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Psychotherapy with Coronavirus: A Novel Experience

Posted on June 26, 2020February 11, 2026 by Psychotherapy.net Team

A Very Strange Referral

When I first met Corona (“©”) in my psychotherapeutic practice early in 2020, I was struck by a contradictory impression. On the one hand, he was almost invisible, with a timid appearance. He was so small that I seemingly had to look at him through a transmission electron microscope. On the other, he had an impressive, crown-like outer shell. It resembled a round naval contact mine with spikes that could explode if one bumped into them. But ©, a master of disguise and transformation, was trying to evade any scrutiny. It was only when he presented himself as the silent killer responsible for the COVID-19 pandemic that he evoked my curiosity.

Despite being retired for years, I decided to accept © for immediate treatment. It was not an easy decision. In the past, I had worked with clients for whom I felt some amount of sympathy and whom I wanted to help. Now I was faced with an adversary I might ultimately want to eradicate.

When © entered my office, I immediately felt nausea and had difficulty breathing. I didn’t make much of it until I gradually became aware of the various symptoms he caused me — fatigue, sore throat, dry cough, and fever. These were not the common countertransference responses all therapists have with their patients. They were warning signs that I might need to develop a deeper appreciation and understanding of who he actually was. Being suspicious of his motivation for coming to therapy in the first place, I decided to keep some distance from him to safeguard my own health, both physical and emotional.

It turned out that people keeping a distance from him was his main “presenting problem.” As a result, he felt chronically lonesome. “Everyone relates to me as if I were some kind of pest,” © said, “as if I have no birthright.” Sobbing heavily, he added, “Nobody has ever told me they love me.”

Not being in close contact with others also made him feel detached from himself. He said that as long as he could remember, he had searched for his real identity and for his genuine “self.” There was no “core” within him, no nucleus that gave him a sense of grounding. He was merely a string of RNA with 29 proteins that had to hijack living cells to replicate. “Sometimes, I even doubt if I am alive at all,” he said. “I feel so empty by myself and thrive only when I can merge with another person’s cells through my spike protein. That is when I obtain some sense of self-actualization. At that moment, I get a kick out of causing a kind of blast in myself and the other person.” It took some time before I understood he was talking about the cytokine storm when the immune system starts to attack its own cells and tissues rather than just fighting off the virus. “Every time this happens, I feel euphoric and am willing to do anything to feel it again.”

The Assessment Phase

Before starting treatment, I sent © for a few confirmatory medical tests to assess his physical functioning. First, he underwent a basic medical examination with the PCR test which confirmed he was indeed made up of the SARS-CoV-2 virus. Then I conducted a psychosocial evaluation to learn more about his childhood history, recent life experiences, and family background.

“© told me he was a child of the animal kingdom. His ancestors had lived a comfortable life within bats and other creatures for centuries”. “When stray dogs had bats for lunch, we lived in them for a while. Then, some hungry dudes made raw hamburgers of the dogs and consumed them with sauce,” he said. “We suddenly found ourselves within the cells of human beings. It took some time for us to adapt to these new surroundings, because they were very different from what we had been used to. The bodies of human beings were so much more vulnerable to illnesses, especially in their respiratory systems. I wish we had stayed within animals, because we had a good life there.”

© was the heir of a long lineage of imperial families who each had a history of causing pandemics. “Some of my predecessors from the SARS and MERS families have told me all about you people long before I came here,” he said in a scratchy voice. “I am a descendant of these prominent protein lines and carry their legacy with pride.” Clearly, there was more than just a slight hint of narcissism at work.

To learn more about his unconscious, I tried a few projective tests. When asked to make up stories about the ambiguous pictures in the T.A.T. test, © expressed considerable emotional agony. An unlucky serial killer being hunted by crooked police in white uniforms evoked anger and fear. A wonderful world without human beings was presented as “heaven on earth.” The common themes typically displayed some kind of paranoid fantasies.

Next, I administered a Rorschach test, which © seemed to enjoy tremendously, as if identifying with and recognizing each picture. Watching the inkblots, he often responded with loud laughs. He saw a lot of animals, but also many details of inner organs. In Card 8, he was visibly thrilled when he recognized some bats. They were at the center of his most burning desires. Overall, his responses revealed a complex personality structure with a multitude of internal conflicts.

Much of ©’s psychopathology was exposed during these intake sessions, and it helped me to suggest a tentative diagnosis. Being a virus, he was addicted to spreading his vibes around, contaminating as many people as possible. “Besides his psychopathic and sociopathic behavior, he was also suffering from a severe narcissistic personality disorder”. To emphasize his superiority over others, he had taken the name “Corona,” which means “crown” and implies sovereignty. He even liked to label himself as © so that he could not be illegally reproduced in any form. Apparently, © had an inflated sense of his own importance, a deep need for admiration, and a lack of empathy for others. All these traits created troubled relationships. In short, he was a genuine example of an insidious egotistical parasite, someone who clings to another for personal gain without giving anything in return.

In addition to these personality characteristics, © had higher than normal intelligence. He was so clever that he had been able to outsmart the most known drugs and vaccines. He presented a completely new kind of psychopathology that nobody had previously encountered. What was most obvious was that he appeared to be more contagious and more deadly than others of his kind. © had already infected millions, and he had killed hundreds of thousands. The consequence of his activities had also caused catastrophic worldwide economic damage.

Researchers from all over the world were searching for ways to crush ©. They sought to understand how to block his proteins from trapping, overpowering and invading the cellular machinery of human beings. Hundreds of experimental antiviral drugs and vaccine candidates were investigated. These would either prevent © from entering a cell or stop the human immune system from going wild when © was inside. Alternatively, doctors would take the blood from recuperated survivors and give it to those who were ill to utilize the antibodies that had developed.

On a molecular level, some of the researchers targeted one of ©’s most precious spike protein receptors — the ACE-2 — but with little success. Epidemiologists had no clue as to when (or if) societies could reach sufficient population immunity to prevent further spread of the pandemic.

Being invisible evidently gave © an upper hand, and he succeeded in escaping being caught. As a result, there was an overwhelming sense of powerlessness among governments worldwide. “I was well aware of the urgent need to find better ways to cope with the threat he posed”.

Treatment Options

I contemplated what to do with ©. Exceptional measures were called for. Should I commit him to a closed ward and isolate him? Should I refer him to a medical specialist? Should I let him out among the people? Would I be able to cure him of his ailment with my psychotherapeutic arsenal? Would psychological techniques help him in his struggle? Did I want to help him? Or, as things developed, would I rather prefer to destroy him?

Despite all efforts to eliminate ©, nobody had sat down to listen carefully to what he had to say. Nobody had tried to understand with an open mind what he was actually up to. That is what I wanted to do.

I had misgivings from the very beginning. I thought an individual approach would perhaps be insufficient in dealing with a global problem that demanded a worldwide concerted struggle. Even if I succeeded in curing ©, contamination would continue to be spread by his offspring.

©, the silent serial killer I was reading about in the media, was now in my clinic, and I felt something needed to be done. My hope was that if I could understand him better, I could perhaps help to end his lethal mission. If I could let him feel what he did to others, he might be able to gain some insight and change his ways.

Alternatively, I wanted to find the best plan to wipe him out.

Therapeutic Process

Even though I tried to establish a therapeutic alliance with ©, the sessions remained scary. When getting close to him, I was afraid he might infect me, and it was hard to build a sense of trust between us. Concurrently, I felt sad for the people who were dying and for their loved ones who could not be with them when they passed away. Being empathic with © was especially difficult when I imagined an apocalyptic world without a future.

Numerous unanswered questions about him remained: How exactly did he infect people and how long did it take for him to do it? Why was he affecting various people in distinctive ways? Was it possible to become immune to him? Did he have a conscious or an unconscious agenda? These questions crossed my mind as I started to meet regularly with him.

Working with clients to help them develop a relationship of mutuality was something I had done before. If I could help them differentiate and integrate their self- and object-representations, their self-confidence would increase. However, I was not sure I wanted © to become more self-assured. Who knows what he could turn into at the end of such a process? The last thing I wanted to do was to help © strengthen his self-esteem and to “find himself” within a relationship of “unconditional positive regard.” I felt it was more important to promote some amount of reality-testing in him. I therefore decided to focus on his identity by asking him, “Who do you think you are?”

Every time I asked © that question, he had a different answer. One day, he said, “I am the Angel of Death to some. To others, I just come and visit with a breeze. Most children don’t sit still long enough for me to get under their skin.”

Another day he bragged, “I am Corona! Nobody knew my name only a few months ago. Now, I am world-famous, and everybody knows me. I am a celebrity, with pictures shown on all TV-stations, and everybody talks about me. Is there someone more recognized than I at the moment? Should I not be proud of my achievements?” He had been quite offended when they called him a “normal flu” at the start of the pandemic. ““There is nothing ‘normal’ about me,” he said”. “I am more contagious and much more dangerous than the unsophisticated viral mutations people are vaccinated against every year.” I looked at him with bewilderment but had to agree.

That made him continue with renewed enthusiasm, and he exclaimed, “You still relate to me as if I was a person, like your next-door neighbor. You cannot accept the fact that I am something else. I am not a human being! I am much smaller than you and much less sophisticated in terms of my genetic setup. That doesn’t mean I am less intelligent than you, however. You still can’t stand this fact. With all your 20,000 genes or more, and your big brains, you are still incapable of realizing the fact that I am more powerful than you. It blows your mind that I can kill you with a simple burp!” He was truly frightening in his sense of omnipotence and clearly was off the charts when it came to lethality.

Enraged, I repeated the same question again with a fiercer tone. “Who do you think you are? What gives you the right to spread your poison around and harm people? You are just a dangerous, cruel organism, for God’s sake! What gives you the right to play God? You can’t do that! Don’t you have any sense of compassion?” He looked at me as if he was unable to understand what I was talking about.

It became more obvious to both of us that I now related to him more as a foe than a friend. But as I looked for the best strategy to get rid of him, it struck me that his existence was ultimately based on a very basic (and eternal) question of survival, adaptation, and evolution that had always found a battlefield within biochemistry. And it was now materializing in my treatment room. I had read somewhere that parasites are intrinsic to biological evolution and that they drive its complexity at multiple levels. All living things are trying to survive and multiply either through fight or through cooperation, and they change a little during this process. Taking this aspect into consideration made me a little more accepting of him.

“As I had now expressed some of my anger, it became easier for me to continue to stay in contact with ©”. The next time I asked him, “Who do you think you are?” it was in a more friendly voice, and he became willing to open up more.

“I do not think who I am. I just exist. I am a chemical structure with a set of proteins that perform specific functions. It is not something I decide to do, and neither is it something I have any conscious control over. In fact, I am not sure if I am conscious of anything at all. Consciousness is a privilege for humans and not for viral beings like me. You know you exist, while we just exist. At the end of the day, that’s why I came to you for treatment. I also want to think and know I have a self. I get so tired of just floating around and multiplying.”

To my surprise, © turned his head towards me and added an important piece of information. “Look at me, doctor…” I looked at © and saw that he was choked up with emotion. “Self-replication is a central part of being me. I am, after all, just a virus.”

That was a smart thing to acknowledge, I thought, for such a primitive molecular creature. He began to recognize he felt bound by his body and had no conscience, no free will, and no self-control. Self-replication was apparently an expression of his libido, his fundamental life instinct. Gaining a sense of self in the form of an inner nucleus would perhaps help him to better control his previously destructive behavior.

It seemed as if we were making some progress in the therapeutic process.

In the Here and Now

From this point on, my respect for © gradually grew. Discovering new parts of his personality also helped me ask © more frankly about his motives for killing so many people. He assured me, “I don’t kill the people who die. I just enter their organs to multiply. When that happens, some of them can’t tolerate it. They can’t breathe and their lungs stop functioning. Or their cardiovascular systems go caput and they develop blood clots. It is just a sad result of my being there. But it’s not my original purpose.

“What I want is simply to multiply; to stay ‘virulent,’ and to be able to co-create. When people get too sick and especially when they die, I cannot use them anymore, and I die with them. That is who I am. I have to find a suitable balance between the infection I spread and the damage I cause to the body I enter. It’s an ongoing process I am still working on.”

My tentative diagnosis of © as a psychopathic killer was obviously incorrect. As therapy progressed, I gained more of his trust. He started sharing some of the techniques he used to spread himself around the globe. “People are so easily infected, you can’t believe it! If I leave a small trace of myself on a doorknob for example, and someone touches it and also touches his mouth, I will be able to get in through the respiratory tract and start my journey to the lungs. It’s so easy!” He was clearly pleased with himself. Then he added, “You should try it once yourself! You will be surprised at how easy it is.”

I had never thought about contagion in this way.

He continued, “What makes infecting more difficult, however, is with people who are too scared. People who have OCD, for example, are really difficult to infect. They clean everything they touch all the time, “and often I am washed away with soap or some ugly disinfectant spray! That’s very cruel! Don’t you think so?””

I understood that contagion for © was equal to ego-building. He was literally strengthening his sense of self whenever he succeeded in multiplying. And in each such multiplication, he was trying to imitate and learn from the host cell, and to change his ways accordingly. I wondered if this was also happening during our sessions but didn’t want to ask him directly. I was afraid of discovering that he was already floating around inside the cells of my body.

Instead, I asked © to describe how he was entering the cells of another body to perform his multiplication strategy. “You must understand,” he said, “I am just an assembly of malicious nucleic acids that infiltrates and burglarizes cells. I am therefore on a constant search for unsuspecting people with immune systems that are unable to detect me. I first disguise myself – into ®, so the watch dogs can’t notice me. That is not so difficult, because they are naïve and usually have no memory of having seen someone like me before. So, I am just let in without any problems.

“Inside the cells, I must prevent being discovered by all kinds of informants who are constantly looking for foreigners like me. But every time I enter a new cell, I am most terrified of the executioners in white T-shirts who want to get rid of me,” he howled. But then he added with an innocent grin, “When I manage to bribe them and encourage them to join me in my revolution, all hell breaks out.”

Envisaging the havoc © wrought inside cells made me feel uncomfortable. But my curiosity grew from his apparent understanding of what was happening in the immune system of human beings, and how to manipulate its white blood cells. I wondered if he was also aware of what was happening in the world. Had he noticed the chaos his pandemic rampage had done to the human population?

His answer to this question surprised me more than anything he had previously shared. © looked at me with distrust, as if he were unsure of how much to reveal. Hesitantly, he said, “While you are looking at me with your fancy electron microscope, you don’t realize I am also looking at you with my own viral magnifying glass.”

A Sudden Role Reversal

Taken aback, I asked him disbelievingly, “So what do you see in your magnifying glass?”

“I see you are scared of me and you try to keep a safe distance from me,” he replied.

Somewhat embarrassed, I nodded and asked in as casual a way as I could, “And…?”

““I see the chaos I have created in your world — the social distancing, the lockdowns, and the panic all around”…I see how you struggle with existential dilemmas, with protecting your health, or saving the economy.”

He smiled at me briefly, and added in a stammering, low voice, “Well, what I see… what I also see when I look at you human beings…” He closed his eyes and opened them slowly as if trying to recollect something. “I see what you are doing. I see what you do all the time, even when you try to hide behind your silly face masks. I see what you are doing with everything around you, with nature, with the planet, with the earth. I see how you contaminate the air we breathe and poison the water we drink. I see how you destroy nature at a faster pace than it can restore itself. I see how you burglarize its resources, and how you fail to give it back.”

I kept silent, waiting for him to continue.

“I also see how you spread your kind all over at the expense of others — the mass extinction of other creatures, all the mammals, the birds, the reptiles, and the fish that have been killed by you people.” He paused again and whispered with his eyes closed as if he doubted I would understand what he talked about, “You assume supremacy over all kinds of biological organisms you relocate and annihilate.”

Then he added, with a more accusing tone, “Who do you think you are?” referring to humankind in general. “What do you think you are doing to the Earth where we all live?”

With those words, he suddenly disappeared in a droplet carried away by the wind. I was left not only with a loss of smell but also with a new awareness. By trying to answer his question, “Who do we think we are?” “I realized human beings are not so different from the Coronavirus. We are only considerably more destructive”. I wonder if the present pandemic will become a “corrective emotional experience” for those who survive it.

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.

Advocating for the LGBTQIAA in Psychotherapy

Posted on April 12, 2019February 11, 2026 by Psychotherapy.net Team

I trace my commitment to serving underserved communities to my Jewish heritage. As a Jewish person, I am a member of a resilient minority group that experienced centuries of oppression and genocide. This cultivated inside me a sensitivity to discrimination and connected me to a passion for social justice. I have become active in my university’s LGBTQ+ club and feel that it is my civic duty to advocate for LGBTQIAA+ (lesbian, gay, bisexual, transgender, queer, questioning, intersex and allies) clients so they can be better served.

I’m also sensitive to others’ suffering because I grew up with a speech impediment. As a child, most people didn’t understand that my stutter was involuntary; peers told me to “slow down,” and “just relax and speak.” People didn’t understand my suffering, and I agonized in silence until I learned how to mostly overcome it. Since overcoming it, I’ve hoped to prevent similar suffering in others.

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How would you feel if the general public regularly imposed a gender and/or sexual orientation on you that did not accurately represent who you feel you are?

You don’t have to have suffered like I did to make a difference for the LGBTQ+ community, which is estimated to be 10% (and this only reflects those who feel safe to report) of the world’s population. We all have experienced a little taste of what it feels like to be discriminated against. This community has been fighting an uphill battle for their lives, with their jobs, families, and interpersonal relationships constantly at risk. They endure constant mislabeling, violence and judgment. The most covert, perhaps, is people assuming it to be a choice when it's not. Here are some questions to think about in your practice:

Do you assume couples are monogamous? Do you assume all your clients are cisgender? Do you assume heterosexuality if someone is currently in a heterosexual relationship? Do you assume the client you’re talking to is heterosexual? For example, have you, knowingly or unknowingly, asked if a female client has a boyfriend instead of a “partner(s)?”

The he-she binary inadvertently erases trans people. There is more variation to human gender than merely “ladies and gentlemen” or “men and women.” Since the vehicle of change for psychotherapists is primarily language, we can start by using inclusive, respectful, and empowering language. You can start by using person-first language, identifying your pronouns, calling out the use of terms like “mankind” and “he/she” and the existence of mostly binary bathrooms (unlike other gender-inclusive countries like Canada with primarily unisex public bathrooms). There’s even a case to call history [his-story], “her-story,” “their-story,” or our-story.” No wonder LGBTQIAA+ youth have a high suicide rate. Here’s a case example.

