Therapeutic Issue Archives - Page 36 of 68

What’s the Limit? Maintaining and Understanding Boundaries in Psychotherapy

Posted on September 23, 2019February 19, 2026 by Psychotherapy.net Team

Anita* was an experienced therapist who consulted with me about a client who consistently arrived late for sessions and refused to leave when his time was up. “I don’t usually have difficulties setting limits with clients,” she told me. “But I’ve tried everything with him, and nothing is working. In our last session, I told him that I was going to have to start charging him for the extra time. He just said, ‘okay.’ And he still didn’t leave.”

We all know that boundaries are extremely important in any psychotherapy relationship, but they are not always easy to define or to maintain. They’re also not always easy to identify.

Defining Boundaries in Psychotherapy

What is a boundary, in fact? I like what a group of physicians has said: “A boundary may be defined as the ‘edge of appropriate professional behavior, transgression of which involves the therapist stepping out of the clinical role or breaching the clinical role.” I also like what Gary and Joy Lundberg write in their book I Don’t Have to Make Everything All Better: In daily interactions with others, boundaries “are statements of what you will or won’t do, what you like and don’t like, how far you will or won’t go, how close someone can get to you or how close you will get to another person…they are your value system in action.”

These definitions apply to both therapists and clients, yet other factors also play important roles. For instance, how we set and maintain boundaries reflects not only our personal and professional values, but also respect for our clients and their boundary needs. Furthermore, boundaries reflect something important about our respect for ourselves.

In fact, this was one of the problems that Anita was struggling with. She wanted her client to respect her, and his behavior around the scheduling of sessions felt to her as though he was disrespecting her. She was having difficulties finding a way to maintain her boundaries, her self-respect, and his respect for her

Boundaries also reflect important information about a relationship between two people, whether the relationship is a personal one or a professional one. Boundaries can be ephemeral and often confusing, in part because they embody the often-unclear lines of connection and separation in a relationship. In psychotherapy, a significant amount of work is done within the relationship between therapist and client. Individuals have an opportunity to work on their relational difficulties. Boundaries, whether they have to do with office rules, payment, scheduling, electronic communication or a therapist’s personal life can become the medium for exploring, understanding and working on issues that emerge in a client’s life with others.

“Freud sometimes made house calls to do therapy with patients and often interacted with them socially”; such behavior is seen as boundary-crossing today. Yet the Internet has created dramatic changes in traditional boundaries. While some therapists refuse to communicate anything other than appointment times in electronic communication, many others conduct psychotherapy online and by telephone, even exploring the benefits of doing online psychotherapy with clients in their beds.

Boundaries Have Meaning

While both a therapist’s and a client’s boundaries need to be clarified and respected, a therapist’s curiosity about any boundary question that comes up for a client can be an important tool in the therapeutic process. In their Psychotherapy.net essay on doing therapy with clients in bed, Giré and Burgo tell us, “Therapists need to pay ongoing attention to boundaries and transference issues, of course; but if we’re mindful, we can also focus on the purpose and meaning of any boundary transgressions.”

For instance, over the years many clients have asked to hug me. Physical contact between therapist and client has long been an area of controversy, and, of course, a question of boundaries. Not only is it significant in terms of potential sexual coercion and assault, but it also raises important questions about both the therapist’s and the client’s comfort with non-sexual physical touch.

I am not a particularly physically demonstrative person and do not always find that kind of contact comfortable. Because I know that to cross my own boundary in those cases would be harmful to the therapeutic work, I have found ways to tactfully and gently refuse the request, often explaining that it is one of my own boundaries that I am careful not to override. Such an explanation often leads to a client’s apologies, and sometimes to a painful discussion of their fear that they are not only unlovable, but also so repulsive that no one would ever want to touch them.

In one instance, with a client who seemed to go out of his way to make himself as unattractive as possible, I asked if it was possible that he actually did not want to be touched. He seemed taken aback by my question, but then he began to wonder out loud. “I think I want to be touched,” he said. “It’s not that. But I think I’m afraid that I’m going to be rejected; so, I sort of set it up that I’m so disgusting that I know that it’s going to happen.” I replied that that made sense to me. I said that I thought he was trying to take control of something that he feared. “It’s better if it doesn’t come as a surprise,” he agreed. “Somehow it doesn’t hurt so much that way.” That client and I spent many years working together, and the process of trying to understand what might be going on with each of us, and within our relationship, helped us to understand some extremely important, complex and subtle aspects of many of his other relationships.

I have learned to share this information about myself with clients in a way that often leads to our finding other ways that they can feel soothed and comforted by me and close to me without touching. In many instances, the process of talking about our different needs has also opened areas in which they struggle with similar issues in their personal lives.

Role Modeling and Boundaries

How we look at and work with boundaries can also serve as a role model for clients, whether it is in the service of protecting their own or respecting the boundaries of others.

For example, there are times when I am comfortable hugging a client. I am not always sure exactly what makes me feel comfortable with the contact, but I have learned to respect my internal communications – the same way that I encourage clients to pay attention to their own wishes not to always do what someone else wants them to do.

Not too long ago, two separate clients who were struggling with painful realities in their lives brought up the issue of hugs. Both had been in therapy with me for some time. One shyly asked if it would be okay if she hugged me. The other told me that I was not to hug her and was not even to look at her sympathetically. In both cases, I agreed to the request. I also asked if we could talk about what their requests were about – what they were hoping for and what they were hoping to avoid. And finally, I asked if they could talk to me about their responses to my response.

I was willing to accept and respond to what they needed, but I also maintained my curiosity about what was going on beneath the surface – what either the hug or the restrictions meant in terms of the larger picture of their lives. In part I was able to provide this kind of approach because of my awareness and respect for my clients’ boundaries and for my own.

Exploring, Understanding and Maintaining Boundaries

To return to Anita: as we attempted to understand her client’s refusal to accept her boundaries, we began to see that the dynamic between them was complicated not only by each of their personal dynamics, but also by social and cultural factors. “I feel like he’s being sadistic,” she said. “By refusing to accept limits that I set, he’s setting up a ‘MeToo’ situation. He’s being an aggressive male and putting me in the position of being a compliant victim. And I refuse to be in that position.”

In his book Attachment in Psychotherapy, David Wallin explores some of the links between a client’s behavior, a clinician’s reactions, and unarticulated, often unknown attachment issues. Because I thought that her client’s behavior might be related to some unspoken, maybe inaccessible relational dynamics, I asked Anita if she could imagine talking about her dilemma with her client. At first she doubted that it would be useful. “Why would I make myself vulnerable in that way?” she asked.

I told her that I thought by sharing some of her dilemma, she might also be putting into words some feelings and relational issues that her client was enacting with her. I said that I thought he might even be relieved that she was able to articulate something that he felt but could not talk or even think about. I said that I also was hoping that by putting her dilemma into words, she would be altering the power struggle between them. She decided that there was really nothing to lose. “I’ve tried everything else I can come up with,” she said.

When he arrived late for his next appointment, Anita brought up the combination of his late arrival and refusal to leave on time. She said, “I’ve been thinking about what’s going on here, and, although I’m not sure you’re going to like them, I’d like to share my thoughts with you. Would that be okay with you?” He nodded, but she said he looked uncomfortable. She then told him what she had told me.

The client seemed deeply moved by her comments. After sitting quietly for a few minutes, he said, “”Wow. I’ve been feeling resentful that you have all the power in this relationship. And you’ve been feeling assaulted by me”. I think you might have just solved a puzzle I’ve been unable to solve for a long time. I haven’t even had a way to think about until now.”

He went on to explain that he often seemed to get into similar kinds of power struggles at work and in his personal relationships with women. “I’ve always felt like I was the one who was being forced to do things against my will,” he said slowly. “But maybe other people feel like you do—like I’m the one who’s pushing them around. That’s really weird. But it kind of explains why people get so mad at me when I’m feeling like I’m just trying to protect myself.”

This insight did not change the power struggle completely, nor did it magically shift the client’s difficulties with other people. In fact, they had to repeatedly revisit the same dynamics both in their relationship and as they discussed his interactions with other people in his life. The client began arriving closer to the proper time for his appointment, but he continued to have difficulty leaving. But now they were able to look at some of the reasons for both behaviors, not as a power struggle, but as an attempt to control both the connection to and the separation from his therapist. Exploration revealed that he found separation extremely painful, but that he was embarrassed to admit how much it hurt him to have to leave—or to be left by—someone he felt close to.

Theirs was a long and productive therapeutic relationship, and the early struggle over the end of sessions became an experience that the two of them referred to over and over again as a template for understanding what was going on when the client began testing boundaries and acting (and feeling) like a rebellious teenager.

Conclusion

Boundaries are crucial to any relationship, including a relationship between a therapist and a client. Yet these often unclear, ephemeral lines between connection and separation and self and other can become the means by which we can understand a client’s self and relational struggles. A clear and consistent frame protects the work of therapy. But that work can be greatly enhanced through the process of exploring, understanding and reflecting on those boundaries.

*names and identifying information changed to protect privacy

Trauma and the Reproductive Story

Posted on September 9, 2019February 19, 2026 by Psychotherapy.net Team

It’s morning. The alarm goes off, the coffee pot goes on, you decide what to wear, and ready yourself for the day. Consciously, but most likely out of your conscious awareness, you expect today will be similar to yesterday, and tomorrow will be like today. The day’s events may differ, but most likely the routine will be pretty much the same. There is comfort in that.

But suddenly something changes. When a traumatic event occurs, your world is no longer the same, no longer the safe place you could count on. It can feel as if the rug has been pulled out, everything is flying in the air and has yet to settle into place again. And as I will discuss, one’s internal world, one’s sense of self, also can feel dramatically off kilter.

Trauma and the Reproductive Story

Trauma, as defined for the diagnosis of PTSD in the DSM-5, is “exposure to actual or threatened death, serious injury or sexual violence¹. We often think of it as a one-time horrific event—a car accident, an earthquake, a shooting. But reproductive trauma, specifically infertility and/or pregnancy loss, is cumulative in nature. For most patients, by the time they set up an appointment with a fertility doctor or with a mental health professional, they have already gone through a year of “trying” to conceive, and multiple losses. As one patient put it, every menstrual cycle felt like a “mini-death.” And indeed, the losses that patients experience—of their hoped-for baby, their own adult development as a parent, their hopes and dreams for the future, of what we refer to as their “reproductive story”—significantly affect their psychological well-being².

Another way to define trauma, and one that fits with reproductive patients, is to think about infertility as an event that causes the disintegration, not just of a would-be pregnancy, but of one’s entire inner world. It affects every aspect of one’s life: feelings about the self, questions about one’s purpose, concerns about relationships—with one’s partner, friends, family, the world—and worries about the future—how does and will one fit in, what is one’s legacy, what is the meaning of one’s life? These are clearly not minor concerns. Trauma, in general, can be thought of as an event that overwhelmingly shatters core beliefs and assumptions³. For reproductive patients, the narrative that they once held, often as an unconscious guideline for the creation of their family, is no longer tenable as originally imagined. The core assumptions they held about having a family are demolished.

As a clinician who specializes in reproductive issues, I have heard a wide range of stories from women over the years, some of whom proclaim, “I always knew I wanted to be a mom. Even as a little girl that was what I wanted to be. I even decided to become a teacher so I would have the same schedule as my kids;” some that are more vague, “I just thought I would have kids someday;” to some that were more ambivalent, “I didn’t think I wanted kids and then one day it hit me. I hope it’s not too late.” These stories often begin in childhood, as we ourselves are parented. The stories evolve over time and the subtle changes that are made to the narrative become subtly yet implicitly assimilated. It is when the story abruptly goes off course, when a woman can’t have children how and when she wants to, that the traumatic loss occurs.

As I have listened to my patients’ reproductive stories, I have taken note of their core assumptions about pregnancy. The more I, as a therapist, can understand what it means to them—how it enables them to fit into their cultural milieu, how it can make them feel they are on equal standing as an adult—the more I have been able to appreciate and begin to understand the depth of their losses. “Acknowledging their own internal narrative, I have witnessed how patients can begin to heal by attempting to “rewrite” their reproductive story”; they may not know exactly how the story will end at this point, but navigating and choosing how they move forward—especially given all the options that current reproductive medicine offers—gives them back a sense of control.

Allison and Core Belief Disruptions

Allison, 38-years-old, had experienced a recently failed IVF cycle. With only one other frozen embryo, she was planning to try another transfer, but was not sure what would happen if that one was unsuccessful as well. Financially maxed out, she and her husband were faced with some very challenging decisions. Should they try another retrieval using her eggs? Should they consider using an egg donor or embryo donation? Should they adopt?

Today, though, she came into session in tears and in a rage. As she grabbed for the tissues and started piling them up on the coffee table between us, I realized that before I even knew what was causing her such pain, “I was feeling helpless and overwhelmed by her emotional state”. I recognized that this was most likely how she was feeling as well. We sat silently for a few moments while she dried her eyes, and then she blurted out that one of her best friends just announced that she was pregnant—and did so via Facebook for the world to see. “She didn’t even have the decency to let me know privately. She knows what I have been going through. It would have been hard enough to find out she was pregnant, but to find out like this? And all the time I opened to her about my struggles, I thought she cared! I feel so betrayed. I don’t even know how long she has been trying for.”

As I comforted Allison by affirming her feelings about her friend, I began a mental list of all the assumptions she had held, and how many had been shattered by her fertility struggles. First and foremost, and a core belief nearly all people have before they start to try to conceive is, “everyone can get pregnant; it’s easy.” Many people assume that all they have to do is stop using birth control and voila! Indeed, it is so drummed into young men and women to “be careful” that it seems as if getting pregnant happens effortlessly. So often women with no fertility issues, and no sense of how their joking comes across, declare “all he has to do is look at me and I get pregnant!” Clearly this is not funny to people in the midst of a fertility work-up or a miscarriage.

