Suicidality Archives - Psychotherapy.net

Practicing Philosophy on the Frontlines of Suicide Prevention

Posted on December 3, 2025February 25, 2026 by rezendevknowfully.com

Philosophy begins in wonder. And, at the end, when philosophic thought has done its best, the wonder remains.
— Alfred North Whitehead

From as early as I can remember, I was haunted by questions others found inconvenient: why does anything exist at all, what does it mean to be free, why do we suffer? I wasn’t trying to be difficult. I was just wired for inquiry, a child tugging at the loose threads of meaning, compelled to see what might unravel.

Long before I read Socrates, I was unknowingly walking his path: questioning what others accepted, resisting the comfort of simple answers, and learning to live in the company of uncertainty.

Philosophy didn’t save me. It found me.

In college, I wasn’t pursuing a career path. I was chasing something I couldn’t yet name—a kind of metaphysical resonance. Philosophy gave me a language for that longing. But what began as an intellectual exercise eventually evolved into something else: a practice. A kind of internal activism. A spiritual discipline rooted in presence, curiosity, and the courage to stay with the unresolvable.

Today, I work as a 988 Suicide & Crisis Lifeline counselor, and it’s here, more than anywhere else, that my philosophical training feels most alive.

Sitting with the Void

Since its rollout in 2022, the 988 Lifeline has radically reshaped how we respond to mental health crises in the United States. With phone, text, and chat options, people in acute distress now have access to real-time support 24/7. It’s a public health victory, but on the ground, it’s something more intimate: a space where people can speak the unspeakable.

As a counselor, I don’t pathologize in these moments. I listen. I co-regulate. I hold. I stay.

It strikes me often how deeply philosophical this work is. Each call is a miniature encounter with what Martin Heidegger called Being-toward-death—the raw awareness of our own impermanence, vulnerability, and aloneness. But in that awareness, something else emerges: the possibility of connection.

When someone in crisis reaches out, they’re not always asking to be “fixed.” Often, they just want someone to witness their pain without flinching. To reflect it back without trying to erase it. That’s not just counseling. It’s the praxis of phenomenology. It’s existential accompaniment.

Myth-Busting as Moral Work

Many of us in the field are familiar with the myths surrounding suicide, but part of our task, especially those of us working outside traditional therapy offices, is to actively dismantle them:

“Suicide is selfish.” This myth misunderstands the psyche in pain. Most callers believe their death would be a relief to others.
“Talking about suicide encourages it.” We know the opposite is true: silence kills. Dialogue saves.
“Only the mentally ill die by suicide.” Suicide is a crisis of meaning as much as a crisis of mind. It stems from loss, trauma, disconnection, and despair, all deeply human experiences.
“Once suicidal, always suicidal.” Suicidal ideation is often transient. With connection and care, people do recover.

To engage with these misconceptions isn’t just educational. It’s ethical. Every time I resist reductive narratives, I expand the space for people to see themselves differently. To imagine a future again.

Philosophy in a Clinical World

In my early years, I often felt that philosophical inquiry was dismissed as irrelevant to real-world problems. People would ask, “But what can you do with it?”

Working in suicide prevention has given me an answer: you can show up to suffering without needing to control it. You can name the void without trying to fill it. You can ask better questions when answers fail.

I don’t carry diagnostic manuals into a crisis conversation. I carry silence. I carry questions like:

“What’s keeping you here, even now?”
“What would it mean to stay for just one more day?”
“What part of you wants to be heard right now?”

These aren’t philosophical riddles. They’re lifelines.

One of the most humbling aspects of this work is realizing how often people just need permission––permission to grieve, to rage, to doubt, to feel lost. Not every call ends in resolution. Some end in quiet. Some end in tears. Some end with nothing more than a single breath that wasn’t taken before.

And that’s enough.

Philosophy asks us to live with paradox. Psychotherapy invites us to do the same. The intersection, I believe, is where some of the most sacred work happens between presence and uncertainty, holding on and letting go.

As therapists, social workers, peer supporters, and crisis responders, we are often taught to do. But what I’ve learned from both philosophy, and the hotline, is that our greatest power lies in our capacity to be, to sit still inside someone’s unraveling and trust that staying is in itself a form of intervention.

A Final Note

In a time when anti-intellectualism is rising, when nuance is collapsed into binary thinking, and when complexity is mistaken for elitism, practicing philosophy—practicing psychotherapy—is a quiet act of rebellion. It resists the machinery of numbness. It says: We are not here to obey. We are here to awaken.

If you or someone you know is struggling, the 988 Suicide & Crisis Lifeline is free, confidential, and available 24/7 via phone, text, or chat.

And if you’re a clinician on the verge of burnout, compassion fatigue, or existential dread, you’re not alone either. This work changes us. Let it.

The Disconnection of Depression: How to Restore Attachment Using Cognitive Interventions

Posted on April 30, 2024March 3, 2026 by Psychotherapy.net Team

“Despair is an ultimate or ‘boundary-line’ situation. One cannot go beyond it.” – Paul Tillich

“I don’t want to be a burden,” she told me. It’s a phrase that I’d heard many times, and it often came from my aging or depressed clients. Her words came from a selfless place. She didn’t want to hurt others with her pain. She didn’t notice that withholding her suffering meant she was introducing disconnection within her relationships. Or maybe she did. As she pulled away from the people in her life, her silent march towards death’s absolute disconnection had begun. It was an incremental, self-inflicted dying.

In the last entry, I shared how clients can experience the moral dimension of suicide. It’s important for me to notice when my clients feel like a burden, because suicide can appear like a strategy to protect others from themselves. In this context, I wanted to explore what my clients have taught me about how to avoid this trap, and how they were able to eventually reconnect to those they desired to protect.

Blended Truths: A Cognitive Intervention

When my clients have talked with me about being a burden, they usually point to a mountain of supporting evidence. They tell me they’re no longer able to work, that their spouse is earning the only income, and the kids are visibly confused. To make matters worse, they aren’t helping around the house. They tried to vacuum, but “the chord got tangled.” Then they tried to cook dinner, but they became “overwhelmed by the existential absurdity of shredding carrots.” So, back to bed they go. In their absence, their loved ones are suddenly forced to do it all, and they’re sure it’s their fault.

When clients present this way, I try to help by asking them to reconsider this belief. At first glance, the conviction that they’re a burden appears to have some merit. The people in their life are struggling to compensate for the consequences of their depression. That’s usually true. But one of the hidden mechanisms found within depressed thinking is the presence of blended truths.

Blended truths are thoughts that contain some amount of truth, but they also contain some amount of falsehood. Facts and fiction co-mingle. The problem with these blended truths is because they hold some amount of merit, they initially seem persuasive. Unable to argue with the apparent validities, clients are simultaneously baited into swallowing their inconspicuous falsehoods. The good goes down with the bad. Blended truths operate like a worm-hidden hook — or an Almond Joy.

But it’s true that their loved ones are affected by their depression. That’s the first part of the blended truth that’s factual. This is an unavoidable part of being a social animal, and it’s the cost of admission when we’re meaningfully connected to each other. But I’ve noticed that my clients believe something more than this. If they simply believed their loved ones were having trouble, this would create feelings of worry, but it wouldn’t create feelings of guilt. So where does the guilt come from? It comes from the second part of the blended truth. It comes from the belief that it’s their fault. This is the hidden falsehood within the blended truth. It’s the sharp hook. Or the chalky almond. This is where I try to help clients address their sense of burdenhood, and if I’m having a good day, it might sound something like this:

Therapist: You mentioned feeling like a burden, can you tell me more about that?

Client: Well, everyone is working to pick up my slack. My wife is exhausted. She’s working and doing the parenting while I watch reruns and avoid phone calls. I hate what I’m doing, but I can’t seem to get myself right.

Therapist: You hate that your family is affected by the depression. I mean, how could you not? It sounds like everybody is really struggling. I’m sorry to hear things have been so difficult.

My first step to untangle a blended truth is to validate the part that’s true. In the past I tried to reassure my clients that their loved ones couldn’t be struggling too badly. That was a mistake. It was a mistake because my clients knew I didn’t know their loved one’s experience, and when I feigned that I could, this made me less credible. My false consolations had led to lost credibility, and my lost credibility led to damaged rapport. What was intended to be a supportive sentiment, ended in a damaged therapeutic relationship. But despite the punishing grind and slothful speed that is my learning curve, I eventually learned that if I could acknowledge the part of my client’s blended truth that was true, I could earn credibility and tighten our rapport. Then with the relationship standing on firmer ground, I could initiate the second step of addressing these blended truths. I could invalidate the part that’s false:

Client: Yeah, so that’s what I mean by being a burden.

Therapist: I gotcha. Would you mind if I picked a friendly fight?

Client: Go for it.

Therapist: So, I don’t doubt that your family is struggling. That sounds undeniable. You make a difference in your family, and so your absence is going to be felt by them. But I’m not sure considering yourself a burden is completely fair.

Client: Well, it’s my fault that they’re struggling and so that’s what I mean by being a burden.

Therapist: Hm, that’s hard. Would you mind if I keep pushing?

Client: Fine.

Therapist: I think worrying about your family makes sense because it sounds like they’re having a hard time. There’s no getting around that. But the second part of what you’re saying — that it’s your fault – this sounds to me like it could be depression talking. So, with the risk of sounding obtuse, let me ask you directly. Are you choosing to be depressed?

Client: What? No, I’m not.

Therapist: Of course not. If you were choosing to be depressed, you could simply choose not to be. But that’s not exactly the nature of what we’re dealing with, is it?

There are a couple things I try to make happen in these moments. The first is I ask to pick a friendly fight. If I can characterize the impending disagreement as friendly, I can emphasize that challenging my client will occur between the cushions of our existing rapport. If I can get their permission to proceed, I can then introduce the idea that part of their thinking might be depression-inspired (“this sounds to me like it could be the depression talking”). This invites the client to depersonalize their thinking about being at fault, and if they can separate their authentic thoughts from the depressed ones, this can make challenging their depressed thinking more realistic. In whatever form it takes, “Is this really you, or is this the depression?” is a question I can’t do without.

This second step of invalidating what’s false is concluded by plainly asking the client if they’re choosing to be depressed. This is a ridiculous question. It’s like asking, “How many inches is the temperature outside?” But the ridiculousness is the point. This makes the implicit falsehood within the blended truth explicit, and it invites the client to sign on depression’s dotted line. When the falsehood within the blended truth is no longer hidden, my clients have a better chance to avoid digesting it.

Divide By Two: A Behavioral Intervention

Untangling blended truths is one way to explore the mental dimensions of the depression, but in some cases, I’ve found that the cognitive strategies don’t work. Sometimes my clients are overcome by their despair, and they lose any interest in thinking abstractly. In these cases, I think it’s better to start with the behavioral interventions.

I’ve found it can be useful to begin by identifying the behavior that’s connected to the client’s belief that they’re a burden. I’ll call this burden-behavior. Burden-behavior seems to present similarly across differing cases. Clients withdraw from their life in order to protect their loved ones from themselves. They hide out in bedrooms, run the fans on high, and bundle themselves in blankets. The judgmental Netflix algorithm keeps prompting them, “Are you still watching?” (What does it take to get some unconditional-positive-regard algorithms around here?)

But as each day passes, life becomes more difficult to reenter. When these determined clients make the choice to re-enter their lives, they quickly run into problems. They plan to go for a walk, but the front door appears miles away. They schedule time to meet with friends, but they immediately find reasons to cancel. As quickly as plans are made, they’re unmade, and their return to isolation occurs. Reentering life feels more like mountain climbing, and each attempt upward is followed by a slide back to the bottom.

In these situations, I try to show my clients that their plans are divisible. When they determine their plans are too difficult, instead of returning to the bedroom, they can learn to divide their plans. My aim is to interrupt the status quo of complete inactivity and to encourage them to find the outer rim of what they can handle. Then eventually, they can widen the circumference of their experience. To provide a sense of how this can work, and to show how much division can be done, here’s an example of how Divide by Two can sound:

Client: So, I tried to go for a walk around the neighborhood, but honestly my body just felt incredibly heavy, and I stayed home.

Therapist: That’s sound really uncomfortable. What did you do, instead?

Client: I just stayed in bed. I’ve been watching reruns of Cupcake Wars.

Therapist: Cupcake Wars? Yeesh. Things are worse than I thought.

Client: Tell me about it.

Therapist: On a serious note, it’s really difficult to feel cemented the way you do. Would you be open to a suggestion that might not apply?

Client: Sure.

Therapist: In these situations, I often suggest dividing by two. Here’s what I mean. If you plan to take a walk, but it becomes too difficult — divide by two — try going to the mailbox. This way you won’t find yourself trapped behind your bedroom door, beating yourself up for the plans you didn’t implement.

Client: This is going to sound pathetic, but the mailbox feels pretty far away, too.

Therapist: I bet it does. I’m glad you said that. The useful thing about this technique is that it’s flexible. You can always divide by two again. If the mailbox is too far away, determine if you can make it to the living room. If that’s too far, divide by two again, discover if you can make it to the nearest bathroom.

Client: If the bathroom is too far?

Therapist: It might be. Depression can be that way sometimes. But the trick is to do more division. Determine if you can put your feet next to your bed. If that’s too much, you guessed it — divide by two — practice a progressive muscle relaxation exercise while in bed. Too much? Start thinking about what it might be like to practice progressive muscle relaxation. The idea is to divide your plans until you find the outer range of what you can handle. Anyway, I’m sorry for preaching. Tell me about where this might not fit your situation.

With this behavioral intervention, I can invite my client to consider how to reenter their life after forfeiting their plans, and this can prevent them from sliding back to the base of the mountain. Instead of returning to complete inactivity, they can ask themselves what half-measures they can handle, and this can boomerang them back to the outer edge of engagement in their life.

The Five G’s: An Affective Intervention

Exploring the cognitive and behavioral parts of my client’s experience of being a burden is important, but so is discussing their emotional experience. This means exploring the emotion of guilt. Guilt has always carried a negative connotation for me. It makes me think about childhood religious guilt or being prompted to donate to sick puppies at the grocery store register. No thanks. Those puppies had it coming. I’m too familiar with the internal wincing that’s created by guilt. It’s an emotion that pinches the heart.

But my clients have taught me how to help them with their guilt. And in order to explore guilt’s excesses, I had to learn about its purposes. There’s a version of guilt that’s deeply important to wellbeing, and once I understood this, guilt’s surpluses became clear. What I learned is that guilt is an emotion that requires training. It’s an unbroken colt teeming with raw force. Nature doesn’t provide guilt with a safe level of calibration.

Without the right technique, it’s dangerous to the rider. This is the reason my perspective on guilt had previously been negative. I experienced guilt’s force, and it led to injury. The only colt that I had ever known had bucked me to the ground, and from the dirt I cussed and condemned it. I didn’t know it needed to be trained. I didn’t understand that before guilt could teach me anything, it needed to be taught by me. More on this in a moment.

I also used to think that guilt was an emotion that was only relevant to my past behavior. When I behaved in ways that were misaligned with my values, my guilt pain came after. Then I’d get stuck there. I’ve since come to understand that this fixation with the past is characteristic of untrained guilt. It can lead to injury. But when guilt is well-trained, it’s not only an emotion related to past regret, but it protects me from future regret, too.

The purpose of guilt isn’t to create suffering for the mistakes I made yesterday, but to prevent more suffering in my tomorrows. This guilt might take a moment to evaluate my mistakes in the past, but its additional purpose is to create fulfillment in the future. It seems that when guilt is well-trained, it’s equal parts retrospective and prospective.

This also seemed true with my clients. When my clients held unbroken eye contact with their past, they lost the ability to move forward. Focusing on their mistakes this way could lead to self-hatred, and this self-hatred would foment the conviction that others must be protected from themselves. When the retrospective was dominant and the prospective was absent, these clients would become convinced they were a force for harm in the world. But in order to join them in these difficult moments, I will try to introduce the 5 G’s. With it bit of luck, it can sound something like this:

Client: I don’t know, I’m just the worst.

Therapist: That seems harsh, and only one of us has that opinion of you, but what brings that forward?

Client: Same stuff. I just feel awful that I can’t get back to work. I tried to contact HR to figure out the process, but I started crying while I was drafting the email. My wife deserves better.

Therapist: It sounds like there’s a lot of guilt going on in there.

Client: Yeah, and I deserve it.

Therapist: Can we explore this guilt a little more? I have a few ideas.

Clients: That’s fine.

Therapist: I don’t believe guilt is harmful in every case, but in this one, I’m not so sure. Can I share a strategy to help you determine whether your guilt is useful or not?

Client: Go for it.

Therapist: So, I think we can assess guilt by using the 5 G’s. This stands for Good Guilt Gives Good Guidance. Yes, the alliteration is excessive but here’s what it means. When guilt teaches us something about how to succeed in the future, then I think it can be helpful. But when guilt doesn’t provide guidance, or if the guidance that it provides isn’t particularly wise, then the guilt is working in service to the depression. It creates an emotional environment where the depression can make itself more comfortable. But tell me what I might be overlooking.

Client: Well, I hate myself for being stuck, but my guilt is also telling me to go back to work. How is that not good guidance?

Therapist: Right. I think you’re close to identifying what your guilt is saying, but I think you might be missing two words. Tell me where this doesn’t fit, but is it possible your guilt is telling you to return to work right now?

Client: Okay, right.

Therapist: I’m wondering if you think that’s good guidance. What do you imagine would happen if you returned to work after lunch today?

Client: It would be a nightmare.

Therapist: We can probably agree it wouldn’t go so well. So, how might we update this guidance to make it more useful to you?

Client: I don’t know. Maybe I should tell myself to return to work eventually? But that doesn’t feel urgent enough.

Therapist: Hm. I can see how that might feel too open-ended. Can I submit a rough draft for your editing?

Client: Go for it.

Therapist: What about something like, “Do everything that’s possible to feel better today, because this will get me back to work as quickly as possible.” But take out your red pen, where should we make edits?”

This framework can help me to extract the wisdom within my client’s guilt. If I can ask them to evaluate their guilt along the lines of its guidance, this can nudge them away from looking backward and towards looking ahead. The client can travel towards their feeling of guilt, but for the purpose of returning with a new direction. This can bring the retrospective to the prospective, the colt to its bridle, and the feeling of guilt to its belated resolution. Once it’s well-trained, their guilt is a guide.

***

Working with clients who consider themselves a burden has been rewarding work. These clients have taught me that when they unravel their Blended Truths, Divide-by-Two, and implement the 5 G’s, they can release themselves from this conviction. Once their sense of being a burden is broken apart, disconnection from others can be incrementally reduced, and attachment to those they wanted to protect can occur once again.

[Editor’s Note: In the next and final installment in this five-part series, the author will address the challenges of balancing empathy and burnout]

Challenging a Beloved Therapist: A Catalyst to Growth

Posted on March 5, 2024February 11, 2026 by Psychotherapy.net Team

A Break in Need of Repair

“I’ll wear a mask, unless you take a COVID test!” This was the message that I emailed Jeffery, my therapist of 29 years. It was a few days after he returned from a vacation that entailed a long airplane flight. My appointment was the following day.

“Wear a mask,” came Jeffery’s reply. He said he didn’t want to “stick something up my nose,” and was sure he didn’t have COVID because he was masked the entire flight.

I was startled. His annoyed tone was out of character. I was also surprised to find I wasn’t devastated. In the early years of our work together, I’d been 100% emotionally dependent on him, a child beneath my grownup facade, and the thought that he might be annoyed would have been the end of my world. Now, I knew this was a temporary disconnect, one that could be repaired if we discussed it.

“Let’s do a phone session,” I emailed back. I was at risk for lung infections because of a health condition. Also, I would feel more secure on my own turf if the discussion proved difficult.

When we Facetimed, I saw that Jeffery was home, not in his office. Though dressed in his usual button-down shirt, he was stuffy and hoarse and looked as if he should have been in bed. But he was back to his usual cordial stance.

“Do you have COVID?” I asked.

“Just a cold. I don’t have any fever.”

By then it was common knowledge that fever wasn’t the gold standard for making a COVID diagnosis. I didn’t pursue the repair. He obviously wasn’t ready. I was glad to see him — he’d been away six weeks — but the session was superficial, not emotionally satisfying.

Before our next appointment, Jeffery texted that we should do another phone session, because he had COVID. Again, I was surprised at myself, this time for not wanting to say, “I told you so.” I understood that he could be wonderful 98% of the time and not wonderful 2% of the time.

When we spoke, I tried again for the repair, explaining that I was afraid of getting sick. He said he thought I was telling him what to do, but once he understood why, he was OK with it.

I saw that Jeffery was trying to be conciliatory, but it didn’t make sense. He’d known for a long time that I was afraid of getting sick, in part because I dreaded needing someone to care for me. We had been working on that in sessions. Also, he had never before gotten annoyed when I told him what would make me feel safe, even if he chose not to comply. Most likely, my COVID test request had triggered something in him that had nothing to do with me.

I grew up in a home that didn’t model the best way to resolve conflict. If my father was displeased at something my brother or I did, he flew into a rage that involved prolonged and intense yelling, often accompanied by physical punishment. If he was displeased with something my mother did or opinions she had, he just yelled. She would answer softly, almost meekly, then later do as she pleased. If he found out, there would be more yelling. Early on, I learned not to rock the boat, a skill that traveled with me to adulthood. I was afraid that people would stop liking me if they became annoyed or angry, so I did everything I could to keep the peace. Now I was stymied.

It was rare that Jeffery let his own issues interfere with our work. In 29 years, that had happened only four other times, the last more than a decade earlier. This was by far the least consequential, but it was the first since I felt like a grownup through and through. I knew that before a meaningful discussion could begin, I would have to wait until he was ready to acknowledge what happened. If this was anything like the other times, that could take months. In the past, I would have discarded the 98% while I waited, just because I wasn’t happy with the 2%. It was a testament to our work together that I didn’t do that now. But gray was a lot harder to navigate than all black or all white.

Healing through Empathic Attunement

At 51, when I began seeing Jeffery, I had already spent 35 years in the mental health system. I’d been hospitalized three times with a misdiagnosis of schizophrenia, lived in a halfway house for a year, and had seen six therapists, each for several years. Though high-functioning at two jobs — weekdays as an I.T. systems analyst, weekends as a librarian — inside I was in emotional pain so great it felt like organ failure.

