Therapeutic Issue Archives - Page 55 of 68

Transforming War Trauma: The Healing Power of Community

Posted on April 18, 2013February 11, 2026 by rezendevknowfully.com

"What's the matter? The war's over," someone said to a veteran. "Yeah, over and over and over," he replied.

Coming Home

It’s January, 2007, the first moments of the Coming Home Project’s first retreat for veterans and their families. Kenny Sargent and Rory Dunn are Iraq veterans who both sustained traumatic brain injuries (TBI). One was shot in the head, one was hit by an improvised explosive device (IED); both suffer from post-traumatic stress. As people mill around, Ken and Rory meet for the first time, up close and personal. Since neither can see very well, they touch each other’s wounds, comparing scars and experiences. They are like long-lost brothers. The process of making palpable emotional connections has begun.

We gather for our first circle—33 vets and family members from seven states, with four facilitators. In the opening moment of silence, as we remember those unable to be with us, Stefanie and Michael’s three-year-old son, Ben, is playing around the edges of our circle with Isaiah, his new three-year-old friend. Amidst the reverent quiet, we all hear Ben say, “My daddy died in Iraq.” We learn later from Stephanie that “Michael committed suicide six months after returning from Iraq.” Out of the mouth of babes, the first words spoken at a retreat have their own truth: something inside Michael died in Iraq.

We go around the circle, introducing ourselves. Stephanie, Ben’s mom, feels isolated in Houston, where she lives with the heavy legacy of Michael’s suicide. Her church has ostracized her. The group’s reaction is palpable: Stephanie is taken in like a family by a swarm of other spouses and parents.

At the end of the workshop, as we are saying our goodbyes, Rory gets up, makes his way over and we hug. He was angry and bitter at the outset, not just about his injury, but about failures in leadership and his friends who died in the IED attack and. “No one but a vet can understand another vet” were his first words. I am not a vet myself but a Zen master, psychologist-psychoanalyst, and the son of a combat vet.

After we hug, Rory says, “You’re alright.” Near his seat I notice a scrap of paper on the floor, pick it up and ask if it’s his. “Yeah, it’s nothing,” he says. I look at it and see quite a legible note, with three family trees. I ask him about it. “It’s all the people blown away by my buddies’ dying,” he replies. I ponder it: girlfriend, baby, church members, mother, father, sister, and so on—three little stories, three little family trees radiating impacts that eat at him. I offer him the scrap of paper and he gently reclaims it.

Love is a Force for Change

After the attacks of September 11, like so many others I felt that if we, individually and as a country, could withstand and reflect on the dreadful trauma we were experiencing, and not react in a blind knee-jerk fashion, we could bring the perpetrators to justice and at the same time forge alliances and communities of nations that would provide a strong foundation for genuine security for all going forward. Many were thirsty for revenge, but many in the peace community were calling for love. I gave some talks that presented love as a force for change, not some naive fantasy that ignored the powerful forces that had been unleashed. I was disheartened and frustrated that, despite the voices of millions here and around the world, and the counsel of seasoned military leaders, the drumbeats to war were impermeable to reflection, forethought, and considered wise action. Knowing the carnage that was to come, I felt helpless and angry thinking of the great damage our country would inflict not only on this generation, but on generations to come.

Rather than stew in this state, it dawned on me that, given my experience with meditation, healing communities, and trauma, I could join with others and make a difference. It was 2006. Troops were returning stateside in droves and, along with their family members, they were falling through the cracks of the unprepared, overtaxed and outmoded healthcare systems of the Veterans Administration (VA) and the Department of Defense (DoD). If we waited for the government to do something, anguish would only intensify and tens of thousands would fail to receive the care they desperately needed and had earned. Most service members who needed treatment, especially for unseen injuries such as post-traumatic stress and mild to moderate closed head traumatic brain injuries (TBIs) were loathe to come forward—afraid of losing their security clearances, their promotions, and, most of all, the respect of their buddies. I sensed that a compassionate, non-judgmental and welcoming community that included families could be an inviting and healing resource for them.

I gathered a cadre of San Francisco Bay Area therapists who began to provide free, confidential therapy for veterans and their families. We soon began offering retreats for veterans and their families—which we distinguished from psychotherapy so as to counteract the stigma of mental illness—that provided small peer support groups, expressive arts, wellness practices such as meditation and qigong, and vigorous recreational activities in the great outdoors. After a few retreats, we began to incorporate secular rituals into the program, and I enjoyed the dawning realization that the five elements that organically came to comprise the retreats were not a new “quick fix,” but were instead rooted in how we humans have, since time immemorial, worked to transform overwhelming trauma: Sharing stories in a safe environment (healing dialogue), resilience exercises such as meditation, yoga and qiqong (spiritual practice), expressive arts, being active in beautiful places (the healing power of nature), and secular ritual (adapted from reverent religious experience). Four core human capacities also emerged from these retreats—aliveness, bonding and closeness, self-regulation, and a sense of meaning and purpose—elements that help create a life worth living.

For veterans, the stigma of needing help is a major obstacle to getting help, but we noticed it evaporate by the end of our retreats, as isolation lifted and they experienced a sense of being in this together, of belonging. We knew we were onto something when, during the closing circles, participants’ comments began to echo across retreats. They said they’d never experienced an environment this safe, this trusting, where they could be real and reconnect with their fellow vets, their families, and themselves—where they could experience the belonging and camaraderie of service again, and feel free to open up, as much or as little as they were ready for.

Since beginning in 2007, the Coming Home Project has offered 25 retreats and workshops for families, male and female veterans, student veterans, and caregivers. We have brought in local health, education, employment, housing, legal, financial and other services so participants can connect with needed resources, and we recruited local volunteers to be part of our logistics team, enabling the veterans and civilian communities to get to know one another better. In their 2012 review of post-deployment reintegration programs, The Defense Centers of Excellence, a joint VA-DoD agency mandated by Congress to identify, study, and disseminate best practices for psychological health and traumatic brain injury, stated that “the Coming Home Project helps rebuild the connectivity of mind, body, heart and spirit that combat trauma can unravel; renew relationships with loved ones and create new support networks.” We were the only reintegration program of thousands studied that met all their criteria (successfully integrating psychological, behavioral, social-family and spiritual dimensions) that also had significant outcome data and whose pioneering research on post-traumatic growth with veterans and their families and caregivers was published in a peer reviewed journal of the American Psychological Association.

