Depression Archives - Page 5 of 6

The Shape of Hopelessness

Posted on June 6, 2019February 11, 2026 by Psychotherapy.net Team

Mr. C doesn’t say he is sad. He isn’t crying. But his face is like stone, draped in a small disconnected smile, and my own insides have turned to lead. Hopelessness clamps down like a vise. I am sitting at the foot of his hospital bed in the nursing facility where I provide psychiatric consultation. Mr. C rarely leaves his bed, around which he insists the thin pink privacy curtains remain closed to wall off the three other men who share his room. The social worker had asked me to see Mr. C because he’s due to be discharged, and she’s been worried about him. Even the air in the room feels heavy. It’s hard to move or even breathe without hope.

Mr. C is only in his early 40’s, but diabetes has taken a part of each foot, and he can no longer work as a chef or care for his mother, who has dementia. “Now I’ve got nobody. Even when I was taking care of my mother and had a job, I could barely leave the house because of my anxiety, and I let my feet rot,” he says. “I’m afraid I’m not going to do the basic things to take care of myself. There really isn’t any hope for me.”

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My thoughts start to churn. There is no way I can help this man. His problems are not solvable. What I have to offer is too puny, and my own background too sheltered. I even notice a small spark of anger at him rising inside me. I want to leave, to retreat to the comfort of my office and sit with thoughts unmarred by unbeautiful things.

I’ve had the luck of meeting a master of empathy, a meditation teacher I met last spring on a day of silent retreat. Attempting to focus on my breath as I sat on my cushion, my mind had erupted with grief over a recent personal loss. The pain was disorienting, concentration all but impossible. My teacher’s advice was simple: let the feelings come, notice them. Her words were ordinary, but her compassion was not. She received my sadness without flinching, letting it vibrate within her as she held my gaze and smiled with warmth and calmness. I felt my connection with her creating another dimension that allowed my sadness to find the space to take its own shape; I did not have to carry the pain alone. It opened like a quilt held between us, and I could see it for what it was and only for what it was. My pain was no longer the sign of inevitable and unending suffering; it was just a feeling I was having in that moment.

Now, as I sit with Mr. C, I gently shake myself from the trance of hopelessness and the trap of my own ego that sustains it. I can’t solve this man’s problems, but that is not shameful. His problems are severe and overcoming them will require a lot of hard work from him. He may or may not be willing to do that work. I can offer him empathy, compassion, and guidance. Those things might not be enough, but then again, they just might be. As I bring myself back to this moment at the foot of his hospital bed, I recognize that within an experience that feels like a burden is a remarkable privilege: that of being close to another human being.

“You can’t see things getting any better. You don’t have your mother to take care of anymore. You won’t have your job, and you are worried that you’ll give up fighting the anxiety. You remember how hard it used to be, and it’s going to be even harder now. That must feel utterly overwhelming, and you are probably terrified and feeling intensely hopeless. Is that right?”

He nods somberly, holding my gaze, and tells me about the spells that come down on him in the afternoons when things quiet down here at the nursing home. The feeling of tunnel vision, of unreality, of feeling almost outside of his own body.

“I have such a sense of sadness as I hear you speak about this,” I tell him. “And at the same time, I am grateful that you are sharing this with me. I admire the strength it takes to be honest about what you are facing. And I can see how believing that things are hopeless might almost feel like a kind of relief. You can stop fighting so hard.”

He almost interrupts me, showing more life than I’ve seen him show to this point, “Yes! It’s so, so hard. I hate it here, but all I want to do is curl up in this bed and hide from everything!” And for the first time, he starts to cry. As his tears fall, he asks me earnestly, “What can I do? Can you help me?”

At this moment, something shifts. He isn’t falling back into hopelessness and helplessness. He is asking me for help. In fact, I have plenty to offer him. “There are powerful tools to address your anxiety,” I tell him. And gently, keeping tabs on his level of interest, I explain how avoidance locks anxiety in place, and how exposure therapy can retrain the mind to experience anxiety differently. “If you want,” I offer, “I could show you how to systematically challenge your fears. It’s very hard work, but it could open a lot of possibilities for you. Would you want to work in that direction?”

“Yes, I’d like that,” he replies.

Hopelessness is a horrible feeling; it is no wonder we flinch from it. When we welcome it between us, it becomes all of what it is, and only what it is, and there is room for something else that looks a lot like hope.

Judith Grisel on Addiction, Neuroscience and Choice

Posted on May 15, 2019February 11, 2026 by rezendevknowfully.com

The Age of Neurophilia

Lawrence Rubin: Hi Dr. Grisel. I first became aware of you when Terry Gross interviewed you on her NPR show, Fresh Air, about your book, Never Enough. You mentioned that after that interview, they led you through a room where they store the hundreds of books they receive each week for consideration. I’m wondering, why did they pick yours from that pile?

Judith Grisel: Three things I guess. One is that we are really in a time in history where we’re very interested in the brain and in science. So, seventh graders appreciate things about the brain that we didn’t even know 30 years ago, and

I think there’s a neurophilia going on

I think there’s a neurophilia going on. Second, addiction is so widespread, practically everybody is touched by it. And third, I also think on my part, being at a liberal arts university and having to speak to students about complex ideas on a daily basis, I must be able to mine the minutiae of scientific inquiry and translate and explain its general principles in a way that people can understand.

LR: That reminds me of Stephen Hawking’s tiny volume, A Brief History of Time. Bringing it to the people, so to speak. What do you hope your slender volume will do that others haven’t in this conversation around the neuroscience of addiction?

JG: My hope is that the readers who aren’t scientists will learn about and be able to appreciate the core principles of brain adaptation—how it adapts to every single drug-related repeated experience that alters the way we feel. Seatbelts and sunscreen were not considered life-saving before the research taught us differently. Now, we understand the risks of not wearing seatbelts or using sunscreen, and both are seemingly simple, but most definitely life-saving practices. I want people to develop that kind of understanding about the brain’s adaptive capacity and drug use. My secondary hope is that scientists who read it will come closer to appreciating what it’s like to be an addict. My hope is that I was able to explain that in a way that made sense to both audiences.

Our Brain on Drugs

LR: You use this term, “neurophilia.” The folks who are going to read this interview may have some neuroscience interest, background or even training. Some may be neurophobic, but many, I suspect are armchair neuroscientists using trendy brain-based buzzwords, but who don’t know how to integrate the fruits of neuroscience into their psychotherapy. How can your book and your work around the neuroscience of addiction help neurophobic psychotherapists?

JG: Well, the first thing I would say—even though I’m not a therapist (and neuroscientists don’t understand it all that well, themselves) is that

there’s a difference between understanding the implications for people suffering with addictions and simply collecting piles of data

there’s a difference between understanding the implications for people suffering with addictions and simply collecting piles of data. I think that there’s definitely a place for all voices and insights to come together and try to work on this problem. It’s certainly not as if neuroscientists have made any great strides. So, that should alleviate some fear.

I also think that scientists like me who are working at a chemistry bench top or with laboratory mice, are looking at little trees or even particular leaves on particular trees. In contrast, I think clinicians are more trained to see the big picture—the psychological and social factors beyond the brain chemistry. I think we need a lot more communication and interaction between the neuroscientists and social scientists and the clinicians actually working day to day with addicts.

LR: I interviewed Jose Rey, a psychopharmacologist, a while back and he spoke similarly of the importance of communication between disciplines, especially behavioral scientists like therapists. But you are both neuroscientists and I worry that our psychotherapist audience needs a bit of a primer—addiction neuroscience 101, if you will.

JG: I’d first define addiction, even though there is some controversy over that, and the definition changes quite frequently as anybody who looks at the DSM would know. I would say that there are five characteristics of addiction: Tolerance, dependence, craving, the drug use or the activity needs to be detrimental to the person and to their community, and denial. Those five things coming together are what I’m interested in understanding better. And the tolerance, dependence and craving are due to the brain’s adaptive capacity.

Any experience or drug that alters our neutral or baseline affective state—and this is a little different for each person, forces the brain to adapt to try to bring the chemistry in the brain, and associated behavior, back to that neutral baseline. Some people are naturally lighthearted and happy and some are naturally a little depressive and melancholy. Whatever their particular neutral is, it is the brain’s business to try to figure that out and return to its neutral position. The pathology arises when that neutral baseline is going up and down like wild all the time because of constant ingestion of drugs, because, in part, the brain is unable to sort what’s happening and do something about it.

I drink coffee every day, and what is going on in my brain is a good example. I am completely addicted to coffee. The only good news is it doesn’t cause any problems for me, so you can say maybe I’m not addicted; I’m just dependent. When I wake up in the morning, I am unable to really think or communicate until I get the coffee. I don’t wake up like my 16-year-old does, hopping out of bed and ready to go. I wake up like I’m in a coma. I get a big cup of coffee, and then I feel normal. That is true for every drug. If you take benzodiazepines regularly to deal with anxiety, your brain produces tension and anxiety so that now the benzos make you feel okay and without them you’re a wreck. The brain does something similar, but in the other direction with opiates.

Opiates affect our neutral or baseline affective state. They make us feel great. The brain makes us feel crappy to counteract that and bring us back to an affective neutral. When we take away the opiates, then we just feel bad and miserable. And that’s true for any drug: alcohol, stimulants, marijuana. I think, if I were

working with clients, I would want them to understand that their using has diminishing returns as the brain adapts

working with clients, I would want them to understand that their using has diminishing returns as the brain adapts.

LR: The brain is always trying to pull the body and affect back to neutral?

JG: That’s right. It’s necessary for survival.

LR: Can you quickly run through the different classes of drugs and how they affect the brain and behavior differently?

JG: Let's start with the most complicated drug, which is also the smallest molecule—alcohol. Because it's so small and can go anywhere, it diffuses easily through membranes, and acts very promiscuously throughout the brain, including making us sedated, euphoric and less anxious.

At the other end of the spectrum are the stimulants; the class of drugs that includes methamphetamine, amphetamine, MDMA. They act in particular spots in the brain to enhance the amount of monoamines—dopamine, norepinephrine, and serotonin—in the synaptic spaces. By acting locally that way, they do two things. They make you more active behaviorally, so that's why they're stimulants, and they also make you euphoric, because dopamine works more directly in the mesolimbic system.

THC also acts all over the brain, like alcohol, but unlike stimulants it has a unique mechanism of action. THC mimics the endocannabinoids which can swim upstream across a synapse—it's a really unique pharmacology. The presynaptic cell sends a message to the postsynaptic cell, which on occasion makes these endocannabinoids tell the presynaptic cell, "What you just told me was really important." It can do that all over the brain, because we never know which circuits are going to be responsible for keeping track of important things. And when it does that with THC, then the whole brain thinks things are important, which is why Rice-A-Roni is delicious when you’re stoned.

And then there is LSD and the psychedelics—mescaline, peyote, and DMT, or the stuff in ayahuasca; and those four chemicals are unbelievably selective. They're agonists, so they mimic serotonin at the serotonin 2A receptor, and that action causes the serotonin filter to turn off. So, we can think of serotonin normally as kind of dampening or inhibiting most of the neural activity in the cortex. It's like a widespread filter. And when the filter comes off, things go wild. And so, there's it's kind of unfiltered cortical activation.

The benzodiazepines and the barbiturates are basically alcohol in a pill. The difference between benzos and barbiturates is that the barbiturates can be lethal, and the benzodiazepines cannot, although they both make a mean dependence.

LR: Is this new craze around cannabidiol (CBD) products potentially problematic, because they're touted as non-addictive and non-pharmacological, but useful for everything—like pharmacological duct tape, I guess.

JG: Placebos work for everything, though it's very hard to sort the science from the hype, and I think people are completely lost. On the other hand,

CBD is not dangerous, as far as we know, and if anything, it inhibits the effects of THC

CBD is not dangerous, as far as we know, and if anything, it inhibits the effects of THC, which has been linked to psychosis. There is also some evidence that CBD can inhibit psychosis. So, CBD is not addictive and it's an antagonist to THC. There is great evidence that CBD blocks certain seizures in children. I think overall that the evidence for THC is 10 times messier than for CBD. And one important way it's messy is that we can see that acutely, it helps somebody sleep or it helps anxiety. But because you develop tolerance, my strong prediction is that those returns are going to diminish with time and, in fact, the drug will create anxiety and insomnia, which is what regular users say. They cannot sleep without it. They cannot get through a day without it.

Self-Regulation

LR: When I teach abnormal psychology to my graduate students, I discuss addictions, eating disorders, gambling and even obsessive-compulsive disorders under the broad umbrella of disturbances of self-regulation. Our society seems so hellbent on opposing the body’s natural need to regulate itself into a neutral state.

JG: I first want to point out that this is a terrific example of what we were just saying—that we need both sides. We need the information that neuroscience provides at the molecular level but also the broader perspective that your observation implies. Your broad perspective suggests that all addictive disorders can fall under the umbrella of obsessive-compulsive disorders. Maybe obsessive-compulsive disorders, in turn, are under the umbrella of self-regulation. So, I really think it’s helpful because we’re focusing on some little, tiny detail and missing the big landscape.

I do want to say that we’re absolutely clear in neuroscience that everybody’s innate capacity for self-regulation is not the same. So, some people are fortunate with metabolism of monoamines, for instance, in a way that makes them a little more cautious and less impulsive. Impulsivity certainly counteracts self-regulation. So does frontal-lobe capacity. If you have a large frontal lobe, you’re better able to do it. I think community support and teaching can contribute to that, so I think everybody’s capable of it. I’m still working on it, myself. It’s not easy for me.

I’m somebody who tends toward extremes right away. I think, just to point out another big-picture view of this, it makes sense from an evolutionary perspective that some of us would be tending toward self-regulation and conscientiousness and careful thought and consideration before acting, and some of us would be more likely to swim to the other shore right away without even considering the implications—whether it’s good for the population—because you need both extremes. So, I think if everybody were reserved or everybody was impulsive, it would be detrimental for the whole group.

I do think in certain conditions, like the ones that you alluded to now of our current social institutions, we definitely value more highly the ability to pause, and you’ll do better if you’re not too impulsive, especially with all these drugs widely available. They are high potency and easy to administer. It’s not a good time and place for people who are poor at self-regulation, that’s for sure.

LR: You say opiates are popular because they are the perfect antidote to suffering. Are we allergic to suffering in this society? We rush to mask it. We rush to medicate it. We rush to therapize it. What is it about suffering that is so abhorrent that it drives millions to drugs and other addictions?

JG: I really love that question. It’s really out of my expertise, so it’s going to be my opinion that I give here, and I can do that best from my own experience. I really did suffer for no good reason as a child. I think I was overly sensitive and tuned in to other people’s plights and confused by the values that seemed to be expressed around me. I don’t know, but I think if I had had an opportunity to talk about this kind of existential confusion, maybe I wouldn’t have found marijuana and alcohol such a sell.

It’s almost a knee-jerk reaction among otherwise sober, sane people to suppress and deny and minimize and escape any feelings of discomfort. Maybe I’m too heavy handed here, but as someone who couldn’t afford to do that anymore, I really think my suffering was the very thing that led to the not so much happy, as the well person.