Relief came only through escape to an imaginary world I called the Atmosphere, where kindly invisible people, more emotionally reliable than real people, understood all my feelings and thoughts. That, and the knowledge that I always had an out: I could kill myself. The one place in the non-Atmosphere world where I was relatively comfortable was at work. I worked seven days a week — to stay alive and to pay for therapy.

Five years earlier, at 46, I learned I had what was then called multiple personality disorder (MPD) and has since been renamed dissociative identity disorder (DID). I was shocked that such a sensational-sounding diagnosis could apply to me. At the same time, I was relieved to finally have a plausible explanation for so much of my past: feeling not real, watching myself from outside myself, talking to faces in the mirror who were not me, functioning on a high level at work yet feeling psychotic outside of work. The diagnosis let me know I was not an alien species. I had a condition documented in clinical literature, said to have been caused by ongoing childhood trauma. That part fit, too.

It was one thing to have a diagnosis, another to find a clinician skilled in treating multiplicity. It would be another five years before I found Jeffery, recommended by a member of the dissociative disorders support group I had begun attending.

Jeffery soon realized that the Atmosphere, which was more real to me than the real world, had developed in response to early attachment trauma. The Atmosphere had been helpful when I was a child, providing the emotional connection I wasn’t getting from my parents, but when I became an adult, it got in the way of my having meaningful relationships with real people. Jeffery believed the Atmosphere had to be dismantled before healing of the multiplicity could take place. His theory, unbeknownst to me until years later, was that I needed to have an Atmosphere-like experience — perfect and unbroken attunement — with a real person: himself. I would then transfer my attachment from the Atmosphere to him, and eventually to other real people.

Over many years, with infinite patience and kindness, Jeffery saw me through the stages babies and toddlers go through when attaching to their caregivers. I may have been in an adult body, but parts of me who were very young still had to learn things as basic as object constancy — that people and things exist even when you can’t see them. Jeffery understood that to my magical way of thinking, I had two versions of him. In-person Jeffery waved goodbye to me at the end of each session, then froze, hand in the air, and stayed that way until I returned. The moment I walked out of his office, Atmosphere Jeffery materialized and remained with me 24/7, knowing everything I thought and felt and did until the start of my next session when in-person Jeffery would be right where I had left him.

In that way, he was with me continuously. Whenever something happened to let me know this was not so (his socks were another color, or he’d gotten a haircut, or worse, I saw the patient before me leave), I would berate him for his betrayal and call him a “deceiter.” He would explain that he hadn’t abandoned me, that I was always in his heart, even if he wasn’t physically with me. His words would soothe me — until the next time.

What went on in any given session depended on which of my parts was “out” (present). There was a sliver of me who was grownup, in particular an administrative part I called AlmostVivian. She kept me functioning in the world but had no depth. The more three-dimensional, feeling parts of me were largely children. These “littles,” who were causing most of the chaos and pain inside me, saw that Jeffery was a safe person, and they gradually began revealing themselves to him. Sometimes the only way I could communicate was by talking in nonsense syllables or writing backward on a piece of paper he had to hold up to the light to read. Other times, a feeling was too big to fit inside me, and I screamed, or hid behind a chair, or wordlessly locked eyes with him in an attempt to connect. And sometimes, ashamed to be visible, I could talk only in the dark, so he turned out the light.

At the start of a session, Jeffery would wait to see where I chose to sit. If it was a chair, he sat in a chair, too. If it was the floor, he would sit on the floor with me. If I was unable to talk, he and I might draw a picture together, taking turns adding a squiggle or something representational, like an eye or a bird. Sometimes we passed a computer back and forth, typing to each other in conversation. I likened our sessions to emotional surgery, where Jeffery dug deep but never more than I let him know I could tolerate. We would both make sure to leave enough time at the end to sew me up, so I could go out into the world and live my life until our next session. The sewing-up routine came to include having toast together, my ultimate comfort food. As we ate, chatting about seemingly mundane things, I would slip in something about my itinerary. “Before I go to work tomorrow, I have to take my mother to the dentist.” Atmosphere-Jeffery always knew where I was. I needed in-person Jeffery to know, too.

There were many bumps along the way, but the more I got from Jeffery what I had previously gotten only from the Atmosphere — feeling seen, acknowledged, understood, and cared about — the more I began connecting on a deeper level with outside people. My cubicle-mate at my I.T. job said, “You seem different lately. More sparkly.” My sister-in-law said, “It’s much easier to talk to you now. You’re more connected.” In my writing workshop, instead of hurrying out as soon as class was over, I began lingering to chat.

It took years, but I finally did “lose” the Atmosphere, and with it, the Atmosphere version of Jeffery. Concurrently, my internal parts were becoming more conscious of one another. While these developments were ultimately positive, adjusting to a new mental map of who I was and how I related to other people was not easy. For a few years, I felt lost from Jeffery, even when he was sitting across from me. A children’s book, Farfallina and Marcel, helped. I kept a copy in Jeffery’s office, and we often closed the session by reading it together. It’s the story of the friendship between a caterpillar and a gosling. One day, the caterpillar says she doesn’t feel well and climbs a tree. The gosling waits below, but the caterpillar doesn’t come down. A long time later, when the gosling has become a goose, he meets a butterfly. As they talk, they find out they each feel bad because they each lost a friend. A while after that, they realize they are the friends they thought they had lost. They look different, but they’re still the same inside.

Confrontation Revelation, and Repair

Jeffery had been my sherpa through decades of monumental changes that literally gave me back my life. Now we were having a tiff about something as trivial as a COVID test. At least I thought we were. From his point of view, the air had been cleared as soon as he understood I was simply telling him what would make me feel safe. I loved this man and wanted everything to be OK between us, so I did my best to ignore the elephant and go on as we had before. But six months later, when he was scheduled to take another trip — brief, but it involved a long flight — the elephant was still there.

“I don’t suppose you want to take a test when you get back, so let’s plan on a phone session,” I said, hoping to start a discussion.

“It’s not going to happen,” he said, smiling as if at a shared joke.

I smiled back, but inside I felt a great loss. The one person who had completely seen and understood me no longer did.

When Jeffery returned, I decided to confront him. I told him again that saying he didn’t want to stick something up his nose had been hostile. He could have just said he wasn’t comfortable taking a test. I repeated that this issue had more to do with him than me. He said he saw it differently. He had always shielded me from things that annoyed him. Now he was allowing himself to be more spontaneous. Then he clarified. During a session, he always saw my point of view, but outside of a session, he felt freer to let his annoyance show.

This initiated a new worry. How many other things had I done over the years that annoyed him? I asked for a list. All he could think of was something from two decades earlier, during the period when I could talk only in the dark. If my session was in the daytime, he had to hang blackout curtains, then take them down when I left.

In our next meeting, I realized it was up to me to get the discussion back on track. I told Jeffery I had been caught in his forcefield, so I’d gone along with his explanations, but they didn’t make sense. His response: “Just because I disagree with you, that’s a forcefield?” This, too, was out of character. I said I didn’t want to know exactly what sticking something up his nose meant to him. I just wanted him to know that whatever it was had more to do with him than me.

There was silence for several long minutes, during which Jeffery’s eyes went up diagonally, the way they did when he was thinking through a complicated issue. At last, he looked at me and said humbly, “You’re right. There is something. I didn’t know it until now. Thank you.”

This was huge, but I didn’t stop. I brought up what he said about being annoyed outside of a session but not during a session. I told him that was hard to deal with. I needed to know he was a consistent person. Jeffery agreed he shouldn’t have said that. “It was mean and not true. I was just rationalizing my behavior.” That might be, I said, but it still hurt. He nodded his acknowledgment, holding my eyes.

We talked about it for a few weeks. I told Jeffery he was so near perfect that it was hard to know when it was legitimate to call him on something, especially when he kept insisting on his point of view. He admitted he didn’t like to think he had faults as a therapist, so he didn’t see when his own issues got in the way. Then he told me a little about his childhood, no details, but enough to let me know that what occurred between us most assuredly had nothing to do with me. I felt a surge of gratitude to him for his honesty. This couldn’t have been easy. But the elephant was gone.

Incremental Progress, Monumental Change

At first, I was just glad to have my therapist back. But within months I found myself acting differently outside the therapy room. I had always been surface-friendly with everyone, easy to be around. I rarely became involved in deep discussions because I rarely had strong opinions. Whenever I did have one, if it was contrary to someone else’s point of view, I soon came to feel the other person was right. Now I was finding myself less inclined to remain safely on the sidelines, more willing to take cautious risks and become involved.

Shortly after the air cleared between Jeffery and me, I was asked to become co-chair of an organization I belonged to. While I liked the group and its mission, the thought of having to run meetings where there were sometimes opposing viewpoints — and hurt feelings — was daunting. I declined, explaining my reluctance to the person trying to recruit me. “But you’re so good at handling that kind of thing,” she said. I knew I was, but it was a skill that came with a toll. I was constantly vigilant in my interactions, never fully relaxed. Still, when she continued trying to convince me, I was flattered. She was someone I respected. After a month, during which I thought long and hard, I accepted, having decided it would be good for me to step out of my comfort zone.

Of all the changes I went through since the start of my therapy with Jeffery, none had announced itself with an ah-ha! moment worthy of documenting in a progress note. Change was so incremental, like the slow movement of tectonic plates, that I never noticed it until a seemingly minor incident, like the COVID-test brouhaha, let me see how far I had come.

It has been said that in psychotherapy, in addition to whatever expertise the therapist has or what their approach is, it’s the relationship that heals. Jeffery was a safe person for me to challenge, and I had become strong enough to trust my instinct that something about his protestations didn’t ring true. While he didn’t agree with me at first, he didn’t try to crush me but allowed a discussion. I saw that we both wanted to reconcile and were negotiating in good faith. Ultimately, the fact that he was big enough to step back and take an honest look at himself, despite his discomfiture, was healing for me.

In my new role as co-chair, I have already been challenged by several disagreements. Each time, I’m initially sorry I accepted the post, but after the issue is resolved, I feel good. When I was on the sidelines, I never took a stand or tried to shape an outcome for fear of upsetting someone. Being involved is more difficult, but also more gratifying. It’s as if I had been snacking before and have only now sat down to a satisfying meal.

At 81, I am still becoming.

Suicidal Debates with Clients in Psychotherapy

Posted on January 24, 2024February 11, 2026 by Psychotherapy.net Team

When I started working as a therapist, the prospect of a client dying from suicide terrified me. I worried I would miss the warning signs, and that my negligence would have deadly consequences. There was a dangerous side of therapy, and I worried that eventually, there would be no avoiding it.

I still remain cautious, but I’m no longer terrified. I’m cautious because tragic events in my own practice have confirmed that the dangers in therapy are quite real. Yet I’m no longer terrified because I’ve learned how to think about suicide and depression more carefully. I’ve learned there are deaths that I won’t have the ability to prevent, but there’s still much I can do to help. I still believe that in most cases, therapy can interrupt clients as they shuffle down the path of despair, and it can turn them back towards the community of the living.

Separating Depression from Sadness

My early concern around suicide came from the difficulty of thinking clearly about depression. The word “depressed” means different things across different contexts. It’s like the word “drugs.” Am I using drugs each time I go through a Starbucks drive-thru? Caffeine is a drug, so by one definition, I’m a daily drug user. A real bad boy. Leather jacket. Fingerless gloves. However, there’s an obvious difference between hot bean water and heroine, even though the word “drugs” can be used to accurately describe them both. When I think of paraphernalia, 20-oz cups and green stirring sticks don’t usually come to mind.

I think the word “depression” is also overly broad in a similar way. Before I was a therapist, I would use the word “depressing” to describe a sad mood, events in the news, or microwaving hotdogs for dinner. I no longer use the word depression in this way. Instead, I try to limit myself to when I’m describing a major depressive disorder. The reason I work to limit my use of the word is because depression, in its clinical form, increases the risk of suicide dramatically, and so I think it’s important to avoid the blurring of language. In matters of life and death, clarity is vital. Forcing myself into this distinction also helped me learn about five significant differences between depression and sadness in my therapy. My clients taught me their five depressing truths about depression.

Five Depressing Truths

When I first met clients who had traveled to the outer frontier of depressed states, I noticed that while despair could be their primary mood state, this wasn’t always the case. For some, it was an absence of feeling that they experienced. The client didn’t always tell me “I’m extremely sad,” but instead they sometimes they said, “I feel nothing — and I don’t know where I went.” Depression could present with a numbness, or more precisely, my clients were experiencing the first of their five truths; self-missingness. Their inner selves had left them behind, and what remained was an empty waiting room. This was one of the first differences that I noticed between depression and sadness.

I also noticed that depression could create sleeping problems, difficulty with focusing, low energy, and a guilt that bent towards exaggeration. This guilt condemned my clients to wrongdoings they hadn’t committed. They felt guilty about being depressed, and when they had moments of reprieve, they felt guilty about that, too. My client’s minds would become kangaroo courts, and they would find themselves guilty on every trumped-up charge they could conjure. But in its most exaggerated form, this guilt could convince my clients they were harming others by committing the crime of simply being alive. More on this a little later. But this guilt, along with the collection of other symptoms, taught me another distinction between depression and sadness. While sadness is the description of a single mood state, depression includes a constellation of interconnected symptoms. In other words — and here is the second truth for my depressed clients — sadness is singular, but depression is plural.

The absence of identifiable causes was a third truth, or dynamic, that my clients taught me. While stressors could certainly inaugurate depressive episodes, depressive episodes didn’t need external events to bring them about. Depression simply didn’t care about how well my clients were doing. Depression would invite itself into their life without notice, track mud into their house, and climb into their bed with its shoes on. In fact, many of my clients would tell me that they were on vacation when they first noticed that something wasn’t right. From their wicker chair, they watched the sun flicker on the water, listened to the waves — and felt absolutely devastated. It was the very contrast of the internal and external landscapes that brought them to realize that something was significantly wrong. These clients showed me this third truth about depression: it can darken the internal world, without identifiable darkness in the external one.

A fourth difference between sadness and depression that I learned from my clients was that sadness is an expression of the authentic personality, but depression is a departure from it. When depression eventually loosened its grip, my clients often expressed how unrecognizable their former self appeared to them. Depression seemed to operate like a spell. It would capture their emotional state and pull them into a shadowed place, and when this spell would loosen its hold, a return to their authentic personality would occur.

The final difference my clients taught me, and I think it’s the most important, is that depression can be quite dangerous, but sadness is not necessarily so. Far from being dangerous, I think sadness is a vital feeling. Sadness is how my clients felt when something important had been lost. Whether they lost a relationship, a home, or a career — sadness was the pain of absence. And as much as it hurt for my clients to feel it, this pain of absence was deeply important. It was important because when saddened, what mattered most to my clients was revealed. The pain of absence taught them what needed to be present in their lives. It was in the same moments they learned which losses they couldn’t bear, that they also learned what must be restored. To return wholeness to their lives, sadness told my clients which way to walk.

But depression didn’t work this way. When my depressed clients looked inward, their inner state offered them no wisdom, but only suffering’s dead eyes stared back. This amount of suffering was unsafe. It was unsafe because this type of pain is simultaneously extreme and pointless. Clients can endure extreme psychological pain if they have a good reason, but depression provides no such reason. It seems that depression is a pain without purpose.

So, these five differences between depression and sadness left me with a more limited definition of depression: it’s a state of despair or self-missingness that requires no identifiable cause. It includes a plurality of symptoms, it’s a departure from the authentic personality, and it’s also dangerous. It’s not about microwaving hotdogs or the news. Or it’s barely about microwaving hotdogs and the news. But as I started to understand depression in this way, two things happened. The first is it made it possible to reconsider how I thought about suicide. The second was that my work with my clients significantly changed.

Disagreeing with the Depressed

It’s hard for me to overstate how difficult it is for me when my clients try to convince me that they cannot be helped. While they might concede that people shouldn’t wish to die, they often tell me there is one exception, and it’s them. They tell me that the details of their pain are unique, and that they’re a rare and untreatable case. Their suffering stands apart from the rest, and in this way, it’s superior. Sometimes depression can cleverly recruit a pinch of narcissistic grandiosity to increase a client’s despair. Bon appetite!

This creates a challenge because my training taught me to honor, and not to disagree with, the feelings of my clients. In my education, disagreement was to therapy what deodorant was to teenagers. They simply don’t go together. But when my depressed clients try to convince me that they can’t be helped, I’ve found careful disagreement to be important. While it’s true that disagreement can elicit defensiveness and early termination with clients, disagreement has been a a useful skill in the presence of a client’s hopelessness. I think this skill of careful disagreement can be especially useful when it’s implemented in two steps. When I don’t mess it up, these disagreements can sound like this:

Client: I’m going to give therapy my best, but honestly, nothing has ever worked. It’s hard to imagine that after trying therapy for 10 years, this will be different somehow.

Therapist: 10 years. I can’t even imagine that.

Client: Yeah, it’s pretty hard to get that across to people. I’m just one of those rare cases where you can’t make any real improvement. I mean, those cases exist, right? I just happen to be one of those cases.

Before getting into the heart of the disagreement, I want to mention how helpful the phrase “I can’t even imagine that,” can be. When I was learning to become a therapist, I worried that unless I shared similar experiences with my clients, they would view me with suspicion. I was concerned they would think of me as someone who “doesn’t get it,” and I’d be exposed as the imposter I was convinced I was. I didn’t handle these insecurities well. Instead, I exaggerated the breadth of my own life experiences. The good ol’ therapeutic skill of misleading clients. A classic. I would find ways to connect my client’s experiences with my own, even when there weren’t real comparisons to be made. I hoped that this would reassure my clients that I was qualified to help them, but mostly, it allowed me to hide my imposter syndrome behind my flexible autobiography. In therapy, this was my hiding spot.

I eventually learned that it was better to handle my insecurities by acknowledging when I couldn’t relate. Not lying, I call it. A cutting-edge intervention, I know. But it wasn’t realistic to expect myself to contain the totality of human experience within my past, and when my clients thought our histories were more similar than they were, I was taking too many steps away from sincerus. For me, this style for building rapport was too far from “whole, pure, and clean.” Not only was stretching the truth of my personal history unethical, but I also risked that my clients could be left with the sense that their pain was unexceptional. “I’ve been there before,” didn’t necessarily carry a reassuring ring to it.

But once I accepted that my clients would experience many problems I would never experience, it became easier for me to tame my imposter syndrome. The truth is that personal experience isn’t a prerequisite for clinical competence. Instead, I think it’s better to share with my clients when the depths of their difficulties are hard for me to imagine experiencing. In the case of depression, most clients already know that most people haven’t felt the depth of depression’s deep waters, but when they hear that I know this too, something paradoxical happens — they know they’ve been heard.

Okay, enough about my poor character. I want to move back into the transcript. Here’s how the beginning of how cautious disagreement can occur:

Therapist: Hm. That hit me a little different than I expected. Let me get some feedback from you, is that alright?

Client: Yeah, go for it.

Therapist: Well, I’m feeling two different things. The first is that I’m hurting for you. You’ve been through so much. But the other is when I hear you talk, I also feel this sense of protectiveness within myself. It’s like an urge to protect you, against you. I’m not sure you’re very fair with yourself. What do you make of that?

Client: Look, I don’t think I need your protection. I’m just saying I don’t think things will get better.

Therapist: Right, after trying therapy for 10 years, improvement sounds unrealistic.

Client: Bingo.

Two things are going on here. The first is that I’m expressing disagreement by sharing my own feelings about their hopelessness. This is Step 1. There’s nothing to be gained by debating with my clients about whether they’re truly beyond help. This can leave them feeling less understood. But when I express how I feel about their hopelessness, this allows me to disagree without being disagreeable. For me, there’s usually a feeling of protectiveness that emerges, but sometimes there’s a feeling of sadness inside me, too.

There’s another part that I try to keep in mind when disagreeing with clients in their depressed state, and I think it’s the most important: I express my own hope about their situation. This is Step 2, and sometimes it sounds something like this:

Therapist: I gotcha. You know, if I’m honest, I wouldn’t ask you to feel hopeful at this point. My fear is it might feel too risky — like a setup for another letdown, and things have already been hard enough.

Client: Yeah, I’ve been through that. Having hope, and then things not working out. Done that several times.

Therapist: With all you’ve been through, not reaching for hope makes sense to me. I guess I’d like to share that in the meantime, I’ll be hopeful for the two of us. Maybe if you start seeing small improvement later, then you can join me, but for now I don’t want you to have hope. I can carry that part for us both.

My hope is that showing my clients that I understand why they’ve rejected hope can be an unexpected act of kindness. This might seem like a strange way to be supportive, but for many clients, I think hope can feel too vulnerable. Allowing themselves to become excited about the possibility of feeling better can seem risky, and so I encourage them to continue protecting themselves. But I also tell them that in the meantime, I’ll be hoping for the two of us. This lets them know that while I disagree with them about their prognosis, I won’t debate the matter — in our disagreement, I’m still on their side.

Preventing Depressive Takeovers

That is how I practice expressing disagreement with my clients in their depressed states, but I think managing my private disagreements is just as important. Here is what I mean. I think disagreeing with my clients about the hopelessness of their improvement within myself is a precondition for honest therapy. How could I work with a client if we both agree that they’re beyond help? But in some cases, this private disagreement is a fluid process. There might be sessions when I find myself more optimistic about the client’s progress, and other sessions, less so.

I think it’s important that when I find myself feeling less optimistic, that I treat this feeling with extreme caution. Hopelessness operates the way that yawning does – when one person yawns, others in the room will involuntarily follow. Hopelessness can also move across the room, and when spending hours in the presence of client hopelessness, it can spread across the therapeutic relationship and into myself. If I’m not careful, I can become worn down, and then I can become pessimistic about the client’s prognosis. When I join in the client’s hopelessness, I haven’t influenced the depression, but instead the depression has influenced me. The therapy itself has undergone a depressive takeover.

A depressive takeover is a phenomenon where a client’s distress spreads to the therapist over the course of therapy. The problem with these takeovers is that if I allow them to occur, my clients can sense that I share their pessimistic outlook, and this can reinforce their preexisting despair. Fortunately, I think there’s something that can be done to prevent this from occurring.

To prevent depressive takeovers, it has helped me to notice the connection between my being emotionally absorbent and the contagiousness of hopelessness. In my view, the more I’m sensitive to experiencing the feelings of others more generally, the more susceptible I am to the contagion of hopelessness. This means that there are rare moments in therapy when, for the sake of my clients, I attempt to become less emotionally porous. I try to shut my inner doors, and to absorb less of their experience.

