Category: Therapeutic Issue

How to Help Veterans Haunted by War Reclaim Their Humanity

Posted on by Psychotherapy.net Team

“I try to not fall asleep, because then I’ll just have another nightmare.”

Rick was a sniper in the Vietnam War. He was sent on “high-low” missions in which he was taken by plane at night to a “high” altitude (above radar) where he would jump out with his rifle, and his parachute would automatically open at a “low” altitude of 1000 feet. He was given a photo of a high-level North Vietnamese commander who was his target on the mission. After completing his mission, Rick would run through the jungle, then swim down the river where he was picked up by an American patrol boat. Rick successfully completed six of these incredibly dangerous missions. He subsequently suffered recurrent nightmares in which he would see the dreadful sights in his rifle scope at the moments of successes, and then be chased through the jungle by groups of North Vietnamese soldiers.

After returning from war Rick became alcoholic, lost his marriage and relationships with his two young daughters, became homeless, and suffered degradation to his health. Now, in the nursing facility, Rick was gaunt, wheelchair-bound, with straggly hair and beard, and largely mute, rarely speaking to anyone. He did begin to speak with me after a few months of my quietly and patiently talking to him.

Rick talked of how he and his sister grew up with alcoholic and abusive parents. To escape, he would shoot tin cans for hours at a local quarry. In our therapeutic work together, Rick was willing to explore the associations with his recurrent nightmares. Even though Rick knew he had acted under the command of superior officers, had skillfully fulfilled his military duties, and was viewed as a hero, he had deep feelings of guilt and shame about his role as a sniper. In part, his guilt stemmed from fantasies he had as a teenager that involved shooting his parents as he took aim at the tin cans. Rick felt remorse over the killing of targeted enemy commanders, even though he knew they were directing their own troops to kill him and his comrades. Rick had imaginary conversations during therapy with the men he had shot.

Rick felt deeply ambivalent about being labeled a “hero.” We considered if it was heroism to jump repeatedly from a plane over enemy territory at night, or to fulfill six sniper missions, or to overcome his trauma and recover his human concern for others, or to begin communicating with others at the nursing facility, or to have a meeting with one of his now-adult and long-estranged daughters, or to reconnect lovingly with his sister.

Rick came to laugh as we speculated that maybe it should be the North Vietnamese soldiers having nightmares after an invisible American sniper jumped from the sky six times and killed their commanders then escaped unseen. As therapy continued over the next two years, Rick reported gradual reductions in the frequency of nightmares from nightly, to once weekly, to “only once in a while now.”

In working with Rick, and others who shared similar trauma, I have come to learn that war is truly hell on earth, and that while heroism surely revolves around the strength and valor to fight, it also includes the courage to reclaim one’s humanity and one’s relationships, and to regain some degree of peace within a wounded soul.

Healing Conversations: Giving Life to the Life of a Person Who Died by Suicide*

Posted on by rezendevknowfully.com

If you or someone you know is struggling or in crisis, help is available. Call or text 988 or chat 988lifeline.org 

Rushing to work for an early start at the Shriners Hospitals for Children–Canada, I decided to listen to my messages in the event an important call had come in. I often have young people consulting me at 7 am, either because of an operation that day and a child needing help facing ‘fears’, or because a conscientious young person does not want to miss school. I knew I had one such conscientious person that morning. There was a call from the mother of a young woman I was to meet that morning. She had called late the night before.

“Linda, can you call me back as soon as possible; this is an emergency.”  “Oh, no,” I thought to myself. I only gave the number to Shriners patients who talk of suicidal ideas because other calls could be screened by the hospital.

This young woman had expressed such ideas but had felt certain she would not act on them. As she was 21 years of age, and had assured me they were only ideas, not to be put into action, I had not informed her parents. We had worked out a list of people she could call if she felt unsafe, and she had said she would go to emergency if uncertain she could control such ideas. We had discussed vulnerabilities, as well as reasons to stay alive. “What could this emergency be?” I tried calling back, but there was no answer.

When I arrived at work, feeling extremely worried, I saw the young woman. She asked to speak to me immediately. “Linda, I want to give up my appointment this morning for Trevor’s parents”. She then hesitated before adding: “Trevor took his life early Sunday morning, and they really need your help”.

Trevor – Prologue

My thoughts flew back to the few consultations I had had with Trevor, a lovely and talented young man who had been so sad and disturbed about falling away from the Christian beliefs of his parents. He had just gone through an extremely complex and quite perilous chest surgery for a deformity. He had assumed such risks in order to live a better life. He was booked to see me the next day.

I was in shock and soon realized that I would have to immediately pull myself together for his parents. I urged myself on with deep breaths; “Be strong, be brave,” I instructed myself. Although I did not know Trevor’s parents, I could only imagine what they had been through these past weeks with Trevor so very despondent while not understanding what led to such despair in their son.

“They must be wondering why he had chosen to have this surgery if he had not wanted to improve his life and to live,” I thought to myself. I reminded myself to be curious about what they were thinking and feeling, to ask them how they were living through this experience and not assume that my thoughts were their thoughts.

The young woman introduced his parents to me in the waiting room. I told them how very sad and sorry I was. I asked myself, “What does one say in such a situation?” I made sure not to say that I was sorry for their loss. 

That was said to me when my sister had died, and at the time it felt very wrong, “Does that mean I can soon find her?” I had thought at the time. Little did I know that, yes, I could find her in a new re-membered way(1). I reminded myself to keep that in mind. 

I have accompanied parents through the death of a child in my work in palliative care(2,3) and also in oncology with unexpected deaths(4) but I had never accompanied parents through a death of a child by suicide. This had never happened to me.

My thoughts immediately went back to Trevor. I had helped so many other children make legacies when they knew they were dying, and I knew they were dying(2)  but I really had come to believe that Trevor was planning to live. I did not think from our conversations that he was planning to die. Yes, he had told me about feeling suicidal and even about those two weeks of desperation a month or so ago during which he made some attempts, but more recently in our sessions, he spoke so fervently about living.

He explained to me that when he tried to suicide, first by pills and alcohol, that combination made him feel terribly sick. His next attempt a week later by carbon monoxide poisoning involved driving into a garage on a cold Montreal night thinking he would just fall asleep. However, he began feeling so sick and dizzy that he abandoned his car. It was then, he informed me that he decided this was a message from God. He was fated to live!

He told his parents of his attempts and assured them that he had work to do in this world and must live. He was going to help other young people. His parents told the young woman, who had generously given up her session for them, about the suicide attempts and that was when she suggested he meet me for help.

Reading the medical notes in his file, I felt extremely sad since it was clear that he had had a very strong psychological reaction to his deformity, that had been expressed to the surgeon. This contact and discussion about his negative psychological reactions had occurred eight months prior and no one had made a referral for psychological support.

I regretted that we could not have met earlier. “If so, might he have found a way to keep on with his life?” I wondered. “Did I miss something? Did I do something wrong?” We had spent some of the first session talking about warning signs that a crisis might be developing. He talked of memories of his ex-girlfriend, who had said that she was Christian but was behaving in ways that he found immoral. He said certain smells, senses, and even songs might bring up the memory of her which could lead to suicidal thoughts.

This young woman was finding worrisome ways, according to Trevor, to secure money. Trevor was trying so hard to assist her to find another way to resolve her financial needs. He prayed at length as well as read the Bible. He told me that under these circumstances he was reluctant to consult his pastor as he might have for other matters to protect her confidentiality.

When God did not answer his prayers for a way to assist this woman, he began to doubt his God. The more he lost his faith, the sadder and more desperate he had become.

We also talked about what he had been doing to manage the thoughts recently. He mentioned running, playing video games with his best friend, watching movies, drawing and playing his guitar. I referred him to art therapy because of his interest in drawing.

At the end of that last conversation, he had stated categorically, “However, I will not try. Period! This is over”. When I asked what was over, he replied, “This trying to take my life is over.” 

He stated that he had felt very sad and hopeless after trying to bring this young woman, whom he felt in love with, to believe in Christianity in the way that he had been taught to believe in it. His decision for surgery had been because he had decided that he needed surgical correction to live and to help others, including his ex-girlfriend. 

Trevor did not know how to tell his parents that, although he still believed there was a God, he did not believe in the way they believed. “I am a theist,” he said. “There is a lot of good to follow in my previous learnings, being kind, forgiving, learning from mistakes.

Seeing the best in this world is something that I will not follow.” Trevor’s family belongs to a very close-knit religious community. He felt that leaving this faith would mean losing his family and friends. We discussed the subject of love and wondered together whether the love might be great enough to outlive a change in his beliefs. He decided it was a possibility.

Trevor did believe that he was loved. He related a story of another young man of his community who had left the faith and was still part of his family. However, Trevor was still certain that he would disappoint his parents greatly with this loss of faith. 

He felt that his ‘deformity’ now with scars from the corrective surgery, (“deformity” was Trevor’s own word regarding his chest difference), would not be accepted by others. Thus, he felt with the loss of faith he also lost an accepting community regarding ‘deformities.’ We explored the possibilities that there are others in this world who accept ‘deformities’ even if they were not of his faith.

We wondered together what he might be able to do for Shriners Hospital for example, where every patient has a ‘deformity’ of some kind? We explored the implications of ‘deformity’ and how his negative feelings about having a different body from others might be culturally developed from our Canadian society and did not have to be taken for granted as true. That even the word ‘deformity’ is a culturally created word. He thought maybe he could be of help to other Shriners patients.

Regarding accepting deformity, I contemplated inviting a past colleague as an outsider witness(5) to speak with us. She is a young woman who is wheelchair bound, due to what is known colloquially as ‘brittle bone disease.’ She is currently studying to become a clinical psychologist.

As a prior Shriners’ patient and later part of our employee community, she had assisted me several times previously, telling her story of how she managed to escape from shame of deformity and fear of others’ judgements. Those consulting her had found these conversations helpful. She is such an inspiration and has many humorous stories. But now, he had died. Taking his own life. None of these ideas could be put into action. 

When Trevor and I had further conversations together we spoke at length about his plans for life and for living. We explored the idea that even with his altered faith, he was creating his own but slightly different moral code.

These discussions seemed to give him hope for finding a new life without his former religious beliefs. I had written in his notes that he had said, “I can take what I have learned and try my best to be a good person”. When I asked how he thought he could use this new moral code he replied with, “I have to find new hopes.”

I learned that Trevor was a musician, an artist and a writer. He had planned to use his talents to promote his past faith and now he had lost his goal in life. I remembered in detail his creativity. “I was writing a book trying to get through my current life story troubles. My character had to redeem himself for mistakes he had made. That person is really me.”  “Are you thinking that you have made some mistakes for which you need redemption?” I asked. Trevor answered, “Maybe I could go and take fine arts at Concordia University.” I realize now that he did not answer the question of redemption and mistakes.

I now think that in a manner of speaking, I had been doing palliative care practices with him as might all narrative therapists in that we are always creating legacies. The book he was writing might now become a legacy that his parents could appreciate. Trevor had planned that his main character, really himself, who lived in a completely different Trevor-created world, would die. We talked of what the ending might be now that he planned to live.

He stated when he left this last session; “I have some ideas that I can use to write a new ending to this book. Do you want me to bring this to our next session?”  I replied with a hopeful, “Yes.”  Maybe I was too presumptuous. I truly expected to see him another time.

All these memories were going through my head in a whirlwind as I invited Trevor’s parents into the room. I felt that it was probably too soon to discuss legacies with his parents, even though Trevor and I had discovered resources, hopes and dreams, which could now allow him to leave legacies. He had written a book, he had his art, and he told me that he had recorded music with his guitar. There were the plans of finding a way to use these arts to help others.

However, in this beginning of our journey together with his parents, I needed to listen to their pain, listen to their story. We were challenged that morning, because at least three times there was a knock at my door. This was very unusual because when my door was closed, most of my colleagues knew I was with someone.

Finally, I answered the door since the knock was so insistent and persistent. I discovered my lovely supervisor standing just outside. She explained that she and my colleagues wanted me to know that they were there to support me at any time. This knowledge gave me strength to return to the room and have courage to start my uncharted journey with Trevor’s parents.

“How does one start such a journey on the day after a child has died by suicide?”

Linda and Brian – First Session

LINDA: Again, I want you to know how sorry I am. How do you feel that I might be of help to you?

Trevor’s mother (MANDY): I need you to hear what happened. We were so sure he had decided to live. (I identified with that). He had made an appointment with you for tomorrow, and also made an appointment with the art therapist.

Trevor’s father (BRIAN), interjected: I asked him how strong the suicidal thoughts were, just Saturday morning, the day before he died. He died in the middle of the night sometime between three and four am. Trevor reassured me by saying, ‘Dad, you know I have decided to live’. And he went to the church youth group.

LINDA: It sounds like you were working really hard to be sure that he was safe. Is that so? (This felt like such a feeble response).  

However, Trevor’s dad’s answer seemed to suggest appreciation of this question:

I don’t know what else I could have done! He was sleeping in our room for the first few nights after he told us about his suicide attempts; then he asked to sleep back in his room. He had his computer set up there and he liked to play both games and his guitar late into the night, and we thought he was better. He seemed better. We had taken him to see a psychiatrist a few weeks ago and they kept him over night and then discharged him the next morning.

We figured if the psychiatrist thinks he can come home, he must be OK. Actually, two psychiatrists sent him home, first from our local hospital, they sent him home with medications, then we took him to the city psychiatric hospital, and they sent him home. We asked for a diagnosis and they said, ‘Well, here we are not big on diagnoses. They just suggested he keep seeing the psychologist.

LINDA: Would you say that you were trying your best to get professional help for him and thus thought you could relax a little and let him sleep in his own room?

BRIAN: He was almost 19 years old and had confided in us. We had to trust him at some point, though we would both wake up in the middle of the night and go down to his room and check on him. I asked him almost daily, ‘On a scale of 1 to 10…’ and every time Trevor answered with ‘Zero’. The local counseling center would call him every day and ask him how he was doing. His youth pastor contacted Trevor regularly and took him out to coffee to talk with him. I took him out a few times for coffee to talk to him outside of the home. We couldn’t keep him in our room forever.

MANDY: I woke up about three am that morning. I prayed and prayed to God to guide me in how to keep him safe. I prayed for nearly an hour. Then I got up. I thought of checking Trevor’s room and then I felt, no, he went to the church group last night, he said he was fine, so I decided not to check. In some ways I am so glad I did not check. I do not think I could have stood it, to find his room empty and know that he was dying while I was praying.

I thought it might be helpful for her to understand more about this.

LINDA: Mandy would you be willing to help me understand what it means to you that you prayed that whole time? 

MANDY paused as she considered my question, she seemed to want to think about this question: 

God was telling me that it was his time to go. Trevor had been suffering so. He could not stand it. That is what he said in his note. He told us not to blame ourselves, that we were good parents, but that he was suffering too much, so he had to go. The file where he wrote the note was called, ‘I am sorry’. I know that he is no longer in such pain, but I am in so much pain now. If only he had known how much I love him. 

I worry for my husband, Brian, who found him hanging in the garage and had to cut him down. He dropped Trevor because he was so heavy. I worry that my husband will not be alright.

BRIAN: I didn’t know how I would tell my wife. How will she stand this? She is not so strong physically and has many family members not so strong psychologically. I went to try to gently tell her and she insisted on seeing the body. She wanted to see him before we called the police. I didn’t want her to remember him like that.

MANDY: I had to see my son. I had to hold him one last time. 

LINDA: Does that mean you were showing him your motherly love or were you trying to figure out how your heart would not break, how to hold your heart together or something I totally could not even think of?

MANDY: I think it was a bit of it all. I didn’t want the police touching him and moving him but now I don’t know what to do because I cannot get that image out of my mind. That was not my son lying there on the floor. 

LINDA: Sooo that was not your son lying on the floor. What are your thoughts about what your son is like now, or where he is now?

MANDY: I know that he is with God. He is no longer in harm’s way; he is safe.

I tried to formulate my next question.

LINDA:  So, (so is a word I realized I use as I try to organize my thoughts and think of what I want to ask), if you wanted to replace the image of something that is not your son with another image that is your son, what image would you want to be thinking of?

Mandy paused and then she actually laughed. What a lovely sound for this moment. I truly felt it was not that the situation was in anyway lightened, but I could see her eyes go off to the side and she was for a moment somewhere else.

MANDY: He used to say, even sometimes recently, “Mum, look at me, see how fast I can run”. That is the image I want to hold on to. That was a bit of the Trevor that we lost when he was about 12 years old. He changed then. He withdrew from us, isolated himself in his room. Maybe something about his deformity at a time when boys care so much about their bodies. But sometimes he would come out of his room and say, “Mum watch me”. Just like that lovely little boy he used to be. That is my ‘true boy’. 

I do not know whether you know or not, but we have a lot of mental illness in my side of the family. I was especially concerned about his hatred of his brother. I thought he had experienced some trauma he was too afraid to share with us that kept him isolated and angry. He denied it when I asked him. I kept searching for anything else I could think of and asking everyone I could think of like doctors, counselors, social workers, other people who had sibling hatred in their family.

Yes, he had this deformity and I know that for teens that can be terrible. But it seemed to me to be something more. Then we found you, and I felt hope, he was coming for therapy; he was even going to start art therapy; he had seen a psychiatrist; he was going to get better. But then, it was too late.

LINDA:   If you could hold that image of that little boy, your ‘true boy’ and that young adult who is saying, “mummy watch me, see how I can run”, what difference might that make to this horrible pain that you are experiencing now, and that horrible image of something that is not your son? 

MANDY: Yes, it would make a big difference. That is what I need to remember.

LINDA: Would you be interested in having some more conversations so that we could re-member Trevor as Trevor used to be before he withdrew from you and to learn what you appreciate about him?

