Therapeutic Issue Archives - Page 40 of 68

Responding to an Immediate Negative Transference

Posted on April 10, 2019February 11, 2026 by Psychotherapy.net Team

A Cold Opening

When my friend and colleague, Jessica, called to make the referral, she said, “She’s an analyst, really smart and a great person. You’re going to love her.”

Sally arrived in my office about ten minutes before her appointment began. When I opened the door to the waiting room to invite her in, I saw a tall, thin, woman with gray hair. She was dressed simply in a gray wool skirt and black turtleneck sweater, but there was something elegant, almost aristocratic in the way she carried herself when she got up from glancing at a magazine and entered my office. I felt instantly inferior to her.

I greeted her: “Hello Sally, why don’t you come in.” I invited her to sit wherever she was comfortable. Then I sat in my chair and faced her silently. I thought about the fact that she was a more experienced analyst than I was. If she had never been in treatment before, I might have waited a minute and if she was silent said, “So tell me what brought you to see me.” But since she was an analyst herself, I just waited for her to tell me why she came.

“You’re pretty cold, aren’t you–silent and cold. But maybe that’s not bad. Maybe that will be more analytic and help the transference come out faster than if you were warm and fuzzy.”

I was taken aback because I don’t imagine myself as silent and cold. I thought I was warm but giving her the space to present herself. Indeed, this was the first thing I learned in my first class in analytic training. So I was speechless when Sally accused me of not knowing how to begin a session properly; but before I had a chance to respond, she continued.

“Let me tell you about my history.” Her face was expressionless as she pulled aside her long gray hair that was partially covering her right temple and continued. “When I was five years old, I was in front of my house waiting for the school bus with my younger brother. A car ran me over and I almost lost my right eye. I was in the hospital for months. They saved the eye, but I have this scar.” She pointed to a slightly indented grayish patch of skin that started at the edge of her eye socket and extended to her hairline. I made an inaudible noise and grimaced to express my understanding that this was a traumatic experience. But she continued before I could utter a sentence. “Then when I was 15, my mother, brother, sister and I were going to California to see my maternal grandmother who was dying. My father dropped us off at the airport in Chicago and then before we got on the plane, a policeman came and told my mother that my father and his driver were in a car accident and my father was dead.” Again I gasped, this time in disbelief that so much tragedy had befallen her at such a young age. But she continued telling the story without affect as if she were giving me a chronology of what she did over the weekend. I wanted to say something empathic to her, but I would have had to interrupt her to do it. So I just decided to listen until she gave me an opportunity to speak.

When Sally finished telling me the history she thought was relevant for me to know, she turned to telling me about her present life. She told me she had a husband, son and daughter. Then she got around to why she came.

Are You Orthodox?

“I’ve come because I’m depressed. I was terribly depressed a few years ago and went into couples’ therapy with my husband John. It helped, but I’m depressed again and I’m also worried about my son. He doesn’t have a job and I’m afraid he’s not doing the right things to get one. Also, I’m going to be 60 and I feel terrible about it…”

I was about to ask her what was so terrible about being 60 when she continued;

“The thing is that I think there’s something wrong with my brain.” She started to get teary for the first time. “I used to remember everything. But now I take notes on every single session because I’m afraid to forget; I walk into a room and forget why I came. I go to get the car and realize I forgot the keys. I know something is wrong with me.”

I thought to myself, I constantly forget what I’m looking for and where I put my keys.

My impulse was to reassure her. I wanted to blurt out: Oh, that’s nothing. I do that all the time. If she were a friend, rather than a patient, that’s what I would have done.

Sally continued in a voice that sounded frightened. “I think I may be getting Alzheimer’s. I always remembered everything and now I have to make lists to remember things.”

I have to make lists to remember things too. I resisted the impulse because reassuring her might seem to her that I wasn’t really hearing her. I didn’t want to trivialize her anxiety. And, after all, “there could be something wrong with her brain”.

“I went to a neurologist and he said there was nothing wrong. But I heard about this cognitive test regimen you can take and I’m going to do it.”

I wanted to say: That sounds like a good idea. But she continued without skipping a beat.

“I don’t want anyone who knows me to know about this. Some analysts talk about their patients with each other. But I think that’s terrible. I came to you because you’re not involved in my circle. I won’t tell any of my friends except Jessica and I’m terrified of them finding out.” I felt stung by her pointing out that I wasn’t “in her circle.” But I knew I had to let that go. I knew what I should say was: “What’s the terror?” But I didn’t want to cut in. I looked at the clock and the session was over, but I would have had to interrupt her to tell her. But then, as if she knew the session was over, she said,

“You haven’t said anything all session. You just sat there like a silent analyst. I guess you’re quite orthodox or maybe you’re just inexperienced.”

I felt “put down” and misunderstood. I needed to say something, but the session was over and I was feeling furious at her. I was afraid I would blurt out something angry. I dug my nails into the palms of my hands to try and get control over myself. “Well, we’re going to have to stop in a minute. But I think it’s a good thing that you’ve come because it sounds like you’ve experienced a great deal of trauma and loss. Turning 60 seems to be a catalyst for re-experiencing those feelings again.”

I sat in my chair for a few minutes after she left and thought about what I was feeling about her and what my friend Jessica had said about her. “You’re going to love her.” But I didn’t love her; I was struck by how controlling and critical she was during the session. I wondered about the disparity in our perceptions of Sally. What’s was going on here?

A Transference Blooms

When Sally returned the following week, she seemed calmer and less frightened. My back relaxed. But then she began the session by noticing that my chair seat was higher than the other chairs in the office.

“No therapist has a chair higher than her patient. It’s such a basic thing.”

I felt like my mother had slapped me across the face. I could feel the sting in my cheeks. I wondered if my cheeks were red and if she could tell. It had never dawned on me to consider the height of my chair in comparison to the other chairs in the office. Sally’s criticism made me feel like a fool. Once again I dug my nails into my palms to try and get control of myself. I spoke very quietly:

“What does it mean if my seat is higher than the others in the room?”

“You must be insecure and need to be higher than your patient. I have never been in a therapist’s office with seats of different heights.”

I bit my lower lip, trying to control my rage. “You seem to equate the height of the chairs with differences in status.”

“Yes, I feel like you’re trying to be superior to your patients.”

After what felt like a long pause during which I was trying to tamp down my anger, I said: “To my patients, or to you?”
“Yes, of course, to me.”

Trying to keep my composure, I spoke slowly and quietly: “Are we competing?”

“Yes, I guess we’re competing. I don’t want to feel lower.”

There was silence for a moment. She seemed to immediately understand that her feelings about the chair were more about her than me. Then she went back to the story about her father’s death that she had told me about the prior week which indicated to me that we had come to some transferential understanding of the importance of the height of the chairs in my office. I could feel the muscles in my back relax.

“My father had a driver. They drove Mom and me to the airport because we were visiting Grandma in California. The driver hit a truck and my father wasn’t wearing a seat belt so he was thrown from the car. He was probably decapitated.”
I felt stunned and I’m not sure if I gasped. Part of what staggered me, aside from the inherent horror of what she was saying, was that Sally said it without affect as if she were saying: “My father was probably wearing his blue suit.” That amplified my shock because I was completely unprepared for it. “I had an image of her father’s bloodied head flying onto the highway” while his disheveled body was thrown to the side of the road. I was speechless and Sally went on to another topic.

“I’m really angry at John because he keeps saying my anxiety about losing my cognitive capacity is silly.” She's worried about losing her head, I thought.

“That must feel like he doesn’t understand how frightening it is for you…" I said. "Unfortunately, we are going to have to stop for now.”

The next session I was afraid to open the door to my office and invite Sally in. I could feel myself tightening up in expectation of her criticism. She was consistent.

“You know it’s really odd that your magazines are old and you cut off the address label on the magazines in the waiting room.”

I felt exposed. What did this mean about me?

“I’ve never seen such a thing.” She continued, “You must order the magazines for your house and then bring them here!” She was outraged at the idea.

It was true; she was right. I didn’t really understand what was wrong with doing that.

“What is it about taking the mailing labels off the magazines," I asked, "that is upsetting to you?”

“It means that you don’t subscribe for the office, you subscribe for your house.”

“What is it about that, that’s upsetting?”

She took a breath; she was trying to figure it out. “My parents had a very romantic relationship. Every night they had a cocktail in the living room together when my father came home from work and we weren’t able to talk to them or even go in the room during cocktail hour. I think it feels the same to me. Your patients are secondary to your real life. We get the magazines with the label torn off.”

I felt that something important was happening. Each week she came in criticizing me and I felt exposed and inadequate. Each time we were able to understand what these criticisms meant to her, but we had not talked about what it meant that she was always criticizing me. I felt a dread that reminded me of how I felt when my mother came home from work. There was always something I had done wrong. I wondered what it meant that I was dreading Sally’s next criticism of me. Was this my countertransference or was this what she felt about her mother? Or both!

Fits and Starts

The next session Sally came in saying she felt very depressed. She realized that she forgot to put on make-up or comb her hair before she came to my office. She analyzed it herself:

“That’s very interesting. I’ve never done that before. I seem to want you to see me without any decoration.”

I thought that was a great breakthrough; she wanted me to see how she really feels underneath her façade. I decided to take a risk and make an interpretation.

“You’re critical of me, but I think you’re hyper-critical of yourself.”

“You mean you think I’m projecting my own feelings of inadequacy on you?”

“Yes exactly. I think you’re treating me the way your mother treated you.”

“I feel so relieved. Yes, that’s right.”

I felt that was an important moment in our work together. I finally addressed how critical she was of me. I was much happier to see her when I opened the door to my office the next week.

Sally handed me the check to pay the bill for the prior month. I took the check and crossed off her name in my book to indicate she paid.

“What are you doing that for?” She said in an outraged tone.

“Doing what?”

“Writing down that I paid you. I’ve never heard of anyone doing that.”

“I don’t know what you mean.”

“You mark it down after the patient leaves, not while I’m here.”

I was feeling speechless once again. I never noticed what Anna did after I gave her a check because I always turned around and walked over to the couch to lie down. I was barely able to utter: “What does it mean that I’m marking down that you paid while you’re here?”

“It’s unprofessional that’s all. Anyway, I’ve been thinking about whether I want to see you or not. It’s a big trip from where I live to get here.”

“Do you think there might be something more to it?”

“Well, I liked what you said last time. It made me feel much better to think that you’re not inadequate; I’m just projecting. But “I think I liked you better when you didn’t talk”. I want to know what you think, but when you tell me what you think it’s what I’d say if I were you.”

“Is that good or bad?”

“I don’t know. When you were silent it gave me room for my own associations.”

I felt damned if I did and damned if I didn’t. It felt just like my situation with my mother—whatever I did it would not be right.

“Do you think not wanting to see me might be related to my saying something that was helpful to you?”

“Yes, I think I’m competitive with you. I want you to help me, but I don’t want to feel you can help me. Especially because you’re so much younger than I am.”

Well, I thought, she’s certainly not like my mother. Sally’s able to consider my questions and look at her own behavior.

The next time I saw Sally she told me she was feeling much better about herself and about me. She realized that her family was very focused on status differences. Her parents were contemptuous of blacks and Jews.

“Do you think that’s related to your feelings about me?”

“Well, you’re probably Jewish and I seem to be competitive with you.”

In the next few sessions Sally told me she felt I was “too nice” and “not analytic enough.” Once again I felt like she was poking a finger at me. It took energy to find something to say to her that wasn’t defensive and angry. Finally, I was able to remove myself and see what this was about. I suggested that “analytic” was her term for cold and uncaring. I was the first female therapist she had and she was ambivalent about whether she wanted a mother who was cold and critical like her mother or warm and “too nice.” Of course, Sally continued to criticize me, but we had developed a working alliance and now the work could continue.

Combatting Anxiety,

Posted on April 10, 2019February 11, 2026 by Psychotherapy.net Team

It occurred to me the other day that I was laughing with a client because I completely and utterly understood where she was coming from. And then it hit me. No wonder I've been so busy helping my young adult clients overcome anxiety—wait for it—I “have it”, or should I say, “it has me” too!

Of course, I have known this for many decades, but that day I had a kind of breakthrough. I can laugh at the insanity of it all. I've been there and done that on almost every occasion. My client Elsa said she was afraid of driving over bridges. Hmm, I don’t have that one. But I do have the one where my husband is driving too fast and I think I’m going to fall into the Hudson River. Then there’s the one where I’m going on a job interview and I think to myself, “OMG, I have gained so much weight since I had kids!” Or my mind goes blank and I forget everything I ever accomplished. Then there was the time my puppy ran across the highway and I had a panic attack. The worst is ruminating. Although I teach clients all day about fight or flight or freeze, I forget that I myself need to take a break from overthinking. When my kids started driving, I gained a new and paralyzing dread that someone would run into them. Add to that health and money worries, and sirens passing by while I’m quietly doing paperwork at home—catastrophizing is my specialty.