Stephanie
It’s March, 2007, and we’re preparing for our second retreat. Former Marine officer and Zen priest, Colin, and I pick up the van and await the arrival of several families in a Hawaiian barbecue restaurant near the Oakland airport. Fifty people from twelve states gather.

Later in the day, in the safety of the small veterans group, 15 vets meet. Stephanie tearfully shares how she feels like a failure: as a soldier (she served as a Captain in the Army herself), as a wife, as a mother, as a person—in every way. She didn’t appreciate the gravity of her husband’s distress and couldn’t prevent him from killing himself. Sadness and self-reproach run deep. Several jump in to reassure her: “You have not failed.” They offer good points: God had other plans for you; you now can be of help in ways you couldn’t have before, and so on. But Stephanie’s expressiveness and emotion dry up as she seems to compliantly agree. When a third person prefaces his remarks by saying that he will offer something to lift the mood, I say, “That’s okay,” trying to keep alive the space for acceptance and disclosure that reassuring and uplifting comments often unintentionally foreclose.

Rory
In a pre-retreat roundtable Rory expresses how betrayed by the government he felt after he was injured—by their lack of responsiveness and accountability. His anger is powerful, but rather than being transformative, it seems to progress into a loop of escalating rage. The more angry he gets, the more the energy of the group intensifies, amplifies. Two people leave the room—one takes issue with Rory’s facts, another feels his comments are too polarizing. Rory, of course, has every right to express his outrage and sense of betrayal, and yet as his complaints become increasingly politicized, he alienates himself from the group. His TBI makes it especially difficult for him to regulate his emotions.

Over the course of the retreat, however, Rory begins to shift in a way I’ve never seen. Through frequent, long conversations with a high-ranking officer and fellow vet, one of the facilitators, he becomes noticeably lighter, more open to hearing others’ stories. He begins to share his experiences with a sense of measure, calibrating his impact, modulating it and bringing it to a close. The recognition and containment that his fellow vets give him is deeply moving to witness. Maybe Rory doesn’t have to repudiate everything about his military experience after all.

Claudia
Claudia is a female Iraq veteran who came with her 18-month-old daughter and her sister from Tucson. She had met Tonia and Ken, fellow veterans on the retreat, while on the TBI ward at the Palo Alto VA. She is friendly and sincere but appears vacant and taciturn. During a breakout group she stands around the perimeter, but toward the end she beings to speak, tentatively. Although she says she doesn’t want to read what she had written earlier during a journaling exercise, it seems that a part of her longs to do so. With a little encouragement, she begins to read: “My world has narrowed from what it was….” Her voice trails off. She describes her TBI and the difficulty she has remembering simple but important elements of her past. She feels that a crucial piece of who she was has been taken from her: she can’t even remember her daughter’s birth. She needs her sister’s help with tasks of daily living, as her short-term memory is also impaired. She is battling to retain custody of her daughter. Claudia’s reading has a palpably catalytic effect on everyone. When families gather later, the aliveness of her young daughter, the glimmer in her eyes, juxtaposed with Claudia’s memory impairment, her sense of vacancy and helplessness are striking, poignant and sad.

Mauricio
At the big morning group early in the day, Mauricio provides comic relief when he states that of the two master sergeants in the group, he is on top of Ken. Everyone laughs about who is on top and who on bottom. He kids us about status and rank and we all laugh harder. In the smaller vets group, however, he is quiet. After Claudia reads, Mauricio opens up about how difficult it is to not be himself in mind and body. He can’t remember important parts of his childhood and it is a continuing blow to his esteem and to his view of himself, particularly given his role as master sergeant of the men under his command. It is an identity crisis of a different order from the normal developmental kind. It isn’t what he says as much as how he says it that makes an impression. He speaks slowly, with an undercurrent of deep emotion, but shows few visible signs of feeling, save a slight crack in his voice.

Jessie
Jessie was a sergeant major in the Army, blinded in an IED blast while serving in Iraq. He speaks with gravity and conviction, conveying a deep sense of betrayal that, after all he’s endured, offered, and sacrificed, he’s had to do it all himself, become his own advocate, find the services and the help he needs. A covenant has been broken. He asks if I will request that folks say their names before they speak. I invite him to make the request himself. He speaks simply and with dignity. After that, when people begin to speak they stop, remember his request, and say, “Sergeant Major, this is Jim,” addressing Jessie by his title.

We usually leave rank and degrees at the door, but this is different: it is an expression of deep respect. When people forget to identify themselves, Jessie gently reminds them, and later on, when Jessie begins sharing, someone says, “You forgot to say your name.” Jessie laughs and everyone cracks up, the role reversal incongruous, funny and poignant all at once.

“There are times during the day when we laugh until we cry, and laugh and cry both, sometimes not knowing which is which.” Our laughter helps us bear the pain and is good for the soul. Everyone knows that by asking people to say their names, Jessie wants to communicate and feel part of the group, wants to hear and recognize everyone, and in turn be recognized by all of us. Though he feels invisible to the institutions entrusted with his care, here among friends his desire for mutual recognition comes across loud and clear. And he is seen.

Paul
Paul comes in toward the end; he’s been resting. Given their brain injuries, some tend to get tired and nap in the afternoon. Paul had been feeling things out around the edges, beginning with the roundtable on Friday. He became upset with the figures Rory quoted during the roundtable, thought they were inaccurate, misrepresentative and needlessly polarizing. He struggled to stay open, thought about leaving, but finally decided to stay. When Paul and I first met, it was difficult to follow what he was saying since the injuries he sustained affected not just his appearance but also his speech. But by now, after two days, I and others can hone in and understand most of his words as well as his feelings. In the small group, he pours out feelings about how he was treated upon his return, and his struggles with physical, emotional and relationship challenges. We hear him.

The Children
In the small teen group, Mark, a Marine helicopter pilot during the first Gulf War, now Buddhist priest and facilitator, began begins with a moment of silence and then asks, “How are you doing?” Tasha is quick to respond, “You really want to know?” and immediately starts to cry. Her sister Alishya, strong like their mom, warns Tashsa not to open things up, but when they share their drawings in the closing circle, they also share how isolated they feel and how hard it is to speak their thoughts and feelings to their parents. With some difficulty, their parents, Tonia and Ken, listen and take in what they hear.