Al is a 14-year-old, assigned female at birth, but who identifies as a male. He has a pronounced trauma history; his father abandoned him to raise another family and, at 5 years old, his mother left him with his grandmother. He was placed in homeschool in 2017, has been isolated, and voiced suicidal ideation in the initial assessment. Virtually all his social contact has been online chatting with other trans youth.

Early in treatment, Al mentioned wanting a doctor’s note for hormone therapy. Not infrequently, psychotherapists working with trans clients receive requests for documentation that a trans person has diagnosable gender dysphoria that has caused substantial mental health issues such as suicidal ideation, and is “mentally fit” for hormone therapy and to make decisions about their own body. This helps doctors/insurers understand that hormone therapy and gender reassignment surgery can support, instead of hinder, a client’s mental health. Insurers and/or doctors may request them.

Contrary to traditional belief, I considered that it was both ethical and empowering to provide Al with this note sooner rather than later in the therapy. Here’s why.

We are not gate-keepers who decide what clients can do with their bodies. We shouldn’t block Al’s access to resources that a cis-person could access without a therapist’s permission. Best practice for me is that if a client wants a letter, I give them one. If a cis-male came in asking for a letter for their doctor to be on hormones and had limited social support, we would not impose stipulations. A trans person is equal to a cis-person and already has enough challenges to overcome to be who they are and have control over their body.

A therapist’s role is to not stigmatize. For example, if we require Al have 6 sessions before writing a hormone letter, it would be stigmatizing something that has nothing to do with mental illness. It would also be operating outside of the scope of our practice because we wouldn’t be determining if their mental stability is interfering with their identity. It is also not our role to determine if Al is sane to make the hormone decision, even if he’s a minor, without his prefrontal cortex fully developed. After we write the letter, it is the role of the medical doctor to determine if the client is medically able to start hormones and the doctor’s job to monitor the client’s physical body.

Al and I agreed that he is likely avoiding social situations because of the chronic mis-gendering he endured, and the invisibility of his identity navigating the world as a trans-person who is not presenting nor is perceived the way he desires. Hormones may be the catalyst that would help Al to make friends once he starts feeling comfortable in his own skin. Isolated, experiencing oppression, lack of control, depressive symptoms and desiring hormones (probably to look a certain way)—not accessing hormones could likely increase depression symptoms and suicidal ideation. After writing the letter, I provided Al with ample resources to connect with other trans-youth.

My role was to support Al where he was at, not dictate where he should be. Since Al was able to make decisions, there was no reason to limit when he started hormones.

I cannot emphasize enough Dr. Martin Luther King’s timeless notion that “our lives begin to end the day we become silent about things that matter.”

* I consulted on this case with Van Ethan Levy, Associate Marriage and Family Therapist, Associate Professional Counselor, and member of the community, who uses the pronouns Van/they.

Brooklyn Zoo: The Education of a Psychotherapist

Posted on March 25, 2015February 11, 2026 by Psychotherapy.net Team

I woke a woman named Ophelia for morning group, and she was not pleased. “You woke me from my sunder,” she kept repeating in an angry voice. She followed me into the dayroom anyway. A man named Juan was dancing in the hallways, and I corralled him, too. There was a third patient, a woman, she looked a little slow. And Mr. Rumbert again. I asked them to speak about why they were in CPEP [Comprehensive Psychiatric Emergency Program].

“I came for a bed, but I was double-crossed,” said Ophelia.

“My fiancée called 911 after Shabbos dinner,” Juan said, which sounded funny because he was clearly Mexican.

“Why did she call?” I inquired.

“You’d have to ask her,” he replied.

The woman who looked slow said she’d done crack for the first time and was full of regret.

She began to cry.

Rhoda [a nurse] walked in to get Ophelia. She needed her help with some paperwork.

“You can come back when you’re finished,” I told the patient as she left. She turned and gave me the finger. Juan told those of us who remained that he wanted to read to us from a book called Recreating Your Self. As we listened, Ophelia returned, and she was worked up. She marched up right close to me.

“You double-crossed me,” she yelled. Her body looked tense, poised for a fight. For the first time in the ER, my fear of being physically threatened was being realized. I made my way toward the door, encouraging Ophelia to come with me, not wanting to leave her alone with the other patients. She was taller than I was, and wiry. I imagined her rage would give her fists great force. I had never learned how to protect myself from a punch, and cowering seemed like my best defense. I remembered what T. [a supervisor] had told me weeks earlier about being soothing.

“It’s okay. Come with me. We’ll find you some juice, something to eat,” I said. She followed me as I walked backward into the hallway, which for once was deserted, the guard having abandoned her post. Ophelia remained too close, still menacing, insisting on my alleged crime, taunting me. I continued walking slowly, my body facing toward her as I backed away sideways. “Hello, hello,” I said loudly, turning my head toward the adjacent halls, trying to get the staff ’s attention without alarming anyone, but someone was always yelling, if not screaming, in the ER, and no one was likely to heed my cautious cries. Calling for help seemed overly dramatic, and I thought it might set Ophelia off besides. Shit.

But Rhoda came out of her office and saw us. She rushed over, inserting her solid body between Ophelia’s and mine. She managed to calm her down while also explaining to me that Ophelia had slammed out of her office two minutes before. “I’ll take care of you,” Rhoda said firmly to Ophelia, shepherding her off to another hallway. I went back to the group room, concerned that the patients might have gotten spooked. Juan and the other woman were now seated side by side. She was choosing passages from his book, and he was reading these aloud. Mr. Rumbert sat across the room, silent but calm. I entered and closed the door and sat to listen and get myself back together. Ophelia was back soon, standing outside the windows of the group room looking in. I saw the guard was back at her post, and I opened the door. “Would you like to rejoin us?” I asked Ophelia, because wasn’t that my job?

““Don’t talk to me,” she said. “You look like a canker sore.””

Afterward, I did not have much left in me, but still I brought Juan into T.’s office for an interview. His chart said he had a long history of bipolar disorder. He told me he was an attorney and a converted Jew and there was no reason for him to be in a psychiatric emergency room.

“Have you been hearing voices?” I asked.

“Yes,” pause, “Guided by Voices,” pause. “Get it? The band?” Guffaw.

“Are you worried that someone is watching you?”

“Yes,” pause, “the Police,” pause. “Every breath I take, every step I make.”

He kept insisting there was no reason for him to be there, and when T. came in, she’d quickly had enough and told him we were done. He got up and walked out, turning off the light as he made his exit.

“That’s so symbolic,” T. said. “Lights out.” I told her about what happened with Ophelia because I thought the staff might want to assign her an assault level. T. asked if I was okay. I was still shaken, but I said yes. Then it was time to go, and as I left, I saw Juan the converted Jew lying on his stomach on one of the reclining chairs. I waved, and he thrust his hands back to catch his ankles in a resplendent yoga bow pose.

All the way to work the next morning I debated whether to bring Ophelia to group. I hadn’t thought to ask T. about that. With a higher-functioning patient—someone who was not psychotic—I thought it would have been important to bring her in, to demonstrate implicitly that her aggressive impulses were not as destructive as she likely feared. I was not sure that the same thinking applied to a psychotic patient, especially a paranoid one, since paranoia reflects a projection of aggression—that is, Ophelia experienced the hostility not as her own but as directed toward her by those around her (in this case, me). I decided I would invite her if she was up but that I would not wake her from her “sunder” if she was still asleep. It turned out not to matter, because when I got the census she was no longer on it—moved to the list of people waiting for a bed upstairs. I was relieved. I found Juan and Mr. Rumbert—who was continuing to speak—and a new woman who was attractive and looked with-it. But then she told me she did “sortation” for a living, which made me suspect she had a thought disorder because I knew, thanks to my month in the psych ER, that use of neologisms was often a symptom of schizophrenia or mania. T. called in sick, and Dr. Brink was my official supervisor for the day.

I spoke to the sortater, who had a long history of psychiatric hospitalizations, for some time and then went to report to Dr. Brink. She seemed distracted, and I felt as if I was bothering her; EOB patients were not her problem, after all, and I didn’t imagine her relationship with T. made her inclined to fill in with her caseload. The hospital police were called to the ER while I sat in Brink’s office, but I paid that little mind. When I got up to go back across the hall, she put her hand out to stop me. ““Didn’t you hear that page? You never leave after hearing the hospital police called. You need to pay attention.”” It had been a month, and there were many things I had learned there, but others that I had not. I sat to wait while the police broke up a fight in the hallway.

The next day was a Friday, and my last in the psychiatric emergency room; on Monday, I would report to inpatient unit G-51. I gathered the EOB patients for my final group with ease. A moment of interpersonal conflict between two group members got me engaged. The drug addict told another patient he didn’t like being asked about his methadone in the hallway in front of everyone the previous day. The offender replied he’d noticed the drug addict had not eaten breakfast and was testing a theory that methadone users in general didn’t like to eat. I tried to facilitate further discussion, which would have been the meat of an outpatient group, but neither man was as interested as I was.

After group Rhoda told me there was an EOB patient pending. A psychiatrist I recognized by face but not by name told me I should see him to try to make something of his story. Darren looked like a handful of the others I’d seen that month: early twenties and handsome and robust, nicely dressed in jeans and a sweater. His presence in the G-ER didn’t bode well, but I was still maintaining my manic hope that somehow nothing was seriously wrong this time. T. came in as I was beginning my interview with Darren and quietly sat down to observe. I felt my usual self-consciousness and also a determination to do better this time, to prove to us both that my four weeks of immersion in her EOB had taught me something. Darren made eye contact and answered my questions in the right amount of detail, without hesitation or mistrust. To make matters murkier, his reason for admission puzzled me, and I didn’t know where to go with it. “A week of really bad headaches,” he said. If there was one thing I’d learned, it was that you didn’t get brought to a psychiatric emergency room for a headache.

“Did the headaches start because you’d been drinking too much or using drugs?” I asked.

“No, I’m not into any of that,” he said.

“Did your headache come from voices you were hearing that no one else could hear?”

He shook his head.

“Was it because someone was stealing your thoughts or trying to put ideas into your head?”

He gave me a wry smile. Still no.

“Did the headache make you agitated? Did you get very angry at anyone, maybe yell at them on the street or shove them?”

Negative. We sat there together, equally perplexed.

“Where was the pain?” I asked, grasping at straws. If he told me it was in his face, maybe I could diagnose him with a sinus infection. He said that it was in his entire head. I turned to T., defeated. “Do you have any questions?” I half mumbled.

She took over with her usual omniscience. It was not grandiosity, she just really was all knowing. I tried to calculate the difference between my four weeks and her twenty years. Even allowing for fifteen vacation days annually, it was considerable. “Your thoughts were all jumbled up last week, and it really made your head hurt,” she said to Darren. He nodded, and it was as if a light had turned on in his brain.

“They were mad bundled!” he said.

“And that happened in school, too, right? It got hard to pay attention, hard not to get confused?” Darren had told us that he’d flunked out of college four months earlier.

He nodded, starting to look upset. T. had his chart open in front of her and was looking at the doctor’s orders. “Has the medicine we’ve been giving you helped with the headache?” she asked.

“Yes,” he replied. “It’s gone now.”

“You’re lucky,” she told him. “Years ago we didn’t have these pills, and people who got headaches and confusion like yours had much more trouble going about their lives.”

After Darren had left us for the hallway, T. said, “Most likely schizophreniform, though it could be a psychotic depression.” She explained that schizophreniform disorder was diagnosed in patients with less than six months of symptoms of schizophrenia; only some of them would go on to exhibit the full-blown disorder. “His prognosis is good. He relates pretty normally, and his affect isn’t flat. If he stays on the medication, he can probably go back to school, next semester even. He should see a therapist, too, of course, to monitor how he’s doing over time, to help him understand his preoccupations better. He’s far from a hopeless case.”

“How about me?” I asked, aware that my minutes there were dwindling, wanting to remind T. that today it was me who was timing out.

“Not hopeless,” she said. “Frankly, I was surprised by how little you knew when you got here. But you’ve been doing a good job trying to take everything in. It’s a lot of information, and it’s a difficult environment. I wasn’t sure you’d come back after what happened the other day with Ophelia.”

This floored me. It never crossed my mind not to return. What kind of wimp did she take me for? “No. I mean, I was shaken, but this is my internship. I signed up for this,” I reminded her. She pulled out the same evaluation sheet that Dr. Young had filled out the month before. T. had not given me high marks, but at least they were scores that actually reflected her own ideas about my work. As she reviewed them with me, I thought again about what Dr. Wolfe had said the month before, and how after so long in the carpeted classrooms of my graduate school it was actually quite hard to pull off, this task of becoming a better psychologist. But also I felt on my way.

Gary Greenberg on the DSM and Its Woes

Posted on February 6, 2015February 11, 2026 by rezendevknowfully.com

The Book of Constructs

Deb Kory: Gary Greenberg, you are a psychotherapist and a writer, author of Manufacturing Depression: The Secret History of a Modern Disease and, most recently, The Book of Woe: The DSM and the Unmaking of Psychiatry, from which we’re featuring an excerpt to go along with this interview. You’ve written for Mother Jones, Harper's, Rolling Stone, The New Yorker, The Nation, and McSweeney's to name a few. In these books you've taken on the mental health industry, psychiatry, pharmaceutical companies, and the culture they have created. Let's start with your most recent book, The Book of Woe. Why did you decide take on the DSM?

Gary Greenberg: Well, I actually didn't decide. I was happily ignoring the whole thing and knew what any person scanning The New York Times would have known until I got a phone call from Wired magazine asking me if there was something about the DSM that might be worth their while. At the time I was sort of aware that there was this rebellion at the top within the American Psychiatric Association—that the guys who had done the DSM-III and the DSM-IV were really unhappy about the DSM 5—and so I started looking into it and realized that their complaints were really about the nature of psychiatric diagnosis. That interested me and I told the magazine I would write the article. I've been thinking and living in this whole set of questions for many years, and it didn't seem all that remarkable to me, but the reaction I got from people who I thought would have also seen it as old hat was pretty strong, so the decision that I made wasn't to go out after the story, but having gone after the story I decided to feed the curiosity of the people who responded to it. In particular because everybody grouches about the DSM.

DK: It’s kind of a monstrosity. Unwieldy on so many levels.

GG: Nobody likes the DSM, including, for the most part, the psychiatrists who author it—but also therapists, clinicians, researchers and academics too.

Nobody likes the DSM, including the psychiatrists who author it.

And when you look into what people object to, a lot of their objections are—I don't want to sound haughty—but they're uninformed. There's an understandable, and for the most part accurate, instinctual objection to the whole idea of it. So I thought it would be interesting to do with the DSM something like what I did with Manufacturing Depression, which was to explore it as an instance of a problematic mental health culture.

DK: It seems like sort of the same book written from a different angle, where you're deconstructing the way that we think about mental health and disease, and taking on two of its principle constructs: depression and diagnosis. One of the things I've heard you say is that the DSM is a book of constructs, not of real entities. Can you explain what you mean by that?

GG: Whether it’s correct or not, in medicine real entities are those that have a biological basis, where you can find the causes and the boundaries of a disease through biochemical means, whether that's by culturing tissue, or looking under a microscope, or doing a blood test, or whatever it is you do. The problem with mental illness, or with psychological suffering in general, is that it's very difficult to come up with those biochemical assays. In fact, I shouldn't say, “very difficult,” but rather, “at this point, impossible.”

DK: Because?

GG: Mostly because the brain is so seemingly infinitely complex and the tools that we have for understanding it are comparatively crude. And if you pay attention to neuroscience, the field changes dramatically all the time. It's a moving target.

So you don't really have the basis for understanding mental illness in terms of real entities in that respect. On the other hand, for many different reasons, there is a strong need to have those entities. From the political and ideological having to do with the authority of medicine, right to the most practical having to do with how society decides to ration its health care resources, and everything in between. The way that psychiatry has bridged that gap is by using the rhetoric of science to create a DSM without ever being able to say that those scientific sounding categories are truly scientific. In other words, you can create the construct and then build all sorts of science around it.

DK: From inside it makes perfect sense.

GG: Right. But so does schizophrenia. And this is a problem with all ideologies. If you accept their basic premise, then everything else makes sense. In scientific methodology this is known as the validity problem. None of the categories in the DSM are valid, and that becomes a problem particularly because once you use that rhetoric it is inevitable, inescapable, that the categories will become reified, meaning that people will take them as real, and they'll use them as real, and they will become the basis for all sorts of political, economic, and individual decisions based on their reality.

One of the things that you find when you talk to the people who make the DSM is they're all really smart—well most of them are really smart people—and they're quite capable of understanding and appreciating the problem that we're talking about. But they have trouble taking account of the fact that the reification is a problem for everyone, not just for the professionals.

DK: Say more about that.

GG: In other words, they're happy to say to you, “Yeah, I understand that. We all know these are just constructs,” as if their knowing it is enough. But what that really means is that they don't want everybody else to know.

DK: Because it confers power on them?

GG: Right. It's the problem of the noble lie. Actually, I think that the best example isn't really the noble lie as Plato saw it, because that's a more complex topic. It’s more like what the Grand Inquisitor presents to Ivan Karamazov [from Dostoevsky's The Brothers Karamozov], which is that, “We in the Grand Inquisitors coterie, we know this stuff and nobody else needs to know, and in fact we're using our knowledge to help people.” That's exactly the pitch that the Grand Inquisitor uses to justify what he's doing to Ivan Karamazov.

DK: That power dynamic does a lot of harm.

GG: Of course. Power unquestioned is always a problem, and the problem is always damaging to the people that don't have it.

DK: If I were to draw your work together thematically, it seems to be challenging power in its various manifestations. You’re also a journalist and have obviously written widely on a variety of topics, but because you're a psychotherapist, you’ve taken on its institutions of power.

GG:

Power unquestioned is always a problem, and the problem is always damaging to the people who don't have it.

I think that's an interesting point. I think that's true. I don't think any of that is particularly conscious. I imagine that’s why I chose these professions—they both try to unearth power relations in one way or another, and claim, anyway, that that's the truth that they're uncovering.

DK: But they reify that power at the same time that they are claiming to unearth it.

GG: In what way?

DK: I'm thinking more of psychologists and psychotherapists than journalists, though the claim could be made for them too. There is a power dynamic in the therapy relationship that I think we are often unwilling to recognize. They come to us, they pay us, they have all kinds of transference reactions to us that we help them “work through” while we choose to reveal those aspects of our internal experience we think might be helpful to them. Having gone through the medical system I think psychiatrists are much more clear about their power in relationship to “patients,” whereas many psychotherapists are not. You take on psychiatry a fair amount but haven’t necessarily gone after psychotherapists.