Allison assumed that her friend had gotten pregnant on the first try. Whether this was true or not did not matter; to Allison it was simply unfair. One of her core beliefs, that “life is fair,” and that “the world is a just, secure, and reasonable place,” was disrupted by her friend’s pregnancy. Additionally, the belief that “my friends understand me and are supportive of me; I can trust them” was crushed. The challenge for Allison was to make sense out of this threat to her fundamental beliefs. Not only had she not been able to easily become pregnant, but a trusted friend had, and in the process, betrayed their alliance. Could it be mended? Could the earth right itself again and the pieces fall back into place? As a therapist who has observed the great strength and growth that reproductive patients exhibit over time, I knew it could. But right now, as the tissues continued to pile up in our session, things were not logical, the world was not fair, and I needed to listen to more of Allison’s shaken world. While I wanted to be present to the current dissolution of her reproductive story, I also wanted to encourage her to think about her strengths and resources.

Allison went on to talk about her last IVF cycle. “I don’t understand why it didn’t work. We chose the healthiest looking embryo—I didn’t care if it was a boy or a girl. In fact, I told them to just pick the best one and not tell us the gender. We had all the embryos tested. These were the two that came back normal, so it should have worked. Now we’re down to one.”

Allison and her husband had opted for an additional procedure after the embryos began developing called pre-implantation genetic screening or PGS. The test entails removing a cell from the embryo prior to transferring it to the uterus and checking to see if the chromosomes are normal. There is some controversy in the literature about this procedure, as it does not guarantee the embryos will develop normally. It certainly can weed out embryos that won’t develop, but there are some conditions in which the embryos can self-correct as they develop in utero, even with an abnormal result. The test is often very useful if the woman is of advanced maternal age (considered to be 38 and older) or if there is a known health risk.

“And I did everything!” Allison continued. “I went to acupuncture; I stopped eating gluten and loaded up on pineapple. And I was so good about resting for 48 hours after the transfer. I basically only got up to pee!”

I validated that Allison did do everything she could that was within her control. She did do everything right. Only, with pregnancy, doing everything right is still not a guarantee. This brings us to another core assumption, what I call the Santa Claus theory, and a significant part of people’s reproductive story: “If I am good, I will be rewarded for it (Santa will bring toys)” or, stated slightly differently, “if I work hard at something, I will succeed.” In our core belief system, the opposite of these assumptions is also true. So, as it goes, if I am not rewarded, I must be bad, or if I didn’t succeed, I must not be working hard enough. When people mention this in their reproductive stories, they often reference other people who they feel didn’t do everything right. I have heard numerous versions of how unfair it is when someone had kids and couldn’t afford them, or drank, or had them too young, or wound up getting divorced. I can recall one patient talking about her older sister who got pregnant as a teenager, had the baby, and then wound up living back at home as a single mom. My patient was adamant that she would never do it that way. She and her husband got married first, waited until they had finished college and had a steady income, waited until they could afford a house. In their minds they were doing it the right way, and “when they were diagnosed with age-related fertility issues (commonly known as old eggs), they were naturally devastated”. The assumption, “what did I do wrong to deserve this,” is one that runs deep.

The facts are that a woman between the ages of 20-25 has about an 85% chance of getting pregnant; by 30 years of age, the rate drops to approximately 60%; by 40, it drops to about 35%, and when a woman is 45, there is only a 5% chance that she will naturally conceive. People are delaying having children for many reasons, such as pursuing higher education, the ensuing student loans and financial debt, needing to move back in with parents because of debt, not finding the “right” person and many more. Many people also assume that reproductive medicine will be available to them, and are astounded by the cost as well as the rates of success. For women under 35 going through IVF, there is about a 40% chance of pregnancy; for those over 40, it drops to about 11.5%. So, although waiting until one feels established and able to take care of a child is smart, it also can come with risks if one waits too long. At 38-years-old, Allison’s ability to produce healthy eggs was definitely in decline.

When All Else Fails, Blame Yourself

Because reproductive trauma disrupts one’s fundamental beliefs about how the world is and how it should be, the search for reasons becomes paramount. This is especially true for individuals or couples who have “unexplained infertility” or a pregnancy loss for unknown reasons. Generally speaking, about 20% of infertility cases are unexplained, while the rest can be equally divided into female factors, male factors, or a combination of problems in both partners. In my clinical experience, the bulk of the feelings of responsibility fall on the woman when a pregnancy fails. This is likely due to the fact that she is the one carrying the baby and feels in charge of its care. Whether it’s an early miscarriage, an ectopic pregnancy, a stillbirth, or an unsuccessful IVF cycle, women not only feel like it’s their fault, but also want answers. Unfortunately, there are times when there are no answers.

“Allison’s failed IVF cycle was unexplained”. The embryo had tested “normal” and according to her embryologist, it had thawed well and was “hatching” when the transfer took place. Her uterine lining was in great shape. All systems were go. In a follow-up meeting with her fertility doctor, she was told that these things just sometimes happen, and that it was not her fault.

“How could it not be my fault? It was my body, after all! I wonder if there are things wrong with me that they just don’t know about. Or…if I’m just not supposed to have children.” She was crying again and pulling out more tissues.

In a desperate search for reasons, Allison was blaming herself. The assumption was that she had done something wrong. My impulse was to reassure her that she did not cause this loss, but I wanted to hear her reasoning. So, I asked why she thought she was not supposed to have children. “I know I never brought this up in here,” she began. “But when I was in college…well…” she hesitated, “…I had an abortion. I don’t know how you feel about that. That’s why I never brought it up. I know it was the right thing at the time. At least it was the right thing for me. He was not the right guy, or the right time. I mean, I was in my first year of college. I was just, well, experimenting. Can you imagine? It would have if completely changed my life. But now when I think about it I wonder if that was my only chance, that somehow I am being punished. That because of what happened then, I shouldn’t have children now, when I am really ready to be a mom.”

At this moment, Allison revealed another of her core assumptions: you get what you deserve. It is not uncommon for fertility patients to blame their current reproductive issues on what they perceive as past indiscretions. Whether it’s about partying too much in high school, or promiscuity, or as in this case, a previous abortion, their self-blame is not always rational, and almost never accurate. Searching for reasons, it felt more reassuring for Allison to blame herself for her current loss, than to believe it to be some random event. As paradoxical as it may seem, self-recrimination may actually bring some relief to the internal chaos of a shattered schema.

So many times, when couples are struggling with conception, they are given well-intentioned, but inaccurate advice to “just relax” or “my sister-in-law went on vacation and came back pregnant; maybe that’s what you need to do.” For fertility patients, this popular notion translates into: “you’re not doing it right.” Whether it’s about not being relaxed enough (and who is when they’re giving themselves shots!) or for having negative thoughts (i.e., “I don’t think this is going to work”), women may absorb this into their self-narrative. If only one could control conception through one’s thoughts! There would then be no need for birth control! And throughout history, women have conceived under extremely harsh conditions: during war, famine, following rape. These are clearly not times when women are relaxed. It can be helpful for the clinician to remind patients that conception is not a skill, but a biological process that has nothing to do with thinking.

“Self-blame that accompanies reproductive losses can be destructive and promote a downward spiral of negativity”. Depending on the strength of the blame and feelings of punishment, these adverse attributes can become incorporated into the very core of one’s being, leading to negative self-worth, an all-encompassing feeling of meaningless, and depression. Although important for patients to give voice to their deepest feelings of guilt and shame—doing so can actually provide relief—it is equally important that they are able to regain control and process their self-deprecation in a constructive way.

Grief-work, Coping, and the Reproductive Story

With gentleness, I addressed Allison: “You’ve really got a lot going on right now. Not only are you grieving the loss of this pregnancy, you are trying to make sense of your friend, and you are thinking back to decisions you made in college and wondering if you deserve what’s happening now. No wonder you’re feeling awful.” The message here was clearly supportive, but it was also meant to remind Allison that a failed IVF cycle is something to be grieved, compounded by the questions she has about trusting her friend and her own past decisions. Sadly, losses involving failed cycles and even early miscarriages are commonly treated as non-events by society at large, and sometimes even by medical staff. Because of how medically frequent these losses occur, they can become easy to dismiss—but clearly not for the particular woman it’s affecting.

Feeling disenfranchised in her grief, Allison needed to be able to label it as such and to understand that grief of a reproductive loss is not simple. “If you had a favorite uncle who passed away,” I continued, “you would have a store of memories, lots of photos, and people around you would understand how sad you are. But lots of people don’t really get how significant a failed IVF is. You have put so much effort into this—physically, financially, emotionally—it’s got to feel awful that you don’t have anything to show for it. And you’re not only sad, you’re angry. It’s not fair that this is happening when other people like your friend can get pregnant so easily. It’s also not fair that you got pregnant at a time that wasn’t right for you and that now, when it is the right time, you are struggling.”

I could feel the room sigh a breath of relief. Allison’s shoulders dropped and she nodded. She felt heard and understood. But the next step was to have her consider how to cope with these changes in her narrative. She needed to be able to compartmentalize her grief and have it coexist and intermingle with her strengths and resources.

Here’s where the concept of the reproductive story can help. Our patients come to us in crisis. They are in the middle of their reproductive story and don’t know how it is going to end. They can look to the past, understand how the story began, recognize their assumptions, and see how their hopes and dreams got thrown off course. They are certainly aware of the enormous pain they are in at present. And the ambiguity of the future—will they become parents, how will they get there, what happens if they can’t become parents—is causing significant stress and emotional pain. What they can’t see is how the experience of reproductive trauma can actually enhance their lives in the future, and produce a new and revised life story.

The Importance of Telling the Story

One thing we know that helps people grow beyond their traumatic experience is grief work. This entails feeling the range of emotions that naturally occur and being able to tell their story—to select people. Sharing their story is the essence of narrative therapy. The process reduces isolation, increases the sense of connection with others and creates a feeling of being understood. Additionally, telling the story without feeling judged allows patients to unburden that which they feel most ashamed about. Whether this happens in therapy (as with Allison) or outside of therapy is less important than the issues of trust and safety. Allison’s loss of trust in her friend compounded her already fragile self-esteem.

It has been suggested in research on trauma that there are two systems of storytelling?. One is for public consumption; the other is the story that we tell ourselves. That story, the one deep inside of us, is the one that produces haunting, intrusive rumination, and with it self-loathing and self-doubt. In therapy, we try to access that deep story. In order to heal, that story needs to be befriended and looked at in a different light. Allison’s previous loss through abortion filled her with immense shame. Had she not been struggling with infertility, however, that part of her history might never have resurfaced. But the failed IVF coupled with the repeated attempts to get pregnant the old-fashioned way overwhelmed her. The fact that she could open up about it in therapy and have it be received without judgment was an enormous step for her. Instead of continuing to be self-punitive, Allison was on the road to replace her harsh and self-punishing inner narrative with a more tender, kinder version. This is a process that takes time, as all grief does, as the gradual acceptance of a new story emerges.

I had three goals for Allison at this point. Although laid out here in numerical order, these therapeutic goals are not linear; rather they co-exist as part of the ongoing process that occurs as one assimilates the trauma into a new narrative:

1. Manage her emotions and reduce her negative self-talk. I encouraged her to express her feelings without the harsh self-critic that was so deep-rooted. Labeling what she was experiencing as grief helped to validate that her loss was real. I also encouraged her to reach out to others for support—carefully. I suggested some local peer-led support groups to contact so that she could find other people who would really have empathy for her story of trauma and loss.
2. Work on ways to craft new narratives, new schemas. Allison found it helpful to think of her reproductive story as evolving. She thought about her remaining embryo; what if it didn’t work? While some people take comfort in focusing on the present and not delving into the “what-ifs,” Allison needed to have a plan ready in the wings if her next attempt didn’t succeed. Although she had yet to make a firm decision about anything, giving space to contemplate the future was allowing her to think about a new narrative.
3. Recognize that her core assumptions about pregnancy, her relationships, and feelings about herself were changing. Trauma can be thought of as a turning point. There was the time before, and the time after. Beliefs about oneself and how the world works can significantly change. And, as will be discussed, post-traumatic growth following reproductive losses can be quite life-altering in a positive way.

Out of Loss There is Gain

There have been numerous studies focused on posttraumatic growth (PTG) and the positive gains that can arise from challenging life crises?. Whether it’s recovering from a life-threatening disease, surviving a car crash, or witnessing a mass shooting, people can grow, change, and appreciate life in profoundly different ways.

As we have observed with Allison, trauma challenges fundamental assumptions—about oneself, one’s relationships, and the fairness of the world. The disruption to one’s narrative or schema commonly results in negative responses such as intense anxiety, depression, anger, intrusive thoughts, and/or feelings of numbness. Physical reactions are also common: headaches, gastro-intestinal upsets, fatigue, or a general sense of not feeling well. While the consequences of trauma result in psychological and physical distress, personal growth can occur in its aftermath as well. There is a cognitive restructuring that occurs in order to rebuild a sense of the future, and focus on what it takes to cope and find meaning. It’s important to note that the ability to grow does not signal an end to the trauma, the pain, or the distress, but they live alongside each other to create a new worldview.

A greater appreciation for life in general is a common characteristic of growth after trauma. There is often a newfound sense of gratitude for the everyday, a not-taking-things-for-granted attitude. For people dealing with reproductive trauma, research has shown that when they do become parents—however they get there—they tend to have a better relationship with their children, with greater emotional involvement?. The speculation is that the parent-child relationship may be strengthened because of the great lengths it took to become a parent, and the appreciation for their family becomes heightened.

From clinical experience, I have seen infertility and pregnancy loss patients grow in extraordinary ways, whether they are able to eventually have children or not. So many who have been down this road want to “give back” as a result of their experience. One couple made memory boxes for other parents and delivered them to the hospital where their daughter was born still. Another woman took to Facebook to educate the community as to what to say, and what not to say, when someone is struggling with fertility issues. Others have taken the opportunity to reevaluate their careers; I have worked with many women in healthcare, including mental health professionals, who decide to change focus and specialize in working with reproductive patients. One nurse opted to return to work in obstetrics so she could be there at the front lines and provide care to those in need.