Mandy responded with a strong “yes.” Brian said that he felt that Mandy was the one who really needed the help.

BRIAN:  I think I will get the help that I need from my community and from my pastor.

I asked Mandy if she might want to bring some pictures, or other memories of Trevor to the next session, cautioning her to do so only if she wanted to and thought it might be helpful to her.

LINDA:    I don’t know that person who asks his mum to watch him run, your ‘true boy’, and maybe the pictures could introduce him to me.

After this session, I reviewed the chapter that Michael White(6) had written called ‘Engagements with Suicide’ to get some ideas regarding how best to work with this family. Michael stated that often the person who took his or her life could become invisible, and the suicide could be cloaked in shame. I did not want this to happen.

I thought about how I could discover from the parents the values or skills required of Trevor to both live and to take his life? What kind of decision would this have been to make? Was the suicide mindful of what Trevor gave value to throughout his life? And thereby, we could try to link his living life and the decision to take his life to what he stood for so these parents could still feel connected to Trevor.

I also remembered Michael saying that some cultures think differently than ours about death by suicide. I remember the old Japanese Samurai movies where suicide was considered an act of honour. And as Michael had suggested, perhaps it would be possible to investigate and honour the ‘insider meaning’ of suicide. 

I also wondered if a book I had co-authored with parents whose child had died of a medical condition, might provide helpful ideas for the family(7).


Trevor’s Created World

The next session, both parents arrived for our therapeutic conversation together. They wanted to know what Trevor had told me in our sessions together. Again, my thoughts went into a bit of a whirl. “Do I let them know that it was a change in faith that was troubling him? What about what he had told me about this girl who he was so worried about? They may know her.”

I decided to begin more generally and to refrain from discussing the information about the girl that Trevor did not want to tell the pastor about. I did not know whether they would have the right to read his file because we are a children’s hospital even though he had turned 18. I had given no such details. (I always work out with the adolescent I am consulting regarding what they agree can be placed in the medical file, after explaining the limits of confidentiality and the way we, at the Shriner’s Hospitals for Children, work as a team). I was conscious that this was all new to me.

I had never, even after many years of working with those who expressed suicidal ideas, experienced someone who had consulted with me end their life by suicide. “How do I navigate this? What are Trevor’s rights? What difference does it make if I do not tell them about his change in faith? Could telling cause them potential harm?”   

However, I soon found out that they had read what was on Trevor’s computer. They knew about the young woman in Trevor’s life and how he felt so hurt because of decisions that she was making. They also knew that he questioned their faith. I decided to discuss the potential legacies that Trevor and I had discovered together. In particular, I thought of the book he told me he was writing. 

LINDA:   Did you find the book that he was writing, and the ‘Trevor-created new world’?

MANDY: No. We did not find that on his computer. I wonder where he put that book. I would love to read it. However, what I really want to know is what diagnosis you gave him. Did he have a mental illness?

It was evident that Mandy was interested in other things than legacies right now. In narrative therapy, we want to follow the lead of the person who is consulting us.

This question, however, produced another dilemma for me. I wondered what it meant to them to have a diagnosis. Psychologists have the right to diagnose mental illness, but this is not my usual way of working and I had not been thinking in diagnostic terms but in therapy terms. When working with a young person I am aware of how diagnoses can make it hard to distinguish the young person from the problem(8). I wondered if a diagnosis could help these parents heal from their grief.

LINDA: What would it mean to you if there had been a mental illness? 

MANDY: Well, I have a sister who has been diagnosed with bipolar, an aunt and my grandmother had agoraphobia and my father may have had depression, so it runs in the family. Having a diagnosis would mean a lot to me because someone else who met with Trevor would have insight into his life and I so desperately want to know everything about my son, especially now that there are no new things to ever learn about him.

LINDA: Well Trevor and I named the problem ‘Trauma’. He felt that some of his experiences with his ex-girlfriend were very traumatic, and he felt that having a deformity was traumatic. When his ex-girlfriend did not want anything more to do with him after he tried so hard to help her, that felt like trauma for him. But he also told me in our last session, “It seems pretty amazing with all that ‘trauma,’ I still want to try to live”. Do you think, ‘trauma’ just got too strong for him? 

BRIAN: I think that trauma got stronger when he was playing his videogame with his best friend and the game died. His friend whom he was playing with said that the last thing Trevor said to him was that on his screen it said, ‘Fatal Error’. He then wrote a letter to the girl asking her if it was worth it not changing her life and doing wrong actions. He actually used much stronger language. That also was so unlike him.

We have another letter he wrote this girl that was just beautiful. Then he wrote us a most beautiful letter. He can write beautiful letters. In his goodbye letter he said he was only trying to survive so that he could join the military and die in battle. But he was too ‘tired of fighting’ and gave up and that is why he committed suicide. He had to have had the idea of hanging because we discovered that he had studied knots on his computer and he had a rope, so I don’t know if trauma was what it was or not?

LINDA: Might it help to think that ‘trauma’ had gotten too strong, and that the game ‘dying’, and ‘fatal error’ somehow gave trauma its hold on him and these ideas of suicide or something different?

Brian thought that this would be better than thinking he had planned suicide all along and was being devious to them all in making them believe he planned to live.

MANDY: The letter we have that he had written before is of grace and love and kindness and mercy. 

LINDA: Could it be a bit helpful to remember how he was able to write such beautiful letters? Could that be more helpful than trying to understand whether he was planning this or not? Or maybe, do you think Trevor was a ‘mindful’ young man? A ‘true boy’ of grace and love and kindness and mercy? It seems that ‘mindful’ might be a word to describe the beautiful letters and the having a rope and studying knots?

MANDY: I actually have his note here to his friend. He just said there was some sort of error. At 2:57, the game ‘died’ – I do not like that word anymore but that is what they use. At 3:08 he wrote to this girl. And at 3:21 he wrote to us. I think he was going through a spiritual battle. It was Trevor’s own will to go through with the decision of death. Yes, I think he was mindful all his life. But I think his death was really something like depression trapping much of him inside a sick mind. Maybe that was trauma caused.

LINDA: Might it be helpful to find your own term for this feeling of Trevor being trapped – trauma caused or something different?

MANDY: I woke up at three am that night and I prayed and prayed for Trevor. I prayed for angels to circle him wing to wing. Angels are ministers sent to help. I wanted them to help break the chains that bound him. I realize now that the angels were also for my benefit. The breaking of the chains I thought were to free him from pain. I just did not know that this freedom would be for him to die. I do need some help with the memory of his body and how it looked after the hanging. It haunts me.

LINDA:  Well might that be something that we can work on next session if that is something you would want? 

The Issue of Diagnosis

Mandy came to the next session with a photo book. She had created a photo book of her family every year and wanted to show me the year that Trevor changed. She also wanted me to see some of the pictures of the beginning of that year when he was the happy little, ‘watch me run mummy’ boy, her ‘true boy’.

There was a note to Mandy written by Trevor saying, ‘I love you the most in the hole world’. Written exactly like that. I discovered from Mandy that even his voice changed that year. He would speak, either in a robot voice or in a kind of baby voice when he was asking, ‘Mummy, come see me’. She discussed how she so much wanted to help her son. She had searched and searched for help. Mandy said that she and her husband had telephoned the psychiatrist from the psychiatric hospital which had kept Trevor overnight. The psychiatrist stated that Trevor had been diagnosed with ‘major depressive disorder’. Both Mandy and Brian seemed relieved to get such a diagnosis.  

(Trevor’s dad later explained the meaning of diagnosis for him:

Trevor’s suicide provoked not only trauma and grief, but an investigation. Suicide was not something we, in our wildest nightmares, would ever think our family would struggle with. Trevor was so talented, so full of life and self-confidence. He was the first to get a full-time job on his own, buy a car, buy his own cell phone, get a bank account.

When we got the diagnosis from the psychiatrist that he had a Major Depressive Disorder we felt that it explained so much to us. In his last weeks I saw his feelings of worthlessness and inappropriate guilt. He felt he was a failure. Suicide presents multiple layers of trauma and inquiry that are not present with a simple tragic death. 

During this session Mandy explained that she was feeling very upset having to live in this world where her son had hanged himself. She wished she had a chance to get help for him early enough. 

(Brian later recounted that he felt similarly: 

This has been hard for me too. Now that we have a diagnosis, every fatherly instinct in me craves the chance to go back in time to help him through this illness, and to explain it to him. He suffered all those years thinking he was just a jerk. He couldn’t help it. He was suffering and didn’t know it had a name. This had to play into his perception, somehow attaching to his deformity. He suffered alone, in my home, under my care, without any help. That destroys me inside. This is an added layer of severe grief in my heart, almost unbearable).

Mandy and I did some work around the image of seeing her son dead and how it made her feel that she failed because she could not save him. She also, in times of great distress, would feel that she was not loveable enough because it felt at times that Trevor did not love her. We discussed the possible relationship of this, ‘I am unlovable’ thought to her thoughts as a young child when her mother left the family for another man. 

Mandy wanted the little boy Trevor, who needed her to watch him run, to stay with her. She remembered again praying for her son during the time that he was organizing to take his life. She believed that praying was for God to protect him and to protect herself. She kept going over and over what Trevor must have done that night. But she came to the realization during our conversations, that she was praying him out of this life and into another life without pain and with God.

She stated that this realization was helping her feelings of panic reduce in intensity. She also explained that she believed it was Trevor’s responsibility to make his own decisions now that he was almost nineteen, and it was her responsibility to pray for him. 

When I arrived at work the next week, I had a telephone message from Brian. He was concerned that Mandy might have the same diagnosis as Trevor. She had been very upset that morning and wanted to climb on the roof to be closer to Trevor. Brian restrained her and asked her if she was feeling suicidal. She said that she was feeling sixty percent suicidal.

I phoned him back and suggested that Mandy might be feeling intense grief. I told him of other parents I had worked who had a child die explaining to me such very strong feelings, especially at first. It had only been a few weeks since Trevor died. I also stated after talking to Mandy, that if either of them were worried about being suicidal they could go to the same psychiatric hospital where Trevor had been admitted. They did decide to go. 

God’s Peace

Mandy came to her next session saying that the psychiatrist told her that she was having a normal grief reaction. I was beginning to like the psychiatrists at this hospital who were not so ready to think of DSM diagnoses and medications. Mandy had been given Ativan by her family doctor after Trevor’s death and Mandy believed that maybe these medications were making her have suicidal ideas. She therefore had decided to take no medications for now and was feeling better. 

LINDA:  Mandy, are you worried for your life now?

MANDY:  No, I am not worried that I will actively do something, but I sometimes wish that I would get the Coronavirus and die. I have weak lungs and I could just die. I miss my boy so much.

LINDA:  Does that mean that you feel that you do not have reasons to live anymore?

MANDY:  That is exactly what my pastor said. He reminded me that it is not my time. That my work is not over here on earth. I have three other children and many other reasons to live. I am reminded that Mary, mother of Jesus, suffered too. She had to watch her son be tortured and to see him die tragically. I was watching my son in a different sort of torture. I just need peace. I just need God’s peace and I find that in scripture.

LINDA:  How can you live God’s peace?

MANDY:  Knowing that Trevor is in heaven with God, and I will be there with him some day, but he will be waiting so long, too long. I can read the Bible and it brings me peace. But that long time of waiting hurts me. However, I will see him again.

LINDA:  Do you believe that the time in heaven will be the same as the time on earth? Might it be that Trevor will only feel it as minutes when you feel it as years, or something at least differently than here?

MANDY:  Yesss. Time would be different. He is in heaven after all. And here I am and here I will stay, even if it will be hard to live in a world without Trevor. I know I tried. At least I do not feel guilty.

LINDA:  Do you see this as a gift, knowing that you did the best you could and tried so hard to help him?

MANDY: It IS a gift. I never thought of it that way. It is truly a gift; I tried so hard.

LINDA:  Mandy, what are some of the many ways that you think the pastor was thinking of when he told you that your work on earth is not over?

MANDY:  Well, we have decided to help others who might have problems like Trevor’s and use his life and him taking his life as an example and a message for others. We want to help parents to find help for their children. We are working on suicide prevention. Thank you for giving us that document that can be used in the youth group. We plan to have his funeral as both a homage to Trevor and as a message about youth problems and ideas for how to get help.

LINDA: Do you think this is showing some of your heart’s concern that you showed for Trevor now being used to help other young people in difficulty? Trevor wanted to help others as well.

MANDY:  Yes, I must not forget that this is my plan for life, and this was Trevor’s plan. I need to help other children to get the services that they need. 

Sun on Wood

Our fifth session started just after isolation for the coronavirus began. Mandy was having the telephone session in Trevor’s room where she could have privacy and thoughts of Trevor’s death felt very close to her heart. 

MANDY: I am having a lot of incorrect thinking. I wake up every night at the time he died. I am so sad. 

LINDA: Mandy, could you help me understand something? When ‘incorrect thinking’ tries to take over, what is it saying to you and how do you respond to it?

MANDY: It is that coronavirus idea thing. I could easily go into public and expose myself to the virus. ‘Incorrect thinking’ keeps saying, this could be good, this virus. I would probably die with my lung problems. 

LINDA: Might ‘incorrect thinking’ be kind of ‘missing Trevor’ thinking? You said last week, ‘I am here to stay’, but staying might still be pretty challenging? 

MANDY: Yes, I AM here to stay. I just don’t like a world that I have to stay in when my son died by suicide. We were looking for the book and for notes about it. We did find some little notes and a long letter. I printed them out. They are precious. That was my ‘true boy’- those notes and letters.

LINDA:    Mandy, I wonder if you would be so kind as to describe that precious ‘true boy’ for me?

MANDY:  I remember two-year-old Trevor with his red tennis shoes. He had a scooter, and he was so agile that even at that age, we put him on the scooter, and he rode in circles, his little shoes so eye catching. His bright blue eyes so sparkling. I always wanted a fair boy who looked like my side of the family, the others are dark haired. I began praying, asking God specifically if my next baby could please have blonde hair, and blue eyes, and if it weren’t too much to ask, curls on top of all that. God gave me it all!

He had a yellow and black coat. He was so happy and thoughtful then. He asked such hard questions about God. I am so blessed to have been his mum.

LINDA:  Is that one of Trevor’s legacies to you, to give you the opportunity to be so blessed to be his mum? Do you have some ideas how to get even closer to the reasons why you are so blessed to be his mum, while still living in this world that you have decided to stay in and find the precious ‘true boy’?

MANDY (very tearfully): I blogged daily, writing little stories about all my children. I was recording it for my family who were far away. They are invaluable now. I sleep with his two stuffies (soft toys) called Nache and Thunder that he always slept with. I kiss them on the nose and tell Trevor that I will take care of them for him. 

LINDA: Mandy what do the tears speak to?

MANDY:  That I forgive him. I am in his room and his smell is disappearing. That frightens me.

LINDA:   Do you have some ideas how you can keep his smell closer to your heart and soul?

MANDY:  I have no idea; it scares me. I am losing him.

LINDA:     Could you describe the Trevor smells?

MANDY:  The smell is a bit of outdoors, like sun on wood; it is warm skin, Trevor’s warm skin. Independence.

LINDA:  We are creatures of words. Would it be helpful if I write this down on a separate paper that I can give to you when we are out of this coronavirus isolation or mail to you now?

 (I always make notes during the session that usually those consulting me can take with them, but I am doing these sessions by telephone, and I wanted to write these beautiful ways of re-membering Trevor very carefully. I thought I might type or send all our re-membering in a written narrative letter 9-13 .

LINDA: Mandy, I am curious, what does independence smell like? 

MANDY:  It smells like sun on wood. That’s my ‘true boy’, independence. Oh yes, please write it all down.

LINDA: I am writing this, ‘sun on wood, a bit of outdoors, warm skin, Trevor’s skin, independence’. 

Do you think he can feel that forgiveness?

MANDY (very softly): Yes, he knows that I forgive him.

LINDA:   What do you think that would mean to Trevor to hear you saying that you will look after Nache and Thunder for him?

MANDY: He would know that there is nothing he could tell me that would make me love him any less. But it is a bit painful to think of bringing him back to hear what I am saying. I don’t want him to know that pain I feel of his loss. You know, a mother is only as happy as her saddest child.

LINDA:  You don’t want him suffering through knowing the pain that you feel. Do you believe that he is suffering now?

MANDY: No, he is at peace. His body and mind are healed, in the presence of God. HE NO LONGER IS SUFFERING. His place and his job is in heaven. But he left us with a job on earth.

LINDA: What is that job on earth?

MANDY:  My job now is, as is part of his job, to help others who suffer like him. I was reading Genesis 50:20. It is the story of Joseph. His brothers wanted to kill him, and he managed to escape and save Egypt. He said to his brothers when he saw them again, ‘You meant evil, but God meant it for good to bring this about’. 

LINDA:  Mandy, can you help me understand your meaning of Genesis 50:20?

MANDY:  Well, we are going to help others benefit from Trevor’s experience and his death. God meant it for good. I hope he knows now that what he did was not him but the illness, and we will help other young people who are suffering like he was. 

LINDA: If he were to hear you now, even though it is a bit painful as you told me, what might he think of your idea of carrying on his wish to help by helping other young people who might be suffering like he was?

MANDY: He would feel relief that he did not ruin our lives. If he could have stayed on this earth longer, he would have been able to turn around the voice of depression, he would have had more tools in the toolbox. If he only will know that his dying was not for nothing. That we are going to use his life and his way of dying to help others. He would know that he didn’t ruin our lives, and his life had meaning. He actually is going to help others live a better life than he was able to live.