When the workshop ends, Tonia and Ken renew their wedding vows. Her eyes reach out for Ken’s, while Ken strains to respond and to make eye contact with Tonia, in spite of being unable to see much. It is heart-wrenching and heart-warming. After the ceremony, outside the room in the hallway, Tasha begins to cry. As Mary Ellen, a family friend and service provider, holds her, Tasha sobs and cries it all out. What is striking is that no one interrupts the pair; everyone recognizes the outpouring of feeling and lets it be.

Jesse’s daughter, Brittney, is feeling isolated, has no one to talk to, and doesn’t want to burden her suffering parents with her own feelings. “Brittney mentions that her father can’t see her face and therefore doesn’t know if she is sad or happy.” His blindness allows her to hide her feelings, but she feels guilty about doing so. She is afraid that expressing her true feelings will be too upsetting for her father.

At dinner on Saturday, Ben, now four, looks my way; he’s restless. I suggest we trace one another’s hands with crayon. He quiets for a while. I give him my drawing of his hand and he gives me his drawing of mine. We take them with us as we part. Claudia’s 18-month-old girl is dancing with exuberance. Paul’s son, Sebastian, three, calls my name several times. Each time I respond. He wants the give and take. I enjoy the call and response. Two days earlier I was an as-yet-unknown quantity, not safe.

As the retreat comes to a close, everyone is so thankful for the opportunity to meet one another in safety, trust and acceptance. I think about the flexibility of roles: now sharing one’s anguish and small triumphs; now helping another with his. And the humor—it rises up in a flash and fades again, sustaining us as we delve more deeply. Laughing and weeping at the same time. These qualities—flexibility, range of emotion, and sense of safety and trust—reflect the health and healing nature of the community. Such a community brings out the best in us, helping us grow emotionally, interpersonally and spiritually, as it offers a collective space to transform trauma.

We Become That Village

Claudia’s little girl, without her father; Ben without his; Sebastian without his mother. And the teenagers, Brittney, Tasha and Alishya, with loving parents both present, yet struggling with the dramatic and rippling impacts of their fathers’ injuries. Mothers, fathers, sisters, brothers; we all step in to fill the gaps. If it takes a village, we become that village.

What drives this remarkable opening to connection? It is the power of compassion that creates a field of unconditional acceptance and love—each of us supporting and being supported. That field becomes the vehicle, the “bigger container” that holds the grief, the loss, the anger, the powerlessness, the damage. And the precious shards of hope. Everyone can feel its power: the trust, the safety, the deep care. This collective field of compassion grows capacities for withstanding, regulating, expressing, and representing inner anguish. “The dynamic beloved community helps transform trauma, turning inner demons, ghosts that haunt the present and foreclose the future, into ancestors.” Real people and real inner capacities we can access when we need them. We take in and make our own the comrades, the camaraderie, and their beneficial qualities. We enjoy being and learning together. New possibilities for being alive open up. All this is the activity of healing.

As children we are taught to be aware of the consequences of our actions. Actions have impacts that ripple out in many dimensions and last a long time. These effects manifest in ways we did not anticipate. Being aware of and anticipating the consequences of our actions is a developmental achievement. Being responsible for the web of impacts that has ensued from our actions, intended or not, is, likewise, an ongoing achievement.

As a society, we don’t take very good care of one another. Our children, our elders, our natural resources are often ignored, overlooked, forgotten or mistreated. Ours is a disposable culture. But what we do not include, recognize and care for does not go away. The impacts last for ages, and they affect everyone. The web of life is our connective tissue: human, animal, mineral and vegetable. What we discard or fail to adequately care for, we do so at our own peril. Our veterans and their families unfortunately have too often fallen into this category. Their suffering, their humanity, their dignity and their sacrifice often go unrecognized.

Since we are interconnected at the core, what happens here impacts what happens there; even if there is no visible or logical link. Almost three million service members have been deployed to Iraq and Afghanistan. Factor in the children, parents, partners, grandparents, brothers, sisters and so on, and that’s a lot of people who have been directly impacted by these wars. As we learned from Vietnam, unattended to, the wounds of war fester and deepen, wreaking havoc on individuals, families, and communities.

"When the Hair Grows Over"

The impacts of war are legend. Some are visible but many are not. There are injuries we can see and injuries that are invisible to the eye but nonetheless radiate deep and wide into a person’s life, health and web of relationships. TBI patients and their families have a saying: “When the hair grows over.” When the visible injuries heal, the unseen wounds to mind, heart, soul and spirit often go ignored. I am not only referring to post-traumatic stress. There are many veterans whose problems do not meet the criteria for a diagnosis of PTSD, but who nonetheless experience profound disturbances in functioning and well-being, as do their families. The ever-present traumatic past crowds out the open present, collapsing hope and possibility. I don’t believe that post-traumatic stress should be classified as a “disorder,” although our inner experience does become disordered, and we ourselves can be temporarily disabled. But I see the loose constellation of clustered symptoms organized by psychiatry manual-makers as the psyche’s means of trying to recover from the shock and chronic helplessness of unimaginably overwhelming circumstances.

Post-traumatic stress and war’s other wounds are not just stress and anxiety problems; they impact our identity, our self-regard, sense of purpose, and our entire worldview. Sometimes war shatters it all. “Rebuilding damaged connectivity among body and mind, heart and soul, among thoughts, feelings, actions, beliefs, and relationships is critical.” There is also a cultural dimension to healing the unseen wounds of war. Although it is important to learn skills to reduce stress and anxiety and rebuild the brain’s capacities to modulate and manage strong emotions—to rebuild internal connections—it is equally important to rebuild connectivity among family members and within communities.

What we cannot hold, we cannot process. What we cannot process, we cannot transform. What we cannot transform haunts us. It takes another mind to help us heal ours. It takes other minds and hearts to help us grow and regrow the capacities we need to transform suffering. This is done in concert, reweaving the web of connective emotional, relational and spiritual tissue that cumulative trauma tears asunder. With another mind and heart, and an informed, compassionate culture, it is possible, to transform ghosts into ancestors.

Concealed within damage often lies great strength. Resilience runs deep but its resources need to be nurtured. It is like a seed that has been buried in a disaster; it needs tending, attending. When the great redwoods are damaged in a fire, their seedpods are not destroyed—there is devastation, but often the forest can return to health, with protection, care and skill. If we cultivate the intention to be of help, if we take the time and energy, if we realize that the responsibility for healing the impacts of war is collective, the seeds of renewal and transformation await us just beneath the charred wounds of war. It takes a village and it begins with each of us.