GG: Well, the only direct approach I make to that question is my critique of cognitive-behavioral therapy.

DK: Talk about that.

GG: Do I have to?

The Problem of Piety

DK: Well, you don’t have to but I think it might be interesting to our audience.

GG: Cognitive-behavioral therapy is an ideology of optimism that is used by therapists to induct people into a more genial understanding of their lives and their circumstances. It's in some ways the diabolical twin brother of Freudian psychoanalysis, in that it trades on optimism rather than pessimism. CBT believes in the perfectibility of the human as opposed to the depravity of the human. It posits, without saying so, a benevolent universe, which is the opposite of what Freud thought.

DK: Is it their certainty that you have a problem with? You seem to wrestle with the notion of certainty a fair amount in your writing.

GG: Well, piety is a problem. Ask the people at Charlie Hebdo. If power is the general preoccupation of my books, piousness is the specific preoccupation. Unquestioned belief. For all of his problems at the granular level, at the macro level Freud was the master of ambivalence and uncertainty, and I think that there is a connection to be drawn between understanding life as infinitely uncertain—at least mental life—and the tragic sensibility.

I think that cognitive-behavioral therapy tries to overlook, or ignore, or erase the tragic dimension of human life.

I think that cognitive-behavioral therapy tries to overlook, or ignore, or erase the tragic dimension of human life. So, to get back to your original question, why do I go easy on psychotherapy? Well, this is one way that I don’t go easy on it and, as you and I both know, CBT is the dominant theme of psychotherapy in this country right now.

DK: Along with “evidence-based” therapies.

GG: It links in with the evidence based therapy thing, which bleeds over into my second criticism of psychotherapy, which is that we're way too tied in to medicine. Regardless of what we individually, or even as institutions, believe about psychiatric drugs, that's not the issue. The issue is how do we get paid and how do we get our status and authority in society? When I pick up the phone and I call somebody and then say, “Hey, this is Dr. Greenberg,” I get a different response than I would if I called up and said, “Hey, this is Gary Greenberg.” I'm not averse to using that power, but I'm implicated in a whole web that I shouldn't be. That critique shows up in both of my books, where I repeatedly question the whole business of psychotherapy.

DK: These days almost everyone talks about therapy as a business.

GG: Well, you've got to make a living.

DK: True enough. But it’s disheartening to me, nonetheless.

GG: We're all doing it. You make your accommodation with it however you can. The problem, when it comes to the DSM and to the medical-model aspect of our practice is that it is so at odds with what we purport to do. If you start your therapy by giving a person a diagnosis that you don't believe in, there's no way that you can't see that as a contradiction of the terms of psychotherapy, because it's dishonest.

The Rhetoric of Disease

DK: That’s interesting. I recently had someone come in claiming to be bipolar, and I pulled out my DSM for the first time in quite awhile because, in my mind, bipolar is not something to dawdle around. It has a high suicide rate, and is one of those diagnoses we are taught is genetic and kind of untreatable without medication. How do you deal with something like schizophrenia or bipolar or autism where there's clearly a mental disorder of some sort happening, there’s a pretty compelling case for genetic transmission, etc. Is there some utility in using the DSM for something like bipolar disorder?

GG: Well, I don't know about the DSM, but I do know about the larger rhetoric of mental illness. The DSM is just the most obvious example. I believe that as symptoms get more severe, and as impairments get more severe, the justification for using the rhetoric becomes greater, because it is a rhetoric that is quite effective. For instance, the rhetoric would say, “Schizophrenia is a biological brain-based illness that is just the luck of the draw. Maybe you had some stressors, but you definitely had this serious predisposition and your brain's all fucked up and now you're going to have to manage this all your life. And the best way to manage it is with Geodon.” Or you can go farther with that. You can say to somebody, “You have to take responsibility for you who you are, just like I do. And who you are happens to be somebody with this vulnerability, and that means keeping yourself in situations that aren't likely to kindle your psychosis. It means recognizing the prodromal nature of it. It means taking medications when it seems to be necessary to keep you and the people around you safe.”

That whole rhetoric is very helpful. I believe at some point it makes sense. And I even would go farther and say that there are some psychiatric illnesses, mood disorders, certainly the autism spectrum, that really are the luck of the draw, in the same sense that type 1 juvenile diabetes is. So the best we're going to do is help you cope. And I think that the rhetoric is useful there.

The problem is that that's the model for everybody, and we have no way of determining who it is that we should consider that way and who we shouldn't. It's like not knowing the difference between who's got type 1 diabetes and who should just eat less sugar, and just treating them all the same way. That's a problem. And it's not a problem that's been intentionally created by psychiatrists. I'm not a Scientologist. I don't believe that that's what's happened here. But I do think that because of its blindness to its power—and I do hold psychiatry more responsible than the rest of us because you and I are just living off of their crumbs when it comes to this stuff—psychiatrists have failed to make those distinctions, have failed to start with the assumption that only a small minority of people who are suffering with mental illness, even severe mental illness, have that classic disease structure. Now it’s reasonable to say, “Let’s err on the side of caution.” We’re talking about serious stuff here, and it's a useful model.

DK: So you sometimes use it with your clients?

GG: I just had a patient go into the hospital because she was sure that laser beams were doing something to her bones. She was a howling, psychotic mess. She's in the hospital and I'm really hoping that one of the psychiatric drugs that they throw at her will work, because her brain's on fire. It’s a useful way to look at it in this instance.

DK: So you pull it out of your toolbox when you need it.

GG: Yes, but do we know when we should and when we shouldn't? Absolutely not. But to get back to your patient who came in with the bipolar diagnosis, you took out the DSM and then what? You never finished the story. Did you then get them to tell their history of manic episodes?

DK: I did. We went through all of the assessment and then I said, “Okay, according to this book”—I mean I literally said this—“you qualify, but I need to qualify that this book is also a load of B.S.”

GG: Yes! Now was this bipolar 1 or bipolar 2?

DK: It's still not clear.

GG: So my guess is, if somebody shows up in your office and they're basically okay, and they tell you they just got diagnosed with bipolar and you're thinking, “What?!” chances are that person is going to qualify for the bipolar 2 diagnosis.

DK: Right, with the less intense mania.

GG: It only requires hypo-manic episodes. And so what you have there is the diagnostic creep that I just outlined.

All of a sudden there's all these people that—sure, they’re not happy, but they are not psychotic—telling me that they're bipolar and they're on Depakote and they're on Abilify. And I'm thinking, “What in the world is going on out there?”

That diagnosis just arrived in 1994. I don't know how long you've been in practice, but I've been in practice for a long time and I remember when these people started showing up in my office with their diagnoses and their anti-psychotics and their stabilizing drugs. All of a sudden there's all these people that—sure, they’re not happy, but they are not psychotic—telling me that they're bipolar and they're on Depakote and they're on Abilify. And I'm thinking, “What in the world is going on out there?” I think there's cases where that's a totally useful and justified approach, and I think there's cases where it isn't, and that's where all the trouble lies.

The Serotonin Myth

DK: In your book, Manufacturing Depression, you say that serotonin came along and seemed to make people happier and so the drug companies had to find an illness that would make people need it, right?

GG: It's not quite that conspiratorial. In the case of depression and antidepressants and neurotransmitters, it’s like strands of a braid that came together advantageously for some patients, and many doctors, and most of all for the pharmaceutical industry, which was brilliant, clever, and lucky.

I guess that's a little cynical. I have to be fair, the cynicism in the pharmaceutical industry didn't really start until the mid-1990s, by which time scientists knew that this whole serotonin deficiency theory of depression was bullshit. They knew that it was wrong, and then they did tone down the rhetoric to some extent in their advertising. The consumer advertising started right around the same time that scientifically the serotonin myth fell apart, the late 90s, but you wouldn't know that to look at the ads. That, to me, was their most egregious move.

DK: They didn't correct for it, they just took advantage of it.

GG: Exactly. They knew that if you could sell it as that kind of disease, it was so overdetermined that it would succeed and they could not resist it. You would have to be some kind of Boddhisattva of advertising to resist that temptation.

DK: A lot of people, myself included, only recently came across this information that it's really not about serotonin deficiency. We literally have no idea why they work, and for whom they work.

GG: Right. Now you say you just came across that. You're an intelligent, well-educated person with a PhD, right?

DK: Yes, but I’ve also benefited from antidepressants, so I had a little bit of denial in the game around it. I’m one of those people with a seeming genetic predisposition for depression for whom SSRI’s just helped, with no bad side effects. I thought I understood why they were helping, but it turns out no one knows yet what they do.

GG: There's two ways to look at that question of why. One of them is, do we know neurochemically what's going on and what, if any, deleterious consequences there are? And the answer to that question is no.

DK: Well, we know a little bit.

GG: We know that you're increasing the activity at certain receptor sites, including some of the serotonin receptor sites, although these drugs aren't as precise as they are sold as. And we know that serotonin appears to be associated with increase in neurogenesis. And we know that at really high doses you can see the axonal growth that appears to be the direct result of increased serotonin activity. So there's all these things that we know, but why that changes a person's mood…

DK: There's no causal correlation.

GG: Right. In order to know that you would have to have an account of how the brain produces consciousness, and good luck with that, because that's just not going to happen. So what you're left with is to say, “Okay, well this drug makes me feel better.”

The cynicism in the pharmaceutical industry didn't really start until the mid-1990s, by which time scientists knew that this whole serotonin deficiency theory of depression was bullshit.

And I don't mean that necessarily in the same way that smoking a joint or whatever makes you feel better. It just makes you feel better, and it works, and it doesn't hurt my life in any other way, and I'm going to take it. To me, anyway, the only problem I have with that approach is the same as with any drug. It's like, “Okay, well, am I hurting myself in any way?” It's the same question I have about vaporizing nicotine. Obviously, the reason that that's become controversial isn't because we know that it's bad for you.

DK: It's because we don't know that it isn't bad.

GG: No, I think it's because we are an anti-drug society, and it just makes it really clear what's going on in smoking cigarettes. People don't smoke cigarettes to get cancer. They smoke cigarettes to get high, and the vaporizer just eliminates the middleman and delivers to people the drug that they want. And in our society, unless you're on antidepressants, or happen to be addicted to caffeine or alcohol, you can't just openly say, “I'm going to do this in order to change my consciousness.”

So I think that the controversy arises because of that, and then it is also true that we don't really know the long-term effects of using nicotine—although we know enough to know that it is not carcinogenic.

DK: And we don't know the long-term effects of taking an antidepressant.

GG: Right.

DK: So how do you deal with people who come in and seem to suffer from depression—have a family history of it and display severe depressive symptoms—who then respond really well to antidepressants?

GG: The way you do with anything that you're wondering about. You just take it as it is. You support it. “Okay. So, tell me about it.” Of course, people aren't stupid, and they tend to expect, particularly from me because of my relatively high profile, that I will disapprove. So I have to spend a little time reminding them that I really don't disapprove. If they actually read what I wrote, as opposed to listening to what people say about it, they would know that. You have to start by letting them know that, for the most part anyway, it's cool with me if this is what you decide to do. But one of the hallmarks of being mature and self-possessed is recognizing that you can't have it both ways. If you want to be on drugs, you've got be on drugs, and live with whatever that means to you and with whatever the implications are. And among the things that it means to be on antidepressants, particularly long-term, is struggling with the question of what's you and what's the drug. People have these severe doubts about their functioning and about their success. There's a whole version of the imposter syndrome that goes along with being on long term antidepressants.

Does Depression Exist?

DK: Do you think depression exists? Is it real?

GG: What does that mean?

DK: Is it an actual illness? You say that it is manufactured.

GG: No, I’m saying that I’m sure there are situations, brains, people who certainly qualify. Let's say that the ability to feel depression as it's described in the DSM is heterogeneous—in other words, there are many ways to get there, both existentially and biochemically. I'm sure that's true. And let's say that some subgroup of people who qualify for the diagnosis—which is insanely broad—

DK: It covers a large swath of American culture.

GG: —nine symptoms, five of which qualify you; there's 125 different combinations to be depressed, just for starters. But let’s say some subgroup of the people that qualify are suffering from some identifiable biological fuck up, some hiccup somewhere. Or maybe more than one. And it wouldn't matter what their circumstances were, once the depression was kindled, they're screwed. Again, I don't know who they are. Nobody knows who those people are. In the meantime, the presumption is that everybody is. And that's the problem.

DK: There's not a model for the remaining majority.

GG: Yes. And I also think that the question of, “Is it an illness? Is it real?” is, in some respects, a red herring. Because why are you asking the question? What is the importance of that question?

DK: Hmmm. That’s a good question.

GG: Why does it matter to know that it is or it isn't?

DK: I guess I’m interested in how much of our internal lives are constructed by social structures and beliefs. I listened to an amazing podcast called "Invisibilia" recently, an episode entitled “How to Become Batman” where a blind guy, blind since birth, learned to “see” by using echolocation, a clicking sound with his mouth, and because his mom let him run wild and didn’t treat him like he was blind. Let him ride bikes, climb trees, fall and get hurt, all of that. Apparently his visual cortex has actually created something like sight for him. It made me think about how we are both blinded and liberated by our beliefs. So if we had an entirely different model and way of seeing depression, it could transform the world.

GG: So the reason that you're asking the question is because you see certain shortcomings, at least potential shortcomings, to understanding it as an illness.

DK: Oh, for sure, at the very least.

GG: The advantage of seeing it as an illness is that certain social resources become available to you if you see it that way. Drugs, medical care, sympathy, understanding, none of which is to be sneezed at.

It's notable that one of the major ways of getting social resources in our society is to be sick.

It's notable that one of the major ways of getting social resources in our society is to be sick.

But there are also disadvantages, as you just pointed out. If you see yourself as sick then you act sick, and if you're sick you're less empowered, maybe you're less active, maybe you take less responsibility for yourself. You cited an extraordinary example, but you're certainly not going to do that if what you decided to do is to live the life of a blind person. So, yes, there's something liberatory about it which is much more likely to be achieved if we understand illness as a contingence category as opposed to an absolute category. As something human-made as opposed to something scientific and medical.

DK: I’ve written extensively about psychologists’ complicity in torture at Guantanamo and other CIA black sites, and in researching what led to it, I found that the profession of psychology emerged out of war, has been funded in large part by the military in terms of training programs and research grants, and is thus inexorably linked to the American war machine. I haven’t had a chance to delve into the role that scientism plays in all of this—and I understand scientism to be viewing science as a religion, basically—but one of my speculations was that this desire for the profession to be perceived as a hard science, to be seen essentially as a “man among men,” was a big part of the problem. You wrote some about this in your article in Harper's, where you take on positive psychology guru Martin Seligman, whose own research is deeply embedded with the military and who coached the very psychologists who created the program at Guantanamo in his theory of learned helplessness. I'm wondering if you have any thoughts about the role of scientism in the militarization of psychology or if you see any connections between what you're critiquing in your work and what's happened with the psychology profession becoming kind of an arm of the military.

GG: Well, I think to start with, there's lots of psychologists like yourself who are appalled at that outcome, so it's pretty clear that it's not a necessary outcome. There are even psychologists who don't buy Marty Seligman's self-serving excuses for his own implication in these things. That conference that I wrote about in Harper’s took place in 2009 and the issue was still alive at the time, and Seligman had some very greasy responses to those questions.

DK: Yes, he claimed to have had no clue what they were intending, which wasn't very credible given where and when he delivered his lectures and the meetings he was involved with.

GG: But there are people who don't buy it and who are critical when these discoveries are made. But, having said that, I think your point is well taken. There is a kind of wish among all the medical health disciplines to be on the inside rather than on the outside. And whether you're on the inside by virtue of having a professional license or by virtue of having the authority to declare people mentally ill, or to get services for kids through special education, or to help the military figure out how to make soldiers resilient, I think this desire to be considered an insider can be problematic. And that in itself is complicated because sometimes it's simply wanting to make a living, or to make a decent living. Obviously, if we didn't have our professional licenses then we probably wouldn't make as much money as we do. If we didn't have our ability to bill insurance companies or, in my case, help people get reimbursed, then we would make less money. So some of it is just about that, but a lot of it is about wanting to be in the mainstream, because, like I said earlier, you can't have it both ways. If you're not in the mainstream, there are some severe prices to be paid.

A Foot in Each World

DK: Do you feel like an outsider in this profession?

GG: I have one foot in each world. Yes, I feel like an outsider in the sense that there's lots of things that I don't do that I would do if I wanted to be on the inside, like joining insurance panels and stuff like that. I probably feel better about that than I ought to though because it's not that important. It does restrict my access in some ways, but mostly what it does is restrict my income.

DK: Right, it can be a tough choice to side-step the whole insurance industry.

GG: Yes. But I'm clearly an insider in the sense that I described before. I pick up the phone and say, “This is Dr. Greenberg,” then I get somewhere on the phone tree.

DK: Do you do that with a smirk?

GG: No. I do it totally straightforwardly, because I'm just trying to be effective and that is the way you're effective. These questions can come down to a kind of moral anorexia—a sort of refusal to take in the goodies that are out there because we all know they're tainted. I think that in some ways you've got to be fair to yourself and to others and say that the life lived entirely outside is very, very difficult and in some ways less effective. There are people who I have helped not by virtue of my education, or my training, or my insider-ness, or my license. It is something inherent to those that have allowed me to help them, but my availability to them, even if it's not about money, just the fact that I'm out there and legally practice my trade, just the fact that I'm available to them is what made it possible for me to help them.

The Writer as Therapist or the Therapist as Writer?

DK: I also was a journalist before becoming a psychotherapist, and I tend to come at things with a critical point of view, and I often have the experience of being critical of the “profession,” of training programs, of the way that we organize—and don’t organize—around issues of justice, etc. But at the same time, I simply love the work, itself, with clients and some of my very best friends are therapists. I feel like I’ve got a real love-hate relationship with the profession that I haven’t fully worked out yet.

One of the reasons I’m so interested in your work is that you seem to be able to traverse both worlds—to be a writer, and to write honestly and critically and self-revealingly about the profession while still very much being in it. Do you see the writer in you and the psychotherapist in you as fundamentally complementary? Do they ever come at odds? Do you ever not write about things because you're worried about your clients?

GG: In both of the books that we've been talking about, I write a little bit about my actual practice, but I hate doing it. I would not be disappointed if I never did it again. I don't know if that's a principled stand—I just don't like doing it. I think it's really hard. I don't know if you ever saw the TV series “In Treatment.”