LINDA:  Mandy, I can’t imagine a better legacy for Trevor than the one you plan to bring to us all. I am so curious about your ideas, how are you going to make Trevor’s life and death be helpful to other young people who are suffering. (I realized that in my role as a narrative therapist, I need to lead people to find their own legacies of their child. This was a much more powerful legacy than what I had first considered, which was the book Trevor was writing).

MANDY:  Well, we have developed this website. It is to help others find hope. We are discussing what tools he had and what tools we wish he had. We are going to give resources, where you might go. 

LINDA:  Yes, you told me about how you organized his service to be both a memorial to Trevor and a help to others. Would you be willing to describe this in a bit more detail?

MANDY:  Well, we had twelve counsellors come to be there for the young ones of our congregation. They are all so close we were concerned about them. The counsellors talked to the young ones on an individual basis and gave them ideas of where to go if they need help. We had moved here from another country and did not know what services existed.

The surgeon who did Trevor’s chest surgery asked if he could have Brian’s talk at the memorial service. Brian talked about what it was like to be a parent of someone with such problems that Trevor had suffered from. The surgeon hopes to use this in some way to help other children at the Shriners with deformities as a way to try to prevent such an outcome as happened to Trevor. 

LINDA:  Oh, I am very interested in how he might use this. I will talk to him, perhaps I can be of some assistance to your ideas and to his, in relationship to the Shriners Hospital for Children. 

What would you like to do about appointments?

MANDY: Well, I know you are so busy, Linda.

LINDA:   It is truly up to you.

MANDY:   I think I would be OK for two weeks. 

Keeping Her True Boy

Mandy called and cancelled her next session. I had planned to spend our last few sessions exploring ideas about how she and Brian could help other young people. We were still in isolation for coronavirus isolation when we began to co-write this article.

Mandy told me again about blogs when Trevor was so happy and living what she called a wonderful life. She was reading books to understand suicide and discussed them with me. She would still question the cause of Trevor’s challenges. She talked some more of all that she had done to try to find the cause when he was alive and to get help for him. With a few questions she came to the conclusion that Trevor died to protect his parents from more pain, pain that he lost his beliefs, pain that he couldn’t feel better.  

She also talked of her ‘true boy’ who could be around even later in life. For example, she mentioned how he wanted to be so independent, he wanted to pay for his own counselor. He even wrote in his ‘I’m sorry’ note that they could sell his car, perhaps to pay for his funeral.

She suggested this was his warmhearted way of showing that he did not want them to be in debt by his death. And most importantly she discussed how she believed Trevor had a healed mind and a healed body and that now he is free. She read to me his wonderful, kind letters. She told me beautiful stories of navigating the parenting journey as Trevor developed from childhood into adulthood and of walking alongside him even when he was making choices she would have preferred that he not make.

But mostly Mandy described her hopes and dreams for being of service to other youth, to follow Trevor’s hopes and dreams. She understood better what Trevor stood for. Mandy believed that God has a purpose for every life, and both her purpose and Trevor’s purpose was to call greater awareness to youth challenges and help youth with this calling. There was no more talk of catching the coronavirus and meeting Trevor sooner.

Mandy felt that she and Trevor now had a common, earthly goal that her husband and her complete congregation were getting involved with. She felt that this was keeping her ‘true boy’ in her heart and soul. Mandy requested that we do one last bit of work together when the isolation due to the Coronavirus was over.

This was to work to help her manage better some of what might be called day and night dreams of the last image of ‘her boy who was not her boy’. She planned to replace these images with her ‘true boy’ and with other young people who were living instead of dying. Finally, Mandy explained to me, that somehow, Trevor did not disappear but will live on in the helped lives of others.

Brian wrote to me when I asked him to edit this paper. In his letter he expressed words similar to those I have heard from others who have had a child die. They were so poignant and heartfelt that I wanted to honour his thoughts here. This is Brian’s perception of his particular experience of having a child die by suicide.

“I am not the man I was before February 8, 2020. When Trevor died my life changed. My wife changed. My family changed. I changed. And I’m trying to come to grips with the new me and my new world. Life has a different meaning. My faith has more gravity. My perspective on my life in this world has been elevated beyond the temporal in a way it has never been before.

When I walk beyond the curtains to grief and back into life where my heart and mind are released from the shadow of my son’s suicide, who will I see when I look in the mirror? My grief is not just grief. A transformation is occurring. A lot of people who lose children have a very difficult time getting past the loss, as if their legs have been cut off from under them, and they will never stand on their two feet again. I have been in the depths of these waters, but I will not stay there. I know that these ashes that cover me now will be redeemed by God.”

I feel so honoured to be a part of such conversations which could explore what Trevor gave value to and then to witness Mandy and Brian finding ways to use what Trevor gave value to help others. I was able to assist them to develop Trevor’s legacy and to carry it forward with their family and others who loved him. I feel that this journey that we took together was also a healing journey for me.

I got to know both parents so much more through our co-creation of this paper. I have co-written papers before with those who consult me and am always so appreciative of the experience. I am happy to add Mandy’s final remarks when she returned this final draft to me:

“I also just want to say thank you again. As I was reading through the paper as a whole, it helped to be ‘counseled’ again. In grief, your mind so quickly forgets what you've determined, or learned. Now I will have this paper to get a quick reminder of the progress and conclusions you've helped me with. Brian wants to say he really enjoyed working with you on this paper. Me too! Blessings.   

All names are changed at the request of the parents. The young man’s parents have read this version of the paper and feel comfortable for it to be published so others can learn how they managed to survive the almost unsurvivable and to carry on their son’s legacy wishes.

Reprinted with the consent and express wishes of the parents, Linda Moxley. and the editors of the Journal of Contemporary Narrative Therapy

[If you or someone you know is struggling or in crisis, help is available. Call or text 988 or chat 988lifeline.org]  

References 

(1) White, M (1988). Saying hullo again. The incorporation of the lost relationship in the   

            resolution of grief. Selected papers (pp. 37-46). Dulwich Centre Publications. 
 

(2) Moxley-Haegert, L. (2015a). Leaving a legacy. Using narrative practice in palliative care  

           with children. The International Journal of Narrative Therapy and Community Work, 2,  

           58-69. 
 

(3) Moxley-Haegert, L & Moxley Haegert, C. (2019). Little steps toward letting the legacy live: Fine traces of life to accompany families grieving the death of a child. Journal of Narrative Family Therapy, 28-53.  
 

(4) Moxley-Haegert, L. (2012), Hopework. Stories of survival from the COURAGE progamme: Families and children diagnosed with cancer. Retrieved from narrativetherapyonline.com/moodle/mod/ resource/view.php?id=577  
 

(5) White, M. (1995). ‘Reflecting teamwork as definitional ceremony.’ In M. White: Re-Authoring Lives: Interviews and essays (pp.172-198). Dulwich Centre Publications.  
 

(6) White, M. (2011). Narrative practices: Continuing the conversations. Engagements with suicide. (pp.135-148). Chapter 10. David Denborough (Ed). W.W. Norton  
 

(7) Moxley-Haegert, L. (2015b).  Petit Pas/Little Steps. www.hopitalpourenfants.com/patients-et-familles/information-pour-les-parents/petits-pas (French) and www.thechildren.com/patients-families/information-parents/little-steps (English)  
 

(8) Marsten, D; Epston, D., Markham, L. (2016). Weird science, Imagination lost. In Narrative Therapy in Wonderland; Connecting with children’s imaginative know-how. (Chapter 7, pp. 157-173). W.W. Norton & Company.  
 

(9) Bjoroy, A., Madigan, S., & Nylund, D. (2016). The practice of therapeutic letter writing in Narrative Therapy, In B. Douglas, R. Woolfe, S. Strawbridge, E. Kasket, & V. Galbraith (Eds.). Handbook of Counselling Psychology, 4th Edition. Sage Publications. 
 

(10) Epston, D., & White, M. (1992). ‘Consulting your consultants: The documentation of alternative knowledges.’ In D. Denborough (Ed.). Experience, Contradiction, Narrative and Imagination (pp. 11-26). Dulwich Centre Publications. 
 

(11) Ingamells, K., (2018) My romance with narrative letter: Counter stories through letter writing. Journal of Narrative Family Therapy, Special Release 4-19. www.journalcnt.com 
 

(12) Pilkington, S.M. (2018). Writing narrative therapeutic letters: Gathering, recording and performing lost stories. Journal of Narrative Family Therapy: Special Release 20-48.  
 

(13) Palijakka, S., (2018) A house of good words: A prologue to the practice of writing poems as therapeutic documents. Journal of Narrative Family Therapy, Special Release, 49-71. 


* Dedicated to the young man who chose to take his life and to his parents who chose to survive

his death.
 

Author Note: “Parents I worked with in palliative care co-wrote a resource document with me and the nurse practitioner in palliative care at the Montreal's Children's Hospital in Montreal. This might be a resource that could be added for reference if you thought it might be helpful to the readers.  


Questions for Reflection

How did this clinical narrative impact you?

What are your thoughts about the therapist’s approach?

Which techniques might you use in your own clinical work?

What about the way the therapists worked with Linda and Brian would you change? How?

What are your own strengths and challenges when working in the shadow of suicide?  

The Existential Importance of the Penis: A Guide to Understanding Male Sexuality – Daniel N. Watter, EdD

Posted on by Psychotherapy.net Team

Existential Sex Therapy in Practice

The practice of sex therapy and psychotherapy can be done utilizing many different modes and theoretical orientations. Yalom reminds us that existential psychotherapy does not represent a standard set of techniques, styles, or protocols. The concepts of existential therapy can be best understood as a lens or guide by which psychotherapy is practiced. Practitioners of all theoretical philosophies can bring an existential perspective to their treatment process. 

When I treat my male sex therapy patients, I follow a similar pattern with all as a starting point. Whether I am treating an individual male or a couple, I like to begin by asking about what brings them in to see me and allow the story to unfold in whatever manner they choose. I am particularly interested in the description of the problem, the conditions under which the problem manifests itself, and the timeline regarding when the symptom first presented. My goal is to begin to get an understanding of the meaning and protective/adaptive purpose the sexual difficulty may represent. Typically, men will present with little to no insight as to the reason for their sexual shutdown. They often describe a generally satisfying relationship with a partner they find attractive. Most of the men I treat, especially those experiencing erectile difficulties, will report relative ease at attaining penile tumescence, and engorgement will be maintained through extended periods of sexual foreplay. But the erection fades as intercourse approaches or shortly after penetration occurs. Typically, these men reveal a current history of satisfying and frequent masturbation. They will often express a vague notion of being anxious about sexual function and a firm belief that their penile difficulties have some medical basis. However, they are at a loss to explain how a physical or medical issue allows for erections that are fully functional during masturbation but not penetrative sex. Their partners are similarly stymied. 

Following the initial consultation, I will focus on family and developmental history. If I’m treating a couple, I will ask to do three individual sessions with each before resuming couples’ work. It is important to me to develop a good understanding of each person’s experience in his or her family of origin and to identify any patterns of trauma that might be getting triggered in the current relationship. I want to learn about the personalities of family members, their relationship with each of them, and their relationship with each other. I want to know if this was a family that was able to communicate about and/or demonstrate emotions, or if theirs was a family of secrets and repressed suffering. I want to know if there was any presence of substance abuse or domestic violence and/or parental neglect/over-involvement. In essence, I am looking to gain an appreciation for any family dynamic that may have felt threatening that could be reenacting itself in the current relationship and, thereby, creating a threat to the man’s existence and well-being.

Many highly regarded sex therapists will spend a great deal of time taking an in-depth sexual history. I do not, as I find much of the information in a standard sex history to be irrelevant, particularly in those men who have had a prior history of good sexual functioning. Through an existential lens, the sexual “problem” is often not about how the man feels about sex per se. The sexual problem is more typically understood as an attempt for the man’s penis to communicate some deep anxiety, concern, and existential threat to his existence. Therefore, to more fully comprehend the message the penis is sending, a comprehensive developmental/family-of-origin/ relational history will be of greater value. Let’s consider the case of Russ from the perspective of an existentially oriented sex therapist. 

The Case of Russ

Fifty-one-year-old Russ came to see me shortly after his wedding to Sarah. This was a first marriage for Russ and the second for Sarah. Both had come from traumatic families of origin, and Sarah’s first marriage was to a man who regularly abused her. Russ’s primary complaint was a lifelong inability to ejaculate. I began by asking Russ for a timeline regarding his ejaculatory difficulties. I have found that the time of onset of problematic sexual symptoms is often of great significance in understanding what may be triggering the current inhibition. While most men presenting with this complaint have their ejaculatory difficulty limited to their time with a partner and have little to no difficulty ejaculating during masturbation, Russ reported that Sarah was his first sexual partner, and ejaculation during masturbation was problematic as well, although it would occur on occasion. Given the unusualness of this situation, I asked if Russ had consulted a urologist or other physician, and he indicated that it was his urologist who provided him the referral to me. His urologist did not detect any medical explanation for Russ’s ejaculation problem. 

We next began to talk about Russ’s upbringing and family of origin. Russ came from a family with two professionally educated parents, both of whom enjoyed great professional success and respect. They also were rather puritanical and punitive. Russ was the oldest of four children, and the siblings all have minimal interaction with each other. Despite the fine professional reputation his parents possessed, Russ recalls them as constantly fighting, explosively angry, sleeping in separate rooms, engaging in multiple infidelities, and hardly being civil to each other. Neither had much to do with the children, his father due to excessive alcohol use and his mother using her work to avoid being at home. He recalls his mother telling him in a fit of rage that she never wanted to be a mother and blamed his father for forcing parenthood on her.

Russ also reported that laughter, enjoyment, and pleasure were not only absent in his home but were considered sinful and to be averted at all costs. Any expressions of joy were severely reprimanded and punished. As a result, Russ learned as a young boy to repress any feelings or demonstrations of delight, joyfulness, and pleasure. He recalled that to the present day, if he is enjoying a television show or a musical piece, he will turn it off. He does not enjoy comedians or most other forms of entertainment. His free time is spent reading serious, nonfiction books and tinkering with electronic devices. Regarding the specifics of sex, he reports a strong libido and easy arousal, but he begins to panic as he approaches ejaculation and, thus, ceases all stimulation. In addition to shutting down all sensations of pleasure, Russ reports learning to be exquisitely attuned to the displeasure of his parents. He was constantly scanning the home environment to head off any actions or commotions that would rouse the ire of his chronically unhappy and volatile parents. Russ grew up a very lonely child. Despite having three siblings, the home was minimally interactive, and Russ did all he could to avoid other family members. He spent a great deal of time alone in his bedroom or in the local branch library. He recalls few friendships with schoolmates, as his parents discouraged such contacts. His activities were primarily solo, and this pattern continued through college and his career. In high school, Russ discovered a love of the sciences, and he decided to pursue a career in medicine. While he enjoyed his studies, he found his clinical rotations to be laborious. For a time, Russ thought he had made a poor career choice until he discovered the field of pathology. Pathology afforded him the solitude he found comforting as well as the opportunity to pursue his interest in lab sciences. In addition, being a pathologist required minimal interaction with colleagues, offered steady, predictable hours, and relieved Russ of the burden of having to deal directly with patients. He had a reputation at work as a hardworking and dependable physician but also as a loner who showed little interest in the lives of his co-workers. Oddly, his workplace was where he met the person who would dramatically alter his life’s course, Sarah.

Sarah was a pathologist in the same lab as Russ. She was also a serious- minded and reserved person, but she was more social and outgoing than was Russ. She found Russ to be appealing for several reasons. She liked that he was smart, hardworking, and seemingly uninterested in office gossip and politics. She also discovered Russ’s dry, witty sense of humor as being particularly self-effacing and clever. She decided to ask him to join her for dinner one evening, and Russ, to his surprise, accepted.

Russ did not date and reports no prior relationships before meeting Sarah. He was quite taken aback when Sarah invited him to dinner, as no other women had ever pursued him. He liked Sarah, thought she was beautiful, and found her laugh to be quite charming. She always seemed to genuinely enjoy her conversations with him, and this was a most unfamiliar experience. Russ recalls being nervous before the date but also excited to go. He reported they had a surprisingly nice evening, and he felt a lightness that was both strange and pleasing. He very much wanted to continue dating Sarah. Fortunately, Sarah, too, recalled enjoying her evening with Russ, and the two began to spend a considerable amount of nonworking time together. Sex proceeded slowly, which was fine for them both. Russ was unable to ejaculate during intercourse and soon began to develop erectile difficulties. Russ found erections fairly easy to achieve and maintain until it was time for vaginal penetration. Russ would then begin to lose tumescence. Sarah was unflustered and patient, but Russ was frustrated. He wanted to be able to fully experience sex with Sarah, mostly because he did not want her to feel bad or worry that he wasn’t attracted to/interested in her.

It seemed readily apparent to me that Russ’s traumatic upbringing was affecting his sexual functioning. His penis was speaking to him and cautioning him against allowing himself to be vulnerable to others. We spent a good deal of time discussing his family of origin and how his penis might be trying to send him a message of prudence. Existentially, Russ suffered from fears of mortality and isolation. Specifically, Russ found his existence threatened by his feelings of vulnerability with Sarah. His past relationships with family left him vigilant against allowing others to get close and potentially harm him. He had spent most of his life as a loner, and this allowed him to feel protected and safe. However, meeting Sarah made him aware of the depth of his loneliness, and he longed for companionship and love. While his conscious mind was telling him how wonderful life with Sarah would be, his protective unconscious was alerting him to the peril and fragility of his existence should he allow himself to be exposed and laid bare to another. The threat of hurt, rejection, and grief was palpable as Russ continued to deepen his affection and connection to Sarah.