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Self-care is our therapy buzz-word and it works wonders. My friend, a fellow therapist, said I need a spa day. “Do it!” My patient debated the whole day if she should take a “mental health day” from her demanding teaching schedule. “Do it!” Another patient wondered if she should take up journaling again. “Do it!” And the very process of pushing through your fears is instructive; it combats avoidance. My client was afraid to call her doctor for some results. “No problem, do it in my office.” My client was terrified to sleep over at his Dad’s new apartment. “Build up to it.” Once, many years ago, when my mother was dying of cancer, a kind and wonderful boss at Disney.com handed me a laptop and said, “I’ll see you when you’re ready.” Ask for help. Take a small step. All the clichés stacked up to the sky, or, as Annie Lamott says, “Bird by Bird.” The simple catchphrase, “Do it” flows so easily from my mouth—it just doesn’t quite make it to my ears and into my brain.

Clients often ask me, “How I can begin to trust my inner voice when all I know is worry.” And I tell them “For one thing, you have a choice. It’s your life. Own it. Take care of it.” It seems to me that people in other countries get more time off to recharge. Only here do we grind ourselves until there’s no more fuel.

And, let’s see if we are mislabeling anxiety as something else? If it’s not anxiety then what is it?

1. Anxiety from the past may be triggering a fear of abandonment. My client Mary wants to marry her boyfriend but thinks he might be cheating. She stalks him on Facebook, Instagram and Twitter on an hourly basis, based on her "hunch." She finds nothing but cannot stop her obsession. This is no longer a gut feeling, it's a bad habit, a self-destructive, relationship-bombing behavior that is sure to drive someone away. In this case, although there is no evidence whatsoever that he's a cheater, Mary continues to rely on her false "gut feeling" which only serves to create more anxiety and self-sabotage. Go back to where it’s coming from and try to counter the fear with a more realistic appraisal.

2. Anxiety masks as fear of the unknown. My client Joya wants to go out with a boy from her fraternity, but he is a “player.” When he finally asks her out, she says no based on what her friends have said. The information she has obtained is from the past, and unproven, especially since Joya really likes him. She continues to rely on second-hand information instead of living her own life. She is more afraid of the unknown than finding out the truth about him by using her own judgment. Unknown fears need to be faced, not avoided. Sometimes when I’m driving to a new place, I make it a habit to stop somewhere en route to pick up a treat or run an errand. This makes the unknown into a little adventure.

3. Anxiety is not the same as intuition. Jessica thinks her boyfriend is simultaneously dating someone else. Her so-called intuition is based on patterns and evidence that she has directly observed—he's always late, keeps his phone locked away and acts sneakily. Intuition tells her from observed experience that he is hiding something. Anxiety, fueled by insecurity misguides her into convincing herself that he is doing something wrong and that he will inevitably leave her, instead of leading her to confront him directly. As psychologist David Barlow warns us, “don’t believe everything you think.” “Ask him what's going on instead of making up stories in your head,” I suggest. Test the intuition with objective observation. Your anxiety may have something to tell you.

If this sounds tricky, it is.

Intuition can be considered a neutral and unemotional experience, whereas fear is highly emotionally charged. Reliable intuition feels right, it has a compassionate, affirming tone to it. It confirms that you are on target, without having an overly positive or negative feel to it. Fear is often anxious, dark or heavy.

Take a step back and breathe deeply for a moment. What's the worst that can happen? What part is objective and what part has no business in the present? If it belongs in the past look at what happened. It's over. You are safe now. The only way to separate from rumination is to pause. My last client of the evening recounted her fight with her ex-girlfriend over text. “Please Hannah,” I said, “unplug for just five minutes. Then assess how you feel. You are only feeding the attention-seeking behavior of your ex. Can you step back? What will happen if you just sit quietly?”

Can a therapist, this therapist, heal herself? The phone rings, the news blares, and real tragedy rings into our consciousness, implanting itself in vivid living color from a smart TV into our visual field whether we want it or not. I can help my clients not because I’m master of my anxiety and of my fate, but because I’m continuously right there with them. My friend calls and says “Let’s take a walk.” “Yes, I say. Let’s do it, everything else can wait.”

Train Professionals, Not Just Therapists

Posted on April 9, 2019February 11, 2026 by Psychotherapy.net Team

Becoming Professional

After hundreds of class hours learning systemic therapeutic modalities and hundreds more working directly with clients in multiple clinical settings, I graduated from my master’s program in marriage and family therapy a competent clinician. I treat couples, families and individuals on issues ranging from depression to trauma to affairs. But graduating clinicians is not enough—graduate programs have a responsibility not only to train clinicians but to help them become professional therapists. And that task is far more complex.

A professional therapist entering the workforce must learn to navigate the employment landscape, land a first job, determine long and short-term professional goals, understand the financial and professional implications of each of those steps, and build the tools to curate a digital presence that supports professional growth. A professional therapist must learn how to conceptualize the digital boundaries between therapist and client in an ever-transparent world and integrate HIPAA compliant technology. The professional therapist must understand the ins and outs of the insurance industry, at least enough to intelligently interact with it. These are the elements of the professional. And currently, most new therapists are running blind.

I consider myself fortunate. By the time I entered graduate school to become a marriage and family therapist, I had worked in corporate marketing, built a resume consulting business, traveled the world, and gotten married. In my second year of graduate school, I published a book that became an Amazon bestseller. I had also been fired from a good paying job and struggled through six months of unemployment and under-employment. When I started graduate school, I did so with eyes wide open. I researched the elements of building a career as a therapist, not just as a clinician. I read books about entrepreneurship. I began writing and trying to build an online presence. But even I, far better equipped than the average student, had so much to learn about building a professional future. Particularly for those students that transition from undergraduate to graduate school, the intricacies and big picture conceptualization of one’s career can feel overwhelming and most feel ill-equipped.

Jumping into a career as a therapist comes with an incredible level of uncertainty. A student leaving a master’s level program must decide whether to pursue a doctoral degree. Upon hearing other students speak about their intention to pursue a doctoral study, I asked them about that decision and what they envisioned for themselves. Many said they did not know, it was just “what was next.” The trajectory outside of academia remains unclear, and involves understanding how to work in a hospital setting, community mental health or private practice, and decide whether to pursue an inpatient or outpatient role.

Job hunting. Entrepreneurship. Business ownership. Accounting. Marketing. Digital boundaries. Online therapy. Working in hospital settings. Whose job is it to teach budding professionals to navigate this landscape with finesse, confidence, and an understanding of what’s required to succeed? I believe that graduate schools need to play a much larger role in not only training competent clinicians but also in preparing professional therapists to enter their careers. If a degree is marketed as a professional degree, then a student has a right to learn how to become a professional. Why don’t graduate schools teach students about more aspects of professional life? I suspect the answer is multi-faceted.

Not My Job

Some argue that professional training related to the non-clinical aspects of a therapist’s career falls outside of graduate schools’ purview. In other words, not my job. We figured it out and you will too. This line of argument, akin to a verbal shrug of the shoulders, a relinquishment of responsibility, fails to compel me. That programs have yet to step up does not mean they should not. I am a student of systems, and to create change that reverberates down the course of a therapist’s career, the initial steps must include the tools necessary to succeed in the world. We can do better.

Some argue that, well, they had to figure it out, and you will too. Sure, I suppose that argument rings true. “Every professional confronts a steep learning curve when they transition from school into the workplace”. But let us not fall into an all or nothing thinking trap here. Teaching new therapists how to plan out their career progression, how to understand insurance systems, how to manage student loans, and how to approach the task of entrepreneurship for many who want to build practices, will not eliminate the steep learning curve. I argue not that the student should be coddled, but rather, that they should be equipped.

Many therapists struggle to connect their work with money. Training as a clinician aligns with the selfless task of helping others, while money, marketing and business models feel like its necessary seedy underbelly. At the agency where I work, a sign on one clinician’s door reads, “I do it for the outcomes, not the income.” While the sentiment is a lovely one, it only reinforces the minimization and vilification of financial success, and unnecessarily puts success and therapeutic work at odds with one another. This thinking also exposes a misunderstanding of the professional therapist. The professional therapist does not sell to sell, they sell to serve. The therapist who can build a successful enterprise, who can reach their target clients effectively (be they kindergarteners struggling with grief or couples on the verge of divorce), who can walk confidently into an interview to work at a hospital or community mental health setting, is a therapist that can effectively help more people. What would our sector look like if new therapists were armed with an arsenal of tools, ideas and resources to help them spread their message more effectively and reach the clients who need them. This model of service reframes the issue as one of great responsibility, deeply in line with the therapist’s work. This is the framework needed when thinking about the business of therapy.

Harsh Realities

Perhaps another obstacle in the way of open communication around therapist career building is the stark economic realities it would force professional graduate programs to face. One imagines the discomfort it would cause to have professors, teaching in programs charging ten to sixty thousand dollars per year, openly discuss the financial reality of most early career therapists. Students who find full-time positions with benefits (scarce in the mental health arena), often struggle under the sheer weight of student loans.

Community mental health positions often come with a rude awakening of fee for service work, extremely low pay, high no-show rates, high incidences of client trauma, and overworked supervisors incapable of meeting the needs of their outpatient therapists. Launching and maintaining a private practice involves daunting start-up costs along with the often bewildering and complex tasks that accompany the effective marketing of the practice, renting or finding a space, learning about billing, purchasing malpractice insurance, ensuring HIPAA protected note storage, and accounting.

Indeed, many programs discourage students from jumping straight into private practice, believing in the growth potential and importance of working in community spaces. Perhaps the prospect of asking students buried under tens or hundreds of thousands of dollars in student debt to take a low paying job for the experience would be a tough sell, or at the very least, an awkward one. I wonder how it would go over for students to learn that professors in their fields either still have student debt or benefited from high-earning spouses who enabled them to work despite the early career steps. These conversations force still more difficult conversations about the access to education and the capital needed to get going.

Alas, the professors and teachers best equipped to imbue their students with clinical skills may feel or be the least equipped to prepare students to operate in the digital landscape. Clinicians with more than 20 years of clinical practice have at most a bare-bones website. Their digital footprint may be limited to Psychology Today. They may not be adept at utilizing modern marketing tools, lead generators, and using SEO technology to bring in more referrals through google and other search engines. They may not know how to manage mainstream social media and address the realities of increased online transparency that translates into the therapy room. Many did not come of age professionally in the digital area, navigating the public and private boundaries that are a constant challenge for new clinicians. New therapists require mentorship from clinicians who have been in the field from five to ten years to learn the trade in its most recent form.

At present, “there is little pressure for graduate programs to reconceptualize their role and implement sweeping changes”. Without pressure, schools are unlikely to change. Without a roadmap, schools would need to dedicate themselves wholeheartedly to the task and not only implement new measures, but also create them.

During my final year of graduate school, I and many of my classmates struggled not only under the weight of coursework, but the questions about what would happen after we graduated. Some of us wondered how to translate our clinical experience into a resume that would attract employers. Others wondered whether to prioritize the stability of a full-time job with benefits or the position that enabled us to work with our target population in a position without benefits. A panel discussion of past graduates inevitably led to sheepish questions by students wondering if graduates would be willing to get specific about just how much they earned and how secure they felt. Now as a recent graduate, settled into a semblance of routine, current students approach me with the same panoply of questions. Year to year, the emotions underlying these questions remain: fear, confusion, frustration, excitement, and bewilderment. Guide us, we beg over and over. Please.

What Now?

Therapeutic training programs are hardly alone in their failure to prepare professionals. Law schools notoriously work their students to the bone learning legal intricacies while failing to touch upon the actual experience of working as a lawyer. When my husband Brian compared his experience of medical school with my late grandfather’s almost sixty years ago, he received more practical training related to charting and taking patient histories. He even had a class called “doctoring.” But medical students, who navigate a siloed version of the economy through their extended training, often complete their residencies with no training in financial management (despite averaging almost two hundred thousand dollars in debt), no training in private practice building or planning, and little understanding of the way that the changing healthcare landscape will impact their careers. Programs training other service oriented professionals, accountants, contractors, architects, artists, and hair stylists must provide their students with at least a starter kit of tools to help them navigate the realities of their craft.