DK: Yes, I loved it. It rankled me, but I loved it.

GG: That was the most realistic handling of psychotherapy ever, that I've seen, in the mass media—and it was boring. Nothing happens.

The person that I am as a therapist is not someone that I want to write about.

I mean, it's okay with me, I was interested in it, but I don't think it did well because it's just day-to-day what goes on in therapy. It's really hard to write about. There are some people who can pull it off nicely, like Irvin Yalom, but for me anyway, the person that I am as a therapist is not someone that I want to write about.

DK: What do you mean?

GG: If someone comes into my office for therapy, I feel like it's a total breach to write about them, even if I ask for permission. Even if I disguise them. That's how I feel about it, having done it now a few times. The Book of Woe went through a very, very extensive legal review and the case material was altered to the point that it was no longer factual. It was really fiction, and if I'm going to write fiction I should write fiction. I really believe that. I don't know that a reporter has any obligation, or even ability, to be objective, but to intentionally make shit up? If you’re going to make it up, make it up. If you're not going to make it up, don't. And if you can't write about it without making it up, don't write about it.

DK: Do you feel like you have to sort of forget about your therapist self when you're writing? Are you split off in some way?

GG: I guess so. I never really thought about that. No, I would say it’s the other way around. I have to forget about my writer self when I'm doing therapy. I can't really think about myself as a writer when I'm working with people. Once in a while something so fascinating occurs, so remarkable that you picture yourself writing about it, but in general therapy is something that I go and I do, and it's a performance—and I don't mean that in a cynical way—it's a thing that I do. But the writing draws on all of me in a way that the therapy doesn't.

DK: So do you feel you are more of a writer than a therapist?

GG: I guess so. I never really thought about it before. There's something that I do as a therapist—there's a way that you use yourself, and all of you has to be available to yourself. But you also as a therapist have to bracket certain things.

You have to look at the fact that you want to write about somebody, and that has to be just as subject to scrutiny as your desire to have sex with your patient.

You have to look at the fact that you want to write about somebody, and that has to be just as subject to scrutiny as your desire to have sex with your patient. It's like, “Okay, yeah, that's something that I feel, and I've got to figure it out, and I've got to deal with it here.” But I can't take it for granted any more than I can take it for granted if I had a sexual impulse, or some strong negative reaction to somebody. Whereas with writing, that's a whole different kind of discipline, where you have to take whatever it is and transform it into words.

DK: You aren't thinking, “What if Sheila reads this?” when you write?

GG: No. I probably should, but I think if I did I wouldn't be able to maintain both disciplines, because people actually do read my writing.

DK: And they come in to talk about it sometimes?

GG: Oh yeah. Sometimes they do. I've got a relatively wide readership, but I'm certainly not a famous writer, and therefore most of the people that I work with may not even know that I have a writing career.

DK: So you don't bring it in.

GG: No. I don't bring it in at all. My books aren't in my office. I don't mention it.

DK: Do you feel like it would be an intrusion?

GG: Yeah, of course. I don't talk about the argument I just had with my son either. Actually, there are situations in which I might talk about writing, but it very much depends. I see people who are artists or writers, and with those people I do sometimes bring it in.

DK: That’s interesting. I'm struggling with my identities in a way that it sounds like you haven't and don’t. You just write, and you're not tormented about it.

GG: Well, I was doing therapy for many years before I got into writing.

DK: Well this has been a fascinating interview. Thank you so much for your time.

GG: Thank you.

What every therapist needs to know about the new natural remedies for mental health

Posted on October 15, 2014February 11, 2026 by Psychotherapy.net Team

Yesterday I was doing some research at a local library. A bus full of middle school children on a field trip was letting the students out in front of me. I made my way around the facility for a good twenty minutes when I overheard a frustrated woman struggling with her computer. She bolted from her computer terminal and marched up to a librarian and asked her for technical assistance.

"I don't have a clue," the librarian candidly responded, "go ask one of those eighth graders."

Welcome to the new age. An age in which the average eighth grader might know more than us about our computer and definitely knows more than we do about our cell phones. But there is another societal dynamic which is somewhat analogous, but decidedly more important. This is the first generation of psychotherapy clients who are often better informed about natural mental health remedies than their therapists.

The object of this blog is not to rectify the lack of knowledge. That journey might entail reading scores of books, perusing endless articles, and watching enough You Tube videos to give you severe eye strain. The idea herein is merely to provide you with enough information so that when a client mentions a natural approach you won't wrongly think he or she has lapsed into speaking a foreign language.

Finally, since the data in this area are so voluminous, not to mention controversial, I will merely give you enough information to fit on the head of a pin. Ready? Let's do this.

St. John's Wort (SJW), an herbal remedy, has become the darling of the alternative mental health treatment movement. Incidentally, that's wort, not wart, so you need not see a dermatologist. Wort is Old English for plant. Your more educated clients may refer to it as "hypericum" the scientific name, but thanks to this blog, you'll know they are referring to good old St. John's Wort. In some statistical studies St. John's Wort ran neck and neck with prescription counterparts for depression and anxiety. Detractors often point out that St. John's Wort can cause sun sensitivity, but so can antibiotics and pain relief medications.

SAMe (Typically enunciated SAMMY) was discovered in Italy many years ago. This nutraceutical has been used for depression, fibromyalgia and arthritis in other countries with a high degree of success. The key selling point is that SAMe often works faster than prescription medicines and negative side effects are extremely rare.

5 HTP or 5-Hydroxytryptophan. This super star is reputed to be superior to psychiatric medicinals in terms of raising serotonin levels in the brain. Some folks also insist it can help you shed a few pounds and swear it works wonders as a sleep aid. Rumors abound that athletes involved in extreme endurance sports have used it for years to counteract the depression brought on by very high levels of aerobic exercise.

Increase your exposure to sunlight or full spectrum lighting. Psychiatrist Dr. Norman Rosenthal (no relation to this author) first described Seasonal Affective Disorder (SAD) which afflicts 7 million women and a rather large number of men. SAD is a type of depression which manifests itself when the days get darker and shorter limiting one's sun exposure. Alternative mental health practitioners worry that the recommendation to wear sunscreen at all times and to avoid the sun has made individuals more prone to SAD. For those who cannot spend time in the sun, full spectrum lights and phototherapy devices are available. Word of warning: Your friendly neighborhood dermatologist who is determined to prevent cancer and related skin damage is not a fan of this theory!

Vitamin D, or should I say hormone D. Cutting edge theory asserts that vitamin D is not a vitamin, but a hormone. Appropriate levels of this nutrient, um I mean hormone, help fight mood disorders and seemingly drastically boost the immune system. The problem: It is possible that traditional government recommendations were way too low. Some clients now ingest 10 to 125 times the amount of vitamin D suggested by Uncle Sam just a few years ago. Interestingly enough, even mainstream physicians who initially scuffed at this idea are now routinely insisting that patients get their vitamin D levels checked. Skeptics warn that we don't know the long term effects of taking such high doses. Zealots, insist that a day on the beach is the equivalent of taking a handful of vitamin D pills. Stay tuned, this one should get interesting.

Fish Oil to raise Omega 3 EPA/DHA levels. In at least one research study, the experiment was stopped because bi-polar subjects receiving fish oil were progressing much better than those who did not, and quite frankly it didn't seem fair to the group who was not ingesting the supplement.
Many therapists have heard the rumor that kids living in fishing towns have lower levels of ADHD and adults residing in these areas suffer from fewer bouts of depression and anxiety. Fish oil, in addition to its ability to stabilize one's mood, also theoretically promotes cardiovascular health and is often championed as beneficial for eyes, skin and joints. As of late, a couple of anecdotal reports indicate massive dosages might even help in cases of seemingly incurable brain trauma (e.g., after an auto or mining accident). The prescription to "eat more fish" is likely not the ideal since our waters are polluted. Moreover, studies in this area use fish oil capsules (not a generous helping of salmon) to enhance scientific rigor and the ability to regulate the dosage.

Supplement critics warn us that fish oil capsules can contain mercury and other toxic heavy metals. This argument may have been true at one time (and early on seriously good fish oils cost an arm and a leg), however, in this day and age, even many low cost drug store brands boast pharmaceutical grade processing and "mercury free" capsules. New research seems to indicate that the urban legend suggesting that fish oil can make one bleed to death is . . . well . . . just that; an urban legend.

The argument against fish oil: Cult biologist Dr. Ray Peat — who proponents say is 100 years ahead of his time — says the omega 3 fatty acids in fish, EPA/DHA are anything but essential. Simply put, Dr. Peat does not recommend fish oil citing studies indicating it actually hinders the immune system. Surgeon and former Olympic rowing champion, Dr. Caldwell B. Esselstyn Jr., the cardiologist who nursed Bill Clinton back to health after his life-threatening heart problems, is famous for yelling "no oils" in his popular lectures. Okay Dr. E, we get the point!

If you, or your clients, do purchase fish oil, it is best to stick to brands packaged in dark glass or plastic bottles and keep the supplement refrigerated to avoid rancidity. Finally, be acutely aware that the number of milligrams on the front of the bottle — generally a huge selling point (say 1200 mg) — has nothing to do with the actual milligrams of the beneficial omega-3 content (which might be 324 mg or some such number). Always scope out the label that graces the back of the bottle to determine the actual omega 3EPA/DHA content.

Niacin vitamin B3 therapy. All-right, here's a question that I'm betting not a single reader can answer correctly: How did Bill Wilson (aka Bill W) co-founder of AA cure his longstanding anxiety? If you said, "duh, he used AA," then you are absolutely, positively wrong! (Nice try though.) Question number 2: What did Bill Wilson say he wanted to be remembered for on his death bed? If you said, "AA" congratulations, you are zero for two!

Bill Wilson loved AA and believed in it with all his heart and soul. He used it to help his own drinking problem. Nonetheless, AA did nothing to help his debilitating anxiety and depression. What did help? Seriously large dosages of vitamin B3, also known as niacin. Bill Wilson spent nearly the last third of his life trying to get AA groups to promote niacin as a treatment for alcoholism, depression, anxiety, and even schizophrenia. It never happened and worse yet the saga has been virtually absent from all the major sources on addiction treatment.

Why didn't Bill W.'s ideas catch on? That's a story for another blog. But the short answer is that high dosages of niacin cause a flush that can be painful and downright scary. Many folks experiencing the flush end up in the ER not knowing it is likely a positive thing! Multivitamin pills rely on small doses of the nutrient or niacinamide to avoid this problem. Modern timed release or so-called "flush free" niacin supplements sold by health food stores and prescribed by physicians to help control cholesterol may or may not have the mood stabilizing effects of pure niacin. By the way, Bill W wanted to be remembered for his contributions to niacin therapy.

Probiotics. These are supplements that promote healthy bacteria in the intestinal tract. Many practitioners are convinced probiotics can be helpful in an array of mental health and digestion disorders; especially autism spectrum disorder. Probiotics have virtually no negative side effects, but some brands require refrigeration or freezing temperatures to survive. Like automobiles, television sets, and vacuum cleaners, every brand claims to be the best, so it's difficult to make a purchase decision.

Eliminate wheat. Wheat and mental illness(most notably schizophrenia) have a longstanding relationship. Although mainstream medicine insists wheat is healthy (if not a required food group), newer research posits that ingesting wheat based products has a detrimental effect on one's blood sugar, emotional state, and might even be implicated in Alzheimer's. The problem may not be so much the wheat itself, but the fact that today's wheat has been hopelessly genetically altered. Or to put it a different way, this isn't your father's whole wheat bagel! The bun that graced a 1970s fast food burger bears no resemblance to the bun you wolfed down for lunch. Proponents of the new don't eat wheat theory, feel strongly that whole grain, 7 grain, gluten free whatever (!!!) products may be just as bad if not worse for you than the run of the mill white bread type foodstuffs.

Take a look at David Perlmutter, M.D.'s book Gain Brain if you think I am exaggerating.

Strategies to boost cholesterol. Say what? Al-right, I'll admit it. I save the most controversial alternative strategy for last. Although most doctors are prescribing statin drugs to lower your so-called bad LDL cholesterol, a number of avant garde thinkers point out that higher may be better. If your cholesterol is below the 160 mark, your physician will give you a big hug and a smooch. But some research shows that if you have low cholesterol your chances of suffering from a major depression or committing suicide goes through the roof. The brain, as they point out, is basically cholesterol. Proponents of the cutting edge, increase your cholesterol theory if you want better mental health, have gone as far as suggesting that a minimum requirement for cholesterol should be added to the food charts in the near future. There is also the issue of longevity. Older adults in good health seem to have elevated cholesterol.

It would be an understatement to say that the aforementioned information seems totally the opposite of what we have been told for years.

I think I'm going to end here, because the eighth grader next door just returned home from school and I have a cell phone question. I wonder if he knows much about DHEA, pregnenolone, or NADH to combat depression my clients have been pondering over. It couldn't hurt to ask.

Psychotherapy with Transgender and Gender Nonconforming Clients

Posted on June 24, 2014February 11, 2026 by rezendevknowfully.com

The Unbearable Otherness of Being

Imagine making your way in a world where your physical appearance makes others uncomfortable, anxious, confused, or uncertain about themselves. Your very presence may be perceived as a threat to another individual’s sense of self or sexual orientation. Everywhere you go, people stare at you—sometimes discreetly, often blatantly—leaving you very little room to walk unselfconsciously through life. The reactions you experience from others, while the result of ignorance and sometimes mere “curiosity,” do nonetheless harm you, for you are perceived as “Other.” At times, people’s reactions are more hostile, the result of conscious and unconscious fears about what it means to deviate from gender norms, and you may be verbally or physically assaulted just for being you.

This is what it’s like to be a gender nonconforming or transgender individual in today’s world. Though there is increasing awareness and tolerance around gender issues in certain small segments of American culture, the truth is, the level of misunderstanding, ignorance and prejudice that surrounds gender nonconforming people as they go about their lives has created a mental health crisis in our society. To illustrate the epidemic nature of this crisis, here are a few statistics from the American Foundation for Suicide Prevention’s 2014 Report, “Suicide Attempts among Transgender and Gender Non-Conforming Adults.”

In a pool of 6,000 self-identified transgender respondents:

41% had attempted suicide
60% were denied health care and/or refused treatment by their doctors.
57% had been rejected by their families and were not in contact with them.
69% had experienced homelessness.
60-70% had experienced physical or sexual harassment by law enforcement officers.
65% had experienced physical or sexual harassment at work.
78% had experienced physical or sexual harassment in school.

For gender nonconforming individuals, the very nature of their sense of “self” lies in marked conflict to society’s gender identity “ideals” and social scripts. The resulting prejudice (transphobia and homophobia), whether explicit or covert, often manifests in forms of denial, invisibility, harassment, bullying or, in more extreme cases, assault and murder. As if this weren't enough, gender nonconforming and transgender persons may be further marginalized by their ethnic and racial identity, economic status, physical abilities, and age.

More subtle forms of discrimination exist, many occurring within the helping professions, including mental and medical health, nonprofit support services, legal and government institutions and public schools. Overpathologizing, misdiagnosing, maltreatment (including refusal of services), neglect and demonization are just some of the ways transgender individuals are routinely discriminated against within systems whose mission is to support and serve. These discriminatory practices are carried out by providers who fail to become educated and respect, protect, or provide treatment that is appropriate, impartial, and equal to the care given to other clients. Following, I will attempt to provide the nuts and bolts necessary for aspiring clinicians who wish to work in a culturally competent manner with their gender nonconforming and transgender clients.

Gender and Language

I often remind my colleagues, students and clients that we all have a gender identity and diverse manners in which we choose to engage in self-expression. As a cisgender female (i.e., I identify with the gender I was assigned at birth—female), I am conscious of the great extent to which I can embrace the everyday conveniences of being privileged. I am not ostracized for my gendered self, and no one questions my choice in using a public restroom. For gender nonconforming and transgender clients, this problem is known as the “bathroom issue.”

We practitioners need to become fluent and speak the same language as our gender nonconforming and transgender clients. In doing so, we demonstrate the intention of promoting respectful communication that expresses an intricate set of thoughts, ideas, and feelings associated with sex, gender, sexuality and identity. The language used among this diverse community is multifaceted because finding words to articulate complex notions of identity is arduous. In fact, the youth in my office frequently inform me, a gender specialist, how some of the language and concepts I use are now outdated. Nonetheless, staying current with the language being used within the gender nonconforming community is an important part of being not only a culturally competent therapist, but an empathically attuned therapist. Such language literacy also enables mental health professionals to understand concepts, organize thoughts, foster discussion, exchange ideas, and support the community in the least confusing, shameful, and harmful way. Familiarity with the community’s positive expressions of self and identity not only helps clients feel understood, but ensures that therapists don’t rely on clients to educate them—an all-too-familiar experience for cultural minorities.

The following list presents a very general overview of how we come to understand the meaning of sex, gender/gender identity, gender roles, and sexuality for our gender diverse clients and ourselves. It’s important to remember that these terms are constantly evolving within the gender nonconforming, transgender, queer or transsexual communities, as well as by the practitioners who intend to help them. Gender nonconforming and transgender identities include but are not limited to: Transgender (TG), female-to-male (FTM), male-to-female (MTF), transgirl or transboy, girl/woman (natal boy), boy/man (natal girl), they/them, bigender, gender fluid, agender, drag king or queen, gender queer, transqueer, queer, two-spirit, cross-dresser, androgynous. The terms FTM (female-to-male) and MTF (male-to-female) encompass a spectrum or continuum from those who identify as primarily female or male, to those who identify somewhere in the middle or both (e.g., queer). Between these two posts or “extremes” (female and male) lie most gender nonconforming individuals.

The sexual orientation of gender nonconforming and transgender clients is a separate identity and should never be presumed or assumed. It refers to the gender one is typically romantically and sexuality attracted to (e.g., homosexual, heterosexual, bisexual/pansexual, polysexual, asexual etc).

Becoming Gendered

It’s important to think about how we become “gendered.” In part we do this by the way we organize and construct language. Most of the English language is “gendered,” constructed in a way that makes it difficult to deviate from strictly binary conceptions of male and female. We tend to acknowledge and refer to one another through pronouns, and consequently become gendered in our relational experiences. For example, when we frequent our local coffee shop, “Excuse me, Sir…Mam…May I have a large coffee?” Here is a simple example of how we have already ascribed gender to a complete stranger.

