that everyone is a Homo Narrans, or a storyteller. So, one of the things that becomes really interesting is how people transform their loss into some kind of effort to help others. So how did the Melissa Institute come about and my involvement therein? So, in the tragic killing of their daughter, Melissa, when she was at college in Saint Louis at Washington University, they have transformed the last 28 years – her loss — into a meaning-making activity.

You can go to the Trevor Project on suicide. You can go to Mothers Against Drunk Driving. There are numerable examples, I give multiple websites of how people have transformed their pain into something good. That doesn’t mean that you don’t continue to have an everlasting sense of grief. There’s nothing wrong with grief. It’s like any other emotion. The key is, what do people do with that emotion? Do they withdraw? Do they isolate? Do they become lonely? Do they use addictions? Do they self-medicate?

So, the key question is not, apropos of the resilience, or that people grieve. The fact that people are in touch with their grief is, in fact, a sign of resilience, right? It’s coming to, how do they honor? How do they memorialize? I deal a lot with returning soldiers. And the other kind of thing is that there are different kinds of losses. There’s loss of people, but there’s a thing called missing loss also. Like imagine people who have individuals who go missing in action. You don’t know if they’re dead right, or in Maui — you know, they haven’t found certain bodies. I mean, does that mean, is there more?

How do I, do I sort of get preoccupied and ruminate about the loss of my loved one, and how I wasn’t there? If I have guilt, shame, humiliation, if I have anger, if these kinds of negative emotions are that which drives me, then that’s the person, those are the folks who are going to be more likely to get stuck, who have hot cognitions and the like. So, you can talk about resilience being the absence of negative stuff, or resilience could be the restorative process on the other end. I don’t know if I’m getting close to your concerns, but…

LR: That resilience, and there are certain personality attributes and certain experiences that predispose people to resilient ways of being, and those people are probably in a better place to move forward in their lives after a loss.

DM: Here’s one of the things I failed to mention. The research indicates that people who have had a prior major depressive disorder are significantly more likely to develop prolonged and complicated grief. So, when I was asking the question, I ask, “Have you had similar losses in the past” and so forth? What we could do is look for vulnerability factors, okay, that are red flags as another tip. To see who would warrant evidence-based interventions, we’re pretty good.

If you look at my core task, there’s a whole way of how we, as therapists, do psychoeducation to educate people about grief. Or how do we help them develop various kinds of coping strategies? And how do we get them to follow through? The big thing is how do you get people who need help to want to come for help? And help them stay there? That’s the artistry of therapists.

LR: Is it more likely that those who have historically reached out to others for help, who have built lives that are rich in community, are just naturally predisposed?

DM: Well, a lot. There’s a fair amount of research by Camille Wortman and Roxanne Silver. Obviously, one of the building blocks for resilience is relationships. I mentioned I have four loving kids who really came to support, I have other people — professionally and others — who’ve come to support. But Wortman then really found a whole bunch of things that people do that are unproductive, that actually make people worse.

They have identified a variety of things that people provide support for, and actually make people worse. Like moving on statements. Things like, “You’re still a young, attractive, bright guy. You’ll find someone. How much longer before you die, You’ll be able to join him. This was God’s mission, He knew something.” So, there are lots of things that social support people offered, so that’s one of the questions you need to ask.

What, if anything, have people done or failed to do that you found helpful or unhelpful, right? Because you want to make sure that you, the therapist, aren’t doing something that I perceive as being unhelpful. So, if you’re a really good therapist, let your patients teach you how to do therapy. Don’t think just because you went to graduate school or took some workshop that you know how. Ask your patient, “What do you think is causing you to still have this lingering grief? And what do you think it will take to help you to move on? And what is it that I, the therapist can do to help you in that process?”

LR: You know, Bob Niemeyer suggests that therapists working in the arena of grief need to be what he calls the guide on the side, rather than the sage on the stage.

DM: Yeah. I like that. That’s a good metaphor. I like him a lot. I’ve read all his stuff. And, you know, my thing is, don’t be a surrogate frontal lobe for your patients. Don’t let the person’s emotions hijack their frontal lobe.

LR: And don’t, as the therapist, let your emotions hijack your presence in therapy. What about those therapists who themselves have had complicated losses, or unfinished business with their own children, parents, and spouses who have died?

DM: Well, I guess those therapists need to be honest with themselves and wonder how it impacts their therapeutic process. Those therapists need to be honest with themselves and decide whether, in fact, they need some therapy. That could help them deal with the issue. And the third kind of issue is, can they strategically use that self-disclosure in a way that facilitates or benefits the patient’s recovery? Rather than saying, you think you’ve got problems with your wife? You want to know what living with cancer has been like? And not only that, my father has Alzheimer’s, and now all of a sudden I have to listen to your shit, right?

So, you can judiciously, strategically say words are inadequate to describe what grief is like. I’ve been there myself. It’s not the occasion for me to share the details, but I want you to know I’ve felt the pain. Okay, I don’t know what the right words are, and you have to say it in an effective way. You can’t say, you think you got problems?

LR: In what way are you — are there any ways that you’re still practicing as a therapist now?

DM: I do a lot of consulting. I work with the head injured thing when people have cases, I train therapists who are doing supervision. I’m not seeing patients now like I did in the past, because I’m not in one place. I’m kind of a peripatetic clinician, so it’s hard to make a commitment to someone being there. I do some consultation with patients by telephone, since COVID.

LR: We could talk for hours Don and I do I hope we talk again. I appreciate your kindness and generosity.

DM: Thank you for the compliment and for inviting me on this journey.

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