The culture of training mental health practitioners needs a comprehensive overhaul to integrate professional training into the process of becoming a clinician. Some programs attempt to address student needs by bringing in the student career center to offer little more than talking points on general resume tips. These fixes fail to address the larger structural deficiencies and fall short of the students’ needs. Professionalism, entrepreneurship, finances and the like should be woven into the content so that one’s professional identity is forming alongside one’s clinical identity. For this to take place, academia needs to make room for the reality of the marketplace, something it historically struggles to embrace.

In the meantime, the private sector has filled the void left by educational institutions. Blogs, social media groups and businesses tout services aimed at helping clinicians build practices, market themselves, curate their social media presence, and guide new graduates through the job hunt and licensure process. There is absolutely a role for this market and the solutions created are often comprehensive and built by professionals who have been through it already. As most things in therapy, the answer likely is not one or the other. We need both.

Hidden Losses

Posted on April 4, 2019February 11, 2026 by Psychotherapy.net Team

No one should die in December. Not that death is ever convenient or well timed, but it is the rare person who has extra time during the holiday season to accommodate the disruption death brings to life. As a psychologist, it is the time of year when my practice is the busiest and sessions often have a poignant depth, setting the stage for the hard work to come in January. The contrast between the joyful expectations of the season and the holiday blues is probably felt most acutely in therapists’ offices.

On December 9, 2018, I was hanging ornaments on my Christmas tree when my home phone rang. Assuming it was an end-of-year solicitation, I almost didn’t answer it, but I thought it might be my mother calling. At 93, she is one of the few people in my life who still uses my landline.

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Instead, the call brought shocking news that Larry was dying. Larry was like a brother to me and had been part of my life since I was 10. Larry was the person I would call if my mother was in the hospital as he lived only a few blocks away from her in New York City. But suddenly I heard, “Larry had a massive stroke an hour ago and isn’t expected to make it.” Two weeks earlier, I had given him a hug goodbye after another memorable Thanksgiving at his home. Our families have shared Thanksgiving for over 25 years. This year, we had celebrated Larry’s recent retirement and 65th birthday as well.

Less than a half hour later, my husband and I were in the car on the Massachusetts Turnpike heading from Boston to Manhattan. Not knowing how long I would be gone, I had grabbed my briefcase with my appointment book. As my husband drove, I began texting my Monday appointments to cancel our sessions explaining that a friend had suddenly died.

Over the next month, despite multiple trips to New York City for family gatherings and the memorial service, I missed just two days of scheduled work. As a result, only a small percentage of my practice learned about my recent loss. Typically, whenever I share personal information with a client, it’s a thoughtful decision timed to illuminate something specific for that person. In this case, it was an arbitrary act of scheduling that created two groups: those who knew and those who didn’t. This contrasted sharply with my experience 30 years ago when my father died, and I canceled all my sessions for a couple of weeks. More recently, I had experienced another loss, when a former client was murdered, a loss I carried privately and never shared with any of my clients. Now, I realized I needed to be cognizant of who knew and who didn’t so I could be emotionally prepared to respond when someone offered condolences.

I suddenly found that I was straddling two worlds within my own practice. I was having the mirror experience of some of my clients, those for whom I serve as the person in their life who knows about a “hidden loss.” I carry the knowledge of abortions and abuse. I am privy to unfulfilled dreams and broken promises. One of the gifts of an established therapy relationship is not needing to give the “Cliffs Notes” version of life events. Clients count on me to understand the complexity of their relationships. I know when the death of a parent is a relief and when it is a deep hurt. Therapy is not a reciprocal relationship, and I do not expect my clients to take care of me, but admittedly, it was comforting to be asked, “How are you?”

Not surprisingly, I found myself feeling closer to the clients who knew of Larry’s death than to those who didn’t. When I could speak about my love for this friend, I felt more whole. When clients asked how I was doing, acknowledging my grief allowed me to put it aside and enter into the therapy hour better able to listen. In the few moments I took to explain that Larry was a dear friend whose hospitality and generosity over the years had made Thanksgiving my family’s favorite holiday, it was an opportunity to pay homage to this extraordinary man. Introducing the information to clients who did not know about this event in my life seemed intrusive and unhelpful. Perhaps at some later date, when my experience of an unexpected death felt applicable, I might have revealed this bit of my own history at my own discretion to a particular client. For now, the discrepancy between the two groups of clients in my practice was the consequence of cancelled appointments. Switching between sessions with people who were aware of my loss and those who were not reminded me anew of how much energy it takes to conceal pain.

Keeping parts of ourselves private is important professionally, but it does come at a cost to our own psyches. As those clients who were not aware of my loss offered well wishes for the holidays and the new year, I tried to join in the cheer. But inside, I was struggling to adjust to a new normal, a life without someone I loved, a loss hidden from much of the world, but certainly not from my heart.

Online Therapy: An Unexpected Space of Freedom

Posted on April 2, 2019February 11, 2026 by Psychotherapy.net Team

Taking Risks

The dramatic story of the Saudi teenager Rahaf al-Qunun¹, who fled her family and country in order to request asylum elsewhere, resonated with many people in different ways. The oppressive background in which women like her evolve is generally far from our eyes, but I have, through my online therapy work, experienced several very touching stories from women in the Middle East.

Engaging in therapy is something that even Westerners do not enter into lightly. It requires taking a risk in opening themselves to a stranger to exercise the power of vulnerability. For women from countries such as Saudi Arabia, this entails a completely different level of personal risk and exposure. The fear of being misunderstood, judged, medicated, or reported to their family and consequently punished harshly, makes it nearly impossible for them to reach out for face-to-face psychotherapy.

As I grew up in Soviet and then post-Soviet Russia, I have firsthand experience of feeling trapped in a place where state-imposed values and rules did not align with my own. The exercise of one’s intellectual freedom turns into a road to salvation when other freedoms are unattainable.

For women in hardline Middle-Eastern countries, online therapy offers a safe space in which to exercise intellectual and spiritual freedom—they can explore their religious doubts, talk openly about their sexuality, voice their frustrations and anger, and eventually find meaning in their experience.

In an interview in The Guardian, Rahaf al-Qunun points out that in her country, no matter their age and life experience, women are treated like children. In a society governed and controlled by men, they are stripped of all power and infantilized.

These women continually strike me with their courage and resilience. One such brave woman was Laila (an amalgam of Middle Eastern women with whom I have worked in online therapy).

Laila’s Story

Laila was 36 and unmarried. She had a stable and reasonably well-paying job at a bank. When she received a promotion, she was allowed to move out of the family home to a nearby town in order to take the position. She was allowed to do this because her youngest brother lived in the same town and worked at the same bank. He was also unmarried and they lived in the same block of flats. He drove her to work every morning, as she was not allowed to drive herself.

Her brother was much younger but had more rights. Laila “needed” him for assistance with the most routine tasks—for example driving her to work or for travelling out of the country for a professional conference. This is how things work: women are made to need men.

Laila was different. At a deeper level, she did not believe or feel that she needed men. She did enjoy the company of some of her male colleagues and rare friends, but she did not desire them. Leila realized this about herself as a teenager, when back at school she felt compelled to kiss the beautiful face of her female best friend.

One of the duties Laila was not able to escape was mandatory attendance at family gatherings. She would sit there, her face uncovered, surrounded by women talking about their children and their little sons running around—already enjoying their privileged status in front of their sisters—and painfully feeling how little she belonged there.

All this fuss around men felt ludicrous to her. It was an ironic situation after all—she had to uncover her face with women to whom she felt attracted and was expected to be separated from men who represented no risk to her emotional balance.

Laila knew that she would never be able to live the life that she dreamt of. She loved her brothers, despite often feeling angry with them. She also loved her father, even if he would not listen to her or take her achievements seriously. She knew that, for her family, she was “damaged goods” and she would remain so, as she would never marry and give them children.

Laila eagerly waited to get old enough to stop receiving proposals from men that she did not know, who, as she grew older, wanted her as a second or third wife. In the meantime, she had occasional moments of joy with her few female friends and secretly experienced excitement and lightness in the body-less company of her virtual friends from the online community of women just like her.

Autocratic states use mental health stigma to control their citizens.Laila was very scared of being accused of being mentally ill. This is exactly what happened to Rahaf al-Qunun who, in the statement released by her family after her escape, was labelled “mentally unstable.”

An Online Refuge

As a therapist who works online with clients, my personal background helps me to understand and relate to what these women experience. Mental illness was stigmatized in the USSR, easily exploited by the authorities to punish and isolate any individual not complying with the strict rules of collective functioning. Therapy was almost nonexistent and was considered a medical treatment for alienated sick people. Online therapy was not an option as it is now, offering an opportunity to reach out to someone from a different culture, which can be useful when someone is trapped in an unfriendly world.

The effects of living in an autocratic country on individuals’ mental health are many. My female clients from hard-line Middle Eastern countries suffer from depression, anxiety, insomnia, dissociation, and difficulty trusting others.

Their individual boundaries are constantly transgressed and violated. The psychological effects of being raised in such an environment are like those experienced by a child growing up in a narcissistic family: the needs of the parents’ system (the society) take precedence over the needs of the child (the individual).

The only way to avoid being mistreated by a narcissist is to limit their power over you or to stay as far away as possible. Oppressed women like Rahaf al-Qunun have every right to rebel and protest as do children of narcissistic parents—they entirely depend on their caretakers and cannot freely leave their country or their family.

Individuals raised in cultures where they must abide by a very strict set of rules that do not take into account their needs, learn how to hide, to keep secrets, to lie. This is a natural way of adjusting to a system that does not accept parts of you; it becomes a question of survival. Such secrecy leads to an impression of living a double life. The cost of such fragmentation is often a lack of intimacy with parents and disconnection from those who are not aware of the “other” life that quietly happens inside or in the online space.

In a way, as their therapist, I must play a part in this secret parallel world, as my clients also hide from their families the fact that they are in treatment. Therapy, especially with a Western therapist, is seen as a transgression. My clients must come up with a plausible pretext for isolating themselves with their computer in a private room within the family home without being disturbed. I am often presented as a colleague, or an online English teacher. Here, the fact that their older family members do not speak fluent English comes in handy. The second language creates the much-needed safe and private space, in which they finally can explore their inner worlds, and the conflicts with the outer world in which they live.

Behind the Veil

I do not share a mother tongue with many of my clients so we must speak in English. Such use of the third, neutral language plays an important role in how the therapy evolves. It facilitates sharing thoughts and dreams that are defined as unacceptable in the clients’ original culture. Speaking English also provides us with an opportunity to play on even ground—as fluent as we are in our second tongue, we are still both foreigners, negotiating our accents, sometimes looking together for the right word. This experiment in equality has an additional reparative value, as being fully recognized as equal is not an easily obtained right in these women’s world.

As a Western woman with a limited knowledge and experience of Middle Eastern cultures, I let my clients guide me through their personal stories shaped by the culture, family, and place into which they were born. With them, I become an avid learner as we move towards a shared goal—a better understanding of who they are and who they want to be within the limits of their world. As we advance, pushing these limits becomes an existential necessity. For any transcultural therapist, this is a rather familiar role, but online therapy expands this in an extraordinary manner.

I have also had the opportunity to work with some Saudi women living outside of their country in Europe or elsewhere. Those with liberal, well-to-do and open-minded parents can study abroad. The sudden freedom comes with another set of psychological challenges—these young women must adapt to the transition and find a place in this new world, negotiating an acceptable balance between their original cultural values and the norms and expectations of the new place and culture.

During this stressful time, therapy offers them a space for dealing with conflicts and dilemmas that arise along the way—to wear or not to wear a headscarf; how to explain to their foreign peers the values and rules they choose to abide by; how to deal with anxious parents’ visits and a stressful life in an unfamiliar environment. Interestingly, they still retreat back to the familiar online space—which feels safer—to find friends or develop romantic relationships.

“Why does it matter that we, freer men and veil-less women, understand the struggle of women in these regions of the world” where many types of freedom are restricted? Will our understanding of their condition and our empathy change anything for them? My intuitive answer is ‘yes’; otherwise I could not do my work as a therapist. But how so?

Humans are social creatures, and the way we are looked at by others very often matters. We all have secret stories about how bad or how exposed we felt when people around us looked at us, judging our looks, words, or differences. In these circumstances, we feel shame. People with a handicap, sexuality difference or cultural/ethnic difference, all those who differ in some ways from the majority know far too well the emotional toll of such unwanted exposure.