I think it’s impossible to be well if you can’t face darkness

I think it’s impossible to be well if you can’t face darkness. We don’t have a lot of ways—I know I didn’t find any—to help people face the darkness. If you’re not taking medicinal alcohol, you’re taking medical marijuana. And if you’re not taking either of those, you’re taking prescriptions. If we look at the percentage of people in western societies who are medicating their existence, we are not talking about a physical malady, so much as a psychological malady. I think it’s hard to find people who are models for walking through it. I think that might be a dead end. I have gotten a lot of notes and letters from young people who say, “This is so hypocritical. My parents say, ‘Don’t smoke weed’, My parents say, ‘Don’t do this,’ but they do these things.” I even had a therapist the other day tell me, “Well, alcohol’s not really a drug.” I think that we’re all in denial, I guess. Not maybe you, but many of us.

LR: Well, it seems that—and I know you’ve studied evolution—that an anesthetized and a medicated society does not build a stronger society.

JG: So true. If there was ever a time not to check out, maybe you could say this at any time, but I’m saying it now.

This is not the time to escape our reality.

Choice Versus Addiction

LR: In the latter part of your book, you say the opposite of addiction is choice. Some would argue that’s a bit on the simplistic side; especially those who say it’s a disease.

JG: I’ve gotten a fair amount of pushback about that. We were so bad at solving addiction and the NIH and NSF were funding all this research on addiction and Congress, probably about 15 or 20 years ago, said, “What’s wrong with you guys? Fix it.” At that time, we didn’t understand how the brain works. Like the “No Child Left Behind,” they thought if they made an edict, it would solve the problem.

So, scientists realized, “Well, we’re not going to fix it if our criterion is that people are well.” So, we’ve said, now, that you can minimize the harm—reduce the harm—and that’s partly strategic to say, “Look. We are being successful.” Suboxone is better than overdosing on fentanyl. I completely agree. So, I’m not dualistic about this; that you’re either clean or you’re not and too bad. I really think every single strategy should be employed.

I think we’re diminishing our potential by capitulating to this quasi-existence where we’re not really engaged with reality but we’re also not dying. So, I think short-term strategies are terrific, but I object to giving someone a prescription for a substitute drug and sending them on their way. The causes of their excessive use, I think, need to be looked at. For me, it was a really hard, multipronged effort on my part and on the part of a fair number of professionals before I was willing to take responsibility.

This may sound trite, but

in order to be free, you have to take responsibility

in order to be free, you have to take responsibility. I think, in some cases, people don’t want that. Initially, I sure didn’t want that. I’m so grateful for it today, because sometimes I have a really rough period or day and it does occur to me, “Oh, my gosh. I would just like a brief—”

LR: Escape.

JG: Escape. I go to the movies or take a hot bath. That’s my option. I think that surviving that, awake, looking at the factors in me that contributed to that discontent, or those things I can’t control, I think that’s powerful.

LR: Can we get back to the notion of choice as a path away from addiction. The choice between addiction and what? What did you mean?

JG: What I meant comes from my experience. When I was using, occasionally I would think, "Mm, it's probably not a good idea to use today." Like, I was going to my grandfather's funeral or I was going to be traveling on a plane, or I had a final exam, or something pretty big, you know. So, the thought would come to my head, "I should not do this." And then I would compulsively steer right for it, recognizing for a moment that it was going to be bad. It was going to hurt, cost me, but I couldn't stop.

So, I think the obsession to use is still occasionally in my brain

So, I think the obsession to use is still occasionally in my brain. But what's different is I have some space now between the thought and the act. And I guess what I meant was that having that space is the opposite, because addicts often don't want to use but it’s just inevitable because they don’t have that space.

LR: So, it's a matter of expanding that space that's left if you confront the impulse, if you wait 5 seconds, although I know it's not as easy as counting to 10 to break an addiction.

JG: Are you kidding? No, I counted to 10 many, many times, and also walked around the block and, you know, chewed on spaghetti sticks and just kind of disconnect that habit part of my brain, the striatal part, which

by the time you become an addict, you might as well be a rat in a cage, because it's just press the bar, press the bar, press the bar

by the time you become an addict, you might as well be a rat in a cage, because it's just press the bar, press the bar, press the bar. Even if nothing is coming out.

LR: Like you said, helping build a tolerance to those spaces that feel like crap or those existential spaces where life doesn't have any meaning and life is still not going to have meaning after you stop using. It's how to deal with that lack of meaning.

JG: Yeah, or disappointment, which is a huge trigger for people like me, because disappointment is sort of low dopamine, you know? But I think that a therapist can have a great role here. Instead of trying to avoid the obsessions, to experience the obsessions with somebody who helps us get that distance would be useful. I remember it slowly dawning on me, wow, just because it occurs to me doesn't mean I have to do it, and that was a novel thought.

LR: Where do you land on the debate between those who advocate abstinence versus controlled use, and how can you help therapists understand that distinction?

JG:

I am not against drug use. I am really against addiction

I am not against drug use. I am really against addiction. I don’t think there’s good evidence that people who are addicted can manage a controlled use, ever. Sometimes, they grow out of it, if they’re young enough, so that can happen if they get stopped really early like before they’re 20. The way I think of controlled use is being on a perpetual diet at a holiday party. It’s just miserable because—and for me, it really would be. How can I control myself? There are all these tasty things. So, it’s just the cost—I think the goal should be freedom. I think that’s hard for most people like me to imagine if I was trying to manage my drug use. I’ve heard a million creative ways of doing it and they all look miserable.

LR: What about the difference between those who have a bone fide addiction and those who are midway down a punitive trajectory?

JG: I guess I would ask you a question about that. When I was in abnormal psychology—and this is in the ‘80s—I thought that my teacher told me that the understanding of pathology was qualitative. So, you’re either sick or you’re well, basically. I thought that seemed surprising, but it was a great relief because I was among the well, I thought, for most things. My understanding of the way it is now is that we see most disorders as spectra and at some point, normal functioning becomes pathological.

For addiction, I think that, at some point, the reward pathway—this mesolimbic dopamine pathway that mediates the pleasure we get from addictive drugs–becomes altered. For some people controlled, moderate use—making other things like your children’s wellbeing, for instance, more important than your getting high—those kinds of things become impossible. I guess I see that in my own life. What happened is all I really cared about was drugs. There was nothing—no consequence—that I wasn’t willing to pay. I basically gave it all away so I could have this momentary escape. I think that is so compelling for some of us, either at birth or as a result of experience or probably both, that it’s a point of no return. I think age might influence that.

I’m really concerned for kids. We know 80 percent of substance abusers—people who have addictions—start before they’re 18. Using moderation or avoiding excessive use before their brain is done developing around 23 or 25 might be the way for them to avoid addiction. I think it’s possible, then, to grow out of it, if you can back away.

Maybe addictions that develop in adulthood might be neurologically different than the ones that come on early

Maybe addictions that develop in adulthood might be neurologically different than the ones that come on early.

Teens and Drugs

LR: That’s interesting because a lot of therapists in our audience work with adolescents who live in a very confusing world full of stress, contradictions, widespread drug availability and increasingly pro-marijuana legislation. What must these therapists understand?

JG: The one thing I didn’t understand was: since when do adolescents worry about death? Don’t they think they’re immune to it? Isn’t their ability to self-regulate naturally and appropriately diminished? Isn’t this the time in life when they’re supposed to be taking risks?

I just want to say to the psychotherapists working with adolescents that this seems to me to be incredibly important. For children growing up today, it is, as you say, unbelievably confusing and drugs are everywhere. You can smoke pot now in school right in your seat where you’re taking your math test with no one knowing it. I think that it’s a treacherous time to try to find yourself and a place for yourself in such a confusing world. I think that our future depends on these kids.

LR: How do we convey the information of neuroscience and addiction to adolescents without their eyes rolling back and them dismissing us? Do we do it through the parents? Do we do it through the therapists? Do we teach adolescents about neuroscience and about the vulnerabilities of their brain and their neurocircuitry?

JG: I think that the kids in my town are very interested in neuroscience and I think most kids are interested in information. One of the things that’s really had a big impact, surprisingly, because they don’t worry about their own death so much or their own mortality, is this idea of the transgenerational effects from epigenetics. There was pretty alarming data piling up and we don’t understand it so well.

We understand the mechanism but it just seems incredibly inconvenient that if an adolescent is exposed to a drug like marijuana or alcohol and then grows up normally—doesn’t get any more of the drug, the offspring of that adolescent partier are prone to anxiety and depression and higher self-administration of drugs of abuse. I have to wonder if the epidemic of anxiety and depression is in part due to what our parents were doing in the 60s and ‘70s. Talk about a complicated, systemic way of understanding suffering, so that you reap what you sow. Also, most of the blame has been on the mothers, on the women who, somehow, were crappy. In fact, we know that the pathway for the sperm through the epididymis is marked by these experiences. We have a mechanism for how this can happen. Fathers to sons and grandsons is clear in the lab. Another analogy for even younger people that I talk about—and I don’t know if this will impact them or not—but it’s almost like you have a bank.

You start out with a certain amount of money in your bank and that’s your affective state. When you use a drug to feel great, you’re withdrawing from that. It is always the case that you have to pay it back; quickly or slowly.

So, a hangover is a little payback of the great time you had last night but there is no influx of funds coming from any place else. They have to come from us, so that’s why, if you withdraw a little bit at a time and you put money in, maybe, by learning the kinds of self-regulation and purposeful nourishing of yourself and your goals, having a little treat every now and then isn’t going to cause bankruptcy.

LR: So, parents of adolescents might benefit from a far less restrictive approach to substance use. It might be helpful for therapists to help parents of teenagers not get so crazy about occasional or small-dose usage, rather than talk to the parents about the importance of absolute abstinence.

JG: If we had a perfect world, I would say nobody would overdo it.

I think kids don’t listen to parents making rules so that’s not a great strategy because you cannot enforce this. They do what they do. I hesitate to say, “Help them do it at home,” or, “help them learn moderation,” because, really,

any time the brain gets a big enough taste of a drug to feel great, especially in adolescence, that’s likely to have a lasting impact in the opposite direction

any time the brain gets a big enough taste of a drug to feel great, especially in adolescence, that’s likely to have a lasting impact in the opposite direction.

So, I’m quite convinced that my brain is less sensitive to pleasure and reward, so that when I got married or had my daughter or any other kind of peak experiences, which were good, they might have been even better if I hadn’t dampened my sensitivity to that. While we know this to be the case, I agree with you, though, that coming down hard and fast is a waste of time.

It’s impractical. In general, I tried to bribe my children. I said, “If you can not get wasted until you’re 21, I’ll buy you a plane ticket anywhere.” That’s what I would like. I don’t think it worked but I do think they’ve, in some way, taken it to heart. I mean, we talk about it an awful lot.

LR: I’ll bet you do.

JG: I put different pictures of the brain impacted by drugs in the book, by the way, because I think those pictures have an impact on kids. So, seeing how chronic pot smoking decreases the number of brain receptors that respond to pot, I think that might help.

LR: Well, there’s also the irony or maybe a paradox that—as you said in the beginning—teenagers are invincible. They see themselves as unbreakable. Unless they’ve had real adverse experiences with alcohol or pot, beyond a bad hangover the next morning, they haven’t been threatened with death. They don’t see their synapses deteriorating. They don’t see brain centers shrinking. So, at a point where the most damage can be done, they’re least amenable to contradictory information. It’s tough.

JG: I have heard, though, from dozens, maybe hundreds, of kids, 15, 16, 17, 18 who completely identify with the lost, empty feeling that they cannot get enough of a drug. If these kids can stop early, their brain is much more capable of restoring things than it would be if they wait ‘till their 30. So, on the other hand, just because they have an increased risk of developing addiction, they also have an increased aptitude for recovering. Maybe this is a unique opportunity for them to begin to understand that these drugs really are so potent and so widely used, that it really is a dead end.

LR: Are you suggesting that it may be more therapeutically useful to point out to adolescents how crappy they feel when they’re not using the drug because the brain is trying to adapt, than how crappy or perhaps stupid and self-destructive they were feeling and acting when they were using the drug?

JG: Absolutely.

LR: So, the real danger is in what their body is experiencing when it’s craving or when they’re doing ridiculous and/or destructive things to acquire the drug.

JG: For me and for many pot smokers, what that looks like is that everything is just completely boring and flat and uninteresting. I mean,

I remember not caring about anything unless I was stoned

I remember not caring about anything unless I was stoned. That is profoundly painful. It’s a big deal.

LR: So, it’s helping our young to build up resistance to feelings of loneliness. To existential pain. To sadness. To injustice. Giving them the skills not so much to battle addiction but to battle the natural response to the pains of life.

JG: I’m interested that you say battle it. I guess I wouldn’t expect that. Is it that we want them to battle the pains or do we want them to negotiate the pains?

LR: Negotiate.

JG: Yeah, and one way that’s helped me a lot is to realize it’s overwhelming if I look at everything. If I just pick something that’s important to me, one thing that’s important to me, and live my life to show that, then that’s enough. I don’t have to get overwhelmed by what’s going on in Yemen or what’s going on with the rising water—these are things that are beyond my scope, but I can do a little bit and that is, I think, maybe a message that’s lost to them right now. That there’s a place for each of us.

LR: I guess the irony, also, is that because they have increased cognitive ability and they can think about thinking and think beyond their skin, the problems of the world become their problems—they have to worry about everything at once. They’re not worrying about Yemen or Syria or rising tides or climate. They’re not doing their job, but it’s in taking on the world just because they can that they forget to take on themselves and what they can control.

JG: Then, you point out the incredible irony, which is that they’re aware of all of this, and how do they deal with it? They completely erase it all by getting high, and by becoming withdrawn into themselves and their own private mental state which is being further manipulated by the drugs they are using. It’s simply not functional or adaptive.

LR: It seems from what you’re saying is that the antidote to addiction is connection.

JG: I think so. Connection! I mean, this is probably, blatantly obvious, but requires another side. Others who need us. I don’t think we can do it outside of the support of wise people. Connecting to art. Connecting to our bodies. Connecting to the earth. Connecting to mentors.

LR: Therapists can play a very powerful role, there.

JG: Absolutely.

Loose Ends

LR: May we shift gears here for a bit because I have, and I know our readers have, so many more questions, like about the recent FDA approval of esketamine nasal spray for severe depression.

JG: Every new drug, when it comes out, has all kinds of promise and no side effects and that turns out to be true for a few months, until we get some data. I think

it’s absolutely clear that the existing pharmacological treatment we have for depression is largely useless

it’s absolutely clear that the existing pharmacological treatment we have for depression is largely useless, and if nothing else, is really benefiting drug companies.

LR: Thomas Szasz’s notion of “pharmacracy,” government and control by and for the pharmaceutical industry.

JG: I don’t think we have good pharmacological interventions, going back to what you said earlier. I think we are a society always looking for a quick fix. I’m not against this. What I like about this new drug is it’s finally a novel mechanism of action. It’s also not something you take every day. The chemical esketamine, though, is a little bit of a baloney because the drug that it’s copying, ketamine, is cheap and old. What do they have to do, because the patent’s out on that? They have to develop a fancy version on that, which is no more efficacious, but it’s going to earn a lot more money.