Irrespective of political or religious beliefs, each veteran, each partner, child, sibling, parent and grandparent, deserves our loving, skillful, attentive care for the visible and invisible injuries from serving in Iraq and Afghanistan. They don’t only need a new set of techniques or new understandings. They need us to harness our own humanity—head, heart, body and spirit—our native connectivity and capacity to respond, in order to make a difference. They need us to participate in creating a culture in which the wounds of war are lovingly and skillfully enveloped as part of a welcoming community, where they can heal and be transformed. Fundamental interconnectivity takes the form of a responsive community that holds the vets and their families in its attentive, loving embrace.

The Lying Artist

Posted on April 16, 2013February 11, 2026 by Psychotherapy.net Team

Once upon a time and many years ago when I was a very new therapist, I worked with a client who had completely made herself up.

A lot of things never added up with her. For starters, there was her presenting problem. Some days she would report a diet of jelly beans (not many) and carrots, and yet she was never low weight. But since clients with eating disorders are so often metabolically out of sync, it didn’t seem completely unbelievable either. And her restricting and purging progressed in fits and starts, with days of nearly normal intake.

So I’ve often wondered, did the lies start from the very first moments of treatment, or even before she entered my office, or did they start later? When exactly, and why? She told me she was singing lead vocals with a band. She brought me flyers, with dates and locations on them. Then she met a young man, an up-and-coming actor. One day she came in with an engagement ring. There was a lot of drama in their relationship, and a few months later they broke up. Throughout, she stoutly refused family therapy with the parents she continued to live with. Should that have been a clue? Over time, her story got somewhat wilder. Her former fiancé had an affair with a girlfriend of hers and the girlfriend became pregnant. When the baby was born, he had a heart defect, and my client became a significant source of support to the child and her mother. She denied conflicted feelings. The child was near death.

I started my private practice in a different state and my client transferred to another therapist, a friend of mine. A couple of years later she transferred to someone else for a similar reason. Occasionally, my former client would call me with brief updates about her life and progress. The last time she called me, it was to confess that none of what she had told me or her other therapists was true. As part of her ongoing therapy, and to her lasting credit, she wanted to apologize. The baby who died so tragically had never existed. There was never a fiancé. The engagement ring was a cubic zirconia she bought at the mall. There was never a band. I was shocked into speechlessness and had little to say or to ask.

Initially, my sense of shame and betrayal was so intense that I could barely think about her. As I told the story over in my mind, it became more and more absurd, an obvious lie. Although I eventually remembered that in the 15 years since I worked with her, I have heard many stranger truths than the lies she told me, at the time I felt a total fool, shamed before myself and (it is some comfort to say) my also-fooled colleagues.

For years, now, though, I have wondered. I have remembered the times when she wept, or when her face turned bright red with sudden anger or shame. Was she simply an extraordinary actress, playing her heart out to an audience of one? Picasso famously said, “Art is a lie that makes us realize the truth.” Lying, it seems, was her art, but what truth did it reveal? Could she possibly have benefitted in any way from our therapy? How did she see me? Bumbling, naïve—a confidence woman’s mark? Or possibly idealized—too good and too perfect in her eyes to be sullied with the probably more boring and more awful truth? How much did I participate in maintaining her fantasy? Surely it was not possible for me to be taken in without some collusion on my part. Did she stroke my ego? Fan my insecurities? I don’t recall at all.

And what, after all, is true in therapy? We know we are shown the distorted perspective of one person as seen through the distorted lens of ourselves. Dreams and fantasies contain truths as genuine as what we call conscious realities. Sometimes the” lies” are the most revealing part of the story, pointing like a flashing neon arrow to the place we need to go: “I don’t blame my mother,” “I’m not afraid to live alone,” “It’s only a diet,” “I just don’t think about sex anymore.” And of course, even with the best of faith, memory always lies.

But still…there are lies, and there are lies. The therapy relationship relies on our clients mostly telling us their truth. I think of my former client often. Hers is a cautionary tale, but in some ways I choose not to heed the caution. The therapy relationship also relies on who I am, and though I make an effort not to be naïve or foolish, I cannot strive toward the openness, honesty, and awareness that makes for an effective therapy when I am harboring too much distrust or suspicion. And although it took a long time and several therapists, my former client did after all find her way to honesty, and that is a good ending and a good beginning.

The Therapist and the Fee: Why Everything Works out and Also Doesn

Posted on April 9, 2013February 11, 2026 by Psychotherapy.net Team

A close friend of mine is a wonderful therapist, a child of the 60s, a gifted man, large-souled, big-hearted and wise. His practice nourishes him and is saturated with life. He is committed to a worldview that eschews anything close to greed. “I won’t ask my patients for more, at least not if I can avoid it,” he says. “Often I will wait years to do it.”

My friend’s position makes perfect sense to me. He is a thoughtful and principled man. His role as a professional is anchored in a deep caring for the poor and those who have less. People trust him and his love for them. Anyone can see why he is successful.

And yet what fascinates me is that there are practitioners equally effective who take the opposite point of view. They are practically bullet-proof around money. They regularly raise fees with no compunctions. One colleague, a psychoanalyst and social worker, charges $200 per session and raises the price every two years in $25 increments.

Both of these therapists have large practices and enjoy their work. Both of them claim that they work in the best interests of clients. In fact, my high-flying colleague insists that she raises her fees in order “to help” her clients. “It is selfish not to raise fees,” she insisted to me.

“Clients form an unrealistic dependency and attachment to me,” she explained. “When I raise them, it allows them to separate from me by getting angry at me. It helps me too to be sure, but it is also a gift to them.”

Who is “right”?

Of course, it would be difficult to establish what is right and wrong in a field where so many different, seemingly counter-intuitive actions can be therapeutic. Where else do you have a field in which the “giving” or “self-sacrificing” therapist who is easy on the rules, winks at missed sessions, lowers the fee at the drop of a hat, can often be counter-therapeutic?

And yet it is possible that both therapists are “right.” Each, by being whole-hearted in their approach, may have a struck a deal with their patients’ unconscious. In the case of my friend who almost never raises fees, he has communicated successfully to his patients a simple message: “I won’t easily leave you. I will be with you and be kind to you.” If you knew this man, you would know how genuinely he feels this and believes this and whole-hearted he is. This communication may be helpful to some people who have experienced the traumas of life. They trust his love for them and their love for him until they gradually integrate reality into their lives and mature.