In addition to the threat of annihilation, Russ also was becoming increasingly aware of his isolation from self. His perpetual scanning of his childhood home environment and vigilance for any signs of upset from his parents made him unaware of what his own needs were. That, combined with the family’s disdain for anything pleasurable, left Russ in a constant state of anxiety during partnered sex. When in sexual situations with Sarah, Russ was so preoccupied with whether Sarah was responding positively that he was oblivious to his own sense of sexual arousal. Psychotherapy focused on Russ allowing himself to become comfortable with experiencing nonsexual pleasure and then moving to sexual pleasure during solo masturbation. A combination of dealing with the trauma of his childhood environment along with some directed behavioral suggestions allowed this to be accomplished over a period of several months.

Allowing himself to ejaculate during his time with Sarah proved more challenging, and improvements came about in small, inconsistent increments. Russ’s ability to fully let go when in the presence of another was (not surprisingly) difficult to overcome. Russ’s childhood home taught him to self-protectively be on guard against the ire of his warring parents. Hypervigilance in the presence of others became his lifelong strategy for survival. Overcoming the trauma of his childhood took considerable work in psychotherapy, but eventually, Russ was able to ejaculate in Sarah’s presence. First, he was able to ejaculate in her presence via solo masturbation. This then progressed to Sarah being able to bring Russ to ejaculation using her hand, and eventually, Russ was able to ejaculate during sexual intercourse. Each of these successive advances occurred inconsistently for quite some time but gradually became easier and easier to achieve. During times of emotional stress/dysregulation on either of their parts, Russ will regress, but such regressions are temporary and typically resolve in a matter of days to weeks. Both Russ and Sarah are pleased with their movement, and treatment is ongoing.

Russ and Sarah’s story illustrates many of the seminal points in existential sex therapy. Note the existential concerns of a threatened existence and the penis speaking through a self-protective shutdown of sexual functioning. Russ feared his existence would be snuffed out if he allowed himself to be emotionally close to Sarah or allow himself to feel joy/ pleasure. In addition, Russ became increasingly aware of his isolation from himself. When with Sarah, he was so consumed with scanning her reactions that he completely lost sight of his own desires. Russ’s anxiety about displeasing another meant that the only time he felt sexually comfortable was during solo sexual activity, when he could focus exclusively on himself with no distraction.

Russ was a man who was deeply untrusting of others, and this, along with his isolation from self, negatively affected his budding relationship with Sarah. While what makes psychotherapy work is always somewhat mysterious, it seems clear to me that a significant aspect of Russ’s improvement was the quality of the therapeutic relationship built between the two of us. Over time, Russ came to trust that my interest in him and his well-being was genuine. As his comfort with me increased, Russ was able to take more risks in therapy and reveal more and more of himself. In addition, he was able to venture into unexplored territory as he began to learn more about himself, his feelings, his fears, and his desires. Existential sex therapy, like existential psychotherapy, is rooted in the depth of the therapeutic relationship. The elements of connection, genuineness, compassion, and safety are the most potent tools available to the practicing sex therapist.

I am often asked if behavioral sex therapy exercises have a place in existential sex therapy. While I tend to use them sparingly, they certainly have an important place in providing some immediate relief of symptoms and encouraging patients to take risks and move forward. However, I believe that a therapy that was primarily based in behavioral exercises would have been ultimately ineffective for Russ. Russ had suffered so much damage from his family of origin that without doing deep trauma work with an existential lens, he would not have allowed himself to move toward tolerating the experience of pleasure. In addition, exercises that focused directly on the functioning of his penis would have been of little value until Russ better understood the messages of anxiety and trauma being communicated to him through his penis. Frankl’s process of dereflection allowed Russ to focus on triggering of childhood trauma and allow his protective unconscious to loosen its grip. Still, behavioral suggestions clearly had a place in Russ’s treatment, as merely working through the trauma of childhood would not have given him the sexual skills he required. I am often reminded of one of Yalom’s most important axioms: “Insight without action is merely interesting.” All good therapy needs to move the patient beyond the point of insight to take the necessary emotional risks to make use of such insights and awarenesses. As a result, even though the bulk of my therapy focuses on deep reflection and insight to assist the man in better understanding the message his penis is sending him, I often find behavioral exercises or suggestions to be of great value.

Let’s examine another case that illustrates the principles and process of existential sex therapy. 

The Case of Ascher

Ascher was a 44-year-old man who had been married for 21 years to Marcie. Both reported a generally satisfying relationship that had recently become distressed due to Marcie’s discovery of Asher’s many infidelities. Ascher admitted to frequent use of pornography, chatrooms, and sex workers. Marcie discovered Ascher’s transgressions after being diagnosed with a sexually transmitted infection at a routine GYN exam. 

Both Ascher and Marcie were religiously observant, and sexual intercourse was not attempted until after marriage. Sex seemed to proceed smoothly with little complication for the first 12 to 24 months of marriage. Both reported a high level of sexual satisfaction during this time. However, Ascher began to pull away from Marcie sexually, and their sexual frequency quickly diminished. When Marcie questioned Ascher about his apparent sexual avoidance, he offered some vague explanations and vowed to increase the frequency of his sexual initiations. Ascher did begin to initiate sex more often, but then he often would experience erectile loss just prior to vaginal penetration. Both Ascher and Marcie found this distressing, but Ascher was reluctant to consult his physician and instead just drifted further away from Marcie sexually. Marcie was troubled by Ascher’s lack of interest in pursuing an answer to this conundrum, and the two began to fight repeatedly. It was later discovered that Ascher’s reluctance to consult his physician was due to his awareness that his erectile difficulties did not occur during solo masturbation or inter- actions with sex workers. Had Marcie not been diagnosed with an STI, this cycle of sexual avoidance may have continued indefinitely, as divorce was not a consideration for either of them.

Ascher agreed to begin psychotherapy and consulted a “sex addiction specialist.” Sex addiction therapy proceeded for about a year, but improvement was minimal. Therapy focused primarily on behavioral interventions designed to control Ascher’s urges to sexually “act out,” as well as regular attendance at a 12-step sex addiction group. Ascher reported enjoying both the individual therapy and the group meetings and found the support he received from both to be very meaningful. However, Ascher felt that his issues were not being adequately identified and addressed, and change was negligible. Both Ascher and Marcie were frustrated by the lack of progress, and they were referred to me for an alternative approach to the problem.

My initial meeting was with both Ascher and Marcie, but their wish was for Ascher to receive individual psychotherapy. Marcie attended the session to be supportive and offer to be helpful in any way she was needed. However, Ascher felt he needed to “confront his inner demons” and wanted to do this via individual treatment. I agreed, as I thought Ascher’s difficulties preceded and were separate from his relationship with Marcie, and we agreed to begin individual therapy with the idea of bringing Marcie into the therapy at a later point if necessary.

Ascher and I began by discussing the onset of his problematic behavior. He reported that he had never felt sexually conflicted or compulsive prior to his marriage to Marcie. He reported loving Marcie and thought she was an outstanding wife, mother, and friend. He found his behavior puzzling, as he found her sexually attractive and enjoyed sex with her greatly. We also discussed his prior psychotherapy and what he found helpful and not helpful about it. Ascher recalled liking his therapist and felt great relief at being able to discuss what he had been keeping hidden for so long. He also enjoyed the support and camaraderie of the 12-step group but had a nagging sense that as inconceivable as it was to him, his problem was not really about sex, which was the sole focus of his prior therapy and the 12-step group. I asked him if his problem was not about sex, what did he think it was about, but he had no answer and found his situation to be quite puzzling.

We next began to talk about Ascher’s family of origin and childhood memories. Ascher was the oldest of five boys born to a religiously observant mother and father. He reports a generally happy home environment in which the laws and rituals of Judaism were practiced, celebrated, and enforced. Ascher was educated in Jewish day schools, where he received both secular and nonsecular education. He recalls enjoying school and being a very good and popular student. Ascher was very much committed to his religious teachings and practices but recollects always fighting a desire to rebel. He didn’t mind or object to any of his religious obligations but always felt an objection to being “controlled.” Ascher described himself as being an intensely curious youngster who frequently questioned the absoluteness of rabbinic authority and wanted to know what the “forbidden” experiences would be like. He had questions about the laws of kashrut (the requirement to keep a kosher diet) and often felt a strong urge to sample non-kosher food and, on occasion, did secretly indulge. As an adolescent, Ascher experienced the expected sexual urges and desires and would occasionally allow himself to masturbate. These transgressions left him feeling guilty but pleased by his displays of autonomy and independence. Again, it was not that Ascher felt forced into a life of religious observance that he did not want, but Ascher abjured feeling controlled, stifled, and limited.

Ascher reported that while he was eager to marry Marcie, he felt rather quickly like marriage was “suffocating.” This feeling was quite surprising to him, since he believed he enjoyed being with Marcie a great deal. Nevertheless, marriage quickly felt confining, limiting, and controlling. Since Ascher did not engage in premarital sex, he did not know how he would have behaved sexually in another relationship with someone besides Marcie, but he suspects he may have felt suffocated in any relationship that removed his ability to feel as if he had choices.

It was becoming increasingly clear that Ascher was reacting to feelings of being controlled (losing his autonomy) and suffocated. Existentially, this would correspond to Yalom’s dilemmas of freedom and mortality. Ascher’s problematic sexual behavior was likely his response to these internal and unacknowledged conflicts, much like his desire to sneak non-kosher foods when a young boy.

When I mentioned this to Ascher, he responded immediately and enthusiastically that this conceptualization resonated strongly. Ascher then described the strong obligation he felt to not disappoint his parents or to be a poor role model for his brothers. Throughout his life, he felt both proud of and burdened with these responsibilities. The combination of family and religious obligation often made Ascher feel as if his life was not his own, and he struggled with his desires for freedom and autonomy against the perceived constraints imbedded in so much of his life. He reported never having expressed these feelings to anyone before, and this was never explored in his prior therapy. As our discussion continued over the weeks and months, it became increasingly clear to Ascher why he was behaving as he was, and he felt that now that he had a substantially greater insight into the meaning behind his actions, he would have an easier time dealing with them. It was now time to ask Marcie to rejoin the therapy.

Marcie was pleased to participate in the therapy, and she had been doing important work on herself in individual therapy. She reported being pleased with Ascher’s new understandings and insights but found herself struggling with issues of trust. Her existence now also felt threatened, as she saw Ascher as not only someone she loved but also as someone who had the ability to do her great harm and destroy the life that she loved. It was determined that they would be best served by another psychotherapist for couples’ therapy, since Ascher wished to continue his individual therapy and growth with me. Both Ascher and Marcie agreed that this was the best way to go, and I referred them to one of my colleagues who did couples’ work. At the time of this writing, Ascher continues a productive individual psychotherapy with me, and the two of them are doing well in couples’ therapy, having recently begun resuming their sexual relationship.

The case of Ascher again highlights how the penis speaks for distressed men. Ascher shut down sexually when he began feeling suffocated and constrained. First, he pulled away sexually from Marcie. This was of great concern for her, and she began to push Ascher for an explanation. Since Ascher felt unable to express his feelings for fear of acknowledging his “less than pure” urges, he subordinated his emotions and tried to bypass them. He then tried to accede to Marcie’s wishes and continue to interact sexually with her, but his protective unconscious would not let his penis function, and the sexual shutdown took a much harder-to-explain path. All of this was further complicated by Ascher’s frequent use of pornography and sex workers. These outlets, while making Ascher feel extremely guilty, also provided him with the “reassurance” that he was not being controlled and still possessed the autonomy to rebel against expectations. Given the internal conflicts Ascher was battling, it is little wonder that a therapy primarily focused on behavioral exercises designed to increase sexual interest and improve erectile functioning fell short. Ascher’s protective unconscious would thwart all efforts to move into territory that created an existential threat to him. Until those unacknowledged and unexpressed conflicts had been exposed, Ascher was unable to understand, and therefore change, any of his problematic behaviors.

Oftentimes, behavioral sex therapy’s treatment failures alert us to the possibility that something else is going on, and it is in these cases that an exploration of existential issues may be most helpful. In the case of Ascher and Marcie, we see that once again, the penis speaks and, according to well-known psychologist and sex therapist Kathryn S.K. Hall [with whom I had personal communication, sometimes it yells!

***
 

In this chapter, we have explored many of the most salient features of existential sex therapy and how sex therapy with an existential lens differs from most traditional forms of sex therapy. Ascher’s case provides us with an excellent transition to our next chapter, hypersexuality, or what is often referred to as sex addiction. Many of the patients we see in sex therapy practice are not suffering from a sexual shutdown but what appears to be quite the opposite — a pattern of sexual behavior that they find difficult to control and manage. The existential issues in cases of hypersexuality are often most closely aligned with fears of death and mortality. Let&

5 Time Tested Methods for Attracting New Referrals and Building Your Brand

Posted on by Psychotherapy.net Team

Suggested Tips for Clinicians:

  • Learn SEO (search engine optimization) to bring foot traffic to your practice’s site.
  • Build your advertising savvy by mastering Google business tools.
  • Consider consulting with a business coach to build your clinical practice’s brand.
For most psychotherapists in private practice, the pattern of the past two and a half years has followed a similar trajectory:

March 2020: Move to 100% teletherapy, and watch as new referrals suddenly become frighteningly scarce.

April 2020: The phone is still not ringing.

May 2020: Referrals start coming back…and then explode. In the summer, waiting lists become commonplace because clinicians can’t handle all the people who need help during the pandemic that is killing thousands of people every month and forcing businesses and schools to go all virtual.  

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In 2020, Mental Health America reported that nearly 500,000 people struggled with a mental health disorder such as anxiety or depression. The organization offered online screenings from January through September, stating that anxiety screens increased by 634% while depression screens increased a staggering 873%. In just one year, the number of mental health visits attributed to new patients increased by 27 percent in July 2020 compared to July 2019.

The pandemic has deepened the mental health crisis, the report noted. The number of US adults expressing symptoms of major depressive disorder increased from 24 percent in August 2020 to 30 percent in December 2021, per CDC figures, and a recent article in the New York Times discussed the serious shortage in the US for child therapists.

As both an owner of a group practice as well as a business coach for psychotherapists and other group practices, I have had a birds-eye view of these patterns as they unfolded across North America. Many clinicians never had a waiting list before and were not sure how to process these inquiries. For some insurance-based group practices, the glut of referrals became a nightmare with waiting lists of over 100 people. Many potential clients were frustrated that no one in their city had any openings. Attempts to automate the process only created more feelings of depersonalization for clients and frustration for clinicians.

Yet despite these hardships, the pandemic also made marketing unnecessary for many private practices. It made it easier than ever before for licensed psychotherapists to go out on their own, working from home without even paying for an office. Spending $29.95/month for a Psychology Today ad was all that many practitioners needed to fill their schedules with new clients.

For group practices, the tricky balance of referrals, therapists and office space has been turned on its head by the pandemic. Referrals have been plentiful, but a significant number of sessions are still being conducted virtually, making decisions about future office space a guessing game. Availability of therapists has been the scarce resource of late, fueled by the sheer number of group practices and the deep advertising pockets of numerous online providers such as BetterHelp and TalkSpace.

But now there are signs that the glut of referrals is slowly diminishing for many private practitioners. As part of my business coaching service, I set up and maintain Google Ads campaigns for psychotherapists. The common refrain in the summer of 2020 was, “Turn the ads off! We can’t handle the inquiries we are getting!” That was great news because everyone could save a lot of money on marketing and still have plenty of referrals to fill caseloads. Suddenly, however, I have begun hearing the opposite from quite a few people: “Hey Joe, can you turn my ads back on? My waiting list is finally down to nothing.”

This trend is especially true for fee-for-service practices with rates over $200 per session. The combination of inflation, higher interest rates, and perceived easing of the pandemic may be leading more people to forgo therapy—especially expensive therapy—and return to other satisfying pre-pandemic activities such as indoor dining, music, travel, and visits with family and friends. Such activities may be serving as a natural antidepressant compared to the stark isolation and Zoom life during the peak of the pandemic.

So what’s a practitioner to do if a few holes suddenly appear in their caseload? As always, it’s wise to prepare for a storm when the first few clouds appear on the horizon. Interest rate increases and inflation are here to stay for a while, and fee-for-service providers are most at risk when consumers tighten their belts. To get ahead of these challenges, here are some of the time-tested methods for attracting new referrals:

     1. Improving Your Search Engine Optimization (SEO): Google is still the biggest source of referrals for most private practitioners, and nothing beats showing up on page one of Google for free. The bad news is that page one is more crowded than ever, and newer websites have a harder time competing against sites with years of immersion in the Google system. A good overview of best SEO practices you should follow can be found in numerous free resources online which can give you an idea of how to improve your ranking in Google’s search priority.

     2. Using Google Business Profile: Google still offers a wonderful free resource, the Business Profile, which includes a description of all your services, displays for photos and videos from your site, free messaging, opportunities to show up on the top half of page one with a Google Map link, and the ability to make free posts with links to your website. Note that managing individual Business Profiles will be moving to Search and Maps in the near future.

     3. Enabling Google Ads: This is still the best and easiest way to show up at the top of page one in Google search, but you’ll have to pay for the privilege. Recent improvements in automated bidding have reduced cost-per-click in many locations, and the ability to have potential clients call your office directly from an ad on their cell phone makes conversions easier than ever.

     4. Posting an Ad in Psychology Today: This grandparent of online directories for therapists still generates consistent referrals for many practitioners, and spending under $30 a month almost guarantees a positive return on investment even if you only get a few referrals a year.

     5. Community Networking: Now that more people are back in offices, marketing to referral sources in the community can offer a unique, inexpensive way to build a practice. Connect with medical professionals, educators, attorneys, and others who often need referrals for psychotherapists in their work.