To do this, I inwardly recite a phrase when I notice that I’ve started to feel pessimistic about their prognosis. I tell myself: that’s your mental health, not my mental health. Reciting this mantra in the privacy of my mind allows me to distance myself from my client’s experience. Creating this internal limit creates a pushing-away feeling, and it helps me close my emotional doors. It’s an empathy reduction exercise. When I create this distance from my clients, it helps me stand apart from the pull of hopelessness, prevent a depressive takeover, and remain hopeful for the two of us.

The Arrow and Shield

Frank was 75 years old, and he’d never seen a therapist before, but he started saying things that made his adult children nervous and so they convinced him to speak with me. When he walked into my office, he got straight to the point. He told me he was ready to die, and shortly afterwards, he told me his name. Frank spoke with energy, “I’ve lived a full life. I’ve had children, grandchildren, and a lovely wife who died 10 years ago. The truth is that I’ve had everything I’ve ever wanted.” He continued, “I don’t want to get much older than this. I don’t want to become less recognizable to myself. I don’t want my kids to have to deal with that either.”

I was perplexed. It seemed like Frank’s desire to die was coming from a place of focused reflection. He wasn’t tearful, nor was he numb — he was grateful. I wasn’t sure if he was making a rational calculation about ending his life, or if he was under the influence of a depression that was undetectable to me. I took a breath and responded, “Frank. I’ll be honest with you. I’m not sure what to make of what you’re telling me, and I’m not completely sure how I should proceed. I’ve never been 75 years old, and I imagine it’s quite difficult, but I’m not sure if your wish to die is related to an underlying depression or not. If I take your word for it, I run the risk of overlooking this possibility, and that worries me. I hope this doesn’t sound too dismissive.”

Frank nodded and I continued, “You mentioned you don’t want to put your kids in the position of helping you age. Can you teach me about that?”

“That’s big for me. I’m no use to anyone anymore. My kids are raising their kids, and they shouldn’t have to care for me, too. I can’t really give to them anymore; I can only take. I’m burdening the people I love the most.”

The word burden flashed in my mind. I felt a hunch and I wanted to test it. “Frank, this simply crossed my mind, and so tell me if this doesn’t fit, but I found myself wondering that if you were depressed, if you might hide it from your family. Maybe you’d worry that, in addition to your age, this would burden them, too. I’m only saying this because if you’re trying to protect your family by keeping things private, I’d hope you’d relax your protective nature with me. But tell me what I missed.”

We sat in silence as Frank looked out the window behind me. He clamped his palms together, cleared his throat, and we restarted the conversation.

Over the course of my therapy, I think it’s been useful to pay attention to the word “burden.” I’ve come to believe that this word, and the emotional experience to which it points, is the first part of suicide’s moral calculus. When my clients begin to think their existence is hurting others, being alive can start to feel like an ethical dilemma. “Should I stay alive if it harms those I love?” they might wonder.

This guilty feeling can become more dangerous when it’s coupled with a strong desire to protect their loved ones. I think this is the second part of suicide’s moral math. While suicide might look selfish from the outside, from the inside, clients often perceive suicide as the way to protect their loved ones from themselves.

With many of my clients who have survived their suicide attempts, they often express that while they were afraid of dying, it was their protective instinct that pushed them beyond this fear. From their vantage point, suicide was the right thing to do. They believed they were hurting their loved ones, and it was their responsibility to protect them. From within their suicidal mindset, many of my clients considered themselves both the arrow and the shield. It was the pulse of a self-sacrificing ethic that motivated them.

***

As I look back at the therapist I was “back then,” and the clinician I have become, I realize that once I better understood depression and the moral dimension of suicide, this gave me something to work with in therapy. I learned that when my clients expressed the five depressing truths or when they believed they were a burden, there were things I could do to help. I could start by gently disagreeing with their hopelessness, disagreeing within myself to prevent depressive takeovers, and disagreeing with my clients when they’re convinced their loved ones should be protected from themselves. I am no longer terrified when the specter of suicide enters the therapeutic relationship.

Editor’s Note: In the next installment of this five-part series, the author will address strategies to address despair in therapy.

Rick Miller on the Clinical Challenges of Working with Gay Sons, Mothers, and Families

Posted on December 20, 2023February 11, 2026 by Psychotherapy.net Team

Gay Sons and Their Mothers

Lawrence Rubin (LR): You may be known to our readers as the founder of Gay Sons and Mothers. But they may not be familiar with how extensively you’ve been trained and how long you've been practicing as a psychotherapist with a personal interest in working with gay men and their mothers.

Rick Miller (RM): I'm a gay man who grew up really appreciating the bond and love of my mother. And, in hindsight, as an adult, what it meant for me was that I got to be myself. She didn't necessarily know that I was gay, or maybe she did, but she never forced me to do anything differently than what I did.

And growing up in a world in the 1960s where it was prescribed, this is what boys do, having a mom who let me be me — and we did a lot of things together — was pretty miraculous. I hear so many stories about people growing up whose parents abused them or forced them to do things differently.

I wrote a book several years ago for clinicians about doing hypnosis with gay men. I thought it would be relevant to do the research or to seek out research about gay men and their mothers. I looked at the literature about gay men and their mothers to include in the book. You'd think this a cliché topic and that there would be way too much information to use. I couldn't find anything! I thought, I’ll write an article about this, and it ended up turning into video interviews. And from there, I started a nonprofit called Gay Sons and Mothers.

We are educating the public about the special bond between mothers and their gay sons and how she contributes to his sense of well-being in the world. It's a multicultural story that looks at strength, at disappointment, and is a very emotional topic.

LR: So, even before you and your mother had a conversation about being gay and you knew, you had no particular concern over sharing it with your mom. You didn’t worry how she would take it, how you'd be perceived, how you'd be treated. You were just free from the start to be you.

RM: Well, I was free to be me, but I didn't come out to them — meaning my parents, my mother and my father — until I was 21. So, it was interesting that I had the freedom to be me, but I didn't feel 100 percent free to be me because I waited longer to come out than I probably needed to in hindsight. Today, many kids are coming out at a much younger age to their parents. Of course, the world is very different.

LR: If you intuitively felt accepted by your mom and weren’t censored or limited in any way from being you — you haven't talked about your dad — why do you think it took you as long as it did to become public about it?

RM: Well, so, it was the early 80s. So, AIDS was hitting the press big time, and I suppose on one level, I was protecting her or them from thinking that something would happen to me, which, knock on wood, did not happen. I was afraid that I'd be rejected, and, not to sound callous, they were paying for my graduate school education, and I just made a mental note in my mind I was going to wait until I finished school to come out, which is so stupid.

Knowing my parents, of course, they wouldn't have done anything differently. It took them a while to come around, a month or so, which I thought was horrible at the time. But I look back and I think that my parents had to go through their own grieving when I came out to them. Of course, they knew I was gay long before I came out, but hearing it was definitive. And it took them a short time to acclimate and appreciate it. I was incensed at the time. And, often, I say to children and to parents, it's okay to grieve.

LR: Incensed about?

RM: They were not 100 percent supportive the second I came out to them. And the first thing my father did when I came out was to become a little weepy saying, “the world is unfair, and I'm worried about what that will mean for you.” I took it as supportive, for sure. And then he kind of changed the tune for a bit, and that is when things turned ugly, and again that lasted a few weeks and then everything turned around.

LR: Smooth sailing with your parents and especially your mom ever since.

RM: Yep. And I had a partner that I was moving in with at the time. So, what I did, which I shouldn't have done, was when I came out to them, I told them that I was moving in with the person they knew as my friend all at once, so that threw them a little bit.

LR: Overload! Going back to the second part of the earlier question about your foundation; how do you think clinicians can benefit from awareness of it?

RM: There's so much inherent in the videos that we share through Gay Sons and Mothers. It's not only about the relationship between a mother and a son, but that part in and of itself is so affirming. Clinicians can watch stories of sons and their mothers and appreciate what it is being gay. And it's not only mother in these interviews. Families are talked about. Extended families are talked about. Culture and religion are addressed in these videos.

So, there's a lot there, and, when mothers are struggling with their kids, I send them videos from Gay Sons and Mothers. On our website, there's a link to our Instagram page. We have a YouTube page. Sons watch. Most people — therapists included — watch these videos and have a deep emotional resonance around the issue of being included, being loved, being supported, being rejected. It's hard not to feel something when you're watching videos pertaining to these themes.

LR: A connection. How would you respond to a therapist or to a non-therapist who’s visited your site and says, “Yeah, well, what about gay sons and their fathers?”

RM: There's way more information in the literature about gay sons and their fathers than there is about gay sons and their mothers. And if there hadn't been any with fathers, I would have pursued that, as well. I grew up with a great relationship with my mother. I had the fame of saying to my siblings, “Mommy likes me best.” It carried me through. So, it seems completely perfect that that would be the focus of my work.

Historically, mothers in the 1970s — or even earlier in the psychiatric and the medical field — mothers were blamed for making their sons gay. And, so, with the lack of literature out there, what's missing is that mothers have the power to raise sons who are mentally healthy, just from being a good enough mother. And, so, that premise is so important to me that I've focused exclusively on mothers and sons.

The issue of fathers and extended family is embedded in the work anyway. So, this project, Gay Sons and Mothers, is inclusive of the entire family. And we're also expanding beyond just gay sons and mothers. We're talking about trans children and all sorts of things.

Intersecting Identities

LR: How has your advocacy and clinical work been informed by your own personal evolution?

RM: Oh, gosh, that's such a big question, but I think I can get there. I came out in 1983 — I was already a clinical social worker. In the 1980s, AIDS was emerging, and gay men were dying in big cities, and people were afraid. Homophobia was on the rise because people were afraid of catching AIDS. I was working in the AIDS field, doing volunteer work at this time, and I started working with the gay community from the start.

Boston, where I lived, was a progressive place. So, I was known in Boston as being an out gay male therapist. I mean, there was no web at that time, but anyone who knew me would know that I was gay. But I was also practicing in a very conservative place, Boston, Massachusetts, very hierarchical, very psychodynamic. So, in the professional world that wasn't the world of AIDS, I worked in a hospital. I kept a very low profile, and I felt like I didn't fit in the hierarchy of psychiatrists, psychologists, social workers.

I'm a social worker, and looking back at my evolution and my history, I wish I had put myself out there more because the contributions that I'm now making to the field in the last ten years as a writer, as a teacher, as someone who's done Gay Sons and Mothers, if I had the confidence to do some of this earlier, I would have done more research focusing on gay men, on gay men and their mothers, gay families. And I think I could have made a bigger contribution to the field.

What happened for me is I started my private practice in the mid 80s, and I switched to full-time private practice. So, I left the hospital. I left the agency where I was doing AIDS work, and basically, I hid in my office with the door closed for decades. And I was very successful in private practice, in part because of my clinical skills, in part because of my personality, and I got to hide.

Once I wrote my first book and I started teaching about working with gay men, I could no longer hide. And, at the time, I was probably 52 years old — 10 years ago. And I'm really glad it happened, but it forced me beyond a comfort level that was really important and good for me, and I wish I did that sooner.

LR: So, you came out of the closet before you came out of the office. I can see that your personal story could be used as an exemplar, not only for gay therapists, but for gay men, whether still not out or out. I would imagine that you don't impose your story on others. But by living it and being genuine, as you've always struck me, you are an unintended role model.

RM: Well, thank you for saying that, and it served me very well in my practice. I grew up in an upper-middle-class family with well-being and mental health and good physical health. And, to me, that's how everyone lived in the world, and that is so not the case. And so, as a gay man who had a sense of self, who worked with gay men, I served as a role model to other gay men, to all my clients really but specifically to other gay men who didn't have the good fortune that I did or didn't have the personality that I did.

So, my being outgoing was a very good clinical skill, and, fortunately, in my early 20s, I was in therapy with a therapist who was gay, who had a very good sense of himself, who had a great sense of humor, and who allowed me in the process of therapy to love myself. If I had chosen one of those uptight, analytical therapists in Boston instead, I don't know where I would be right now.

When I was looking for a therapist, I was given the name of eight different people. Back in 1983, I was calling their answering machines. On some, I was hanging up because I was frightened by them. Others shamed me through their tone, and thank God, I didn't work with them.

Clinical Challenges of Working with Gay Men (and their Mothers)

LR: What are some of the clinical challenges you've found in working with gay sons and their mothers?

RM: Long before I ever knew I'd be working with gay men and their mothers, I had a gay male client who was really struggling with confidence. He grew up in the projects outside of Boston, and his father left the family, and deprivation was a big part of his upbringing. So, one day, for whatever reason, I had his mother join him in a session and it was like the heavens opened up.

I understood him so much more, and the bond and the strength of their relationship was amazing. It helped so much in the clinical work. He was a catalyst that led to this project, Gay Sons and Mothers. Every now and then, I'd have another mother and son together, but it wasn't why they were in therapy. Once I started working on this project, various people consulted with me, families for help with their families. For some, in the field of psychotherapy, for others, through the nonprofit where, for free, I just consult with people and help them along.

What's been interesting is one mother and son that I'm working with right now in therapy are enmeshed with each other, and they're seeing me every two weeks. On certain days, it feels like couples therapy and I really have to work with them to detangle and let go of their expectations with each other. And, so, this is a divorced mom with an only child who's gay, and they expect each other to meet needs that goes well beyond what they should be for a mother and a son.

This isn't the case in all circumstances, but I think it's a great example of how it can be a bit of a burden on both ends to have this close bond that goes kind of way too far on both ends.

LR: So, enmeshment is one of the challenges. I imagine acceptance is another.

RM: So many gay men are way too careful, and they're not coming out to their families as soon as they might, or they give absolutely no details about their private lives to their families who really want more from them. So, that is another challenge, that in being careful, even once they come out, being careful continues to be their MO, even when they don't need to be, and people want more from them. They want to hear more details about their day-to-day lives or what they struggle with, or are they in a relationship with someone?

LR: And I wonder if these particular men are so cautious and close to the chest with their families, if they're even more so outside of the home.

RM: Correct. I'm working with a bunch of men in their 50s, let's say in their 60s, who came out in an era where it wasn't okay to be gay. And even though it's fine now and they have jobs where they are out, they, without even realizing it, are kind of slipping into modes of privacy and protecting themselves because it's a habit that's been with them through their life.

LR: I was going to ask you a little bit later about working with elderly gay men. But this seems like a good point to interject the question of, “what are some of the clinical challenges in working with elderly gay men whose mothers, I imagine, have long passed?”

RM: The most significant challenge is that they grew up in an era where they couldn't be out, where it wasn't safe, and many older men were kind of forced indirectly or even directly to live conventional lives and got married and had children without even questioning the freedom of living life as a gay man.

I had a great-uncle who was gay, and he never came out to my family. When I came out to my parents, they said, “Well, Paul has lived a good life. So, we know that you'll live a good life, too.” But this great-uncle, my grandmother's brother, was in his 80s when I came out. And he said to me, “I really appreciate that you have freedom that I didn't have, and I hope that you will keep my secret from your family because I just don't feel comfortable being out there.”

LR: Well, I wonder if that fear of abandonment, being cast out by remaining family is that much greater to an elderly man?

RM: He had an incredible social network. He lived in Washington and was cryptographer for the CIA because keeping secrets was something that they did well. So, he had the love of a community of people, and my mother, his niece, and us, meaning my mother's children who were generations below him. And he was still worried about our knowing. It was just a pattern that was ingrained for the time with which he was raised. It's that simple.

LR: Can you imagine taking homosexuality, or any significant part of your identity, to the grave?

RM: When he died, my mother and I went to Washington to clean out his house — he saved everything. There was a pile of letters that his gay friends wrote to him in the 1950s and the 1960s about falling in love with men that they met in cruising areas in parks, and how they couldn't tell their spouses and how tortured they were.

We were cleaning out his house with three of his close friends. My mother came to me, without saying anything, handed me the pile of letters, and I read them. And I thought poor Uncle Paul would die if I kept these letters, so I shredded them and threw them out. And it is my biggest regret because in these letters was the reality of gay history lived by all these men.

But, in my desire to be loyal to my great-uncle, I threw them out. And this was maybe three or four years after I had come out. I was still living in a careful way and more worried about loyalties. If I had these letters now, what they would mean? Oh my God.

LR: What clinical challenges have you experienced working with gay sons of mothers from other cultures, the Caribbean culture, the Asian, the Southeast Asian, or even African, where homosexuality is shunned and punished, sometimes even fatally?

RM: In these cultures, homophobia is rampant and masculinity and norms around masculinity are such that fathers are not accepting of their gay kids. Religious norms are such that being gay is a sin and these are beliefs that communities buy into without questioning. So, fathers are often emotionally and physically abusive to their sons. Mothers are forced to choose between their husband or their child.

Some mothers choose their husband over their child. I had a guy that I interviewed who was Latino, and his mother said to him, “First comes God, then comes your father, and then comes you.” So, when he came out, they sent him to an aunt's house far away to Texas where he would somehow have a different life for himself. He ended up responding to a personal ad from someone who he didn't know at the time was a human sex trafficker, and he became a victim of human sex trafficking. It's a tragic story, and he's now an advocate for all of this. But his parents kicked him to the curb and still don't accept him.

LR: Have you worked with men and mothers and their parents from other cultures, where the parents themselves were afraid of being sanctioned, punished, or harmed?

RM: You're saying that with a great degree of sensitivity and attunement. Most situations, that is exactly what the parents are feeling, but they don't recognize that in themselves. What they recognize is what they're supposed to believe, and that's what they've gone along with. I've worked with Mormon families who have rejected their children. I've interviewed a Latino Mormon man whose mother read his journal and packed up his bedroom one night and put all his belongings in the garage and said, “You're not going to live here anymore. What you're doing is a sin.”

Eventually, they came around and made up years later. These horror stories unfortunately exist. Some families that are less severe than the examples I gave don't let their kids come to family holidays. They insist that they not come out to extended family that there’s all these conditions. There's a woman named Caitlin Ryan who’s done a lot of research through her organization called the Family Acceptance Project. Her work shows that LGBTQ family members can gain acceptance with their children or their siblings through being exposed to other people that give a message that it's okay.

And that's essentially what we're doing through Gay Sons and Mothers. We're sharing stories saying, “Look, we're out in the world and everything is fine.” And as family members realize that it's okay, they are far more accepting of their gay children. So, that's the message that we need to get out into the Latino, the Asian, the Black communities, and the best way that they're going to accept it is by hearing stories through people like themselves.

If they're hearing from a gay social worker who's White that it's okay, maybe some percentage of people will listen to me and be comforted, but they're going to hear it most from another father who's found through his own experiences that it's better to have a relationship with their child than to reject them.

LR: I imagine there’s a significant number of these families that don’t make it successfully through therapy with you. This young man is left feeling just as isolated and rejected as before.

RM: Right. Or the young man will stay in therapy and build his own community, but, unfortunately, not with his family, outside of the family and elsewhere. That said, I am a family therapist. I’m a couples therapist. I'm totally optimistic. I never give up on families reuniting. And, last year, I worked with a fundamentalist gay man in his 30s, really successful in his career and in his life. But he didn't come out until his 30s to please his parents. I had three joint sessions with him and his mother, with the hopes of bringing them together. He never thought it would happen.

I met with her alone first, and she was talking about the Bible and blah, blah, blah, blah. They didn't stick with the sessions, and eventually started talking to each other. A couple of months ago, she was potentially diagnosed with cancer, and that's what brought them together more than anything else. And I wish it could have been sooner.

LR: How would you advise straight therapists working with gay men, beyond the standard of “unconditional acceptance?”

RM: You raise a very important issue about unconditional acceptance, and many well-intentioned straight therapists try way too hard with their gay clients. In my life, socially, I'll go to a party, and they'll say, “Oh, do you live where all the gay people live? And do you know so and so, and so and so, and so, and so?”

LR: Gay Jewish geography.

RM: Exactly, and often I do. But therapists who try to promote unconditional acceptance and convince their clients that they're gay-affirming and then offer, “Oh, I have a neighbor who's gay,” which actually may induce a lack of trust. The best way to promote unconditional acceptance is to simply say, “I’m straight. Are you comfortable working with me? I am accepting, and I've worked with other gay clients. But, please, if you feel any bit of discomfort, let me know. Let's talk about it.” To me, that's unconditional acceptance, and that's more welcoming than doing a sales pitch that ends up sounding like a microaggression more than anything else.

So, my mentor, Jeff Zeig, accepted me for who I was, and he’s a straight man. There was something so profound in that experience for me. Was he the first straight man that accepted me? No, but it was wonderful to have a mentor who didn't care if I was gay, didn't pathologize me, and said, “Write a book about working with gay men, the field is lacking this information.” It was so validating. And so, what he did for me, which all therapists ideally do for their clients, is embrace, love, support, and send me out into the world to be successful.

That is unconditional love, and that is what straight therapists can do for their gay clients. And what I say in the work that I do is you're giving your clients a bigger gift of healing than you would even recognize because your clients are coming into your office with their presenting problem, whatever that happens to be. It may have nothing to do with being gay. And, through the love and the acceptance and the respect that you're showing to them, they're getting additional healing from the experience of being in your office.

So, frequently, when people want a referral to a therapist who's a gay client, frequently I'll say, “Why don't you work with a non-gay therapist? Because there is extra work that you can have done, as a result.” Some people will do that, some people won't.

LR: I used to think it important to be colorblind, but we must see color to validate the experience of the “other.” that idea. Similarly, one can’t be gay blind, because being blind to that does not suggest acceptance. It suggests walling off and not affirming that person, not accepting that person. So, I imagine that a clinician working with a gay person has to be very cognizant of the stories, the history that this person brings into therapy.

RM: Yes. The words that are coming to my mind are cultural competence. And that's what we need in the field these days. And I, too, did the same that you just described. I worked with an Asian gay man and a Black gay man, and I cringe when I think to myself or I even probably said things aloud that it's not as bad as you perceive it to be, which is absolutely not true.

LR: It’s not affirming.

RM: Right. The best thing that we can do is to hear the experiences that our clients are bringing to our offices and trust that to be true. The other best thing that we can do to become culturally competent is to go to workshops or watch videos like this or read a few books or speak to your gay friends and family members about their experiences to get educated. It's not hard to do. I find that in our field of mental health there are many people who are well-educated and liberal in their thinking, so that they feel like they have all that they need to know.