The other therapist seems to have communicated the exact opposite message—that may be equally helpful: “I will always leave you. I will always raise fees and I will always take care of myself in this relationship as well as you.” Paradoxically, for some people, that may be a building block of psychological maturation. Patients may need to trust the therapist’s narcissism in order to accept their love. Bertolt Brecht once famously quipped, “I desperately need someone upon whom I can firmly not rely.”

The late Hyman Spotnitz, father of modern psychoanalysis asked: How do you know if someone needs treatment? He likened a person to a car. “If the driver turns the wheel to the right and the car goes right, or if he steps on the brakes and the car stops, he won’t need to bring the car to a mechanic. But if you turn right and the car goes left, or you brake and the car doesn’t stop, then you need a mechanic.”

People try to lose weight, to be better spouses, to not yell at their kids. We give ourselves all kinds of commands and yet some of us find ourselves moving to the right when we ordered ourselves left. Instead of saying no we said yes or the other way around. And we are astonished.

Many therapists are confused about what to charge in the first place and when to raise fees. One therapist in a supervision group I ran was skittish about her fees, but wanted very much to raise them. She drilled with the group over and over again: “I am going to tell that patient my fee is $150!” I am going to wash that man right out of my hair. And the group cheered her on: “You go girl!” But when it came to saying it to the patient, the actual number got stuck in her throat. “How much do I owe you?” her cooperative new patient asked her. “$110,” the therapist blurted out uncontrollably. “I hate myself,” the therapist later told the group. “I am a loser.” The group would have none of this self-attack. They warmly helped her to talk about her conflicts around money, which were deep, and within a short time she proudly set her fee with a full heart.

If you’re whole-hearted about what you do, as in the cases above, it usually works out just fine no matter what you do. If you are conflicted, it won’t and you, your practice and your patients will suffer.
We therapists may resist this as intensely as our patients, but most often, the way to find out more about what is right for you and what is in your heart, is to talk about it in treatment and supervision.

Self-Care for Therapists

Posted on April 9, 2013February 11, 2026 by Psychotherapy.net Team

There’s a beleaguered mom on the couch in my office, and she’s feeling skeptical about my idea that she needs to “double-up on self-care.” She shakes her head—tosses it—and says, half-pitifully/half-defiantly: “Even if I had a few minutes alone, I don’t even know what to do to take care of myself. All I want is to sleep. Creativity is not even really a need right now—it’s like wishing for the moon. I just want to work, pick my kids up from school, and make dinner without feeling like I am going to punch someone in the face.”

We talk about martyrdom—about her own mom’s pattern (that she desperately does not want to repeat) of losing track of herself within a family and all the needs there, of the divorce, of the drinking. My client is clear, is crusading, that this will not happen to her. But I have to let her know that I don’t see her protecting the most precious resource in the family—the sanity and happiness of the mother. The red flag, to me, is her burnout.

So we talk some more, we identify three regular times in her day when she has a few minutes to herself: after school drop-off on her way to work; an occasional lunchtime when work is not too demanding; and on the way from work back to pick kids up from school. Then based on what she thinks she might enjoy, we identify three experiments she can try during these times: a journal and pen and a list of simple questions like, “how are you feeling?”, “what are you grateful for?”; a gentle, non-preachy meditation recording she can listen to; and a “mini” relaxation exercise we co-create, focusing on tracking her breath for a few minutes. This is not enlightenment, but it is a line in the sand symbolizing that the mother’s mental and emotional health is very important. I know too that if she can get in the habit of nurturing a relationship with herself, it will evolve and it may one day be enlightenment.

It should be enough to do this because the mother is a person who needs what every person needs. But it is worth saying, because of the sticky habit of martyrdom associated with mothering, that the whole family benefits—partners, kids, pets—when mother is happy. In fact, according to a study done at the Institute for Social and Economic Research, a mother’s happiness is the number one indicator for a child’s happiness.

Moms are my specialty, but I am writing today to make an association between therapists and moms. The day I worked with this mother on her first steps to reclaiming her relationship with herself, I spent the morning at an HIV+ Women’s Health Clinic from 8 to 12 seeing deeply troubled clients, then I saw private practice clients from 12:30-3:30; then rushed over to see my supervisor, then back to the office for several evening clients. I had my whole day planned out, down to the taxi I took to make supervision on time; and the important phone call squeezed in before a session with a client who is always a few minutes late. There was only one problem I realized by mid-day—I had not budgeted any time to get or eat food, all day. Many of my therapist friends and colleagues have told me of similar schedules, and when there is not a commitment to self-care, it is a big problem for therapists.

It was that day that the connection between mothering and therapizing hit me—both are based on nurturing others, both can tend towards an unhealthy martyrdom. I assert that both roles need a radical re-balancing program in the form of intensive, sumptuous, deep self-care for the nurturer. And the better the self-care, the better the mom or therapist will be at their job of caring for others. This is provable in the simplest of mind-body studies available to look into everywhere, but it is something I also know in my bones. When I am thinking, writing, resting, feeding myself really well, having sex, and laughing a lot, I am a great mom and a great therapist: I feel the creative energy and power that comes from a sense of flow and gratitude. From this place, giving feels natural and right.

Therapists, like moms, may have a tendency, in a life dedicated to listening intently to others’ troubles, to set aside or even sometimes ignore their own needs. But it is not easy to prioritize self-care for anyone these days. True self-care involves placing the self at the center of the spotlight for a time; and listening in, tenderly, to what the soul is asking for. It is a mysterious process. This is the realm of the numinous—what ultimately makes our lives feel fulfilling and where the deep joy that makes life worth living is found.

Self-care is a process of turning inward, thinking and feeling about what brings our unique self true refreshment. I’ve been through this process with a lot of moms lately and I’ve seen some beautifully unique ideas emerge that I think are worth sharing for inspiration: learning to play the drums, learning to surf, staying with a friend a few times a month, scheduling a regular date with a partner for sex in the daytime, cutting out drinking and instead writing in a journal every night at cocktail hour, starting to bike to work, making an altar to the things that bring joy, or drawing with kids.