As clinicians, we need to learn to ask and address our clients appropriately. More importantly, we need to develop the capacity to become conscious of our own gendered ways. Specifically, we need to ask all our clients about their gender identity and development as well as their gender pronoun preferences. The youth that show up in my office often challenge this binary model most of us are so accustomed to, and request to be referred to as: ze, hir, one, or the plural “they” “their,” “them.” Interestingly, I often find myself arguing with my cisgender colleagues, who get caught up in grammar policing, about the importance of honoring the self-identification of these clients. The English language is constantly evolving, after all, and human and civil rights struggles play an important part in its evolution. At the same time, it’s important to not make any assumptions about people’s identification preferences. Plenty of gender nonconforming or transgender clients prefer to be referenced by conventional pronouns such as “him” or “her” because it feels congruent with their internal identity.

People tend to be preoccupied with gender long before a child is born. “Do you know your baby’s sex?” is a constant question for pregnant parents. Sex, in this case, refers strictly to the external genitalia of the child rather than their potential internal gendered self. “Gender is assigned prenatally and from that moment it determines—and severely limits—acceptable gender expressions and desires.” Our early training begins with our parents’ color selection for our nurseries, the names we are given, and the activities we are encouraged to enjoy, and because we want their love and approval, we emulate what is desired of us. We internalize the societal roles, behaviors and beliefs ascribed to us by the culture around us (including that of our family) and may not know that any other way of being is possible. Boys get blue items, are given toy trucks and guns, and are prompted to be assertive and confident. Girls wear pink, are given dolls to play with, and are encouraged to be empathic and compromising. These behaviors, beliefs and customs are socially constructed—situated in the context of historical time, social class, ethnicity, culture, power, politics, physiology, and psychology—but they are deeply entrenched in our psyches and ways of being.

Clinical Practice

As the presence and experience of transgender people has entered both public consciousness and mental health facilities, clinicians are now beginning to think about transgender/gender issues. However most clinicians are not trained to identify clinical themes prevalent for transgender and gender nonconforming individuals, and consequently misunderstand their mental health and their global treatment needs. Our traditional training fails to address gender and sexuality development for transgender persons from a nonpathological perspective. In addition, negative countertransference from providers and institutions is common and lends itself to discriminatory practices or, worse yet, thoughtless analysis of clients’ needs that may lead to irreversible medical interventions. Common feelings and attitudes for inexperienced clinicians toward these clients may include anxiety, fear, disgust, anger, confusion, morbid curiosity, and rejection, all of which can severely compromise the therapeutic relationship, our ability to help, and an individual’s identity development and transition process.

The journey of self-discovery for gender nonconforming and transgender individuals is laborious and often lonely because, simply put, the desire to become more congruent with their “True-Self” in body and mind may require a shift in physical identity. Children tend to be the most disadvantaged in this phase of life as they may be required to repress their desires to play with “cross” gendered toys and are left feeling ashamed to admit their favorite colors and activities (e.g., the boy who is prohibited from playing with dolls and having a pink bedroom).

As gender nonconforming individuals become more psychologically distressed they often feel the need to have a more congruent experience of their internal and external selves. They may need to first embrace a social transition—choosing an alternative name that reinforces their internal identified gender, dressing in a stereotypical fashion that supports their gender identification and engaging in “cross” gendered behaviors. In my clinical experience, when given the permission and support, gender nonconforming children and adults tend to become less anxious, depressed and gender dysphoric as a result.

However, some gender nonconforming and transgender individuals have a persistent need to modify or transition the physical attributes of their body to the opposite of their ascribed birth gender. This process is often too confusing for most people to comprehend, and is especially difficult because one’s gender expression and behaviors are typically the initial identifying marker for organizing one’s relational experiences among others. The clients with whom I work often desire bodily change not only to feel more congruent with their internal self, but with the hope of being experienced relationally as they truly are. For example, my transgender FTM clients use heavy-duty binders to flatten and contain their breasts so that they will not be mis-recognized as tomboys or lesbians. This experience of congruence tends to reduce gender dysphoric intrapersonal and interpersonal experiences. Our transgender clients need additional support around the use of physical and medical interventions, so it’s all the more important that we be well-educated and sensitive to these issues.

Gender Dysphoria

The new addition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), released in May of 2013, has removed the diagnosis of Gender Identity Disorder and has re-classified Gender Dysphoria as a clinical condition that gender nonconforming, transgender and transsexual clients may experience. Gender dysphoric symptoms arise when one’s self-concept and expressed gender in relation to their ascribed gender is “incongruent.” The psychological distress that results from these internal and external conflicts can lead to dysphoria, depression and a host of other conditions commonly experienced by transgender or gender nonconforming individuals. This turmoil is often created by internalizing the “gaze” of the world around them, i.e., they experience a great deal of psychological discomfort due to being publicly misgendered. Yet, it is also important to note that many gender nonconforming and transgender clients do not experience Gender Dsyphoria. They tend not to make it to our consulting rooms.

What of the clients who do end up in our offices? If a gender nonconforming or a transgender client and his or her family seek our support, are we available to console them, educate and advocate on their behalf, and offer culturally informed and sensitive treatment to the client and the family without getting caught up in our own agendas? How do we determine whether a child is an appropriate candidate for social transition, hormone blockers or even cross-hormone interventions? How do we determine whether the child is an appropriate candidate for genital reassignment surgery, which is often irreversible? How do we think about their fertility options and future family plans? How do we help a transgender child assigned female at birth who is in distress after his first menstrual period? Some of these interventions may seem radical, but if we fail to educate and train ourselves adequately around these issues, we can actively cause harm to our clients. Self-harm (body mutilation), substance abuse, homelessness, suicidal ideation or even suicide attempts can result.

A number of other conditions emerge in gender nonconforming children, particularly when their families aren’t able to provide the support and unconditional love that is necessary for them to thrive. These include adjustment issues, depression and anxiety disorders, trauma, substance dependency, and characterological pathology. Clinicians must be aware that families, too, must be educated about transgender issues, learn skills for coping with the child’s gender change, and be able to mourn and seek social and emotional support for themselves. And, of course, many clients may have co-occurring conditions, such as Autism spectrum disorders, that are beyond the scope of this article.

When treating a client with a gender nonconforming or transgender identity, clinicians may find themselves involved in a few situations unique to these clients. They may be asked to assess and substantiate a client’s preparedness for various biomedical interventions—usually involving the Real-Life Test/ Real Life Experience or a Gender Readiness Assessment—which involves encouraging a gender nonconforming client to begin living in their self-determined gender role and then assessing the impact of that experience. For example, some clients might experience a reduction in gender dysphoric distress, while others—say those whose family or community context is hostile to their nonconformity—may experience an increase in symptoms. Though this assessment is no longer required by the Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People published by The World Professional Association for Transgender Health, many medical providers and insurance agencies require it for coverage.

Bridging the Gap

A transgender or gender nonconforming individual’s psyche and the issues they face are very complex—and at times, convoluted—with complications in the psychological, medical, legal, and social realms. Because of this complexity, and the severity of their suffering, it should not be left solely in the hands of clients to educate their clinicians, nor should these clients be put in the vulnerable position of relying on their clinician’s empathy to determine whether they will receive the care they require. An ignorant clinician who responds negatively to such clients—even if only at an unconscious level—can cause untold harm and make it that much more difficult for clients to seek the help they so desperately need. We need to take responsibility for becoming educated and seek guidance from gender specialists—trained providers who can inform clinicians about transgender history and integrate traditional psychoanalytic and psychodynamic perspectives with queer theory.

Diane Ehrensaft, PhD, director of Mental Health at the Child and Adolescent Gender Center in San Francisco, and her colleagues are doing groundbreaking work in this area, bridging the gap between developmental, biological, queer and psychoanalytic theory using what she calls a “Gender Affirmative Model.” She draws upon Winnicott’s ideas of “true gender self” and “false gender self” in formulating her notion of gender creativity to better understand gender nonconforming and transgender children and adults. Turning prevailing wisdom on its head, she argues against labeling gender nonconforming invidividuals as dysphoric and instead views their varied gender expressions as fluid, dynamically intertwined between biology, development, socialization, and cultural context in time. Gender is not binary and may change over lifespan.

Understanding the issues that gender nonconforming clients face creates the possibility of an authentic and empathically attuned treatment that can be a true corrective emotional experience. Having the competence and confidence to administer a Real-Life/Gender Readiness Assessment can make all the difference in our patients’ lives, allowing them to socially transition and integrate their gender identity with other aspects of themselves. Thinking of the client as whole is instrumental to their overall well-being.

Not until we as clinicians grapple with our own gender identity, behaviors, and attitudes can we begin to utilize our assessment skills in developing diagnostic impressions, identify and observe our countertransference feelings, and implement treatment interventions that will lead to a balanced internal and external sense of self that improves a client’s overall quality of life. I encourage all my fellow colleagues to become more cognizant of the their own identities, values, and beliefs, and particularly to confront their fears and prejudices when working with transgender individuals. We must become mindful of what we ask—and do not ask—in our clinical interviews.

We also mustn’t assume that gender nonconforming clients are coming to us because of their gender or sexual identity and be open in creating our hypthotheses about our clients’ needs and desires. Let us accurately reflect the true clinical condition with which our client’s struggle. As I noted at the beginning of this article: imagine making your way in the world where your very sense of being makes others anxious, confused, and uncertain of themselves. By becoming culturally competent, we will be better able to provide an empathic approach to treatment that considers a range of gender nonconforming expressions and behaviors as healthy, as an authentic gender identity and bodily presentation, albeit variant from societal expectations. Gender deviation is not pathological, and if you think it is, you’ve got some work to do. On the other hand, it’s important to not be reflexively “progressive” and mindlessly support a transition that is not first deeply understood clinically.

Reflections on the theory of gender development, diagnostic conditions, and clinical treatment implications must include the role of the clinician as a gatekeeper to another’s self-determined gendered body, heart, and mind. The exploration of the transference-countertransference relationship is paramount, regardless of whether you are a case manager, a medical doctor, or a psychotherapist. Let us play with gender, and in our journey, discover the kaleidoscope of possibilities for clients as well as for ourselves. As providers, it is our social responsibility to change the role of the clinician from a gatekeeper to one who can form a therapeutic relationship that offers a way for clients to integrate their sense of self in relationship to the other that can hopefully be emulated in the outside world. A solid sense of self is likely to build confidence and self-esteem that will foster healthier relationships and diminish uncertainty and fear, decreasing the risk of self-harm and—hopefully—violence toward gender nonconforming and transgendered individuals.

Recommendations for Clinical Practice

Ask your clients about their gender identity and preferred pronoun. Explore their internal experience and how it impacts them interpersonally.

Foster multiple and integrated identity development: race, ethnicity, gender, class, sexuality, profession etc.

Educate parents about the importance of not pathologizing the gender expression of their children.

Treatment interventions should include allowing children the space to explore their gender expression, family education and support, as well as parental support to mourn the loss of their fantasies about their birth child's ascribed gender.

Collaborate treatment efforts with the providers involved, e.g., social workers, endocrinologist for hormone blockers and hormone treatment, family therapist, and treatment team staff.

Remember: Gender nonconformity is a natural expression of human development and experience.

Do No Harm: Seek consultation from a gender specialist. Monitor countertransference and refer out if you are not able to act fully in the best interest of your client.

Clinical Resources

Report of the APA Task Force on Gender Identity and Gender Variance.
Standards of Care for the Health of Transsexual, Transgender and Gender Nonconforming People, Version 7.
Achieving Optimal Gender Identity Integration For Transgender Female-to-Male Adult Patients: An Unconventional Psychoanalytic Guide For Treatment (2008), Karisa Barrow.
Gender Born, Gender Made: Raising Healthy Gender-nonconforming Children (2011), Diane Ehrensaft.
The Transgender Child: A Handbook for Families and Professionals (2008), Stephanie Brill & Rachel Pepper.

Deconstructing Gender: Self-Exploration Exercise

What is your own gender identity?
How old were you when realized you were a “girl” or a “boy?”
Who and what made this clear to you?
Did you agree with your parents clothing choices for you as a child?
What activities did/do you enjoy?
Have you expressed your own gender identity differently over the course of your life?
How do you feel about your body? Your genitalia?
What messages have you received about your gender and from whom (e.g. parents, media, religion etc.)? Were you “policed” by others around your identity, gender roles and social practices or body?
How has your gender shaped your beliefs, social engagements and practices?
What have you been allowed/encouraged to do because of your gender identity and what limitations have you faced (e.g. social sanctions/promotions)?

After the Diagnosis: Helping Patients Cope With their Emotions

Posted on May 20, 2014February 11, 2026 by rezendevknowfully.com

The New Normal

“I just got diagnosed. Now what do I do?”

The focus of my professional work is on helping patients to cope with medical diagnosis, so I hear this question a lot. But many psychotherapists tell me that their patients also talk to them about their health issues, including sudden, serious medical diagnoses.

As mental health professionals, we may provide the only opportunity that newly-diagnosed patients have to talk to someone in this situation. The traditional medical establishment is equipped to help patients from a medical, but not an emotional, perspective. Family members and friends are also suddenly thrust into the emotional chaos surrounding the diagnosis, and often need help with their own emotions and helplessness.

Our patients facing a medical diagnosis look to us for help in sorting out complicated and scary feelings during a highly stressful time so that that they can move forward in their lives. In this regard, our job is to help patients define and embrace a “new normal” —with a positive self-image, retention of as many cherished routines and rituals as possible and supportive relationships—but also help them to integrate the effects of treatment and make ongoing lifestyle adjustments. Patients facing a diagnosis want nothing more than to be as normal as possible.

If newly-diagnosed patients are able to get needed emotional support early on in their diagnosis, they will be that much better prepared to cope as they move forward with their treatment. As therapists, we help them to prepare for the road ahead.

Medical Diagnosis=Stress

Receiving a catastrophic medical diagnosis is a stressful and sometimes traumatic event. Newly-diagnosed patients feel an immediate sense of uncertainty—life will never be quite the same. And life may end. And like other stressful events, our minds and bodies are hardwired by nature to react. The initial reaction is shock, as our conscious minds essentially shut down while, subconsciously, this information is processed.

As the shock fades, it gives way to one of three reactions that occur in response to stress: flight, freeze, and fight. The flight response is primarily an emotional reaction, and patients may be so caught up in their emotions that they may not be able to make objective decisions regarding their condition and its treatment. On the other hand, those having a freeze response may be unable to acknowledge their feelings at all or may have a fatalistic view, either of which may result in inaction. Those in fight response are best equipped to deal with a new diagnosis. They have access to their emotions as well as their logical resources, and are able to harness both as they face their illness. Most important, patients can be taught how to be Fighters.

These basic reactions impact the kinds of emotions that newly-diagnosed patients experience, and how they cope with these emotions, as well as how they deal with their diagnosis from a rational standpoint (e.g. information-gathering). For better or worse, how patients cope during those first few days and weeks after receiving the diagnosis will have implications throughout their treatment process—from decision-making to coping with the treatment to ongoing recovery and life management. And if those patients find their way to the office of a mental health professional, we can play a formative role in their journey.

The First Reaction

Whether catastrophic or chronic, almost invariably patients describe their reaction with one word: shock. People often experience numbness, as if they are in a trance, or simply have “no feeling at all.” The experience of shock is often associated with disbelief or a sense that their emotions might be so strong that they should be held at bay for fear that they might be overwhelming. There are of course exceptions. For example, when a condition from the past is recurring, or when symptoms over time have rendered the diagnosis inevitable, patients may report an initial feeling that “the other shoe has finally dropped” or that they are about to go down a road that that they have previously been on. Still, it is only human nature to cling to that possibility that “it won’t happen to me.” This belief is mainly unconscious; after all, most of us don’t spend our time assessing our chances of getting hit by a medical diagnosis.

Carole described her reaction when she was first diagnosed with cancer.

"It was like the world suddenly stood still. I mean, all I could hear was my own breathing, and the thumping of my heartbeat. At first, I was completely numb, and I wasn’t thinking anything. And then I started saying the word “cancer” over and over. Still, no feelings. But deep inside, I realized that, no matter what, my life was never going to be the same."

The initial shock may last a moment, hours, days, or may continue on, as the patient’s emotional and rational sides are both struggling with the news. If you have been through the experience of a diagnosis, you might remember how you first reacted, or didn’t react, to the news; or maybe you have seen someone else go through it and felt your own helplessness as you watched them struggle.

In a way, being faced with a diagnosis, while not usually a death sentence, is similar to hearing about a death. As Carole, in the example above, described her diagnosis—nothing will ever be quite the same. Newly-diagnosed patients are left with the knowledge that, yes, bad things can happen, that they really aren’t invincible after all. And the diagnosis —whether it requires extensive treatment that interrupts normal life for months or longer, or whether it requires medication and alterations in diet and lifestyle—will at some point require the patient’s acknowledgement and full attention. Knowing that this looms ahead can also be initially overwhelming for the patient, and the healthcare professionals they are working with may or may not be able to provide emotional support for their patients.

During this time of initial shock, patients are often not open to more information, nor willing to discuss their diagnosis and what it means. It is difficult to communicate with patients who may be unable to hear or comprehend what they are being told, which presents a particular challenge to their healthcare providers who may need to begin a medication regimen and/or make a decision about the path of treatment. The newly-diagnosed patient may need some time and space to sit with the news, and if the healthcare professional pushes them too hard to discuss the treatment plan or to make a treatment decision during this time, the patient may become defensive and refuse to talk further, potentially becoming even more resistant.

Patience is required. Human beings can’t be forced to take in more information than they can process at any given moment moment, and often the best way to help patience move through this early stage is to be willing to sit with them, offering support while being sensitive to the readiness of the patient to process this news. Psychotherapy can provide vital support during this time, a chance to vent about the frustrations and the fears.

Clearly, sensitivity to how a patient is responding must be balanced with the level of urgency in taking any necessary action. For example, it may be appropriate for the therapist to act as a patient advocate by encouraging the patient to schedule a follow-up appointment with their healthcare provider to further discuss the diagnosis and formulate his/her questions. And even to help the patient formulate a list of questions to ask their healthcare provider. Scheduling a follow-up session with the patient to discuss and process what they learned in this second appointment can also be invaluable.

The Three Fs

Accepting that life is going to change is the first step toward coping with the emotional impact of the diagnosis and making decisions. Though newly diagnosed patients come to this realization differently and at different times, most patients fall within one of the fight/flight/freeze responses.