But their gay clients are testing them indirectly and don't feel safe because they're presenting a norm that may be uncomfortable. The other thing that I found, and I've mentioned this to you before, is that the field in general, of course, is run by metrics and numbers. And the most successful clinicians and teachers in the field have large numbers of followers and huge turnouts to their conferences. When I teach, sometimes I get 20-25, maybe 40 attendees, if I'm lucky, at a big mental health conference. Well, that's not good for the conference.

So, I'm not advancing as I'm teaching about working with LGBTQ people. And there are very few courses offered at huge conferences, which is unfortunate. So, my advice to people who are organizing conferences is to put us in panels with other people, and that way we can kind of gain exposure and educate people.

LR: So, the idea of a gay-affirming therapist is more cliché than anything else I would think because if you're not a person-affirming therapist, you're not going to be a gay-affirming therapist. Am I getting it, right?

RM: Yeah, yeah. And I mean, interesting. A clinician that's worked a lot with the gay man or the LGBTQ population by nature is gay-affirming. I know through conversations with a person who has worked a lot with the LGBTQ population is gay-affirming, and they've cultivated acceptance and skills that are affirming and comfortable. As a person, are you a gay-affirming person? I'm not asking you that. I know that you are, but I'm asking people who are listening to this. Do you understand what it's like living life as an LGBTQ person in today's world?

And if you're honest with yourself, maybe there are things you don't understand, and there's ways of getting information. If you pretend that you are, you're fooling yourself. People are going to see beyond that.

LR: They’re going to catch up.

RM: So, when you go to therapy, you should be talking about your sexual life. Many gay clients, out of shame, won't even broach the idea of sex with their therapists. Or, when they talk about sex, their therapist winced because they don't believe in open relationships, or they think that gay men are too sexual, and their biases are coming forward. I h

Mary Jo Barrett on the Collaborative Treatment of Incest and Complex Developmental Trauma

Posted on October 3, 2023February 24, 2026 by Psychotherapy.net Team

Lawrence Rubin: Hi, Mary Jo, thanks for joining me today and sharing your clinical expertise in the systemic treatment of incest and complex developmental trauma. Just before we went live, you were sharing an experience you had while giving a webinar this last weekend, and something caught my ear that I wanted to ask you about. You suggested that there is something different between what is currently being practiced in the field of incest and complex developmental trauma, and what, in your experience, is correct, or what should be practiced.

Mary Jo Barrett: That’s a good place to begin. When I first started, which was 45 years ago, I was a worker for the state, basically doing in-home counseling. I discovered that in all these child abuse and neglect cases, there was a significant number of cases involving incest and sexual abuse — whether immediate family members or close family members or clergy or whatever. I would go to my supervisors for guidance, but no one really knew how to treat it.

For example, Minuchin told me that I didn’t need to focus on the incest. I just needed to look at restructuring and building a hierarchy, and that the incest would then be alleviated. Carl Whitaker, who I was madly in love with, basically said, “You know what? I don’t know what to tell you.” At least that was honest. He said, “I do schizophrenia. You better figure out how to do incest.” He was my teacher, so I decided I needed to figure it out.

And so, over the years, I started asking my clients more formally about incest and sexual abuse. I also had my supervisees ask their clients. And whether I was conducting training in Europe or here, I began to ask the clients what the most effective thing about their therapeutic experiences was, and what about the therapy they had received made it “good therapy.”

Basically, nobody said “techniques.” They said what we know they would say and did actually say. It was the relationship between the therapist and client. But they even said more specific things. And of the specific things they said, I narrowed the list down to what I call the five essential ingredients of trauma treatment. But what they said applies to all models of treatment. And as we know, none of these models are better than the other I developed what I call a meta-model that applies to any trauma protocol that exists based on these five essential ingredients. And so, whether you do IFS or CBT or SC or any of the alphabet soup of techniques or protocols that are out there, they will be successful if they have the five essential ingredients.

The Key to Effective Trauma Treatment is Collaboration

LR: What exactly are these five ingredients for effective trauma treatment?

MB: People, especially those who have been abused, need to feel that they have value, power, control, and connection. So, these “ingredients” include the client:

feeling valued
learning specific skills in finding resources
understanding contextual variables needed for an engaged mind state
developing workable realities
building a hopeful vision for the future

When a therapist, case manager, or foster care worker gets stuck with a client who has been abused or neglected, I suggest that they don’t go back to the protocol, but instead to the relationship.

LR: Going back to the question that I opened with, how do you see what’s in the zeitgeist now, what’s popular now, as being lacking in comparison to this collaborative model that you developed?

MB: The basic essence is that I go to the client to tell me what to do, versus going to a model or technique to tell me what to do.

LR: Can you think of a recent clinical instance in which the relationship seemed that much more important in the moment than any technique or model?

MB: Larry, every day! That is my model. Every session. In every session when you’re talking about trauma, there will be an impasse. I call it differently. In any moment, there’s going to be what I call a traumatic stress, which means the client, because of their trauma, is going to experience therapy as dangerous.

As we always say, survivors often see danger where danger doesn’t exist. I mean, that’s a standard thing. But that happens in therapy all the time. That’s because the therapeutic relationship is based on hierarchy and attachment. There is a hierarchy, right? I mean the therapist has more power. And the therapist is often controlling the sessions or the direction or what’s going on. And there’s a necessary attachment. There’s going to be an attachment between therapist and client.

Abuse and neglect are embedded in hierarchical attachment relationships. Now, the thing is, every time I say abuse and neglect, people might go, “But we’re talking about trauma.” And I’m saying, again, almost all the trauma cases we talk about revolve around interrelationship violations.

LR: So, if we practice anything other than a collaborative model, then we may in some way be replicating the hierarchical violation in the family that contributed to that abuse.

MB: I’d say that a majority of these clients anticipate and experience, from time to time, that violation in the therapeutic relationship.

LR: So, if the therapist moves too quickly or dives right into the trauma narrative or says, “Tell me about this,” or, “I’d like you to do this,” they are abusing their power? Even using directive words or a tone of voice or body posture can trigger a client so that they feel unsafe. And that’s when you would be cognizant of that, hypersensitive to that, and readjust any of those facets of your approach?

MB: Correct. And the collaborative change model is exactly that cycle. What you just described. And what’s interesting to me is that the collaborative change model is a natural model. And when I describe it, folks at the clinic say, “Oh, my god, yeah!” And the good clinician says, “That’s what I do in my sessions anyway.” And all I’m saying is, make it conscious. It’s a natural cycle of change.

The first phase is creating a context — which is creating refuge, making assessment, figuring out what’s going on — then making a direction, deciding what kind of intervention to use. And then when we start doing our interventions, which is natural, we’re challenging, right? And the relationship becomes embedded in this hierarchy because I’m sort of pushing and challenging by asking them to do something different. And in that moment, the client might experience a moment of fight-flight-freeze-submit. Or fix! And I have to, as a clinician, recognize that.

And in that moment, instead of pushing harder to make an assumption of, “Oh, they can’t tell,” or whatever it is, I need to stop and recreate a context of change. So, at that moment, I stop and say, “What do you need now? What’s going on? How do you feel? Should I slow down? What’s happening?”

I’ll give you an example. I had a client who often during the sessions would say, repetitively, “You don’t get it. You don’t get it. You don’t get it.” And I’d often get defensive. I’d sometimes want to say, “Well, help me understand,” or, “Explain it.” And then one day after the session, I was thinking, “I think that’s a trauma response. So, I said, “I’m wondering if when I’m doing something that triggers you, you experience me as threatening and go into ‘You don’t get it’ as a repetitive response.” And she really thought about it and looked at it and she said, “You know, I’ve often felt there’s things you do that remind me of my mother.”

This client’s mother was like Joan Crawford’s character in Mommie Dearest, and we’re not just talking severely abusive. I asked her what reminded me in those moments of her mother. In response, she said that I talked loudly, and it was the way I dressed in skirts. She experienced me as dressing in a way that was, for her, reminiscent of her mother, which she experienced as provocative. I don’t know that it was, but she experienced it as such, so for her, it was.

So, when we then had that conversation, and from then on, I did consciously change how I dressed on the days I saw her. And I consciously changed my voice. And after that conversation, she never said, “You don’t get it,” again.

LR: So, when she emphatically repeated, “You don’t get it, you don’t get it,” it was metaphoric for something like, “You’re not hearing me, that hurts, stop it, you’re not hearing me, you’re dressing in a way that confuses me. You’re not hearing me. Daddy did this, or Mommy did this, or my brother did this.” It’s like this broad statement of, “I am feeling abused right now.” She may not have been able to put a finger on exactly what element of your relational moment was triggering her, but “You don’t get it,” meant, “I am feeling powerless and unsafe.”

MB: Violated. She was feeling violated.

LR: She was feeling violated. Because you’re much more cognizant about the relationship and the attachment, and breaches in the attachment, you were able to look inward and ask yourself, “What could I be doing? How could how I be talking? What would I be wearing? What might we be talking about? What is it about the way I’m asking questions that could be replicating at some level what happened in her family?”

MB: Yes.

LR: Did I get it right?

MB: You did get it. I should bring up my PowerPoint. You’re doing a very good job. I have three slides that I use in trainings, which I introduce by saying, “These are the three watchwords or phrases of my faith.” The first one is by Mandela that says, “A good head and good heart are always a formidable combination.” The second one was by R.D. Laing who talked about the importance of awareness by saying something like, “If you aren’t aware that you’re not aware, there’s nothing you could do to make change.” And the third one is by Jay Woodman which says that “Life is a series of cycles of getting lost and finding yourself.” And that each time you’re lost, if you look at it as a possibility, then you will find yourself in a new place. And so, my thing is, therapy is a cycle of getting lost and finding yourself again. And once you’re aware of that, you integrate your mind and your brain, your heart, and you’re golden.

The Healing Power of the Therapeutic Relationship

LR: Is there something about trauma, and incest in particular, that drives clinicians to cleave to techniques and theoretical models; bypassing what they truly know to be effective, with is the relationship?

MB: It’s an integration of the two. When we spoke with these clients, it was clear that they did need new skills. It was the third most important thing, not the first. But the first thing they said was connection. The second thing they said was they had to feel valued, and they had to value the clinician. Then they said they had to feel empowered. And then they said skills.

Everybody that’s developed a protocol model is going to argue with me and say the relationship is the basis of all those protocol models. I would say I got you; I believe you. But if you ask the people who are trained in those models, they will say the emphasis is on the protocol and the interventions.

And they would also say that the difference is that when they’re stuck or a client gets activated, that it’s “go back to the protocol,” versus going to the client to collaborate.

LR: I wonder if there’s something about trauma, and particularly incest, that compels clinicians, especially those who aren’t experienced, to have to “do something.”

MB: A hundred percent! This is actually the new thing that I’ve added to the “fight-flight-freeze” paradigm, which is “fix.” So, I think what happens when a clinician becomes overwhelmed — I call it a place of traumatic stress — fix becomes part of a trauma reaction. The traumatic stress reactions.

When a therapist falls into a “fix-it” state, that should be an indication that they are in the trauma field and are feeling dysregulated. They then have to get re-regulated in order to move to a different place. And it’s the same with the client, who at that moment needs skills to re-regulate themself. I don’t believe when a client or a therapist is dysregulating, that’s the time to automatically use a technique.

LR: So, by jumping in with “a fix,” the therapist might be trying to regulate themselves at the cost of their client’s regulation.

MB: I want to say one other thing which is not going to be popular. I believe that when therapists jump in with a technique, they’re hoping it’s a solution for the consumer of their services.

LR: Giving them something.

MB: Giving them something, which is capitalism. Everything is an agreement in the contract with my clients.

The Importance of Working Systemically with Incest

LR: Someone reading this interview might say, “Well, it sounds like she’s working with the individual,” but I know you’re deeply systemic. So, I’m assuming that this collaborative model infuses your family work around complex developmental trauma?

MB: Yes. Most of the clinical work I do is with couples and families. And this goes back to the research we did with these clients who said that rarely, if ever, did other clinicians include their family. So, what would happen is that after those sessions with the “other” therapists, these clients would go home and have abusive fights or get hit. Or a parent would continue the abuse or violate.

Here, I go back to what I said earlier. Abuse, neglect, and childhood developmental trauma are embedded in a relationship of hierarchy and attachment. So, I believe healing should happen in a relationship.

I want the therapy to recreate some of the crisis right in the room with me. So, if there’s a fight, and dissociation, we all can witness it together and address it in the moment — together. If there’s eyeball-rolling that then triggers the other person, I want it to happen in the room, because those are the cycles that cause the traumatic stress at home.

Everything I’m saying to you here and now is what I say in the first session. When I start a session, I want the safety in our relationship to spill over into their relationship. I want their relationship to be a source of regulation. Not me. I don’t want to be the primary person in their lives.

LR: I can see how this would apply working with intimate partner violence. But are you saying that in cases where there is past or present childhood incest, that you would work systemically with either the current or past family members?

MB: Let me delineate two things. One; when the incest is currently happening and its children, yes, I include everybody. But I have all sorts of rules and boundaries. If it’s currently happening, and in most states, if incest is currently happening, then usually the perpetrator, whether it’s a sibling or a parent or not, is kept away from the child, right?

So, I don’t bring the alleged offender, or the offender, into the room with the victim until they’ve acknowledged facts. So, if they’re denying facts and saying, “She made me do it,” or, “He made me do it,” or, “It never happened,” I don’t do family with them. But I would do family with other family members. But I don’t bring the alleged offender into the room until after they’re no longer denying facts.

LR: Is that enough? Just getting past the point of denial? Would they have had to have done some significant reparative work of their own before you brought them into the room with the victim?

MB: They are in therapy. Yeah. I mean if it’s currently happening, then the offender is in individual and group therapy, according to how I think good incest therapy should happen. And the rest of the family are either in individual, group, or family treatment for whatever their issues are. And the kids could be in individual concurrently with the family therapy.And then when the violator has met certain criteria, then they can start coming into the sessions.

LR: So, who’s your client? In a case of incest, where it happens currently, or even in the past, who do you identify as the primary client?

MB: The family. But/and my collaboration is with all. It’s a team. I mean it takes a village. Absolutely. When we’re talking incest, it can’t be done effectively by one therapist.

LR: Do you or can you even work effectively with adult survivors of childhood incest?

MB: I’ve developed what I call the “family dialogue program,” which is for adult survivors with their families. And so, I do bring them together but it’s different. I often do it in these intense weekend workshops because if people live all over the country, it depends on if we’re doing therapy about wanting to talk about the abuse and neglect or are we doing what I call the third reality, which is, let’s just focus on the future. Let’s not focus on, did it happen, didn’t it happen, what’s going on? Let’s just focus on, am I going to come to your funeral? Am I going to come to Passover? How can we be in the room together? Am I going to go to my niece’s wedding? Are you going to ever meet your grandchildren? That kind of thing.

LR: That presumes that the perpetrator must take responsibility. They must be willing to listen, at least. Be present and listen. In other words, if you want to ever see your grandkids, you’re going to listen to me. You’re going to hear me. And that perpetrator may leave not feeling very healed, but at least he or she will have given the opportunity to the victim to be heard.

MB: And that’s why I call it the third reality. Because we’re just focusing on, “it’s not about your reality,” it’s about if you want to see your grandchildren. If I want to come to your house, are you going to be able to tolerate me…you know, me believing this and being in the same room as you.

LR: In a sense, it’s a way for the victim to recapture some power.

MB: Oh, absolutely. And that’s what most survivors will say to me. I mean a lot of people have said, “I was in therapy for 10 years, and that weekend with my father was the most important thing in my healing.”

The Gratification of Working with Trauma and Incest

LR: Okay, okay. My guess is that many in private practice would run when they receive a referral for incest. But you seem to run toward it.

MB: I don’t think people in private practice run from the adult survivors, but they run from when it’s currently happening.

LR: Why is that?

MB: Because I think it is one of the greatest taboos. And they never learned how to deal with it. And I think they never learned how to manage. And they often don’t understand how anybody can even want to see their father or their brother or their mother based on what they’ve done to me. Or done to them. Done to the victim. And so, I think a lot of them experience transference and/or feel inadequate.

I don’t know if it was a particular case, and I said to my husband, “What kind of person likes working with sex offenders?”

And in terms of me, Larry, I supposed we could get me on a couch to figure out why. I do remember very distinctly one time bolting out of bed, like sitting up straight. I don’t know if it was a particular case, and I said to my husband, “What kind of person likes working with sex offenders?”

But I would rather work with incest any day of the week over depression because people I work with change. And I see that change. I have seen plenty of sex offenders change. And I’ve had the fortunate experience of being able to follow up on some of my very first cases. I’ve seen one of my first cases 40 years after they stopped. It was an unbelievable experience.

Well, partly it was fun because I got to ask them all sorts of questions. I’ve always been a very creative therapist, where I just make shit up as I go along, that seems to fit. I remember one of my cases — it was incest and domestic violence. The father was in supervision and was told he couldn’t be within 365 yards of his family when he first got out of jail. He actually parked a mobile home 365 yards from the family home. And he was something else.

About a year into it, maybe less, I went back to court to get permission to have him come to family sessions. And he did. And one time, I was doing a good old family therapy looking for strengths, and I said to them, “You’re not always abusing each other. There are times when you’re not. Let’s talk about those times.” And the kids were younger, like 16, 11, and 10. I handed out these little recipe cards where I asked each family member to write down the recipe for nonviolence. Like a cup of this, and 3 tablespoons of that.

I gathered them all and laminated them, and then had them talk about it. The mother said, “It’s half a cup of going to church, and another quarter of a cup is no alcohol.” I mean that kind of stuff. And so literally 30 years later, I interviewed the same family. And the woman, the daughter who was the incest survivor was 40-something. I asked her a couple questions, one of which was whether she had gone to any trauma therapy. She said, “Why would I? I already had it.” So, I asked, “When you were getting married, or dating, what was that like? Were you always anxious? Were you afraid?” She opened her purse and pulled out the laminated card, and said, “I only dated people that had the ingredients.”

LR: Talk about having an impact. Wow, that must have felt great.

MB: I burst into tears. I didn’t do the initial interview, one of my graduate students did. But I was behind a one-way mirror, because who wouldn’t want to see one of their first clients? I went in and I asked them questions. So, in fact, there’s an example of the use of a particular skill. I don’t know that- would it have been the same if it hadn’t really come from them? I don’t know.

LR: Had you not had a relationship, they wouldn’t have taken the cards to begin with.

MB: Right, right.

LR: Do you see yourself in charge of the treatment village when working with the perpetrator?

MB: I have a case right now of sibling incest, and one of the kids is a young adult, but not even, I mean probably a teenager still, 18, 19, who is in individual therapy. I’m trying to do a family session because the parents have two children. So, the parents are involved, and the son who offended his sister. And I’m trying to coordinate. And the sister’s therapist didn’t call me.

LR: What recourse do you have?

MB: Well, the recourse I have is the parents. He is still a teenager. So, the parents can call this person up and say, “Our daughter signed a release, we signed a release. You need to call.” I’m not saying it in a nasty way. But I try to avoid doing that because I don’t need to start an adversarial relationship. But that’s the recourse I have. If the person was an adult, I mean I’d still have the parents to talk to their child and say, “Look, we want to heal this.” As it turned out, the son’s individual therapist calls me and cooperates. We have a great working relationship.

The Complex Arena of Incest Work

LR: Earlier on in one of our conversations, you said, “Incest is virtually neglected in our field.” Clearly, incest hasn’t stopped.

MB: Incest hasn’t decreased at all since I started in the field in ’78.

LR: What do you mean it’s neglected? By clinicians? By researchers?

MB: : I think everybody’s neglecting it. I think that the problem is that we’ve lumped trauma into one thing — complex developmental trauma.

I think that there is something very important to calling violence or violations what they are. Incest is unique. It’s not just a sexual assault. It’s unique because this is often a relationship where the people also have a very positive connection. “This is my parent,” they might say. I had a client way back, I mean again, 30 or so years, who wrote a poem. The one line that sticks out into my head was — and I don’t think she was writing it just to me, it was in general — she said, “I asked you to put an end to the abuse, and you put an end to my family.”

LR: Oh! Did she write the poem to you?

MB: I don’t think it was to me because I asked her. It was to the system. She’s another one that I still have contact with because periodically she’ll write me and say things like, “I just had a baby, just won a marathon.” I mean that kind of stuff. I think professionals feel anxious. I think they feel traumatized. I think it feels like you said. It’s such a moral violation that, as clinicians, we don’t know how to manage. How do I manage that I care about somebody? How do I manage that this woman stayed married to somebody who sexually abused her child?

I just think the taboo is so deeply entrenched that it causes such distress to those who work in this area. I just was working with a family where one of the children was sexually abused. And the other two weren’t. And when I talked to all of them, I said, “All of you were abused. But what happened to Susie is more of a moral violation.” And so that’s why people can’t tolerate it. I think there’s something about not being able to tolerate it. Like I said, I can find something positive. It makes sense to me that someone can be abused by a family member and still care.

LR: The popularity of complex developmental trauma overshadows the clinical attention on sexual assault.

MB: All I know is that so many clients tell me that people either never asked them or understood it. So, it just gets lumped into a category of trauma. And all traumas are not created equal. I’m not saying incest is worse than being physically abused. I’m not saying it’s worse, I’m just saying it has its own unique connected relationship with somebody they cared about who I also had many positives. And it leaves me even in some ways more confused because it isn’t linear or simple. Even if the person was abused by somebody that came and left like a babysitter or Boy Scout leader, with whom they also had an intimate relationship, it’s very confusing.

LR: The deepest form of betrayal.

MB: Yes. I think sometimes clinicians can’t manage that level of complexity. Which goes back to your question; “Give me some techniques, it makes things less complex. I can feel better about myself if I know how to do this. Do that.” Larry, every single day, I go, “Wait, I don’t know what I’m doing exactly. What do I do now? I just had this explosion.”

I was sitting in the room last week with somebody that got up, grabbed something off my table, threw it on the ground, and smashed it. “I got to go,” they said So, I said, “Wait a minute, okay, let me figure out.” What was I going to say in that moment? “Follow my finger?”

LR: What did you do? How did you handle the moment?