I know it can be hard for moms and therapists, and lots of other conscientious people to institute a program of self-care. It’s vulnerable to look inward and try to figure out what really feeds and nourishes us. It is different than simply taking care of ourselves by going to the gym or getting enough sleep (though it can include these things). It is a process of experimentation, and it will probably be somewhat elusive at times. Many times our first guesses about what will soothe and inspire us are wrong—the pilates class is full of competitive supermodel types; the writing class causes us deadline anxiety; the date night dancing lesson is awkward. The important thing is to try to find what gives us that flow-feeling, that yumminess, that bliss. Like athletes who train every day to be at the top of their game, I think it makes sense for therapists to try to live in such a way that they are integrally joyful and feel a natural conviction that life is a gift.

Psychoanalysis is Alive and Well

Posted on March 28, 2013February 11, 2026 by Psychotherapy.net Team

Although we have evolved many schools since Freud articulated psychoanalytic theory at the turn of the 20th century, in almost all of them conspicuous analytic features remain. These are so familiar that for the most part they exercise their dominance without our being aware of them or their origins. We may think psychoanalysis has been discredited and that almost no one practices it any longer, but there are ways psychoanalytic theory is present in our listening and thinking because of the vocabulary we employ and have come to take for granted.

An example, from an older use of language. Freud’s German word for cathexis (a word that goes in and out of fashion) is besetzen, which literally means the occupation of an area by a military force. The metaphoric atmosphere is of course lost in our translation, but not perhaps in our understanding of the supposedly aggressive way we take hold of an object and occupy it with our attachment. Even when we use a different vocabulary, when we say someone is “over-attached” to something, or “fixated” on it, we import the negative psychoanalytic attitude. Of course, a cathexis might also be viewed as a passionate interest in something; then we would not have to burden it with a military metaphor.

Or the word resistance: A number of implications reside in this word, most often hidden. Clients use the word, therapists who have never been trained analytically also use it and succumb to its seductions. It is tempting to believe that we, the therapist, know the right thing for the client to be talking about, and if she isn’t talking about it, she’s resisting it; that is, she is avoiding a thought or feeling we think she ought to be discussing. Our meeting together has been turned into a battle: between the client and the content supposedly being resisted. I try not to use the word, although my clients do. I tend, instead, to talk about self-protection. If someone seems to be venturing forth, then cutting herself off, then taking off on an apparent tangent, she might say: “I just can’t figure out what I’m trying to say. Am I resisting it?” I assure her that the timing of this discussion is entirely up to her. The choice is hers, to go forward now or to save it for another time. People tend to take this permission much to heart. I have noticed how often they touch back on a subject they didn’t feel ready to discuss, perhaps to mark it, to hold it as potential, to keep track of it. Eventually, when they feel safe enough the self-protection no longer seems necessary and the content emerges. Best of all, the timing of this important moment has been left to them. I see no reason to call this process of hesitation and caution, of delay and postponement, a resistance.

And then there’s the concept of repression, another word that has entered our common language. A wary, watchful, guarded, unexpressive, anxious and withdrawn person is said, even by people who do not know the technical meaning of the word, to be repressed. But known or not, the word carries implications. It is also used in our political discourse, where it evokes the circumstance in which a group of more powerful people is repressing another. We know this circumstance; it costs lives, evokes rebellion, is most often an affair drenched in blood. Our clients also have these associations to the word. Is it useful to bring this imagery into our understanding of an individual who has come to talk with us?

People coming into therapy for the first time seem to know the rules, the lingo, the appropriate behavior and much of this is, I think, a carry-over from psychoanalysis. They often expect a fifty-minute hour, as if this length for a therapeutic session had been written as law. I’ve had people say to me “Are you sure you’re doing this right?” because I invite them to go on past what they assume is the set time. “I know I’m not supposed to ask you questions,” is another popular assumption. “Or well, I guess I can ask but I know you’re not supposed to tell me the answer.” Who says? It is important for my clients to know the worldview I hold because, obviously, it is going to influence the type of listening I do. Having left psychoanalysis behind we are no longer constrained to be detached listeners. But do we sufficiently tell our clients who we are in our listening? I mean, really take pains to inform them? To explain the school we adhere to? And what its assumptions are? And if not, is that not still the shadow of psychoanalysis falling upon our work?

Vanquishing the Inner Critic

Posted on March 19, 2013February 11, 2026 by Psychotherapy.net Team

In my work with clients who were severely traumatized in childhood, I sometimes feel hopeless in helping them to address and deconstruct their inner critics. I feel daunted by the viciousness and incessancy of their self-attack.

When a child is relentlessly rejected by contemptuous parents, she mimics them and learns to obsessively scorn herself. Like them, she focuses only on her defects and deficiencies; like them she radiates hate and scorn at herself. Her superego grows into an outsized critic as she, like them, blames and shames herself in a thousand different ways. Over time, she so thoroughly identifies with her aggressors that her critic rebukes her in the first person.

In her first session she may tell me: “It wasn’t disgusting. I’m disgusting!” Her inner critic virtually is her Self. In such cases standard tools, such as interpretation, mindfulness and unconditional positive regard barely make a dent in the critic. After numerous futile attempts to stir the client into resisting the critic, my urge to give up sometimes feels irresistible. Early in my career, I would think: “This critic stuff is so Psych 101. I have addressed the client’s critic issues so often that we’re both clearly sick of it. If I don’t back off soon, she’s going to leave. She’s just not going to get it. Her critic’s just too big for her to see. It’s a forest of self-hate camouflaged by the trees of this particular moment’s worries.”

Eventually, I learned that nothing would change for this type of client until we reduced the totalitarian hold the critic held on her psyche —until we eked out some psychic space for her ego to grow into a user-friendly manager of her psyche. Until this was accomplished, we would never awaken her developmentally arrested need to cultivate an attitude of self-support.

I now rely a great deal in early therapy upon psychoeducation and family of origin exploration. Out of an ongoing elicitation of the client’s childhood trauma, we weave an accurate narrative of how she was inculcated to habitually attack and scorn herself. I help her see that she was a tabula rasa as a child, and that her toxic “care”-givers brainwashed her into routinely hating, shaming and abandoning herself.

Psychoeducative interpretation about the genesis of the traumatizing inner critic is, in my opinion, a step that cannot be bypassed, and with such clients, I do it as much as they can tolerate. Sometimes, I derive motivation to persist with this very slow, repetitive process by garnering the energy of other countertransferential feelings that I have. For example, I now typically feel guilty and neglectful when I let the inner critic—the internalization of the parents’ contempt—get away with abusing my clients. At such times, I feel derelict in my human and professional duty to bring attention to how they are hoisting themselves on their parents’ petard.