Fight	Freeze	Flight
Positive Thinking	Isolation	Empowerment
Rigidity	Helplessness	Emotional Coping Skills
		Rational Thinking

Flight: The Case of Dave

The best way to introduce the Flight response is through a case example of a newly-diagnosed patient I’ll call Dave. An active man without a history of health problems, his diagnosis of a heart condition took him totally by surprise. His physician presented him with what she thought was the best recommendation, which was a triple bypass, and then suggested that Dave go home and do some thinking before making a decision.

Dave later reported that the sense of shock continued not only that evening, but for a couple of days afterward. He couldn’t believe that he, of all people, was being told that he was in anything but top condition. And his heart? Not a chance. He told his wife only that his doctor was watching his heart, but that he was absolutely fine, which of course she was skeptical of but knew better than to push if Dave wasn’t ready to talk. Dave describes the next few days like this:

"”Once the numbness started to wear off, I kind of went into a panic mode. It was like I had this thing around my heart and I wanted it cut out as soon as possible.” I was afraid to think because I was afraid I might talk myself into doing nothing, or that I might put too much strain on my heart. I imagined my doctor as my savior. I wanted to put all of my faith and trust in her and have her direct my path. I was in such a rush, I asked her to call the cardiologist she had recommended to try and influence him to schedule me for surgery as soon as possible"

While Dave is placing all of his trust in the first physician he encounters, he is also running toward the treatment that feels most expedient. He is not considering the implications of the treatment, in terms of side effects, recovery, and ongoing lifestyle management. As a result, he may later discover that this is not a treatment that he was prepared to deal with, which has implications for ongoing compliance as well as dissatisfaction with his healthcare provider.

The flight reaction has other implications as well. Individuals in this state may—out of a sense of panic—run toward unproven alternative treatments with potentially alarming results. They may also be susceptible to the recommendations of healthcare providers with whom they feel comfortable with emotionally but who may not offer the best treatment option. For example, they may profess to “love” their practitioners, which can preclude them from obtaining a second opinion on the diagnosis, investigating treatment options, and at least checking into the credentials and track record of their physician. Patients in Flight reaction may also attach themselves to an unproven, non-medical treatment with potentially alarming consequences.

The flight reaction can also result in such strong emotions that patients are unable to access their logical mind. Excessive crying, expressions of anger, giving in to fearfulness—these responses signify that a patient is also in flight of a different sort—not toward the first available treatment or the most loved practitioner, but instead running away from their diagnosis.

Freeze: The Case of John

Not all patients “take flight” toward the first available treatment. Some don’t take flight at all. Instead, the initial shock gives way to sitting and staring into space, waiting for the nightmare to pass, or for someone, often a family member, to step in and take charge. This is understandable. After all, between the shock of the diagnosis, and their perception that they are unprepared to make the decisions that are suddenly thrust upon them, or that they have no hope, they are essentially immobilized.

When in freeze reaction, emotions appear to stop working, not because they are broken but because they are being tightly held in place. And while this might be an opportunity for the rational side to kick in and take charge of the situation, logic without emotion is not necessarily going to result in rational thinking, as evidenced by John.

"I just sat there when the doctor told me, and I guess I’m still just sitting still. I can hardly get out of the chair, to tell you the truth. I kind of decided to be philosophical about it. I don’t know much about this but I do know that statistically, the numbers are against me. I mean, what can I do when fate isn’t on my side"

John is using the defense that individuals in freeze reaction often adopt: refusing to react emotionally. Not getting actively involved in learning about the condition and its treatment. Unfortunately, this also means giving up.

Essentially, the freeze reaction is an extension of the original feeling of shock, but with some key differences. Shock is the mind’s way of shutting down the emotions, and allowing the brain to process the information, before reaction. Patients in freeze reaction aren’t consciously suppressing their emotions, but their emotions are nonetheless inaccessible to them. They may think they are being “rational” based on their view of the facts, but there are risks involved when the logical mind is operating without the emotions.

Patients in freeze reaction, because they are operating without their emotional side, may adopt an attitude of hopelessness and helplessness. By not allowing themselves to work through the initial emotions, like anger and fear, they essentially remain stuck. Often they refuse to discuss their condition any more than absolutely necessary with their healthcare professionals, and may avoid telling family members as long as possible. Whereas patients in flight reaction may completely give themselves over to their emotions at the expense of rational thinking, patients in freeze don’t acknowledge their emotions, which leads inevitably to avoidance isolation.

One characteristic common among patients in freeze reaction is an unwillingness to make decisions about their treatment. They rely on their physicians, possibly working with family members, to make these decisions for them. In essence, they decide not to decide.

Fight: The Case of Marie

Being open to emotions can result in an inner sense of optimism and hope. If this optimism is balanced with rational thinking, patients are in the best position to make treatment decisions, deal effectively with treatment and lifestyle changes, and otherwise cope with the changes and challenges that may arise as they face the future. These are the fighters.

Fight doesn’t necessarily imply aggression and, in fact, sometimes patients resist this word because of that association. “Being a fighter means being empowered in terms of understanding the diagnosis, the options for treatment, and what lifestyle adjustments need to be made in the near future and beyond.” Being empowered is about arming oneself with emotional coping skills as well as rational thinking.

Fighters acknowledge the feelings that arise as a result of hearing the diagnosis and continue to honor their own emotions. It would even be reasonable to say that dealing with the emotional aspects of a diagnosis opens the door to rational decision making. Fear may, realistically, never fade away. The anger and disappointment may flare up at times. But emotions like fear and anger, when they are acknowledged and experienced, may also give way to hope, optimism, and a renewed passion for life.

Marie said it this way:

"I sat and cried and asked 'why me?' for quite awhile, maybe a few days. And then I stood up and said, 'I am going to fight this beast. I’m not going to let it beat me down.' The next day I made a list of who I needed to talk to, where I needed to go for information, and what I needed to start planning for. That doesn’t mean I don’t feel overwhelmed sometimes, because I still do. But I’m also in active mode."

Marie didn’t hold back on her emotions but, instead, faced her disappointment and fear. She sat alone with her emotions and, in her case, had a good cry. She also discussed her emotional reactions with a member of the healthcare team, who was comfortable being a “listening ear.” Had she not taken the time to experience how she was feeling, she would have been forced to sit with a large block of emotion, and it would have essentially taken all of her mental energy to hold it down. By doing so, she was able to start asking questions and making decisions.

Patients in fight reaction are more prepared to take action with their condition. By working through their emotional reactions—feeling their feelings and expressing them to supportive listeners—they are not running from their feelings, nor are they so overwhelmed by them that they can’t think. The result is a sense of self-confidence that comes from being aware of, and open to, emotions. Fighters also have access to their rational minds. This doesn’t mean that they are in perfect balance every day, or that they don’t have bad days when nothing seems to go right, but they are on the whole able to search for, and process, information. They are more likely to ask questions and to evaluate alternatives. They take more control over their treatment decisions and the ongoing lifestyle adjustments that they need to make.

Their balance of emotions and logic results in an attitude of empowerment toward their healthcare and the individuals who deliver it. For some patients, the fight attitude comes naturally; they may be more temperamentally inclined towards this kind of response to adversity once they move beyond the initial shock. These individuals will sometimes present challenges to their healthcare team, because they tend to be much more active in their own treatment, and believe that the ultimate decisions regarding sources of information, treatment alternatives, and lifestyle adjustments, lies in their own hands. However, the healthcare team can work with patients experiencing freeze and flight reactions to create and enhance fighter skills.

Psychotherapy: Bridging the Gap That Healthcare Professionals Can’t Fill

Healthcare professionals are not expected to be psychotherapists or counselors, nor to deliver direct mental health services to their patients. On the contrary, attempting to counsel patients without the benefit of being a trained mental health professional can be harmful to the patient and risky for the untrained professional. But newly diagnosed patients often have a hard time processing the overwhelming information they are bombarded with by their healthcare providers, and this is where psychotherapy can play a vital role.

Often patients are so flooded with emotion when they first receive their diagnosis that they aren’t really listening to what they are being told; they might “hear” it, but not be able to make sense of it and, as a result, they may miss key pieces of information or misinterpret what they’ve heard. This can be frustrating and alarming for the healthcare professional, who may or may not have the patience or skill to help their patients through this initial phase. Psychotherapy can help the patient to cope with the fear and anxiety that may be preventing them from processing information about their diagnosis and their treatment options, and to evaluate the options from both rational and emotional perspectives.

This can also be a good time to involve family members in the therapy. They often need support as well in processing and understanding the diagnosis, figuring out how best to support the patient, and deciphering what their role will be throughout the treatment process. Both patients and their families and close friends may not yet have the words they need to discuss their feelings and reactions with each other, and therapists can play an important role in helping to facilitate communication between patients and their loved ones.

Newly-Diagnosed Patients in Psychotherapy

A new medical diagnosis brings with it the probability of change—in routine, in relationships, in self-image—and human beings are creatures of habit, not wired to embrace change. Uncertainty about the future and what challenges might soon be presented, fears about loss, including finances, relationships, favorite activities and one’s future dreams are all a part of what the newly diagnosed patient brings to therapy.

Some of the factors that influence the way an individual reacts to a medical diagnosis include:

Perceptions of the severity of the diagnosis—Patients often have minimal information about their condition when they first receive their diagnosis, or erroneous information, or a vague awareness of the condition but not enough of the facts to evaluate it in terms of the implications for their own lives. These perceptions —and misperceptions —may lead to an emotional reaction that is not consistent with reality. Alternatively, patients may be well versed in their condition and experience emotions that are realistic and consistent with its severity. Either way, perceptions have a direct influence on emotions.

Personal coping style—Some people grow up in families in which emotions are always on the surface, and family members are encouraged to express how they are feeling. In other families, emotions are not so acceptable, and are suppressed. Newly-diagnosed patients who don’t have a history of being comfortable with their own feelings will most likely have difficulty talking about, or expressing, how they feel.

Prior experience of illness—Newly-diagnosed patients who have had a past illness may experience some of the same feelings that they experienced in the past. Having already dealt with a medical diagnosis may have provided them with coping skills to deal with a new diagnosis; alternatively, the diagnosis can reignite fears and other feelings that they had hoped not to re-experience. Patients who have helped a friend or family member cope with a medical condition may react similarly.

The Unanswerable Question

Newly-diagnosed patients inevitably ask one question: “Why me?” This may be a medical question, as the patient tries to understand the medical reasons behind the diagnosis, though there is usually an undercurrent of self-punishment—“If only I’d eaten better” or “if only I didn’t smoke” this would never have happened. People may also feel guilty about asking this question, as it can seem to suggest that it would be more fair and right if it happened to someone else. And patients may also express acceptance, but nevertheless ponder the randomness of life.

The point for therapists is not to answer this question. For many patients, “Why me?” opens the floodgate to releasing their own emotions, because it is a way of articulating that basic question of fairness and the role of fate, core issues that patients grapple with as they begin to process their diagnosis and move toward acceptance and empowerment. Ultimately, “Why me? is an existential question, and as therapists, we can use it to delve more deeply into the meaning of life for our clients and, if appropriate, work with them to cultivate a deeper connection to their religious or spiritual communities and practices.

Facing Difficult Emotions

When I first met with a patient I’ll call Yolanda, who had been diagnosed with cancer, she said:

“All I could think about was how concerned my doctor was when she told me I had cancer. I had never seen this look on her face before, and I just kept thinking that if she was this concerned, I must be in big trouble. I felt like I was on the edge of a cliff and I needed to hang on to something but there was nothing to hang on to. And at any second I might go falling into the darkness.”

During the course of our counseling sessions together, I was able to help Yolanda identify the emotions that she was experiencing, especially those that she thought she “shouldn’t” be feeling (I always begin by kicking the positive-thinking police out of the room). I also supported her as she began to deal with her diagnosis on a day-to-day basis, including giving the news to her family, making the treatment decision, undergoing surgery and chemotherapy, and making lifestyle changes. Helping Yolanda recognize, accept, and cope with the emotions around her illness allowed her to move into an empowered fighter position.

Yolanda gave voice to her greatest fears about cancer. As we worked through the “why me?” question, I told her about similar experiences by other patients facing cancer to help normalize her reaction. It’s important for people to remember that they are not alone and that many have walked the path before them. I also encouraged her to arm herself with real facts by asking questions of her treatment team and information-gathering on her own, and at her own pace. Information is an antidote to fear.

As Yolanda faced her fears about her cancer diagnosis, I encouraged her to express other emotions as they arose. Allowing herself to be angry was an important step for her, as she was able to express her frustration at having to take a break from her active life to go through treatment. As she stated, “I want to scream at life and how unfair everything is!” During a later session, as she was beginning cancer treatment, she talked about attending a wellness lecture and leaving feeling ashamed that she “might have avoided this if I had taken better care of myself.” And during chemotherapy, she expressed sadness that she wasn’t able to “be the mother that my kids need me to be.” Yolanda needed the opportunity to express these emotions in a safe, non-judgmental environment so that she could continue to cope with her day-to-day life and responsibilities.

Challenging Harmful Beliefs

As patients react to the stress of their diagnosis, their fundamental beliefs about life are put to the test, many of which, from a Rational Emotive Behavior (REBT) perspective, may be irrational and therefore lead to reactions and emotions that are unproductive and self-destructive. I was able to gently help Yolanda to identify beliefs that resulted in, as she said, “beating up on myself” and “telling myself that I shouldn’t feel the way that I do.” Irrational beliefs common to newly-diagnosed patients include:

My life will not change unless I want it to.
I must be available to the people who need me at all times.
If I live a good life, bad things won’t happen to me.
If I don’t keep a positive attitude, other people will think I am a failure.
If I don’t maintain control of my emotions I will collapse.

“I can’t emphasize enough the importance of first and foremost being a supportive, listening ear in the true sense of Carl Rogers—non-judgmental, unconditional positive regard.” This is what patients need most when they first get diagnosed. Motivational interviewing techniques can also be helpful in assessing readiness and introducing alternative ways of coping.

As Yolanda was ready for me to move from the role of supporting and normalizing her emotional reactions to examining her beliefs and understanding the connection with her emotions, I used a more active approach to help her identify her triggers, reframe her irrational beliefs, challenge either/or thinking, recognize and replace negative self-talk with health-enhancing affirmations and use progressive relaxation techniques.

A Note About Grief

Newly-diagnosed patients often go through a grieving process, and this can be an essential step in coming to terms with their condition and moving forward with treatment and lifestyle adjustments. When they grieve, they are beginning the process of accepting that a change is occurring in their life. Regardless of the diagnosis, accepting that life is going to be different in some way, and that these changes are out of their hands, is an important step forward. For many newly-diagnosed patients, their diagnosis causes them to take a look at one or more of their basic beliefs about life and to reevaluate them. This may be the first time that they have looked at these beliefs and how they affect their actions and emotional reactions. During this process, assessing a patient’s spiritually, and encouraging them to seek spiritual guidance in whatever way is meaningful to them can be helpful in getting through the grieving process.

Sensitivity to the Influence of Culture and Gender

It is also important for healthcare professionals to be aware of the influence of culture and gender. Cultural background can influence how patients interact with the medical establishment, how they experience and express emotions, and their willingness to accept mental health intervention. Gender can present further complications in expressing emotions around illness as well as in getting informed. In Western culture, women tend traditionally to be more active medical consumers than are men.

Working with the Healthcare Team

The healthcare professionals that are working with newly-diagnosed patients can greatly benefit from the ability to understand and recognize how patients are reacting to their diagnosis, and psychotherapists can play an important role in consulting with them. Understanding whether a patient is having a flight, freeze, or fight response, for example, will guide healthcare professionals in gauging their readiness to receive information, so that it is presented in a manner in which patients will most likely be receptive. Those in flight reaction may need some additional emotional support while those in freeze reaction may need some coaching in interpreting what they read and hear with a sense of optimism. Fighters may ask a lot of questions for which the team needs to be prepared. And going forward with treatment and recovery, patients who don’t become fighters may continuously erect barriers to compliance and life management.

I often work directly with physicians and, depending on the wishes and permission of the patient, will contact the healthcare team to share information and, as needed, to advocate for my patient. Where possible, maintaining open communications with healthcare providers, and offering to support them during especially difficult times during and after treatment, can be invaluable to the patient. Many healthcare providers also recognize the emotional component as key to enhancing recovery and ongoing compliance and are happy for the support.

Offering the healthcare team an understanding the patient’s particular reaction style can help them tailor their approach in ways that leverage the patient’s strengths. We can specifically give the team advice about how best to:

Present information on the condition and its treatment
Coach patients through the treatment process
Make recommendations on lifestyle management
Encourage patients to seek support with activities of daily living
Monitor ongoing compliance

Preparing for the Road Ahead

Finally, I always tell my clients: You are not a diagnosis. Your diagnosis is only part of who you are. Remind yourself every day that you are a fascinating, multi-dimensional creature with a past, a present, and a future that belongs to you and to you alone. Embrace life and your potential to live your life, with all of its triumphs, set-backs, surprises, and detours. Now, let’s get prepared for the road ahead!

Infertility on Both Sides of the Couch

Posted on September 20, 2013February 11, 2026 by rezendevknowfully.com

Family Planning

"When are we going to start a family?" asked my husband.

I felt a boa constrictor wrapping around my throat. For months now, the topic of children had evoked tension, leaving us powerless and detached from each other. The argument had become a tradition on Saturday mornings. We would sit in the living room in an awkward silence, avoiding eye contact, until my husband pierced the hush with what he deemed a simple question about our future.

My husband was comforted by having a plan. Three years into our marriage—my second—we were in our mid-thirties, established in our careers, and financially stable. For him the next step in our lives was to start a family, but his need for a plan set off a vicious cycle. I felt ignored and disrespected in our relationship and couldn't justify bringing a child into a fractured marriage. I craved connection and love and was not willing to commit to having a child until we resolved our relationship problems. My resistance made him more insecure and unsure of his focus, and he would ask me about starting a family as a way to relieve his anxiety. Unfortunately, his persistence pushed me away, leaving me feeling trapped and controlled and leaving him stranded without resolution.

“I felt immense pressure both from him and from society to conform and have children. Gradually, I isolated myself from my husband and emotionally shut down, as my sense of self and my voice vanished.” Feeling alone with no one caring about my thoughts and feelings, I believed I was not enough for my husband and that he had married me solely for procreation. Meanwhile, I was inundated with inquiries from our family and friends about when we would be parents.

My mother-in-law often phoned my husband's siblings to convey that her children were failing her since she did not have grandchildren. While growing up, my husband's mother talked a great deal about heirlooms—each piece of jewelry or china was a link between past and future generations. Grandchildren were an essential part of keeping the family traditions alive and to not have them meant the family had failed. She made it clear that my husband was not enough, just as I felt I was not enough as his wife. My resistance to the "plan" was a clear message to him and his mother that I would not conform.