I think people are desperate for treatment for depression. There are so many people who are pleading, “Please, let me have brain surgery to alleviate my depression.” So, we clearly need something. I don’t think that it’s going to be a magic bullet, but maybe it’s good to see some movement in that area.

LR: We may start seeing esketamine clinics and esketamine overdoses and illicit copies of esketamine. It will be helpful to some perhaps, but will the societal consequences be far worse?

JG: You know, it’s possible. It’s a dissociative anesthetic. It’s Special K, basically, which is abused.

LR: You mentioned that women metabolize alcohol and some drugs differently than men because of the greater distribution and density of fat, as opposed to muscle. I know you’re not a therapist and I’m not asking you to be one, but you have some really good insights and you’re raising a young person. Do we have to work differently in therapy with girls and women as opposed to men and boys?

JG: Oh, my gosh. That is worth an hour in itself. I think it’s critical. We basically did 96 percent of our research until the turn of the century on white males. They are not the default population, so it turns out—especially with drugs of abuse,but much more than anybody suspected—women respond differently. That’s evident in the clinic because

women progress toward addiction and to toxic side effects much more quickly than men

women progress toward addiction and to toxic side effects much more quickly than men.

Women need lower doses. I think the reasons for using are different. I suspect—and it’s borne out by some data that’s accumulating—women use drugs more to cope and men use more to get off—to enjoy it. Those are really two different things. I think for men anger and resentment are big precipitating factors. For women, anxiety and insecurity are the precipitating factors.

LR: So, as you said earlier in the interview, we need to address the core issues that girls and women struggle with by virtue of being girls and women in a patriarchal society. Do you have any final thoughts you’d like to share with our readers?

JG: I think the conversation was really enriching for me because I think we are both interested in the same goals but from different perspectives. I think it’s important to have these conversations, these bridges between what I know and what you know and our shared experiences from these different sides. So, I think that was really pleasant and novel for me because everybody only wants to talk about the brain molecules, evading these big, important, systemic, and social and spiritual questions.

LR: Did I betray my roots? My psychosocial roots?

JG: I hope so.

LR: You really have some powerful insights and I think your wisdom goes beyond mice and the lab. I think it also transcends neural circuitry. I think you understand the bigger issues and I hope more neuroscientists recognize the importance of the psychosocial elements of addiction and disease. I did an interview with Allen Frances a while back. He, like you, thinks that we really need to create bridges between the scientists—the behavioral scientists and the neuroscientists.

JG: Can I tell you, lastly, why I think you don’t have to worry about that? The neuroscience is not yielding answers. So, it’s going to be the data itself or the lack of data—the lack of understanding, the lack of impact—that brings us back to the wider community—to these connections outside of ourselves. As I say in the book, we thought that the brain was acting like Oz behind the curtain.

Now, we realize, “Oh, the brain is just a way that the environment influences us.”

Now, we realize, “Oh, the brain is just a way that the environment influences us.” We are coming full circle, I think, and we will, eventually, get to the same place where we realize everything’s social, psychological and biological.

LR: So, what do you say to those psychotherapists out there who are addicted to neuroscience research and who have fallen in love with the brain and who are rabid neurophiliacs?

JG: I would say they don’t understand it. I guess they’re selling something but it’s not understanding. It’s not wisdom.

LR: So, psychotherapists need, as you said, to position themselves along the spectrum somewhere between the extremes of neurophilia and neurophobia?

JG: Absolutely.

LR: On that note, Judy, thank you so much for sharing your time, research and wisdom with our readers.

JG: Thank you.

Michael Gurian on Masculinity, Neuroscience and Psychotherapy

Posted on April 25, 2019February 11, 2026 by Psychotherapy.net Team

Psychotherapy and the Brain

Lawrence Rubin: You are a prolific author and experienced clinician who's best known for your work at the intersection of gender and neuroscience. As you know, there's a fierce debate in both fields about the relative influence of genetics and culture on the experience and expression of gender. What does a psychotherapist need to know about both sides of this debate when it comes to working with boys and men?

Michael Gurian: As you know, my work focuses on nature, nurture and culture. So, I and my team work in all these areas. On the nature side, the brain differences are quite robust, and it's important for psychotherapists to consider this when working with male clients. In the psychotherapy profession, it’s, “come in, sit, talk for 50 minutes,” and that may be a beautiful match for the female brain in the aggregate, and in general a beautiful match for a brain that does words on both sides, that connects words to feelings and memories on both sides.

It's not as good a match for male clients, who only do words on the left, mainly the front left; who only connect words to memories, are sensorial, and who need more movement, more cerebellum involvement. So,

the male/female brain differences, I think, are one of the most important and underutilized parts of our profession

the male/female brain differences, I think, are one of the most important and underutilized parts of our profession. And when we do use them, when we do train people, like when I speak at psychotherapy conferences or do trainings with psychotherapists, their minds are blown when they see the brain scans.

And they say, “Oh. Okay. We'd better take this into account.” And they alter their practices and succeed more with boys and men. So, I would say that's a primary thing. And it doesn't negate LGBTQ clients. Those groups are set up ideologically by people as if they're in opposition, but they're not and their experiences are well-integrated into neuroscience.

LR: So, you say that language is differentially represented in the brains of boys and girls, men and women. And for that reason, we must consider gender and age when planning our psychotherapeutic approach and techniques. It sounds like you're saying you just can't sit with boys and say, “Tell me about your childhood.” You advocate a peripatetic approach.

MG: The sit-and-talk method will work with about one out of five males darn well. It sure works with me because I like to sit and talk when I'm in therapy. But we've got to always remember that we also only have about one out of five males in general staying in therapy, boys or men. So, it can work with some, but no. We must expand and use peripatetic methods.

LR: I associate peripatetic with movement, perhaps taking a walk, maybe some sort of sports activity. What about the use of the different methods of art and play, music and dance—the expressive therapies? Do you find that boys and men, maybe more so boys, are amenable to these expressive, creative modalities?

MG: Yes, they're all within that range. Prior to writing Saving Our Sons, I wrote, How Do I Help Him?, which is a practitioner's guide for psychotherapists. And all those methods you listed are featured in that book because I have had success with all of them. They all come within the range of expressive modalities, and I have found that boys and men really like working with sand and art. I've even expanded it to looking at the use of video games in treatment. Graphics allows movement, so yes, all of those are great.

Video Games and Violence

LR: Do you have any clinical examples of using any of these movement-oriented modalities with a specific male client?

MG: I work with adolescents, puberty onward – 10, 11, 12. I worked with one such boy whose father fought over in the Middle East in Iraq, came back and was struggling with a lot of issues. The boy, therefore, was having issues as well. And we used video games including Halo, and we looked at what were the messages in Halo and what was Halo trying to do for soldiers. He really got into that. And at a certain point I was able to work with the whole family. The dad and the son, who was 13, had a session in which they were working through what the father had experienced in Iraq and his own PTSD using Halo.

LR: Over the history of media from radio through comics, television, movies, and now videogames, there's been a concern with the potential impact of violence and aggression on the development of boys, especially teens. On top of that is the notion of toxic masculinity. Doesn’t playing violent video games with an adolescent whose father is in the military just stoke the potential for aggression?

MG: I think you know from reading my other work that I have a different vision of male development. Let me preface it by saying that I always caution males and families about videogames. But videogames, even more than the violence in them, are fantasy and not as causal in my mind—

and there have not actually been causal links proven between violent video games and violent behavior

and there have not actually been causal links proven between violent video games and violent behavior.

And one of the ways we know that is we look at how violent the videogames are in Japan where there's very little violence. And so, we can do cross-cultural studies and try to really figure this out. For me, the bigger worry is how these games may desensitize kids to violence even though it hasn't been causally proven. The thing that worries me the most about videogames is the whole way that the dopamine system is getting messed up. That's harming male development even more.

For instance, I'm begging parents, “No videogames on school nights—only a couple hours on the weekends.” And I show them the scans and all the research about how this goes. And I show this to therapists too. I'm not a huge fan of video games. I also don't overreact to them. I try to use them. So, if it's a good link to something like for the kid with the dad who returned from war, there was useful language in Halo that I could use in therapy to help both father and son communicate better. I worked with that family to cut back on the videogames out of concern for his brain development even more than out of concern for violence.

Toxic Masculinity

LR: In light of this particular discussion, can we circle back to toxic masculinity?

MG: I don't do much with that. By focusing on toxic masculinity every ten years or so, our culture is recycling an anti-male movement. And we've done this for all the decades that I’ve been in the field, 30 years, and each one has some merit. None of us like bad men doing bad things. I was a victim of sexual abuse as a boy and I certainly am very clear on males who abuse and who rape. None of us want that.

The issue and the reason I don't use the concept of toxic masculinity much in my work is that it's based on a conceptual structure which we would never apply to females. We don't talk about femininity anymore and we don't talk about toxic femininity. Well, with males, what we do is we say, as the APA just said, “Well, you know, masculinity is the problem, especially traditional masculinity. And then it becomes toxic masculinity.” Well, masculinity is not a problem. And, in fact, masculinity is crucial for male development.

And masculinity does include, even though it's a culture construct, male/female brain difference. It includes the male development arc, which is different than the female development arc. It includes all the necessity for males of rites of passage. All these things that come under “masculine,” we simply should not condemn. And one of the primary ways we know that masculinity is crucial to male maturation is through father and absent father studies. So, we can directly link male disturbance, discomfort, difficulties later in life—and a lot of female issues as well—to lack of a father.

What the father transmits to the child is masculine development. So, I think the problem is with the word and what people think is masculine or isn't masculine. And then, of course, we add on “toxic masculinity” whenever we see a guy do a bad thing. And I think it's the wrong frame, and what it does is disallow what I think is the most necessary, which is to figure out what males and masculinity really are and to work with those.

By focusing on toxic masculinity every ten years or so, our culture is recycling an anti-male movement

For instance, there are more than 100 brain differences that all of us as psychotherapists have to integrate. If we're arguing about masculinity and toxic masculinity, we're not going to integrate those. We're going to be saying, “Well, guys should be crying like girls do. They should be talking about their feelings in the same way. Why can't they just sit down in my…” And then, “They shouldn't be stoic because stoic is toxic,” which, of course, has been disproven. Stoicism is not toxic. You know, on and on that goes.

I'm very vigilant about male behavior and male accountability. But I don't use that frame, and I think the APA used the wrong frame.

LR: You vociferously critiqued the new APA guidelines for working with men and boys based on it ignoring hard science and its stance, as you said, that masculinity is toxic. If you were to rewrite or be asked by the APA to write an addendum to these guidelines directly for therapists, what would that be and what do we really need to do in therapy with boys as we help them move toward mature male adulthood?

MG: The good thing about the APA guidelines is that our profession has stepped up and said, “Okay. The world isn't a zero-sum world in which girls and women are victims and are struggling and boys or men have privilege and they're doing fine.” In fact, as all of us have been saying for decades, boys and men are behind girls and women. They're not doing fine. They need a lot of help, and they need help from our profession. We are in the trenches as a profession to help them.

as all of us have been saying for decades, boys and men are behind girls and women. They're not doing fine

I love that the APA did that—it is great and a long time coming. But once they go with a pure psycho-sociology approach in which they never mention the male brain—they just don't mention it—then we're back in the big problem. So, the rewrite for me would be, “Look at all the great stuff in these APA guidelines, but you're not going to change male lives, you're not going to save males, you're not going to help males heal by constantly talking to them about how bad masculinity, and that they shouldn’t be stoic, and shouldn't be aggressive.”

And males are simply not going to stay in our profession. And once they hear it—their wives drag them in, their moms drag them in for the first two or three sessions, they just keep hearing this stuff—they're going to find ways to leave. They're going to say that the therapist doesn't understand them. So, what we have to do is understand them. I would say rewrite the guidelines to spend more time now on understanding how important masculinity is to their development and their maturation, how to work with them based on the way the male brain is set up.

Males Need a Nudge

LR: So, what does this mean for working with boys and men therapeutically?

MG: I gave one example about verbals. You talked about expressives. I'll give another example, which is aggression and a strategy that's a great with males. We're taught not to interrupt, to use our cognitive behavior strategies and to elicit from the client what's going on inside through a lot of listening—a little bit of guidance but a lot of listening.

Well, a lot of guys need us to interrupt them when they go off on tangents, and/or they need us to interrupt them and/or prompt them because they don't have access verbally to the feelings that we are asking them to access. A male brain can take an hour, two hours, a day, two days longer to access that thing we're trying to get them to access in our office. If we prompt them some, we can help them. We were really trained to work with females but weren't really trained to work with male brain.

And, in fact,

most or all of us were not given anything in grad school to prepare us to work with males in particular

most or all of us were not given anything in grad school to prepare us to work with males in particular. We came out of grad school thinking males and females are basically the same. Well, now what we do is we practice this strategy. And as they go tangential or as they are trying to figure out the feeling or the memory we're trying to get them to access, we prompt.

And so I will prompt and say, “Okay. So, it sounds like you're saying you got really angry right then,” or, “it sounds like you're saying that actually made you feel ashamed,” something like that, to help them. And then they say, “Yeah. Yeah, yeah.” Or they'll say, “No, no, no,” but then about 30 seconds later, they'll say, “Yeah, and then I felt really bad.” And so, the biggest thing we can do for males is to not see the 50 minutes as a pure listening environment or a mainly listening environment with the assumption that they'll get there themselves.

A lot of guys won't get there themselves. And if we don't prompt them, interrupt their tangents, get them back on track, they won't respect us as therapists. Guys are task-focused, and they want their mentor, who is their counselor now, to really help them. And they don't respect someone sitting there for 50 minutes, listening to them go off on tangents. They just don't respect that.

LR: You are clearly a very passionate advocate for masculinity.

MG: Well, male development, because masculinity is such a charged word, you know? I'm an advocate for everyone understanding male development, and I do think our profession isn't as good at that as I wish.

LR: You say that because of the way boys and men are wired and then socialized, that they may need some prompting to develop a language around what we might call the anti-male feelings, such as vulnerability, fear, insecurity and weakness. Are we putting words in their mouths when we're pushing them to reflect on those feelings or incorporate those feeling words? Might that be a little too aggressive?

MG: I don't think so. Everyone should be case-by-case. We were talking about the brain spectrum and the one-in-five males, like myself, who can just come in and sit and talk. And then my therapist says a little something. Then I go off on a deep tangent. You know, there are a lot of guys who do that, and they don't need what I'm talking about here. But for the majority of guys, I would not say it's too aggressive. And what it will do is it will keep them in therapy.

I also use spatial and motor activities to get the right side of their brains working

I also use spatial and motor activities to get the right side of their brains working. I'll throw a ball back and forth and, as I talk, I'm squeezing the ball. Obviously, most of the talking should be going on with my client. I throw the ball to the client. That excites the right side of the brain, which is completely dormant when all we do is sit and talk. That can create more connectivity. So, then it's his turn. He's got the ball. More of his brain is already active.

He throws the ball back to me. He didn't quite get at it. I say, “I think what you're saying is you were really scared right there. Is that what you're saying?” I throw the ball back to him. About half the time, he'll say, "No. I wasn't scared," because that's a vulnerable feeling. “No. I wasn't scared.” But he'll process. We'll go back and forth.