I find now that I can no longer passively collude with the internalized parent by failing to actively notice it, as various adults typically did while he was growing up. If an adult does not protest when a child is being attacked with destructive criticism, s/he tacitly approves it. The child is forced to assume that contempt is normal and acceptable, as the witnessing adult forsakes her/his tribal responsibility to protect the child from other adults who perpetrate child abuse.

When I label the traumatizing behavior of the client’s parents as egregious, I begin the awakening of his developmentally arrested need for self-protection. I model to him that he should have been protected, and that he can now resist mimicking their abuse in his own psyche. With most of my clients, this eventually encourages disidentification from the aggressor and weakens the internalization of the attacking parent as the locus of the critic.

In my own case, I felt loved by my grandmother who lived with my family, but she failed to tell that my parents’ vitriolic rages were wrong and not my fault. In retrospect, I believe that her neglect crystallized my belief that I totally deserved their abuse. The stage was then set for me to morph their contempt into self-loathing, chapter and verse, for nearly two decades.

I have also noted that clients, who had one influential adult in their childhood who helped them to see that the destructive behavior of a toxic caregiver was wrong and not their fault, do not seem to develop such a ferocious, self-annihilating critic.

As therapists, we often have the unique opportunity to become the first person in such a client’s life to help him see how horribly and unfairly he was indoctrinated against himself when he was too young and impressionable to resist. Let me paraphrase Milton Erickson’s challenge to us all: We must remain resolute, brave and creative about repetitively confronting key deeply imbedded pathologies that do not easily resolve from our attempts to treat them.

Through the Anger Looking Glass

Posted on March 14, 2013February 11, 2026 by Psychotherapy.net Team

On this past Sunday’s broadcast of “Weekend Edition” on National Public Radio, the focus was on the 50th anniversary of Betty Freidan’s The Feminine Mystique. In this book Friedan raged against the status of women in the 1960s. Although millions of people have read this feminist manifesto, it seems very few presently understand how anger in general and Friedan’s anger in particular could be a source of insight, motivation, and personal and social transformation.

Anger is an emotional state that has a bad rap. There’s far more written about anger control than about how anger, when nurtured and examined, can transform. As most mental health professionals already know, anger is an emotion, not a behavior. And emotions are acceptable and desirable. When anger fuels aggressive or destructive behavior is when it becomes problematic.

But since everyone knows about and talks about the destructive capability of anger—let’s talk about the constructive side of this emotion instead. Hardly anyone articulates anger’s positive qualities as clearly as the feminists. Feminist therapists consider “encouraging anger expression” as a meaningful process goal in psychotherapy for at least five reasons:

Girls and women are typically discouraged from expressing anger directly. Experiencing and expressing anger without repressive cultural consequences can be an exhilarating freedom for females. Similarly, experiencing anger, but not letting it become aggression is a new and productive process for males.
Anger illuminates. There’s nothing quite like the rush of anger as a signal that something is not quite right. Examined anger can stimulate insight.
Alfred Adler suggested that the purpose of insight in psychotherapy was to enhance motivation. Anger is helpful for both identifying psychotherapy goals AND for mobilizing client motivation.
During psychotherapy anger may occur in-session towards the psychotherapist. Skillful therapists accept this anger without defensiveness and then collaboratively explore the meaning of their in-session anger.
Anger is a natural emotional response to oppression and abuse. If clients consistently suppress anger, it inhibits them from experiencing their full range of humanity.

For feminists, one goal of nurturing and exploring client anger is to facilitate feminist consciousness. Feminist consciousness involves females (and males) developing greater awareness of equality and balance in relationships. However, using anger to stimulate insight and motivation is useful in all forms of therapy, not just feminist therapy.

But working with (and not against) anger in psychotherapy is complex. The problem is that anger pulls so strongly for a behavioral response. Reactive anger is destructive. Clients want to let it out. Experiencing and expressing anger feels so intoxicatingly right. Clients want to punch walls. They want to formulate piercing insults. They want to counterattack. Unexamined anger is reactive and vengeful.

Imagine a male client. He’s uncomfortable with how his romantic partner has been treating him. You help him explore these feelings and identify the source; he recognizes that his partner has been treating him disrespectfully. But good psychotherapy doesn’t settle for simple answers. His new insight without further exploration could stimulate retaliatory impulses. Good psychotherapy stays with the process and examines aggressive outcomes. It helps clients explore alternatives. Could he be overreacting? Perhaps the anger is triggering an old wound and it’s not just the partner’s behavior that’s triggering the anger?

Relationships are nearly always a complex mix of past, present, and future impulses and transactions. When anger is respected as a signal and clients take ownership of their anger, good things can happen. It can be used to help clients become more skilled at identifying and articulating their underlying sadness, hurt, and disappointment. Clients can emerge from psychotherapy with not only new insights, but increased responsibility for their behavior and more refined skills for communicating feelings and thoughts without blaming anger, but in a way that serves as an invitation for greater intimacy and deeper partnership.

None of this would be possible without the clarifying stimulation of anger and a collaborative psychotherapist who’s able to help clients face, embrace, and understand the many layers of meaning underneath your anger. And it’s about time we learned a lesson from the feminists and started giving anger the respect it deserves.

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

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

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

Michael Lambert: Right.

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

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

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

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

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

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

We Are the 90 Percent

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

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

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

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

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

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

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

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

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

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

The Moneyball Approach to Therapy

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

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

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

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

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

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

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

But Therapy is So Complicated and Nuanced…

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

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

TR: Are you a practicing therapist yourself?

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

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

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

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

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

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

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

My Therapist Was Glad to See Me

TR: What do you use to measure the alliance?

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

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

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

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

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

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

Suicide and Substance Abuse

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

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

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

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

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

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

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

When Confidence Hinders Us

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

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

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

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

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

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

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

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

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

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

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

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

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

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

TR: Absolutely.

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

The Fact is, We're All About Average

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

I hope this is not too disappointing.

TR: How so?

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

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

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

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

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

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

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

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

ML: : It was my pleasure.

The “L” Word

Posted on January 15, 2013February 11, 2026 by Psychotherapy.net Team

Lisa hefts herself heavily up the stairs to my office. She must come up two feet to a stair, like a small child. She is breathless by the time she gets to my office and has to take a few moments to collect herself. As she settles in, I realize she has gained even more weight in the few weeks since I last saw her.