MB: What I did in that moment was said, “I need a drink of water. You need to sit down. I am feeling afraid. And I want to talk about this. But right now, I need to calm down. And you need to. We both need to.” I had been seeing this guy for a while. It made sense to say, “We need to regulate.”

Well, the wife was there, and they have a child. But the child wasn’t there. I had a separate session with the child. And I had a separate session with the wife. I did break them all up. And then I had a session with him, and we just talked about it. And I talked to him. And of course, like every other, he said, “This is what happens when she does blah, blah, blah.” “This is what happens when my child…” And I explained to him that acts of violence are linear. I don’t think I said “linear,” but… “I get it. It is all these other things that activate you. However, you have to make a decision about how you’re going to react to these things.”

LR: I would see where a younger therapist, or a frightened or threatened therapist might have ended the session immediately, out of fear for themselves, out of loss of control of the session. But you saw it as part of the way the system functions, and your role in that moment was to regulate. To me, the external regulator, the governor of sorts. Is apology critical?

MB: Acknowledgment is important, not apology. Because people say they’re sorry very easily.

LR: So, how do you know when an acknowledgment is sincere and productive, moving forward?

MB: So, when somebody is going to make a formal acknowledgment, it’s a planned session where they write a narrative. They write it down, they talk about… Basically, I have them talk about facts, impact, responsibility. So, they’re giving it to me beforehand. And that’s part of the therapy process. They’re writing their acknowledgement as a therapeutic technique. So, they’re writing this, and that’s how I know it’s sincere.

LR: What are some of the common presenting problems that people come to therapy with that raise your incest red flags?

MB: Well, on that level, they probably don’t look any different than any other form of abuse, neglect, or violation. They really don’t. Eating disorders, self-mutilating, suicide. Any of those things. Most of these are symptoms, I think are survival skills. I think they’re skills that people have used over time to survive their abuse and neglect. And now it’s become problematic. The skills themselves are problematic. The skills work. If I drank too much, if I cut, if I was sexually promiscuous, if I was suicidal, if I was dissociating. It might have worked to avoid memory and pain. That’s how I tell my clients; that most of their symptoms are utilized to avoid memory and pain until they don’t.

And now the symptoms themselves are causing the pain. To me, incest doesn’t look any different. What happens is, as I start my sessions by asking people how they heard about me.

If they didn’t know my name, they might have typed in “trauma, abuse, childhood something.” And it’s not just “therapy.” Usually, they got to me, somehow, they typed something else in. Or they got to me through a therapist. And so, when they say trauma, which is usually what it is, I then say, “Look, if we’re going to talk about it, we’re not going to talk about it now. But I need you to know I feel really comfortable talking about incest. I feel really comfortable talking about sibling abuse. I feel comfortable talking if you beat each other up.” So, I’m just saying, down the road, if any of those things come up, I feel comfortable.

LR: Has there ever been an instance where all roads pointed to incest and the person allowed you down that road, right up to the door, and then just closed it in your face?

MB: No. When I take a family history, when I do a genogram, and everything points to incest, I might just say, “You know what? I just need you to know from what you’re telling me; I’m not saying it was incest. But there might be, it could have been. It feels to me like emotional incest at least. Like you are hierarchically your father’s peer. Or it feels like you and your brother turned to each other in ways to get affection that you didn’t get from anyone else or your parent(s).”

So, it doesn’t have to be. And this isn’t your question. But it’s a question people often ask me. Do you need to know all the story to help? And the answer is no.

LR: And I think clinicians sometimes may forget that incest is a violation of hierarchy. It’s a violation of trust. And not all incestuous relationships are sexual. Are there any questions I could have asked or should have asked?

MB: Well, I mean we have maybe a couple of million. But I think what I would say is, you know, we should talk again.

LR: I would like that. Thanks Mary Jo.

Katja-Writing: Being Author and Audience to Fictionalized Stories of Trauma- Part I

Posted on July 25, 2023February 11, 2026 by Psychotherapy.net Team

“Love of the Written Word”

Poem by Irene

I feel like singing, dancing, — yes, even weeping,

I feel like playing music, loudly rejoicing, — yes, even singing psalms,

I feel like exploring, re-experiencing, — yes, even dreaming,

Each time I look to the written word.

I feel special, chosen, — yes, even honored,

I feel pure, poetic, — yes, even pretty,

I feel happy, joyful, — yes, even worthy,

Each time I look to the written word.

I enjoy paper, pencils, — yes, even glue,

I enjoy stanzas, verses, — and rhyming too,

I enjoy letters, notation, — yes, even grammar,

Each time I look to the written word.

I fill with harmony, trust, — yes, even wisdom,

I fill with loss, sorrow, — yes, even wrath

I fill with zeal, loyalty, — yes, even love,

Each time I look to the written word.

This paper describes a writing-based, storytelling approach to engaging with the consequences of extreme violence and sexual assault in childhood. This approach emerged spontaneously during a therapeutic collaboration between myself, psychologist Christoffer Haugaard (Aalborg Psychiatric Hospital, North Jutland Region, Denmark), and Irene. We wish to provide an insight into how this approach arose, how we practice it, and what effects it appears to have. In doing so, we hope that others may derive some benefit from these experiences towards finding ways to live a life beyond trauma that maintains and empowers one’s dignity and humanity.

Irene is in her early thirties. Throughout her childhood, her parents had subjected her to a multitude of forms of violence, including rape and physical as well as psychological violence. Shortly after reaching adulthood, she started seeking help in order to deal with the traumatization caused by her parents. This eventually led her to contact psychiatric services. Prior to this, Irene had some experience with self-harm practices, but this was inconsequential. This changed dramatically upon becoming a psychiatric patient, after which extreme and even life-threatening self-harm was a persistent hazard (Irene has not performed self-harmed since 2015). She was diagnosed with a personality disorder.

The Early Therapeutic Relationship

I met Irene after she was referred to psychotherapy for the second time within the hospital. This was in early 2012 when Irene was in her twenties. By then, she had frequently been hospitalized on account of dramatic self-harm and suicide attempts over the previous seven years. We have had weekly meetings since then and up until the present. Finding a way to engage with Irene’s story proved to be a significant challenge in itself. The fact that I am a man made it no easier for Irene. Therefore, our collaboration has also very much consisted of a search for, and a testing of, ways of talking about matters of concern. We would like to begin by describing some of the history of how the approach to therapeutic conversations that we discovered emerged:

Christoffer: We were attempting to talk about your life, Irene. I was focused on understanding how the things you were subjected to through so much of your life had been a shaping force on your way of being, and how you had resisted that power and the violence. I think that sometimes led to rather divergent characterizations of your person, whether your past self should be regarded as wrong, selfish, dirty, and guilty, or alternatively be regarded as caring, intelligent, and strong-willed.

At that time, I began to write abbreviated stories about you to convey what it was that I saw in you. I remember you telling me that when you read those stories, you were seized by a strong urge to refute the veracity of my claims, as if the text was subjected to an intense criticism because I dared to propose a different perspective on your character to the dominant version. At some point, you named this urge to criticism The Shadow Side. It readily reacted against attempts to challenge the heavy and dark interpretation of your story and your moral character. I recall you forcefully bringing The Shadow Side’s refutation to my attention at one point regarding the significance of me referring to you by the pronoun “you.”

Irene: I could hardly read the texts when you referred to me as “you.” The Shadow Side, the judging side of me, got angry and became automatically defensive. It wanted to tear the paper apart and shout at you, but it knew nothing was to be gained that way. Instead, it scolded me for being so stupid as to talk to you or read anything from you. We talked about how it was nearly impossible for me to read anything that portrayed me in first- or second-person grammar, so you changed your text into the third person. It was still a tough read, but it was acceptable because The Shadow Side perceived a small victory in this.

Christoffer: The first time I wrote to you addressing you in the third person was in 2013. You made me aware of The Shadow Side, and we described it and tried to deal with it through 2014. Would you mind describing The Shadow Side as it was at that time to provide an impression for our readers?

Irene: The Shadow Side destroyed my possibilities by repeatedly telling me that I was too ugly for anyone to like me, too fat to have friends, too dirty to receive a hug, too stupid to give my opinion, too wrong to breathe, and more insults like these. It constantly brought my attention to similarities with my parents whenever I said or thought anything that could remind me of their cruelties. If I got angry, The Shadow Side immediately made me think that I was evil and therefore capable of becoming violent or otherwise mean-spirited. Even though I never became violent, it had me believe that I was. The Shadow Side convinced me that I had anger like my parents and therefore I was identical to them and their atrocities.

The Shadow Side was a merciless judge or a desperate prosecutor. It devised well-thought-out and devious methods of making me portray myself as stupid and unworthy. Every time the cautious Defence managed to argue well, the desperate Prosecutor convinced everyone in the court with 10 strong arguments to the contrary. Some were a little far-fetched and had no truth to them, but when you listen to something long enough it is likely that you will come to believe it.

The Shadow Side was always hard, indifferent to anything anyone else said and always awake and alert. It never took a break. The Shadow Side made me become hard and live my life in a self-destructive bubble. It made me harm myself so that I could cope with everyday life, keep others out so that I would not be let down, live a façade so that I did not fully realize the horrors, ignore possibilities for getting help so that I could be strong, and so on. The Shadow Side made me believe that I was insignificant, as if I wasn’t even alive. It always told me how wrong and useless I was. The Shadow Side was my thoughts, beliefs and actions. It took over everything and swallowed my identity.

Christoffer: We arrived at me attempting to write about a fictional person instead. Someone not you, but similar to you and having endured similar trauma. In 2013, I started writing such stories about a fictional version of you in the third person that I called Kate. These stories were surprisingly not attacked by The Shadow Side. They were allowed, and you were able to read them, and we could talk about them without The Shadow Side attacking the veracity of the facts in the story or Kate’s moral character. It also made it easier for me to write stories, because now that it was fiction, I had creative license and consequently didn’t have to worry so much about getting all the facts right. Instead, I could focus more on the moral of the story. You have told me that when you read these stories about Kate, you were able to have an opinion and feelings concerning the subject matter. It became possible for you to feel compassion for Kate in the story.

Irene: That is correct. Kate came alive through third-person stories.

Christoffer: In 2015, we were focusing on circumstances, events, and actions that have contributed to your survival and to the moral character that you have today [Christoffer and Irene looked through examples from her childhood with a focus on her ways of taking care of herself and her dignity, as well as her survival strategies]. There were many things, but two things are of particular relevance in this context:

Having an Audience

As a child, Irene was the one amongst her siblings who took care of most of the practical tasks on a daily basis, while her parents did nothing. At a young age, her parents charged her with the responsibility for cleaning the house, tidying up, cooking, doing the dishes, looking after her younger siblings, including comforting them, protecting them from violence and rape, helping with their schoolwork, washing clothes, tucking in her siblings at night, getting them up in the morning, getting them to school and so on. She was also held responsible for unjust chores, such as chores given to other siblings that they had neglected or avoided, in addition of course to the basic unfairness of being forced to do all the work parents normally do.

Irene was often given additional tasks on top of this, or their demands were increased with the intent of punishing or humiliating her. She was forced to live such a slave-like existence by means of threats of violence, humiliation as well as acts of brutal violence leading to physical injuries.

How does a 10-year-old child survive such circumstances? Irene did so by imagining she was the main character in a fairytale like Cinderella. She would make believe that all these exhausting, humiliating, and unfair chores were like Cinderella’s, and that she herself was a kind of Cinderella in a movie and had an audience that witnessed everything.

This audience understood Irene to be the main character of the story and felt sympathy for her. They could see all the injustice that was otherwise hidden from everyone’s view and never spoken of as anything unjust within the family. The audience saw what happened, understood the injustice and reacted to it. This type of fantasy contributed to Irene maintaining a sense of dignity and justice throughout her childhood.

Writing Stories

Irene only revealed to me that she had previously invented a similar writing practice for herself after we had already developed our method of writing fictionalized versions of her life in the third person. She had begun writing stories about a fictional alter ego when she was around 10 or 11 years old and had even made an illustrated story prior to having the skills to author a written narrative. Irene’s fictional alter ego was called Katja, and Irene continued to update Katja as the years passed. The latest additions were written when Irene was in her early twenties. I was quite amazed when Irene told me this. Had we reinvented a new version of a practice that Irene had in fact invented for herself many years before? Unlike Irene, Katja of the story fled her home and had adventures and faced dangers in the wide world, finally becoming a physician and married with children. However, this alter ego was more to Irene than a character of this unfolding narrative. She was also a sort of invisible friend and companion to her. Here is Irene’s poem about her, written in July 2018:

Who Is Katja?
Katja was once a little girl who fled from her home.
She is the girl who held my hand when mom yelled at me.

She played with me when no one else was around.
Katja was moved to a foreign land.
She is the girl who held me when I fell.

She helped me when life was hard.
Katja was subjected to horrible things by her own parents.
She is the girl that hid with me when dad beat me.

She whispered words of comfort into my ear when dad left my bed.
Katja hurt herself.

She is the girl who carried the pain when I cut my body.

She managed fear so that I could breathe.
Katja experienced many betrayals.
She is the girl who suffered with me when dad kicked me.

She gave me sustenance when mom starved me.
Katja was assaulted many times.
She is the girl who never complained when we were tortured.

She sang for me so that I could fall asleep.
Katja never grew up.
She is the girl who shielded me from evil.

She followed me my whole life as a side of myself.
Katja’s life is my life.

Looking back and wondering what may have inspired the character of Katja, Irene points to fictional characters that were significant to her in her childhood: Astrid Lindgren’s “Pippi Longstocking” and Katarina Taikon’s tales about the Roma girl Katitzi that she had seen on television (Use of the name Astrid in the stories about Kate is in tribute to Astrid Lindgren).

We did not consciously create a therapeutic method out of these elements, but we discovered in hindsight that these survival strategies seem to foreshadow the approach that we arrived at. For that reason, we have chosen to name our approach after, and in honor of, Katja. The step from me sometimes writing to Irene about a fictitious version of her that I called Kate (Both names — Kate and Katja — are short for Katarina, a name that means “The Pure.” What a fitting name!) and to the approach containing precisely those two elements described above didn’t happen until 2017.

The World of Katja-Writing

Irene had been haunted by several nightmares her entire life. They were connected to her childhood but were not simply horrifying memories on repeat. Some of them did indeed take place in her childhood, but they contained twists and events that belonged in other periods of her life and even contained events that had never happened in waking life. An example was a nightmare about her school years in which she self-harmed in a way that was not part of her life until later. It also happened that she discovered her parents’ violence in a dream, and that someone tried to help her, even though that did not happen in waking life.

Anticipating such nightmares prevented her from getting any proper sleep. She would wake up in shock every morning due to the extreme content, feeling as if the events of the dream had really just taken place. It took half a day to get out of this state of shock and it was difficult for her to relate to other people due to the nightmares. She would have this surreal sense of something catastrophic having just happened; by contrast, all the while the whole world acted as if nothing had happened.

This chronic lack of sleep resulted in periodically occurring depressive states that involved an increase in risk of self-harm and suicide attempts. This pattern had led to frequent hospitalizations for years, often involving physical restraint. Irene and I had been working since 2012 on escaping the emotional numbness she had experienced for many years, so that she could feel and react to these bouts of depression at an early point and reduce the intensity of these cycles. We hoped that this would lead to less dramatic hospitalizations and a reduction of the risk to Irene’s health and life. This part of our collaboration was quite successful.

In June of 2017, we were focused on finding ways of alleviating these nightmares. I had the idea that perhaps Irene could influence her dreams by bringing moods with her from the waking to the dreaming state and thus create a less devastating course of dreaming. Irene had said that she was sometimes able to become lucid towards the end of her dreams and then be able to influence the events to some extent. Could this be expanded so that Irene could act within the dreams or shape them? I suggested writing a kind of good night story to investigate if elements of such stories could be brought into the dream if Irene read it just before retiring. The nightmares felt indescribably horrible to Irene, and therefore she had not described them to me in great detail. Based on what impressions I had, I wrote a short fiction about the girl Kate, and let the story take a turn in which Kate fled her parents and sought refuge at the house of a kind woman living next door. This woman realized that Kate was a victim of violence and called the police. Irene took this story home to read before bedtime.

It did not work!

Irene had become annoyed and frustrated with my story. It did not succeed at all in describing the reality of an 11-year-old girl who is a victim of rape and violence from her own parents. Irene was shocked at how ignorant I was and realized that she had assumed that I understood a lot more than I actually did. I could do nothing but admit to this and say that my own life experiences had not equipped me to know what it is like to grow up amidst such violence. It became very apparent to us both that we were on opposite sides of a deep gulf in understanding and experience.

We came from very different life experiences that amounted to inhabiting different realities, each lacking insight into that of the other. She felt compelled to write a story of her own and wrote an account of the fictional Kate, based on one of her many recollections of being brutally beaten by her parents. Like me, she allowed the story to end with Kate running away with her younger sister. She then gave me this story to help me gain some insight into the reality that she knew only too well.

I admit that her story was horrible to read. It confronted me even more directly with what I already knew I did not comprehend: How can parents do that to their own child — or any child for that matter? It was painful to read and to know that it was based directly on Irene’s reality as a child. The story also taught me something of what it is like to be a child under such circumstances that I obviously had great difficulty imagining dependent on my own imagination and disparate life experiences.

For example, the sympathy she felt for her father as he kicked her again and again. Or how guilty she felt for every blow she received, as if she deserved it. And how most of her attention was directed at her little sister who was hiding nearby, and how Kate was preoccupied with keeping her parents’ attention fixed on her, so that her sister was not discovered. It was so painful and heartrending to read that I felt I could not refrain from some kind of response. But how? This was a fictional version of something that happened many years ago. I had the spontaneous inspiration to write a reaction to the events, much like a witness that sees all these things unfolding, but who cannot be seen or heard by any of the people involved until many years later. I read the story again, but this time I marked every place in the text that made me think, evoked an emotion — whether it was anger, despair, compassion, hope, or that provoked my sense of justice and morality — and made comments that were sincere, immediate, and spontaneous responses to everything I had marked out. I gave this, unedited, to Irene to read and then we talked it through at our next meeting.

Without knowing it, we thereby created a method that we would continue to use with a number of Irene’s nightmares and memories from several periods of her life, a method that uncannily seemed to contain those two prominent survival strategies from Irene’s childhood: Writing fictional versions of her life about an alter ego in the third person, and having a sympathetic and responsive audience, advocating for the protagonist of the story.

In August 2017, Irene decided to convert one of her recurring nightmares into such a story about the alter ego Kate, who had now become our shared version of Katja. We agreed to follow the same procedure as before: I would write down my immediate, unfiltered responses while reading the story and send this back to Irene.

An Example of Katja-Writing

Irene and I would like to share with you an example of this work as we believe demonstration is the best possible explanation for it. We also hope that the contents of the example may contain knowledge about the effects and the responses of a survivor of severe childhood trauma, sexual assault, parental violence, and horrification. We hope such knowledge may be of some assistance to others seeking to address such problems. This specific example is the second story of this kind that Irene wrote to me in August 2017, based on a recurrent nightmare. It makes reference to sexual assault and parental violence but does not contain explicit descriptions of such actions. It does, however, contain an explicit description of self-harm which might affect some readers and therefore reader discretion is advised. To read this material, we refer you to Part Two of this paper, which will be published separately.

How We Do It

Irene writes a fictional story about an alter ego going through something very much like real events from her life or an actual dream. I receive this story and respond to it in writing as I read it. The concept of responding that guides me is this: I read the story as if I were a fly on the wall, an invisible presence in the story as if it were reality, or like an audience watching a live documentary in the cinema. I take Kate to be real, but someone I can only reach with considerable delay. I respond as a human being and not a therapist delivering psychological interventions to some determined effect. I am a representative of humanity and a moral universe that is against violence and oppression and holds the person to be of fundamental worth, and life to be sacred.

When I have received such a story, I find the time to privately commit myself to it without having to hurry or be interrupted. I return the text to Irene with my comments and when she has read it on her own, we have a conversation where we go through it comment by comment and discuss the significance and meaning of it. Conversations emerge that are by no means limited by the story but go beyond it. Sometimes Irene writes a response to my responses. And sometimes I also write a response to her responses to my responses, creating a written record of effects and reflections emanating from the story. Such material has been an invaluable source of learning for me.

Effects of Katja-Writing.

The following is Irene’s account of the effects of working in this way for about a year:

Irene: Having this heap of accounts is evidence. Evidence for reality and existence. It is hard evidence of a history and a life. It is there — no matter what anyone else thinks. It makes it possible for me to be a person, and not to just have to fit in, in the eyes of others. These accounts give me a place to stand. It makes it possible for me to live and exist and find peace with myself and not have to “pretend” so much to other people, in place of the feeling that I always have to please others by approaching them, being polite and similar things. The heap of tales make up my life and give me the right to be — in my own way. This is a great change. Being able to feel that way just some of the time is unbelievable!

Living with these stories about Kate and the responses to them is a whole other way of living your life. It makes a very big difference. Everyday life itself becomes different. For example, it matters in daily life that I can say to myself that, “I am allowed and have the right to go and buy groceries.” This gives me a place to stand in life that makes it possible to be. My history still takes up space and haunts me, of course, but suddenly without being heavy and depressing. I can breathe.

All those things I have been called so many times, I have always just had to take it. These words tear one’s personality apart – one’s whole identity that you try to build up — and divide body and soul. It is ripped to pieces so that it is in rags and tatters, but the stories about Kate make it possible to sometimes accept myself.

Working with Katja-writing means that I don’t have to be the main character and carry all the burdens. Instead, it is “someone else,” even if it is about me. It is not remote, but there is more distance. It is almost like becoming part of the audience, and there it doesn’t hurt the same way. There is space to have an opinion about the story. When it is not “yourself,” then maybe you don’t need to keep your guard up to defend and explain yourself so much.

Reading the stories about an alter ego makes it possible to think about the content. It makes it possible to feel something, to see clearly, and to have compassion for the person in the stories. It sort of takes all the “noise” away so that you are able to look at something ugly, but at the same time relate to it. When it is written about someone else, then you can feel something without it being “wrong.” If it is written about me, then it is dangerous and forbidden.

The stories and the responses are enticing. They give me a desire to read them again and again, both inside my head as well as reading it aloud to myself. It is fascinating that it is your own story that you suddenly gain access to.