By prompting him to try to understand that he was scared or for him to say, no, he wasn't scared, he will ultimately say something that's got emotionality to it and maybe he will link to a memory. And then we can get back to the root feelings like fear. We can get back to shame. It may be too aggressive for some clients. I'm case-by-case, for sure. But since we're talking in the aggregate, I think, for males, it keeps clients sitting in our chairs.

Boys, Men and Depression

LR: On the heels of this discussion about boys, men and their feelings; what about toxic and unfettered masculinity, and the belief that if you don’t “tame” boys, they will go out and shoot up schools?

MG: Unfettered masculinity! Boys don't shoot up schools because of masculinity, right? They're mentally ill, depressed. I was asked to look at all the profiles of all the school shooters around 1998 to 2003. I'm going to speak in the aggregate because there's confidentiality there. Basically, all those guys were depressed.

The key element is, when males get depressed, they tend toward withdrawal and/or toward violence. The AMA has worked with this for 25 years. So, I don't bring masculinity and toxic masculinity into my practice. I'm not talking to my male clients about toxic masculinity. It's not my area.

Boys don't shoot up schools because of masculinity, right? They're mentally ill, depressed

If they're doing something that is wrong behavior—you know, adultery or some kind of violence—of course, I'm pointing that out and I'm working with that. They don't need a frame that says that it’s toxic masculinity. That's not really going to help them anyway. What they need is help with depression. They need help with understanding why they don't have the impulse control to not hit, what is chemically going on for them. That's what they need.

The masculinity/toxic masculinity thing is more a public frame that folks can use, and I believe to a great extent, to avoid what is going on inside male development. It avoids the depression. It avoids all these developmental issues males face by attaching it to a culture construct. So, no, I don't use it much in my practice.

LR: Are we as a culture afraid of masculinity, and for that reason have vilified it and toxified it? Is there something about those characteristics of boys and men that you think are very positive that society and perhaps the APA is not comfortable accepting?

MG: Absolutely. We have a bunch of guys, and right now it's mainly white guys, who are at the top. They control a lot at the top. So, there's one set of optics that really helps push the concept that males inherently have privilege, especially white males. And that creates then a war—a gender war and a race war—because, of course, tens of millions of males and white males don't have privilege. They are depressed. They're struggling. They can't find jobs. So, we have that mythos and the optics that white males control everything and have everything.

we have that mythos and the optics that white males control everything and have everything

Then we've got the other set of optics, which is a bunch of bad guys who do bad things. Their numbers are not actually very high. If we look in the aggregate of males, it's not very high, but they're constantly reported. None of us like that behavior. And so, the academic universe said, “Come up with a concept.” And that concept was toxic masculinity.

And then we run with that when, in fact, the real life that's lived in the trenches is males of all colors who are struggling, in the aggregate. Absolutely more black and Latino males when we proportionalize that out. But we still have at least nine million white males right now who are without work and who've stopped looking for work and they're not even counted in the unemployment rolls. So, we've got the reality of that.

And then the reality with our male clients is that very few if any of them are becoming violent because of masculinity. They're becoming violent, again, because of mental illness, lack of impulse control, self-regulation—all of these things that are not cultural constructs but rather have to do with the way the brains work and issues that have arisen for them in their family systems

The three actual causes are: 1) neurotoxins affecting cells in the brain, 2) trauma, and 3) under-attachment, especially in infancy, to a primary caregiver. Those three are proven causes of male violence, and those would be the ones that I would be trying to help them with. And in all these cases, they become depressed, and they tail toward withdrawal and/or violence. So, that's really what I work with.

For actual male clients in the trenches, I don't see a lot of gain by us spending a lot of time with cultural constructs that are not causal. Just like I wrote quite a bit in my books on girls, I don't spend a lot of time arguing that girls become anorexic or bulimic because they see images of thin women. That is not causal, right? That is something we've got to get them away from—we've got to get them to stop looking at those images of thin women.

LR: So, it's not toxic masculinity that we need to worry about. It's addressing depression, the sense of powerlessness, and the brain's impact on their behavior—as you say, the neurotoxins.

MG: Oh, yeah, especially the male brain.

LR: What does the depressed brain look like in boys and men, what should therapists need to be aware of?

MG: Therapists may think of male aggression, even male anger as covering up fear, right? Therapists are often trained to see that as something to avoid or something that may show defect whereas I look for depression. It's not always there, but I know that aggression is one of the ways that the male brain masks depression.

aggression is one of the ways that the male brain masks depression

Guys are covert in their depression, and females are more overt. When covert, it hides under anger and aggression. It can also hide under substance abuse. One of the ways that covert depression manifests for males is through substance abuse—they're medicating depression. They may also be genetically predisposed to addiction , and so arises the need to medicate depression.

LR: Has the male brain become predisposed to depression over the course of evolution?

MG: The reason it crosses cultures is that it comes in on the Y chromosome. In utero, the brains differentiate male and female, even including the whole gender spectrum. But they still differentiate male and female in utero. So, as these kids come out, yeah, we've got a much more fragile male brain than we realize.

LR: A fragile male brain! What does that mean?

MG: Both brains can be fragile, meaning that they can be vulnerable to neurotoxic effects and trauma. Social-emotional development is tougher for males, especially tougher if they don't have fathers—another Y chromosome in there helping them, and/or male role models throughout the lifespan, but especially ten to 20.

What the male brain tends to sacrifice is social-emotional. It'll retain things like spatial, but we don't have as many brain centers and connectivity. Females do that on both sides of the brain and are oxytocin-driven which is the so-called bonding chemical. If males don't have key relationships early on in life and are then impacted by neurotoxic effects too early, their brains tend to sacrifice social-emotional growth at the cortical level, and it then manifests behaviorally.

Mentoring our Males

LR: Many boys grow up without male role models. Some are raised exclusively by their mothers or grandmothers while others are raised by lesbian or transgendered couples. Where do boys find mentors outside of male therapists and what does it mean for a boy to have a male role model or mentor?

MG: If their role models are bad males, obviously, we don't want them, but most men can provide good mentoring. Coaches can be mentors. Faith communities are systematically set up for mentoring. If kids are in school, we can become citizen scientists and watch them gravitate at five, at six, at seven, at eight to whoever is the male teacher. We also want to remember that female therapists and women are mentors too. This is not either/or. And gay couples can raise great kids.

Many boys grow up without male role models

I beg therapists to create academic systems that support more males so that they can become therapists. A lot of these guys who are raised by single moms and grandmas would benefit from a male therapist. As a profession, we have got to generate more male therapists to be these mentors and then generate more information to female therapists so they understand guys so that they can be mentors too. Again, it's not an either/or. You don't absolutely have to have a male therapist. At a certain point, you're going to need a one, but you don't absolutely have to have a one right now. A woman therapist could do it right now too if we train her in it.

LR: It's an interesting irony, perhaps paradox, that a disproportionate number of clinicians, especially for boys and teens, are female. Does that mean that boys and men in therapy are being mentored by clinicians who may not be as adept around masculinity issues Are boys at risk by being treated predominantly by women?

MG: I love the women who are treating boys, but yeah, it's a systemic problem that started around 50 years ago, assuming and remembering that before between 30 and 50 years ago, most psychologists and psychiatrists were male.

But as we moved toward more verbal literacy and the notion of “use your words” that is practiced in both these professions, we set the profession up to be a verbal literacy platform without neuroscience to understand male/female brains differences. So, males are pulling out and pulling away in stages.

Fewer males than females move into our academy. They're not going to graduate school. They're not going to become therapists. And more males will become psychologists and psychiatrists, but far fewer become therapists. The males know that the academy is doing this—it's inchoate for them; it's unconscious. I don't think they've studied brain science, but they know, “Wow! Am I going into a profession where I'm going to be sitting there with a client for 50 minutes, trying to get this client to say stuff, knowing that for many clients, especially males, it won't work? And for me as a guy, I need to be a certain kind of guy to be able to sit eight hours a day, 50 minutes per hour, in that chair,” right?

So, I think that to some extent, we're losing them at the academy level. And then as they come out, we start losing the men as clients and as patients because there isn't academic training for most of the therapists, who are female, in understanding the male brain. And, we lose them in our therapeutic work with couples as it is generally the wife or the partner who brings the guy in, and it's clear the therapist doesn't know how to work with him. So, he pulls out of treatment as well. He's seen as a failure. So, from the academy to the therapy office, we are losing males because of systemically pervasive attrition.

Which Therapy is Best?

LR: Have you found that there are therapeutic models that are more effective with boys and men? A client-centered approach, I consider a more-traditionally-feminine approach. It's about listening and reflecting feelings whereas a solution focused approach seems to fit more the male stereotype. “Let's

Shame Part 4: I Deserve to Feel Bad, Because I am Bad

Posted on January 29, 2019February 11, 2026 by Psychotherapy.net Team

In my previous blog posts, I discussed the difference between shame and guilt; both of which are painful, self-evaluative affects. Guilt involves the evaluation of a specific behavior and therefore, offers the opportunity for reparation. If Gary fails a test and feels guilty, he believes he can do things—like study harder—that will relieve some of his guilt. Even the thought that he is able to do something, alleviates some of the distress from his self-evaluation.

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If Gary perceives himself to be a loser who can never do anything right, then he is experiencing shame. Although shame can be transient, there are people whose experience of shame (shame-proneness) is pervasive; meaning that at the very core of their sense of self is the feeling of being small, insignificant and/or bad.

In my most recent blog post in this series, I discussed how shame-proneness compromised empathy, causing conflict and turmoil in relationships. Another lasting and painful consequence of unresolved shame is shame-based depression.

Depression is at best, an umbrella concept, not easily understood or reducible to a diagnostic label. Just because people share symptoms does not mean the cause is the same. Think of all the different underlying reasons for a headache. If we are to hope for good psychotherapy outcomes, we need to understand the causes of the symptoms, not an easy endeavor with distress as broad as depression.

When depression is shame-based, it is not only the symptoms that debilitate, but also the ingrained belief that the person does not deserve to feel better. Because fundamentally they feel bad, small, unimportant, the suffering feels congruent. Relief feels foreign and undeserved. If the shame basis of the depression is left unidentified, improvement will be a tortuous, uphill battle for both you and your patient.

Take Madeline (an amalgam of patients suffering from shame-based depression), for example. She’s a 39-year-old woman who came in for depression and reported a lifelong history of related symptoms. She described apathy, anhedonia, problems with motivation and concentration, appetite and sleep disturbances as well as feelings of worthlessness. As the therapy progressed over the first year, it became clear that Madeline experienced deep-rooted and chronic shame.

She regarded herself as unintelligent, unattractive and uninteresting. In response to these feelings, she developed grandiose aspirations to compensate for her supposed deficiencies that no one could ever live up to. Consequently, she experienced continuous and inevitable failures which confirmed and perpetuated her shame-narrative.

“I’ll never be intelligent. Everyone knows more than me,” she said, averting my gaze.

“Can you tell me more about that?”

“I need to read every single book on a particular topic before I’ll feel knowledgeable enough to have a conversation about it.”

“Does that seem a realistic endeavor?”

“I have to. It’s the only way I’ll feel smart enough,” she said flatly, fighting a frown.

“I worry that you are setting yourself up to fail by having expectations that are impossible to reach.”

“I never meet any of my goals, anyway.” She crossed her arms.

“You’ll never find a feeling of accomplishment or meaning if you keep setting insurmountable goals. I’d like to understand why you’re doing that. What would happen if we worked together to set realistic goals, things you can accomplish?”

“Well, then I might feel better.” She released a sarcastic laugh. “I wish that was a joke. I don’t feel like I deserve to feel better.”

“Tell me more about that.”

“No one ever supported me or any of my interests. I was told I wasn’t good enough. And it’s the truth, isn’t it? Look at my life. I’ve done nothing to be proud of. Failed at everything I ever tried or ever wanted.”

After I better understood her shame, I realized that despite our seemingly strong relationship, Madeline continually undermined the therapeutic process. Every time she started to feel better, she’d set these impossible standards, which ultimately confirmed her feelings of not being good enough, of being a failure. Of not deserving any relief.

Madeline knew nothing but her depression. She held onto it as if without it she would descend into an unfathomable void without it. When patients have a history of emotional abuse, as she did, where disparaging statements are woven through the fabric of their identity, the depression is often shame-based. And the treatment is extremely challenging. We have to help our patients to find ways to question, then challenge and finally close the book on their shame-narrative.

To some degree, all depressions contain an element of shame. But in Madeline’s case, it was pervasive, evolving more like a personality trait than a cluster of symptoms, making it harder to treat. Her shame caused her to perpetuate her own distress.

I combined humanistic, psychodynamic and cognitive-behavior therapy for Madeline. Psychodynamic, to help her understand how the shame evolved through her childhood experiences of emotional abuse; humanistic to focus on helping her identify and foster the many strengths she did have and to help her find meaningful pursuits where she could feel her endowments; cognitive-behavioral to help her with her thought distortions. I had her keep a journal of the false narratives. Every time she had an experience that disconfirmed them, I had her write it down. For example, she thought no one liked her and as a result, she was socially isolated. Every interaction where someone complimented her or showed interest in her, every time someone asked her for advice, she wrote it down. This was to reinforce different statements about who she was.

The more Madeline discovered her unique strengths and used them and felt them, the better she became at recognizing the falseness of her narratives. And the more she understood the distortions, the better she became at pursuing goals that were attainable.

I also did some psychoeducation in the second year of our treatment. I explained the shame and tried to help her understand her depression. Madeline had become curious and open and was able to introspect even in areas that were very painful.

Madeline developed an observing ego. She became more cognizant of her distortions and began to question their validity. In order to help patients recognize their shame, we need to listen closely to these narratives. We need to identify the shame. And then, we can adjust our therapeutic techniques to meet our client’s unique needs. We need to believe they deserve to get better and can get better, even when they are undermining every step of the process. But for the deepest and most lasting change to occur, they need to believe in a narrative free of shame.

Treating the Physical Effects of Depression

Posted on January 17, 2019February 11, 2026 by Psychotherapy.net Team

The quick deterioration of our bodies following severe flu, broken limb or difficult surgery is often surprising. We quickly and abruptly transition from feeling strong, energetic and balanced with a full capacity to eat, walk and climb stairs, to feeling weak, exhausted and frail with little appetite or mobility. In short, debilitated. A close relative recently had pneumonia; fortunately, the wonders of modern antibiotics brought about a quick end to the chest pain, fever, and coughing. But more than a week later, this normally athletic, fast-moving individual was having trouble climbing stairs and walking long distances. It took him weeks to regain his physical strength and overcome the fatigue that had him longing for a daily nap. Indeed, it may take several weeks or even months of physical therapy and rehabilitation programs to regain strength and stamina after the end of an acute or severe illness.

But what if the deterioration of the body is due to mental illness? What if the severely depressed individual stops eating and rarely moves from her bed in a darkened room for days at a time? What happens when anxiety is so pervasive that chronic gastrointestinal disturbances and sleep disruption result? What about a person with bipolar disorder who cycles into depression with such frequency that there is little time for recovery from the previous depression? Wouldn’t such circumstances bring about reduced nutrient intake, loss of weight due in part to loss of muscle mass, difficulty with balance, and overwhelming exhaustion—similar to that seen after a physical illness such as pneumonia or severe flu?