How can a woman wearing the full veil feel when walking in the street in a tourist area of a big Western city? She is entirely covered in a black veil, her face hidden. On both sides of the veil we feel uncomfortable. The veil is a barrier, and, when we do not see the face behind it, we struggle to empathize with the individual. Behind the veil, there is sometimes deep discomfort and a feeling of shame. They may feel trapped, and our misunderstanding of their condition and our judging them for choices they do not have, may add to their suffering.

To connect with others and to be understood, without their body being seen, can be a challenge for these women. It is another reason why the online communities of Saudi women are thriving. Probably this is also what makes online therapy a hopeful space in which they can develop a connection with a Western therapist who represents this “other.”

As with any therapist, I am here for those who have psychological difficulties and struggle with some form of conflict. Surely, many women living in the strict Middle Eastern countries are happy enough with their circumstances, and not all of them would relate to my clients’ stories. But even if women I meet in my practice are a minority, it is important for them to be seen and acknowledged in their struggle, and to be offered a safe space like online therapy in which they can feel recognized and strive toward a better life.

Resources
1 Rahaf al-Qunun: “I hope My Story Encourages Other Women to be Brave and Free”

Therapy with a Condom On

Posted on April 1, 2019February 11, 2026 by Psychotherapy.net Team

Editor's note: The following is an excerpt taken from Maybe You Should Talk to Someone: A Therapist, Her Therapist and Our Lives Revealed, by Lori Gottlieb, published by Houghton Mifflin Harcourt © 2019 and reprinted with permission of the publisher.

Shall We Skype?

“Hi, it’s me,” I hear as I listen to my voicemails between sessions. My stomach lurches; it’s Boyfriend. Though it’s been three months since we’ve spoken, his voice instantly transports me back in time, like hearing a song from the past. But as the message continues, I realize it’s not Boyfriend because (a) Boyfriend wouldn’t call my office number and (b) Boyfriend doesn’t work on a TV show.

This “me” is John (eerily, Boyfriend and John have similar voices, deep and low) and it’s the first time a patient has called my office without leaving a name. He does this as if he’s the only patient I have, not to mention the only “me” in my life. Even suicidal patients will leave their names. I’ve never gotten Hi, it’s me. You told me to call if I was feeling like killing myself.

John says in his message that he can’t make our session today because he’s stuck at the studio, so he’ll be Skyping in instead. He gives me his Skype handle, then says, “Talk to you at three.”

I note that he doesn’t ask if we can Skype or inquire whether I do Skype sessions in the first place. He just assumes it will happen because that’s how the world works for him. And while I’ll Skype with patients under certain circumstances, I think it’s a bad idea with John. So much of what I’m doing to help him relies on our in-the-room interaction. Say what you will about the wonders of technology, but “screen-to-screen is, as a colleague once said, “like doing therapy with a condom on.””

It’s not just the words people say or even the visual cues that therapists notice in person–the foot that shakes, the subtle facial twitch, the quivering lower lip, the eyes narrowing in anger. Beyond hearing and seeing, there’s something less tangible but equally important— the energy in the room, the being together. You lose that ineffable dimension when you aren’t sharing the same physical space.

There’s also the issue of glitches. I was once on a Skype session with a patient who was in Asia temporarily, and just as she began crying hysterically, the volume went out. All I saw was her mouth moving, but she didn’t know that I couldn’t hear what she was saying. Before I could get that across, the connection dropped entirely. It took ten minutes to restore the Skype, and by then not only was the moment lost but our time had run out.

I send John a quick email offering to reschedule, but he types back a message that reads like a modern-day telegram: Can’t w8. Urgent. Please. I’m surprised by the please and even more by his acknowledgment of needing urgent help–of needing me, rather than treating me as dispensable. So, I say okay, we’ll Skype at three.

Something, I figure, must be up.

At three, I open Skype and click “call,” expecting to find John sitting in an office at a desk. Instead, the call connects and I’m looking into a familiar house. It’s familiar to me because it’s one of the main sets of a TV show that Boyfriend and I used to binge-watch on my sofa, arms and legs entwined. Here, camera and lighting people are moving about, and I’m staring at the interior of a bedroom I’ve seen a million times. John’s face comes into view. “Hang on a second” is how he greets me, and then his face disappears and I’m looking at his feet. Today he’s wearing trendy checkered sneakers, and he seems to be walking somewhere while carrying me with him. Presumably he’s looking for privacy. Along with his shoes, I see thick electrical wires on the floor and hear a commotion in the background. Then John’s face reappears.

“Okay,” he says. “I’m ready.”

There’s a wall behind him now, and he starts rapid-fire whispering.

“It’s Margo and her idiot therapist. I don’t know how this person has a license but he’s making things worse, not better. She was supposed to be getting help for her depression but instead she’s getting more upset with me: I’m not available, I’m not listening, I’m distant, I avoid her, I forgot something on the calendar. Did I tell you that she created a shared Google calendar to make sure I won’t forget things that are ‘important’”—with his free hand, John does an air quote as he says the word important—“so now I’m even more stressed because my calendar is filled with Margo’s things and I’ve already got a packed schedule!”

John has gone over this with me before so I’m not sure what the urgency is about today. Initially he had lobbied Margo to see a therapist (“So she can complain to him”) but once she started going, “John often told me that this “idiot therapist” was “brainwashing” his wife and “putting crazy ideas in her head.”” My sense has been that the therapist is helping Margo gain more clarity about what she will and will not put up with and that this exploration has been long overdue. I mean, it can’t be easy being married to John.

At the same time, I empathize with John because his reaction is common. Whenever one person in a family system starts to make changes, even if the changes are healthy and positive, it’s not unusual for other members in the system to do everything they can to maintain the status quo and bring things back to homeostasis. If an addict stops drinking, for instance, family members often unconsciously sabotage that person’s recovery, because in order to regain homeostasis in the system, somebody has to fill the role of the troubled person. And who wants that role? Sometimes people even resist positive changes in their friends: Why are you going to the gym so much? Why can’t you stay out late—you don’t need more sleep! Why are you working so hard for that promotion? You’re no fun anymore!

If John’s wife becomes less depressed, how can John keep his role as the sane one in the couple? If she tries to get close in healthier ways, how can he preserve the comfortable distance he has so masterfully managed all of these years? I’m not surprised that John is having a negative reaction to Margo’s therapy. Her therapist seems to be doing a good job.

“So,” John continues, “last night, Margo asks me to come to bed, and I tell her I’ll be there in a minute, I have to answer a few emails. Normally after about two minutes she’ll be all over me—Why aren’t you coming to bed? Why are you always working? But last night, she doesn’t do any of that. And I’m amazed! I think, Jesus Christ, something’s finally working in her therapy, because she’s realizing that nagging me about coming to bed isn’t going to get me in bed any faster. So, I finish my emails, but when I get in bed, Margo’s asleep. Anyway, this morning, when we wake up, Margo says, ‘I’m glad you got your work done, but I miss you. I miss you a lot. I just want you to know that I miss you.’”

John turns to his left and now I hear what he hears—a nearby conversation about lighting—and without his saying a word, I’m staring at John’s sneakers again as they move across the floor. When I see his face appear this time, the wall behind him is gone, and now the star of the TV series is in the distant background in the upper-right corner of my screen, laughing with his on-camera nemesis along with the love interest he verbally abuses on the show. (I’m sure John is the one who writes this character).

I love these actors, so now I’m squinting at the three of them through my screen like I’m one of those people behind the ropes at the Emmys trying to get a glimpse of a celebrity—except this isn’t the red carpet and I’m watching them take sips from water bottles while they chat between scenes. The paparazzi would kill for this view, I think, and it takes massive will-power to focus solely on John.

“Anyway,” he whispers, “I knew it was too good to be true. I thought she was being understanding last night, but of course the complaining starts up again first thing this morning. So I say, ‘You miss me? What kind of guilt trip is that?’ I mean, I’m right here. I’m here every night. I’m one hundred percent loyal. Never cheated, never will. I provide a nice living. I’m an involved father. I even take care of the dog because Margo says she hates walking around with plastic bags of poop. And when I’m not there, I’m working. It’s not like I’m off in Cabo all day. So, I tell her I can quit my job and she can miss me less because I’ll be twiddling my thumbs at home, or I can keep my job and we’ll have a roof over our heads.” He yells “I’ll just be a minute!” to someone I can’t see and then continues. “And you know what she does when I say this? She says, all Oprah-like”—here he does a dead-on impression of Oprah—“‘I know you do a lot, and I appreciate that, but I also miss you even when you’re here.’”

I try to speak but John plows on. I haven’t seen him this stirred up before.

“So, for a second I’m relieved, because normally she’d yell at this point, but then I realize what’s going on. This sounds nothing like Margo. She’s up to something! And sure enough, she says, ‘I really need you to hear this.’ And I say, ‘I hear it, okay? I’m not deaf. I’ll try to come to bed earlier but I have to get my work done first.’ But then she gets this sad look on her face, like she’s about to cry, and it kills me when she gets that look, because I don’t want to make her sad. The last thing I want to do is disappoint her. But before I can say anything, she says, ‘I need you to hear how much I miss you because if you don’t hear it, I don’t know how much longer I can keep telling you.’ So I say, ‘We’re threatening each other now?’ and she says, ‘It’s not a threat, it’s the truth.’” John’s eyes become saucers and his free hand juts into the air, palm up, as if to say, can you believe this shit?

“I don’t think she’d actually do it,” he goes on, “but it shocked me because neither of us has ever threatened to leave before. When we got married we always said that no matter how angry we got, we would never threaten to leave, and in twelve years, we haven’t.” He looks to his right. “Okay, Tommy, let me take a look—.”

John stops talking and suddenly I’m staring at his sneakers again. When he finishes with Tommy, he starts walking somewhere. A minute later his face pops up; he’s in front of another wall.

My Idiot Therapist?

“John,” I say. “Let’s take a step back. First, I know you’re upset by what Margo said —.”

“What Margo said? It’s not even her! It’s her idiot therapist acting as her ventriloquist! She loves this guy. She quotes him all the time, like he’s her fucking guru. He probably serves Kool-Aid in the waiting room, and women all over the city are divorcing their husbands because they’re drinking this guy’s bullshit! I looked him up just to see what his credentials are and, sure enough, some moron therapy board gave him a license. Wendell Bronson, P-h-fucking-D.”

Wait.
Wendell Bronson?
!
!!
!!!!
!!!!!!!

Margo is seeing my Wendell? The “idiot therapist” is Wendell? My mind explodes. I wonder where on the couch Margo chose to sit on her first day. I wonder if Wendell tosses her tissue boxes or if she sits close enough to reach them herself. I wonder if we’ve ever passed each other on the way in or out (the pretty crying woman from the waiting room?). I wonder if she’s ever mentioned my name in her own therapy— “John has this awful therapist, Lori Gottlieb, who said . . .” But then I remember that John is keeping his therapy a secret from Margo—I’m the “hooker” he pays in cash—and right now, I’m tremendously grateful for this circumstance. I don’t know what to do with this information, so I do what therapists are taught to do when we’re having a complicated reaction to something and need more time to understand it. I do nothing—for the moment. I’ll get consultation on this later.

“Let’s stay with Margo for a second,” I say, as much to myself as to John. “I think what she said was sweet. She must really love you.”

“Huh? She’s threatening to leave!”

“Well, let’s look at it another way,” I say. “We’ve talked before about how there’s a difference between a criticism and a complaint, how the former contains judgment while the latter contains a request. But a complaint can also be an unvoiced compliment. I know that what Margo says often feels like a series of complaints. And they are—but they’re sweet complaints because inside each complaint, she’s giving you a compliment. The presentation isn’t optimal, but she’s saying that she loves you. She wants more of you. She misses you. She’s asking you to come closer. And now she’s saying that the experience of wanting to be with you and not having that reciprocated is so painful that she might not be able to tolerate it because she loves you so much.” I wait to let him absorb that last part. “That’s quite a compliment.”

I’m always working with John on identifying his in-the-moment feelings, because feelings lead to behaviors. Once we know what we’re feeling, we can make choices about where we want to go with them. But if we push them away the second they appear, often we end up veering off in the wrong direction, getting lost yet again in the land of chaos.

Men tend to be at a disadvantage here because they aren’t typically raised to have a working knowledge of their internal worlds; it’s less socially acceptable for men to talk about their feelings. While women feel cultural pressure to keep up their physical appearance, men feel that pressure to keep up their emotional appearance. Women tend to confide in friends or family members, but when men tell me how they feel in therapy, I’m almost always the first person they’ve said it to. Like my female patients, men struggle with marriage, self-esteem, identity, success, their parents, their childhoods, being loved and understood—and yet these topics can be tricky to bring up in any meaningful way with their male friends. It’s no wonder that the rates of substance abuse and suicide in middle-aged men continue to increase. Many men don’t feel they have any other place to turn.