     6. Creating Email Newsletters: Connecting (with permission) to past and present clients can be a wonderful way to get the word out about your services. Programs such as Constant Contact and MailChimp offer inexpensive ways to generate attractive email newsletters.

     7. Offering Lectures and Workshops: Offering lectures and workshops is a great way to attract people who may initially be resistant to psychotherapy. In my group practice, we have consistently found at least 20% of workshop attendees follow up with a therapy appointment. These can be offered in a variety of settings in the community, as well as in your own office if you have the space. And of course, if you can stomach it, you can also do them on Zoom.  

***

Attempting to read the tea leaves of psychotherapy practice is always a risky and imperfect task, especially in volatile times when unexpected events can quickly change the trajectory. Nonetheless, it seems clear that the peak of mental health referrals for some practitioners has passed. Preparing for this now will never hurt, and in fact will help to smooth out the transition if referrals drop to pre-pandemic levels.

 Questions for Thought

  • How did the pandemic challenge you to think differently about the way you practice?
  • What is your strategic short and long-term plan for building and maintaining referrals?
  • What can you do to revitalize your brand through internet marketing, pro bono workshops, and podcasts?
  • What is the feasibility of consulting with a marketing expert for you?
  • What about this article challenged you to do or think something differently to increase the client flow in your practice?  

In a Volatile Post-Roe World, Morals and Medicine Clash

Posted on by Psychotherapy.net Team

Having kept in touch with one of my former clients (EN), an OB-GYN, I (LR) was curious about the personal and professional impact on him of the recent Supreme Court decision in the Dobbs v. Jackson Women’s Health Center case that overturned Roe, and with it, federal protection of womens’ reproductive choices.

While EN neither sought me out for counseling, nor was the following conversation part of a therapeutic interchange per se, I hope that excerpts from that conversation might be useful to fellow psychotherapists, counselors, supervisors, and trainees who are or will be working clinically with medical health care professionals who serve women.

***

Morals, Ethics, And Medicine

LR: I was thinking of you and wondering, as a practicing OB/GYN, how the Supreme Court’s decision to overturn Roe has affected you both personally and professionally.

EN: It's challenging because there's EN, who has very strong political views, and then there's Dr. N, who is supposed to separate his political views from his medical practice — and EN doesn't necessarily care about offending people. But Dr. N doesn't want to offend anybody because people are entitled to their opinions. With that said, as a women's health care provider, obviously my first concern is women's care, women's health, women's access to care, what women can do with their own bodies. And having anybody try and place limitations on that is disconcerting.

In Florida, the new rule is 15 weeks. But there are loopholes, and you can read into it, and read around it; but it's up to the doctor's discretion. I personally don't perform terminations anywhere near that gestational age, but we’ve certainly had plenty of patients who have required it for one reason or another. It's one thing to refer somebody down the street; it's another to have to refer somebody out of state. And we've had that issue.

Typically, when you're referring somebody for those reasons, they're not happy about it because they've already likely been dealt a somewhat devastating diagnosis for their desired baby. Then they have to make a very challenging decision, and are forced to do so in an uncomfortable, unfamiliar environment, likely without the support of their family and friends that they would have at home. So, it's easy to say, “Sure, just travel to this state or that state,” but not everybody has the means or support to do that. There are so many different angles that you can come at which create their own additional set of problems.

LR: In thinking of the last one or several women that you had to refer out of state for pregnancy termination, what were some of those interactions like for you — since many of them, I would imagine, you've had ongoing relationships with?

EN: Fortunately, there haven’t been many, but those I’ve referred were due to major fetal anomalies that were diagnosed after the legal limit for termination. That in and of itself was a tremendous challenge. Most of our conversations were focused on their devastation and processing of the diagnosis — not about having to travel to get it done. I think that part of it was a bit on the backburner. But that was just for them. I think that the more cases one has the more complications that are going to arise.

LR: How did these conversations impact the relationship you had with these particular women as well as you personally?

EN: I don't think they impacted our relationship because they know that I don't perform the procedure anyway. It is a challenging procedure with more risks and more complications, regardless of where you have it. And many of us have chosen not to do it for that reason. I'd rather have someone who has quite a bit of experience do it. So, whether I'm referring them down the street or three states over, they know that I'm not the one who's going to do it. And so, I don't think that has any negative impact on our relationship. It's more just a matter of the logistics of finding somebody — helping them to locate somebody and them having to arrange their plans.

LR: Have you stopped performing procedures completely or just after 15 weeks?

EN: My limit was always about eight weeks. And it's never been something that I advertised doing. It's more if I have an existing patient who finds herself in that situation, it's something that I can offer to my existing patients. There are plenty of other resources. There are plenty of physicians who welcome referrals for it. That's a controversy that I've tried to avoid. But for my own existing patients, my preference has been, “I'd rather be the one to help you through this than have to refer you elsewhere.” But I have my limits also. And that's just out of comfort medically for the procedure and nothing else.

LR: Have you grown more wary or vigilant that somehow, you'll raise attention of a regulating body, or someone will launch a complaint, or someone will hear or mis-hear this or that and report you? I guess what I am asking is, have you become more fearful or threatened in this post-Roe environment?

EN: Not yet, because again my practice routines are well within the limits of current legality in the state. Should that change? Yeah, of course I'm concerned about the ramifications. But like I said before, I try to limit my exposure. I don't want it necessarily out there well known in the community that this is something that I do or offer, because no matter how you look at it, there's a stigma and there's controversy associated with it. And it's just something I'd rather avoid. I want to be there as a physician for my patients, and offer them what they need, and avoid all the other drama that might come with that.

LR: Have there been clients or patients you've consulted with or treated where your political and personal views clashed and were difficult to suppress?

EN: Yes, but not necessarily for that patient's particular healthcare needs, but more so because we'll strike up a conversation and they'll make an offhanded remark, not necessarily understanding all the medical implications. You know, it's very easy for somebody to pass judgment and say, well, 15 weeks seems very reasonable. But the reality is, it's incredibly challenging to diagnose a genetic abnormality, a chromosome abnormality, a major fetal abnormality prior to that time. And so, there are medical limitations to what we can do and when we can do it. So those tests aren't really available and they're not confirmable. You can't confirm it until right around that time at the absolute earliest. So, it's easy to say, ‘well, 15 weeks sounds reasonable’, and patients have had plenty of time to make a decision. That may be the case for an elective termination. But for medical purposes—which once you're extending into the second trimester, the great majority of them are for medical purposes anyway. It's not enough time to make that decision.

LR: Is it the case that genetic anomalies might not be manifest in an observable way at 15 weeks?

EN: We typically begin screening for chromosomal abnormalities — the most common example being Down syndrome — at around 12 weeks.

LR: Tight margin, but that’s a screening test which is by definition non-definitive.

EN: Correct! So, if that test comes out abnormal, the typical recommendation is for amniocentesis, which historically was performed after about 16 weeks. You can't make a screening test any more than it is, and they are inherently designed to have false positives. And so, you can't make a definitive diagnosis and a definitive management plan with just a screening test. And if you don't have the ability to confirm, then, you know, you're stuck. That's for chromosomal abnormalities.

In the case of fetal anomalies — let's just call them birth defects — the first full anatomy ultrasound is done somewhere between 18 and 20 weeks (about 4 and a half months). So, yes, you can see some vital anatomy earlier than that for sure. But not all the structures, not everything.

LR: And neurological sequala of these chromosomal or genetic anomalies won't show up until after birth?

EN: Right! That, there’s no way to screen.

LR: Do you get a sense that this 15-week window was determined after comprehensive consultation with medical specialists or the result of political footballing?

EN: I'm sure it was some kind of a behind-the-scenes compromise, and I don't know who came up with that 15-week gestational age. But, you know, I'm sure there was something behind the scenes.

LR: What about the overflow of the Roe decision into your personal life—conversations with your wife, with your friends, with family members, where the EN who is free to express his political views is not tethered by his professional obligations? How has it affected you outside of the consulting room?

EN: For the most part, the people I converse with are like-minded people. And even if some of these people vote Republican — which some of them do — they’re voting Republican for other reasons like Israel and taxes. And so, when we talk about this, it's easy to have a room of like-minded people, and just get angry, and talk about how ridiculous it is.

LR: In your deepest, most personal place, what has been your visceral reaction as a person, as an OBGYN, or some combination of the two? What has it been like for you since the overturning?

EN: It's frightening because there was always the threat that Roe would be overturned. But most people felt it would never happen, that it was established law. Look, even the most recent Supreme Court nominees would say it’s established law, and yet here we are. So, we all were fearful that it could happen but didn't really think it would happen. Now that it has happened, it's frightening. And then for a while afterwards, it was the thought of what's next? Is gay marriage next on the docket? Or contraception? You know, where are we going here?

LR: So, frightening in terms of what rights would be taken away from women and other groups next—frightening ideologically, frightening from a humanistic standpoint. What about this is personally frightening to you, perhaps as a father? I know you have sons.

EN: This country is regressing. I have sons who are perfectly capable of impregnating someone else. But, you know, we try to teach them responsibility. I don't have any intention or feel like I'm ever going to have the need personally to have a termination. And so, my fears and my anger are more because of how it affects others and because of the type of practice that I'm in and it affects me at work. So no, this is one of those issues that doesn't have a direct impact on me as a person, but I feel incredibly strong about it. And that's the part that has the deepest effect.

LR: So, the most frightening personally is, as a citizen of a country that seems to be going backwards?

EN: How about as a conscientious human recognizing that not all political issues are personal? I have no intention to marry someone of the same sex as me. But I feel unbelievably strongly that everybody should have the right to marry whoever they want. That's not affecting me directly. But that's deep down in my core.

LR: Do you see yourself as an active or increasingly active outward advocate in some way in your professional future?

EN: I’ve always emphasized prevention because I think it’s the right way to go anyway. So, I think termination is a choice. And you've got the morals and you've got the ethics and then you've got the medicine, right? So, from a strictly medical perspective, prevention is better. And so I've always pushed that, I've always emphasized it. But now, I'm doing so even more because while there might be certain limits now, those limits might become stricter down the road. And so, patients should want to be proactive in prevention anyway. Number two, they may not have the same options later. And who knows what kind of access they're going to have to birth control later on? You know, is that in jeopardy as well?

It's a ridiculous hypocrisy, because they want to limit access to birth control; they want to limit access to pregnancy termination. But they also want to limit the social programs that might help with these unwanted children once they're forced to be born to parents who can't afford to have them and don't want to. I don't think I am going out on a limb to say that a solid, substantial number of those who advocate pro-life have somewhere at some point in their life been in a situation either directly or indirectly where they probably needed a termination.

LR: In closing, are there particular patients that you've had over these last few months that have really struck a chord in you and sort of torn you up inside? And if so, how did you deal with it?

EN: How I dealt with it personally is different. Professionally, it's hard not to have empathy. It's hard not to feel for someone who was given the diagnosis that their baby, who they wanted, is not going to survive the pregnancy. And so now they had to make a very difficult decision, and it was just made that much harder for them.

I'm grateful that I don't have that many patients yet who I’ve had to refer out for terminations due to chromosomal anomalies. A fair number of those end in early miscarriage before you get to that point. But it's still there, and it's always going to be there. It's the nature of the field.

LR: Thanks so much for sharing with me today.   

How to Learn from Painful Early Career Failures

Posted on by Psychotherapy.net Team

A friend's adult son recently returned home after a failed relationship. When his parents questioned him in hopes of understanding the relationship’s demise and to help him process the experience, they were quite discouraged to learn that from their son’s perspective, “she (his now ex-girlfriend) was always on me for not taking my clothes out of the washing machine when the cycle was done so it had to be rewashed or else it would become mildewed.” Had the son been unfaithful or did the infidelity lie with his girlfriend? Was it financial strain? Immaturity on one or both of their parts? Had the stress of childbearing done them in? Or was it, as the girlfriend claimed, relationship death by a thousand spin cycles? 
 

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Since hindsight is 20/20, metaphorically speaking, the story of my friend’s son gave me pause to reflect on a couple I worked with many years ago. In looking back, I regret not having had the confidence, skill, or comfort in using metaphors at the nascency of my clinical career when a couple was referred to me for counseling. And yes, perhaps I should have referred that ailing dyad to a more seasoned clinician, but I was, after all, receiving supervision. In retrospect, my supervisor was very task-oriented, not particularly emotionally focused, and to add just the right pinch of irony, I had recently graduated from a behaviorally- inspired clinical Ph.D. program. At the time, behaviorism seemed like very powerful magic to me, and my supervisor’s cock-suredness provided the necessary added ingredients I needed to help this couple. Ah, 20-20 hindsight! 

The husband had come to counseling with his wife under duress — more likely threat of who knows what. He didn’t perceive anything to be wrong in the relationship and couldn’t — truly couldn’t—understand why his wife was “so damn upset with me” over the chicken.” Ah, the chicken! According to the aggrieved wife — and I am paraphrasing from remote memory, “all he ever wants to eat is chicken, whether we eat at home or go out to a restaurant…I’m fed up!” She went on, “he doesn’t even want me to spice it up!” 

Although my graduate training and clinical supervision at the time blended to offer me what I thought was the right recipe for clinical success, I’m almost embarrassed to admit to what I did in those tense two or three sessions I had with this couple. I attempted (and you probably have already guessed where this is going) to build a behavioral contract which included small steps the husband would take to diversify his poultry paltry palate which would then be reinforced by the wife. God only knows what I cooked up for them in that ridiculous contract. But they were willing customers, and of course, the counseling predictably ended as quickly as it takes to flash-fry chicken wings. True to form and quite predictably, my supervisor lambasted me for failing to create a sufficiently detailed contract.  

What might I have done differently? Well, I might have used the husband’s singular food choice as a metaphor for his desire for certainty and predictability, maybe going as far as he would let me in exploring the basis for that need. I might have reframed his diet as the desire to make it easier for his wife to prepare meals. I might have shifted focus to his wife’s frustration and encouraged expression of what about her husband’s restricted food choice was particularly distressing for her. Or, I might have worked within the metaphor of spicing up the relationship. I certainly would have worked harder to create a therapeutic atmosphere in which emotions could flow freely to the top.  

I often wonder whatever happened to that couple who had the misfortune of falling under my care all those years ago. Did the marriage survive my ineptitude? Did the husband ever learn why his wife was so upset about his unrelenting choice for chicken? Did they find their way to a therapist who was able to salvage the meat from the decaying bones of their frayed bond? 

   ***


Questions for Reflection 

How did the author’s reflections impact you personally? Professionally? 

How have you framed/re-framed some of your early therapeutic mistakes?

What might you have done with the couple depicted in this narrative?

What are some of the resources you rely upon when confronted with a challenging case? 

Victor Yalom on Psychotherapy and the Pursuit of Mastery

Posted on by rezendevknowfully.com

Keeping Current

Lawrence Rubin: Dr. Yalom, you are the founder of Psychotherapy.net so by definition, an entrepreneur. But as your Editor, I also know you to be a self-taught tinkerer, craftsman, and artist, as well as a practicing psychotherapist. While I’d like to touch on each of these facets in our conversation, please tell us first what are you working on now?
Victor Yalom: Well, I am always working on many things at the same time. I don't know if that's due to an inability to focus on one thing or just that I have multiple interests and duties running this small enterprise of Psychotherapy.net. 

We're always thinking of ways to provide content in a form that is useful to therapists practicing in the field as well as adapting to current times
One of my focuses after 27 or so years of recording who I consider to be the greats in our field and making training videos, is finally stepping up to the plate and doing some recordings of my own work as a therapist. Just yesterday, I recorded a case consultation group that I led online. This should result in one or more online courses in which I will be teaching some core skills in therapy that I have learned from my mentors as well as from my clients. So, that's very exciting. 
 

In addition, we at Psychotherapy.net are always scouting out and finding experts to be featured in videos. We have a new video coming out on Emotionally Focused Therapy and another on online crisis counseling. We're always thinking of ways to provide content in a form that is useful to therapists practicing in the field as well as adapting to current times. We realize that while people have grown accustomed to receiving video content in shorter bursts, we haven't quite reduced ours to the 15-second clips of TikTok. However, we are producing, for example, a shorter series called Mastery in Minutes that are up to 30 minutes long where we're trying to present core ideas or skills to therapists.

LR: Now that you’ve made this transition from interviewing experts in the psychotherapy field to being videotaped while you personally do psychotherapy, do you see yourself at this stage in your therapeutic career as an expert?
VY:
doubt and uncertainty are inherent in our work
I do feel that after practicing for almost 40 years now, I've acquired some valuable skills that I think are important to pass on that are not commonly being taught by others. It's an evolution because I think like most therapists, even experienced ones, that there's so much ambiguity in our work that a lot of the time I feel like, gee, I'm not sure what I’m doing. Would X or Y expert think that I’ve studied enough to be doing this? What will other colleagues think? How will the establishment of experts, or those who are practicing evidence-based techniques or teaching them in universities view this?

So, those are some of my doubts. But then the other side is that doubt and uncertainty are inherent in our work. I don't think it's a realistic or even desirable idea that we should reach a state of certainty about our work, but perhaps more comfort with our doubts and our questioning, and our realization that therapy is an ambiguous and creative enterprise.  
LR: I hope that the younger therapists who read this interview will embrace this idea that certainty is elusive, and therapy works but sometimes for reasons that are simply outside of our understanding. I understand that you've also been doing work with foreign distributors so I'm wondering what that looks like and what are some of the challenges?
VY: To a great degree, we've been trying to take the valuable, rich library that we've created over the last 27 years and make it as widely available as possible. It started very slowly at first with VHS tapes and then DVDs, but once we got into streaming, it was a lot easier to get it out there widely and internationally.

a lot of businesses have pulled out from Russia, but it's not something I've struggled with too much because the therapists there want to learn
But obviously, not everyone speaks English, so we've partnered with some businesses and organizations overseas to translate our videos and make them available. We have distributors in China, Italy, Greece, Russia, and a couple other countries. Typically, they've simply translated our videos with subtitles, but the Russians have been dubbing them using voice actors as well and so it's pretty simple in that sense, but there are unique challenges.