She is huge, solemn, powerful, inert. Once she is seated, nothing moves but her head and hands and her big, expressive eyes. Her pace in therapy has been glacial. I wheedle, nudge, poke, prod, shove, usually with very little effect. My anxiety stimulated by her apparent weight gain, today I shove, for all the good it does me. A boulder slammed into the earth by the gravity of her rage, she is immovable.

During the session, she makes some small, wry, self-aware and self-deprecating joke about her resistance to change. I can’t even remember what she said, but flooded with affection for her—impulse and action melded together, racing along the same neurons in tandem—I burst out with, “Oh Lisa, I love you.” I am a little shocked to hear my own voice saying the words. It is true enough, but I did not expect to say it. Had those synapses fired at any distance from each other, I would not have.
She does not look shocked. She has, in fact, a small smile. I would guess that in her half century of living she has heard these words spoken to her fewer times than I could count on one hand. I can practically hear the tectonic rumble of pack ice shifting.

I have so flustered myself that I just carry on with our conversation, ignoring my own exclamation. As we talk, I ask her a question that I have asked her many, many times. “What do you imagine would happen if you stopped bingeing?”

This time she responds differently. Her eyes widen. She looks so frightened I want to turn and look behind myself. “I can’t,” she says. “You don’t understand.”

“What don’t I understand?”

“I am just like them. I am just the same.” I know exactly what she means. She means she is like her brothers, her mother.

Looking at her, I feel as though I am both seeing and imagining a child in her bed, piled high with blankets of flesh, her big, wide eyes peering out at me from beneath her coverings. She is not fully present—her eyes are shifting rapidly back and forth. She has the terrified look on her face of someone who has received a blow and is expecting another. I have been sitting with one leg crossed under me, but I shift both my feet squarely to the floor in an unconscious effort to ground her.
“No,” I say, “you are not like them. You are afraid of being like them.”

“If I wasn’t bingeing,” she says, her eyes still flicking, one shoulder slightly hunched as if to protect herself, “I could really hurt someone. I could kill someone.” Usually, she talks about how her fatness protects her from others, but she has never before talked about how she believes it protects others from her.

I speak to her in the low, soothing voice that you would use with an injured person or a frightened child. In a few moments, I can see her breaths start to even out. Her eyes stop moving and focus back on me. She smiles shyly, almost in greeting. She has been gone, but not gone. The session moves on and before the end, she commits to what is for her a big step.

I have never said “I love you” to a client before. I do not understand what unconscious imperative drew those words out of me. It felt as if I had no choice at all. I am as easily blinded to myself as the next person, but I can think of nothing in my life or day, no need of my own, that drove me to share those words with her in that moment. If my assessment of myself is correct, what then in her impelled those words from me, and what did they mean to her? Did I frighten her into a dissociated state, given that her experience of love is so deeply intertwined with violence? Did my expression of love for her provide her with some increased security so she could reveal more about her experience of herself? Did she want to warn me what a dangerous person she is to love? I am inclined to believe all of the above are true. Clinical error or simple human caring, countertransference enactment or empathy, I believe that in the session our separate continents shifted just a little, perhaps even measurably, toward each other.

Seeing Medusa in Every Client

Posted on January 15, 2013February 11, 2026 by Psychotherapy.net Team

In Greek traditions, Medusa is the notorious stone-cold killer who was well known for turning people into statues. Her reputation became so brutal that she was often depicted as evil itself. However, like everyone who eventually comes to hurt others, Medusa had a life before she was the snake-haired statue-maker, but few seem to remember that. This is that story:

Medusa was a stunningly beautiful young woman. She was so striking, in fact, that everyone around her pursued her and longed to be her husband. Medusa had thick, gorgeous hair that men longed to see, and even be near. Suitor after suitor came and presented himself to her, transfixed by her beauty.

Medusa’s magnificence was so great that the gods themselves not only took notice of her, but also could not control their impulses to be with her. One of the gods, the ruler of the sea, Poseidon, became obsessed with Medusa. He sought her out while she was in Athena’s temple. There, in the midst of the holy place, beautiful, innocent Medusa sat praying to the goddess.

Poseidon did not attempt to hold back his urges, and sweeping in with a terrible ferocity, he raped Medusa on the altar of the temple. In an instant, he was gone. The deed was done. Medusa lay shattered on the floor of Athena’s house. “Why?” she thought. But she hardly had time to think. Athena was appalled that such a sacrilege would take place in her hallowed temple, and she swept in with almost the same speed with which Poseidon left.

Medusa, turning to the divine being with a look of desperation, did not receive the compassionate look in return for which she hoped. Instead, a fury overcame Athena. “How dare this take place in my temple!” she thought. Athena was enraged at Poseidon for defiling her sanctuary, but she could not punish a fellow immortal, so she turned with hatred and viciousness to Medusa.

Someone had to suffer for the atrocity to the goddess, and the victim was the target. With unquenchable anger, Athena blamed Medusa for her carelessness, for “enticing men,” and used her deific power to transform Medusa’s hair into snakes. As though the pain of serpent-hair were not enough to repel the sons of the world, she further cursed her in a way that ensured men would stay far away from her from that day forward. In a rage, Athena proclaimed, “He who looks on you will be turned to stone!”

And so a victim of rape, misdirected rage and hatred—and all for being nothing more than beautiful—Medusa, came to be known as she is today: the face of evil itself. The wrath and disgust for others that Medusa became known for were taught to her by the very figures she trusted.

There is no violent offender, no person who hurts another, and no villain in this world who does not have a story of how and why she or he came to be. We must learn to see Medusa. We must learn to see beyond the snakes and the curse that holds others at bay, and look into her deep, tragic history to get a fuller understanding of who she is… and we must also and equally do that with every client we encounter.

As therapists, we need to consistently evaluate our own personal judgments of others—not just in lip service, but in actual, in-depth explorations of who we are, and why we might hold the judgments that we do. Medusa had reasons for hurting others as she did, and so does everyone else. Our job as therapists is to assess, understand, and explain human behavior, without judgment or bias. The more we know about the past (others’ and our own), the more feasible that task becomes.

If we do not learn to see Medusa, we run the risk of remaining transfixed in our own sculptured, static mind-set: a place from which we will forever stand as judge, jury, and executioners in our own minds.

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