Katja-Writing and The Shadow Side

In October 2017, Irene explained to me something of the conduct of The Shadow Side when she read my responses to her stories. It had basically given us permission to do this writing practice and seemed to have an interest in it. Irene told me that she got the impression that The Shadow Side is like a frightened child acting in a violent and repellent way to keep everyone away. It doesn’t trust anyone. It had helped and protected Irene and she feels she has an obligation to it. Hearing Irene’s impressions of it, I began to feel sorry for The Shadow Side and desired to recruit it “on our team” rather than seeing it as something “evil.” Irene explained to me that it can take on many guises and speak with different voices, but she could tell that at its core, it is basically a frightened, rejected child.

Irene has kept a continuous diary of every conversation she has ever had with me. In May 2021, she decided to share an entry with me as part of a letter from her, concerning our work on the story Freedom:

“Around the summer of 2017 I suddenly felt a stomachache — in a good way. I started to look forward to reading Christoffer’s responses to my Katja-stories about Kate. I think it was when I read the responses to the story Freedom that I quietly smiled to myself. It was responses like: “Dear Kate. You protected your sister in this ugly night. That is what you did. Your love is so great that I struggle to fathom it. And the injustice is so great.” Did he just praise Kate? And if it was praise for Kate, then was it not also praise for me who survived that ugly night?

In the same text, Christoffer responded: “You are giving something good to your sister’s life, Kate…” Did Christoffer think that Kate did a good thing when she looked after Little Sister? In that case, would that also be what he would think of me, if he had been around at the time?

I smiled and got all warm inside — someone thinks I am doing well. That I did well when everything was at its most chaotic and I didn’t know what to do.

For some reason, I was not attacked by The Shadow Side when I read these responses to Kate. That was probably why — because they were for Kate. But I was Kate! The responses had to apply to me too! Apparently, that was all right with The Shadow Side, who began to empathize with me instead of acting like a harsh judge.

In a diary dated August 18th 2017, I wrote about a conversation with Christoffer:

“We started talking about those responses he has written for the first part of the dream. I asked him if he wrote these responses for ME or Kate?! He replied that it was probably for Kate, but that he was also aware that there was a certain connection between me and Kate. He told me that he didn’t try to analyze what was me and what was Kate but responded very directly to what the story said. I was happy with this. I made a point that I was not Kate and at the same time not not-Kate [This is similar to the ‘Insider Witnessing Practices’ of Epston and Carlson (1)]. So, he chose to respond in the same way. I felt gratitude that he could be so liberated and honest, without hidden motives about achieving something definite. That he was willing to share his immediate thoughts with me without reservation. I explained to him that by doing this, I actually felt that Kate was finally getting a response! Yes, and maybe I am getting it too through Kate, but that is really good, because when I reflect on all that has happened, then it feels so real and at the same time so unreal. Almost like Kate — or Katja.

I said that this in a way made the past easier to deal with. And that someone could react to it. I added that at home, I had imagined that I had to remove everything that didn’t fit into the story. Make it chronological and detailed — and as such write a completely truthful account of that time. I would not have been able to do that. It would not have been nearly as free — and it would have been way too hard. But th

Love is Not All You Need: A Revolutionary Approach to Parental Abuse

Posted on June 8, 2023February 11, 2026 by Psychotherapy.net Team

The Referral Letter

The referral from Dr. Adams, the psychiatrist, read:

13-year-old young woman took an overdose of paracetamol 3 weeks ago. Called mother who took her to Accident & Emergency. Seen and followed up over last 2 weeks. No suicide ideation. Discharged to GP. Family issues. Please can you meet with this family this week?

Session One, Part One: Overdose and Desperation

A few days later as I (Kay) walked into the waiting room at the family medical practice where I worked, I saw Becca hunched over her cell phone, radiating animosity. Her mother Jane sat on one side of her, eyes on the latest New Zealand Woman’s Weekly story, but without the eye movement of a reader. Her father, Al, resigned, stared out the window at the dripping rain. Susie, Becca’s 15-year-old sister, picked absent-mindedly at her nail polish.

My step faltered as I sensed that the meeting ahead of me might be testing but I strode in, hand outstretched: “Hi! You must be Becca. I’m Kay.”

Temporarily startled, a reluctant smile escaped her as she awoke from cyber-land. “Hi, you must be Jane. Hi, Al. Hi, you must be Susie. Would you like to come up?” I gestured toward the stairs that led to my office stairs. As I reached the first landing, I noticed Becca glancing at herself with uncertainty in the floor-to-ceiling mirror that filled the stairwell. The family awkwardly found their way to their seats. I began my usual introductory patter but didn’t get far before Al expostulated, “Look, we need to sort this out! We can’t handle it any longer.” His eyes shot towards the brooding Becca. “She hit her mother in the face the night before last and then she locked herself in the bathroom for hours. We tried to get her to come out and talk but she just shouted abuse at us.”

Jane glanced towards me as she found some words.

“Becca went very quiet, and I got really scared. We thought we had taken all the medicines out of the cabinet after the overdoses, but we couldn’t help worrying after what happened the other week. We took turns sitting outside the bathroom door just listening in. Eventually, she came out and went up to her room. It all started when Al tried to tell her she couldn’t carry on talking to me like she was.”

“Becca,” I ventured, “did you realize that your parents are feeling so scared and don’t know what to do?” My question was met by a “no” that ricocheted around the room like a bullet. “Becca, would you be willing to help me understand what has been going on in your family?”

Becca’s reply began with a fake whine which escalated to foul-mouthed accusations. “She’s always saying, ‘Honey, what’s wrong?’ What’s wrong? What’s wrong? What’s wrong? What’s wrong? What’s wrong? What’s wrong? What’s wrong is that she’s annoying me. My mum is a stupid bitch with no life. That’s what’s wrong.”

I said, “Becca, is this way of talking the kind of talking that is causing trouble in your family?”

Becca said, “This is so fucking dumb.” Susie let out a protracted sigh.

“Becca, stop talking like that. It’s not fair. Mum and Dad have had enough and what have they done to you?”

The door slammed loudly as Becca made her exit. Jane leapt out of her seat, but Al caught her by the arm.

“Let her go. You always go after her. It’s no good. You can’t keep running after her like this.”

Concerned to sidestep the impasse between them, I spoke up.

“Okay, how about I go downstairs and find out what’s happening, and we can take it from there?” Al and Jane nodded, defeated. Susie was pale.

It turned out that Becca had found the back door to the building. I caught a glimpse of her crouched down with her back against her parent’s car, head between her knees. She looked up, saw me and went to sit on the other side of the car, out of view. I asked Emma, the receptionist, to keep a discreet eye on her. When I went back to the room, Jane and Al agreed to sit it out.

Al began, “It’s good you have seen her like this. We are falling apart. We can’t do this on our own.” There was a moment’s silence. Al looked to Jane. Jane’s shoulders began to rock as if she were holding back sobs. Al continued, “Becca doesn’t treat her mother like a parent. I mean she says things to me that I would never, ever have thought of saying to my parents. You just want to slap her face, but you can’t you know?”

Jane, her body stiff, said with a look of desperation, “The other night, Becca was screaming at me that the dinner was ‘crap’ and ‘shit.’ Adam, our 4-year-old, hid under the table. It broke my heart to see him so scared of her because he loves Becca. I feel like we are losing Susie too because she can’t stand it. She is staying ‘round at her friend’s house all the time.”

Al looked towards Susie, raising his eyebrows.

“You’re no angel either, Susie, but at the moment you come a long second to Becca.”

The story unfolded. It appeared that this was a long-standing pattern which had recently escalated from initial bad-tempered-ness to dramatic, life-threatening actions. I discovered that Al and Jane considered that they were being held hostage by Becca’s threats to harm herself, both subtle and explicit. Such threats followed any insistence that she carry out some duty that she didn’t wish to fulfill such as tidying her bedroom or if Jane said “no” to her persistent demands for money or to stay out late.

Jane had begun to fear returning home from work, anticipating that she would be met with yet more demands from Becca, and find herself caught once again between holding out against them or risking further threats of self-harm. Al was also finding home life unbearable. He longed to be able to “fix things” for his family but, in the face of Becca’s threats, had no idea what to do and couldn’t find words for the mixture of frustration, fear, and anger that preyed upon him. Al had started going around to his friend Mike’s house each night for a drink until what had started as occasional visits had become habitual. He felt guilty that he was not at Jane’s side but told himself and Jane, “I no longer have a place in this family. I am sick of being abused in my own home.”

Jane and Al had no idea what to do. Becca had been “seen” by Mental Health Service several times and, after the usual assessments (in which “mental illness,” abuse, and other possible sources of distress were excluded as a cause of Becca’s behaviour), the service had come to the conclusion that the overdose and threats of self-harm could best be explained by what was referred to as “family dynamics” and suggested that Jane and Al seek family therapy. That is how they arrived at my door.

How many parents, confounded by a family life that has become dominated by teenage tantrums, threats, violence, and the dread that their daughter might respond to any challenge to their demands with an overdose or violence, would be willing to talk about how they fear living in their own homes? How many would tell family and friends? Wouldn’t it be more usual for parents in this predicament to remain silent in their humiliation that their own child is abusing them? Of those family members and friends who had some knowledge of the situation, how many of them would be too respectful to speak up about this family’s predicament without being invited to do so?

Could these tantrum overdoses and the tyrannical threat of them instigate a servicing of young people’s every want? What might these young people be led to think about themselves if their each and every whim was serviced? Where would this lead? How might this have them lead their lives? How might this affect their family life? All these questions went through my mind as we reflected on this family and their tribulations; all these questions guided us in our considerations. This is the story of a family worn down by tantrums and abuse. This is also the story of a mother who decides to revolt.

Session One, Part Two: When Loving and Giving is a One-Way Street

“You know, Kay, we’ve always said, ‘love is all you need.’ It’s been our motto. I’m beginning to think we’ve made some big mistakes because I can’t understand why Becca is behaving like this. We have given them all so much love. We have always bent over backward to make sure that they are okay. It’s just so unfair. I try to listen and understand but she doesn’t want to talk to me anymore, and then she starts with her threats. I know I shouldn’t give in to them, so I try and hold my ground, but I feel like I have overreacted. Then I feel bad and give in. I know I shouldn’t. I just feel like I am stuffed!”

Jane’s voice faded into despair. As tears began to form in her eyes, she wiped them away hurriedly with the sleeve of her hoodie. Al chipped in, his voice weary with resignation.

“I just don’t know where we’ve gone wrong.”

I addressed the despairing Jane and displaced Al.

“Do you think it’s possible that all your loving and giving has become a one-way street, and that somewhere along the way your children’s wants have become confused with their needs?”

Jane swallowed hard.

“We’ve always tried to give them what they wanted. I always thought that if we respected them, they would respect us, but they don’t seem to. I just find it so hard to know what to do.”

I asked, “What do you think Al?”

Al shifted uneasily in his seat.

“What’s going to happen to them in the hard world out there?” he said wearily. I wondered if servicing their children’s needs had, contrary to their good intentions, been depriving their children of invaluable life lessons.

“Al,” I asked, “are you concerned in any way that unfairness has crept into the care of your children in that, by giving so much, your children may not have had enough opportunities to learn what they need to learn to live in the hard world out there?” Al had no trouble replying:

“Yep. I don’t think they have any respect for other people, and they don’t know how to be responsible.”

“Susie, what do you think of the idea that your parents have been unfair to you by not helping you to be ready for the hard world out there? Do you think that maybe, out of their love for you all, they need to find ways of mothering and fathering that might seem unfair to you now but may prove to be fairer to you in the long run?”

Susie stared at me, her eyes fixed in surprise, then she recovered herself. “I don’t think they’ve been unfair, but I suppose we have had it pretty easy. I don’t know, it’s getting me down too.”

“Susie, have you been worried about Becca?” Susie’s lip began to tremble. “Susie, how would it be if I carried on speaking with your mum and dad to see if we can find a way to help things be better for Becca and for you all? Would it be alright if I spoke with them without you present? I think your mum and dad need to find the way forwards on their own as your parents.”

Susie’s face softened with relief. Jane and Al agreed that the next time we met we would continue to explore how this habit of unfairness had taken root in the mothering and fathering of their children. I warned them that the road ahead might well be a rocky one and that other parents facing similar challenges are often met with intensified threats from their daughters or sons when they re-establish their parental authority. Jane and Al left our meeting, sobered by the realisation that they could go no further along the road that they had been travelling but relieved to be no longer standing paralysed at this crossroads.

Session Two: The Dif?culty of Knowing What’s Fair and What’s Unfair, What’s Unreasonable and What’s Reasonable?

Jane announced that there had been something of a turning of the tables. The day after our session she had decided that it was time the girls learned to do something for themselves. Instead of doing their clothes washing for them as she had always done, she had left their washing lying on their bedroom floors where they left it and stayed in bed herself for an extra hour. When later that day Susie asked where her clean washing was, Jane simply said, “Oh, I’ve given up doing your washing now.” Much to her surprise, Susie asked her to show her how to use the washing machine. Not surprisingly, Becca had left her dirty washing in a heap in her room.

Al, who was running late, joined us. I put him in the picture.

“We were talking about wants and needs and I was asking Jane about whether or not your parenting in the past has been about 'loving and giving?’”

“Well Susie has been getting too much until now,” Al responded. “My sister set her up with an interview as a summer lifeguard and she didn’t even bother to go. Lynette was really annoyed about it and had a real go at me. She said, ‘You two have to toughen up with those girls.’ I’ve realised she’s right.”

“What do you think you have been serving? Have you been serving her wants or her needs?”

“Her wants!”

“What do you think her needs are?”

“Her needs are to take some responsibility for herself. She hasn’t lifted a finger all holidays. She’s just sat at home emptying our fridge.”

“At what point do you think mothers and fathers should let their children know that if they as parents continue to take responsibility for them, they will be depriving them of taking responsibility for themselves?”

“Well, we do but we don’t stick to it,” Jane said.

“Yes. We lay down the law and then we give in,” Al replied.

“Looking ahead to when Susie is 40 years old, do you have any idea what she might wish you had done or said to her right now, aged 15?” I asked.

“She’d say ‘take responsibility for yourself’ wouldn’t she?” Al suggested.

“I suppose so, but we would have to make her do it and I would find that very difficult,” Jane responded.

“You said last time we met that you have a motto of ‘love is all your need.’”

“Yes, you know I have always thought that if we just loved our kids, it would all work out,” Jane said. “Last Sunday morning was a real low point. Becca started swearing at me when I got home from a late shift and was on my bed with all her friends drinking and eating. I found myself thinking ‘whatever happened to my lovely daughter?’”

“Do you think it’s possible that in the past, even though your intentions have been so very loving, love has been confused with giving in to what your children want?” I enquired.

“I guess so. I just thought they would love us if we loved them and that if we respected them, they would respect us,” she said.

“Are you coming to question how children learn love and respect for their parents and others?” I asked her.

“Yeah, I guess I haven’t made a point of them respecting me so maybe they haven’t learned it. I lose their respect for myself every time they say ‘no’ to me and I let it go,” she said.

“Al, what do you think about this? How do you think children learn to be loving and to practise respect?” I asked Al.

“Well, it’s been harder for Jane,” he said, adding, “I’ve always worked long hours and before we had Becca, we agreed that she would stay home and be a full-time Mum. We were really hanging in for Becca.”

“Yes,” Jane agreed. “You see Susie isn’t Al’s. I had Susie when I was 17 and I was a single parent until I met Al when Susie was 2. We had some problems and had IVF. Then she was preemie and we thought we were going to lose her. It was a terrible time.”

“Given you had to go through so much heartache to have her, did you ever think that Becca deserved special treatment in any way?” I suggested.

“We were just so thankful that she had survived,” Jane admitted. “Looking back now, I tried to give her the best of everything, and we doted on her.”

“Yeah, it was our one time away from her and she was all we could talk about,” Al said.

“Do you think that loving Becca so much has led you to be especially sensitive to her moods, wishes, and feelings?” I asked them.

“When I look back now, I think so,” Jane said.

“To be honest, she was very spoilt,” Al added after.

The Letter

The next day I wrote Jane and Al the following letter.

Dear Jane & Al,

It was good to meet you yesterday. As I mentioned, I often write to families after our sessions to ensure that I have adequately understood their situation and in addition to ask questions I wish I had asked during the session itself.

Sure, enough some questions came to mind whilst I was reflecting on your situation. I would be most interested to hear your answers or any thoughts you might have about these questions next time we meet. If you think that I have not described what we talked about fully or have misunderstood your situation in any way, could you also bring it to my attention next time?

Jane, before Al arrived you talked about some changes you had made. You said that a couple of days before we met, you had decided to have a ‘lie in’ and had resolved that you were no longer going to do the girls’ clothes washing. You also informed me that you felt you hadn’t had enough expectations of the children in the past and that you wished that you had started years ago. But you said that your lie-in was not as peaceful as you had hoped because you found yourself troubled, wondering whether or not your expectations of the girls were unreasonable or unfair.

Jane, do you suspect that your expectations may be having a late growth spurt but that perhaps, and very understandably, you are feeling a few growing pains? After all, have you ever noticed how overnight changes often feel as uncomfortable as a new pair of shoes to begin with?

Jane, do you have any ideas about why it was difficult for you to work out what expectations might be reasonable and fair? Do you think it may have been in part because your expectations of Becca at least, have been so shaped by the weight of your gratitude for her very existence?

Now that you have decided that your children can learn to serve themselves rather than being served, what kind of response do you think you might anticipate from them as time goes by? Do you think that they will take kindly to your new expectations which express your love for them in a way that serves their needs rather than their wants? Or do you think they might protest the changes in some way or other?

Jane and Al, towards the end of the session we talked about how separating your children’s wants from their needs had been especially hard with Becca.

Isn’t it understandable that if you have waited so long for a child and then when she is born and you are in fear for her life, you might want to treat her with especial care? Is it any wonder that your love and concern might leave you blinkered to some of her needs and sensitive to her wants?

Jane, do you think your ‘special care’ of Becca might have had a bearing on ‘giving in or setting boundaries and sticking to them?’ Thinking about it now, do you suspect that weak boundaries might be even more painful for you than for her in the long run?

You both told me that you don’t want to make your children unhappy, but then you talked about some realities that life holds. You said there was a difference between real unhappiness and tantrumming. If you always say ‘yes.’ if you’re always ‘manipulated.’ Where do your children hear ‘no’ from? What kind of lives will they lead if they never hear ‘no?’

Al and Jane, at what point do you think a mother or father should say to a young person: ‘I will not allow you to have such power over our family anymore; we are in charge, not you?’ Truth be told, what do you guess Becca would most like her parents to do right now?

I cannot believe that departing from the ways in which you have mothered and fathered your children in the past is going to be easy. In fact, would you consider that it might be one of the most difficult things you might ever take up in the course of your lives?

I look forward to meeting with you again on the 4th of March. Best wishes,

Kay Ingamells

Session Three: ‘Self Sensitivity’ 90%, Sensitivity to Others 10%

Jane came on her own to the next session. Although Al told her he was busy at work, she suspected that he had been overcome by his feelings of powerlessness and resignation. We began the session with my reading the letter aloud to Jane. Jane reported that the letter made her “realise I thought being a loving mother meant taking care of them in every way 100% of the time and this has made it difficult for them to respect me as well as for me to respect them.”

Once again, she reported some novel developments. Jane had “put her foot down” when Becca had decided at the last moment that she didn’t want to attend her surf rescue training.

“I said, ‘we are going in the car now,” Jane said. “And when we got there, she said, ‘Don’t make me go. You’re so mean, I hate you.’ I found it really difficult, but I insisted she stay. I went away feeling really upset but when I came to pick her up, she said she had enjoyed it.”

“Did you take a stand for what you knew in your mother’s heart was right only afterwards to be undermined by guilt for not responding to her wants?” I replied.

“Ummm I did.”

“How come you put your foot down even though the guilt was putting such pressure upon you to give in?”

“Well, I thought it was the best thing for her.”

“Does putting what was ‘best for her’ first rather than giving in to her wants say something about your wisdom as a mother?”

“Yes! That I know what’s right for her and it’s okay to say it and insist that she does what she says she will do.”

“Do you think guilt would have got in the way of your motherly wisdom in the past?”

“I think it would have. I wouldn’t have wanted the children to plead and cry. I wouldn’t have wanted them to be unhappy. I would have brought her home again.”

“What has enabled you to act on your motherly wisdom and use your motherly voice lately rather than be sidetracked by their pleading and crying?”

“I don’t know.”

“You’ve given me one example after another of how you have used that motherly voice very powerfully and afterwards.”

“And yet I don’t feel in control. I don’t feel in control at all.”

“Do you also think it is possible that using your motherly voice is uncomfortable because you are not that used to speaking with it yet?”

“I said to Susie when she butted in, I said, ‘I’m the mother. I’ll decide what Becca will do and what she won’t do. I don’t need input from you.’”

“Do you think that it’s possible that your children have developed over-sensitivity to themselves and to their own feelings and insensitivity to you and to your feelings?”

“Yes!”

“If you were to put that in percentages, what percentage of the time do you think they are sensitive to their feelings and what percentage of the time do you think they are sensitive to your feelings and the feelings of others?”

“They consider their own feelings 90% of the time. Al is really kind and generous and caring, but certainly he would put what he wants to do above anything or anyone else, especially me.”

“What happens to your feelings and to your needs?”

“They get forgotten.”

We talked about the effects this imbalance of sensitivity, e.g., self-sensitivity, versus other sensitivity was having in her relationships with her children and their relationships with her. Some of the questions I posed were:

“Would you be interested in restoring the balance between Becca’s over-developed sensitivity to herself and her under-developed sensitivity to others and in particular to you as her mother?”

“What kind of struggle would you expect if you were to pit your mother’s wisdom against the widespread mother guilt?”

“Overdoses as tantrums” and a big night out.

A month later, I had a call from a worker from the after hours Mental Health Crisis Team to report that Becca had taken another overdose. The overdose had followed an argument with her mother about tidying up her room in which Becca struck her mother in the face breaking her glasses. Jane had to go immediately to her optometrist as she was due to start work an hour later and could not work without them. Becca tried to stop her mother leaving the house, but Jane had no choice but to do so. Becca took the overdose as soon as Jane left. This overdose posed a greater risk than the earlier ones and it looked like she was, in a manner of speaking, “upping the ante.” Jane became concerned that Becca would take her own life and so arranged a safe haven for her at Becca’s aunt’s home for a few weeks.