“As people balance feelings of loss with a sense of growth, the strength that emerges is distinct”. Knowing that bad things happen, that we are all vulnerable, and that—most importantly—we can get through it, increases one’s resiliency. A new core belief can develop: “I am a person who is tough, hardy, and can handle just about anything!”

The Reproductive Story Ends

Our reproductive stories have a beginning, middle and end. As discussed earlier, patients enter therapy in the middle of their story at a heightened state of loss and pain. Using the story as a therapeutic tool addresses the inner beliefs and core assumptions of pregnancy and how it was supposed to be. Whatever the trauma or loss that has brought them in to our office, this experience is clearly not how their reproductive story was supposed to unfold.

One of the pluses of using the reproductive story in treating patients is that they immediately get it. Although there is a great deal of psychological theory behind it, it’s instantly recognized and understood without any psychological jargon. Knowing that they are in the middle of their reproductive story, gives them a sense of a timeline. Where they had felt a loss of control, they can utilize the idea of their story to edit, rewrite, and come up with new possibilities. They can try on different endings: if I use an egg donor, how will I feel? Can I emotionally and physically handle another miscarriage? If we decide to stop trying, how will our lives have meaning?

The reproductive story allows patients to understand the personal meaning of pregnancy and family, and the depth of what is lost when the story and their core beliefs go awry. I have the opportunity to explore these narratives, and the trauma they have experienced opens doors to explore new possibilities in creating a family, and in the broader context of their lives. Although their reproductive trauma has changed them forever, they also can embrace the ways in which they have grown through the process.

Postscript

As for my work with Allison, over the course of the next several months she continued to progress in a constructive way, between grief and growth. She was preparing herself for her next IVF transfer with the one remaining embryo. In looking at options beyond that, both she and her husband agreed to “wait and see” and keep the option of using an egg donor on the table.

The day she walked into my office beaming I knew she was pregnant. Her blood test results came back with a really high beta and had doubled, meaning that the embryo was developing as it should. We celebrated, cautiously, as we knew that there are never guarantees with pregnancy. She was trying to enjoy the here and now, even though it was filled with anxiety about all the things that could possibly go wrong. I normalized this for her; everyone who has had a reproductive trauma is anxious about a subsequent pregnancy, another loss. Gone are the days of that innocent assumption that getting pregnant and having a healthy child is natural and easy. As I welcomed her into the next chapter of her reproductive story—pregnancy—I reminded her that whatever happened, we would get through it together.

References
(1) American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th ed.; American Psychiatric Association: Arlington, VA, USA, 2013.

(2) Jaffe, J. & Diamond, M.O. (2011). Reproductive trauma: Psychotherapy with infertility and pregnancy loss clients. Washington, DC: American Psychological Association.

(3) Cann, A., Calhoun, L.G., Tedeschi, R.G., Kilmer, R.P., Gil-Rivas, V., Vishnevski, T., & Danhauer, S.C. (2010) The Core Beliefs Inventory: a brief measure of disruption in the assumptive world. Anxiety, Stress & Coping, 23:1, 19-34, DOI: 10.1080/10615800802573013.

(4) Van der Kolk, B. (2018). Trauma conference: The body keeps score. www.pesi.com.

(5) Tedeschi, RG & Calhoun, LG (2004) TARGET ARTICLE: “Posttraumatic Growth: Conceptual Foundations and Empirical Evidence”, Psychological Inquiry, 15:1, 1-18, DOI:10.1207/s15327965pli1501_01

(6) Golombok, S., Lycett, E., MacCallum, F., Jadva, V., Murray, C., et al. (2004). Parenting infants conceived by gamete donation. Journal of Family Psychology, 18, 443-452. DOI: 10.1037/0893-3200.18.3.443.

An Ending Without Closure

Posted on August 15, 2019February 11, 2026 by Psychotherapy.net Team

Being a psychologist is a deeply rewarding and meaningful profession, but it is often tinged with a sense of loss and a lingering concern over my clients. I regularly form complex, genuine and caring relationships with a multitude of clients, but these same people can and often do disappear from my life, leaving me to ponder how they are faring and whether they are safe and taking care of themselves.

One client in particular returns often to my mind; I wonder if he gained some semblance of control over his substance abuse issues, whether he was able to resist prostituting himself again for his food and rent, or whether he was alive at all.

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As with the other clients I work with who have severe borderline pathology, it was challenging to determine which serious, self-destructive behavior to begin treating first. Should I focus on his growing weed, alcohol and amphetamine addiction? What about the self-harm scars adorning his arms and legs? Or the chronic, suicidal thoughts that had consumed him since he was 10 years old?

The smiling young man in his twenties who greeted me in our first session was attentive but difficult to connect with. He responded to my initial queries with short, practiced responses. He had already visited with multiple therapists and been hospitalized several times beginning at a young age, and he understood his role to be compliant but not forthcoming. Those early sessions forced me to slow down my typically quick therapeutic pace and to meet him where he was. The focus was simply to get him to trust me, to validate his pain and to reframe his self-destructive behavior as an understandable, albeit unhealthy, coping mechanism. He had experienced a great deal of shame because of the various traumas he had endured, so it was soothing for him to feel understood and accepted.

One of the struggles in working with clients with borderline pathology is that there is often a different crisis that has transpired each week that threatens to become the focus of the session, crowding out the larger, more pervasive patterns and issues. I would try to spend some time each session dealing with whatever had happened over the previous week, while focusing on behaviors and thought patterns that were impediments to his health. An ongoing theme of our work was self-esteem, which I have found undergirds many mental health issues. If a therapist can effectively improve a client’s sense of self-worth, issues such as depression, anxiety and self-destructive behaviors often begin to improve.

In those early sessions, I had explained to my client that self-esteem can manifest as an internal, critical voice. We can recognize that voice because it tends to be vague and it disparages our basic personality and worth. For example, if my client ate too much at a meal, his inner critic might say, “You are disgusting and have no self-control.” Or if he was avoiding a task and laying on the couch instead, it would yell, “You are so lazy.” I encouraged him to pay attention and to try and notice this critical voice, and then to yell back at it. I told him that when he heard the critic in his heard criticizing him, he should say, “Shut up critic, go away!” I explained that through repetition, noticing and responding to the critic in this manner, he would diminish its intensity and frequency, and feel better about himself.

In addition to his self-esteem, we also worked diligently on his distress tolerance. This client, like many of those with borderline pathology, felt emotions intensely but didn’t know how to manage them. Since he couldn’t express them in a healthy way and didn’t feel justified doing so, he would internalize them, manifesting as self-harm or binge eating. We worked on identifying and accepting his emotions and then discussed ways to self-soothe. Due to his intense self-hatred, he often struggled to justify treating himself kindly or performing otherwise self-calming activities. In time though, he would occasionally come into a session and report back on something he had done to feel better, earning much praise and support from me.

Over the two years we worked together in weekly sessions, I developed a great deal of sympathy and concern for this client. Even at his young age, his life had already been exceedingly difficult, and I worried about his future. How would he find and maintain work? Would he meet a partner who would treat him well? Would he go back to school? With each new crisis, my apprehension for him grew. The worry morphed into sadness, as I grew to acknowledge to myself how little control or influence I had over my client’s life. I could provide compassion, strategies and tools, along with a safe environment, but I couldn’t save him, despite how much I wished to.

Eventually, my young client moved out of his home and found his own place, though he moved several more times within just a few months, as he struggled with landlords and finding money for rent. The frequency of our sessions diminished, and often several months would pass before an email would arrive, requesting a session.

It has now been a year since I have heard from him. In our last session together, my client was struggling to maintain his new job at a coffee shop. He was also feeling lonely and drinking too much. We discussed ways for him to feel better and explored options in his community where he could receive further support. Whether he followed through on these recommendations, I don’t know.

In my more hopeful moments, I reassure myself that my young client likely availed himself of at least some of the resources that we had discussed, given his desire to get healthy and improve his life. Surely, he wouldn’t have gone through with all of our therapy sessions if he didn’t harbor some optimism for a better future. Yet my worry and doubts remain to this day. All I can do is hope that wherever he is, he is safe and knows that I am here if he needs me.

Daryl Chow on Reigniting Clinical Supervision

Posted on August 13, 2019February 11, 2026 by rezendevknowfully.com

Supervision at the Crossroads

Lawrence Rubin: Good morning Daryl. Thanks for sharing your time with our readers. Your research and writing suggest that supervision as it has traditionally been practiced is in crisis. What is the crisis in the field of supervision that you are responding to in your work?

Daryl Chow: I think there are weaknesses in the status quo practice of supervision, and that is something that we should pay attention to and do something about. I think change needs to start to grow from what we know from the research, as well as from clinical practice in supervision. We need to do something that's closer towards two domains: helping therapists improve their performance and, while they're doing that, also emphasize what they are learning. So,

it's not just helping supervisors with what they're doing on a case-by-case basis, but also helping them to develop and evolve through time

it's not just helping supervisors with what they're doing on a case-by-case basis, but also helping them to develop and evolve through time.

LR: What does it mean to help supervisees or therapists grow and develop, as opposed to just performing in supervision?

DC: In my online course, Reigniting Clinical Supervision, we make an important distinction from the get-go between coaching for performance and coaching for development and learning. Coaching for performance is one way of doing clinical supervision where we help each therapist improve in the stuck cases they are presenting in supervision. This is indeed important in helping them work through the clinical issues that may be blocking progress or preventing them from making inroads in their work with clients.

But I also think what supervisors need to support is an undulating process of helping clinicians with their stuck cases, while also trying to glean general principles with which they can help clinicians then create or identify patterns that are showing up through these stuck cases. It is a matter of looking closely at the cases in which the clinician is not making progress in order to help them in their own personal and professional development. This transcends a case-by-case supervisory discussion in order to focus on the therapist’s growth edge; those skills and characteristics that are generalizable, or what Wendell Berry talks about in terms of agriculture, which is solving for patterns. So, these two worlds of coaching, or supervising for performance and development, need to come together in the supervisory relationship.

If you look at the literature right now from Edward Watkins and others who have done great work in the study of clinical supervision, we have not made any progress. If the outcome of effective supervision is reflected or measured in client improvement, we have not actually moved the needle.

Tony Rousmaniere and his colleagues wrote a paper in which they concluded that

the variance in client outcome accounted for by clinical supervision is less than 1%

the variance in client outcome accounted for by clinical supervision is less than 1%, which means not much, right? That's concerning, because we put so much time, effort, and money into supervision. So, while I don't think I would use such a strong word as crisis to describe the field of clinical supervision, there is definitely a need for change. I really think that we are seeing things slowly changing on the ground level and there are people who are trying to change what we have come to accept as standard practice in supervision.

Supervising for Development

LR: Okay, so what is the supervisor actually working on when she is focused on the supervisee's development?

DC: Well, the short answer is specific stuff such as the supervisee’s learning objectives. And their learning objectives are based on their performance. I will give you an example. If a clinician was to seek help from a clinical supervisor, that clinician (the supervisee) would first need to have a baseline of their performance, not just at the client-by-client level, but based on a composite of cases that they're seeing that provides them with enough reliable client outcome data.

And then, from those results, they would try to figure out where they're at before deciding where they need to go and what issues they need to address in supervision. I think that's a critical first step, because better results in in clinical supervision as measured by client outcome are obtained sequentially, not simultaneously. By that I mean we need to figure out where the supervisee is at. If their clinical outcomes are average, that really doesn’t say much about what they need to do in order to improve their performance. It is a matter of taking the second step, which is zooming in or focusing on those areas of clinical practice and therapeutic relationship where that clinician needs to improve. Simply focusing on the fact that the clinician is “average regarding their clinical outcomes,” doesn’t tell the supervisor where she needs to focus her lens regarding the supervisee’s skills and development.

So, as an example, if a clinician’s performance was average compared to international benchmarks, the supervisor would then focus in on those cases in which the clinician was stuck. They might listen to some recordings of the clinician’s work to discover that the clinician and the client did not develop therapeutic goal consensus. And it is often the case that

goal consensus is one areas that's not often fleshed out or verified in the process of the first or even in subsequent sessions

goal consensus is one areas that's not often fleshed out or verified in the process of the first or even in subsequent sessions. You and I both know that the goalpost changes as we go, right?

Sometimes the goal is to figure out the goal, to figure out what is or should be the focus of the session. Then the therapist and supervisor work on that one specific area. And then—and this is the critical piece—if the clinician and client are indeed working on goal consensus, it's important for both the therapist and the client, as well as the therapist and the supervisor, to follow through with the work towards that goal and then determine if doing so actually had an impact on therapeutic outcome.

LR: And just to define the outcomes variables you're talking about—are you talking about outcomes in the client progress, or in the supervisee’s behavior?

DC: I think you hit on an important note, because the feeling of benefit for the therapist does not mean actual benefit for the client that they work with. Remember, we're dealing with two steps removed from the office, so we need to make sure that the work we are doing with the supervisee translates into positive outcome for the client. It's almost like a paradox if you see two overlapping circles. Yes, it's about the supervisee’s performance, but if you focus purely on their performance, you're not going to go anywhere with the client. You're going to be riddled with anxiety. "Am I doing well? Am I doing badly?" And there's so much judgment involved.

We need to see the impact on our clients and see if our learning leads to impacting the people that we're working with. If the learning was focused on goal consensus, we want to see that it actually translates to an actual impact on the clients that you're working with on that level, on one client at a time. But we also want to see if that helps you to move up your effectiveness above your baseline.

LR: It seems you're saying that, if a supervisor is good at his or her job and guiding the supervisee effectively in the deliberate practice of therapy, then the client will by definition improve.

DC: Wouldn't you expect that?