Our Russian distributors, not surprisingly, are having incredible challenges given the war and the boycotts. We were speaking with them yesterday and they’re actually moving to Georgia, the country, not the state, and we're finding ways to advertise, get payments, have money transferred to Georgia, and then sent here. At least that's the plan.

And with that, there's the potential ethical concern. Obviously, a lot of businesses have pulled out from Russia, but it's not something I've struggled with too much because the therapists there want to learn. They’re certainly not responsible for Putin's madness and butchery. I feel pretty clear that if we can find a way to continue to offer our videos to Russian therapists, that's a good thing.  
LR: That's interesting. I was going to ask you about possible ethical concerns and conflicts, but when you couch it in the context of therapists, whether in Russia or China still want to learn, you are providing a needed service. The therapeutic skills that these therapists will learn because of our association with them will help the citizens of these countries who have access to therapy. I don't know how widely accessible therapy is, however.
VY: Right. It reminds me several years ago, we had an inquiry from some Iranian therapists who wanted to publish our videos there. Let's just be upfront, in smaller countries like that, it’s not really about making significant profit. They’re relatively small markets. But it’s more just wanting what we’ve done to be viewed and used in training therapists. It turns out they were on the list of nations that the US does not look favorably upon. We finally figured out how to apply to the US State Department to get permission to have our videos translated and sold in Iran. But, after about a year and a half, we got a one-page letter that said, “Sorry, no!”
LR: It’s interesting with regard to Russia and Ukraine and the Middle East, that some of the contributors to our websites, some of the folks who write blogs and articles are doing so from those places about some of the challenges of delivering therapeutic services to people who are directly impacted by the war and related political tensions. So, I can see the benefit of partnerships with some of these entities. I also see the ethical concerns. Are there any other challenges when translating therapy into different languages considering that much that occurs in the therapy space is non-verbal? 
VY:
in Russia, they're using voice actors to dub our videos, apparently because that's quite common there as well as in other countries
As I said, in Russia, they're using voice actors to dub our videos, apparently because that's quite common there as well as in other countries. I was concerned about that. It’s so important and that's one of the reasons I started producing videos in the first place—to capture the non-content information, like body language, facial expression, tone of voice, inflection, and all that. I was concerned that a lot might be lost or missed. However, they've assured me that their actors are capable to a remarkable degree of mirroring that of the recording. Since I don’t speak Russian, I’ve got to take their word for it that they’ve done a good job. But they typically offer both, the option to listen to the dubbed version and/or subtitles.

Well, if it's a good translation, then it should work and that's not my area of expertise but just a little example. I recall looking at one of the transcripts initially done in China many years ago be one of our distributors. They were translating some discussion with my former teacher and mentor, James Bugental, who was referring to growing up in the Great Depression and the ways that impacted him in terms of his attitude towards money. It was quite a traumatic thing for that generation.

I came across the transcript, and I don't recall how I did it, because I don't speak Chinese, but somehow I became aware that they referred to the Great Depression, the historical event, as major depression, the psychiatric diagnosis. So, you have to have good translators. Language is very nuanced.

With our Chinese distributor, they're used to presenting videos in more of a weekly webinar format, so they've taken our videos and chopped them up into 30-minute segments that they offer once a week. They’ve wanted to add some live Q&A to some of our videos. For example, we have a popular course with my father, Irvin Yalom, “The Art of Psychotherapy,” and I've done some live Q&A even though I’m not him. I know the content well, so I’ve been able to answer some questions from the Chinese students that hopefully helps make it more understandable to them.  

How I Built This

LR: All meaningful ventures such as creating Psychotherapy.net have an origin story, so I think our readers would be interested to know yours.
VY:
I had the chance to study in-depth with James Bugental, who was a real master psychologist, psychotherapist, and teacher
After I completed my doctorate in psychology, I had the chance to study in-depth with James Bugental, who was a real master psychologist, psychotherapist, and teacher. I felt in many ways that my education or training as a psychotherapist really commenced with him. There was a group of us who learned from him in yearly five-day retreats, after which I formed a monthly consultation group with a smaller group. I call him a master because of his skill and dedication to the work and his thoughtfulness in teaching others.

As part of his work, he often demonstrated various aspects of psychotherapy, including doing demonstrations with us, either through role plays or with those of us who wished to be able to explore our own personal issues, particularly as they impacted our work as psychotherapists, which it always does, of course.

For several years, we kept saying “We needed to get this guy on tape” for the benefit of those around the world who haven’t had a chance to work with him personally. And at some point, I had the great realization that he wasn’t getting any younger. He was 80 years old, so a buddy and I recruited a couple of volunteer clients and secured the services of a videographer to record him doing two sessions with two clients.

Like many ventures, we didn’t really have a goal in mind at that early point
So, we created a videotape, VHS, which was an initial venture in crowdfunding. We actually snail mailed his mailing list of about 200 folks saying, “Would you be willing to purchase a copy of this videotape to help us in our production?” We raised a few thousand dollars, which got us maybe halfway there to the costs, chipped in some of our own money, and ended up producing a videotape.

Like many ventures, we didn’t really have a goal in mind at that early point. It was not my plan to start a business. I just wanted to make a tape and ended up going to the Evolution of Psychotherapy conference, getting a booth there selling some of these and some other videotapes. One thing led to another after that. But that’s the short version.  
LR: If I were to magically transport myself to that Evolution of Psychotherapy conference and interview that guy in the corner with the booth and the VHS tapes and asked him, “Have any idea where this thing’s going?” or “Do you have your next master in mind?” what would he have said?
VY: It was very exciting because Jeff Zeig, who runs those conferences, was kind enough to send out a letter to other speakers telling them that Victor Yalom, the son of Irvin Yalom, was going to be selling some tapes, and if others had some to contact me. I ended up getting a small collection of videotapes, including some group tapes of my father, and pricing them much lower than they were otherwise available, at the price of a textbook or a professional book. Not some of the very high-cost textbooks that we see today. 
  

There was tremendous demand and excitement, so I realized I was onto something. Now recall this was 1995, right at the birth of the internet, so if you were a professor or a therapist wanting to get or see therapy in action, it was very hard to do. There was no YouTube. There were no online courses. And the few videos that were out there were hard to track down. 
 

I realized I had found an untapped need
At that point, I realized I had found an untapped need. I’m not a trained businessperson, but I did learn a bit over the years, like when folks are pitching business ideas now, one of the things they think about is what problem are they solving? In looking back, I was solving a problem that I had experienced in graduate school. Up to that time, I had hardly ever seen a therapist do therapy, and I thought, “This is crazy.” So, I clearly felt there was something there. 

LR: So, an unintended pioneer in a market that didn’t yet exist. A venturer without capital. Aside from the technological savvy that you had to acquire along the way, were there any major obstacles in accessing the masters or getting people to sign on to this “little engine that could?”
VY:
What was more surprising was that clients were and still are willing to be on camera and reveal personal things about themselves
I think I’ve been pretty fortunate. Perhaps my enthusiasm has carried me quite a long way, and honestly, sharing the last name of my father certainly opened some doors for me. I can’t say that was a great benefit in what I was doing at the time, which was doing private practice. Certainly, name recognition is nice—and has some downsides as well—but nobody refers patients to you just because you have a famous last name. But in terms of getting legendary clinicians to return a phone call or be willing to trust themselves with me to make a recording of them, I’m sure that helped.

What was more surprising was that clients were and still are willing to be on camera and reveal personal things about themselves for the benefit of having the opportunity to get some free treatment by famous therapists, as well as contribute to the training of our field. Of course, not all clients are willing to do so, but every time we’ve wanted to produce a video, we’ve been able to find clients who are willing to bare their souls to a wider audience. I’m always grateful for that, and also feel protective of them in terms of wanting to carefully screen them to make sure that they are comfortable with the types of things that might come up and be willing to edit out material that just felt too sensitive, even if they were willing to share.  
LR: That’s an interesting perspective because in Narrative Therapy, one of the goals is to help the client assert expertise over their own life, and one aspect of that expertise is giving clients the opportunity to teach other clients through written narratives or through videotaping. 

I hadn’t thought until you just mentioned it how much value, over and above whatever benefits accrue to the audience of these videos, the clients might reap in being with a master, and how putting themselves out there might give them an opportunity to share in some way beyond the isolated room of therapy, and even truly benefit others who might be reluctant. 

VY: I feel, although I don’t know this for a fact, that some of the clients with whom we’ve worked obtain a sense of advocacy from their participation, particularly when they are part of an underrepresented population, for example, a military veteran or an African American client. We recently published a video series on counseling African American men. You know because you were a part of that. 

I strongly suspect that part of the clients’ motivation in that series was, “I can help normalize this therapy process for African American men who have certain struggles often related to racism, and I want to encourage others who may have similar struggles as me to get therapy and to train therapists in how to better work with this population.” So, I suspect there’s some sense of advocacy and caring that therapists get the best training possible to treat folks that are similar to them in whatever characteristics. 

LR: Having well over 300 video titles, how has Psychotherapy.net kept pace with the expanding demographics that psychotherapists serve?
VY: Just to be clear, yes, we do have over 350 titles now, but we have not produced all of those ourselves—maybe a third of those. The rest we’ve found by going far and wide looking for videos that were out there but, in many cases, not widely available. 

I made a conscious effort starting several years ago to produce videos with both therapists and clients of more diversity
One case always stands to mind. I made a video with Natalie Rogers, art therapist and daughter of Carl Rogers. At the end of the production, we were filming in her house, and she brought out a shoebox full of old VHS tapes and DVDs for me to look through. She entrusted me to take them home, and I reviewed them. Some were home recordings with poor video or audio quality. But I came across one excellent interview of him, professional quality, and finally tracked down that this was produced in Ireland by RTE, I believe it stands for Radio Television of Ireland. Lo and behold, they had the original master in the vault and managed to work out a deal so we could distribute it, so I recorded a new introduction with Natalie. That’s a little aside just to state that we haven’t produced all the videos we offer. 
 

But we have a legacy of titles. And I realized some time ago that we were, not surprisingly, overrepresented with master therapists. Let’s take out the term master therapists, but with White male therapists and Caucasian clients. So I made a conscious effort starting several years ago to produce videos with both therapists and clients of more diversity. So, we’ve been doing that, but I have a lot of catch-up to do. 

LR: In this era of YouTube and TikTok, the consuming public seems to crave products that pack their punch in shorter bursts. Do you see that as an obstacle to your goal at Psychotherapy.net of portraying therapists doing the real and often laborious work of therapy?
VY: It’s a balancing act, indeed. Several years ago, we did a focus group with some of our customers to try to better understand their needs, and that was certainly one of them. Therapists told us they may have a 30-minute gap in their schedule, or they may have a cancellation, and your typical videos of one or two hours in length, often showing full sessions of therapy, didn’t fit that particular need. So, we launched a collection of videos called “Mastery in Minutes” that are 30 minutes or less. They are at times new productions, at other times excerpts of our longer videos with some additional introduction or discussion. 

So, we try to meet both needs. We do try to offer shorter videos, and our longer videos are broken up into chapters. We have some very long courses that might be 6 to 10 hours, but they’re broken up into shorter chapters. 
 

One of our productions I'm most proud of, Emotionally Focused Therapy Step by Step, is the most ambitious project we’ve ever done
One of our productions I'm most proud of, Emotionally Focused Therapy Step by Step, is the most ambitious project we’ve ever done and frankly, I think that anyone has done. We filmed over 100 hours of EFT sessions with six couples and four different therapists over a year and a half, edited that down to about eight hours of sessions and a few hours of discussion and commentary. I have to give my wife, Marie-Hélène Yalom, our Senior Director of Strategy and Product Development, a lot of credit. While she’s not a therapist, she’s learned a lot about EFT and painstakingly edited this down with Rebecca Jorgensen, the main therapist featured in this project. 
 

Obviously, we don’t expect someone to sit down and watch that all at once. So it’s broken down as the title implies, step by step, into many small skill sets, and EFT, for people who know, is broken down into steps and stages. So, you can watch our longer videos in shorter chunks and skip from chapter to chapter. 

LR: It sounds like a real challenge to balance the demand to satisfy the customer but remain faithful to the practice of psychotherapy. From an insider’s perspective, I think you’ve done a nice job of that balance, but I’m a bit biased. 
VY: Yeah, it’s a tension that exists in our field and in many aspects of society, people want short-term fixes, quick fixes. People want short-term therapy. Some therapists promise that. Some approaches promise that, but whether they’re able to fulfill that promise? That’s debatable. I think at times you can convey some powerful ideas in a short amount of time. But to master them, like anything, takes—
LR: Hours….
VY: Dedication. Practice. Maybe some luck, or the right circumstances with the right clients who are ready to make some changes. Other times it’s painstaking, and you may work with a client for years and not see a lot of changes but nonetheless, they may benefit greatly from having support.
LR: How have you evolved in your approach to interviewing the masters over the last several decades?
VY:
I’m able to be myself more and reveal more of myself in all aspects of my life. I believe that shows up in doing interviews
I think it parallels my development as a human being, which is not an unusual progression in that I feel more comfortable in my skin, have more confidence that I have something to offer, and have come to accept parts of myself that I felt uncomfortable with or ashamed of not as only part of who I am, but that I like and feel proud of. So, I’m able to be myself more and reveal more of myself in all aspects of my life. I believe that shows up in doing interviews. That hopefully shows up in how I do therapy, how I relate to my friends and loved ones.

Specifically, in interviews, I feel more confidence that I know a lot about therapy. I have to be a jack of all trades to know a little bit about different techniques and approaches as I’m producing videos of various types. I don’t have the academic background like you do, and don’t keep up as much with the research, but I feel I know enough to ask questions and engage in dialogues that I hope are informative to our viewers and entertaining to watch in the sense of seeing the discussions and the therapy sessions, which are typically featured in our videos as being alive and representing the best of humanity.  
LR: One of the qualities of your interviewing style, which I assume filters into your therapeutic style as well, and perhaps into your personal style, is that you don’t seem afraid to ask hard questions. You’re clearly willing to put someone on the spot in search of the most real they will allow you to have access to.

And that, to me, suggests a certain degree of confidence, and also an unwillingness to accept what’s offered as expertise without proof of that expertise. So, that’s just sort of a side comment for those of who will venture into this interview, which will probably take more than five minutes to read. I think it’s as important to watch your style of interviewing these masters, and the way you hold them accountable for their presumed expertise, rather than just fawning over these masters.  

The Art and Artistry of Psychotherapy

LR: Most of your audience “knows” you through the interviews you’ve done with master therapists and through the cartoons you create for the site, but they likely don’t know that you also work in paint, metal, and wood. I’m wondering how this continual drive to express your creativity has manifested in your own identity and practice as a therapist?
VY: Interestingly enough, I didn’t grow up doing things I considered artistic, certainly not in the visual arts. This all started at a workshop with my mentor, James Bugental. I have a hard time sitting still and listening, so I would draw. I was drawing little stick figure cartoons, one of which eventually evolved into a cartoon. It was a stick figure of a cactus laying on a sofa saying, “Well, I didn’t come from what you would call a touchy-feely family.” 

My drawings were literally stick figures. And when I created the website, I had an idea to put a few cartoons up there, so I hired some people who knew how to draw and took these ideas and made cartoons out of them. And then at some point, an ex-girlfriend of mine said, “Well, you have a very primitive drawing style, you should draw them yourself.” So, I started drawing my own cartoons, and that led me to taking a painting class, and as you mentioned, I now do metal sculptures. But this all started maybe 20 years ago when I was about 40. So, I credit Psychotherapy.net with helping me to discover some activities that bring me a great deal of pleasure. 
 

increasingly view therapy as a creative enterprise
In terms of your question about how that may impact my therapy or show up in my therapy, I increasingly view therapy as a creative enterprise. I grew up in an academic family. My parents are writers. I’m taking another little aside here, but I always had an interest in or fascination with the business world but was very much an outsider, and back then, you know, when I graduated from college, you couldn’t start a business as you can today. If you wanted to work in the business world, you worked in a Fortune 500 company. I tried and I was fired. I failed miserably. 
 

And in the process of creating Psychotherapy.net, which was just a side hobby for many years while I was in full-time practice, I came to realize that building and growing a business is the ultimate creative enterprise. I had an idea to make a videotape, I took that idea and created something from it, and then that evolved to something else, which evolved into something else. 
 

And now here, you and I are having this interview on a technology that didn’t exist when I started this, so getting finally to your question about psychotherapy; it’s an extremely creative enterprise, just like this conversation. A client comes in and says something and you react, you have internal reactions, and then somehow words come out of your mouth and you say something, and it goes from there. 
 

You don’t know what’s going to happen with what you do with them and what’s going to happen with their life. You try to adapt what you do and what you say in a way that’s going to be helpful. Certainly, there are certain approaches that give you more structure or guidance, and those can be critiqued as overly manualized or cookie-cutter, but ultimately, in my opinion, if you’re going to do work that’s at all meaningful and helpful, you need to find a way to enter their world and to do so in a creative and imaginative way. 

LR: And that goes back to what you were saying before in terms of your own personal evolution, becoming more comfortable with who you are in your own skin, warts and all. I think therapists are most effective when they are most genuine and when they’re most vulnerable, and they invite themselves into a co-creative experience with their client. That’s evident in watching you work, at least in the interviews.