Becca was seen for an urgent psychiatric review. The psychiatrist concurred that Becca’s overdoses appeared to be an extreme reaction to her parents attempting to set appropriate boundaries. A safety plan was put in place with the parents, and I met Jane and Al a couple of days later. To my surprise Al and Jane were not as shaken by the overdose as I had expected. Instead, they concluded that Becca’s extreme behaviour was her way of “testing us.”

We discussed how they had dealt with tantrums when their children were toddlers. On seeing the similarities between toddler tantrumming and Becca’s extreme form of teenage tantrumming, Jane and Al became inspired with a renewed courage and confidence. It now appeared that perhaps this was a problem that they recognised and not only had some experience in handling but could rightfully assume they might overcome. The next morning, I had a phone call from Jane. She had discovered from the mother of one of Becca’s friends that Becca was planning a big night out to a nightclub in the city with a group of teenage friends. The nightclub called Krave was in the heart of the city, an hour by bus from the suburb that Becca lived in. Jane and Al told Becca that she couldn’t go as she was underage. Becca was outraged and insisted that she would go regardless. Jane later discovered that $100 was missing out of her purse and challenged Becca who, as usual, denied taking it.

Jane and Al enlisted the help of Becca’s aunt, uncle, and elder brothers to come around that evening. Despite this, Becca made her escape out of her bedroom window.

The team hot-footed after her, combed the local mall and found her waiting at a bus stop with two friends. Al took hold of her arm and asked her to get in the car. Becca began to scream “blue murder,” shouting “you are not my parents. I don’t know you. Help someone! Help! Help!" The passers-by that had assembled called the police who arrived very quickly at the scene. The police believed Jane and Al’s version of events rather than Becca’s street theatre. Becca’s protest resulted in her being handcuffed, read her legal rights and taken down to the cells.

I asked Jane how she felt about the evening’s events.

“It’s good to be in charge at last. I have never seen Becca so demure. The police wouldn’t release her until she had promised not to harm herself.” Guilt had not had its way with Jane this time.

Session Four: Instigating the Revolution

While Jane and Al had begun to turn the tables on the habits of parenting which had flourished on their sensitivity to their children’s feelings and servicing of their wants versus their needs, I was concerned about the extreme nature of Becca’s actions and that Al and Jane’s newfound determination could be compromised in the face of them. Consulting with David in supervision, we decided that a community approach was needed to match the gravity of the situation and to provide sufficient reinforcement for Jane and Al’s fledgling initiatives. While no approach was without its risks, any alternative

How To Map the Toxic Impact of Social Media on Families in Therapy

Posted on May 4, 2023February 24, 2026 by Psychotherapy.net Team

Learn how to see. Realize that everything connects to everything else

— Leonardo Da Vinci

The internet in the late 1990s was exciting because you could research topics including sports, education, and entertainment and stay in contact with old friends. In retrospect, however, when working with adolescents at a local PHP and IOP, I/we ignored the impact of Myspace and other social media websites that encouraged cutting and suicide. We attributed the increase in behavior to peer influence and the impact of dysfunctional family relationships.

Today, social media’s algorithms and influencers have more of an impact on the family than we are willing to acknowledge. It has been argued that social media’s algorithms entice family members who use social media to spend more time on the app than with their own family or friends. As a clinician who works with families in private practice and schools, it has become increasingly clear to me that social media’s algorithms and influencers often occupy the “empty chair” in the family sessions.

The “Therapeutic” Power of Influencers on Family Systems of Care

It was evident to me while watching the hearings in Washington, DC a year ago that social media companies will not change their algorithms and will not share them for everyone to understand. The Netflix documentary The Social Dilemma had many former social media employees expressing eye-opening concerns. The film revealed how tech companies hire psychologists to make a persuasive algorithm to increase the appeal and use of their apps.

Unfortunately, Congress appears powerless, unwilling, or both, to make changes due to the powerful lobbying groups. Some have said that Congress is waiting for the UK’s Parliament to take the lead in regulating this industry.

Social media makes money by showing images or comments that their algorithms “say” are interesting and encourage consumers to “like,” “comment,” or “share.” Social media companies have also learned the more divisive and inflammatory the post, the more views and money there is to be made.

Well-designed apps continually boost the user’s connection by showing information, comments, or images that they have discovered are of interest. Showing an opposing view or people from a different “virtual tribe” will decrease the views/time spent on the platform and decrease money for the makers of the app. The app creates a virtually closed system that does not allow any “disliked” information or contradictory views.

If different members of a family “like” different apps, or different posts on the same app, each member of the family may conceivably align with a virtual presence against their actual brick-and-mortar kin or friend. As a result, algorithms have the power and potential to intensify the already-present pattern of conflicts within a family system or relational circle. Disconnection, chaos, conflict, and exacerbation of individual and/or family pathology may follow.

Influencers have always been present in our society. For many years, our influencers were teachers, family members, neighbors, friends, supervisors, actors, news anchors, and other people in our community. We would ask our immediate community personal and embarrassing questions. Many times, adolescents and young adults would get personal and difficult questions answered by building up the courage to approach someone face-to-face in their community.

Building up the courage to ask questions taught us how to manage our fear and anxiety. Navigating face-to-face relationships also teaches us how to manage embarrassment, frustration, anger, resentment, and rejection which is an important step in our development. Non-virtual relationships also allow us to feel emotional and physical closeness that is missing in social media/virtual relationships.

Today, our society is teaching the belief that anxiety is a bad thing that needs to be kept at bay. We in the field know that anxiety is not the problem. Arguably, anxiety is a result of the person’s core belief and/or what is going on in a relationship that will not change for the better. Because of this, adolescents and young adults are narrowing their non-virtual relationships because it is the path with the least amount of risk.

When asking intimate or difficult questions face to face, we learn how to manage proximity and closeness in our family and friend groups. We learn who in our family and friend groups has earned the privilege to be asked these intimate questions. We learn who can keep our personal life private and who may have the better answer, which builds friendships and family relationships.

Social media triangulates family and friends to find the immediate answer and connects people to a tribe that challenges them the least. Many believe decreasing their non-virtual relationship decreases their anxiety, but it actually increases their isolation from their community and increases their anxiety when meeting someone face-to-face. Also, virtual relationships give the illusion that all of these important ingredients are present on social media.

Family members are turning to influencers as if they are therapists/experts with answers (good therapy doesn’t give answers.) Or they are turning to politicians that they must blindly follow (good politicians allow debate.) We know the politicians who are at the extreme right or left posting inflammatory statements get the most views.

These influencers are making statements encouraging family members or friends to pick sides, skipping the process of face-to-face discussion with follow-up questions or reflection that occurs in non-virtual relationships. When a person stops exchanging ideas with their family members or friends, it creates a dangerous virtual closed system.

During my training at the Minuchin Center for the Family, I was always asked, “Whose shoulders is the adolescent standing on?” One year, a family I was working with agreed to meet with Dr. Minuchin for a consultation. Dr. Minuchin said to me after the consultation, “You will fail because the system of care erodes the boundaries of the family.” It became evident that each of the six members of the family relied on their own individual therapists to reinforce their view of how everyone else in the family was toxic.

This taught me the importance of understanding the family map in addition to evaluating if different family members were in coalitions with other therapists, social workers, and/or even agencies. It was an important step to understanding the map and identifying where the coalition(s) across generational boundaries occurred with the family and larger system.

In many of the sessions, other families were able to overcome their symptoms once they began to work on their relationships and change their relationships with the systems of care. It was exciting to see when the system of care noticed their triangulation with the family. Other times it was sad to see how systems of care did not see how they were triangulated against family members.

Today, influencers are present in the family session as seen by the virtual coalitions that the member(s) must maintain as if they were their closest friends in order to be a part of their tribe/team.

The Impact of Social Media on Family Relationships

Families are always ahead of the researchers and therapists, but do we listen to the pieces together as therapists? The following are the themes/symptoms families have discussed in my own family therapy sessions as well as those of colleagues in the wider clinical world. Each of these impacts adolescents, and, in turn, how they impact the adults in their home. On both sides of the relational equation, social media has a powerful impact, and not always for the good of individual and shared relationships.

When one or more family members are engaging in excess screen time from two to sometimes more than six hours a day on social media, the research shows there is an increase in symptoms of depression and/or anxiety. If someone has this much daily screentime, they are displacing healthier activities or hobbies such as walking, sleeping, drawing, painting, mindfulness, and gardening, to name but a few. And this displacement impacts the interactions in the family and community by isolating them.

Algorithms encourage constant social competition and comparison, and as such function as social currency between peers and family members. Adolescents typically feel that they are on stage competing to increase their position in the “hierarchy” with peers and/or parents. They continually compare themselves to peers at school and other families.

The algorithms that draw them in make it difficult for them to turn off the social app and get away from the stresses of adolescence. Jockeying for competition and comparing their lives to others may at times backfire, leaving them feeling poignantly and painfully alone. Again, this constant competition and comparison mirrors similar interactions in the family that can contribute to increased anxiety and depression.

The adolescents I’ve worked with discussed how they feel lonely and alone. They feel lonely when they are not supported or perceive they are not supported by family or friends, and feel alone when they have little face-to-face contact with peers like we all experienced during COVID.

The two-dimensional views people experience when using Zoom as the primary source of connection do not “feed the soul.” There is no substitute for good eye contact and close physical proximity. The irony is social media was created to decrease feeling lonely and alone but actually amplifies it. In family sessions, many, if not all, talk about how they feel lonely and hoped that social media would fill this void but were unsuccessful.

Adolescents typically think they are invisible or always on stage. These polar positions can occur on the same day for any adolescent. They think they are invisible when they are spending more time on their phones not getting enough likes and/or views, whatever that means to them.

This causes them to work harder on their online stories and identities, decreasing the proximity with their non-virtual friends. Many adolescents begin to look for the “genuine” or “real” friends, determining they are only present in social media and not in their own hometown or within the family walls. In the family, these themes are very common when there is already a pattern of disengagement (invisible) or enmeshment (always on stage).

The adolescent also thinks their peers are waiting for them to make a mistake so it can be posted online. This position makes them feel as though they are always walking into the cafeteria for the first time as a freshman in high school. Adolescents are supposed to make mistakes, struggle, learn about relationships with typical external distractions (friends, family, media, work, and politics). But does social media fill the lonely times when the adolescent and young adult are reflective and recoup?

Being invisible or always on stage prevents the adolescent from developing close connections with peers, teachers, coaches, or other family members. This results in adolescents seeking temporary relief from asking a “person” and instead getting information from social media.

Information on the app is monitored by the algorithm and is not as embarrassing or stressful as asking a family member, friend, or teacher. This is where social media begins to enter the family, impacting the adolescent development and challenging their family’s belief system.

The algorithm also motivates the adolescent to seek select information that aligns with their narrow/closed view about politics, friendship, religion, sexual identity, sexuality, gun laws, suicide, mental health, or any other hot topic.

The Atlantic, 60 Minutes, Pew Research, the New York Times, and the Wall Street Journal have done a great job discussing all the different ways social media has triangulated members of our families. The New York Times article on suicide, “Where the Despairing Log On and Learn Ways to Die,” by Megan Twohey, or The Wall Street Journal essay, “TikTok Diagnosis Videos Leave Some Teens Thinking They Have Rare Mental Disorders,” by July Jargon are exemplars.

Social media focuses on the “person” and navigating them to topics they are interested in and picking what tribe to belong to. The information is flowing into one part of the family system and not to the whole family which triangulates family members against virtual friends or influencers. This occurs if the family is already in a state of constant conflict or conflict avoidance. A recent 60 Minute piece discussed how China does not allow TikTok to bring up divisive topics to their children or adolescents.

For the adolescent to decrease feelings of anxiety and depression, they must work for the “likes” and “views.” They will be trying to affirm their sense of self, but many times they will be accused of bragging and will feel they are not good enough when comparing or competing with others.

Body image and feeling unattractive are especially amplified by social media’s filtering app. Many plastic surgeons are reporting an increase in adolescents wanting to get surgery to look like their filtered self. Current data shows that 55% of surgeons report seeing patients who request surgery to improve their appearances in selfies, up from 42% in 2015. They want fuller lips, bigger eyes, and smaller noses. “This is an alarming trend because those filtered selfies often present an unattainable look and are blurring the lines of reality and fantasy.” (1)

When I’ve met with families and these themes come up, I have encouraged them to discuss these themes which have allowed me to see the systematic position of each family member, system of care and the influencer/algorithm.

Every family has its struggles and at times feels out of control when it goes through a stage of what Monica McGoldrick calls its family life cycle. I have seen this especially when a family enters my office as it is attempting to (re)adjust to the needs of their childhood, adolescent, or young adult. Now add the influence of social media to one or all members of the family, the spiraling becomes more intense.

Crisis of Voluntary Play for Children

The importance of free and voluntary play with children to teach them how to give and take has been well documented. There is no substitute for non-virtual relationships in the early stages of childhood. Antithetical to this, algorithms require constant attention, taking the time away from connecting with others face-to-face.

Whether it is the child who requests to go on the smartphone or the parent who gives the child a cell phone in social situations (i.e., play dates, restaurants, long car rides, it decreases the opportunity to negotiate, argue, entertain themselves, compromise, and resolve conflict. This “tech choice” leads to delaying the development of the family and prevents them from moving to the next stage of a family with an adolescent.

Children Entering Adolescence Have Not Learned to Play

There comes a point in families when adolescents are told they are no longer a child, yet neither are adults. For some adolescents, not knowing the initial stages of voluntary and free play puts them into limbo looking for answers. The adolescent and family know on some level they are missing the tools for non-virtual relationships.

First, this is where the social media’s algorithm and influencers potentially intensify the family’s struggle. When the adolescent looks to social media for the answers, this intensifies conflict. Naturally, the adolescent wants to grow away from the family. They want to connect more with peers.

The adolescent in families with intense enmeshment/disengagement and different forms of coalitions struggle the most. This is where social media’s algorithms direct the adolescent to find a group. The algorithm pulls the adolescent in to spend more time on their app, resulting in the app making money and the adolescent searching for connections separate from the family.

However, virtual connections encourage the same patterns of enmeshment/disengagement and the different forms of virtual coalitions. These intense virtual connections are sometimes in opposition to the non-virtual relationships of the family and/or community.

Secondly, this social media generation has grown up learning to communicate more virtually and less in person, especially during COVID. Many adolescents have decided that they would rather communicate virtually. It is hard for some adolescents to look into someone’s eyes, read body language, and feel the energy of being in proximity because it makes them anxious. Look at any lunchroom at any local high school. If the school allows students to be on their phones during lunch, adolescents prefer to spend time on their phones working to maintain a social virtual hierarchy.

Social media offers a prime context for navigating these tasks in new, increasingly complex ways: peers are constantly available, personal information is displayed publicly and permanently, and quantifiable peers’ feedback is instantaneously provided in forms of ”likes” and ”views.” (2). Many of us who grew up before social media can only imagine if our mistakes were on a permanent record and followed us around for the rest of our lives, never allowing us to move forward.

Thirdly, the family does not have a chance to limit the adolescent’s time on the apps because the social media’s algorithm encourages constant attention, reinforces isolation from family and non-virtual friends.

Many parents have approached me saying, “The phone is their lifeline to manage their anxiety,” or, “The phone is the only way they connect with their friends.” During these moments, I have found it useful to explore how the whole family has come to the belief that the social app has become a way to maintain the homeostasis of the family.

A Non-Virtual Family Map

I often ask families about their virtual and nonvirtual family maps. I think it is important that we ask the family about their social media involvement to understand the virtual map of the family. Do families understand the impact of the social media algorithm? Do families know how to get out of the social media web? Do we ask each member of the family who they talk to virtually or non-virtually when they are struggling?

In initial evaluations, I often explore if the family is aware of how many hours they are spending on the social media apps. It is important to assess if the family is aware of how much social media raising/influencing is involved in the marriage, parenting, and sibling subsystem. Some providers want to focus on social media addiction, but the algorithm is not like any other “addiction.”

The algorithm allows many of the family members to covertly — and sometimes overtly — bring influencers into conflict with different members in the family. These virtual relationships amplify the family’s symptoms, and unfortunately today’s therapists use the medical model to diagnose the adolescent symptoms, further pathologizing and pushing the relationships in the wrong direction. This narrow view further sets the enactments, reinforcing the enmeshment, disengagement, and coalition patterns.

Non-Virtual Family Map

It is hard to shift our medical model training from a focus on the individual’s (child, parents, siblings) deficits to one that acknowledges strengths and competencies within individuals and the family system. When individual therapy does not make significant change, families often turn to family therapy as a last resort.

After experiencing this different approach, they often express frustration that they were never given the opportunity to move forward together, instead deferring to the experts for the correct intervention and diagnosis.

Structural Family Therapy was so different in the 1970s and 1980s; it was transcendent. While many new theories of family intervention have reached the mainstream, so too have many reverted to focusing on the individual. When starting individual therapy with the adolescent, I have found it important to ask the adolescent to overcome the algorithm on their own without their parents’ involvement. As family practitioners, we need systemic thinking more now than ever to approach the intense cultural impact of algorithms and influencers.

Below is a “traditional” family map that does not consider social media. It represents a compilation of families I’ve seen in therapy, rather than any one family. The symptoms include those typically seen in family practice — poor school performance, school avoidance, vaping, drinking, and using drugs.

From a system’s orientation, the symptoms are a result of the functional and dysfunctional interactions within the family system.

It’s hard for me to understand how therapists begin assessment and treatment without considering or involving the whole family. Some clinicians might say the conflict is too high, and it would only impact the adolescent negatively. Others might assume from the start that one or both parents are not willing to work or are too busy. Some might even be unaware of the importance of beginning from the position that families do not have the strength to make change.

Sometimes therapists and school staff buy into and reinforce the belief that the child or teen is the problem. In the case of this particular map, Mom “reportedly” goes to her private therapist while the son sees his own therapist. Mom and son separately complain about dad to their respective therapists and to the school staff. When mom and son voice frustration about dad and each other in the individual therapy session, disengagement with dad is reinforced. Mom and son are trying to get the type of connections from the system of care that they cannot get with Dad.

While this disengagement takes place, the son turns to his peers, attempting to pull away from mom’s enmeshment, activating her to pursue more. At home, Dad complains that his wife and son always bring up their therapist who agrees that he is unavailable and/or flawed. When this occurs, Dad becomes more distant and angrier, feeling like he is the odd person out.

When Mom gets angry at dad, she turns to her son and vents to him which activates him to challenge his father about money, drinking, and the way he treats her. At other times, the son may jump into the conversation when the parents interact about money, drinking, or the way he treats Mom.

When I attended graduate school, the common exercise was to map the triangles in the family system. Based on the above map, there are at least 24 triangles that are activated in the family-school-mental health system. The 24 triangles are:

The mom, son, and dad
The mom, son, and school social worker
The mom, son, and principal
The mom, dad, and school social worker
The mom, dad, and principal
The mom, dad, and school social worker
The mom, dad, and school principal
The mom, son, and mom’s friends
The mom, dad, and mom’s friends
The mother, dad, and dad’s friends
The mom, son, and son’s friends
The mom, son, and son’s therapist
The mom, son, and son’s psychiatrist
The mom, dad, and son’s psychiatrist
The mom, son’s therapist, and psychiatrist
The mom, dad, and son’s therapist
The mom, school social worker, and mom’s therapist
The dad, son, and son’s therapist
The dad, son, and son’s friends
The mom, son, and mom’s therapist
The mom, dad, and mom’s therapist
The son, son’s therapist, and school social worker
The son, son’s therapist, and psychiatrist
The son, school social worker, and principal

These 24 triangles are at the same time difficult for adults in the family to appreciate, even harder for an adolescent, and deeply challenging for the clinician to manage. In those triangles within the family where cross generational coalitions are activated, the symptoms in the family increase. I have often been challenged whether to discuss the impact of all these cross generational interactions with the family and whether it is important to differentiate the healthy, less healthy, and unhealthy ones from each other

On top of the above complexity, other questions arise like “where did the boundaries go?” The therapist must keep in mind how the boundary between the family and the outside world becomes invisible and the symptoms become more intense, to the point more professionals are recruited to “fix the dysfunction.”

I have also had to maintain awareness of how managed care’s enforcement and reinforcement of the medical model has influenced me and other members of the community of care, including other therapists, psychiatrists, physicians, and schools. This reinforcement has an impact on the family’s interaction with the son focusing only on his diagnosis and the correct medication, while failing to address the family relationships.

As mom turns to the school and the system of care for answers, things are not changing. She reports that her son is getting worse. Mom blames dad’s aloofness and dad blames mom’s overindulgence. Mom increases calls to the psychiatrist. The psychiatrist adjusts the medications frequently. The frequency of crises increases and the boundaries between the family and the outside world are dissolving due to the interaction between the family and the system of care.

The number of alliances increases between different family members and different professionals as more professionals/agencies are pulled into the drama. Professionals unintentionally begin to write/rewrite the individual’s and/or family’s stories, especially when utilizing the medical model.

With more stories, there are more opposing interests for each family member. This phenomenon between families and agencies is a result of a collision when both parties collaborate to uphold sociocultural trends. The goal is not only to interrupt multiple unhealthy alliances with existing professionals/agencies, but to also prevent new transactions from developing. (3)

This phenomenon was usually seen when the system of care worked with economically challenged families. We now see this also occurring with families of significant means because they can afford an individual therapist for each family member and psychiatrist(s) if needed.

As we look back at the map, it is now easier to understand that because the family has already identified what they think is the problem, it really needs to address the triangle between mom, dad, and son. It doesn’t really matter where to begin. A clinician can enter through mother-son enmeshment and coalition, father-son disengagement, or parental/marital disengagement.

It might also be useful to address the system of care coalitions between the therapist and school with the mom and son. Having the family identify how to change the interaction between the whole system allows them to move forward. It may be a challenge because getting directives from an expert, rather than looking within their own system, is what they have come to expect.

Using a Virtual Family Map to Identify Issues in Families

Before talking about the influence of social media on the family, it is important to acknowledge some of the “players” in social media. The system of social media has many parts. Social media success is dependent on an algorithm, which encourages frequent interactions by virtual and non-virtual friends.

The frequent interactions result in the shareholders receiving monetary return on their investment, the employees maintaining their jobs and bonuses, and the advertisers increasing the visibility of their product resulting in increased sales. The influencers are dependent on social media to reach as many people as possible to receive income from the app. There is a lot of pressure to have an effective algorithm to support social media.