His side of the family was not the only problem. My stepfather had the impression that all couples wanted children. He frequently dropped hints about what a joy they are, pointing to his grandson and saying things like, "See, aren't these fun and not so bad?" For him, family represented connection and closeness. Initially this was endearing but it soon became annoying.

While at a party, I declined an alcoholic beverage, which ignited rumors that I might be pregnant. When I heard the gossip, a wave of heat washed through my body. How dare my friends speculate? It was as if I were starring in the reality show, "When Will Wendy Pop One Out?"

The Family System

In 2005, I started therapy with a psychotherapist who practiced from a Family Systems model, the premise of which is that the family is an emotional unit—systems of interconnected and interdependent individuals, none of whom can be understood in isolation from the system. Over the course of my therapy, I came to understand that my symptoms of sadness, loneliness, and detachment were a consequence of the recurring patterns and interactions within my family. The sense of powerlessness I experienced evolved from my marital dynamics, my family history, and the cultural expectations of a woman in her thirties.

My parents divorced when I was thirteen years old. I was an unplanned pregnancy and the reason my parents had married. It was bad enough that I was a mistake, but I resented my parents even more for their divorce, and the struggles that I encountered during my teens trying to navigate through the turmoil of their divorce played a role in my delaying the start of a family.

During my first marriage, I was enrolled in graduate school and wanted to wait until completing my program to start a family. We would have been in our early thirties by then and my ex-husband wanted to be a father sooner. He had an affair and decided to leave. This time around I wanted to make sure I was in a healthy relationship, that we were not introducing a child into a doomed family. I did not want to recreate my childhood trauma for my own children.

At Christmas in 2006, my stepsister announced over dinner that she was pregnant with her second child. I broke down sobbing at the table. A hush blanketed the room as everyone stared at me. Although embarrassed and humiliated, I could not stop crying.

Two weeks later, my stepbrother shared the news about his wife's first pregnancy. My sister-in-law had planned on not having children but had changed her mind. I was consumed with feelings of betrayal. I was my own childless island in a world that demanded parenthood. I dove deeper into despair.

Couples Therapy

My husband finally realized that our marriage was at stake and agreed to couples counseling, but I wondered whether it was too late, as by this time my rage had evolved into numbness. I recalled our minister's marriage sermon encouraging us never to throw in the towel when things were broken, but another part of me was tempted to do just that. “You don't need a man, you survived a divorce,” the voice said. "Trust me, you’ll be much happier single." I contacted therapists, but they either did not return my calls or have any openings for new patients. Was the universe telling me it was too late for my marriage? The battle inside me grew more crushing until finally after three months, I found us a therapist.

Couples therapy became our new Saturday tradition. My husband had never been to therapy, hated conflict, and had always made choices with tremendous caution, sometimes over the course of many years. Therapy for him was about finding ways to manage his stress. If he knew when we would have a baby, he could plan accordingly. Should we reserve a slot at the day care now, since there could be a waiting list for a couple of years? “Should we start putting money into a college fund? Or should we begin grieving about not having a child?”

For me, therapy was about maintaining autonomy and establishing a healthy marriage. I wanted the freedom to make choices within the marriage, but feared he would leave me if I did not have a baby. It felt like an ultimatum. And for my husband, despite his discomfort about the therapy, he began utilizing what he learned about me. He realized that asking questions about starting a family was torture to me, so he stopped asking. As a result the perceived threat of the ultimatum faded.

In my professional life, I had wanted to open a private practice. Should I be saving money for the grand opening of my business or for a divorce? The marriage had to be healed before the practice could be born.

During our treatment, I wrote my business plan. My husband was proud as a peacock and bragged to others that I was making my vision come alive. I opened my practice in mid-2007, feeling finally alive after an emotional coma. When I purchased the new office furniture, my husband questioned the size of the sofa, believing it should be larger. Prior to our therapy, this question would have offended me and I would have felt undermined in my judgment. Instead, I confidently explained that the sofa worked well in the room. Understanding his tendency to err on the side of caution, I did not personalize.

He went ahead and assembled the office desk and filing cabinet and moved the sofa into the suite. To this day, he tells others it was a good thing that I ignored his advice because the sofa barely fit into the space. This was the sexiest thing he had ever done. Life was wonderful. I was enough as a wife and my business was thriving. Without pressure to conform and have a child, I decided to go off the Pill.

For three years we did not get pregnant.

Mystery Solved

From the time I was a teenager, I had a history with difficult menses. Like clockwork I got my period every 18 days and bled for 10 days, uncertain what PMS symptoms I would experience. My blood flow would be heavy, dark and impossible to keep up with, changing my tampons and pads every four hours and during the night bleeding onto my bed sheets. At times to get through my school day, I took over-the-counter pain pills for heavy cramps, lower back pain, or headaches. For my peers and teachers I maintained a pleasant façade, but what I wanted was to retreat into a corner and savagely eat raw meat and growl or be in my bed weeping and eating salty chocolate. I applied copious amounts of zit cream to my face attempting to fight a hopeless battle with breakouts. My bra and pants would restrict my breathing because I was bloated. During my annual exams, a range of doctors had explained these symptoms were stress-induced by my parent’s divorce, my divorce, and graduate school, and had prescribed birth control pills.

Now while off the pill, my life was good and I had no stress on which to blame the problem. I was receiving holistic care and yet was still physically and mentally suffering. Why was I having the same problems I had as a teenager?

I made an appointment with an OB/GYN specialist with little faith that I would find answers, but for the first time, a medical doctor was eager to learn what was going on with my body. He believed my symptoms were pathological and not related to stress and ordered blood work and an ultrasound.

A month later, the OB/GYN nurse escorted my husband and me to the doctor's office for my consultation. He was perusing my test results with a look of concern on his face when we walked in. Gazing up at us, he said, “I am unsure where to begin.” The blood work was perfect. The ultrasound, however, revealed why I’d suffered for decades and had not become pregnant during the past three years. Both of my ovaries were smothered in various types of growths (some were thyroid tissue), my fallopian tubes had blood, my uterus had polyps and was malformed, and as a result I was unable to carry a pregnancy. The doctor recommended a full hysterectomy.

My symptoms were not stress related. They were not my fault. A sense of calm flowed over me; my eyes welled up with tears. My husband took my hand and asked questions while I continued to absorb the news.

Judging Claire

Meanwhile, my professional life was evolving beautifully. I had the satisfaction of seeing my vision coming to life, and I loved owning my own business. For several years I had been seeing Claire*, a married and successful professional in her mid-thirties with a significant history of depression and anxiety. She had a warm sense of humor and loved to learn about herself. During the first couple of years working together, she feared her future children would be genetically predisposed to suffer from similar aliments and struggled between the desire to feel a child growing inside of her and her desire to adopt.

During the course of our therapy, Claire forgave herself for having a diagnosable mental illness; she realized the illness did not define who she was. She began to consider that she had plentiful and warm offerings as a mother and decided to conceive naturally. After a year of not getting pregnant—this was around the same time I went off the pill—Claire was diagnosed with infertility.

By then I was secure in my marriage and waiting to see if I got pregnant, but I struggled to maintain my alliance with Claire. Still vulnerable with my own triggers, I had my own opinion about the infertility treatment process and our sessions evoked strong emotions for me.

One in ten couples struggle with infertility issues. According to the medical model, infertility is a disease of the reproductive organs, and usually the first option in treatment is a daily injection of medication to stimulate the ovaries to develop eggs in the follicles (the structure in the ovaries that contain developing eggs). The side effects can include bloating, weight gain, headaches, and nausea. If this is unsuccessful, IVF (in vitro fertilization) begins, in which eggs are surgically removed from the ovaries and combined with sperm. Weekly ultrasounds and estrogen blood levels drawn twice a week assist the doctors in determining the best time to retrieve the eggs. The last resort for infertility treatment is the egg donor cycle, where an embryo formed from another woman's egg is transferred to the uterus of the woman trying to conceive. More coordination and time is involved since two women are being monitored for transfer.

As I witnessed Claire’s physical and emotional agony and the suffering in her marriage it caused, I began to judge her harshly. “How could she brutalize her body from treatments and spend so much money to conceive and carry?” I hated her for choosing to participate in the infertility treatment process and holding faith in the medical model. I felt lonely and betrayed that she conformed to society's pressure to attempt pregnancy at all costs. I wanted her to join me in rejecting this awful and debilitating process and to redirect her energies toward adopting a child.

Though I had every intention of becoming a mother, once I realized I was infertile, I never considered infertility treatment or adoption. Both seemed too unpredictable and a setup for repetitive grief and loss. It was disturbing to have such an intensely negative reaction to a client, so I began to repress these feelings and thoughts in an attempt to protect both of us. In the process, however, I became increasingly disconnected from Claire.

What was happening between us put strains on my belief in the humanistic approach, which emphasizes that we are in control of our destiny, our choices, and the discovery of meaning for our life’s narrative, and makes use of the relationship created between the therapist and patient as a catalyst for exploration and change. A safe arena was vital for Claire to share her narrative and to discover the meaning of her experiences—the energy in the room could then provide an atmosphere conducive for healing. Regardless of my opinions and beliefs, I wanted to support her in her destiny and choices. But did I have the freedom to accomplish this?

As a therapist, I participate in a weekly supervision group. While disclosing the pain of my challenges with Claire, I shared about my sensitivity to the fertility topic and my beliefs about the infertility treatment process. My peers validated me and understood why I felt threatened, but also challenged me about my countertransference and helped me to work through it. Other colleagues were offended by the infertility treatment process and called my patient "greedy." A few of them had been adopted, and were exasperated that it wasn't Claire's first choice. Others were sympathetic with her plight and could relate to her need to biologically conceive a child. Through the group process, I was able to witness all the different parts of myself being voiced through my peers, and I felt safe enough and free enough to get to some of my own core fears and doubts about infertility. Ultimately this freed me up to be much more present with Claire in the coming months.

Working Through and Joining With

During a subsequent session, Claire tearfully shared how painful it was to have no control during the infertility treatment process. My inner voice whispered, Ask her if she feels she has the choice to stop the infertility process. Before working through countertransference with my supervision group, I would have suppressed this voice, believing it was my own “stuff" and would not be helpful to Claire. Now my heart pounded; I couldn't help but speak up: “Who says you need to continue to fail with the pregnancy attempts?” Something in the room shifted. After a pause, Claire affirmed, "I could stop." I exhaled. We had finally found a moment of empowerment and connection.

Claire continued to participate in the infertility treatment process, and I joined the emotional roller coaster with her. This freed up much more space to explore her process and mine.

Therapy is not immune to the disruption of the infertility treatment process. “The scheduling of appointments revolved around Claire's menstrual cycle and she cancelled appointments due to the side effects of medications and clinic appointments.” We had lapses between appointments while waiting for the doctors to contact her for the next treatment cycle. All of this meant that I needed to figure out what would take care of me during her infertility series. That involved answering questions such as: How do I cope with my anger? How do I keep from getting stuck in her holding pattern of waiting? Do I charge for missed appointments?

With the ongoing support of my supervision group, I continued to explore my emotional reactions. Claire and I collaborated about payment for missed appointments—she willingly paid and the joint conversation made her an active participant in an otherwise helpless period. The medical doctors had no clear diagnosis about why she didn't get pregnant for three years and she suffered continuously from a sense of loss. She had always dreamed of being a mom and having a family and now she had to face the fact that it might not happen.

Claire tried to detach from her emotional turmoil and did her best to function at work, but the clock ruled her while she anticipated lab results. Her job performance began to suffer and the cost was guilt, shame, and embarrassment. Work became heavy and dreadful. Her depression ignited, leaving her brooding in isolation and sleeping for 17 hours or more every day. Her “should” cognitions were in overdrive and kept her paralyzed.

The Breakthrough

"I'm afraid you're mad at me for the last minute cancellation last week," she said. "I'm failing at everything." In fact I was angry about the appointment. Missed appointments touch on my vulnerability around not being recognized as valuable. But our agreement for her to pay for missed sessions, combined with my own awareness of the reasons behind my countertransference, made it possible for me to process my response outside of session and bring my full attention to figuring out what she was enacting and what it meant for her. I responded, "You think you should be able to manage life better. But things are dropping all around you: your relationship with your husband, your work, your friendships, and especially not getting pregnant. You're feeling so alone." I watched her reach for a tissue, look down at her lap, and wipe her tears. "What are the tears saying right now?”

In her soft voice, Claire answered, “I'm afraid my husband will be angry at me for not controlling my emotions. My anxiety is through the roof. I want to be in my bedroom with the covers over my head. It's unfair to expect my colleagues to do my work. I want to be with my friends but it hurts too much because they have babies or are pregnant.” She believed she needed to be perfect and worried about disappointing everyone around her, including me.

But this conversation about failure and disappointment positioned Claire to begin healing her marriage and bring her husband, family, and friends back into her life. Through addressing her loneliness, Claire articulated her envy about her friends being pregnant or having newborns. “She felt conflicted about whether to maintain her connections or isolate herself because it was too painful to be subjected to swollen bellies and to the innocent scent of newborns.” She also acknowledged she pushed her husband away because she did not want to be perceived as a "burden." He had a demanding job that made him unhappy, but it provided them with medical insurance to pay for the infertility treatment. She secretly fantasized about him attending medical appointments with her and being readily available to abruptly leave work to provide comfort when she received bad news. I encouraged her to share her emotional burdens with her husband, to let him feel her burden, as that is part of what it means to be intimate with another person. She began to feel less guilty and apologetic about her struggles and to share the craziness of the process with him. They became closer and her sex life began to thrive again.

Over the two-year period of her IVF treatments, Claire's visits to the reproductive health center would evoke a sense of helplessness and lack of emotional safety. She often felt rushed because she didn't get satisfactory information to her questions, and the clinic became increasingly more uncomfortable and sterile. As our work progressed, she was more assertive and less apologetic about demanding the attention of the nurses and doctors until she was satisfied with the gathered information. To increase her comfort at appointments, she brought her own pillow and blankets.

Unfortunately, Claire was given a lot of unhelpful advice from her own support system of family and friends, even medical doctors. She was told, for example, to "just relax" because her stress could be interfering with the infertility process. In the therapy sessions, we worked on how to handle unwanted and sometime hurtful advice and not absorb the harmful implications. When she deemed it appropriate, she informed people about what would be helpful or harmful.

Different Kinds of Pregnant

When the IVF failed, Claire opted for the final remaining option: an egg donor. Our sessions were spent with her describing how a donor was selected and the various reasons they donated their eggs. It was a surprisingly fun process for both of us.

After her second cycle with the egg donor, she curled up on the sofa in my office, hugging a pillow with a distant look in her eyes. Her lip trembling, she said, "For four days, I was pregnant. Now, I am pissed off.” Her rage demonstrated no guilt. She did everything right but was unable to carry her first pregnancy.

The following month, her third attempt was successful.

One day, well into her second trimester and beaming with life, Claire effused, “My boobs are huge!” She shared her ultrasound pictures of her healthy son and we talked through her stress about finances with the arrival of her baby. In her desire to save money and prepare for the baby's arrival, she requested a break from therapy. I encouraged her to go and create a loving home for her son. Tearing up, she said, “I can’t believe I can hear ‘my son’ after all of this.” Claire would soon be a mother.

Through quite a journey, Claire and I mirrored each other for a couple of years. My marriage and business were at last breathing life. I scheduled my hysterectomy, knowing my body would be cured. I learned a valuable lesson: Psychotherapy is a fertile process.

* Claire's name had been changed to respect confidentiality.

Michael Lambert on Preventing Treatment Failures (and Why You’re Not as Good as You Think)

Posted on February 24, 2013February 11, 2026 by rezendevknowfully.com

Tony Rousmaniere: Let’s jump right in. You’re a leading researcher in the field of helping clinicians track their clients’ outcomes.

Michael Lambert: Right.

TR: Despite a quickly growing body of evidence that tracking outcomes can really help clinical practice, there are still many clinicians who don’t do it or who don’t want to do it. How would you make the case to these clinicians that tracking outcomes can be beneficial for their practice and for their clients?

ML: Well, the system we developed, the OQ (outcome questionnaire) Analyst, essentially monitors people’s mental health by asking 45 questions about their mental health. Clinicians can’t do that on a weekly basis because it takes too much time to do it, so the best way to do it is through a client self-report measure that asks very specific questions about different areas of functioning. It’s important to use a self-report measure and to tap into a broad range of symptoms that wouldn’t normally come up in a session, since sessions usually focus on what happened last week. It’s like taking a patient’s blood pressure and checking their vital signs for each visit. It gives you a much more precise measure of how they’re doing over time.

We developed the measure essentially to reduce treatment failure. It came out of the problem of managed care bothering clinicians with management bureaucracy around cases they knew nothing about. And so the idea was to stop managed care from managing all the patients in the clinician’s caseload and to focus on the management of patients not responding to treatment. So it’s not for all patients. It’s not necessary for the majority of the patients, actually—but it is necessary for patients who are not progressing or are getting worse.

About 8 percent of adult patients actually deteriorate at the time they leave treatment, and with kids it’s double that at least. So 15—24 percent of adolescent child clients actually leave treatment worse off than when they started.

Our estimate is that about 8 percent of adult patients actually deteriorate at the time they leave treatment, and with kids it’s double that at least. So 15—24 percent of adolescent child clients actually leave treatment worse off than when they started, which doesn’t include people who simply aren’t improving. But in our survey with clinicians we asked what percent of their patients were improving in psychotherapy, and they estimated 85 percent. This is a major blind spot for clinicians. They’re not good at identifying cases where patients are not progressing or are getting worse. Even in clinical trials where you’re delivering evidenced based psychotherapy and get well trained clinicians who are following protocol, etc., you’re only getting about two-thirds of those patients responding to treatment. And then in routine care, the percentage of responders is closer to one-third. So clinicians’ estimates are way overstated.

In many ways, I think it’s a necessary distortion for clinicians; in order for us to remain optimistic and dedicated and committed and engaged, we have to look for the silver lining even when patients are overall not changing or outright worsening. It’s kind of a defensive posture, and it serves clients well generally and it serves clinicians well generally because the more success we see in our patients the happier we are in our jobs. But the downside is for the subset of patients who are not on track for a positive outcome. The distortion doesn’t work in their favor.

We Are the 90 Percent

TR: So are you saying that therapists are kind of inherently optimistic and positive, which helps them with most clients, but creates a blind spot for clients who are possibly deteriorating?