You have taken what I consider a heroic step, as you recently transitioned from the man behind the camera to the man in front of it. You did part one of an experiential teletherapeutic interview with an Italian woman. I wonder what it took for you to put the director’s hat down and step in front of the camera and, in a sense, expose yourself to your audience in a new way?  
VY: I feel very fortunate that I had a chance to study with quite talented therapists like James Bugental and, of course, learn a tremendous amount from my father, and then in the process of creating other videos work with and get to know Sue Johnson and Peter Levine and Otto Kernberg and Reid Wilson, and many others. Some I had more contact with and thus learned more from, and others less. 

I feel reasonably confident that I have some things to offer myself and some important things I’ve learned that I don’t think are widely taught
And over the years, like I think any maturing therapist, I have been able to integrate and internalize that into my own style of working to the point where I feel reasonably confident that I have some things to offer myself and some important things I’ve learned that I don’t think are widely taught. 

LR: Such as?
VY: Two things come to mind. From Bugental, some specific techniques to help clients more vibrantly explore their internal world, their subjective experience in an alive and present way versus just talking about themselves. In particular, he taught some specific techniques as well as an underlying philosophy, and numerous ways to deepen that exploration. He suggested that therapists often encounter what he referred to as resistance, which can be a confusing term. Another way of thinking of it is that we get stuck in our ways, whether you call them defense mechanisms or just modes of coping or ways of being.

As we know as therapists, it’s hard for clients to really change the way they adapt to situations even when they aren’t helpful. So, we can help clients explore themselves, but often they reach a wall or there are restrictions in their ability to explore freely, and those could be that they intellectualize, that they shut down, that they focus excessively on pleasing you and the people around them and have a hard time accessing their own experiences and needs. So, in the process of getting them to do this internal searching, as he called it, you hit these roadblocks. He taught ways to help identify and loosen up those roadblocks; that might be a way of putting it. So those are some things that he taught me that feel very vital and powerful, and I don’t think are widely known.

with the advent of online therapy, it's been much easier to make recordings of not just one session, but longer-term therapy
And my father writes a lot about working interpersonally in the here and now between client and therapist in a way that I haven’t seen discussed much in other forms of therapy. How do you use the here and now of the therapeutic relationship? How do you work with that in a way that’s beneficial to the client?

So those are a few ideas that I feel are important and I don’t see discussed or represented in most of the types of therapies that are generally taught. Now, there are exceptions to that, but I feel compelled to teach them. And I’ve been mulling over this for several years now. And finally, with the advent of online therapy, it's been much easier to make recordings of not just one session, but longer-term therapy. I’ve just completed the course of seeing a client for 18 sessions, which we recorded, and I’m at the beginning stages of producing a course that will include excerpts of these sessions, and hopefully of some other colleagues as well, to teach some of these ideas.   
LR: You’ve mentioned James Bugental numerous times as being historically and personally influential in your own life’s work. So, I want to ask you, Victor Yalom—perhaps you haven’t thought in these terms before, but do you see yourself as an influencer?
VY:
I’m proud of what we’ve created with Psychotherapy.net, and I think we’ve done something useful and I’m certainly part of that
IOver the years running Psychotherapy.net, we’d get phone calls and emails, and sometimes when I’d answer the phone, I would get comments like, “Oh, I can’t believe I’m talking to Dr. Yalom,” and I always assumed they were confusing me with my father.
LR:  would never do that. [Note: LR actually did this when first applying for the Editorship]. 
VY: And many times they were. But since you asked, I can’t resist responding from time to time to customer emails. I find it helpful to keep my finger on the pulse of what’s happening there. And occasionally I do get people who know me from the videos I’ve made. Our videos are widely used in universities in the US and around the world, so it’s fair to say that I’m proud of what we’ve created with Psychotherapy.net, and I think we’ve done something useful and I’m certainly part of that.

The Long View

LR: As someone who has had a front seat to the evolution of the field of psychotherapy over three decades, how do you think the field has changed on your watch? Or more specifically, what tensions in the field have you noticed?
VY: It’s really hard to say. I remember when I just started grad school, Nick Cummings, who started the California School of Professional Psychology, and hence the whole professional psychology school movement (we have an interview of him on our site), gave us a rousing lecture about how private practice is dead. This was in the late 80s, and that hasn’t come to pass. 

In terms of approaches, CBT and other so-called evidence-based approaches are being taught much more widely. I have concerns about that. I think that yes, we want to do therapy that’s effective, and yet we seem to have traded on the idea that evidence-based treatment somehow defies this entire other line of valid research showing that the most important elements of change are the therapeutic relationship and client factors. 
 

The research consistently shows that one approach is not better than another approach
The research consistently shows that one approach is not better than another approach. And that may be just a research limitation—there are so many complexities and variables involved. But it’s clearly easier to research treatment methods than relationship variables, and there’s more funding available to research certain types, so there may be more data showing that those approaches are effective, but that does not mean that other approaches are less effective. 
 

So I don’t know what the answer is. I’m not involved in policy making or in formal training programs. But I am concerned about the narrowness or limitations that seem to be taught in many of the clinical graduate programs that students are being trained in. 
 

There are obvious other big changes in the field, the most striking of which is the move to online therapy that accelerated with the onset of COVID. And that’s never going to go back to fully in-person, though it’ll be a hybrid model. I think in many ways, it’s a good thing. It’s going to increase accessibility. It’s going to increase availability. 
 

I continue to do a group that moved online. While I was reluctant to do so initially, it allowed people who have moved or are on vacation or in another town to continue to be in the group. So, it’s better in that way, but you do lose the vitality of the in-person group experience. 
 

We all know of these other changes, app-based therapy, chat therapy, different pricing models, etc. There are problems with many of them, the reimbursement rates for therapists are quite low. Does chat have a useful place in therapy? The good thing, I think, is that it’s loosened up this historic and restrictive idea that therapy should be once a week in the office for 50 minutes, which came out of the idea that people have to get in their cars every day and drive to the office. Well, you know, I was guilty of that as well, in having our staff work primarily in the office. Suddenly we realized, as with all our assumptions, that doesn’t need to be the case. 
 

Therapy, like most every other business, has moved online and is doing just fine. So, in terms of therapy, what’s the best way to do it? Can it be fully online? Can you, when possible, combine online with in-person sessions? Should it be every week for 50 minutes? Should it be some more fluid model? I mean, for clients in crisis, why not meet for 90 minutes or two hours, and why not be able to have email or text during the week? Then you have to come up with different pricing models for reimbursement. But surely, we’re not going to go back to once a week in the office for 50 minutes, and I think that’s a good thing. 

LR: Traditional models have to be challenged and evaluated on a regular basis, or else they just become vestigial.

As we near the end of our time together and this journey you’ve taken us on, I can’t help but to reflect on the passage of time since I was in graduate school and what I have witnessed. And maybe it’s just a function of my getting older, but are therapists getting younger? It seems that therapists are getting younger and younger each day.  
VY: It’s incredible.
LR: They’re getting master’s degrees at 22 years old and within a year, and at the cost of sounding jaded and cynical, they have business cards advertising that they specialize in working with children, adults, and the elderly.
VY: I don’t know if people even have business cards anymore.
LR: Right. We have websites. It just seems that the entire field, both therapists and clients, if not society, is so much more restless, so much more impatient, and as you said before, hungry for quick change. Everybody’s an expert. There are a thousand books out there, 18 ways to this and 17 ways to that. How will Psychotherapy.net survive that seemingly insatiable hunger for more, faster, shorter, and sexier? What will be the secret to your survival? 
VY:
as many of the masters die off or have died already, we try to find clinicians who are doing good work and try to capture that work on camera
I’m not worried about that. I think we just have to keep producing relevant, good content, and as many of the masters die off or have died already, we try to find clinicians who are doing good work and try to capture that work on camera. That’s what differentiates us from most of the competition out there. 

Most of the online training seems to be done primarily by talking heads, lectures, webinars, and it just seems crazy to me that this is the way training has traditionally been done in our field, reading books, talking about therapy. In every other field, and I’ve said this over and over and over again, whether you’re a plumber, a dancer, a lawyer, or an architect, you learn by watching others do their work. I mean, you have to study and know the basics, but you learn by watching other masters doing their work, your bosses. 
 

You’re in court. You’re in second seat in a trial, and then your bosses are watching you do the work and giving you feedback, giving you coaching. Hopefully, constructive feedback. So, that’s kind of the essence of what we do, which is to show excerpts of therapy in action and explain why we’re doing it. Now, certainly, we’ll adapt. We’d like to do some live events, live webinars, and do these interviews. I don’t know what we’ll be doing, exactly. People talk about gamification and interactive video. I haven’t seen much of that yet, at least in our field, that’s useful. So, I’m not worried about that. 
 

I think the great thing about our field is that life experience helps
In terms of your thing about therapists getting younger, well, obviously, there’s partly a tongue-in-cheek thing going on there, because we’re getting older. I still have this little thing going back to Transactional Analysis, kind of a one-down stance where I still feel like I’m the kid in the room. I’m often surprised, I may be emailing people, I get on a Zoom call, and “Hey! You look so young.” I’m still kind of assuming that I’m going to be the youngest. 
 

But I think the great thing about our field is that life experience helps. Yes, you’re more in touch with young students, or have been as a professor for many years, but it’s a great profession for people to go into as a second career. If you start doing this when you’re 30 or 40 or 50, what a gift that you know something about life, having worked in other fields, having children, having a family, having suffered losses that invariably occur. So, you do what you can with the resources you have, and hopefully those grow over time. 

LR: Kicking and screaming in some cases. I think that’s it for me for now, Victor. Do you have any last thoughts or questions you want to ask me or reflections on how our time together went for you?
VY: It’s been a pleasure working with you over the last several years, Larry. In terms of this conversation, what I’ve tried to do is to respond in the moment to thoughts or feelings that come up as we’ve been talking.

I’ve done a number of these interviews, we’ve been on podcasts, and I just realized it’s easy to start telling the same stories over and over again. It’s an interesting phenomenon. And if you think about therapy, it’s easy for clients to do that. They tell a story about the losses they’ve had or the disappointments they’ve had, and it’s important for them to convey that to you. But as Frieda Reichmann has allegedly said, “Patients need an experience, not an explanation.”

It’s strange and honorable, and at times a captivating and rewarding profession to be able to sit with clients and enter their world
I don’t know if I’ve said anything new. Hopefully, I’ve conveyed some ideas that someone will find interesting. As I reflect on our conversation, the one thing that stands out is when you asked me about my own evolution and I talked about becoming more comfortable with myself and things that I was uncomfortable with, and I used the words “ashamed of.” That felt like one moment where I said something I don’t think I’ve said before.

I’m sure it’s true for all of us. We have things about ourselves that we don’t feel good about or feel ashamed of or feel vulnerable around. And it’s also true that those, in general, for me, are much more contained and more in the past, and I’m grateful for that.

As I say that, it makes me think about the work of a therapist and the work we do with clients to really cherish and embrace the idea that everyone has this unique world inside of them, and sometimes that world is extremely painful and chaotic. Sometimes that world is just chugging along and doing okay, and sometimes that world is expansive and exciting. It’s strange and honorable, and at times a captivating and rewarding profession to be able to sit with clients and enter their world and see what help we can be to them in navigating their life’s journey.  
LR: From my perspective, and as I prepared for this interview, I was acutely aware that our relationships these past five years have evolved. And as I became more comfortable in my space in our relationship, I’ve come to feel more confident, not just in my role as Psychotherapy.net’s Editor, but also in my own skin. I think every good relationship, whether it’s therapeutic or not, is a growth opportunity, whether it’s inside of a therapy room or not.

And I wasn’t looking for this interview to be a growth opportunity per se. I wanted to offer you something interesting; how do I ask interesting questions when you’ve been asked so many similar questions before? There was a part of me that wanted to ask interesting enough questions to interest you, to please you. I wanted, and perhaps still do want, to be interesting, relevant. Perhaps even more so after having retired from the university. I wanted to honor what you’ve done, and I wanted to also provoke you when I could without unnecessarily doing so. I wanted to create, I guess, as in therapy, a safe space where sharing could happen.

This was different from some of the other interviews that I’ve seen conducted with you. I sensed an even greater level of vulnerability, especially in that comment you made about shame, and I was very impressed with your willingness to share that. So, before we sign up as the first two members of the mutual admiration society, I’ll say goodbye and thank you again for welcoming us into your space.  
VY: Well, thank you very much, Larry. It’s been a wonderful and enriching conversation. 

Self-Esteem is Overrated. Here’s Why Self-Compassion is Better

Posted on by Psychotherapy.net Team

  

For decades, hordes of psychologists and those of similar ilk and inclination, have preached the gospel of self-esteem as the agreed upon hallmark of sound good mental health. Admittedly, haven’t most of us been persuaded by the cogency and utility of this lionized concept? Its strongest advocates boast that it is the lone-star indicator of psychological and emotional health. Can you think of any other sole criterion of mental health that has the same gutsy, enveloping reach? But what exactly is self-esteem and how is it best achieved? In short, most would likely agree that’s a global assessment that yields a zero-one type metric — an either-or proposition. Simply, the esteem I have for myself is either “good” or “bad.” 
  

Those of our clients who are fortunate enough to have “good self-esteem" are to be admired and emulated while those who don’t have it are in need of psychological repair. Not surprisingly, low self-esteem is “transdiagnostic,” meaning its threads run throughout the fabric of many mental disorders. Still, how do we help our clients achieve it? Are there evidence-based methods for acquiring it? To me, and other critics, there is one big, seemingly obvious question ominously hovering over the traditional concept of self-esteem — shouldn’t one’s self-appraisal reflect the reality of one’s uneven and multifaceted development, which is rarely if ever, binary, and vastly more complicated and nuanced? Of equal concern; if one’s self-evaluations are too dichotomous, too rigidly black or white, cognitive inflexibility could easily upset the proverbial emotional applecart. 
 

One in 76 Trillion

Besides being problematically binary in concept and application, the conventional notion of self-esteem faces another problem in that it subsists upon a steady diet of interpersonal comparisons; in short, it “makes its living” on “I’m better (or less) than you — I’m special (or not).” One must see themself as set apart in some way, above average — where mediocrity is decried and even anathema. Imagine complimenting a friend by saying, “Good job! That was so average!” Further, all our clients can’t be above average; this is statistically illogical. However, whether they like it or not, their judgements of “better” or “worse” are entwined in the minefield of interpersonal politics and deeply embedded in everyday social commerce. Moreover, this “who is better, me or you,” juggernaut can be so thoroughly baked into their thinking that it steamrolls everything in its path. And clients are not always fully aware they’re doing it. Commonly, without a speck of thought, their esteem for themselves instinctively balloons when others praise them, and conversely, their egos deflate with the explosive speed of a pricked balloon the instant they are targeted with criticism or perceive any one to be more attractive socially, physically, professionally, financially, or otherwise.  
 

Further, self-esteem can have an insatiable appetite that feeds upon an unending influx of accolades, the conspicuous trappings of social success — e.g., prestigious professions, high-paying jobs, big homes, luxury cars, and the like. Measured in these terms, the warm glow of success is rarely permanent and must be continuously re-lit, just as a healthy economy thrives upon never-ending consumerism.  
 

Of course, this familiar business of making comparisons flourishes across an expanse of social functions and activities of every kind both formal and informal. Classic example: On the sports field, scorekeeping is a precise and indispensable numerical gauge of the competition among individuals or teams — a comparison of athleticism. Imagine gauging the degree of sportsmanship or fun with the same precision. However, consider the plausible illegitimacy of making person-to-person comparisons from another perspective, one conducted on the larger “playing field” of our everyday lives. To explain, statisticians have calculated the probability of genetically duplicating any one of us is one in 76 trillion (the exception is homozygous or identical twins). Nature has gone to great lengths to ensure each of us is genomically unique. Given our uniqueness, should person-to-person comparisons be regarded as a valid metric?  
 

Granted, many of our clients make comparisons and for a variety of reasons, but isn’t it arguably more legitimate to make a “me-to-me” rather than a “me-to-you” comparison given that each of us has a unique set of genes — not to mention, a unique history of experience and learning which are even more individualizing? By this logic, none of us occupies the same exact “playing field.” For instance, compare two distinct types of self-dialogue: “I did better this time than I did the last time — maybe I’m improving” (a me-to-me” comparison more akin to the reasoning of self-compassion). As opposed to this, “I did better than John…but will I do better next time” (a me-to-you comparison more akin to the reasoning of self-esteem). 

The Ideal Self vs. The Real Self

Carl Rogers dubbed the terms “ideal self” and “real self” to mean the person we would like to be, in contrast to the de facto person we are, respectively. In sync with Roger’s reasoning, self-esteem is tightly bridled to our aspirations. Our clients (and we, their therapists) are indeed aspiring creatures who set goals which, by contrast, differ from who they are, or what their abilities are, or what they currently possess. However, this chasm between what they would like to become or attain verses what they have attained, generates tension, and often desensitizes them to any fulfillment stemming from our past accomplishments. Or worse, it can discourage or even disable them by fomenting a crippling, demotivating discontent with themselves. And we often see the fruits of this painful labor in our clinical sessions, particularly with depressed and anxious clients. 

Maybe at their best, these same tensions create a “deficit motivation” that can energize goal-directed action. Certainly, many assume this deficit motivation or tension-filled chasm is necessary to mobilize our clients to take actions in pursuit of their goals. Again, however, the opposite often occurs, and they can become discouraged as their esteem is hinged to the achievement of the next success or accolade. But at their worst, unrealized goals, especially chronic ones, can breed a sense of failure leading to despair and self-contemptuousness. Despite all the homage we pay it, self-self-esteem has a discernable dark side: It promotes all or nothing, either or, forced choice self-evaluations, coupled with its “who’s better than who,” social comparisons and its insatiable appetite for unending social success, all of which may be self-esteem’s kryptonite. Fortunately, research on self-compassion, even amid personal failings, can spawn strong motivation that can be used in the pursuit of our goals without self-esteem’s clear pitfalls.  