As you next look at a map depicting the interactive nature of the family and social media, it is important to keep in mind that the 24 triangles from the non-virtual map are still present, and the family boundary is already disintegrating with the school workers, friends, and therapists to seek help with the identified patient.

Now in addition to these non-virtual professionals and friends, the family is inviting social media’s virtual friends and influencers to seek help with the identified patient. Clients (and non-clients) often turn to virtual friends and influencers to provide the same connection as non-virtual friends, but these connections are void of physical closeness. Children and adolescents believe a virtual relationship can replace a non-virtual relationship. But all virtual relationships are void of physical closeness in which touch, eye contact, and a warm smile can feed the soul.

The family can turn on a social media app at any time of the day or night and the outside world is invited into the family, increasing the number of triangles exponentially. From the clinical perspective, it is critical to examine what actions (social competition, social comparison, loneliness, etc.) in the family trigger a member(s) to invite social media into the family. The therapist must also discuss how social media algorithms are activating/triggering the member(s) of the family to turn to an app to surf or post an event. This increases the time spent on the smartphone to maintain these virtual friends, non-virtual friends, and influencer relationships.

At times, social media decreases connection with non-virtual relationships and increases the connection with virtual friends and influencers. In the therapy session with this particular family, some members discuss how they rely on virtual friends and influencers more because “they understand me more than the friends in my own town/school.”

The adolescent believes these virtual figures want to listen to them more than family and non-virtual friends. It is important to ask the family what influencers and virtual friends provide that their own family members or non-virtual friends cannot. This allows the clinician to address the patterns and interactions in the family.

In the map below, I do not draw the number of different social media apps, influencers and virtual friends who are involved with the family. However, I do recommend when meeting with families, to draw each app, virtual friend, and influencer to show the number of triangles the family is managing or attempting to manage. For simplicity’s sake, I use one (black) box to represent all the social media apps and one box for all influencers and separated mom and son’s virtual friends.

Husband, Wife, and Social Media Triangle

What is the impact of social media on marriage? The wife turns to social media and influencers to figure out how to “fix” her marriage. The wife tries to talk to her husband about what she has learned about marriage on social media. The husband discounts the wife’s attempts to “educate him about marriage.” She eventually gives up on the marriage and “wants to focus more” on her son. She also tries to connect with previous friends and boyfriends from past life because she feels lonely and alone “looking for a connection.”

What you will see in this triangle, and all the triangles which involve social media, is a substitution of a virtual relationship for a non-virtual relationship whose connections are full of conflict or conflict avoidance. The virtual relationships convey an illusion of meaningful connection, but the person(s) feels alone and lonely because it lacks the important ingredients for a fulfilling relationship.

Mother, Father, and Social Media Triangle

Now the wife stops working on the marriage and focuses on parenting. The husband is not aware of this decision, focusing on “making money to provide food, clothing and shelter.” The father continues to feel alienated, disconnected, and disempowered, becoming angry towards the mother and son. The mother turns to school staff, therapists, non-virtual friends, virtual friends, and influencers for ways to “fix her son.”

This fosters more of an enmeshment with son, and disengagement with Dad. The son turns to school staff, his therapist, non-virtual friends, virtual friends, and influencers. Each family member describes a feeling of disconnectedness trying to overcome the feelings of being lonely/alone. Dad voices his frustration, complaining that he is “old school,” and they are “hypnotized by that damn phone.”

Mother, School, and, Social Media Triangle

In this triangle, mom calls the teachers and guidance department for support. She has frequent phone calls with the guidance counselor because the guidance counselor “is an expert with adolescents.” As you can see, dad is left out of the interactions with the school.

After a few months, her son’s behavior is not changing, and mom is frustrated with how the school is not helping her son. Mom begins to turn to social media looking for answers. Mom spends hours on the app talking to non-virtual friends, virtual friends and reading/commenting on influencer’s posts. Mom displaces healthier activities with time spent on social media. Mom begins to complain that the school is not meeting the goals set out by the Individualized Education Plan (IEP). Mom cites information from influencers from social media and the internet. The tension rises between the school and mom.

Schools today are under tremendous pressure to perform. Schools are understaffed, and do not have the mental health training or support to bring in a countercultural systemic approach into the schools despite the money being put into schools after COVID-19.

Parents, Son, and Social Media Triangle

Mom is spending hours on social media looking for answers to why her son is struggling. She also spends time looking for connections. The son also spends hours on the app interacting with non-virtual friends, virtual friends and reading influencers’ posts.

Mom pursues the son, but he only is aligned with her to challenge dad’s limit setting. When the parents attempt to be aligned, the son acts out more. We see the son increase his conflict with parents, who struggle due to their enactment/conflict avoidance with each other on how to help their son. This results in the father leaving and the mother turning to social media to find answers or overcome feelings of loneliness.

When the family interactions are in intense conflict or conflict avoidance, many children, adolescents, and young adults get most of their answers from non-virtual friends, virtual friends and influencer’s posts. The son is seeking temporary relief by getting information and trying to affirm a sense of self.

The non virtual, virtual relationships, and influencers introduce beliefs that are the opposite of the family’s beliefs and further impact the self-esteem of the adolescent. The son discusses what he learns from social media of what “real parents are like.” The decrease in face-to-face communication with family increases his anxiety, depression, irritability, and intrusive thoughts. This also confuses the family of how their family member can “think so differently.”

Son, Non-Virtual Friends, and Social Media Triangle

The son in the session discusses constant social competition/comparison, working for social currency, and thinking he at times is invisible to his non-virtual friends. The son gradually believes his non-virtual friends “don’t understand.” He believes he cannot turn to his parents because “What do they know?!”

The son begins to engage in the same interactions with his peers as his parents and avoids turning to his peers for support. The son begins to spend more time on social media with virtual friends and influencers to seek select information that matches a narrow/closed view, hoping to avoid conflict/interaction. The son then turns more to virtual friends and influencers for answers. Again, this increases his time on his smartphone and increases the family’s sense of not being good enough for each other.

Remember, the son believes there is “less stress” getting information from a stranger, pop culture icon, or a virtual friend than an enmeshed mom, disengaged father, or face-to-face with a peer(s). However, the decrease in face-to-face communication with family and non-virtual friends increases his anxiety, depression, irritability, and intrusive thoughts.

Despite the time spent on social media, the son feels alone/lonely, looking for emotional, face-to-face and physical connection, but does not have the words to express these thoughts to each other.

Mom, Therapist(s), and Social Media Triangle

Dad continues to be absent from the triangle that involves the therapist. The mother attends her own therapy and attends her son’s sessions to discuss what new information she has seen on social media.

She reviews with both therapists what she has learned on social media about new treatment, new medication, and new diagnoses. She advocates with all providers that her son is incorrectly diagnosed, hoping that would help him with his symptoms. The quality of training of the therapist determines their response to entertaining or challenging mom’s research. This may result in mom seeing a new therapist.

The individual therapists and psychiatrists are not looking at how the parents avoid “getting on the same page.” They are reacting to reports by mom about the son’s behavior. Mom and dad are unable to interact differently because they have not figured out how to work together to decrease their son’s phone usage to increase his time with non-virtual friends. The professionals are avoiding addressing the parent’s avoidance!

Mom, Psychiatrist, and Social Media Triangle

Dad is absent from the triangle that involves the psychiatrist. Mom becomes disgruntled with the psychiatrist. She begins to challenge the psychiatrist’s diagnosis and medication recommendation. The psychiatrist recommends if mom is not satisfied with his assessment, she seek a second opinion. Mom begins to look for a psychiatrist who agrees with what she has read on social media.

Son, System of Care, and Social Media

The son is seeing his individual therapist 1-2 times a week and his psychiatrist once a month. He is also spending 2-8 hours on his social app each day. The therapist has not assessed the hours the son is spending on his phone. The app is only showing views/opinions/likes/images that interest him.

The son begins to complain that the therapist does not understand him and challenges his therapist saying, “This doesn’t help.” When the therapist explores the son’s statement, he begins to discuss information from “reliable sources” from social media and influencers. He too begins to diagnose himself and discusses medication that can help. When the system of care discusses reliable sources such as universities and professional journals, the son becomes irritated saying “I don’t want to read them.”

Son, School Staff, and Social Media

Not only does the system of care increase their sessions, but the school staff increase their time with the students. The number of triangles with the son in the school increases between the child study team, teachers, and administration.

The teachers are pursuing him to get his work done — offering to meet him before school, lunchtime, and after school to complete his work. He never shows. The son is seen in class on his phone. Some teachers ignore him, and others nag him. When a teacher challenges the time he is on his phone, he tells the teacher other instructors let him do it.

The social worker is calling him down to discuss his avoidance of work and disruptive behavior in the classroom. Only when the son becomes overwhelmed, he discusses with the school social worker his home life and that medication is not working. The vice principal is meeting with him to give him detentions. The son feels frustrated with the school stating, “They are only doing this because it is their job.”

Son, Non-virtual Friend #1, Non-virtual Friend#2 with Social Media

The son leaves school to go home to continue to work on his non-virtual relationships on social media. It becomes evident that in social media apps, the same social stressors occur online like in school. It is exhausting to navigate being included and avoid being excluded at school and online. The son and non-virtual friends are jockeying for social currency and social position, never getting time off to charge their own social battery.

The son and non-virtual friends stress about the images they post. They are anxious about what the image means to them and others. The son is trying to understand the unspoken rules for posting and the reaction by his peers regarding the image. The son worries if the image appears “authentic” and will help him maintain his position inside the social media group or if a new group be formed without them.

Son, Non-virtual Friend(s), and Virtual Friends

The son struggles connecting with his non-virtual peers. He is not getting feedback from his non-virtual friends about his art and his physical appearance and finds out they have different chat rooms that do not include him. (Remember, he does not want feedback from an overly involved mom or detached father.)

He begins to look for feedback about his art and physical appearance from virtual friends. When looking for connection outside the non-virtual friend group, he states he is looking for virtual friends who are nonjudgmental.

But as time went on, it began to mirror the non-virtual group. Some of his virtual friends on social media become competitive and attempt to increase their social currency on this platform. They do this by making fun of his physical features and his art. This mirrors some of his non-virtual friends’ behavior. The son frantically searches for another virtual peer group that he believes will not activate anxiety by not challenging his views, providing a stress-free venue.

As the son increases his time searching for virtual peers and influencers over non-virtual friends — reinforcing a closed system, increasing isolation at school, and decreasing time to sleep at home. His virtual relationships are now more important — increasing time spent on the app and continuing to strive for more likes and views.

Lack of face-to-face contact with family and non-virtual friends fosters more of a virtual enmeshment with virtual friends. He describes them as “nonjudgmental” and “more accepting.” This further increases his self-doubt and increases his feelings of loneliness and creates a virtually closed system (Virtual Enmeshment).

Son, Virtual Friends, and Influencers

The virtual group is important to maintain when avoiding contact with his parents and non-virtual friends. The son describes his virtual friends as more “authentic” and describes his non-virtual friends as “fake” and “not genuine.” However, some of his virtual friends on social media become competitive and attempt to increase their social currency.

The son frantically looks for another group that is an anxiety and stress-free venue. This further increases his self-doubt and increases his feelings of loneliness. This increases the symptoms of anxiety and depression when waiting for approval from virtual friends saying, “They are the only ones who understand me.”

As the son looks for new virtual friends, he and his virtual (and non-virtual) friends look to influencers for answers on how to portray themselves. Influencers work hard to establish and maintain their position in their virtual community. The influencers are working hard to make money and increase their viewership. The influencers often ask adolescents to agree with their beliefs and recommend products they are selling. The influencers work hard to appear on the “right side” of an issue.

As the son tries to replicate the beliefs of his preferred influencers, he looks for fellow virtual friends that have done the same “research.” They notice the more they make comments in opposition to a belief, it increases their views and likes.

As the symptoms in the family increase in intensity, the members increasingly must decide who to align themselves with in the virtual and non-virtual triangle. The therapist highlights this and encourages the family to discuss and identify the boundaries of virtual and non-virtual triangles that maintain these alliances/symptoms. This allows a family to discuss non-virtual triangles that are underutilized, which reinforce healthy boundaries that benefit the family.

Using Exploring Questions to Make Circular Statements

Much has been written about joining, unbalancing, and mapping in SFT. One of the beautiful ways Structural Family Therapy (SFT) uses language is by employing circular statements to connect the family member’s behavior in the system. When SFT enters the family, the systems therapist uses the family’s own observations to connect their interactions.

It is important today to make a circular statement to widen the lens in which the family sees how all virtual and non-virtual relationships impact the relationship in the family. Below are some examples of circular statements using the words used by each family member.

I agree with you, Mom, that as long as you do not have a voice with Dad and work together, your son will not stop posting explicit images on Snapchat

Dad, as long as you sound like a drill sergeant, Mom will not find her voice as a woman and work with you as a wife and mother of your son who will continue to believe he must mirror images on Instagram

Mom, I agree that the harder you work, the less Dad helps you with parenting your daughter— your daughter will have to turn to influencers about how a woman should look and act

Peter (son), as long as your mom is worried about the frontstage appearance, she will fight with your father who is more concerned about your backstage struggles with you and your mother

What do your virtual friends give you that you cannot get from Mom, Dad, or your non-virtual friends?

Conclusion

Many are worried about the continued increase in suicide, suicide attempts, and mental health issues in the family and how Congress is powerless to challenge these companies. Many providers are not looking at what has changed in our lives in the past 25 years.

Relationships are becoming more complicated than ever. Many families and therapists are unaware of the impact of the system of care and less aware of the impact of the ubiquitous “algorithm.” It is hard to understand how the algorithm works because it is important for these companies to keep the algorithm secret for fear of losing profit.

We must also remember that each influencer, virtual friend, and nonvirtual friend has their own family map. Just as many professionals do, influencers understand how their stories, views, and images echo in the family.

Are families aware of the alliances that occur with virtual and non-virtual friends and influencers? Are we aware that when more virtual influencers and friends enter the family, more alliances increase establishing social hierarchy, increasing social competition and social currency? Are we, the clinicians, aware that influencers and virtual friends unintentionally/intentionally begin to write/rewrite stories in the family and permanently on the internet?

We must begin to understand that with more stories, there are more opposing interests for each family member. This phenomenon between families, virtual friends, nonvirtual friends, and influencers (social media) is a result of collusion when all parties collaborate to uphold their preferred sociocultural trend.

The goal is not only to highlight and interrupt the multi-alliances with existing social media but to highlight the transactional pattern in the home that maintains this pattern. Remember, a virtually closed system impacts all family members, whether one or all are using these platforms excessively.

References

(1) Susruthi, R., Myara, Maymone, B. C. & Vashi, N. Selfies-Living in the era of filtered photographs. JAMA Facial Plastic Surgery. 2018 20:6, 443-444.

(2) Nesi, J. (2022) The impact of social media on youth mental health: Challenges and opportunities. North Carolina Medical Journal, 81(2), 116-121.

(3) Colapinto, J. (1995) Dilution of family process in social services: Implications for treatment of neglectful families. Family Process. 34:59-74.

Questions for Reflections and Discussion

How has social media influenced your personal and family life?

How does the author’s premise resonate with you and the way you practice family therapy?

How have you integrated social media and app use into family therapy?

In what ways do you agree or disagree with the role of social media in family systems?

Current Developments in Clinical Suicidology and Mental Health Crisis Management

Posted on April 4, 2023February 11, 2026 by Psychotherapy.net Team

* If you or someone you know is struggling or in crisis, help is available. Call or text 988 or chat 988lifeline.org. Text MHA to 741741 to connect with a trained Crisis Counselor from Crisis Text Line.

There are significant developments in the world, the United States, and our field in recent years that are significantly impacting contemporary clinical suicide prevention. The Covid-19 worldwide pandemic, the launch of the 3-digit 988 Suicide and Crisis Line in the U.S., and recent SAMHSA and Centers for Disease Control data are all examples of major forces that are fundamentally transforming the field of clinical suicidology. Many of these contemporary developments are spawning necessary and overdue changes and adaptations as to how mental health providers can more effectively work with suicidal risk. And to this end, I will explore these major developments and their impact on clinical suicidology.

Telehealth Care and Suicidal Risk

An impressive development in response to the coronavirus outbreak was the remarkably rapid embrace of telehealth to deliver mental health care. As the worldwide pandemic spread rapidly in early 2020 there was an initial hesitation of widespread use of telehealth with people who were suicidal. Indeed, there were certain large healthcare systems who moved, suspended, and even discontinued screening for suicidal risk with patients online because of a flawed presumption that one can only work with a person who is suicidal face-to-face. In other words, if you cannot tackle the patient at risk who is fleeing your office to take their life it is better not to ask! In response to this naive notion, certain leaders in the field of suicide prevention made significant efforts to identify key adaptations to working with suicide risk remotely. These adaptations mostly involve using informed consent carefully, identifying third parties who could intervene in case of an acute emergency, and anticipating issues such as a poor Wi-Fi connection and what to do in such an event (e.g., having a phone number to call if online connectivity is an issue).

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As we were all collectively compelled to learn to provide care online perforce, many unexpected developments followed. For example, telehealth now offers a genuine opportunity to democratize the delivery of care to rural, frontier, and potentially more diverse populations. Another development in psychology was the advent of PSYPAC which enables providers to increase clinical care across state lines. Another notable Covid-based development was the common practice of instructing people who are acutely suicidal to go to their nearest emergency department for care.

With emergency departments brimming with coronavirus patients, such a recommendation became ethically and clinically dubious. Common reliance on inpatient care similarly posed the increased risk of patients contracting Covid during the pandemic's height. As the developer of the Collaborative Assessment and Management of Suicidality (CAMS), I have long been a vocal advocate of keeping patients who are at risk of suicide out of hospital emergency departments and inpatient care (if at all possible) by providing proven suicide-focused care supported by randomized controlled trials (RCTs). In response to the early stages of the pandemic, our training company CAMS-care converted the training and delivery of CAMS to online modalities (including the use of CAMS in three RCTs). We soon discovered that both training and clinical care can be effectively rendered online, and this development is helping to transform clinical care for those at risk for suicide.

The 988 Suicide and Crisis Line

In July of 2022, a major federal law was put into effect that is profoundly transforming how we must think about suicide risk and mental health crises. The “National Suicide Hotline Improvement Act of 2018” is one of the most significant legislative developments in the history of U.S. mental health care. Suddenly, we have an easy-to-remember 3-digit number that connects callers who are suicidal or otherwise in a mental health crisis to crisis professionals who are ready and able to effectively deal with them. With the knowledge that the pre-existing Lifeline was already having capacity issues, millions of dollars were subsequently allocated to help better support the new 988 mental health crisis line.

While all of this is very encouraging, the launch of 988 has created some growing pains and posed various challenges to policymakers, systems of care, and clinical providers. For example, how well do Americans know the difference between calling 911 and 988? There is a need to educate the public as to how to re-think emergencies that would have previously prompted calls to 911. There are significant issues related to “wellness checks” or “safety checks” that are primarily conducted by law enforcement officers who may have limited to no training as to how to deal effectively with mental health care crisis. For a person of color, having a police officer show up uninvited to protect you from yourself has inherent issues. 988 also brings a major focus to our existing healthcare model that is overly reliant on emergency departments and inpatient hospitalizations that too often may not be altogether therapeutic.

Fortunately, alternative models of crisis response are emerging. For example, “The Hope Institute” in Perrysburg, Ohio, provides intensive outpatient suicide-focused care using next day appointments (NDAs) wherein either CAMS or Dialectical Behavior Therapy (or both) can be provided up to four times a week to help stabilize a person who is suicidal as they await weeks — sometimes months — `to engage in available outpatient care. Within this model, adults are stabilized in six weeks while youth at risk are stabilized in just over five weeks. This is but one promising model that is re-imagining working with suicidal crises. Other promising approaches include mobile crisis response, respite care, retreat centers, certain crises-oriented technologies, and extensive use of peer support which can help reshape crisis responses.

Recent Trends in Suicide-Related Data

Over the last several years there have been notable developments in suicide-related phenomena. While we were initially encouraged when suicide rates declined a bit in 2019 and 2020, this decline was erased by an increase in 2021 (the most recent data reported by CDC). And with Covid-19 becoming a leading killer, suicide is no longer a top ten leading cause of death with 48,183 lives lost to suicide in 2021. But what has preoccupied my attention has been steady increases in the number of Americans who report having “serious thoughts of suicide” within 30 days of a survey completed by SAMHSA. Indeed, in 2021 this amounted to 12,300,000 adults and another 3,300,000 teens, altogether a whopping 15,600,000 Americans with serious suicidal thoughts! This number is over 300 times greater than the number who died by suicide in 2021.

While we grieve the loss of Americans to suicide, I would argue that we must do a much better job of identifying, assessing, and treating millions of those who suffer such that they seriously consider suicide. In truth, the suicide problem we have in the U.S. is a suicidal ideation problem — by a lot. It therefore behooves all mental health professionals to learn proven interventions like Dialectical Behavior Therapy (DBT), suicide focused cognitive behavioral therapy (CT-SP and BCBT), CAMS, or Attachment-Based Family Therapy (ABFT) to name a few of the rigorously proven interventions for suicide risk. Moreover, there have been other demographic developments of note. As suicide rates among white males have decreased, we have seen in recent CDC data that suicide ideation and behavior is on the increase among young people, particularly those of color. We certainly know the pandemic has been tough on all of us with clear increases in depression, anxiety, substance abuse, and suicidal ideation.

***

Given these recent developments in our world, I would assert that it is critical for mental health providers to become a part of the solution to suicidal suffering. We are uniquely positioned to make a life-saving difference and help decrease suicide-related suffering by keeping abreast of major developments in the field and learning to use evidence-based approaches to suicidal risk.

Questions for Thought and Discussion

In what ways did this article impact you personally and professionally?

How have you modified your own approach to suicidality in recent years?

How have you collaborated with colleagues in and around the mental health community to improve your services to suicidal clients?

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The “Therapeutic” Power of Influencers on Family Systems of Care

The Impact of Social Media on Family Relationships

Crisis of Voluntary Play for Children

Children Entering Adolescence Have Not Learned to Play

A Non-Virtual Family Map

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Telehealth Care and Suicidal Risk

The 988 Suicide and Crisis Line

Recent Trends in Suicide-Related Data