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Several years ago, a client with bipolar disorder who had been coming weekly to our weight-management center at a Harvard University-affiliated psychiatric hospital suddenly disappeared. Phone and email attempts to remind her of the meetings and to check on her well-being were ignored. Weeks later, she appeared and told us that she had been severely depressed and unable to get out of bed to answer the phone. She had lost weight due in part to muscle loss because of her inadequate nutrient consumption and inertia. The clinic’s exercise physiologist noted that our client’s physical stamina and balance had declined significantly, and her balance was precarious.

Fortunately, we were able to establish a meal plan and exercise routine to compensate for the days in which she was inadequately nourished and inert. But what happens to other patients whose mental illness, whether acute or prolonged, causes periods of almost total physical inactivity, inadequate nutrient intake, even lack of exposure to sun and fresh air? They may be as debilitated at the end of their episode of depression or anxiety as someone recovering from injury, infection, or a broken limb. Who recognizes their fragile physical state and takes steps to ensure their physical rehabilitation?

Therapists may play a crucial role in facilitating the help these patients need to bring about an improvement in their physical as well as mental state. They may be able to encourage the patients to seek out medical attention if needed, to consult with a dietician about restoring adequate nutrient intake, or to suggest using physical therapy to restore lost muscle mass and stamina. Moreover, with the permission of the patient, it might be useful to bring the caregiver into this discussion to help make appointments with these health care specialists and to discuss ways of preventing the physical decline when or if the depression recurs. It makes good clinical sense that the psychotherapist might just be that person.

Might Physical Activity be an Effective Antidepressant?

Posted on December 11, 2018February 11, 2026 by Psychotherapy.net Team

The well-known recommendation to exercise in order to relieve and /or improve a wide variety of health problems may sometimes seem exaggerated. One might ask whether going to the gym or chopping wood will truly improve sleep, cognition, fragile bones, cholesterol levels, high blood pressure, and decrease vulnerability to developing diabetes, obesity, heart disease, cancer and Alzheimer’s disease. That is a lot to ask of a daily bout of physical activity. However, many studies over the past several decades have confirmed these positive relationships. Exercise is not going to prevent us from eventually exiting this world but engaging in physical activity may make us healthier while we are still in it.

Relieving depression should be added to the long list of benefits of physical activity-depressed patients may benefit as much from routine exercise as they do by taking antidepressants. Several years ago, an extensive review on the effects of an exercise program on clinical depression strongly indicated that physical activity may effectively reduce stress, anxiety, and depressed mood.

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A woman came to me for weight loss counseling because she had gained about 27 pounds while being treated with an antidepressant. With the consent of her therapist, she decided to stop taking the drug and instead signed up for a four-month exercise program with a personal trainer. After several weeks she not only lost weight but her depression went into remission. Her personal experience reflects that described in many studies in which depressed patients enrolled in programs of frequent physical activity such as walking, resistance training or a combination of both show improvement in their mood. Indeed, in another study, patients receiving medication (sertraline), exercise and the medication, or just exercise had the same rates of remission.

However, if exercise is to be treated like any other therapeutic intervention, do we know the most effective program? Should the exercise be mild or intense? Is it better to exercise outside in the fresh air and sunlight or does it not matter? Might yoga or other group exercise be more beneficial than solitary workouts or a walk because exercise classes diminish social isolation? Is there some way of identifying patients at the onset of their depression who might benefit from exercise rather than antidepressants therapy? How long should it take for an exercise program to produce a lessening of depressive symptoms? Many antidepressants take several weeks before they seem to have an effect. Should the patient wait the same amount of time to see if exercise relieves their symptoms?

These are questions that can be answered fairly easily with additional studies. What is more difficult is how to translate these findings to the real world. To begin with, who is going to treat these patients? Therapists are rarely, if ever, trained as exercise physiologists. And exercise physiologists may not have any training or experience working with depressed clients. Do these professionals even communicate with each other? A therapist may be able to refer a patient to a physical therapist for an initial consultation as to what kind of exercise the patient can do without injury or pain. But how should the patient follow up? Where will she exercise? Does he have to join a gym or a local Y to exercise? Who will determine the type of exercise program? What oversight is available to make sure the exercise program is carried out effectively and without injury or pain from overused muscles? Who will help /motivate the depressed patient to participate over several weeks rather than dropping out? And finally, even if exercise can be as effective as medication for depression, who will pay for it? Now visits to a therapist and medication may be paid for in their entirety, or at least in part, by health insurance. Therapeutic visits with an exercise physiologist rather than a prescription for an antidepressant is probably not covered under billing codes for mental illness and thus may be an out-of-pocket expense.

And yet, exercise should not be overlooked or discarded as an effective way of managing depression. Its value in increasing general health, sleep efficacy, and increased physical fitness in addition to relieving the symptoms of depression without the side effects of drugs cannot be overstated or overestimated. Isn’t it about time to figure out how to apply this knowledge?

Jose Rey on Psychotropic Medications: A Primer for Psychotherapists

Posted on September 11, 2018February 11, 2026 by rezendevknowfully.com

Lawrence Rubin: I recently had the pleasure of attending your lecture on psychotropic drugs at Nova Southeastern University in Fort Lauderdale where you are a pharmacologist and professor of pharmacy practice. I was impressed not only with your seeming encyclopedic knowledge, but also by your enthusiasm and understanding of the social, political, financial, and historical issues related to psychotropic drugs.

Therapists are not typically trained in the use of psychotropic medication beyond a graduate course or CE workshop or two, and even then, the training may be done by a representative of a pharmaceutical company. Beyond that, we may read articles in a journal or hear a story about these medications in the popular press, or learn from our clients what has worked and what hasn’t. At times we even hear horror stories about their misuse. With these things in mind, what would you say are some of the basic guidelines that therapists can follow when a client asks questions such as “should I consider medication for my anxiety, depression, or mood swings?”

Give Psychotherapy a Chance

Jose Rey: That's an excellent question. I still would like to think that areas like mild to moderate anxiety and depression are very responsive to psychotherapy, and so that question would ideally come in the middle or late stages of treatment where frustration may have set in and therapeutic response is not occurring.

We should really give psychotherapy it's best chance to work first.

We should really give psychotherapy it's best chance to work first.

Medication might give us a little bit of a faster response, but it doesn’t seal the effect the way psychotherapy can. What I mean by seal the effect is that a drug doesn’t teach you anything. If you're taking a Xanax for anxiety and if you're so anxious and so distraught that you can't engage in therapy, well then by all means use something that helps you get into the room. But if you are only taking Xanax every day for your anxiety, for instance, then what have you learned about the cause of your anxiety? What have you learned about any coping mechanisms or other areas or ways to deal with the anxiety other than the behavior of popping a pill. I don’t like drugs alone, I prefer psychotherapy with medications.

Medications also are not curing anybody, they are tools. If you go with evidence-based medicine, you really don’t have a lot of great long-term information regarding the use of these medications. Yes, we know they can work in limited four to 12 week trials, but we really don’t always follow patients for 12 months or 24 months after treatment ends. And therefore, I think that using these agents up front to help a patient with more severe forms of anxiety or depression to engage in therapy is the best place for it, but you have to gauge the severity of the illness. Someone who is having the occasional anxiety attack should not be taking a Xanax or a Prozac every day. If you're having debilitating anxiety so that you can't engage in social or occupational activities, then you're already at a moderate to severe level in my book, and therefore the idea of pharmacotherapy seems attractive.

Our medications manage symptoms…but they don’t generally treat underlying issues.

I just don’t want to think of all of us as just bags of chemicals and that a new chemical like a Prozac, Xanax, Paxil or Buspar will somehow correct an underlying problem. Our medications manage symptoms. They do it very well, but they don’t generally treat underlying issues. Even if the underlying issue is biological like genetics, these drugs aren’t going to correct your genetics. You're always going to have that genetic aspect of the illness. They can only change the chemical availability of a neurotransmitter like serotonin, but even that wears off over time. And now we're back to where we started from.

Sometimes, these medications only work for a few months or a short period of time, and then your body finds a way to become tolerant to them. One of the smartest things I heard from a psychotherapist years and years ago about a person who was breaking through their antidepressants was, “if the brain wants to be depressed, it will find a way to be depressed.” And therefore, we can use multiple antidepressants with this individual, but they find a way to overcome them. And that does speak well to genetics and the other aspects of depression such as our view on the world and our expectations of the world. I don’t like to think that drugs can insert thoughts. Therefore, they can help our sleep or our level of anxiety but they won't teach us anything.

LR: Just as a side note, does the research on the medication efficacy consider psychotherapy in the process?

JR: No, not at the point when you’re in phase one through three or in premarketing stages of drug development. It is extremely odd to see a drug go head to head with therapy. Historically speaking, for mild to moderate depression, psychotherapy and pharmacotherapy did very well. You only might see a separation for pharmacotherapy doing a little bit better than psychotherapy in the most severe cases. But in one of our best antidepressant trials, the STAR*D trial which was published more than 15 years ago, everybody had been given Citalopram, the drug Celexa. If they had done poorly on Celexa then they were then randomized to receive other treatments to see if they failed on one drug would they have a preferential response to the next drug. And in that case, they went from Celexa to Zoloft, Celexa to Wellbutrin, Celexa to Effexor, and there was a fourth arm, Celexa to cognitive therapy. And in all four of those arms, they had the same outcome, about 25 percent of the patients.

LR: Even with the cognitive therapy?

JR: Cognitive therapy did as well as any of those three antidepressants in achieving remission. And it was just fantastic to see that because we could argue that they had already failed Celexa, and even though they now met criteria for adding an antipsychotic,

cognitive therapy did as well as any of our medications.

Guiding the Prescriber

LR: Are you saying that because research suggests that a combination of medication and psychotherapy is a powerful tool, we must also consider where the person is in the trajectory of their symptomatology? So much so that medication may be useful upfront if they come in with severe symptomatology, and then we can back off a little bit and focus on the psychotherapy more. And there may be a need to revisit the medication at different points, depending on the severity, almost inserted as needed for a trial or period of time?

JR: I like that. That's a more concise way of saying what I was alluding to especially, when it comes to those periods where there might be more stress. Again, we're back to something like benzodiazepines like valium or Xanax. They're great on an as-needed basis, i.e. I need the effect to happen in 20 minutes or I need it to happen in 30 minutes,

but I don’t want the individual to take the medication every day in an almost avoidance behavior and not engage with that anxiety.

but I don’t want the individual to take the medication every day in an almost avoidance behavior and not engage with that anxiety. I prefer that benzodiazepines, for instance, be used only sparingly on a PRN bases and not on a regular daily basis.

LR: Perhaps the therapist can help the client develop a healthy relationship with medication and find a way to use the medication sparingly, but more intensely when necessary. Is the psychotherapist’s role in that venue right there, to help the client discuss their relationship with the medication, or is that more the province of the prescriber?

JR: That's a very good way to look at it or to ask that particular question, because I would like to think that the physicians would have that conversation with their patients.

LR: You would hope.

JR: But I don’t think they do. Most physicians these days are not engaging in any form of psychotherapy beyond 10, 15 minutes a session. Hopefully they are preparing the patient for medications, maybe what to expect including side effects and positive and/or negative types of outcomes. But they are probably not addressing these questions of how long will we be using this medication, when will we be using this medication, what does this medication represent? It should represent a tool and something to assist in the treatment outcome. But if you say a drug is all you need, then you're saying your problem is almost all biological. And let’s face it, it's not that.

LR: How can we best collaborate with the medical prescriber in the real world of clinical practice?

JR: Some psychologists or some therapists may overstep the boundary and say, “I recommend we use this particular drug.” And the prescriber will almost immediately say, “you didn't go to medical school,” or “you didn't do this, and that sort of thing.” I wouldn’t approach it like that. I would approach it as “there are some aspects of our therapy sessions that make me think that along with the trauma that they may have gone through or the family issues that may be going on, they have some symptoms that might be very responsive to pharmacotherapy.”

The therapist can be recommending pharmacotherapy without a specific drug. But I think if the therapist could give [the prescriber] a list of the target symptoms, then that should guide their prescribing. Sometimes we lose sight of the fact that we're managing symptoms most of the time anyway. We could say for example that the patient is having this specific type of insomnia which is dominated by anxiety. The prescriber is then given a better assessment of the patient’s symptoms because it's hard for them to pick up on all the symptoms with a five or ten minute interaction with the patient.

There are primary and secondary selection criteria for a drug such as a psychotropic, and one of our primary selection criteria should be matching the patient’s clinical presentations to the other aspects of the drug, maybe its side effect profile. If the person is having insomnia, I might pick a sedating antidepressant. I have 30 antidepressants to choose from so why not pick a sedating antidepressant with a side effect that can have a therapeutic benefit to the patient. And therefore, instead of waiting four, six, or eight weeks for an antidepressant to kick in – when I match the side effects like sedation to an insomnia symptom of the patient, then that patient can sleep better today and tomorrow and they don’t have to wait a month to start sleeping better. When that therapist can give me the target symptoms that the patient is experiencing, that should guide the choice of the antidepressant.

Speaking Their Language

LR: Many therapists may not work with prescribers or know how to find their way to prescribers other than through word of mouth. Can you offer a few tips for psychotherapists to help their patients find prescribers and what a therapist could recommend that their patient should look for in a prescriber?

JR: It depends on the age of the patient. As I review the medical literature, I remember geriatrics. I know a good prescriber is someone who will stop a medication before they start a new one. Many of our patients have had multiple prescribers and have accumulated medications or accumulated disease states.

LR: Interesting. But how open will a prescriber be to a therapist who needs to know this information?

JR: That's hard to find. I won't say it's a unicorn, but it's a pretty rare situation. Of course, your patients are going to have to look at their insurance list.

Many of our physicians are specialized and they're very good at what they do, but I get worried about general practitioners, family practitioners and internists prescribing psychotropic medications because they weren’t specifically trained in that area. And unfortunately, but maybe fortunately depending on which insurance company you're talking to, they are the gatekeepers. A majority of our psychotropic medications are prescribed by non-psychiatrists and non-neurologists. They're prescribed by general practitioners and that is the system that we've developed.

LR: It sounds like psychotherapists really have to do their homework not only on prescribers but on what makes for good prescription practice. Elderly patients don’t clear medications quickly and there is potential for buildup and bad medication synergy.

JR: It is a very difficult situation when a patient is experiencing a problem due to accumulation and approaching levels of drug toxicity. It may be a non-psych drug, maybe a medical medication that they're not clearing either, but their presenting symptoms might look like depression or anxiety.

LR: You make it sound like psychotherapists really need to be savvy about medications, complications, side effects, medical illnesses, and the medications which may lead to pseudo- psychiatric symptoms. Therapists don't have the luxury of not being informed.

JR: If they're not going to become experts at pharmacotherapy, then at least maybe some psychotherapists could learn more medical terminology. If you're going to have a meaningful conversation with a prescriber, then use the same terminology that they're going to use. You can go online and take a course on medical terminology. At least when you're having conversations with those prescribers, you're better informed on the language.