So, I let John take his time to sort out his feelings about Margo’s “threat” and the softer message that might be behind it. I haven’t seen him sit with his feelings this long before, and I’m impressed that he’s able to do so now. John’s eyes have darted down and to the side, which is what usually happens with someone when what I’m saying touches someplace vulnerable, and I’m glad. It’s impossible to grow without first becoming vulnerable. It looks like he’s still really taking this in, that for the first time, his impact on Margo is resonating.

Finally, John looks back up at me. “Hi, sorry, I had to mute you back there. They were taping. I missed that. What were you saying?” Un-fucking-believable. I’ve been, quite literally, talking to myself. No wonder Margo wants to leave! I should have listened to my gut and had John reschedule an in-person session, but I got sucked in by his urgent plea.

“John,” I say, “I really want to help you with this, but I think this is too important to talk about on Skype. Let’s schedule a time for you to come in so there aren’t so many distract —”

“Oh, no, no, no, no, no,” he interrupts. “This can’t wait. I just had to give you the background first so you can talk to him.”

“To . . .”

“The idiot therapist! Clearly he’s only hearing one side of the story, and not a very accurate side at that. But you know me. You can vouch for me. You can give this guy some perspective before Margo really goes nuts.”

I Won’t Do It!

I noodle this scenario around in my head: John wants me to call my own therapist to discuss why my patient isn’t happy with the therapy my therapist is doing with my patient’s wife.

Um, no.

Even if Wendell weren’t my therapist, I wouldn’t make this call. Sometimes, I’ll call another therapist to discuss a patient if, say, I’m seeing a couple and a colleague is seeing one member of the couple, and there’s a compelling reason to exchange information (somebody is suicidal or potentially violent, or we’re working on something in one setting that it would be helpful to have reinforced in another, or we want to get a broader perspective). But on these rare occasions, the parties will have signed releases to this effect. Wendell or no Wendell, I can’t call up the therapist of my patient’s wife for no clinically relevant reason and without both patients signing consent forms.

“Let me ask you something,” I say to John. “What?”

“Do you miss Margo?”

“Do I miss her?”

“Yes.”

“You’re not going to call Margo’s therapist, are you?”

“I’m not, and you’re not going to tell me how you really feel about Margo, are you?” I have a feeling that there’s a lot of buried love between John and Margo because I know this; love can often look like so many things that don’t seem like love.

John smiles as I see somebody who I assume is Tommy again enter the frame holding a script. I’m flipped toward the ground with such speed that I get dizzy, as if I’m on a roller coaster that just took a quick dive. Staring at John’s shoes, I hear some back-and-forth about whether the character—my favorite!—is supposed to be a complete asshole in this scene or maybe have some awareness that he’s being an asshole (interestingly, John picks awareness) and then Tommy thanks John and leaves. To my amusement, John seems perfectly pleasant, apologizing to Tommy for his absence and explaining to him that he’s busy “putting out a fire with the network.” (I’m “the network”). Maybe he’s polite to his coworkers after all.

Or maybe not. He waits for Tommy to leave, then lifts me up to face level again and mouths, Idiot, rolling his eyes in Tommy’s direction.

“I just don’t understand how her therapist, who’s a guy, can’t see both sides of this,” he continues. “Even you can see both sides of this!”

Even me? I smile. “Was that a compliment you just gave me?”

“No offense. I just meant…you know.”

I do know, but I want him to say it. “In his own way, he’s becoming attached to me”, and I want him to stay in his emotional world a bit longer. But John goes back to his tirade about Margo pulling the wool over her therapist’s eyes and how Wendell is a quack because his sessions are only forty-five minutes, not the typical fifty. (This bugs me too, by the way). It occurs to me that John is talking about Wendell the way a husband might talk about a man his wife has a crush on. I think he’s jealous and feels left out of whatever goes on between Margo and Wendell in that room. (I’m jealous too! Does Wendell laugh at Margo’s jokes? Does he like her better?) I want to bring John back to that moment when he almost connected with me.

“I’m glad that you feel understood by me,” I say. John gets a deer-in-the-headlights look on his face for a second, then moves on.

“All I want to know is how to deal with Margo.”

“She already told you,” I say. “She misses you. I can see from our experience together how skilled you are at pushing away people who care about you. I’m not leaving, but Margo’s saying she might. So maybe you’ll try something different with her. Maybe you’ll let her know that you miss her too.” I pause. “Because I might be wrong, but I think you do miss her.”

He shrugs, and this time when he looks down, I’m not on mute. “I miss the way we were,” he says.

His expression is sad instead of angry now. Anger is the go-to feeling for most people because it’s outward-directed—angrily blaming others can feel deliciously sanctimonious. But often it’s only the tip of the iceberg, and if you look beneath the surface, you’ll glimpse submerged feelings you either weren’t aware of or didn’t want to show—fear, helplessness, envy, loneliness, insecurity. And if you can tolerate these deeper feelings long enough to understand them and listen to what they’re telling you, you’ll not only manage your anger in more productive ways, you also won’t be so angry all the time.

Of course, anger serves another function—it pushes people away and keeps them from getting close enough to see you. I wonder if John needs people to be angry at him so that they won’t see his sadness.

I start to speak, but somebody yells John’s name, startling him. The phone slips out of his hand and careens toward the floor, but just as I feel like my face might hit the ground, John catches it, bringing himself back into view. “Crap–gotta go!” he says. Then, under his breath: “Fucking morons.” And the screen goes blank.

Apparently, our session is over.

Ethics Over Coffee

With time to spare before my next session, I head into the kitchen for a snack. Two of my colleagues are there. Hillary is making tea. Mike’s eating a sandwich.

“Hypothetically,” I say, “what would you do if your patient’s wife was seeing your therapist, and your patient thought your therapist was an idiot?”

They look up at me, eyebrows raised. Hypotheticals in this kitchen are never hypothetical.

“I’d switch therapists,” Hillary says.

“I’d keep my therapist and switch patients,” Mike says. They both laugh.

“No, really,” I say. “What would you do? It gets worse: He wants me to talk to my therapist about his wife. His wife doesn’t know he’s in therapy yet, so it’s a non-issue now, but what if at some point he tells her and then wants me to consult with my therapist about his wife, and his wife consents? Do I have to disclose that he’s my therapist?”

“Absolutely,” Hillary says.

“Not necessarily,” Mike says at the same time.

“Exactly,” I say. “It’s not clear. And you know why it’s not clear? Because this kind of thing NEVER HAPPENS! When has something like this ever happened?”

Hillary pours me some tea.

“I once had two people come to me individually for therapy right after they’d separated,” Mike says. “They had different last names and listed different addresses because of the separation, so I didn’t know they were married until the second session with each of them, when I realized I was hearing the same stories from different sides. Their mutual friend, who was a former patient, gave both of them my name. I had to refer them out.”

“Yeah,” I say, “but this isn’t two patients with a conflict of interest. My therapist is mixed up in this. What are the odds of that?”

I notice Hillary looking away. “What?” I say.

“Nothing.”

Mike looks at her. She blushes. “Spill it,” he says.

Hillary sighs. “Okay. About twenty years ago, when I was first starting out, I was seeing a young guy for depression. I felt like we were making progress, but then the therapy seemed to stall. I thought he wasn’t ready to move forward, but really I just didn’t have enough experience and was too green to know the difference. Anyway, he left, and about a year later, I ran into him at my therapist’s.”

Mike grins. “Your patient left you for your own therapist?”

Hillary nods. “The funny thing is, in therapy, I talked about how stuck I was with this patient and how helpless I felt when he left. I’m sure the patient later told my therapist about his inept former therapist and used my name at some point. My therapist had to have put two and two together.” I think about this in relation to the Wendell situation. “But your therapist never said anything?”

“Never,” Hillary says. “So, one day I brought it up. But of course, she can’t say that she sees this guy, so we kept the conversation focused on how I deal with the insecurities of being a new therapist. Pfft. My feelings? Whatever. I was just dying to know how their therapy was going and what she did differently with him that worked better.”

“You’ll never know,” I say.

Hillary shakes her head. “I’ll never know.”

“We’re like vaults,” Mike says. “You can’t break us.”

Hillary turns to me. “So, are you going to tell your therapist?” “Should I?”

They both shrug. Mike glances at the clock, tosses his trash into the can. Hillary and I take our last sips of tea. It’s time for our next sessions. One by one, the green lights on the kitchen’s master panel go on, and we file out to retrieve our patients from the waiting room.

Working with Silence

Posted on April 1, 2019February 11, 2026 by Psychotherapy.net Team

Silence often makes people uncomfortable. In U.S. culture, particularly, we are prone to filling up silences in conversations as quickly as possible. One reason for this is that prolonged silence may be interpreted as a sign of discomfort or disapproval. For the same reason, new psychotherapy students often feel a need to jump in and ask questions when things become quiet. At times, this can be a supportive thing to do. But, there are other times when this may signal discomfort, and when a period of silence may be just what a client needs in order to process feelings or to reflect on what has just been said. When a client who is usually verbal begins to fall silent while talking about something difficult, corresponding silence by the therapist is often helpful and supportive. It may convey attention and interest, as well as the therapist’s commitment to not interfere with the client’s need to process what is going on. If the silence continues for a substantial period of time, the pressure to help the client by saying something becomes greater. Therapists differ in how they handle this situation, depending on their orientation to treatment and their own individual style. I, personally, rarely let a silence last more than a minute or two without saying something—even if it’s just “Would you like to say anything about what’s going on?” On the other hand, some therapists have had breakthrough sessions when they gave a client a significant period of attentive silence that no one else had ever offered them. While many clients can use periods of silence productively, there are others for whom silence is not a good strategy. In my experience, older children and younger adolescents generally fall into this latter category. This can present a double-bind because these young clients often do not want to talk but also hate to be questioned. I have worked with many adolescents who have had previous unsuccessful therapies. Their two most common complaints about previous therapists are “He asked too many questions!” and “He never said anything!” Over the years, I have come to the conclusion that while questioning may be painful to many adolescents, silence is often downright excruciating. So, what do you do with an early adolescent who finds questions painful, who can barely handle talking at all, but who also hates silence? Many therapists try to engage such clients by talking with them about things they like to do. This can be a good way to start therapy with an adolescent, but it is not always easy to do, and some adolescents also find it irritating and patronizing. This is especially true for adolescents who know that they are in therapy for serious problems and who may legitimately experience small talk as disingenuous or “fiddling while Rome burns.” I have found that it is often preferable to go a different route with these nonverbal youngsters, taking over most or all of the talking at first by gently describing what you know about the client and then gradually introducing some speculation as to why they may be acting as they do. My first experience with this was in working with a 13-year-old girl who had been hospitalized with borderline features and possible early-onset schizophrenia. She had been acting increasingly depressed, erratic, and withdrawn, and had begun engaging in drug use and self-mutilation. She was barely verbal, responding to questions with one-word answers minimizing her problems, or with silence or shrugging. With my supervisor’s help, I began relying less on questions and spending more time talking sympathetically to her about what her parents and the hospital staff had reported about her behavior, and making some guesses about how she must have been feeling at the time. Before long, she began to acknowledge some of these feelings, and eventually she started talking about other significant issues, including having frightening hallucinations and feeling stress about her father’s alcoholic behavior, which her parents had not revealed to us. Interestingly, very young children often tolerate silences quite well in the context of play therapy. They are used to playing on their own and may feel comfortable with an adult in the room quietly accepting what they do and making only the occasional comment. When they get older, however, children cross a certain threshold—typically around 8 years of age—when they start to become self-conscious about playing but are not yet accustomed to talking with adults, especially about personal issues. A few years after this—at, say, 14 or 15 years of age—they start to become sufficiently verbal to express themselves more easily and to tolerate some appropriate silence from therapists. It should also be noted that not all adults feel comfortable with therapists who are silent, especially adults who come from backgrounds in which it is not culturally normal to share personal information with an unknown professional. With these clients—and indeed with all clients—some preliminary assessment is usually advisable to determine how comfortable they are with a more exploratory approach in which some silences may occur, as opposed to a more problem-solving approach in which they probably will not. Looking back over the silences I have shared with my clients, I am struck by how full and how varied they have been—each with its own special meaning: anxiety, sadness, recalcitrance, closeness, and speechless perplexity, to name a few. Each one is different, and each can lead, potentially, to a greater understanding of the client.