ML: Exactly. The evidence for that comes from a few studies we’ve done. It’s been true since it was first studied in the 1970s that individual private practice clinicians are overestimating treatment effects. This has been going on for 40 or 50 years that we know of and probably forever and it goes on today.

So if you’re in that world of overestimating the successes, then you’re not going to be motivated to adopt what we’ve developed because you can just stay in the happy world of optimism. But if you actually measure people’s symptoms and their interpersonal relationships and their functioning at work or homemaking or study, then the patients aren’t reporting the same thing that clinicians are reporting. That’s a problem.

Another related problem is just how good clinicians think they are at having success compared to other clinicians. Ninety percent of us who practice—I’m one of those 90 percent—think our patients’ outcomes are better than our peers outcomes. So

90 percent of us think we’re above the 75th percentile.

90 percent of us think we’re above the 75th percentile. And none of us in our survey saw any clinician who rated themselves below average compared to their peers; whereas, 50 percent of us have to be below average because it’s normally distributed. So we live in this world where we not only think our patients are having excellent success, but we think we’re having greater success than our peers.

That’s one line of evidence to support formal measurement. Another one is a guy named Hatfield in Pennsylvania, who did a study where he compared patients’ mental health with clinicians case notes, and clinicians missed 75 percent of people who were getting worse.

In the study we did we asked 20 clinicians, doctoral level psychologists, and 20 trainees getting doctorate degrees to identify the cases they were treating where patients were getting worse and who they predicted would leave treatment worse off. The patients answered a questionnaire at the end of every session and we identified 40 out of about 350 patients who got worse over the course of their treatment. Of the clinicians in the study, one trainee identified one of those 40 as being worse at the end of the treatment. The licensed professionals didn’t identify a single case.

We live in this world where we not only think our patients are having excellent success, but we think we’re having greater success than our peers.

They did identify about 16 people who were worse off in a particular session than they were when they entered treatment, so if they had just used that information alone, they would have increased their predictability a lot. We thought maybe licensed professionals would be better than trainees, but there was absolutely no difference. It’s a blind spot. We’re just ignoring it.

The Moneyball Approach to Therapy

TR: This reminds me of that movie, “Moneyball,” where they talk about using statistics to improve baseball outcomes. It’s like a Moneyball approach to therapy.

ML: Exactly. And if you listen to any recent talks by Bill Gates about improving the health of kids in underdeveloped nations and teaching in the U.S., he’s advocating essentially the same thing we’re advocating. You’ve got to measure it. You’ve got to identify the problems because you can’t solve the problem unless you can identify the problem.

Our clinicians are no better now than they were before we started doing this research. They actually have to use the data.

The way to identify it is not to ask clinicians. We are optimistic. We have to be. I want clinicians to continue thinking that they’re better than their peers. I want them to continue to have huge impacts on their patients. But there are some patients for whom it just isn’t true. So clinicians can’t do it with their intuition.

In our statistical algorithms, we look for the 10 percent of clients that are furthest off track and then we tell clinicians, “This patient is not on track.” That’s what clinicians can't do on their own. That’s information they need. They don’t actually get better at this over time. Our clinicians are no better now than they were before we started doing this research. They actually have to use the data.

TR: So this isn’t something that therapists should hope to improve, like getting rid of this blind spot?

ML: No. All our data suggests they don’t improve.

But Therapy is So Complicated and Nuanced…

TR: We use the OQ Analyst here at my clinic and we find it really helpful. When I talk about it with other clinicians, one thing I hear a lot is, “Therapy is so complicated and nuanced and subtle. How could a computer program possibly understand that?” What would you say to them?

ML: I’d say that computers weigh evidence properly and clinicians don’t. Clinicians don’t know what evidence is relevant to predicting failure and they don’t weigh it. A statistical system actually gives things weight.

TR: Are you a practicing therapist yourself?

ML: Yes, and I think I’m better than 90 percent of other therapists [laughs].

TR: I’m sure you are! So how has using the OQ affected your personal practice?

ML: Well, I pay attention to it. I realize that it’s much more accurate than I am. So when somebody goes off track I take that seriously. I say, “Well, whatever is causing this—whether it’s something about our therapy or something in the outside world—something is making them deviate from the usual course to recovery.”

The second part in what we developed was a clinical support tool for identifying what might be going on that’s causing the deterioration. We have a 40-item measure, the ASC, the Assessment for Single Cases, that measures generic problems in psychotherapy like the therapeutic alliance, negative life events, social support outside of therapy and motivation. And there’s a prompt to consider referral for medication. If a patient is getting worse and we’re working hard in therapy, then maybe they need to consider being on a medication. And there’s a prompt for change in therapy tactics, like delivering a more structured psychotherapy—you start increasing the directiveness of the therapy for the off track cases. If you’ve ever read any of Luborsky’s stuff, they do brief psychodynamic psychotherapy of about 20-25 sessions and they divide what they’re doing into supportive tactics and expressive tactics. One goes into deeper exploration of a person and the other one offers a more supportive environment. So you might shift from an expressive tactic to a supportive tactic when people go off track instead of pushing harder to break down fences. You start to try to strengthen the defenses that are there.

When clients are interviewed about the course of therapy, they lie to protect their therapists. But when they take a self-report measure, they're inclined to give a more honest appraisal.

For example, if I were treating a posttraumatic stress disorder patient and we were doing exposure and I was tracking their mental health status and they were going off track, I’d think about giving them coping strategies to deal with their anxiety. We might back off from exposure and make sure they have the tools they need to deal with the anxiety that’s provoked by the exposure. Because they should get more anxious, they should become more disturbed, but it shouldn’t last every day of the week after an exposure session. So you might think you’ve got them in the habit of breathing, but they’re actually not breathing and you have to go back to basics and make sure they’re taking some time to breathe when they get panicked. So the problem could be anything from a technique that’s being misapplied, like exposure therapy, or the need for medication because they’re not really able to make use of the therapy and they’re decompensating.

Another blind spot for clinicians is the therapeutic alliance. Clinicians tend to overrate it as positive, but it really does correlate with outcome if it’s based on client self-report. We’ve looked at studies where clients are interviewed about the course of therapy and in that case they lie to protect their therapists. But when they take a self-report measure, they’re inclined to give a more honest appraisal.

My Therapist Was Glad to See Me

TR: What do you use to measure the alliance?

ML: We use the ASC for that, too. Eleven of the 40 items are alliance items and they’re based on traditional conceptions of therapeutic alliance, but with 11 specific items like “my therapist was glad to see me.”

It would be nice if therapists knew when patients didn’t think they were glad to see them.

It would be nice if therapists knew when patients didn’t think they were glad to see them. That’s something that therapists can take action on pretty fast unless there’s strong countertransference problems, in which case they probably need to seek supervision and figure out why they don’t like a client.

It might be the time of day, for example. If you see somebody at 5:00, you may not be as perky as at 4:00. Or it may be certain client characteristics like they’re intellectualizing and boring. So we just try to provide clinicians with individual item feedback on items of the 11 that are below average. But it’s only for the 20 percent or so of clients who go off track.

TR: What about dropouts? That’s a pretty chronic, widespread problem in our field that we generally don’t like to talk about. Did OQ help clinicians with that at all?

ML: Yes. What it tends to do in our feedback studies is it keeps the patients who go off track in treatment longer with much better outcomes at the end. And it tends to shorten the treatment with people who are responding well to treatment because it presumably facilitates the discussion of ending treatment. So overall you get about the same treatment lengths, but you’ve got more treatment aimed at people who are having a problematic response and less treatment than people who are responding. We actually find that about half the dropouts are completely satisfied with treatment. So they quit because they felt better. And that can happen really fast, so not all dropouts are a bad thing; about half of them are.

Suicide and Substance Abuse

TR: You mentioned earlier that the OQ assesses for suicide and drinking and other red flags. Maybe you could just speak to that and how it can help clinicians dealing with these issues.

ML: Well, there are three subscales. There’s the symptom distress subscale that’s mainly anxiety and depression with some physical anxiety symptoms. Then there’s one on interpersonal relations and one on social role functioning. The role of adults is often to go to work and do their job and get raises and advance their careers. If you’re a student, it’s succeeding in college or some training program. You can look at those different areas and sort of calibrate problem areas in those three areas. Is it across the board or is it one of the three? And then you can focus your treatment based on where the problems are. And then there are critical items that go into those subscales that are substance abuse and suicide.

We find clinicians tend to underestimate the problems people have with substances.

We find clinicians tend to underestimate the problems people have with substances. They’re under reported, but when they are reported it’s often not addressed because people underestimate the negative consequences of substance use. With suicide, no clinician asks patients at every session how suicidal they were this last week, but that can spike quickly. A patient can go from not thinking of suicide much at all to thinking of it almost daily over the last week. One item on suicide isn’t a predictor of suicide, but, of course, predicting suicide is sort of beyond us generally speaking. So it’s important to ask more questions about It more frequently.

When I see a client and I give them the OQ45, it gives me right off the bat a gauge of just how unhappy they are, but I don’t find it a rich diagnostic instrument. It’s more like a blood pressure test. Some people come in with a really high score. If they score a 100 then I’m really alert because if that doesn’t come down, they’re going to do something stupid. They’re going to try suicide, or drink too much or be too promiscuous or they’re going to end up in the hospital. So for me, if I was tracking somebody that has a score of 100 and we had three weeks of therapy and their score didn’t come down, I’d be thinking about medication if they were depressed more than if somebody had a score of 70, which is moderately or mildly disturbed.

For people scoring really high, they’ll likely have a better outcome if they’re not just relying on psychotherapy. So it could prompt a referral, but certainly it’s going to prompt you to be very alert. I usually have a good sense in the first session without the OQ45 of how disturbed people are—unless they’re that exceptional person that doesn’t want to admit to anything, but has plenty of problems. They may not trust you and they may not trust the system and they may not want to report stuff. You find that a lot in the military. When they start to trust you they’re more open.

I saw a borderline patient who didn’t look very borderline on the surface, and it took six months for me to learn that she was cutting herself. I gave her the MMPI as well and she scored quite normally on the MMPI and then was within the average range with OQ45. She presented herself with a simple phobia, a driving phobia. So we were concentrating on the phobia, but there was all kinds of stuff that came out once she felt more trusting. So if there’s a discrepancy between the score on the test and your own intuition, then that tells you the patient may be too ashamed or distrustful to tell you.

When Confidence Hinders Us

TR: It seems that a real crux of this is therapists being willing to acknowledge their own limits or blind spots. I came across the outcome measurement before I was licensed. I was a beginner, so it was pretty easy for me to acknowledge. Do you find that more experienced clinicians have a harder time acknowledging that they have blind spots and might need something like the OQ45 to help find them?

ML: I think people trained in CBT and behavior therapies would be open to measurement. Although, in routine practice, they don’t really do it the way it’s supposed to be done and start relying on their intuition. But CBT therapists generally are more open to it. If you get somebody who’s psychodynamic, they’re very, very resistant. I’ve found that it does depend on theoretical orientation. I think also in certain community mental health settings where the patients are so disturbed it can be quite disheartening to see the slow rate of change if there’s any change at all.So you’d just rather not see the bad news because you’re kind of used to people not responding very much.

So it’s a lot harder to sell with psychodynamic therapists and maybe post-modern therapy. Even though client-centered approaches have a long history of studying the effects of psychotherapy and the process of psychotherapy, they still see simple self-report measures as easily faked.

Psychodynamic therapists are usually overly confident in their clinical judgment, so they see defenses at work everywhere and don’t trust self-report measures.

Psychodynamic therapists are usually overly confident in their clinical judgment, so they see defenses at work everywhere and don’t trust self-report measures. But I think underneath all of that is that once we get into a routine and we develop confidence, we think there is no reason to give new interventions a try. You just hear all kinds of excuses for why people can’t do this and they usually don’t hold water. For example, patients don’t mind doing it at all. They like it.

It’s true across all of medicine, where people are really slow to take advantage of innovations. They only adopt new innovations when the gal in the office adopts it. So you’ve got to get people doing it around you before you decide you’ll give it a try. In our very first study, we only got half the therapists to participate. And then by the time we did our third study, all but one participated. And now if the computer system goes down, people get really upset. They don’t want to work without it. But it took two or three years to get all of them into it.

Innovations are a hard sell. Unfortunately, the way most clinicians get exposed to this is through administrators who make them do it, and then their general attitude is distrust of the way the information is being used. Clinicians passively-aggressively don’t participate, and as a result they sabotage the whole effort. It ends up being a power struggle between clinicians and administrators.

TR: This brings up a question I wanted to ask you, which is about using the OQ to compare therapists. I think I’ve heard you say that you don’t think it or other outcome measures should be used to compare therapists. Is that accurate?

ML: Yes. I think you end up being on thin ice in settings where patients are assigned randomly. In most settings, like private practice settings, they’re not assigned randomly but you can’t assume that clinicians have equivalent caseloads. Plus we find most clinicians are in the middle. But you can see a big difference between clinicians at the extremes. The average deterioration rate at the institute is about two to three percent, and then we’ll find a clinician that has a deterioration rate of 17 percent. We had one clinician in our center whose patients on average got worse. So I think you can do something with that data. But you wouldn’t want to make too much of it because most of us can’t be distinguished. Our patients do well. And our student therapists do as well as our licensed, supervising professionals. That’s very disturbing [laughs].

Our student therapists do as well as our licensed, supervising professionals. That’s very disturbing.

The only thing we can find is that when you see somebody with a lot of experience, their patients get better faster. But the overall outcome is the same. Even the stuff on paraprofessionals doesn’t show a huge difference between professionals and paraprofessionals.

If you go to a conference where people present outcome data on borderlines, they spend half their time arguing that the patients in their setting are real borderlines and the patients in the other people’s settings are mild borderlines or not real borderlines. Everybody always wants to say, “I have tougher cases,” but it’s not true all that often.

TR: Well, that’s how I personally know them in the top 10 percent of therapists, because I’m getting average results, but with really tough cases [laughs].

ML: But the really tough cases, from the point of view of measuring outcomes, are patients who aren’t disturbed. If I was going to fill my caseload to make my data look good, I’d go for the moderately disturbed patients. I would not want a patients who were close to the norm because those people are not going to change. They have nowhere to go. Whereas, the people that are admitting a lot of disturbance, it’s harder for them to get worse and there’s a lot of room for them to improve. Does that make sense?

TR: Absolutely.

ML: They would change a lot. They may never enter the ranks of normal functioning, but they would definitely improve.

The Fact is, We're All About Average

TR: There’s a handful of therapists, including myself, who have been making our outcome data available to the general public, to prospective clients. Do you think that’s a legitimate use of the outcome data?

ML: I have some concerns about it, so I guess it depends on how it’s used. Because in some ways you don’t want patients to know the truth that they have, say, a 50 percent chance of recovering. And if it’s in comparison to other therapists, then you’ve got to make sure there’s some way of making the cases equivalent. Individual clinicians can’t do this, unless they’re gifted with statistics. What we’re doing in managed care is we can calculate the expected level of success for a clinician based on their mix of clients. So if you had one kind of mix, the expectations would be higher than if you had a different mix. And then you can see how they perform in relation to the expected treatment response for their mix.

You don’t want patients to know the truth that they have, say, a 50 percent chance of recovering.

The fact is we’re all just about average. So we have no unique claim to effectiveness unless we’re the outlier. So it might be good for outliers on the positive side. For the average clinician you are just able to say, “my outcomes are as good as others.”

TR: Our outcomes, as a field, are pretty good, though, especially when you compare it to medical outcomes.

ML: Yes, I think we have a lot to be proud of.

TR: So your average clinic therapist is actually pretty good.

ML: Yes, I think so. But knowing routine care clinics, the average number of sessions is three or four. So that’s a dose of therapy that’s good for 25 percent of people, not 75 percent.

TR: What about for therapists who do want to get better? I know a lot of the Psychotherapy.net readers are there to learn new techniques and broaden their skills and knowledge. Can the OQ help people become better therapists?

ML: Maybe in the long, long run, but I don’t think there’s any evidence for it. I think you’ve got to go through the procedures, get the feedback and figure out a way to make it work for the patient. But if they don’t get feedback, they’re not going to be able to identify problem cases and make appropriate adjustments.

What’s true is you need to be measuring patients on an ongoing basis and get feedback when client’s are failing. I don’t think there’s too much effect for giving feedback to clinicians whose patients are progressing well. They may like it, but as far as improving their outcomes, most of the bang for the buck is when the therapy has gone off track. That’s the novel information.

Feedback helps when it’s novel, when it’s giving you information that you didn’t know about.

TR: It sound like what you are saying is the way that we improve is by really recognizing our blind spots and finding tools to help us there rather than thinking we’re going to overcome them.

ML: Yes. The practice of medicine is a good analogy. I don’t think my doctor is any better at guessing my blood pressure after measuring everybody’s blood pressure and getting feedback. I just don’t think he can operate without a lab test. I don’t think we want people managing medical illnesses without lab tests. And they don’t feel any shame at all. They feel like they really get good information and they wouldn’t dream of managing a disease without that information. They don’t expect themselves to be able to do it or learn from it.

If you look at the psychoactive medications—I’m just shocked at how poorly it’s managed. If you work at UCLA, you believe one thing’s the best practice and if you work at NYU, you’ve got a completely different set of practices. And it’s not like it’s based on how your patients are responding to the drugs because it’s very poorly monitored.

I hope this is not too disappointing.

TR: How so?

ML: Well just that the feedback is absolutely essential. Therapists can’t just “get good.”

TR: I actually find it liberating because it means I don’t have to try to become good at something that I’m just inherently not good at. So it kind of takes the load off. I just hope we can find more things like this in the future to point out our blind spots and help us so we don’t have to run around pretending they’re not there.

ML: We’ve confirmed our findings in study after study—and now there are more studies coming out of Europe—but it’s really hard to get clinicians to do it. There are people who adopt this early in their careers, but many people are pretty closed and defensive.

TR: Well I’m a psycho dynamic therapist—I do short-term dynamic work and I’m part of a psychodynamic community—and I have found that newer therapists are just a lot more open to it and are kind of growing up with it.

ML: And they’re not so afraid of technology.

TR: Yeah, that too. So I’m really hoping that the psychodynamic community can start to embrace this instead of resisting it.

ML: It’s not an easy sell, but we’ll see.

TR: Well, it’s been a really fascinating conversation. Thank you so much for taking the time to talk about your work.

ML: : It was my pleasure.

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