LR: Not that we're trying to curry favor with prescribers, but at least if we're attempting to speak their language, and they're of course attempting to speak ours, then there's a better collaborative effort for the patient.

JR: Even courses in basic anatomy and physiology.

Let the therapist take it upon themselves to learn something about the medical world, as the medical world needs to take it upon themselves to learn more about the psychotherapeutic world.

A Place for Medications

LR: In your workshop, you said something about targeting diseases versus targeting symptoms. And now it makes more sense to me because if I'm hearing you correctly, depression has a trajectory. It may be time-limited, it may not be. It may be exacerbated and will have peaks and valleys. But if a particular depressed patient is experiencing significant insomnia at point A, then the prescription of a psychotropic that also assists with sleep might take a chunk out of the depression.

JR: Exactly.

LR: Or if their behavior is interfering with their appetite, a certain other antidepressant may stimulate the appetite.

JR: Stimulate the appetite or reduce the appetite.

LR: It's looking at the disease as having its own life in a sense, and how can we help the person by optimizing their functioning even when they're depressed or anxious.

JR: Exactly.

LR: Even with someone in the throes of bipolar disorder or schizophrenia, we can help the prescriber by feeding them information about targeted symptoms and then work collaboratively to optimize the person’s functioning, even though, for example, it may not change their cognition or impact their executive functioning.

JR: Sure, especially with schizophrenia and bipolar disorder and other severe forms of mental illness, where it's an issue of whether the medications are managing symptoms. But we're back to an individual suffering from schizophrenia or having to deal with those issues, and they may not even be able to engage in therapy or even educational or occupational interventions until their level of paranoia or hostility or insomnia has been addressed. And so these medications manage symptoms so that the person can then achieve a level of functioning that will allow them to engage in other activities.

LR: Are there some psychiatric or behavioral conditions where you’ll want to refer for a medical evaluation right from the start? I mean someone who is blatantly psychotic is not going to come to see you. You may find your way to them in an emergency room but you're not going to see them on an outpatient basis.

JR: That's a great example. Let me give you a hypothetical, but a very common case. Let’s say that we are dealing with therapy and the therapist is doing everything right. Their therapeutic relationship has been established and the patient is coming to see them. They're doing the work, they seem to be engaged in therapy, but they are not fully responding.

LR: Improving, but not optimal.

JR: Exactly. Now let’s say that despite the therapy, the patient is still very anergic, they're sleeping a lot, have no energy and a lot of fatigue. This therapist might actually be obligated to refer the patient for a medical workup because all the therapy in the world won't reverse hypothyroidism. It's a relatively common medical condition where the first presenting symptom is depression, but not including negative cognitive thought, just the physical manifestations.

When therapists are feeling that they’ve hit a wall, that therapy is no longer benefiting the patient or you're doing everything right and nothing is improving, well then yes let’s refer. Let’s work out anemia. Let’s work out hormonal dysfunction, whether it's hypothyroidism or low testosterone or estrogen occurrences. Maybe we're getting the person in the very beginnings of a perimenopausal state and hormones are changing but the person is feeling anxious. They don’t recognize anxiety as anxiety. They recognize sweating, palpitations and hot flashes. This is a great area where the therapist should say the target symptoms could be medical conditions. I think it does behoove a therapist to have more than a passing acquaintance with medical conditions that could present with symptoms of depression and anxiety.

LR: We need to pay attention to those subsections in the DSM that talk about medical conditions because those should be on our checklists.

JR: Absolutely.

LR: In the DSM-IV there were the decisions trees and the first two categories were medical conditions and substance abuse. Are you saying that we should be very cognizant about some of those medical conditions that are likely to have psychiatric sequelae?

JR: Absolutely.

In an ideal world, every patient who is getting therapy should probably be medically cleared.

In an ideal world, every patient who is getting therapy should probably be medically cleared. If they're not being seen on a regular basis by a physician then yes, I would love for things like hypothyroidism to be ruled out early so we don’t waste a lot of time engaging in certain activities when all they needed was some Synthroid or hormonal replacement.

LR: A testosterone shot!

JR: I had a case presented to me just a couple of weeks ago where this person was dealing with a lot of depression and anxiety. They also suffered from migraine headaches but sleep apnea was an issue. And really one of the roles of the therapist is to help the patient recognize their conditions that need to be addressed, and even use something as simple as motivational interviewing to get them to use a CPAP machines or to more be adherent to their medications. If we can address these medical conditions, their secondary depressive and anxious symptoms will be addressed as well. If you have sleep apnea and you're not sleeping well, you're fatigued during the day. You're not concentrating during the daytime. You're checking off a list of DSM criteria for depression but you may have sleep apnea.

LR: You said something which hit me paradoxically, that perhaps one facet of psychotherapy, from a motivational interviewing perspective, is that it can help the person develop a healthier relationship with all of their medications. I can see that being a challenge. If the clinician is not generally supportive of medication but is open to its utility on a limited basis, then they can use their therapeutic skills to help the person use the medication more optimally. It would be analogous to helping a client who was resistant to using cancer drugs or thyroid drugs.

JR: Absolutely.

Every time we take a pill, no matter what the condition is, we are at least briefly reminded of why we have to take that pill.

Every time we take a pill, no matter what the condition is, we are at least briefly reminded of why we have to take that pill. And sometimes the patient doesn’t want to be reminded that they have a medical condition.

LR: Or a psychiatric one.

JR: Exactly. Schizophrenia, bipolar disorder, depression, every day you take that pill, that Lithium or that Prozac or that Risperdal or that Haldol, and you're reminded of the problem. That is actually a barrier to adherence. If you don’t want to be reminded of your conditions every day, a good way to avoid it is to simply not take your medications.

Everything Old is New Again

LR: What do you think is important for practicing therapists to know about the rapidly changing field of psychopharmacology? For example, SSRIs were once seen as the great hope but there has been some recent research suggesting the addictive potential of SSRIs.

JR: Well, I think every therapist should engage in whatever continuing education that they can to try to stay on top of it. Our current and future therapies are still not offering cures, they are managing symptoms. If the patient stops taking these medications we see high relapse rates. We have not discovered a cure coming down the pike. Everybody wants the magic pill. And this is where I think a lot of our patients might engage in illicit drug use or using prescription drugs from somebody else off-label and without a proper indication. Everybody is looking for that but it's not going to happen for us anytime soon.

We are expanding the pharmacology so that the newer drugs that are coming in the pipeline are going to be working a little bit differently from our current medications. That makes for interesting and hopeful expectations regarding their efficacy, but they're not going to be changing the landscape in any significant way. You had mentioned SSRI’s, which were never shown to be superior to our older tricyclics or monoamine oxidase inhibitors. They were safer but not superior in efficacy. The newer SNRI’s [selective norepinephrine reuptake inhibitors] or our other antidepressants that have come out in the last few years are still working on serotonin and norepinephrine. We might be coming out with different medications, but we're still locked into a very simplified view of the problem.

That's what I love about psychiatry and depression, schizophrenia, bipolar disorder, no two patients are alike. We are different genetically and experientially; everything that makes us who we are makes us different. And therefore,

we can't just apply one drug to treat all problems.

we can't just apply one drug to treat all problems. We reach this wall where two out of three people get better meaning that a lot of our patients are still partial responders or resistant. And that is the research ground for our newer medications; trying to treat SSRI partial responders, the patients taking Prozac or Paxil who have gotten better but haves not achieved remission. Or our threshold can change for adding an antipsychotic to the patient’s medication list like Rexulti that you see advertised on TV. As an adjunct to an SSRI or SNRI partial responder, we can ideally achieve a greater level of symptom reduction.

It's interesting that if we were having this conversation in the ‘70s, and ‘80s, and ’90s, we wouldn’t have added antipsychotics. One of my favorite antidepressants is a drug called Amoxapine. It is kind of in the tricyclic group although it's a tetracyclic and it's a serotonin and norepinephrine reuptake inhibitor. It has some serotonin receptor antagonism as well. But one thing that everybody remembers about Amoxapine was that it was the antidepressant with EPS (extrapyramidal symptoms). It had a little bit of dopamine blockade because it was derived from an antipsychotic. And we said, “oh no,” I don’t want to use Amoxapine because it might cause EPS.” And now our threshold for that has changed because all of our drugs that are FDA approved for resistant or refractory depression have the ability to cause extrapyramidal symptoms because they all belong to the atypical antipsychotic class.

LR: Back where we were.

JR: I think it's just very interesting that even some of our older drugs had the qualities then, and we found a way not to like them. And now 20, 30 years later, we're back to combining then in treatment for depression.

Enhancing Normal

LR: Everything old is new again.

Changing direction for a moment, could you share your thoughts on cosmetic psychopharmacology which some of our audience may not be that familiar with?

JR: Okay, now that's a bit of a soapbox for me. Cosmetic psychopharmacology as I define it and how it has been defined by others in other cases like cosmetic neurology or neuropharmacology, is using medications to enhance normal. Let’s not talk about pathology and medications that were created to either treat it or prevent it, but now let’s take whatever definition you want for normal and enhance that. We've been using cosmetic pharmacology for a great number of years. We used amphetamines in World War I and World War II allowing a soldier or pilot to stay awake longer than normal. The soldier or the pilot did not have pathology, but we gave them amphetamines. And we still do this today, by the way.

LR: Students?

JR: Students are a great example of using the Adderalls and the Ritalins. We all drink coffee when we, study which is cosmetic pharmacology. I have a problem with the excessive use of cosmetic pharmacology in certain areas. I worry about teenagers in high school and about the college students using Adderall and Ritalin; thinking and believing, an urban myth by the way, that it will enhance their grades or their test performance. That has not been proven because every medication becomes the means of getting a better grade and then they believe that “this gives me a better grade so I will take it for this test. But I need to make a good grade in this class, so every test matters. I need to make a very good grade in all of my classes, so every class matters.”

Every test including the MCATs, PCATs or some GRE becomes a high stakes exam. And now what we thought might have been occasional one time, as-needed medication use becomes weekly, if not daily, use of these medications over the course of high school, undergraduate, and graduate school. Some of our children and young adults might be taking these medications for a period of at least eight to twelve years. And I don't know what's going to happen to their brain because your brain isn't done cooking until you're about 25-years-old, so there is still neuro-development going on.

And I think it's interesting how some individuals have rationalized the use of stimulants for brain enhancement

And I think it's interesting how some individuals have rationalized the use of stimulants for brain enhancement for lack of a better word. Now, every time a professional athlete trying to make money, trying to win an award, using maybe some steroids or using some oxygen enhancement drug is getting an asterisk put on their names.

If you have the most home runs and you did an anabolic steroid designed to enhance muscle performance whether it's strength or conditioning, why is it that we have somehow criminalized the use of steroids for muscle performance, but we are not criminalizing the use of the stimulants for brain performance?

Medicating Children

LR: When you have a kid graduating high school with a 6.2 GPA who has been on stimulants since they were six, perhaps their diplomas should have an asterisk.

Since we’re on this topic, I would like to talk about psychopharmacology for children. I was speaking the other day with psychiatrist Allen Frances who chaired the DSM-IV task force and who later criticized the DSM-5 particularly for its invention of the diagnosis of disruptive mood dysregulation disorder, or childhood bipolar disorder. He believes that this diagnosis justified the use of powerful medication for children for what amounted to tantrums. And then you have parents and teachers pushing for medications for young children for conditions like ADHD.

JR: I worry that sometimes we're requesting medication for symptoms that could be easily managed behaviorally or through psychotherapy. I worry about the snowball effect in child psychopharmacology. I will refer to the typical ADHD child as Timmy. Little Timmy has developed or has demonstrated some symptoms of ADD or ADHD and someone prescribes Adderall or Ritalin or some other stimulant. Now Timmy is highly activated because those symptoms may not have been true symptoms of ADD or ADHD. Add to that that our teachers have a fairly low threshold and they want a perfect classroom. You can't deviate from the norm very often in a large classroom setting. Timmy is now looking highly agitated, revved up, a little manic and now we're having to give him something at night to help him sleep or to bring him down. I use the term that we're “speedballing” little Timmy or he won't eat and won't sleep.

And now the drug that we give him to help bring him down brings him too far down and now someone entertains the idea of depression. Little Timmy is now getting an antidepressant along with a stimulant and some kind of medication that would reduce the neurotransmitters, these newer agents like Guanfacine, Clonidine or an atypical antipsychotic also approved for children with bipolar disorders. Our prescribers can rationalize that they're approved for use in these children. Follow me here! You’ve started with a stimulant, you end it possibly with an antipsychotic or neurotransmitter decreasing agent which looks like a downer. The downer results in someone saying depression and now we're back to an antidepressant. Timmy is now on three drugs, but drug number two and three could have only been in response to the side effects generated by drug number one which may not have been necessary. Our threshold for using, what I think are powerful medications in 5, and 6 and 7-year-olds is both impressive and sad at the same time. We really aren’t wanting to invest as much time in the therapy and the behavioral modification options. It takes work.

Our threshold for using…powerful medications in 5, and 6 and 7-year-olds is both impressive and sad at the same time.

LR: The implication for the child therapists is that they really have to be very aware of what medications the child is on.

JR: Absolutely. And the side effects that those drugs cause might look like other therapeutic issues to be addressed.

Psychotropic Drug Dependence

LR: And help coach parents to ask better questions to the prescriber or help them not to over-rely on the pediatrician for a prescription of psychotropic medication even though it's easily done.

In a similar vein, psychotherapists often work with patients who have substance abuse problems and are typically trained to recognize not only the physical signs but also the psychological, social and behavioral symptoms. Can you think of a checklist of symptoms and/or signs a psychotherapist might consider for a patient whom she thinks is having a problem managing their psychotropic medications?

JR: Oh, that's a very good question. Well, it depends on the psychotropic medication. For argument’s sake, let’s say a person has been prescribed Xanax and told to take it only as needed in more extreme situations of stress and anxiety. If they are refilling their prescription every 30 days as if they are using it and consuming it on a regular basis, then this sends a message to the therapist, as it should to the prescriber, that this person is having anxiety every day to the point to where either they are taking their medications even when they don’t need it to avoid anxiety, or their level of response is not where we want it to be, or physical dependence has set in.

Physical dependence on a drug like Xanax probably sets in as early or earlier than even addiction.

Physical dependence on a drug like Xanax probably sets in as early or earlier than even addiction. The reason why that is – and this is why I think benzodiazepines can be a trap for a lot of our patients, is that if I give you a benzodiazepine like a Xanax or an Ativan or a Valium for longer than two to four weeks, then when you don’t take the medication, the first symptoms that occur are anxiety and insomnia which are the very reasons why they were prescribed in the first place. Their continued use is reinforced and if this person is now having to take their medications on a regular basis and that was never the treatment plan, then you're looking at the signs of at least physical dependence.

Here’s an example. Grandma might have lost Grandpa 15 years ago. It was unfortunate and it was sad and she was having grief and couldn’t sleep. They gave her some medication for sleep or they gave her some medication for anxiety during the day. And 15 years later, she’s still taking that medication, way beyond the grief reaction time frame. Someone says to Grandma: “you know what I think, it's time that you stop taking the Halcion or the Valium or the Xanax.” First, she has a regular anxious reaction but then says, “you know what, you're a healthcare professional”, or “my daughter said something, so I will stop taking that medication as you recommend.”