Depth

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

Elizabeth was a first-year college student who was finishing up a short period in psychotherapy subsequent to the breakup of a relationship with her boyfriend. In our final session, she expressed feeling good and looking forward to the future—but she also made a comment that caught me off guard. She said that she wished she knew how to be a “deep” person. Not knowing how to respond in the moment, I said something reassuring about being who she was, and that depth would take care of itself.

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Since that time, I have often thought about the concern she expressed and wondered if my response did her justice. What, exactly, had she meant by wanting to be a “deep” person, and had I, in effect, brushed it off?

Several years after working with Elizabeth, another situation emerged that appeared to be related. One of the students in my counseling lab was expressing confusion about a practice session with another student who had brought up an issue to talk about but had seemed unable to elaborate it in any meaningful way. “What do you do,” the student-counselor asked, “when the client can’t say anything more about their problem—when there’s just nothing more there?”

My response was immediate: “Oh, believe me, there’s always more there!” As an afterthought, I added, “You may never get to it, but there’s always more there!”

I was a little surprised by the emphatic certainty with which I uttered this comment, and I have thought about this, too, on several subsequent occasions. What made me so sure that there is “always more there”? It seemed that in the years since I had worked with Elizabeth, I had learned more about what “depth” is, and that I had learned it in a deeper way.

I’d worked with hundreds of patients since Elizabeth. I had seen case after case in which patients who had presented in a defensive or superficial manner in therapy had subsequently opened up to reveal poignant, sometimes moving, emotions underlying their problems. And on other occasions, I had seen patients who had persistently avoided opening up, but in ways that made clear why they could not afford to do so.

Ironically, as I have come to appreciate the meaning of depth, the field of psychotherapy has moved in the opposite direction. In some ways, the field has been a victim of its own success, as increasing demands for therapy and concerns about costs have led to the development of faster, more cost-effective, and more problem-focused approaches to treatment. These more structured approaches are often favored by third party payers and others concerned with the efficient use of resources. Unquestionably, these approaches can be more practical, more down-to-earth, and more immediately helpful to many patients with discrete and clearly defined problems; it might even be argued that they are more democratic and empowering, as they have removed much of the mystique that previously allowed some therapists to elevate themselves as shamanistic elites.

But I fear that the move we have witnessed in the clinical field toward more symptom-focused therapies also represents a retreat from the very real insights underlying the discoveries that are possible in psychotherapy. These insights include an appreciation of the complexity of the dynamics that underlie many forms of human suffering and the degree to which these dynamics sometimes involve co-optation of individuals by familial, social and institutional forces.

A few years ago, I discovered an example of the latter when I wrote a detailed critique of a videotaped therapy session conducted by Aaron Beck¹. Beck’s patient Mark was suffering from anxiety about his performance as a manager on his job. In the session, Beck used guided discovery to help Mark see that he suffers from “social anxiety,” that such anxiety is perfectly normal, and that it can be reduced by learning some simple techniques of self-acceptance and reassurance. A close review of the video, however, suggested that Beck’s focus on a pre-categorized symptom blinded him to some important underlying dynamics. The job in which Mark was experiencing so much anxiety was one in the clothing industry where he was caught in an inescapable conflict between his superiors, who were forcing him to set progressively lower piece-rates, and the workers, who were blaming him for the cuts in their pay. It seemed never to have occurred to Beck to ask Mark how he felt about the job itself. Instead, Beck repeatedly directed Mark’s attention away from the job and labeled his problem “social anxiety.” In doing so, Beck unwittingly aligned himself with Mark’s superiors and failed to explore his feelings about his role at work, the meaning and significance of these feelings, and what he might do about them.

Thus, while symptom-focused therapies can be genuinely empowering in some situations, cases like this suggest that they can also be disempowering if they fail to consider the personal histories and social forces that shape the symptoms that clients bring to the therapy. And more than this, they may leave the client alienated from his or her own internal experiences, values, and feelings—that is, from the underlying issues that led the client to seek psychotherapy in the first place.

The student-client who was unable to elaborate her problem in the counseling lab had not yet discovered some of the depth of her own internal life. Interestingly, I came to know this student quite well over the next few years as she learned more about herself. She worked in several stressful jobs, including doing manual labor and, later, human service work in a poorly governed agency that created more problems than it solved. The stress from these experiences led her to a time in therapy and a period of soul searching about her values and goals. Eventually, she decided to pursue a career in a health-related field with an emphasis on doing in-depth interview research. She had come to be a different person, and a deeper one, than the student I had originally known.

Returning now to my session with Elizabeth, I doubt that her wish to be “deep” indicated a need to reopen her treatment. But if I had it to do over again, I would ask her more about what she had meant: Who were some of the “deep” people she was thinking about? What kinds of traits suggested depth to her? Had she ever experienced any of these traits in herself? Perhaps these questions would have led nowhere. But then again, they might have touched her in some way and given her something to think about in the future.

After all, there’s always more there.

Resources

1 https://psycheandsense.com/empiricism-and-psychotherapy/

Joseph Burgo on Shame, Narcissism and the Art of Empathy

Posted on March 29, 2019February 11, 2026 by rezendevknowfully.com

A Personal Journey

Lawrence Rubin: You’ve been a practicing psychotherapist for over 30 years and have authored several best-selling clinical books. You seem fascinated by the clinical concept of shame. What’s its appeal to you personally and professionally?

Joseph Burgo: I guess it begins personally because for the last 15 years I’ve been coming to terms with my own shame, learning to recognize the role it has played in my life that I didn’t quite understand even at the end of my analysis. During that time I’ve been applying my new understanding to my clients in my clinical practice, and writing a book about it that would be helpful to people who aren’t necessarily in therapy. So, I suppose it’s the case that when you’ve been researching, and writing and thinking about something for a while, it takes a central role in your life.

Right now, it seems to me like shame explains almost everything

Right now, it seems to me like shame explains almost everything.

LR: It seems to be a really elastic concept that can be applied to all forms of pathology and client presentation. What kind of therapist do you think you were before you worked through your own shame issues?

JB: I was a blank-screen, classical sort of psychoanalyst trained in the object-relations school—Melanie Klein, Donald Winnicott, those people. I focused on issues of need and dependency because, from the object relations framework, everything is viewed in the context of maternal-infant relationships—what it’s like for a baby to depend upon her mother and the emotional impact when dependency doesn’t go very well. This is when the infant must protect itself from unbearable feelings of pain and disappointment.

That was the old paradigm. I wouldn’t say that I don’t think that way anymore, but I focus more now on shame and self-esteem. I don’t like the word self-esteem but it’s the word we’re stuck with. I focus more on shame and defenses against shame, the way we protect ourselves against feelings of defect and unworthiness, rather than defending against feelings of neediness and helplessness.

LR: If your personal work on shame has allowed you to be freer of its pull, would you say that, irrespective of the type of therapy you practice, you’ve become a better or different therapist as a result of your own resolved shame issues?

JB: I like to think so. I’ve become a more empathic therapist for sure. I’ve always been empathic and had the ability to empathize with what my clients were going through, but for too many years I regarded that as information I needed to use in order to formulate interpretations. I still do that, but often now it means that I need to say something a little more personal or more directly empathic like speaking to the agony of their shame and letting them know that I have felt that way too. I understand what they’re going through in a way that isn’t distant, isn’t intellectual, but is immediate and authentic.

I’m much more likely to communicate my affection for my clients because I think that feeling joy and interest from another person is a very healing experience

I’m much more likely to communicate my affection for my clients because I think that feeling joy and interest from another person is a very healing experience. It isn’t enough just to make interpretations.

LR: That’s interesting because somewhere in my readings about or by you, you said that clients must wait for their therapists to grow enough to be able to help them. Is that what we’re talking about here?

JB: It is, and when I wrote that I was thinking in particular about two of my very long-term clients who went through a fallow period in their therapy until I addressed my own shame, and then understood shame better and could help them address theirs. That took a while. And it’s interesting that one of them will sometimes refer back to that period when I hadn’t quite figured it out as a fallow period, when we were kind of spinning our wheels.

LR: That fallow portion of the therapy was in part influenced by the growth that you had not yet made!

JB: I think eventually I was able to communicate that to them. However, in the beginning of that fallow period, I defended myself. I had been giving the correct interpretations, but they weren’t making use of them. I didn’t say that, but I think that was my attitude, and it was a somewhat blaming attitude.

LR: It must have been very empowering for you and those particular clients to reach out of that fallowness and find your ways to growth.

JB: It was. It was very productive. It was very moving and relieving that we found a way through that impasse.

LR: You also mentioned that you’ve been most successful in helping those clients whom you have found endearing. Has your own growth around shame allowed you to find clients more endearing and maybe, by association, have you felt more endearing?

JB: I don’t think so. I think this has been a feature of my work from the very beginning. The longest-term client I’ve dealt with, who I’ve mentioned in some of my writing, is very difficult, very volatile, probably in the realm of borderline personality disorder. And yet, endearing to me from day one for some reason. I don't know why, and that was many, many years ago.

LR: Do you find that you’ve become more endearing as a person and a therapist as a result of the work you’ve done on your own shame?

JB: It’s something I hadn’t thought about before. I know I’ve become warmer, more accessible, less intimidating for sure. I don't know if I’ve become more endearing. I think to my closest friends, yeah, probably. They will remark on how I’ve changed.

LR: What are some of the signs that a therapist is being overly influenced by their own shame to the point that it’s adversely affecting their work?

JB: I would say that one of the most common ways is for the therapist to hide behind their professional role and to allow clients to view them in an idealized light–as if they’ve got it all together. This sustains a therapist’s own defenses against their shame. I think this is common, and you hear about therapists who are amazing to their clients, adored by them, and their personal life is a disaster.

The Value of Shame

LR: What do therapists need to understand about working with clients whose pathology is shame-based? Clients don’t come in wearing t-shirts saying, “I’m shame-based.”

JB: I think there are several things. First, I think we need to expand our idea of what shame is.

We’re stuck in this paradigm in which shame is viewed as this uniformly bad thing

We’re stuck in this paradigm in which shame is viewed as this uniformly bad thing, and it usually has to do with some intolerant social perspective, some way that people are influenced by perfectionism and intolerance in the broader culture, and the work of John Bradshaw and toxic shaming. That’s the way we view it. That’s one of the things I try to challenge in my new book, to help people, both clients and therapists, look at shame as something else. The other thing I’m trying to do in that book is to look at the ways that everybody defends against shame. There are a consistent set of defenses that people use when shame is unbearable in their lives. I talk about as avoiding shame, which is in the realm of social anxiety; denying shame, which focuses on narcissistic issues; and controlling shame, which is more in the realm of masochism and self-deprecation.

I think you have to learn to recognize a defense against shame, understand what it is, and then help the person to gradually, over time, defend less against it, understand what it is that they’re running from and learn from it. Sometimes, when we’re behaving in ways that we don’t respect, we have a lesson to learn about our behavior, and shame is a message to us that we need to take a look at ourselves. Sometimes shame is telling us we need to try harder and that we’re not holding ourselves accountable. Sometimes shame is telling us that we have some room to grow. That’s a way I really try to reframe shame as an opportunity for growth rather than this uniformly bad thing.

LR: If we look at shame as part of being a human, we can then consider whether it is serving us and how we can develop a new relationship with it so that there’s more room for growth.

JB: I think so. I think that’s a good description.

LR: You wrote about a client named Caleb, the one we highlighted in the excerpt on this site in a chapter called “Superiority and Contempt.” Upon reading, I didn’t like him and know that you struggled to feel connected with and empathetic toward him. What impact did he and clients like him have on you?

JB: It’s a challenge working with a client like that because your own feelings of worth are impacted. Intentionally and inevitably, when a client like Caleb is in flight from their own shame and defending against it, they will often project it onto other people and then hold them in contempt as inferior and defective. Even though I’ve evolved a lot, I still see the transference and the working relationship between therapist and client as a microcosm of the client’s issues, and often the best way to address them.

Caleb was always trying to make me feel inferior, that he was better than me, that I wasn’t very smart and that I wasn’t very insightful

Caleb was always trying to make me feel inferior, that he was better than me, that I wasn’t very smart and that I wasn’t very insightful. If you’re not aware it’s very easy to become defensive and to make the sort of interpretation that might be shaming to the client, or to sort of shore yourself up, and end up in a tit-for-tat relationship. It’s a conversation that’s being had beneath the conversation in therapy.