Conspicuous vs. Inconspicuous Outcomes

Self-compassion, on the other hand, delivers all the benefits of self-esteem without its cognitive rigidity, its “either or’s” and “better than’s.” For example, self-compassion is not an either you have it, or you don’t proposition. In fact, it’s not an evaluation, or a comparison, nor is it contingent on fleeting social success. Instead, it is a deeply non-judgmental love relationship with the self for who and how I am. Further, this affirming self-approbation promotes how I am like others, not set apart from them. This sense of similarity and belonging is strongly correlated with feelings of well-being and is served with a healthy topping of deepening self and other understanding and forgiveness. Thus, self-compassion’s enrichments are not characterized by the usual metrics of success, the conspicuous outcomes we expect or hope for, but the inconspicuous ones as measured by a stable, enduring, and positive relationship with oneself.  
 

For example, consider this episode of “personal failing” couched within several subtle but far-reaching successes: As an adolescent, my son loved to play baseball. Once during a championship playoff, he struck out in the bottom of the ninth with two men on base with his team behind two to four. Had he hit a homerun or even a base hit, his team might have won a critical game with a dramatic comeback — a conspicuous outcome of success. But as is often the case, it didn’t happen, and my son was devastated. Days after the game, once his acute frustration and self-disappointment had softened, I surprised him by telling him I was proud of his unflinching determination and courage at home plate where he had made his best effort to hit the ball, despite the enormous personal and team pressures on him and that he had done this in the face of an uncertain outcome. I told him these were the inconspicuous outcomes or successes that had escaped his recognition and that of the crowd of spectators (mostly other moms and dads). I tried to explain that these qualities defined success in broader terms and were the very ones that would serve him best over time, even more than a self-exalting memory of a heroic hit. I remember thinking at the time, I hope I’ve planted a seed of self-compassion in my son’s fourteen-year-old brain that will germinate, even flourish into his adulthood.  
 

A Quick Recipe for Self-Compassion

When genuinely “friending” others, aren’t we, and our clients in particular, unconditionally accepting, warm, supportive, respectful, and generous with praise, understanding and encouragement? The answer is unequivocally yes. Now, simply by reversing the flow of this patently compassionate prescription and dosing themselves with it, our clients have an excellent recipe for self-compassion. So, quiz them by asking these pertinent questions: Are you as compassionate to yourself as you are to your friends? Specifically, can you turn inward to your own internally siloed resources for self-compassion and reliably draw upon them to nurture and uplift yourself, especially during times of personal stress? Further, are you more likely to criticize than to praise and accept yourself? Similarly, are you as quick to exonerate yourself for your inevitable missteps and shortcomings as you are ready to forgive your friends? 
 

I am a true believer, a devout but amateurish practitioner/proselytizer of self-compassion in both my professional and personal life. I’ve found self-compassion to be a challenging but worthy lodestar that very gently nudges me and my clients upward to the highest quality of self-care and love. When self-compassion is most needed, it can be elusive, difficult to access or apply. Here is another personal example to further explain what I mean: I treated a severely abused adult survivor of intense and chronic early childhood trauma. Sadly, her symptoms would peak and trough unpredictably and, all too often, would overwhelm her diminished abilities to regulate her emotions. During one never-to-forget session, after making what I thought was a kind, empathic comment, the patient suddenly erupted in a firestorm of crude expletives, dropping the “F-bomb” repeatedly throughout her intense diatribe. All this full-throated venom was launched at me because I had inadvertently jabbed at a raw, and extremely sensitive psychological nerve.  
 

While under attack, the sheer volume and malicious content of her verbal salvos made them especially transmissible, and I was instantly infected with deep self-doubt about my professional abilities. For what felt like a brief eternity I agonized in recriminating self-interrogation: “Had I committed a ‘clinical crime’ of some type. Had my clinical clumsiness harmed my patient?” For a painfully embarrassing moment, I convinced myself that other clinicians never find themselves in these same indignant circumstances; they don’t make the same mistakes.  
 

Almost as quickly as it had started, my patient's fury ended with a remorseful, “I'm really sorry, I just go crazy sometimes.” With her contrite admission, my abrupt and steep dive into self-reproach was replaced with a moment of mutually felt awkwardness while we stared at each other as if to say, “So, what do we do now?” Mercifully, her sincere apology, combined with my prior efforts to learn self-compassion, sped the retrieval of my professional composure, despite the maelstrom of emotion we'd both just endured. Before the session was over, I was fully recovered and back to the business of trying to accurately empathize. Most importantly, I awoke to the fact that my first negative reactions were self-esteem based — they were the regrettable by-products of comparing myself to a nonexistent, illusory ideal clinician. You know, the one who is always unerring, competent, confident, and who never reacts, or in this case, overreacts to their emotionally dysregulated patient. 
 

                                                                 *** 
 

A much-welcomed calm began to settle back over me. Practicing self-compassion had worked (I acknowledge that it came easier following her apology). I pictured myself digging out from under a needless and self-imposed misadventure of being buried alive in the debris of self-condemnation. Further, I focused on my therapeutic intentions and how they had been benevolent and forced myself to remember that all therapists make mistakes. With these efforts, empathy for myself rose, like Lazarus from the dead. But self-empathy came first, a necessary precursor followed by a revival of my empathy for my patient — in that order. It's cliche but still valid to say, relationships require work, but the relationship with our self-compassion is the one needing the greatest amount of never-ending work. And when done well, it can change how we view others, even “difficult others.” In fact, we may be no more compassionate to others than we are compassionate towards ourselves. I highly recommend it. 
 

 

Final Questions for Thought 
 

How important is the concept of self-esteem in your own clinical work? 
 

How did the author’s argument “sit with you” regarding the concept of self-esteem? 
 

In what ways does the concept of self-compassion resonate with you personally? Professionally? 

Improving Your Clinical Presence with Receptivity and Gratitude

Posted on by Psychotherapy.net Team

Suggested Tips for Clinicians: 

  • Practice methods for strengthening your therapeutic presence.
  • Ask yourself if you are or are not empathically attuned with each client.
  • Explore barriers to full presence and empathy with more challenging clients.

 

A capacity crowd in the large conference hall rose to its feet in applause. Daniel Siegel, renowned author, clinical professor of psychiatry at the UCLA School of Medicine and Executive Director of the Mindsight Institute, had finished his presentation. I too stood with enthusiastic appreciation, not only for this lecture, featuring the clinical significance of therapists’ mindfulness, but for all the ways his research and writing about developmentally informed parenting, neuroplasticity, and the incorporation of science into the practice of psychotherapy. All of these had influenced my thinking and work over the past ten years.   
 

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Dan had begun to move away from the podium when he seemed to catch himself and walked back to centerstage. He stood, fully facing the hall, hands clasped in front, nodded his head and bowed. For our part, the applause of several thousand therapist attendees showed no sign of relenting. Then an event unfolded I have carried with me since. 


It began with the simplest of gestures. Dan took and held Tadasana, a standing yoga pose. His feet parallel and facing forward, Dan released his fingers, opening his hands which moved to the sides of his legs, palms open, shoulders relaxed as he appeared to empty himself and stand receptive before the crowd.  
 

The audience responded with delight and gratitude at this embodied receptivity. The volume of the applause rose, and Dan, smiling gently, took a deep breath. The crowd responded again. Waves of mindful presence, enthusiasm and gratitude rolled through the large hall back and forth, until Dan took a final bow and joined the crowd he had just helped to unify.  
 

Gratitude is amplified by its reception. Reception is its own expression of gratitude. A feedback loop, formed by gratitude and receptivity, generates a mindful, compassionate field that feels very much like love.  
 

Tears rolled down my professional cheeks. I quickly brushed them away hoping the strangers around me noticed neither my intense emotion nor its expression. Unleashed by the power of that loving field, my tears flowed freely and powerfully, apparently straining for release. I felt seen, heard, and appreciated. I was included, a true part of this collegial, communal event. There was a transcendent quality in which this loving field was not so much being created but being acknowledged as existing before this moment. All of us stumbled into an awareness of a much larger and enduring field of love.   
 

I was awed by the immediacy and goodness of the human family. But it was an ecstasy undifferentiated from loss and longing. My tears expressed my grief at how seldom I had been aware of my presence in such a space. Having often felt unseen, unheard, and unappreciated, I suddenly experienced a sense of loneliness and despair of enduring connection. The pangs of longing and the shame of my dissatisfactions with self and others were ignited by my embrace of this mass symbiosis. Yet, there was also relief at the quenching of my childhood thirst for an uninhibited expression of mutual affirmation and solidarity.   
 

In the religious experiences of my young adulthood as a youth minister, a shared faith and religious ritual turned what might have been merely an experience of communal intimacy into an encounter with the metaphysical. My peers and I tasted, not merely the immediate experience, but elements of a universal interconnectedness: with one another, with the Church, and even, it seemed, with God.     


As I grew older and my religiosity subsided, the felt importance of that faith and my need to participate in a loving field never waned. If Dan Siegel had continued off stage to privately appreciate the applause, he may very well have experienced a profound sense of what his work meant to us, he may have been moved to tears and even been motivated to write another great text, but his personal experience of appreciation and inspiration would not have generated the mindful, compassionate field of love we all shared. To generate such a field, he had to turn around and move back to the edge of the stage, putting himself on display. He needed to make the mindful choice to allow his body to express his emotional state, ultimately taking a posture of reception easily understood by the community before him.  
 

As an audience member, I too had a role in creating the moment. While Dan closed his presentation, I might have remained seated, turned to a neighboring attendee and, in a relatively hushed tone, remarked upon an outstanding insight or application. My neighbor may have responded with her own insight and drawn my attention to aspects of the presented theories elucidating my thinking. This might all have had a positive impact on my practice, but none of it would have generated the field of love.   
 

 All of us that day physically manifested our emotional reaction by standing, applauding loudly, and maintaining focus on Dan. We allowed his gestures to carry meaning and translated that meaning into action with vocalizations of delight and even louder applause.  
 

After any professional conference I strive to identify the clinical application of what I have learned, knowing that for me to retain information I need to utilize it. While I came away from that conference with much information, it was this personal, emotional experience that I most wanted to incorporate into my life and work.  
 

But where would this powerful manifestation of gratitude and receptivity play out in the consultation room? Although, as a psychotherapist I am sometimes the recipient of heartfelt expressions of appreciation, I have never received a standing ovation. Nor do I often feel deserving or desirous of one! The emotional waves of gratitude between therapist and client are smaller and quieter and, as a possible result, the loving field we generate is more easily dismissed or completely overlooked.  
 

It is a process that unfolds in many sessions. It unfolds with the subtlety of a raised brow, a silence, the slightest of gestures. It is carried by a word, a smile, a tear. We know it as empathic attunement and the creation of a therapeutic space. It is enacted when a client experiences acceptance in response to long held shame. I wonder how open my stance is in receiving such gratitude. Does the client feel my reception and the gratitude I feel for their gracious expression?  
 

Recently, in a relational-process group I co-facilitate with my colleague Aisha Mabarak, a field of love made a surprising appearance. Sheila* arrived late due to complications at her job that held her past the end of her shift. She reported being exhausted and ill-prepared to share her feelings with the group. 


“I’m in a fog,” Sheila said with an uncharacteristically flat tone. I responded by thanking her for making it to the session and affirming her inclination to take a restful, though present, pose. Aisha, however, had a different approach. Not wasting any time, she asked: “Sheila, why don’t you share with the group a little more about this fog you feel stuck in?”  
 

Sheila proceeded to describe, with increasing emotional range, how deadened she felt by a sense of invisibility in multiple facets of her life. Examples spilled forth of her efforts to meet the needs of others only to be met with thoughtlessness and a glaring absence of gratitude from family members, friends, colleagues, and bosses.  
 

Other group members expressed empathy and support. One member voiced these sentiments succinctly, saying that she felt Sheila’s pain and she was, at that moment, imagining how hurtful and difficult it must be to feel so unappreciated by people who care for you. In approximately fifteen minutes Sheila had gone from a depression-based brain fog to expressing her anger and upset assertively, leading to smiling and expressions of appreciation for her fellow group members.  
 

My inclination to support Sheila by giving her space was intended to express, both to her and to the group, that it was acceptable to feel your pain in session and to choose to set self-protective boundaries. This intervention may have been simply wrongheaded, or it may have, by reminding members of their autonomy, laid the foundation for co-facilitator Aisha’s fruitful follow-up. While I had responded to Sheila’s verbal communication and her depressed presentation, Aisha responded to another expressed impulse—this one non-verbal.  


Sheila expressed her impulse to participate in the group by showing up and letting us know how bad she felt. Rather than disappearing off stage, a space she was also entitled to occupy, she had moved her body to a visible place. Rather than closing herself off, she showed us how she felt, as Daniel Siegel had opened his hands and exposed his palms.  


Aisha’s response might be analogous to the convention applause. This applause was an essential welcoming saying: “Sheila, your sadness, hurt, embarrassment and anger are all welcomed here!” Group members said: “This is your group! Take the time you need. We are here for you. We see you. We hear you.”  


Hearing and feeling this welcoming presence, Sheila responded at first with tears, then with expressions of anger and ultimately with smiles and the laughter of gratitude for the group’s support. The faces of the other members lit up with warmth and solidarity.  
 

*** 


Facilitating such moments of conscious gratitude and receptivity is something I try to bring to all my sessions. Of critical importance is my understanding that my role in this regard is that of facilitator, not creator. It is a powerful, organic experience that can only be had within the context of a collaborative effort. Daniel Siegel, for all his talents and wisdom, could not create that field of love by himself. Nor could the audience of thousands of therapists, even if they were consciously working in unison to do so!  


As a therapist, my receptivity to gratitude only increases the availability to the client of a mindful, compassionate field. A field, that I argue, has the healing qualities of love.  
 

While love is not “all we need” in the consultation room, it is a quality of human experience necessary to both healing and health.  

 

*This client’s name has been changed.  

How to Overcome Self-Doubt as a Therapist

Posted on by Psychotherapy.net Team

“Steve, I’ve decided to stop talking to Marc,” said Sheila, starting the session without the usual pleasantries. I could hardly contain my excitement. 
 

I had been working with Sheila for two years, attempting to help her develop a sense of self-worth. She had been in and out of multiple abusive relationships and thought very poorly of herself. This was despite having two master’s degrees, a rewarding career, and being highly attractive (all societal markers of success). 
 

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Sheila had permitted Marc to enter her life and erode what little self-confidence she had left in the wake of the abuse she had suffered prior to meeting him. She complained of his manipulation tactics and how he had recently “gotten a prostitute pregnant behind my back.” I was ecstatic that she was finally standing up for herself. 


I decided to follow up with a Rogerian type of approach. I feared that questioning might be too confrontational. Instead, I wanted Sheila to reflect on where she got her courage from to finally cut Marc off. Secretly, I wanted to be praised for being a world-class therapist. I wanted to hear that our work had paid off and that she felt stronger. So insecure and immature of me, right?! 


“Say more about that,” I gently nudged. “Well, my psychic told me not to do it,” she replied flatly. Two years of weekly 45-minute sessions invalidated by a single 15-minute psychic reading. It felt as though I had been punched in the stomach. I could feel my face getting numb. I was at a loss for words. 


“She told me that Marc is bad news and has wicked intentions for me,” Sheila continued quite proudly. While I was pleased that she was no longer tolerating oppression, I felt small and insignificant. I also thought of it as a flight into health. One discussion, and now Sheila was cured. It made me reflect on countless times that my therapeutic efforts were dismissed by a client who just so happened to be influenced by a friend, clergy member, or some insight they received on TikTok. 
 

This case caused me to reflect deeply on my role as a helper. Why did I feel the need to be the sole agent of change for Sheila? Why wasn’t I more open to all (other) avenues of support that Sheila could receive? Doesn’t it take a village? I also wondered about how often clients come to me for direct advice. Sheila was no exception. 
 

So many times, I have non-directively responded to “What do you think I should do?” with “What would you like to do?” It is not that I am afraid to answer questions from my clients. I do it often. However, I have found it to be ineffective to give clients direct answers when their presenting problems are highly nuanced—such as relationship dynamics in the case of Sheila. If the advice works, I’m heralded. If it fails, I’m demonized. I find it much more effective, as well as in their interests, to help clients come up with their own solutions. 


Within two weeks, predictably, Sheila was sending Marc a barrage of text messages and outwardly professing all his admirable qualities. There was no longer any mention of the psychic. “What good is that psychic now?” I wanted to cry out but restrained myself. Instead, I maintained a calm, nonjudgmental demeanor and allowed Sheila to tell me all about what led her to reach back out to Marc. 


By the end of that session, Sheila thanked me for “always being there for me.” That was all the validation I needed. She reminded me that while all the men in her life—including her father — were inconsistent, I was the one man who stood by her side. It wasn’t necessarily about giving or not giving her advice. Sheila is smart enough to make her own decisions and deal with the consequences. It was more about the fact that I was the one person who had been there for her. 


I had spent two years of therapeutic effort wondering when I would say something that might resonate with Sheila. However, the true work has revolved around being a consistent and supportive presence in her life. My work with Sheila is far from over, but I do feel that I am on the right track for us to make meaningful progress together. 
 

Questions for Therapeutic Thought 

  • What about the author’s experience with this client challenged you to think about your own clinical work? 
  • What types of clients trigger your own self-doubt and how do you address that discomfort? 
  • How might you have addressed this particular issue with Sheila?