LR: I would, but isn't it possible that—and I'm not trying to be provocative—but that a supervisor may be very effective in guiding the supervisee or the clinician in deliberately practicing their craft, but the client doesn't improve? Does that mean that the supervision failed? Or might it just be that something was missed? In other words, can you have good supervision and still poor therapeutic outcomes? Or do poor outcomes in therapy mean that the supervision was not effective?

DC: That's a really good point that world-champion poker player, Annie Duke, talks about in her book, Thinking in Bets. She makes a very important distinction which I think we need to think about slowly and carefully. And the point that she was making is:

we tend to conflate outcomes with process

we tend to conflate outcomes with process.

She says that when we get a poor outcome, let's say in the game of poker, we think that our process is responsible for that outcome. She says we tend to conflate the two. If you take some time to think carefully about how you're making decisions, how you're building the process and making a good plan, then if the outcome is bad, don't make that conflation too quickly.

Because in the game of poker, just like in the game of life, there's a lot of random noise, a lot of things that are beyond your and my control. But if you understand with the help of a supervisor that you are working on something critical—in our case, goal consensus because we know the effect size for goal consensus is huge, then it becomes a matter of focusing more directly on building that particular skill in supervision, not other skills unrelated to goal consensus.

And if goal consensus is indeed important—even if one client doesn't work out well, you don't want to go and throw the baby out with the bathwater. You want to just go back and refine goal consensus building skills again. Close the loop. And this is one thing supervisors and therapists can do, is to make sure that, after a discussion, they close the loop.

It sounds so plain and simple, but I think it's really something that's lacking in supervision as well as clinical practice, that people don't really close the loop by figuring out ways to refine the important skills in supervision that actually impact client outcome. If you continue doing this with other clients, will this have an impact as well?

Deliberate Practice

LR: Along these lines, you have an upcoming book, Better Results: Using Deliberate Practice to Improve Therapeutic Effectiveness, with Scott Miller and Mark Hubble. How can supervisors use deliberate practice to improve not only their supervisee's performance but their own performance as supervisors?

DC:

When we are working in supervision… we are really working within a multi-tiered structure that includes the supervisor, supervisee and the client.

It's a brilliant question, and I know, Lawrence, we've talked about this. My belief at this point is I think that it is critical. We are really in the early days of this type of investigation, but I think it's an important area to work on, and here's why.

My belief is that knowledge is multilevel. When we are working in supervision, we are doing just that because we are really working within a multi-tiered structure that includes the supervisor, supervisee and the client. And let me just use an analogy from the world of music. I'm always impressed by not just what the musician does in a music studio or how they work. I'm always interested in who else is in the room. And one of the things that comes up very often for me is the role of the producer. Sometimes it's the group of artists itself, and sometimes it's someone else.

And a couple of people that stick out to me are Brian Eno, who has worked with Talking Heads, Madonna, U2, and Rick Rubin who has worked with death-metal bands like Slayer. He's worked with many Hip Hop artists. He's also worked with the late Johnny Cash. There’s something about being in the presence of these types of producers that brings out the best in the musicians.

My question is twofold. One, what the hell are these producers doing that brings out the best in the musician? But I also am interested in how I can help others and myself be able to become more like a coach or mentor the likes of college basketball’s John Wooden. And the one thing that I think is becoming a little bit clearer as I go is that we really need a system of practice, a way to systematically organize ourselves around how we think about supervision. So, when I say system, it just means as simple as: how do we track outcomes?

My mentor and collaborator, Scott Miller, talks a lot about feedback-informed treatment. To me, measuring what we value is key, because measurement precedes professional development, so it is critical to help people, supervisees in this case, to systematically track their outcomes and to have a system of coaching already in place by the time they come into supervision.

And then we develop a taxonomy of deliberate practice activities so we know where they're at in the baseline, how to help them figure out a way to deconstruct the therapy hour and then pick up little things that they can work on. So, I guess my short answer, or rather my long answer is really, to figure out a system that can function as a platform from which we can begin to work on the more nuanced stuff in the role of supervisor. Am I making sense about this?

A Portfolio of Mentors

LR: You are indeed, Daryl, and related to this notion of the producer and artist working in collaboration, you recommended that clinicians build a portfolio of mentors. Does that mean that, even though supervision is, as you call it, a signature pedagogy, that clinicians should build a production studio of sorts with other professionals?

DC: As much as supervision is a signature pedagogy for our field, what's interesting for me of late is how people reaching out for consults or coaching often follows having given up on working with a supervisor for various reasons, unless they are in an agency setting where that is provided. But, yes, I think the idea of a portfolio of mentors is to say that

if you can figure out what's your leading edge or the gap that you're trying to work on, your default supervisor may or may not have the knowledge to help you

if you can figure out what's your leading edge or the gap that you're trying to work on, your default supervisor may or may not have the knowledge to help you.

And what you want to do is to create a community of people that you can turn to, that you can talk with, and then maybe a certain person you turn to more routinely. For instance, I've known a supervisor for more than a decade, and I always return to her. But if there was something else that was missing, or I wanted to stretch out and pick another mind to think of it from a different perspective, I would reach out to other people, even people who are so-called experts, and send them an email. I would ask them, "What's the fee? Can I come talk with you?" And most people are friendly.

LR: In a way, isn’t that what you are trying to provide through your online supervision training, Reigniting Clinical Supervision?

DC: My focus for Reigniting Clinical Supervision is to help clinical supervisors design better learning environments that sustain real development for therapists, so as to achieve better client outcomes. The choice of an online learning platform is not a mere substitute for live teaching. Instead, gleaning from the best of what we know of optimizing learning, adopting a “one idea at a time” drip-based method of delivery of content and maintaining learner engagement, helps the busy practitioner weave what they learn into practice, and return to renew and reconsolidate new knowledge as a result of being in the course with me and other clinicians/supervisors.

Here’s how I think about the difference between a live training and how Reigniting Clinical Supervision is designed: A real-time training/workshop is like a river. It is a constantly flowing torrent of ideas. If the learner steps out of the river for a few minutes, or needs some time to think, he is now behind. The learner may be able to ask questions but needs to constantly try and catch up and not fall behind. A chance for a revisit of the content after some time of reflection is not possible, with only the notes or slides that you've captured.

Online learning, on the other hand, is like a lake. The learner can step in and out of the water at her own time

Online learning, on the other hand, is like a lake. The learner can step in and out of the water at her own time, and pace herself as she moves along; the water remains the same. This stillness allows for pausing, revisiting the material, reflecting, and connecting with past knowledge. Online learning at its best allows for the learner to ask questions, revisit the materials, and for the person to master a difficult segment before moving on.

LR: Within this community of mentors model, there are different factors that predict therapeutic outcome. They include goal consensus, alliance and repairing therapeutic ruptures. Can the same principles be applied to improve supervisor performance and development?

DC: Hopefully, that's paralleled or modeled within the supervisory work. I would encourage supervisors to also elicit feedback within the supervision. And most of us do that, but it is also important to do it in a way that's a little bit more about a ritual. This would mean using some quick check-ins that give the supervisee some space to think about it, and then to explore the nuances of the supervisor/supervisee relationship. It's much harder when you really know somebody well, like the supervisor knowing the supervisee, to give feedback.

LR: Have you experienced working with expert clinicians who are lousy supervisors?

DC: I'm thinking of the converse. So, let me look back in my mind. I don't mean this in any disrespectful way because I really respect this person's work. Jay Haley of the strategic school of family therapy talked about this and said that he was really good as a supervisor, but not as good as a therapist [laughs].

LR: I think of myself as being a better supervisor and teacher than therapist. In your language, perhaps that’s because I have not deliberately practiced therapy.

DC: Yes, right.

LR: I've performed therapy, but in the words of Scott Miller, I've not deliberately practiced it. So, it's interesting that just because someone may be a very competent clinician, it doesn't mean that they have the patience or skill to guide a fellow clinician as a supervisee, and vice versa.

DC: This harkens back to your question about the role of training supervisors in how they do deliberate practice, because, to me, there are overlaps, of course, but there are also distinct skills required in their roles as supervisors and therapists.

The role of a supervisor requires some skill to be able to articulate the concepts without getting lost in the weeds of abstraction

The role of a supervisor requires some skill to be able to articulate the concepts without getting lost in the weeds of abstraction.

Cardinal Supervision Mistakes

LR: Talking about getting lost in the weeds, you wrote an article for us about seven mistakes in clinical supervision. If you were to pick the top two cardinal mistakes from that list of seven that supervisors make, which ones flash red to you, and what can supervisors to do about them?

DC: This is tough because the language around mistakes is all negative. I think, for me, the one that I've seen in my own experience and through my own mistakes is that of too much theory talk.

I think we talk too much. On the ladder of abstraction, talk is quite high up there

I think we talk too much. On the ladder of abstraction, talk is quite high up there. Bear in mind, when we're in supervision and in the absence of the actual client, we spend all our time talking in abstractions, at the level of theories about the client rather than about the therapeutic relationship.

When we're doing that, we've got to bear that in mind, that we don't have that person there, and we're talking at the level of theoretical abstraction, so many steps removed from what is occurring between the supervisee and the client. It's very easy to speak of it from whatever orientation or whatever philosophy you hold, without joining the dots of what's going to ripple down into the actual therapeutic relationship where the real work is happening.

Another big mistake in supervision is that when the clinical work is stuck and the supervisee and client are not making progress, the supervisor may say something in an attempt at being supportive to the supervisee like, "Well, at least they keep coming back, right?" In this instance, the supervisor is doing little more than what I call, patting them on the back–encouraging the supervisee without giving her any clear direction out of the stuck situation.

I'm really conflicted about that statement that I hear very often. Is that good enough for you, that they still come back? Or what else? What else can we be thinking of? How do we escape this domain of just talking on their level and to be able to make some real impact?

LR:

Another big mistake in supervision is…encouraging the supervisee without giving her any clear direction out of the stuck situation

I know that being able to effectively conceptualize a clinical case, to think about it from different theoretical perspectives, is important. But you're saying, Daryl, that sometimes we err on the side of overthinking the theory at the expense of guiding the supervisee in building the relationship with their client, and then we congratulate the therapist for minimal progress? Seems like damning by faint praise.

DC: Yes and no. I think all prudent supervisors know that therapeutic relationship really matters. And by therapeutic relationship, let's be clear, it's not just about the emotional bond, even though that is one critical part. But the other part is the focus, which is about the goals, the directionality, where it's going. The next is also about whether there is a cogent method for both the therapist and the client. Are we in agreement? Is there a fit in where we're going? All those things relate to the therapeutic alliance.

I think most people are focused about that. But as you will see in the upcoming blog that I am writing for Psychotherapy.net, I will be talking about the three types of supervisory knowledge. One type of knowledge is about the content knowledge, about the clinical case, about the psychopathology. Those things are necessary but not sufficient. The second type of knowledge is the process knowledge about how you engage with somebody who's, say, depressed? How do you engage with somebody who's anxious? That's a process or type of relating kind of knowledge. How do you have that kind of conversation? As David Whyte, the poet and philosopher, would say, "the conversational nature of reality." How do you engage in that? How do you come into being with another person into that field? But the third one is conditional knowledge, which is; if you're working with somebody who's depressed due to bereavement, it's going to be very different than when you're working with somebody who is depressed as well but due to, say, domestic violence. The context is very different, and you need to figure out a way of relating with them given the different situation. So, by considering all three of these in supervision; playing into the content knowledge, process knowledge and conditional knowledge, I think the supervisor can synergize them for the benefit of both the therapeutic work and the development of the supervisee. The supervisor and supervisee having this multi-level conversation will benefit both the client and the supervisee.

The Humble Teacher

LR: What do you see as some of the important personal qualities of an effective supervisor or a clinician who might become an effective supervisor?

DC: For me, of course,

a good teacher is somebody who is willing to be a good student

a good teacher is somebody who is willing to be a good student. If I'm picking a supervisor for myself, I'm always looking for somebody who implicitly—and it's not something that people would say explicitly, is willing to be wrong, willing to seek the counterfactuals, and then to have by default a stance of humility not just because they're trying to act humbly or bragging about their humility.

This humble teacher will say, “Hmm. Oh, hang on a second. I've really never thought of that.” And they're rethinking. That, to me, is interesting. And it's not because they don't have a wealth of knowledge. It's because this is dis-confirming what they know. And that's so exciting. That's like fresh air, you know, when you're working with somebody that way.

Additionally, somebody who has mental models or mental representations and concepts in their head about different ways to think about clinical situations and suggestions for the supervisee. They know that when they're facing this kind of situation, they have what Gerd Gigerenzer calls fast and frugal heuristics. They have little maps of how they will approach stuff. You know, they've thought it through before. They have ideas in their memory bank that they will pull into their working memory.

And you know that because when they're just giving off-the-fly statements, you know that it's off the fly. But if you know that they've thought about it, you realize their mental networks are vast. They know that it's an “if-then” situation, and they're thinking about it and all kinds of communications. That excites me because that shows to you this person has done some thinking before meeting with you.

LR: Is this what you refer to when you say that true experts think like novices, or beginning therapists, while true novices think they're experts? Is it related?

DC: I think so. [chuckles] I think so.

LR: I like that idea that the expert supervisor, who may or may not be an expert clinician, has these—what did you call them—fast and frugal heuristics? Was that the term that you used?

DC: That's right, and I mean that's the term from Gerd Gigerenzer, who studies cognitive science. He talks of the importance of having these sorts of heuristics. You know, the way we've been terming it is mental representation. Things that happen might not just be easily explained using therapeutic models but by different ways of thinking. Like, what do you do if you meet somebody who is angry or depressed in the session? These heuristics or maps are not like stock answers but are based on clear principles that flow from these mental representations. What do you do with somebody who doesn't have a goal? How do you work with them? They have a rough and ready guide.