LR: Exactly. This very morning, I had to decide to delete a contact from my phone contact list, a guy that I’ve known for 50 years. We are in a constant tit-for-tat, but it seemed that at the core was his need to shame me. He finally stopped communicating with me, and then I texted him on his birthday and got no response. I texted him again yesterday with no response, and this morning I was thinking, and this was my own shame talking, “What can I say that will shame him the most deeply?” And I came up with a perfectly crafted text that would have probably put him through the roof, but instead I decided that that’s sort of a poison you take waiting for someone else to die, so I just said “the heck with it,” and deleted his contact.

JB: The difficult thing about that experience is when someone doesn’t communicate with you and ignores your texts, what they’re saying to you is that you are unworthy of their attention, which is shaming. It’s painful when you express interest in somebody else and they don’t return it. That’s a kind of shame, and it’s natural for people to want to retaliate in kind and to say, “No, you’re the one who ought to feel ashamed.” But you did really do the right thing, which was to recognize that you wanted to shame him, and then decide not to do it.

The Flip Side

LR: We seem to be in a golden age of narcissism. A few years ago, you wrote, The Narcissist You Know. Why are we all so fascinated by narcissism?

JB: Well, I will start off by saying that nobody wanted a book on shame. I originally tried to sell a book on shame about 10 years ago. It was called Learning from Shame: The Less Traveled Road to Self-Esteem, and nobody wanted it. I was told by agents and editors that the book was a downer and that nobody wanted to read about shame. So, I said, well okay, I will then write a book about narcissism, which I see as the flip side of shame, because everybody’s interested in narcissism right now.

I think that

as a culture we’re fascinated by narcissism in the wrong way. I think we’re not horrified enough by it

as a culture we’re fascinated by narcissism in the wrong way. I think we’re not horrified enough by it. We’re not repelled enough by it. We’re fascinated by it because we really enjoy these images of people–particularly celebrities–who seem to have it all, who are beautiful, rich and successful, and we like to believe that somebody actually does get to have that ideal life. Then we spend our time on Facebook, Instagram, and Twitter convincing everybody else that we’re leading this incredible life, that we have these amazing vacations, and we go to these fantastic parties, and here’s this amazing meal I’m having at this incredible restaurant. It all feels really unhealthy to me.

LR: So, narcissism is a destination for people in hopes that once they are on display and revered, they will be able to escape shame? So, as you say, narcissism the flip side of shame?

JB: Yes it is. It’s the primary defense against shame, to disprove to everybody else and yourself that you’re damaged in any way.

LR: What’s interesting to me is that both are equally illusory and not tangible, though both can have tangible impacts on the body and mind. They seem so illusory but so powerful in their ability to just take over a person and deprive them of a true sense of self.

JB: Well, I agree. I think the problem is that for the narcissist, shame feels like an actual condition, an actual state of being in which they’re damaged, defective, ugly. It’s felt on an almost physical level to be a real sort of damage, a deformity, and that’s unbearable. So, they try to create this opposite steady state, this idealized self, that’s perfect and complete, which completely denies the existence of that other steady state: shame and the sense of being damaged.

That’s the problem I see.

The quandary for the narcissist is that either you’re perfect and you’ve got it all together—you’re fabulous; or you’re so damaged and defective that you’re beyond hope and there’s nothing to be done

LR: And it makes sense that the dichotomy of shame and narcissism are part of borderline functioning, this either-or, black or white, idealized or brutalized images of others.

JB: Absolutely.

LR: Is that why in your writing and thinking you’re drawn to borderline pathology–because it is the epitome of this dual narcissism-shame quandary?

JB: I also see the same issue in bipolar disorder. You see people vacillating between thinking that everything about themselves is so damaged, so screwed up that it’s hopeless, and then going on a manic flight into some magical state in which none of that’s true; they’re super powerful, super capable, they can do anything. I see the polarity not only in borderline symptoms but also in bipolar symptoms.

LR: We seem to be so caught up in seeing bipolar disorder as a so-called emotional disorder of dysregulation, so we medicate people for it. But the medication is not going to modify the core dynamic that drives the bipolar behavior, which is the vacillation between shame and narcissism.

JB: Exactly.

The Challenge of Treatment

LR: What are the clinical challenges of working with narcissistic clients, especially those whose narcissism is considered toxic? It must be very trying and demanding for a therapist.

JB: Well, yes. But the truth is that the people who have extreme narcissistic symptomatology usually don’t come for therapy. They think they’re fine or they’ve got some other mechanism for dealing with it that doesn’t involve acknowledging their own difficulties and asking for help. But when they do come, it is a challenge, whether or not you’re dealing with someone like Caleb, the therapist client we were talking about who projected shame into me, or some of the clients who struggle with borderline symptom.s People who have struggled with borderline symptoms are challenging because they go back and forth between idealizing you and hating your guts. As the transference gets underway, it’s a very volatile and emotionally immediate relationship in which what’s going on between you and how you’re viewed is at the core of the work. It’s very painful to have clients say, “Fuck you. I hate your guts. You’re a leech feeding off my neediness,” and on and on and on. I’ve had clients say the most vicious things to me over my career, and the hard part is that the clients I’m describing often are very insightful in certain ways, like they’re able to identify something true about you but use it against you in a really hurtful way. So, your own issues get stirred up. Are you going to defend against that because it’s so painful? Or are you going to hear it and maybe learn something from it yourself? I don't know. I would say

I’ve grown the most with my clients who were the most difficult

I’ve grown the most with my clients who were the most difficult.

LR: I can imagine that a therapist who’s not done their personal work around shame and whose self-esteem vacillates would have the most difficulty and be caught up in the most damaging counter-transference relationships with clients like this.

JB: I think so, and I think those clients probably don’t stay very long with that type of therapist.

LR: I briefly had a client who I really messed up with because he was like Caleb, but younger and much more energetic, and I constantly found myself trying to prove myself. And there are some clients I’ve had that I wish I could call now and say, “I’ve grown. Can you come back and give me another try. I think I could help.”

JB: Oh, do I know that feeling. And the shame of failure. I feel that.

LR: Some people reify therapists, perhaps out of their own shame and inadequacy. We are the mental health celebrities, the equivalent of the celebrity athletes who they idolize. Then when we fail in their eyes we also fail in our own.

JB: Yes, absolutely. It’s kind of nice to be idealized in the beginning. It can easily feel great that somebody thinks you’re a really together person, and you’re full of insight and empathy, and they look up to you and want your attention. That’s flattering, right?

LR: Until it’s not.

JB: Until it’s not. Until they flip to the other side.

LR: You got that little thing there, doctor, in your teeth and now I’m going to just tear you to shreds.

JB: Exactly.

LR: It seems that working with these complex, characterologically involved clients is not about going to an evidence-based manual and pulling out a couple of techniques drawn from a meta-analysis. It’s not that kind of approach. Can you say a few words about the orientation, beyond technique, that’s necessary to work with narcissistically damaged or shame-influenced clients?

JB: It’s a very personal experience for the therapist because inevitably you’re going to be triggered and your own narcissistic issues are going to be stirred up. So, working with that kind of client means that you have to be paying a lot of attention to yourself. You have to be learning and growing from your shame experiences and acknowledging when you’re off base, when you make a mistake, when your interpretations aren’t helpful, and modeling a kind of ability to tolerate shame experiences and to learn from them for your client. So, it’s really personal, I think.

LR: I’m just sort of wandering back to this morning and how I spent 15 minutes crafting the most toxic, shaming message I could to someone who seemed hell-bent on diminishing me over the years, five decades, and how liberating it was, although painful, to delete his contact. Not that I couldn’t find him if I needed to, but the symbolic gesture of saying to myself, “I won’t allow myself to be shamed in this way anymore because I don’t need to pursue shame.” It came with the package.

JB: But they key element there, I think, is that you said it was painful.

Too often I think we want to take flight into some sort of superior position where we don’t feel any pain

Too often I think we want to take flight into some sort of superior position where we don’t feel any pain. We want to think “In fact, they weren’t worth wanting anyway. They were a terrible friend and I don’t really care about them.” That’s an understandable position to take. I always think that allegory of the fox and the grapes explains so many things. That’s one position we can take but what you said is, “Look, this isn’t good for me because this hurts me.”

LR: The allegory of the fox and the grapes?

JB: It’s the “sour grapes” story. There are some grapes hanging over the wall and the fox keeps jumping up to try and get them because they look so yummy. And then when he can’t he finally decides, well, they were probably sour anyway, I didn’t want them.

Rebuilding Esteem

LR: You have been interviewed by countless folks like me. You’ve offered your words in a public venue. You’ve written, so your words are out there. Does this feed your narcissism in a good way or bad way?

JB: I’d say both. In my new book I talk about how the real antidote to deep feelings of shame is to behave in ways and achieve things that build self-respect and pride to sort of off-set this sense of defect and damage. That has been absolutely true for me. I was at a low point in my life following the economic downturn in 2008 and 2009, following the end of my first marriage. I was just feeling bad about myself. The temptation was to sort of give up and to sink into despair. But I worked hard instead to build my website, rebuild my practice, write my first, second and third books, and to become an authority in some sense on a number of subjects that matter to me. I would call that healthy narcissism, building pride and self-respect, and I feel so much better about myself now than I did 10 years ago.

At the same time there’s a part of me that wonders: Why aren’t I Brene Brown? Why don’t I have my TED Talk?

At the same time there’s a part of me that wonders: Why aren’t I Brene Brown? Why don’t I have my TED Talk? And why aren’t I a public authority who’s making lots and lots of money off very similar ideas? So, I think there’s an unhealthy sort of narcissism that wants me to be bigger and better than I am.

LR: I understand in ways that sort of transcend this interview. My work with Psychotherapy.net came at a really good time for me. I was a low point professionally, just tired and drained. Teaching but not giving, more withholding than anything else, and wondering how much I really knew and protecting what little was left of my energy and empathy. I feel good about what I do know and what I’ve learned. I feel better about myself, so I think there are those of us who, like you said, embrace opportunities to escape shame and others see shame as sort of a deceptive friend that we can’t quite let go.

JB: That illustrates exactly what I’m trying to say in the book. There was a choice point in your life. You could have continued in that kind of ungiving way. You could have abandoned your profession and looked for something else, or you could find this opportunity that allowed you to apply everything you knew in this new framework where you felt good about yourself. You built self-esteem by doing something you feel good about.

Exploring Defenses

LR: We’ve been talking about shame and narcissism, your training, and your own professional evolution. It seems that at the core of your understanding and your work is the notion of defense mechanisms. You wrote a book called, “Why Do I Do That?: Psychological Defense Mechanisms and the Hidden Way They Shape Our Lives.” Is it always necessary to attend to a client’s defense mechanisms? And if we don’t, is the therapy doomed to a lesser level of effectiveness?

JB: No, I don’t think so. We all have defenses. We couldn’t get through life without our defenses, and some defenses are healthy and helpful. I don’t think those need to be pointed out or challenged. But, when defense mechanisms are deeply entrenched and pervasive, they get in the way of everything. And that’s why we have to draw our clients’ attention to them and help them understand what they’re defending against, so that they can deal with the pain in a more constructive way. For example, narcissism is a defense against shame, and we need to help our clients see how their defenses—their narcissistic behaviors that are meant to defend against shame—are causing all sorts of trouble in their lives, and that the solution is worse than the problem.

LR: So, if a therapist is not psychodynamically trained, and does not understand how to work with defenses and is themselves shame-based or defended against shame through narcissism, is the therapy doomed to a lesser level of positive outcome if for whatever reason defenses don’t get acknowledged or worked through? Is it just going to be patchwork?

JB: I think that a lot of growth and development can occur even if somebody doesn’t think the way I do. Even if they don’t view people in terms of their defensive structures or they don’t see shame in narcissism the way I do, lots of growth can occur. There are a lot of great cognitive behavioral therapists who are helping people, but certain issues aren’t going to get addressed, that’s all. I think that the deeper, more profound issues aren’t going to be addressed. That doesn’t mean it’s not helpful.

LR: The book itself is a self-help manual. I agree, as you said, that a lot of good work has been done by CBT therapists. There are apps for CBT. There are self-help manuals for CBT. Is a self-help manual for dealing with defense mechanisms really going to be helpful without the supplemental work with a real live therapist?

JB: I have clients who have asked me the same question and challenged me on having written self-help books. I don’t know. I do know that I hear from people all the time who have read my book saying how helpful it was to them and how it opened their eyes to themselves and they saw things they hadn’t seen before. You know, I just feel that most people can’t afford therapy. That’s the bottom line. Are we just supposed to say, “Well, you can’t afford therapy, so you’re doomed?” Or do we try to find some way to bring these ideas that inform our practices into a book that people can read, and offer them exercises that they can work on? I feel kind of obligation to do that.