That first night is the worst night of her life. It is insomnia and anxiety and it sends the message to Grandma that “I still need the medication. I've got the same problem I had 15 years ago.” Physical dependence sets in nicely with some of these controlled substances that we have.

If a person is demonstrating an avoidance behavior to stopping their medication, then they're avoiding withdrawal symptoms. Now if they are drug seeking and more overt and they’re taking more than prescribed, I think those symptoms are a little bit easier to see for individuals trained in substance abuse and addiction. It's the avoidance of withdrawal symptoms that look like the psychopathology for which we started the medications in the first place. That's why Grandma gets in trouble. That's why she’s still taking Ambien 10 or 20 years later or Xanax that much later.

LR: It goes back to this idea that as psychotherapists who work in the province of the mind in this age of medication and era of the brain, we have to be so much more aware of the relationship between the behavioral, cognitive and emotional changes in our patients and the possibility of their drug using behavior, whether licit or illicit.

Health Literacy

LR: In 1997, the FDA lessened restrictions on advertising pharmaceuticals including psychotropics directly to the public. One of the results has been that people make specific medication requests to their physicians. What are your thoughts on DTC (direct to consumer) advertising?

JR:

direct to consumer advertising…told them they were not alone.

At first blush, I don’t like it. Okay, let me qualify that. The appropriate answer is that direct to consumer advertising when it was approved did one good thing to a lot of our patients which was that it told them that they were not alone. A lot of individuals are in their psychopathology-depression and anxiety, and they might think they're the only ones who feel that way and that no one understands them. They might even be fearful of seeking out treatment. Direct to consumer advertising usually casts a wide net of symptoms such as anxiety, depression or mania so the individual says: “wow, it looks like there are other people out there with this problem.”

LR: It provides them with a sense of community.

JR: Right. It might reduce their reluctance to seek out treatment, which is good. However, telling you a very specific drug is the drug for you is not a good way to go. These newer drugs that are in direct to consumer advertising are sitting in the sample closet of every prescriber and the prescribers may be thinking, “I don’t want the patient to spend a lot of money.” They give their patient a sample box with a seven, ten, twelve or thirty-day supply for free.

If that drug works then great. However, that drug might cost $100 or $200 per month. And who’s going to pay for it? If that patient doesn’t have the financial resources or the insurance, then why did we just pick an expensive drug that they can't use beyond seven or fourteen days? Now we have to go to our generically available medications that aren’t advertised. For this reason, I don’t like direct to consumer advertising about a specific drug. I prefer for patients to tell me about a disease state and not mention the name of the drug. That's the better advertising.

LR: It sounds like therapists almost have a moral obligation to engage their clients in conversations about psychotropics and advertising and to help them be the smart consumers of media. And to be diligent in their choosing of prescribers. In other words, helping psychotherapy clients beef up their courage to ask the hard questions, otherwise they're just going to be victimized by marketing, medicine and medication.

JR: Health literacy goes beyond learning about your own disease state and your disease state’s management. I think it goes into this area of being informed consumers, asking the right questions to the prescriber. And therapists can help their patients become health literate by referring them to the right resource, or at least helping them ask those questions. Now, granted, what have we asked for our therapists to do in the last hour? We've asked them to be well- informed through continuing education regarding pharmacotherapy, prescribing, laboratories and basic medical terminologies. We want that for their patients as well.

I really wish more of my patients would take responsibility for their disease state and its management.

I really wish more of my patients would take responsibility for their disease state and its management. The patient really is the center and one thing that we don’t do as often as we probably should is let the patient be part of the decision-making process. Not just a recipient but an active member of the treatment team. Because all our efforts will be for nothing if they don’t do their part of the treatment plan.

Wrapping Up

LR: As we wind down, can you offer advice for the psychotherapist just starting out who is not particularly cognizant or even desirous of learning about medications, or is maybe even anti- medication?

JR: Well, given that we should ideally all belong to some interprofessional collaborative practice, I think that a psychotherapist really needs to do their very best at keeping up to speed, going to educational programming, continuing psychopharmacology education, and learning medical terminology so that they can have meaningful conversations with other practitioners. When they are referring a patient who is seemingly resistant to psychotherapy and the depressive symptoms are continuing, they could say this might be hypothyroidism. At least then we can do the thyroid function test, at least we can do iron levels, at least we can do a complete blood cell count, to make sure that the patient doesn’t have a certain anemia.

LR: So not only build a lexicon but nurture their relationship with the field of medicine.

JR: Yes.

LR: I can almost ferret from what you're saying, there there’s a the need to include mandatory biennial psychopharmacology continuing education for licensed clinicians. In Florida we have mandatory CEs for ethics, domestic violence, and medical errors, so why not chew off an hour of that and make it mandatory training around psychotropics?

JR: Given our world of psychotherapy, I think that would be prudent-absolutely.

Shame Part 2: Shame Proneness

Posted on August 15, 2018February 11, 2026 by Psychotherapy.net Team

Megan came into session and sat down. Her eyes wandered around my face, but didn’t meet mine when she said, “I did it again. I went back to him.”

“Tell me,” I said, leaning forward.

“I’m a – a loser. I can’t stay away from him even though he’s bad for me.”

Megan had come into therapy after failing to sever ties with her most recent boyfriend, Tim, a man who repeatedly left her feeling emotionally abandoned and worthless. She reported a history of tumultuous intimate relationships that consistently left her feeling lonely and dissatisfied.

Tim was no different. Every time he dismissed her or invalidated her, it tore a little more of her heart out. Worse yet, it confirmed her inner fear: She was worthless and no one would ever, could ever love her. Trying to repair fractures to her self-esteem, she would search for the next man to love her, only to find herself in another relationship where she felt dismissed and worthless.

This isn’t unusual. It’s certainly a story I’ve heard variations of many times as a psychotherapist. Megan, who was thirty-five years old, reported that she had been going through this cycle since she was a teenager. She felt hopeless that she would ever find the stable, loving relationship she so wanted. I felt it as soon as we started our work together. Shame.

In my last blog post, I discussed the shame that entered the room in early sessions, when patients began exposing themselves. Megan’s shame was more complicated. Normal shame is transient, but for Megan, her inclination was to experience shame in all ambiguous situations. This proclivity has been assigned various names. I like to call it shame-proneness, which is the term June Price Tangney, one of the leaders in research on moral affects, (shame and guilt), named it.

When Megan came into situations that naturally elicited self-assessment, her emotional response would be feeling bad, small, defective. Self-esteem is a cognitive evaluation of the self; shame, on the other hand, is an affect, and therefore, permeates the entire self, spilling into every crack of someone’s being, coloring all their experience-darkly.

On some level, Megan believed that she deserved poor treatment from men, causing a repetition of the very pattern she was trying to stop. No matter how hard she tried to find a different outcome, she was always confronted with the same feelings of shame. Thus, the narrative – I am bad – that she desperately wanted to change, perpetuated itself.

Megan explained that she went back to Tim during the week when he promised it would be different, only to be left again. This was the fifth time she went back only to be left.

“He threw me out.” Tears trickled down her cheeks. “See, I’m weak. I’m a failure at everything. I’m never going to find what I want. It’s me.”

Her feeling bad about herself in the Tim situation pervaded other aspects of her life. That is, she felt bad all around, not just in relations to Tim.

I knew I had to help her see how her self-perception created a type of self-fulling prophecy. So, I reminded her of what we had been working on. “Remember what we talked about?” I often use psycho-education with patients, even when I’m working more psychoanalytically as I usually do with a shame-prone patient. I don’t find that keeping the nuances of therapeutic work undisclosed helps, especially for patients who feel so exposed already. It’s like throwing them outside in the cold without a coat, alone.

Megan and I had discussed shame. She knew that it tied back to early experiences of emotional neglect and abuse, where she unfortunately heard messages that she was bad and wouldn’t be anything different, ever.

“I remember, that just makes me feel worse. I should know better by now,” she whispered. This is where shame is so tricky; it’s very hard to intervene without evoking more shame.

I addressed her experience in the room. “We knew it would be hard not to go back if he called. Intellectual insight comes before the emotional connections that make change easier. You are working very hard to undo a narrative that took years to build. It takes time.” I leaned forward, again. “Remember, what we talked about last session, during the break from Tim.”

“Yes, I’ve – gosh, I can’t believe I forgot.” She pulled out her phone and showed me a schedule of all the workouts she had done the last week. Megan had been very athletic. I encouraged her to go back to exercising.

I wanted her to feel her strength and resilience. I wanted her to find her value in her activities. One of the most effective ways to help people combat these shame narratives is to help them access and activate their natural strengths, the parts of them that weren’t fostered, because no one acknowledged them when they were younger.

It’s our job as clinicians to discover these natural endowments and cultivate them for all of our patients. Shame-prone patients need more help figuring out what they are and more time to develop motivation.
Megan smiled as she showed me what she had accomplished that week. I saw pride glowing in her eyes. I observed it with her. “What are feeling?”

“I feel good.”

I smiled, thinking that we had found a space for Megan that was shame free. “What’s it like to feel good?”

“It’s something I knew I wanted to feel, but I could never quite find.”

“Now that you know what it feels like, it will start to get a little easier. Be hopeful.”

“I am.”

*Megan is an amalgamate of patients suffering from shame-proneness.

Shame Part 1: Walls are Fears Disguised as Safety

Posted on August 13, 2018February 11, 2026 by Psychotherapy.net Team

The wind blew in strong gusts, howling and shaking the windows. Tracey pulled her cardigan tighter, then rubbed her arms with her hands. “I hate strong wind. It feels like the walls are going to come down.”

Interesting, I thought, we’re getting closer. This described exactly what was happening in the room.
Tracey and I had been working together for four months but had barely scratched the surface. She discussed work-related stressors and dating. She would go into detail about the many men she dated, but she never described her feelings. I wanted to know more about her inner life, but I felt her guardedness. She had a wall up. And I had to respect it.

Walls are fears disguised as safety.

But why are they there in the first place? When patients come in, but have trouble disclosing, this is the question.

We call it defensive structure or defensive mechanisms or resistance, this wall. We have words, but one I rarely hear that is significant, is shame. My dissertation topic involved a thorough analysis of shame and I have continued my research. Every time I’ve presented on the topic, students and established clinicians alike ask the same question: “Why aren’t we having classes on shame?” It’s important.

Shame is the deepest and most painful affect, as it involves an evaluation of the entire self. Whereas guilt assesses what we do- “I shouldn’t have done that”, for example; shame evaluates the entire self: “I shouldn’t be that.” Guilt says, “what I did is bad.” Shame says, “I am bad.” Shame pervades our sense of self – entirely.
Shame also involves the real or imagined perception of another. It’s the reason why infants and toddlers will run around nude without feeling exposed. They haven’t reached the developmental stage where they recognize themselves in the eyes of others.

The essence of psychotherapy requires that patients come in and reveal their innermost self, layers of secrets, elaborate fantasies. We are asking them to tell us the very thoughts and feelings that are usually hidden, because we don’t want others to see. Shame inevitably arises as the bricks come down and the patient feels exposed.

For patients like Tracey who have never been in psychotherapy before, this is often even more difficult. Additionally, unresolved shame creates more psychotherapeutic challenges. Unresolved shame (which I will discuss in the next blog), develops when injuries to the self occur over and over; any type of emotional abuse will leave people with some unresolved shame, which is woven into the very fabric of their identity.
In a lecture I had given some time ago, a psychodynamic student asked if I thought it was our own shame that made us avoid discussions of shame. I hope not. We need to afford patients the luxury of a safe room, where we are sensitive and cognizant of the shame that naturally arises as disclosure increases.

I had to help Tracey feel safe enough to slowly remove the bricks she felt were loosening. I went with the metaphor. “What do you imagine would happen if the walls came down?”

“I dunno.” She crossed her arms tighter.

“Are you feeling that right now, like the walls are coming down?”

She diverted eye contact, picking at a string on her shirt. “I don’t want you to think I’m crazy. I feel crazy sometimes.”

I leaned forward. “I know this is hard. Everyone that comes in here feels like their thoughts are crazy. I have thoughts sometimes that others might think were crazy. It’s normal.”

She looked back at me. “You do? But you’re a doctor.”

“We all have ideas and thoughts and fantasies that feel bad or scare us sometimes.” Small self-disclosures to normalize the situation and show patients that we are also vulnerable to emotions helps ease shame-ridden angst. Also, keeping the dyad collaborative instead of hierarchal reduces shame.

“I have thoughts like that all the time.” She placed her hands over her face. “There are things that I’ve never told anyone before. I know I should tell you, but it’s very hard.”

“I know it is. Maybe we can start with what you’re afraid I will think.”

“OK,” she said with a small smile. I felt a few bricks had come down as I acknowledged her shame. I knew that the more we discussed her fear, the safer she would feel to explore what was behind the wall. It would be two bricks down, one back up, but at least we were finally at a start.

*Tracey is an amalgamated example of patients during early sessions struggling with shame.

PhDs in Therapy

Posted on December 5, 2017February 11, 2026 by Psychotherapy.net Team

Academics and Mental Health

My online psychotherapy practice attracts PhD candidates from around the world. Young academics are passionate people—articulate, often self-aware, intelligent, and eager to learn. But one would not guess how much this population suffers from poor mental health, how exposed and fragile they can actually be.

Research on occupational stress amongst academics indicates that it is widespread, with younger academics experiencing more mental health issues than their older counterparts. A recent Belgian study suggests that PhD students are 2.4 times more likely to develop a psychiatric disorder than the highly educated general population.

Other studies show that as much as 50 percent of doctoral students leave graduate school without finishing; it is reasonable to imagine that mental health issues play a major role in such an attrition rate.

“Young academics are often reluctant to disclose mental health problems to their universities out of fear of stigmatization and punishment in the highly competitive academic world.” PhD candidates who do their fieldwork abroad are particularly vulnerable. Not only do they feel a high pressure to achieve their fieldwork, but they also lose their social support system and have to adapt to a different culture.

Opening Doors with Online Therapy

Online therapy can be a unique opportunity for postgraduates to get support and resolve some developmental issues.

This vignette illustrates such a case.

When Jane engaged in online therapy with me, she was in the third year of her PhD program from a top American University. She was studying literary theory, and her fieldwork had just brought her to St. Petersburg, on the trail of the Russian thinker Michail Bakhtin and his main object of fascination—Dostoevsky. This city, affectionately called “Piter” by the locals, happens to be the one where I grew up before leaving Russia in my late teens. A bit of nostalgia was triggered inside me.

Jane had arrived in St. Petersburg in November. It had greeted her with gale-force winds and freezing weather, even worse than what she had imagined after reading the novels of Pushkin, Gogol, and Dostoevsky. At first she had been excited to discover its canals and lightless courtyards (kolodzi or “well-yards” in Russian) hidden in the middle of buildings, but after the first months, her fascination with the place was replaced by a lingering anxiety that she was not yet able to understand.