At the Cutting Edge

LR: So, the supervisor should aspire to flexible thinking, drawing on different belief systems, different ways of looking at the human condition, different interpretations of the same clinical presentation? It sounds like the advanced supervisor is out at this cutting edge of creativity, untethered to any one way of thinking.

DC: Yes.

This domain of creativity is something I'm really interested in. I think one thing we need to remember about creativity is that it's about something novel and something useful coming together? Wouldn't it be great if supervisors were not restricted to thinking solely in terms of the field of psychotherapy in the course of doing their supervision, and could bring in greater creativity?

Just thinking about architecture, music, art—thinking about other aesthetic forms and how all of these can inform ways of thinking. Coming back again to the example about goal consensus, why do we need to only think about this within the domain of psychotherapy? Why don't we learn about how other fields and business organizations think about creating focus?

LR: So, we should consider using a flexible system of metaphors that transcend psychology and psychotherapy. When we first contacted each other, I mentioned that there seemed to be almost a spiritual undertone to the way that you described your personal philosophy of living and helping. Am I seeing it correctly, that there's a certain spirituality or spiritual dimension to your work as a clinician and a supervisor, and perhaps we should embrace that as well?

DC: Well, I'm grateful that you picked that up. To me, the answer is yes. And I think that's personally a deep embedment in my life. I was raised a freethinker from my Singaporean days. You know, this means I'm free to think or whatever that means. But I converted to become a Catholic when I was 21. When everybody else was running out of the Church, I was going back in. So, to me, that was my start.

But I think, fundamentally beyond religion, what's really driving me on a first principle level is human dignity. And the way I think about this is that

if a person comes to seek help and opens up to another person, that's a sacred moment

if a person comes to seek help and opens up to another person, that's a sacred moment. We need to honor that. We need to figure out a way that we can help each other come alive, because it's not just about creating purpose and meaning, but it's really to help each other come alive. And the therapist needs to come alive. The therapist needs to be alive and kicking and playful and to be able to ignite that. And the therapist also needs help and guidance from a supervisor. And for the supervisor to do that, the supervisor also needs to come alive.

LR: I remember Bill Moyer’s interview with Joseph Campbell at George Lucas’ Skywalker Ranch. He said to Joseph Campbell, “So, you're saying that people are searching for the meaning of life?” And Campbell said, “No. People are searching for the experience of being alive.” How does that find its way into the world of supervision, that tripartite relationship between supervisor, supervisee, and client? Where does that element of being alive get infused in that three-level process? And whose responsibility is it?

DC: Sounds like a family.

LR: Yeah, doesn't it?

DC: Yeah. I think everybody is going to come into play. I think it is the interaction. It's this ecology of a systemic perspective that's going to be important. How does it come alive? You know, I think we need some kind of platform for this to work, which we have talked about. But I think it critical is to keep this conversation going. Once we see that therapists are working hard to improve in what they are doing—once they figure out the baseline, once they figure out what to work on based on the baseline, then they develop a system to help them do their practice on an ongoing basis. And that they see the payoff of what they're doing.

It's like your child who's worked hard for the math test and starts seeing see the result. There's the real payoff. I mean the whole temperature of the room changes. Their focus becomes more intrinsic. And at that point, the role of the guidance is going to evolve as well. There's always going to be state of change. You’re right when you pointed out that quote from Joseph Campbell as well. That's something I'm very familiar with, and I think it's important that we continue to keep the conversation alive within clinical supervision as well as at the level of the therapist and client.

Fanning the Flames

LR: So, just as we encourage clinicians to take care of themselves and to grow and to rest and to seek meaning and a reason for being alive, so too must supervisors continually replenish and rest and grow and seek internal expansion, because if they wither, then the supervisee withers and the client withers. Who are the roots, and who are the leaves in this tree? It's a quite interconnected system.

DC: [chuckles] It is. It's just like our world now, isn't it? I mean I'm suddenly reminded about this teenager from Sweden that's really been striking me about what she's doing. I don't know if you follow the news about Greta Thunberg and how she's doing this protest about climate change and rallying a million teens around the world to protest about how the adults in this world had better take this seriously. And she's been going on global forums just speaking about this.

And I heard one of her speeches which she starts by saying, “Our house is on fire. What would you do if your house was on fire?” And she expands on that. And I think that's so important, that somebody her age is speaking about this.

LR: So, supervisees must find ways to, in your words, reignite supervision. I have one last question. You were born in Singapore, you live and practice in Australia, and you've traveled the world doing training in therapy and supervision. What have you noticed about teaching and supervising cross-culturally?

DC:

I think the first thing that comes to my mind is how similar across culture we are in terms of helping people

I think the first thing that comes to my mind is how similar across culture we are in terms of helping people, trainings and our roles as therapists and supervisors. But, of course, each culture has its own subcultures that you're dealing with. But to me, really what's striking is how much similarity there is. We're all in the same boat.

LR: What do you mean, the same boat, Daryl?

DC: We're all struggling to get better. We all want to. I mean all therapists and all supervisors want to do a better job. And that propels us. That makes us stay hopeful. It makes us invest time, money and effort to go and do CPE [continuing professional development] activities. You know, we're all trying to get better. But what's implicitly underneath that wish to get better is worry. We do worry about, “Am I getting any better? Is what I'm doing really helping to translate?”

And people are asking this question as they are looking deep, long, and hard. And I think the onus is on us as a collective, as a field, to start to come together, to start to build this brick-by-brick, to help out from the therapist's level and the supervisor's level, and to help us build this house, build it up again, and to help us to get just that 1-2% better each step of the way. Because the payoff and the morale that comes with that is going to move us even further.

LR: So, if everyone in that multilevel relationship strives to be a little bit better, then the whole system becomes better.

DC: That's right.

LR: If client outcome improves, then that goodwill is shared beyond the therapeutic space. If the supervisor is dedicated to practicing their craft, then they are in a better position to teach clinicians. And if clinicians practice deliberately, they are in a better position to help their client. And that is consistent across cultures.

DC: That's right. And, you know, I'm not the only one who is doing this, but I think I've started doing this whole thing about clinical supervision because I think we are a critical piece to the puzzle. And I think this one little story might help to illuminate this. You know, this gentleman, he knocks on his son's door, and he says, “Jamie, wake up, please. Wake up. You've got to get to school.”

Jamie then says, “I'm not going.” And the father says, “Why not?” He says, “Well, Dad, there are three reasons. First, school is so dull. And second, the kids tease me. And third, I hate school anyway.” And the father says, “Well, I'm going to give you three reasons why you must go to school. First, because it's your duty. And second, because you're 41 years old. And third, because you are the headmaster.”

LR: [laughs]

DC: I think we play that critical role. We do need to show up. And when we show up, we then need to think about what's our status quo and what's the one thing we need to start in order to refine our work to bring us alive again.

LR: To play that instrument a little better, to hit that tennis ball a little straighter, to run a little bit more efficiently. The supervisor must have a commitment to continued growth and development if the supervisee and the client are to improve.

DC: Yes, and I will say one last thing, if I may, Lawrence.

LR: Of course.

DC: If we use the musician analogy, I don't think it's to play the instrument a bit better.

LR: No?

DC: I think it's to play the instrument well enough but to be able to become better songwriters. I think that's a tougher job, because you can get technically better as a musician, but to write the next Hard Day's Night or Yesterday or Bohemian Rhapsody, I think that's a different skill. And I think we need to find a way to become better songwriters in our field.

LR: So, we can make better music together and because the audience is indeed listening.

DC: That's it.

LR: I think on that note, Daryl, I'm going to say goodbye, and on behalf of our readers, thank you so very much.

DC: Thank you.

Internal Emigration & Online Therapy

Posted on August 8, 2019February 11, 2026 by Psychotherapy.net Team

“I was born in the wrong place,” one of my online clients told me. She is someone with fidgety feet and a knotty relationship with her homeland. Growing up she had felt out of place in her native town, tucked in the middle of Pennsylvania. I keep hearing different versions of this harsh statement, from clients from various cultures and social backgrounds.

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The feeling of not fitting in, not belonging to their original environment, is shared by many emigrant writers. Edward Said’s account of this experience is probably the most quintessential: “There was always something wrong with how I was invented and meant to fit in with the world of my parents and four sisters. Whether this was because I constantly misread my part or because of some deep flaw in my being I could not tell for most of my early life. Sometimes I was intransigent and proud of it. At other times I seemed to myself to be neatly devoid of any character at all, timid, uncertain, without will. Yet the overriding sensation I had was of always being out of place¹.

Said’s experience of being deeply flawed, his constant uncertainty and confusion about his own worth, are all indicators of various degrees of feeling shame related at least in part to his sense of not fitting in.

Joe Burgo, a psychotherapist and the author of a recent book Shame, insists that: “Unreciprocated affection or interest will always stir emotions from the shame family. As part of our genetic inheritance, we want to connect with a loved one who will love us in return; when our longing is disappointed, when we fail to connect, we inevitably experience shame, however we name the feeling². The motherland, which does not love us back, is similar to a parent that fails to meet our expectations of love. Both unfortunate situations naturally result in feeling that something is deeply wrong with us.

One of the ways we can cope with such circumstances is by leaving our original place altogether. For some, the decision to emigrate, often a difficult one, is unconsciously driven by the need to avoid shame provoked by the discordance between who we are and who we are expected to be in order to fit in. In many cases, the choice to leave home is the best survival strategy. The most obvious examples are queer individuals from countries that pathologize and punish homosexuality: they flee their homes in order to be able to freely live their lives in the way that feels right to them.

But such physical escape is not always possible. Individuals who grow up feeling that they do not fit in countries that they cannot leave for various reasons (e.g., an iron curtain of any kind, family situation, physical handicap, economic dependence) feel trapped and disempowered in the face of such an unresolvable conflict. Not being able to escape the place that is rejecting them only reinforces the feeling of shame triggered by a constant experience being different and not fitting in, and of being excluded.

When emigrating outwards is impossible, the only way of fleeing such reality is inwards. My own Russian culture offers abundant examples of such a psychological strategy for subsisting in an unfriendly reality. Soviet history gave us not only the concept of internal immigration, as mentioned by Angus Roxburgh in a recent Guardian article on life in the 70’s, but also a rich cultural heritage, which thrived “underground” despite the intermittently tyrannical regime. Many artists—Shostakovich being probably the most striking example—lived a paradoxical experience of inner freedom in the middle of an oppressive outer reality.

Russian emigrant writers give us a powerful lesson of resilience in dealing with hostile but inescapable realities. Through their art, they created inner bubbles of freedom, and often had to evolve in parallel realities like Joseph Brodsky who, decades before emigrating, introduced the notion of an “indifferent homeland” in his early work inspired by the quintessential poet in exile, Ovid.

Emigrant writers such as Brodsky or Nabokov’s use of a foreign language for writing is emblematic and has deeper meaning: they claim a new freedom from constraints imposed by their culture. Committing to a chosen second language, despite the difficulties and losses that this choice implies, is a powerful affirmation of individual freedom. This second language, according to Kellman, becomes the tongue of the parallel inner world and a language of freedom.

The same is true for some of my clients living in the state of internal exile. They often reach out to a therapist who speaks English even though it is not their mother tongue. This choice certainly complicates their therapeutic journey, but also allows it some unexpected depth and richness.

When I meet with clients who evolved under an authoritarian regime (e.g., Saudi Arabia, Putin’s Russia, China), I recognize the strength of this coping strategy. Our sessions happen online through videoconferencing systems, as the clients are often unable to find a suitable support in their home countries. The regimes they live under have no love lost for therapy, which aims at empowering the individual; they usually opt for a kind of punitive psychiatry, which was so well developed in the Soviet Russia. Its aim was, in Brodsky’s words, “to slow you down, to stop you, so that you can do absolutely nothing…”

Evolving in self-created bubbles of parallel realities drives us even further away from those who share this harsh external reality with us. This further isolation can only deepen the shame that we already feel about being deeply flawed and not fitting-in. Those who are restricted to these self-created inner worlds often display some recurrent symptoms: depression, anxiety, low self-esteem, and constant self-doubt.

Online therapy can offer these inward emigrants a third space, located outside of their unfriendly environment, on the outskirts of their inner reality. In these two conflicting worlds, they are alone, but in the virtual space of therapy, they find a friendly person in front of them, open and curious to learn about their worlds. The online reality shared with their therapist eventually becomes a safe space to reflect on the painful discordance of their inner and outer worlds.

Communication media that online therapy actively uses for its own scope often play an important role in dealing with life in unfriendly inescapable surroundings. Many of my clients living in the state of internal emigration turn to social media on the internet to find like-minded peers and feel less alienated and less ashamed.

There is an intriguing parallel between the voices of the free radio that had offered an opening towards the other side of the curtain during the Soviet times, and the social media of today. The latter is more interactive by nature. During the Soviet times, one was only able to listen and feel connected by a stranger’s voice talking in one’s own language from the other side of the divisive wall, whilst modern technologies offer the possibility for a dialogue, often in English used as the lingua franca.

I have witnessed many situations in which such an outlet kept individuals sane: Saudi women who connect with each other in the ethereal space of freedom; a gay man from Siberia finding connection with those like him and acquiring some form of validation of his own experience; a queer young woman in Putin’s Russia working for a liberal news online platform and through her work connecting with those whose thinking she can share.

Online therapy with a transcultural therapist, who evolved on the other side of the wall, in a different and often freer reality, becomes an ultimate opening for individuals who experience their external realities as oppressive. In some lucky cases it can shake up the juxtaposition of the two incompatible realities the individual is locked in and offer something else—a less lonely space in which they can experiment with fitting in, belonging and imagining other, less lonely and shame-filled, and freer possibilities.

References

(1) Said, E.W. (1999). Out of place: A memoir. New York: Knopf.

(2) Burgo, J. (2018). Shame: Free Yourself, Find Joy, and Build True Self-Esteem New York: St Martins Pres.

Addiction: What Glory in the High Recidivism Rate?