Digital Empathy

LR: As we wind down, I want to draw attention to your involvement with distance therapy for these last five years. What are some of the advantages and disadvantages that you see in this delivery method?

JB: Mostly I see advantages because it gives people the opportunity to have contact with a professional when there isn’t anybody they can see face-to-face. I’ve worked with ex-pats in other countries where there isn’t anybody available. I’m thinking of a client I work with who is married to a Japanese woman and lived and taught in Japan. He couldn’t find anybody there that really would be able to understand him and his culture. So, there’s that great advantage, or there are places where there just isn’t anybody.

It’s usually very convenient for everybody involved, but sometimes there are obstacles. The client might live with somebody else so privacy can be a challenge. When I was in analysis it was really time consuming because I had to leave enough time for traveling and parking. When you do it digitally, you can log on and have your session and then you’re done with it.

Other therapists are often very skeptical about the fact that you’re not in the same room and feel that that might mean there’s a lack of immediacy and lack of a real personal empathic connection. I understand that, and I understand that’s got to be true to some extent but, especially after researching how empathy works in my last book, it’s not magic, and it doesn’t necessarily have to do with physical proximity. When we empathize with other people, we are reading their emotional experience on their faces, and we are unconsciously bringing our own facial expressions into alignment with theirs, which stimulates an echo of their experience inside of us. You can do that on a video screen, and I do.

I do feel a deep empathic connection with my clients when we’re face-to-face over a computer

I do feel a deep empathic connection with my clients when we’re face-to-face over a computer. I have worked by telephone. I won’t do it anymore because it’s so inferior if you can’t see somebody’s face.

The other thing is there’s often an extra bit of information that comes with seeing a client in her own milieu that you don’t get when they come to your office. That’s your terrain, right? I wrote an article for The New York Times about some of my clients who have pets and who connect from their homes, and how I get to watch them interact with their animals and I learn things about them that way. You learn things about people by what they choose to include in the video frame for their sessions. You sometimes have intrusions from people who forget that your client is in session then and they’ll come into the room or there’ll be sound from another room in the home. There’s all these extra bits of information that make it a very rich experience.

I do understand the reluctance of some therapists to work this way, and the sort of mystical view of empathy as this kind of ESP that happens when people are physically in the same space, but my experience tells me otherwise.

One of the personal bonuses of working in distance therapy is just this exposure to all these people I never would have had the chance to meet and work with on the west side of Los Angeles. It affords me the freedom to transcend the only thing I have never liked about my job, which is that I’m stuck in one place. I spent two months in Europe this summer and I worked the whole time. It’s always been my dream to not be a tourist but to just go somewhere and have my daily life there. I would do what I would normally do but at the end of the day rather than being home in Los Angeles or Palm Springs, I’d be in London or Paris, which is what I did, and it was fabulous.

LR: So, doing distance therapy can be liberating in that you’re in many places by virtue of the clients with whom you’re working, but you can also be in many places and sort of get filled up in that way.

JB: That’s a good way of putting it.

Distance therapy feeds me, and it makes me a happier therapist to be able to do that

Distance therapy feeds me, and it makes me a happier therapist to be able to do that.

LR: A happier therapist is a better therapist.

JB: Yes.

LR: Has it expanded your world view as a therapist in addition to making you a happier therapist?

JB: I like to think so. It’s kind of a humbling experience. I remember I was working with a man who came from a wealthy family in India. He had grown up in India, then been educated at boarding school in England, and was presently working in a family business in Dubai. There were so many aspects of his experience that I had to keep reminding myself that my set of cultural assumptions really weren’t going to hold true for this guy. I just had to listen and learn a lot about his experience and not try and impose my own fully Westernized values on him. It was challenging.

LR: I would imagine that the ability to rise to that challenge is based on one’s humility, but as you said, it is about empathy–the willingness to open yourself to others no matter who they are, where they are, and how they struggle.

JB: People might have different sets of cultural values and assumptions but their faces all express emotion in the same way. That’s biological.

LR: I guess that is as good a place to stop as any. Thanks so much for your time today and the wonderful conversation.

JB: I really enjoyed this interview, it was different from many that I’ve had before. Thank you for reading my books and for giving me the opportunity just to go on at length about subjects that mean a lot to me. This was very enjoyable.

Changing Places

Posted on March 26, 2019February 11, 2026 by Psychotherapy.net Team

The Nesting Instinct

Thirty years is a long time. When I started my psychotherapy practice as a newly-minted licensed psychologist in 1986, I didn’t expect to spend my entire career in one office. But the brownstone building and the location were great, and the space felt comfortable. The office was part of a suite with five offices, a shared waiting room and a bathroom. It was a large room with windows overlooking a tree-lined street. I never felt the desire to relocate my practice. Recently, however, the noise from new tenants in the apartment above my office became intolerable. The landlord was unwilling to intervene and clients were starting to look up at the ceiling due to the sound of a toddler jumping out of bed overhead. Additionally, the condition of the waiting room and bathroom had deteriorated. My frustration finally compelled me to start looking for new office space.

Although psychotherapy is about helping people realize change in their lives, personally I am often resistant to change. I love to travel and explore new things, but ever since my parents’ divorce when I was a young child, I developed a strong nesting instinct. Creating familiar and warm surroundings is core to my well-being. I will venture out into the unknown, but I like my surroundings to stay the same. “Moving is not something I do lightly”. During those same 30 years, I had moved homes twice, each time to accommodate a growing family. I was always grateful that my office stayed the same. It was the constant in my life, a proverbial “room of my own.”

There had been days when the comfort of my office extended to me as much as it did to my clients. Each time I was pregnant, I would nap on the couch whenever I had a free hour. The office was never cluttered with the accouterments of young children or the inevitable accumulation of “stuff.” Every night as I closed the door behind me, I knew I would find the office in the same condition the next day. The familiarity of the space was reassuring to me.

Time for Change

Therapists often admonish clients against “a geographical cure,” but sometimes relocation is the right decision. As I began looking for a new office, I knew I wanted to stay in the same neighborhood. Keeping my phone number and location was important to the stability of my practice. I was fortunate to find, just three city blocks away, an office with large windows and my own waiting room. The ceilings were higher and the building was non-residential. I signed a five-year lease, guaranteeing myself some permanence. I reassured myself that there were important lessons for me, as well as my clients, in this decision.

In the weeks leading up to the move, I was aware of feeling uncharacteristically unsure of myself. Finding a new parking space was challenging and I regularly forgot the code for the bathroom in the building as I checked the progress of the renovations in the new office. When I had the opportunity to meet the psychologist who was leaving the office, he reassured me that “The office has good karma.” He was retiring after 30 years and welcomed the opportunity to bequeath this important space in his life to another psychologist. He shared helpful insights about how the building worked and volunteered to introduce me to fellow therapists on the floor. His clear desire for me to be happy in the office eased some of my doubt about having made the right decision. The fact that he had had a successful practice in that space for thirty years seemed like a good omen.

It was critical for me to manage my own anxiety about unforeseen consequences of moving so that it would not be detrimental to my clients. Like all therapists, over the years I had weathered personal difficulties while continuing to work. During those times, I relied on a few trusted colleagues to support me. This time, through word of mouth, I sought out other therapists who had moved offices to learn from their experiences. It was enlightening to learn just how complicated most therapists find this decision. We all agreed that our attachment to our office was a by-product of our work. Opinions varied about how far in advance to tell clients about the move and whether or not it was important to bring anything from the old office to the new one. One colleague who had moved due to a fire in her old building, rather than by choice, spoke about how this trauma had been more than some of her clients could bear and consequently they did not follow her to her new office. Another colleague shared that after his move a few of his clients told him how uncomfortable they had found the previous office, something he had not been attuned to. In retrospect, he realized that his own comfort in the space had kept him from recognizing how dilapidated the surrounding neighborhood had become. These conversations, along with my own self-reflection, led me to wonder what was in store for me as I made my own move.

My Clients React

A therapist’s office reveals the personality of the therapist in subtle ways. Although family photos or other highly personal artifacts are typically absent, the color of the walls, the seating, and the artwork are chosen with care to convey safety and comfort. Indirectly, these choices do reveal something of our personalities to our clients. I had redecorated my old office a number of times over the years. Now, as I looked at the new space I was about to occupy, I wondered what to bring with me and what to replace. A complete makeover felt too unsettling. In the end, I decided I would paint the walls the same green I have loved for the past eight years and keep most of my furniture. I added an oak, two-drawer, lateral file cabinet and changed the artwork from Gauguin to Sargent. Having my own waiting room for the first time, I thought about how I wanted to present myself to potential new clients as well as my current caseload. It was exciting to have more control over my space. I doubt I would have felt comfortable in a professional office building at the start of my career, but now I was ready to leave the homey brownstone I was used to.

A month before my moving date, I informed my clients of the coming change. Relieved to learn I was not retiring, they had varied responses to the news of the relocation of my office. It was revealing to learn how deeply some of them were connected to the physical space, while for others the transition seemed seamless. One client enthusiastically said, “Where are we going?” Some were thrilled the new office would be closer to public transportation. Others talked about how much they loved the tree outside my window, and a few worried whether the new space would feel as comfortable as the one they knew. A couple of clients asked me directly what had led to my making this decision and when I shared my reasons about the noise from above and the general deterioration of the common space each one commented on how my decision to act made them feel cared for.

One long-time client, a woman who had a history of sexual abuse as a child, was very attached to my physical space. She revealed that, during many painful and uncomfortable hours of therapy, she had memorized the order of the books in my bookcase and counted the seashells on my windowsill when eye contact was too penetrating for her to bear. She took time to say goodbye to the office and to reflect on the hard work she had done over the years to voice her deepest fears. Her one request was that I put the books back on the bookshelf in exactly the same order.

One of the hardest truths for therapists is that we rarely get to hear the end of the story. On moving day I found myself overcome with an array of emotions, as I sat on the floor of my old office boxing up my files. Like long-forgotten photo albums dusted off only during a move, each file brought back the connection I had made with the person whose name it bore. There were some people I had seen for a single visit, but whose stories I had never forgotten. I’d known others for over twenty years. I grieved again the loss of someone’s son and the tragedy of a terminal illness. I calculated the current age of past clients and let myself wonder about them. Had he found love? Did she have children? There were clients for whom I was not a good match, a few who had left in anger. Reflecting on the depth of connections with clients past and present reminded me anew of why I love being a therapist.

Looking Back, Moving On

As I walked from my old office to the new one with boxes of files in my arms, I was aware that these were possessions too precious to leave to the movers. Of course, it is my duty to protect the privacy of my clients, but physically moving these files, my life’s work, over three trips, on my own, to their new home gave me confidence that this was a positive change. In a very real sense I was moving alone, but all the people I had known over the years were coming with me. I was no longer a brand-new therapist, but a seasoned professional eager to continue my work. Suddenly, the journey from my old office to my new one felt less like starting over and more like an affirmation that I was on the right path.

All of my clients chose to follow me which was a relief. I knew the move presented an opportunity for each of them to reflect on their commitment to therapy, and to me, at this point in time. For those where the connection between us felt more tentative, I was not sure if the disruption of the move would tip them toward terminating therapy. Other clients touched me by their vocal appreciation for my presence in their lives. A few even brought me “office warming” gifts and I was reminded that my ability to receive as well as give in my role as a therapist is helpful. I can model change, not just prescribe it. In fact, since the move, two of my clients who were unhappy with their living situations have made moves of their own. Perhaps this is mere coincidence, but I suspect not.

Change isn’t always for the better, but when it is, it is a great reminder that holding on for too long can be detrimental to growth. Initially, when faced with the need to move, I saw only the potential for loss. In fact, the opposite occurred. I am no longer distracted by unwelcome noise and the new space is beautiful. By listening to my feelings, but still taking action, I enhanced my own capacity to change. Undertaking this move at this stage of my career has reawakened in me the joy I felt starting my own psychotherapy practice so many years ago. The relocation of my office has affirmed for me the value of taking care of oneself. Unconsciously, I was overly attached to my old office and I failed to recognize that change could actually help me thrive. The insights I have gained from this experience will undoubtedly help me both professionally and personally.

Everyone loves the new office, particularly me. But the most important lesson I learned from changing places was summarized best by one my clients, “The office doesn’t make the therapist—the therapist makes the office.” After thirty years of practice, I have more confidence in what I offer my clients and I am looking forward to a vibrant next chapter in my career.

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