For our first session, Jane connected from the room that she was subletting in a big kommunalka, or shared apartment. The room was dark except for a surprisingly green wall gleaming behind her back, where she sat barely illuminated by the Russian winter’s scant natural light. Jane was slowly plunging into depression, which was draining all joy out of her research and her life. The faculty members she had met at the local university had first seemed friendly enough, but now she was avoiding any contact with anybody who could ask her questions about her research progress or about anything else for that matter.

The only window in her room was facing the plain yellowish wall of another building. If at first this grim view on the bare well-yard had reminded her of Dostoyevsky, it now felt like a metaphor for her current life prospects—long, dark Russian winter, loneliness in this foreign place, and a very uncertain outlook for a career in academia.

The day before she reached out for therapy, Jane had found herself sitting on the windowsill, looking down upon the dirty snow, and imagining her body lying in the middle of the well-yard, covered with her quickly freezing blood.

Now we were starting our first session, and she greeted me in Russian:

“Zdravstvuite.”

After a few minutes, I could sense that she was struggling, looking for words to describe the way she felt. As is often the case with bilingual individuals, we spent some time in this first session exploring Jane’s relationship with her two languages. Her Russian had developed through academic work, becoming her language of organized thought; when she wanted to describe her feelings, we had to switch to English. This going back and forth between the two languages allowed us to make better sense of her experience.

Soon we settled into our linguistic routine, using either language according to the subject. As with many emigrants, this arrangement suited us both, letting our multiple selves into the encounter.

Jane spoke Russian the way linguists often do—with unnatural care and respect for its intricate grammar. Strictly speaking, Russian was her mother tongue, but her mother had always been emotionally disconnected from her, and preferred to speak to her daughter in a limited English, without nuances but enough to give orders or rebukes. In high school, Jane then learned proper Russian, a language that she had until then perceived as unsophisticated.

Her father was a Texan estate developer. He had met his wife during one of his visits to Kazakhstan, where he had high-risk-high-reward investments. Jane’s mother was at that time young and beautiful; her secretary job was just a step towards her glorious future, where she knew she would have a shiny red car and a penthouse with views on skyscrapers gleaming in the night.

When Jane was born, her mother had already experienced deep disillusionment with life in general and her husband in particular. Texas was nothing like she had imagined, except for the consolation of owning her shiny red car; she used to drive on the endless dusty roads with fury.

As Jane grew up, she only added to her mother’s disappointments: she was neither beautiful nor particularly gifted for any girlish activities. Her academic achievements did little to change her mother’s opinion that she had been thwarted by fate in her motherly aspirations.

By the time Jane turned twelve, her father had lost most of his estate investments. She could remember him drinking whisky and grumbling about taxes and politics, only to rouse when his wife would come back home and scold him, provoking a fight. They both seemed to enjoy fighting, often loudly and in front of their daughter or other unwilling witnesses.

When Jane was accepted into a top university, her parents seemed relieved at the idea that she would finally be “out of the way.”

The First Session

In our first session Jane seemed withdrawn and extremely vulnerable. I wondered whether it was best for her to meet a therapist online. It probably was not, but she felt unable to get out of her flat and make it through the snow to the practice of one of the few English-speaking therapists available locally.

Looking through the dark window in front of her, Jane told me that she felt lonely and homesick. The homesickness felt even worse because she did not have a proper home back in the States any more. “This feeling of homesickness paradoxically associated with the experience of homelessness resonated with me.”

Her college friends were spread all around the country, busy with their own research or jobs. During her first months in Russia, she had managed to maintain the illusion of contact with some of them through Skype or WhatsApp, but now the calls were becoming rare. Maybe they had lost interest in her; maybe they never had any genuine interest at all. She had started doubting everybody and everything. Her parents had not paid her a visit.

And for several months, her academic advisor had not even been responding to her emails. Jane felt hurt and humiliated by this lack of interest from someone who had initially seemed so supportive and enthusiastic about her research. Her advisor was a middle-aged woman known for her feminist views and a difficult character.

Jane complained that her advisor’s silent ghost seemed settled at the end of her desk, at the other end of the room. Jane had been unable to sit there for days, and preferred to connect for our sessions from her sofa bed, crumbling under books and printed papers that she was unable to read or remove, even though sleeping in the middle of this improvised library—“the den,” as she called it—was becoming tricky.

As Jane was lying low in her den, the ghost was comfortably occupying her desk—an ever disapproving and punitive presence. Each time she tried to formulate a thought and write it down, she could sense, almost physically, the imaginary advisor winking in distaste at her poor efforts; simply knowing that the results would never be good enough. This room that Jane seemed to share with her imaginary advisor was suffocating, but the anxiety she felt at the thought of getting out was even worse.

As Jane described her advisor’s malefic ghost, I asked how its presence made her feel.

Alienated, confused… little.

As we explored these feelings, Jane’s usually calm face changed. She looked like a young and very upset child.

Have you ever felt like this before?

She had; it was a strangely familiar feeling when she curled up in her den, sucking her thumb at times she confessed. This is how she used to sooth herself, alone in her childhood room, when her mother was annoyed with her for some reason, or busy exercising.

As a child Jane often secretly thought that she had been born to these particular parents by mistake: she had little or no affinity with either of them. Roald Dahl’s character Matilda resonated deeply with her.

Jane had had as little choice when an academic advisor had been allocated to her, as she had had in choosing her own mother. She actually resented both of them. “The awareness of her dependence on her advisor was producing a deep anxiety—the same she used to feel when she was dependent on her mother.” This time the advisor seemed to be failing her in the same way her mother had done before, and this resonance made Jane’s anger even more overwhelming.

I knew first hand how the supervisory relationship, not unlike the therapeutic one, has the potential to repeat earlier traumatic experiences.

Shame in Academia

This incident opened a door into what would become the most important part of Jane’s therapy: working with and through her shame, towards a better sense of self and higher self-esteem.

During her first steps in academia, Jane had quickly learnt that she had to justify her every word or thought. Entry into the academic environment can trigger a feeling of shame in newcomers. It is easy to feel small and under-developed when entering a community of seasoned academics that you look up to: a dwarf in the presence of giants.

Jane would spend hours imagining how her advisor and other committee members would “laugh in her face” as she presented before them. At night, she would stay awake picturing the most humiliating scenes of her academic fall made public.

As Jane was describing how little, insignificant and defective she often felt, despite her obvious academic success, it became clear that this was a familiar emotional experience for her. She had felt this way many times before. As a little girl, she idealized her mother—a beautiful, tall, elegant, and snobbish woman. She remembered how proud she had felt of her mother as her primary school mates were admiring her beauty and expensive clothes. But as she grew up, her mother lost interest in her; Jane’s awe was replaced by disappointment. Why didn’t her adored mom like her? Did it mean that something was wrong with her? A feeling of not being good enough, not likable, had put roots in her very nature. This shame was later exacerbated by the tough rules of the academic world.

A few months into our work, Jane’s mother announced that she would be visiting her in Russia. Jane felt disorientated and anxious. She thought that her mother must have been bored with her Texan life. But I could also sense how the little girl in her craved her mom’s attention; Jane was still hoping that her mother might end up appreciating her.

She went to pick her up at the airport. The first comment her mother made brought back the past: the airport hall looked provincial and rather under-equipped for a city praised by all touristic guides for its “emperor glory.” When they reached the luxurious hotel her mother had booked and sat together in the bar, facing the straight line of the Nevsky Prospect, Jane was already dreading the days to come. Looking at the middle-aged heavily made up woman, Jane realized that, however familiar she appeared, she did not really know her. In her bright yellow jacket, her mother looked strangely foreign. When Jane tentatively switched to Russian, she did not seem to notice, and carried on talking in her consistently poor English: Jane’s hope for acknowledgement of her efforts and progress in her mother’s tongue were vanishing. A young waiter came to take their order and smiled at Jane; she could not avoid noticing how her mother’s face froze.

When Jane finally heard her mother talking in Russian to people in shops and restaurants, she was shocked by the poverty of her vocabulary and the unpleasant notes of a foreign accent—maybe consciously produced by her Americanized mother.

Later on, reflecting on our use of Russian in therapy, Jane acknowledged that communicating in her mother tongue within a warm and genuine relationship was a meaningful experience to her. For a long time she had been reading about literary characters’ feelings in Russian; to speak about her own feelings in Russian to somebody genuinely interested was new to her. “Putting her childhood experiences of loneliness and hurt into words in Russian moved something deeper inside her: she was now able to express anger towards her academic supervisor, but also acknowledge the anger she felt towards her mother.”

The Work Continues

We eventually survived the winter together. As the days got longer and the first rays of a shy April sun illuminated Jane’s room, her shame seemed to lift. She washed her sole window for the first time since she had moved in, and realized that she did not feel any desire to fall. The snow underneath was starting to melt, and she noticed a neighbor looking at her from a window on the opposite side of the yard. She had never noticed any signs of life in that window before. As their eyes briefly met, she felt strangely alive.

Spring brought its own anxieties. Jane’s academic clock was ticking, and she had only a few months left to complete her fieldwork. Even if she now saw her adviser in a much less grim light, the support she was getting from her was scarce and inconsistent. The White Nights kicked in, and Jane lost sleep again over her work. Researching contemporary Bakhtinian thought, she was trying to contact the academics who saw themselves as his followers. The risk she was taking in reaching out to this closed circle triggered familiar shame: Jane was convinced that these seasoned academics would never take her seriously, and her Russian was certainly not good enough.

We had a session just before she was due to present her research project to this group, hoping to convince them to participate. Jane kept picturing how they would look bored or even leave the room before she could finish. She was particularly intimidated by one of them. This older professor looked like Bakhtin himself—the same high forehead and the white beard. Jane was not sure whether this resemblance was a cultivated forgery or unconscious mimicry. When they first met, he had spoken so quickly and pretentiously that he made little sense to her.

Her mother’s constant absence, combined with the little interest she had shown in her daughter, had never allowed Jane to confront her.

It took us a while to reach a point where Jane felt ready to have a direct and honest conversation with her advisor. She learned that she had been grieving her husband’s recent death and was being treated for depression. After this conversation, her advisor’s ghost dwindled and eventually left her desk, making space for her own thoughts. Her research journal came back to life and Jane’s eyes sparkled again when she spoke about her work.

One day Jane did not switch her camera on as we began our session. She wanted audio-only. When I asked her why, she said she did not feel well enough to shower or brush her hair. Or in essence, she felt too ugly and too unfit to be looked at. As she shared this with me, she cried. What Jane was painfully experiencing at that moment was a deep sense of inadequacy resulting in feelings of shame. To let me witness her shame felt unbearable to her; she was terrified to recognize in my eyes the same disgust that she used to see in her mother’s gaze.

Eventually we agreed that she had to take this risk to dispel her shame. After a few minutes, she was able to switch the camera on: her face looked puffy from crying and very young.

My natural response was to give Jane a hug, but the limitations of the online therapy added to the natural ethical concerns around touching a client. This time I was painfully aware about the physical distance between us.

Jane was close to cancelling but she did not.

The meetings of their little group were informal and usually held in the apartment of one member or another. She was kindly asked to bring a cake to go along with the tea. As she rang the doorbell, she was close to fainting. Once inside, she was greeted by a giant St. Bernard dog, which managed to lick her on the nose. The laughter reaching her from the sitting room and the familiar smell of the books lining the walls of the corridor reassured her. Bakhtin’s twin brother’s wife—a tiny woman with sparkly blue eyes (also a former ballerina as she would learn later)—accepted the expensive cake with an evident pleasure and led her into the sitting room. The place was warm and the academics looked like old friends enjoying a tea together.

After an hour, she felt an almost painful sense of belonging; for the first time she was part of a welcoming family. They listened to her presentation with genuine interest, asked questions, and ended up having a heated and mostly inspiring argument in which Jane was able to take part. She forgot about the imperfections of her Russian and was able to enjoy this simple warm connection with her senior colleagues.

The inclusion and warmth Jane experienced at that meeting gave her a new boost. On her way home, Jane bumped into the blond neighbour. He was walking his scruffy dog beneath her windows. She spontaneously invited him in for tea. In bewilderment, she found out that he was a PhD candidate too, but in physics. It was a long night; his dog turned out to be a real cuddler and accepted her as a new friend.

I continued meeting with Jane for another year or so. She moved back to the US and started writing up her dissertation. Bakhtin’s twin brother died suddenly a few months after their encounter, and she returned to St. Petersburg to attend his funeral. His ballerina widow gave Jane some of her late husband’s books, insisting that such had been his wish. Jane cried and felt like an orphan. Grieving for the friend and mentor she had found in this old Russian philosopher made her question her relationship with her father.

In the meantime, his drinking had got worse. Jane went to visit. She needed only one dinner in his company to realize that he did not seem able to listen to anything she attempted to say and was clearly craving another drink. Once she returned from this disappointing trip back home, we had to mourn her hope of having at least one “good enough” parent.

In the process she finished her thesis and started teaching. This activity brought back the familiar feelings of shame, but her genuine interest in her students and her revived passion for Russian literature helped Jane to eventually enjoy her work.

The therapeutic relationship we developed helped Jane survive the definitive separation from her parents; their absence in her life was not plunging her in despair any more. She has finally been able to thrive in other close relationships—with her friends, colleagues and, finally, with her first supervisees. In our ending session she talked a lot about how much our relationship meant to her, but also about her desire to be there for her students. This filled me with warmth and gratitude—towards her, but also towards my own supervisors who were genuinely and consistently there for me. Their presence has been a real game changer for my own academic journey.

The path towards a PhD is never easy. It takes a lot of work but also a lot of daring. As any transitional stage of life, it abounds with demons that we must tame.

Jane is actually a fictional character inspired from many stories of PhD candidates whom I work with in my online psychotherapy practice, or during the course of my own PhD. I admire their courage, hard work, and passion for knowledge. These qualities are a great asset in therapy, which is a natural and inspiring companion for such a journey.

Reaching out for therapy online can help young academics to get the much-needed support, even when they are far away from home.

References

Bozeman, B. and Gaughan, M. (2011) "Job Satisfaction among University Faculty: Individual, Work, and Institutional Determinants," The Journal of Higher Education, 82(2), pp. 154-186.

Kinman, G. (2001) "Pressure Points: A review of research on stressors and strains in UK academics," Educational Psychology, 21(4), pp. 473-492.

Kinman, G. and Jones, F. (2003) ''Running Up the Down Escalator: Stressors and strains in UK academics," Quality in Higher Education, 9(1), pp. 21-38.

Levecque, K., Anseel, F., De Beuckelaer, A., Van der Heyden, J. and Gisle, L. (2017) 'Work organization and mental health problems in PhD students," Research Policy, 46(4), pp. 868.

Lovitts, B.E. (2001) Leaving the Ivory Tower. The causes and Consequences of Departure From Doctoral Study. Rowman & Littlefield.

Shaw, C. (2015) http: //www.th eguardian.com/education /2015/ feb/13/un iversitystaff-scared- to-disclose-mental-health-problems (Accessed on 23/9/2017).

Walsh, J.P. and Lee, Y. (2015) "The bureaucratization of science," Research Policy, 44(8), pp. 1584-1600.

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