Posted on August 5, 2019February 11, 2026 by Psychotherapy.net Team

When I began my career as a psychotherapist, I was sure I would focus on addiction recovery. After graduate school, I ran into an amazing professor and took a year of courses with her on dual diagnosis. Thirty-six years sober, she was my guide to a world I hoped I would never enter personally, but would focus on professionally.

I proceeded to work at a number of drug and alcohol rehab clinics, from tony Malibu in-patient programs to down-and-dirty outpatient clinics for people fresh from prison or the streets. I was a “newbie,” one of the few working in these organizations that did not have prior addiction as one of my credentials. I talked my way into the jobs by stating that I could offer an alternative to the way people had been living. I had learned how to talk the talk, from AA to NA to no A’s at all. But I learned that as hard as I worked and as connected as I felt to clients, I was never going to lower that +70% recidivism rate reported by the National Center on Addiction and Substance Abuse. Success stories were rare. Those who emerged from a facility often found their way back in. I treated a 20-year old woman in her 10th rehab program. When asked the first thing she would do when she had completed this stint, she stated she would escape from her home and go straight to her dealer for ‘H.’

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In private practice I continued working in addiction recovery. There was the shopping addict whose addiction not only emptied her pocketbook, but also derailed her marriage. I like to think out of the box, so we made a deal: she could shop till she dropped on Saturday, Saturday night she could try on her bounty, but on Sunday she had to return all of her purchases. This was monitored by mandatory photos sent of the purchases and returns. It became such a tiring process for this client that she eventually gave it up. When she needed something for a special event, she had to call me for permission. When she “graduated” from therapy, it was with a growing bank-account, sadly a divorce, but an understanding of her addiction and the knowledge that she could never go back to that behavior again. You might be saying, oh a shopping addiction is not as life-threatening as drugs or alcohol, but in another way it is. The depression precipitated by being broke and now divorced was mentally debilitating. Take gambling addiction. All you need to do is read former Good Morning America anchor Spencer Christian’s book, You Bet Your Life, about the thirty years of shame he hid and the near ruin he continuously faced, to know that addiction in almost any form is a health threat.

I also began to understand that giving up one addiction often leads to another. Why do you think that during AA breaks, so many people are outside smoking? The hole that created the addiction in the first place needs to be filled. So why not with something healthy? I began to find those “hole-fillers” for my clients. Exercise became the most successful. Hangovers and the day-after partying like a rock star are not feel good moments. Getting your health back, your body back, a clear mind—that became the goal.

One client was a law school student. After two years of Taco Tuesdays, Thirsty Thursdays, Freaky Fridays, Saturated Saturdays—and oh well, Sunday too, she was a full-blown black-out drunk; failing out of law school, sabotaging friendships, avoiding her family. When she came to work with me, eschewing AA, she had to come three times a week. She also had to pick a physical activity; her go-to instead of drinking. It was a long year. It became a long second-year of maintenance and on the anniversary of the completion of year two, her official graduation from therapy, I had baked a cake and had sparkling cider ready. She walked in, and to my shock, was followed by her parents, 2 sisters and her soon-to-be fiancé. There were hugs. There were tears. She was carrying a large wrapped photo.

I looked and said, “What a great picture of you and your Mom.”

“Susan,” she grabbed me. “That is me when I started seeing you and me now. I am sober and 60 lbs. lighter and a rockin’ marathoner.”

Did I move the needle on the overall recidivism rate? Probably not, but small successes are what makes this profession worth practicing.

When the Grass Becomes Greener

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

I feel fortunate to live in a climate where four seasons prevail. The first having passed for the year (ski season), we are on the precipice of entering the second: lawnmower season. Spring has sprung! And, with the recent rains we’ve had, our grass is taking off to new and varied heights! It’s about time to unearth the mower from way back in the back of our garage, get dressed in some comfortable work clothes, put on some old tennis shoes, and officially commence lawnmower season, week after week, one hour at a time.

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The usual routine involves noticing that the grass is starting to eclipse the stone borders around our blackberry and raspberry vines, and lamenting the development of dandelions and hard woody weeds that tend to shoot up above the rest. The latter of these are actually the persistent leftovers of a sour cherry tree that we used to have in our backyard, perennial manifestations of seeds haphazardly planted by the birds who used to steal the ripened berries straight off its branches.

After a long day of therapy, processing trauma with clients who have lived through the darker side of our shared humanity, I welcome the physical exercise that weeding and lawn mowing provides. With old volleyball kneepads pulled over my knees in homage to my favorite sport, I work at ground level, eye-to-eye with the garden nemeses that impede our barefoot backyard adventures. (If you’ve never stepped on a sprouted sour cherry tree root barefoot, it’s like traversing your living room and stepping on an errant Lego® block, randomly left behind, circle-side up! Ouch!)

While weeding, I enter the quiet space of a self-induced Eriksonian trance and process my day, thinking of clients’ stories, past and present, and their journeys to face the unimaginable to try to evolve beyond what they’ve experienced. I think of the importance of taking the time and putting forth the determination and commitment it takes to dig with my hand trowel to the bottom of those sometimes sprawling roots to carefully and tenderly lift them out of the ground so as not to leave a piece of them behind that can regrow and repopulate in their place. I meditate. If only the “errant” thought, belief, or behavior (their own or someone else’s) that caused or continues to cause them harm could be uprooted, whole and in its entirety, and cast away onto a compost pile to be transformed and recycled, seeped of its energy and sustenance and used to nurture a new thought, behavior, or self-affirming belief in its place. Perhaps the grass truly could be greener on the other side.

I continue my gardening from behind the lawnmower, upright and removed from the closeness of the weedy encounter, gear up to “rabbit” mode, and pull the cord until it sputters to a start. Although it sometimes takes a few tries to get our old mower going, once it is, we’re off and running steadily for about an hour together. I typically break a sweat as I push our mower back and forth, systematically turning around trees and our kids’ swing set, breaking down the task by completing small sections of the yard one at a time. Despite the heat of the day, I take comfort in the steady pace I can keep, guided by the mower’s propulsion system, and the constant hum of the engine in motion. I can more easily see the progress we make using the larger and more powerful tools of the trade. The tall and uneven blades of grass are trimmed for a fresher and more orderly appearance.

As I push the mower, it’s easy to set the direction. The machine, unthinking and unfeeling, willingly moves forward and turns under my guidance. Its ease of use allows me to enter the same unthinking and unfeeling space by the grace of our interaction, a welcome break after a hard day at work, providing therapy, then weeding. We only need to pause once or twice so I can empty the grass catcher and refill the gas tank, operations that are simple to complete and require no real brain power on my part. The wonderful part about mowing is how progress is steady and visible, and how it’s easy to estimate how far we’ve come and how much is left to go before it’s done.

As a therapist, I find it important to be able to do things in my personal life where the beginning and end are easily marked and where progress along the way is obvious and quantifiable. Systemic training has taught me to look for the smallest incremental measures of success, counting each little step as a victory, and celebrating each in turn. To have physical reminders of this progress and the success it implies is rare in the therapy room.

We need to concentrate and rely on our clients’ reports, drawing out the stories of their successes with our encouragement, questions, and genuine interest, because gardens invaded by weeds do not tend themselves. Neither do gardens of the mind invaded by psychological trauma. Left to fester, the deleterious effects that characterize what Judith Herman referred to as “the central dialectic of trauma”—simultaneously wishing to deny the existence of the events that underpin the trauma, and needing to uproot them from their nestled hiding places and expose them to the harsh light of day—require an experienced hand to contain and prune them until they can be thoroughly weeded. Gentle guidance, using the powerful tools of the trade and the established therapeutic relationship, can help our clients activate their own self-propelled encouragement engines, even if only for an hour a week, during a season that may be more—or less—long in their lives. I fervently guard the hope that with practice and over time, they will learn to operate at a higher gear, developing their own containment, pruning, and weeding skills, will recognize their own successes, and will notice the greener grass growing in their own backyards.

Reference

Herman, J. (2015). Trauma and recovery: The aftermath of violence – from domestic abuse to political terror. New York, NY: Perseus. (Original published in 1992)

Grasping at Optimism: When Helping a Suicidal Client Means Letting Life Happen

Posted on July 24, 2019February 11, 2026 by Psychotherapy.net Team

A Woman Named Charlie

I tend to think of the initial few sessions with clients as a delicate endeavor, not so different from cooking a soufflé. If I ask them to dive too fully into a painful topic, or challenge their defenses too soon, the person may fold in on themselves, and the therapeutic process, like a rising cake whose oven door is opened too soon, haplessly deflates. But when we proceed gently and slowly during this early phase, a client who is in real trouble may allow her reality to surface, even revealing a serious crisis that might otherwise have been missed.

“My most delicate soufflé was a woman named Charlie”. I was just five years post-practicum when Charlie, ten years my senior, sat across from me for her first appointment. She held a strong, upright posture and bravely deliberate eye contact that didn't square with her disheveled appearance. It was as if her combination of long, scraggly hair, wrinkled clothes, slouched posture and no make-up were deliberate tools used to give the middle finger while at the same time beckoning for help. Her voice was menacing with this tone that was a combination of critical professor and sincere consumer. As we got to know each other, she rattled off effortless soundbites about her position as a president of research development with one of the world's largest technology corporations. She then detailed an exhausting list of stressors, including frequent eighteen-hour workdays, nightmares, loneliness, bereavement from a recently ended relationship and admitting that she knew, given the way she lived and what she did, that there might be no end to the pressures.

The more we talked, the more I marveled at how my conversation-style intake questions were answered with explicit brags about her academic and career accomplishments. This chance to let a new client explain why she’d come to therapy started to feel like a verbal tennis match, with each volley of words leaving me a little more bowled over by her intelligence and concerned that I had nothing to offer her.

And yet, I could hear in her voice a tinge of high-pitched panic just beneath the surface. It surfaced in response to her commenting about my arms being crossed. My gut told me this was a test to see if she could put me in the spotlight so that she might feel safe and no longer the focus. I responded by asking her what her incentive was for investing her precious little surplus time and energy in therapy. What was in her life or what did she want to have in her life that would make this worthwhile? “She stared at me for just a second, but looked right into my eyes and said, “I want to not want to die.”” She then said, “I ‘m not sure you can handle this, and, in a way, I apologize for being here.” My gut told me not to bluff and so I told her what was true; “I can handle hearing about your hell here on earth. I can handle learning what that is like for you. There is an unknown beyond this, because we are just starting, and the work and the process remains to be seen. I can handle someone feeling like giving up. But to handle you actually giving up is something I will do my best work to spare us both from.” Now I had the most important piece of information that was so well hidden under layers of success. This super-powered woman was in desperate pain, and for this, I vowed she would get my best efforts. Even if she did scare the crap out of me.

Playing Emotional Poker

One of the perks of being a therapist is that honesty and transparency are prime capital. I like how free clients and I are to ask each other deep questions, and I think there is something inherently optimistic about a conversation focused on learning how to heal and grow. In that first session, Charlie seemed to tune into that optimism herself. She said she was surprised that she didn’t feel like leaving, adding with a grimace, “at least not yet.” Soon she was telling me about her father's death when she was twelve, and how her mother reacted by shutting down, quitting her job, and beginning a new existence of voluntary confinement to her house.

Charlie sat forward and exhaled slowly before saying, "My mother made me promise not to go out after school so instead I kept to myself and read. It was my freshman year of high school when I checked off three months of not talking to anyone outside of school besides her."

It was nearing the end of the first session and besides forming the frame of therapy with the set weekly time and day, I continued to stay almost solely in the information gathering mode. By doing this, I stayed with Charlie as I let her know what she could expect from me and that she could refuse to provide any information she did not want to at any time by just telling me no. I assured her that the fact that she didn’t want to discuss something was enough of a reason to stop. During a pause in our dialogue, I wanted to tell her she was brave, that it wasn't too late for her to live life with happiness, but the immediate therapeutic silence won out.

Two reasons prompted me to keep my encouragement unspoken. Even though my optimism was sincere, I had no idea of how to create a plan of action for her, nothing specific on a clear behavioral goal level to point to as a potential defining path. Also, “I ran the risk of her perceiving my optimism as evidence of my failing to appreciate the magnitude of her pain”. The timing was off as what was relevant in that moment was that she endured hardship and was hurting and wanted these two points acknowledged without any competition. I was the port in the storm, and I was acknowledging her pain. Regarding adding anything more, this was one of those times when more would he the enemy of good.

Once we were there with the sadness of her early life out in the open, something shifted in Charlie, and she began testing me by admitting to a problem and then pelting me with a personal question. First, her voice inched up a register and she said, " I've never had sex. Not until three months ago when I met…his name is Daniel and he is not available. I knew he was married but I hooked up with him anyway. You would never do anything like that, would you?"

The way she stared at me in that moment I knew she wanted to see if I would judge her and was also letting me know that she was not afraid to shift focus and put me on the spot.
"You know, I can't really delve into my personal life, Charlie, but I’m curious. What makes you so sure about what I’d do? What makes you so sure that when or if faced with a mirage in the desert at a time when I’ve reached a breaking point, I might not try to drink the water?”

The staring continued but was now accompanied by silence.

“Look, I get it,” I said. “Sometimes the world makes professional therapists out to be mascots of all that's socially ideal, when in reality, I may be just as isolated as you. And capable of making similar choices."

"Sure, you are," she said, settling her gaze on my diploma on the wall.

“Was Dan…” I stopped myself for a second. I wanted to ask about Dan, but not have her feel defensive or think I was trivializing, “can you tell me about him?”

“I can’t. He’s a father, husband, son, best friend, author, researcher, gym rat, middle class. Cute, more than handsome. He needed braces and never got them. I can’t talk about him any more than that. Oh, except he’s my co-worker on certain projects we work together.” She was being vulnerable with me. “She was sharing something that hit on such a universal theme: unrequited love” of sorts. I saw an opportunity to bridge the gap between her and the general public by my relating. Since I was the mascot for the public at large, if I related, it would be a start to her being less removed, separated.

“Charlie, there are many things I would do differently if given a second chance. It sounds like we may have that in common," I told her. “And you have this is common with so many women and men”, I wanted to say, but didn’t for the sake of being too much the salesperson for society at large. She sat quietly. Then leaning forward, she said,

"Well, I hope you're nicer to yourself."

With that her eyes grew soft and she gazed at me with friendship. I chose not to hit any more balls back to her at that point. Instead I smiled, and told her, “Thanks.”

Being Both Therapist and Client

For her second appointment, Charlie sat again with hands folded and posture strong, and then began the session by telling me that my arms were again crossed, and I seemed like I didn't want to really talk with her. This test, I thought, may have been an attempt to obtain reassurance that she hadn't overshared at our last meeting. Perhaps she also needed me to know what it felt like to be evaluated, in case I was doing a similar thing to her. My reply, I decided, would be measured kindness, but I needed her respect too. Instead of saying "my guess is you're scared, but I promise, I'm safe,” I went with what felt like cliché boundary setting 101.

"You seem concerned about making sure I'm really interested in talking with you. I'll confess, I tend to be on the cold side temperature wise, you may see my arms crossed at times."

I decided then that giving her the overview of early therapy would be better than either continuing to spar or immediately picking up with what she said last session. I did this because I was concerned the deep, candid disclosure she made last time might be a sort of self-sabotage whereby she made herself too uncomfortable to return, while at the same time getting some small relief by having shared. She might even see my bringing any part of this disclosure up as challenging or even shaming. In other words, way too soon for the soufflé!

I kept going. "Now, it's time for us to get to recent history. Probably like your field, which I know next to nothing about, we need to create a baseline and the first step is getting all the remaining important information out on the table."

She looked frozen and I grew concerned that at any moment her critical parent persona would return to challenge me. So, I quickly continued. "Recent-history is an oxymoron. It's a phrase to encapsulate my question of what life is like for you. In the back of my mind at this point, is the question of why decide to meet with somebody now?"

She didn’t move and didn’t answer me for what might have been a full minute. Finally, she said, "Do you like to get lost in all these little lives around you or just dismiss them by the time you leave?"

"Ouch, wow." I said.

I resisted my own people pleasing tendency—the residue from my own family of origin-—and just sat there, with my eyes as expressionless as possible. “I wanted, in that moment, to address her need to matter”. I did my best active listening pose and moved slightly forward, leaning in to communicate non-verbally without looking overly deliberate, like a perched egret.

She stepped up.

"I had to take a shower to come see you and it was the first shower I took in days. After my co-worker ended things, I started drinking at night. Every night. He would call all through the night and the next day saying he was worried about me, but that I had to stop calling him and that he could no longer respond. I don’t remember any of my calls to him, but he once sent me a call log. He disconnected our private phone line, but we still talked at work. To get through it I made myself more available for the bigger overseas meetings and wound up spearheading our entire overseas communications. Others have the in-person meetings, but everything starts and stops with me. That’s how everything at work changed. I now only work from home, with little exception. My world is my phone and computer. I have no time to eat or bathe. I hardly go to the bathroom. But I always walk Yoda."

“Her dog, Yoda was her love supply and a reminder that kindness existed in the world”.

I took a deep breath and but before I could exhale, she continued, "So now you have the following: alcoholism with blackouts for over six months, so Alcohol Dependency on Axis I, abandonment by father, then death and bereavement, oh, emotional incest is missing in the DSM, clinging relationship with obsessive features with anger outbursts, I'm saving that outburst detail for next session, so, that gives us a rule out of BPD, attachment disorder, co-dependency and intermittent explosive disorder on Axis II. There. I laid it all out for you. And I'm sorry."

While some of her diagnostic summary was surprisingly on point, I did not want to discuss that. She next told me she was valedictorian of her doctoral class at one of the top ivy league schools and studied psychology for her electives. In a way it seemed like she wanted to impress me. In another, it was possible she was fearful of her own problems.

"What are you sorry for?"

She paused for a moment. Therapeutic silence sometimes feels so long.

"I guess I'm sorry I'm here."

My interpretation was that either Charlie concluded that based on my young age I would find working with her overwhelming, or she liked me and felt guilty for bringing in “darkness.” Maybe a combination of the two. She was used to being smarter than everyone else, being the one with the information as opposed to the one seeking it. I told her that for therapy, she was doing exactly what she was supposed to be doing—albeit in a much more organized manner! She allowed us this humor and laughed out loud. I told her about the multi axis of 1-IV and how it is the format for putting everything together to map out a problem and solution. She didn’t chime in about being familiar with this. I continued by saying that I'd like to develop this together with her in session.

My goal was to take away any perceived armor she may have assigned me and by unmaking the work, she would feel safer. I described the importance of ruling things out and stabilization. Those two terms would be the focus before anything else. I didn’t want to go right back into what she said about wanting to die because I wanted her to tell me electively. We spoke about the hierarchy of her more negative circumstances and when I asked her which was the riskiest in her mind, I was prepared for her to face alcoholism in tandem with her upfront style.

"Oh, probably that I am very suicidal at times."

Suicide Enters the Room

I tried not to appear shaken and went into question mode to assess suicide risk. With each new question I tried to communicate care without sounding patronizing.

“Can you tell me what that’s like?”

Long pause.

“Do you ever think about how?”

Long pause. It would not have surprised me if she knew about passive and active ideation, but I didn’t want to get into an intellectual conversation, so I did not use those terms or ask.

“No, just that I want quiet and then I drink and take Yoda and go to sleep.”

“Does anyone in your life now know or even have hunches about your pain? ”

“My best friend, my one friend who I’ve known since undergrad is a psychologist in Beverly Hills. She’s like family and I consider her, her husband and sons my cousins.” She then started laughing.

I wanted to bring things back to my questions about safety but knew that would be too schoolteacherish.

“Something about her work in Beverly Hills always makes me laugh. We don’t talk as often anymore. Southern California gets crazy.”

I let the rest of the session go towards her friend’s work and the “imperfections” of the people of Beverly Hills. She seemed to enjoy this.

The next session, Charlie was ready to focus. She painted a picture for me of her day-to-day life: wake up between six and seven a.m., brush teeth, splash water on face, walk Yoda or let him out in the backyard, feed Yoda, sign in online, make coffee, take out a frozen something to microwave. The next few hours would be a blur of vomiting, coffee, mild level of shakiness, combined with conference calls, emails and other various computer-based tasks. Then after Yoda's second trip outside and a few hours post-lunch, she would begin drinking vodka. Sometimes in Diet Coke, sometimes straight. She would do this slowly while still working all through the night. Voice communication typically ended completely by 2am. At this point, her drinking continued and eventually she would "wind up in bed" after a shower, energy permitting. Occasionally, she had visits by phone with her cousin in California.

“I kept thinking, "start where the client is at."” Because I was not hearing about deliberate self-harm on a planned or immediate level, self-care became my target pitch with Yoda at the center. If I pointed out that I was concerned about black outs, the level of her drinking, the level of her depression, she would have shut down, possibly discontinued and perceived me as a critical parent. I would wait for just one or two more sessions.

"You want to be around for Yoda. She's dependent upon you, right? I'm not out to preach sobriety. My goal is to help you get what you want and for you to be happy—or at least feel less pain. But, I need your help on this.” She gave me a look that indicated an inner reply of “bull” and so I added that her drinking is risky and dangerous and that seeing what she wants in her life, such as caring for Yoda, is a step towards sobriety because it would be a by-product of it.

She responded by shifting away from the here and now and going into her teenage years with her mother, when she would read her schoolwork to her mother, working to get an eventual smile. This would be followed by cooking dinner, cleaning up, watching TV with her mother and helping her into bed. Often, her mother would wake her during the night in tears and she would do her best to comfort her.

“I would pretend that my mother had pneumonia and my father was stuck working late.”

“So that made it a more comfortable situation. Very resourceful and creative. You worked with what you had.”

“I got good at creating alternate circumstances. I did this when I made my speech to our graduating class. I pictured myself as a scientist wishing them well. I had no family in the audience.”

I did zero redirecting and just let her lead. Eventually she paused, looking sad.

"Is it me, or does it seem that I have more to deal with than most people?"

I nodded, "You have been through a lot and pain is the by-product. And you're still here."

"So, what does that mean?" she asked, her eyes boring into me.

"It means you can give" —ugh! beginner's mistake—better to have asked her what it meant for her, but too late to shift. “You can give love to Yoda, to your cousin. To the world you live in and are part of.”

"Oh God, you're one of those people," she laughed.

Our time was suddenly up and despite the bomb she’d dropped, she left my office a little bit happy.

I hoped at this point that the therapeutic alliance, combined with Yoda, seemed enough for the time being to compete with any desire to die. My experience at that point of working with suicidal patients was limited to practicum work in a residential facility, where supervision of the patients was constant. On the one hand, my assessment was that her ideation was passive, and she was not at risk of intentional self-harm. On the other, she could possibly hurt herself unintentionally while under the influence of alcohol, or her tolerance for her pain could escalate along with a decrease in impulse control, making it tempting for her to torment herself. My next worry was along the lines of “who was I to determine such a thing?” I was afraid to trust myself, but at the same time, if I continued with that thought process, I would not be able to do my work at all. I needed to permit myself to trust my instinct. “I white-knuckled it until she returned for her next session”, convincing myself in the intervening days that she’d just need to avoid alcohol clumsiness or an impulse emotional reaction to something, such as a conference call where Daniel was a participant. Thankfully, none of that happened.

I did not disclose my concerns because I did not want to seem controlling, but in hindsight, this would have solidified my role as a professional and communicated care. A novice mistake, I wanted her to see me as an ally or possibly even a friend on some level, though I was not aware of this at the time. This personal state of mind may have interfered with expressing my concerns directly at that time.

Atypical of my work style, I placed stability and structure as the focus of the initial sessions and her life, while not touching the alcoholism-in-the-room. I was afraid that if I tried to finesse recovery beyond minimal references to it, she would terminate therapy. It seemed to work. Charlie made every meeting with me and was actively engaged in her therapy. I’d asked her to try expanding and deepening her support network and she tried. We talked about developing a curiosity of others and using this a fuel for practicing casual conversation. She reported more conversations with her cousin in California and she stopped and chatted enough to get on a first name basis with a couple of her neighbors whom she met while walking Yoda. My plan was for her to achieve a set routine of basic self-care, physical hygiene, and an emotional hygiene of having a “no fly zone,” where she dedicated a set space and time to be work-free, even if just a half hour in her living room. From this, we’d then work on social hygiene—a routine interval of basic conversation with neighbors or others. Once these forms of care were in place and working with me was more familiar, then the odds of a conversation about alcohol being productive were greater.

“But then one day this optimistic effort all came to a screeching halt”. Her drinking escalated once again after Daniel began refusing to answer even her work calls. She had been redirected to a new administrator every time she tried to speak with him. Sessions were never the same. Her depression was escalating and riding right along with it was active suicidal ideation. She attended therapy without fully emotionally attending. She had this blank stare and even left early a few times, telling me she needed to go. I increased her sessions to twice a week, and to my surprise, she complied, no longer leaving early. Her disheveled look returned and gone was the new ponytail and barrette she began wearing just a few sessions ago. I felt like I was watching a flower shrivel up in anticipation of the inevitable. I wished she had better care than what I was providing, to then have better results—less pain. I knew referring her out would be seen as abandonment. I also knew she had made progress.

Though she kept showing up, she was becoming more and more zombie-like in sessions. One day she had a mark on her cheek, but shrugged her shoulders when I asked about it. It matched dark circles under her eyes. Next I asked about her drinking and got the same shoulder shrug in response. And then I asked about wanting to live. Void of emotion, she shook her head no.

"But what becomes of Yoda?"

"I'm thinking about taking her with me."

That's when I knew I needed help.

I asked her to help me understand what that meant. She said that was a “nice try,” but that she had already said too much about it. She then said that she “must leave” but would be back for her next appointment.

The Ground That Was Gained

After Charlie left that session, I broke her confidentiality by speaking with the psychiatrist from her company’s HR network. I had a release from her original paperwork and did not mention this to her at her next appointment. She sat down, looking slightly more rested. I told her she needed intensive treatment and that residential detox and weekly group therapy were my minimum requirements for us to continue working together. She refused and tried to talk me into keeping things as they were. I terminated our work, making it clear she could contact me any time after completing the two requirements. She denied any ideation during this last session.

I felt a combination of self-serving relief from a challenge being taken away from me, second guessing what else could benefit her right then as some sort of discharge plan, and some faith that she had an inner resilience.

To me, this was not a complete failure because, in my experience, people never lose the ground they gained while in therapy. They may disregard it, but the experience of having learned cannot be deleted—it happened, learning happened. I knew this logically, but this was sad for me. The magnitude of her suffering, the factual collective meanness in her experiences of the world, felt sad to witness. I wanted to alter it, or rather, have her alter it, and for me to be able to provide what was needed to empower her to do this. No matter the logical argument that some progress was made, pain won that day. I felt sad, scared for what she might do—but I did believe she would survive. I questioned my motives—did I want to end the risky work for my own benefit? Though she could make it less risky with compliance. In a way, I did feel some relief, but not enough to acknowledge at the time.

Epilogue

Five years later, the mystery of what happened to Charlie would be solved quite by happenstance, when I ran into her on one particular sunrise. We literally crossed paths as I was headed to my car after a run. Charlie seemed happy and calm. She was walking her dog, a new puppy she introduced as Chewy, and told me she was married to an artist. We briefly joked about the unofficial pre-sunrise running/walking community. With the laughter in place, I smiled and said it was good to see her, and resumed my morning activities. I wasn’t able to grasp the meaning of that encounter at that time beyond an intellectual level. The significance was that this was someone who once wanted to die and now was walking her puppy, happily married and healthy in appearance.

I’ve thought often about the weeks it took for Charlie, someone so successful and yet struggling so much, to express her suicidal feelings to me. Since suicidality has an aspect of masking, it is only natural for a client to keep it hidden at first. We therapists get it—why would someone who feels so little power be eager to turn over the one thing they have control over? And to a stranger, no less? It makes sense that they’d feel it might be too early to know what this relative stranger would do with the information.

But then, what can we really do once a patient does make the declaration? Yes, we can thoroughly access the ideation. Is it active or passive? Longstanding or reactionary to something recent? If active, how likely is the plan to be attempted and, if passive, how likely to progress to active? But really, we are just people, with our own subjective views, painful memories and blind spots.

We have the capability as therapists to gain entry into our patient's lives, learn the particulars of how they see themselves, who they want to be, what they want in life, what they see as impasses, how they feel. We are given access to the personalities and relevance of spouses, partners, exes, family, friends, co-workers and neighbors. We offer validation to people who feel misunderstood. Sometimes we help them to connect the dots, making what feels confusingly fragmented into related parts that share a pertinent life-theme. We do this by offering clinical explanations for what they describe as struggles, helping them see the relationship between what they are experiencing and their own internal motivators. At once we are both the motivational cheerleaders and the "Keepers of the Gloom" (borrowing from Robert Plant). But at no time are we mystical fortune tellers and at no time can we clap with one hand. “When it comes to suicidality, we aren’t the only link to staying alive”. We’re one in a chain of a system of care that’s there not just for them, but for us too.

In retrospect, I told myself that breaking Charlie’s confidentiality those years before was supposed to feel like being clinically responsible. Despite my direction, at that time, I felt like I was some kind of a turncoat traitor, even as I was dialing. After some exchanges and being transferred, put on hold and transferred again, I was trading information with the director of human resources for the entire company. He was a clinical psychologist who had an Ivy league quality. From my Philly background, I placed his accent as having a familiar quality, from what I always saw as the “other” Philadelphia, and I later learned that he was adjunct faculty at Penn. I gave him a full overview of Charlie, her progress, her impasse and the status quo. I felt a phone version of “active listening” and from his prompting, I felt comfortable continuing. He continued to ask questions that encouraged more information from me. Finally, I had said it all. The specifics of what he said escape me now, other than one surprising thing. He said that he thought I would benefit from looking at why I accepted this case in the first place. His direction felt like it should feel uncompassionate, but it did not, rather it felt sincere and matter of fact. Surprised, sad, somehow oddly feeling vindicated, I thanked him for his time, and without asking the actions he would take-or not take, we ended the call.

Dual Aspect Monism: Centering Psychotherapy on Mind

Posted on July 23, 2019February 11, 2026 by Psychotherapy.net Team

“My brain needs to be fixed.” My prospective client looked down, then up, to search my eyes.

The statement is deceptive in its simplicity. I feel an involuntary retreat from almost all the multiple layers of meaning I can fathom for the utterance. I don’t think my client’s neuro-chemical functioning is the cause of his pain. I think I can help him more effectively if we explore his mind.

Back in the day, there was body, and there was mind. Medical practitioners treated bodies. Therapists and analysts treated minds. Every binary hides a hierarchy: the people who treated bodies were highly respected. Those who treated minds were considered, well, a little off.

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Then people started realizing how much mental and physical functioning affected each other. They can’t be completely separate. The obvious solution (that preserved the hierarchy) was that mind must be an epiphenomenon of brain. Somehow, matter (brain) behaves in a way that creates a non-material phenomenon (mind). The battle cry became “mental illness is disease of the brain.” If you believe that mental illness is a disease of the brain, the way to fix it is to alter the brain. Chemically, surgically, magnetically, whatever. Talk therapy in this scenario is a poor substitute for direct neuro-chemical intervention, and one glorious day we will remember psychotherapy as a treatment analogous to applying leeches.

Except…logic dictates that the effect cannot impact the cause. The effect cannot precede the cause. So, if mind is caused by body, then mind cannot, logically, affect the body; a change in mind cannot precede a change in the body. And yet we know that it does. So maybe mind exists separately from the body after all? But if they’re separate, we’re still left with the problem of how two completely separate things can interact with and affect each other, as we know mind and body do.

As an ontological position (a statement concerning the nature of reality) offered by some philosophers of mind, Dual Aspect Monism offers a simple solution. The position is that there is a single reality that has two equal and irreducible aspects: mind and matter. Prior to the development of Dual Aspect Monism, there were basically three competing views concerning what is real. The dominant view today is Material Monism. From this perspective, reality is believed to be that which has physical properties. If you can’t measure it, it isn’t real. From this perspective, mind is the product of physical (neuro-chemical) activity. Idealistic Monism is the view that what is real is mind, and that matter is an illusion generated by mind. The third ontology is Dualism, which posits that mind and matter are both real, but they are completely separate realities. If they are completely separate realities, it’s hard to imagine why changes in one covaries with changes in the other.

According to Dual Aspect Monists, there is a single reality that is both physical and mental. Neither of these aspects is derived from or reducible to the other. These aspects are like two sides of a coin: you can’t make the head side of the coin square without altering the structure of the tail of the coin. But this does not mean that the change in the head caused the change in the tail. It is the change in the coin that changes both the head and the tail. When we use this analogy to understand humans, we see that some changes are more easily accomplished if we focus on body (I would not suggest that we focus primarily on mind to treat cancer), others may be more malleable by focusing on mind (I would not want to give a client a drug to help them develop a more fulfilling sense of self).

The implications are profound for psychotherapy: if mind is real and irreducible, we can legitimately aim our interventions directly at mind. We can use our minds to help clients change their minds. That means that our minds are the mutative factor in therapy. More precisely, the connection between our mind and the client’s is the mutative factor in therapy.

This means that some of the most profound changes our clients experience are changes in qualia (purely subjective experiences), and hence difficult to put into words, let alone observe from some outside objective position. It means that we know when our clients are improving because our minds are working together, and when their minds change, ours does too, a little bit. It means that what I do/say next is completely dependent on what my client and I are experiencing in the connection, not on some pre-determined protocol. That, in turn, means that my mind must remain attuned to the connection between our minds, not busy trying to problem solve, predict, or control the direction of the process.

We are psychotherapists. Many of us entered this field because the human mind is fascinating to us. Some of us have felt that the understanding of what we do has been slowly eroded as mind has become more and more devalued as an epiphenomenon of body. We always knew the two were connected (Freud was, after all, a neurologist). But many of us also know that what we do is not best captured by purely physical descriptions, or best understood using methods designed to understand the physical world. For us, dual aspect monism offers a way of understanding the world that explains what we do.

“Can you tell me what it feels like for your brain to be the way it is?” I try to join my client’s quale. By seeking to do so my mind reaches out, searching for, inviting a connection that can lead to change.

It’s Time for Supervisors to Help Clinicians Marry Data with Intuition

Posted on July 18, 2019February 11, 2026 by Psychotherapy.net Team

“It’s easy to lie with statistics, but it’s hard to tell the truth without them.”
—Andrejs Dunkels

Nearly every therapist I ask says that they regularly monitor the progress of their clients. Besides, why wouldn’t therapists check in and ask for verbal feedback?

Yet, given our clinical expertise, how is it that the assessment of our client’s progress is often inaccurate? In addition, why is it that therapists’ view of the process of clinical engagement is less predictive of outcome than that of their clients?

I believe this is because of our over-reliance on clinical intuition. We are trained to listen and take heed of our gut sense. Don’t get me wrong; intuition is critical, as scores of studies on this topic will attest (see Gary Klein’s body of work). Yet, relying solely upon clinical intuition is like asking a physician to treat a patient without the use of a stethoscope, a thermometer and the results from a bloodwork.

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From Assessment Thinking to Conversational Thinking

It’s time that practitioners learn to use outcome measures and engagement tools as part of regular clinical practice. And not merely as assessment tools, but as conversational ones. And to make this happen, clinical supervisors need to be on-board, trying it for themselves (especially if they are also practitioners), learning as much as they can about how to integrate measures as part of treatment and then teaching them to supervisees.

I once had a supervisee who wanted help getting “unstuck” with a client. We talked at length about the presenting concern, clinical background and what she had previously tried. The supervisee and client had just completed their 4th session when the therapist described that “things aren’t moving.” In other words, there was no discernable clinical progress.

Therapist View of Progress in the First Four Sessions.

I asked if she used any form of measures in her work. I learned that this therapist had been using outcome and alliance measures in her practice, but had not reviewed the graphic description of those measures. She was using the measures only because the management team insisted that she do so. I suggested that she bring the graphs to our next supervision meeting.

Here’s what the graph looked like:

Therapist View of Progress Alongside Client’s View of Session-by-Session Progress and Engagement

Even though there was a dip in the alliance at the 2nd session— a rupture from which the clinician was able to bounce back—contrary to her perception, this client’s experience suggested that outcomes were gradually improving. Not only was the therapist’s appraisal off the mark, but the plans we had devised with which to repair the perceived rupture were not right for the context. It was like wearing winter clothes in anticipation of being in the frigid Alaskan north, but instead finding ourselves baking on a beach in Bali.

We went back to the drawing board. We spent time working through the supervisee’s uncertainty and anxiety about her perceived lack of progress, while keeping in mind that the client was clearly perceiving and experiencing benefit from the engagement. As it turned out, the therapist was torn between addressing the psychiatrist’s referral concern of OCD, versus the client’s implicit desire to improve his relationship with his father. Thankfully, the therapist maintained fidelity to the client’s rather than the psychiatrist’s concerns.

In supervision, we re-focused our attention around attending not only to this particular client rather than the referral source, but how to do so with future clients so we could also address the perceived need of their referring sources. More importantly, the therapist needed to unpack and clarify some inferences about what she was doing and thinking that might have contributed to this gradual improvement, despite thinking that none was being made, so that she could continue doing so.

In this instance, thankfully, the client was improving. However, the opposite can just as easily happen, i.e., when we think that improvement is being made, but the client reports that “things aren’t moving.” When intuition and real-time data are either out of synch with each other or not taken together into consideration, clinicians (supervisees in this case) are prone to self-assessment bias. While we are re-playing mantras in our heads that say, “The clients will get worse before they get better,” we quickly realize that our client has dropped out of treatment.

Quick tip: In clinical supervision, make sure that supervisees bring in graphs of the client’s outcome and engagement. This is one critical way to privilege the client’s view of progress and engagement across time, while incorporating it into supervision. In turn, we can also monitor the impact of the “backstage” conversation of supervision on client outcomes.

But Why?

Here are two primary purposes for weaving ongoing measures into therapy and using them in clinical supervision:

1. At the Client Level

a. Guide the treatment process: “Are we on-track, or are we off-track?”

b. Use the feedback to feed-forward: Real-time feedback allows you to tweak the service delivery to fit each client, each step of the way.

2. At the Therapist-Level

a. Effectiveness: If used systematically, session-by-session with every client, the
therapist can figure out the nagging question at the back of all our minds: “How
effective am I?”

b. Individualized Development: Once you figure out where you are with the help of a
supervisor who is attuned to this type of process, you can start the journey of figuring out
“where you need to go” in your individualized professional development. (More on this in an upcoming blog post).

There may be many reasons not to use routine outcome measures in therapy, and only a few good reasons to do so. Personally, I am not a fan of numbers. The irony is not lost on me being Chinese and failing math (and Mandarin) in my early years. Besides, it is not as if therapists around the world need another thing to pile onto their existing and ever-growing paperwork! Yet, the benefits far outweigh the costs of not integrating some form of measures—tracking what is of value to the client.* A groundswell of studies now show that the use of measures such as a real-time feedback tool not only reduce deterioration in client well-being by a third, but doing so cuts drop-out rates by half, and as much as doubles the overall effectiveness of therapy.

The use of intuition without high-value data** is like trying to drive in a foreign country without a GPS or an old-school map. It’s possible to still get to your pinpointed destination—especially if your sense of North is better than mine—but the journey is likely to be mired in and derailed by unwanted detours. On the other hand, the use of data in the absence of intuition is like blindly following your GPS into a ditch, when the new road, which is just to your left, has simply not yet been updated into the system.

The knowledge gained from the marriage of data and clinical intuition contributes to a type of dialogue that is richer and aids clinical decision-making. Sometimes, client-reported data confirms what we intuit. Other times, the data contradicts our gut sense. The point of monitoring progress and weaving it into clinical supervision is not to defer all judgement to cold and unintelligent data. The point is to wrestle with this tension in order to see and think more clearly.

To learn more about becoming a better supervisor, check out the in-depth online course, Reigniting Clinical Supervision.

Notes:

*It is highly possible to be measuring something systematically that is not relevant to your client. For instance, capturing data without integrating the measures to inform the treatment process. Second, dogmatically using a symptom-specific measure that may not make sense for all your clients. This is why it makes more sense to be capturing information about a person’s global wellbeing.

** Data is only valuable when you are not valuing whatever you measure but measuring what is of value.

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Explore

Meet the Experts

CE Requirements

Defining Boundaries in Psychotherapy

Boundaries Have Meaning

Role Modeling and Boundaries

Exploring, Understanding and Maintaining Boundaries

Conclusion

Trauma and the Reproductive Story

Allison and Core Belief Disruptions

When All Else Fails, Blame Yourself

Grief-work, Coping, and the Reproductive Story

The Importance of Telling the Story

Out of Loss There is Gain

The Reproductive Story Ends

Postscript

Supervision at the Crossroads

Supervising for Development

Deliberate Practice

A Portfolio of Mentors

Cardinal Supervision Mistakes

The Humble Teacher

At the Cutting Edge

Fanning the Flames

A Woman Named Charlie

Playing Emotional Poker

Being Both Therapist and Client

Suicide Enters the Room

The Ground That Was Gained

Epilogue