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Jennifer Baggerly on Disaster Response Play Therapy: Shelter from the Storm

Posted on January 7, 2026February 24, 2026 by rezendevknowfully.com

Lawrence Rubin: I’m here with Jennifer Baggerly, Professor of Counseling at the University of North Texas, Dallas, a licensed professional counselor supervisor, and a registered play therapist supervisor. As an award-winning and distinguished leader in the field, she has trained thousands of graduate students to be competent counselors and play therapists. We will be speaking with her today about her work at the site of natural disasters. Welcome, Jennifer.

Jennifer Baggerly: Thank you. It’s wonderful to be here with you, Larry.

Navigating the Terrain

LR: It’s great to be here with you too. Some of our readers may be familiar with play therapy, some not. So, I’ll start by asking about your particular orientation to play therapy, and how it lends itself to working at the scene of a natural disaster?
JB: Typically, when I’m working with children in private practice in the United States who have experienced trauma, I use a child centered play therapy approach in which I’m allowing the child to direct the play. In this non-directive approach to play therapy, I’m trusting their self-actualizing potential. I’m providing a protocol of therapeutic responses during their play and trusting that through the therapy, the therapeutic relationship, and their play, I can facilitate self-understanding that promotes their emotional understanding and eventually their healing.

Along with this child-centered, or in a broader sense, this person-centered play therapy approach, I will sometimes add some psychoeducation in the form of children’s books that may be relevant to their particular presenting problem or to something else that they may need. So that’s typical in my private practice in the United States.

Disasters, and natural disasters in particular; however, require a different therapeutic approach. There, I work from a disaster response therapy perspective, which is a trauma-informed disaster response/play therapy perspective. There’s a whole protocol for this that is reflected in some of my earlier work around preparing play therapists for disaster response and cultural adaptations for play therapy after Hurricane Maria in Puerto Rico. Just recently, the Association for Play Therapy has developed disaster response guidelines for play therapists.

That’s very helpful because it takes into account the particular setting and scene of a disaster. There are many different types of protocols you must follow. For example, the number one protocol is you do not go to disaster to provide disaster response for children unless you have been invited by a particular organization. When you get that invitation, you’re going to be following the incident command structure, depending on whether it’s been a very recent event such as a hurricane that just happened.

Many families will be staying in shelters. You also need to be able quickly oriented to the particular culture that you’re working with which means that you need to work closely with the contact person on the ground who is helping you to understand the social and political issues that are occurring. And from there, it is important to be able to adapt your clinical approach.

That’s the preparation stage of the work. And then when you get there, the primary goal is to do no harm. We’re not going to do a big assessment looking into their past traumas and such. We’re just focused right there, at that time, and that’s where child-centered play therapy really fits well.

We’re just looking at that child in the moment and giving them a safe place to play. We also have to be aware that every child comes with a family who may need some help and guidance while the child is in their play session. Sometimes they need a little bit more structure, or perhaps they need some psychoeducation about typical responses after a disaster. Sometimes they need coping strategies to calm themselves down and get themselves back into the window of tolerance of being able to emotionally self-regulate. We provide that as well as opportunities to play. It’s a much bigger picture in disaster response that you have to navigate compared to the work you do in an office.
The Very Serious Work of Play
LR: Non-directive play therapy focuses on allowing the child to guide the play, to choose the objects to, and to play out whatever theme is important to them. The therapist is a supportive guide and reflective presence. Is the therapist more directive and directing at the site of a natural disaster?
JB: We’re using the child-centered play therapy within the trauma informed disaster response. So we provide a lot more structure leading up to the actual play sessions. But when we do provide the sessions, we often take a mobile play therapy kit in a suitcase which we’ll have available for a local response.

For example, I did some responding after the tornadoes in Oklahoma and Texas. If the events are local, I can bring more equipment. Like I might bring the bop bag, often known as Bobo. What you bring depends on the setting you’re going into, and I prefer to be in a setting that is a little bit more contained like a school or a place of worship where they have rooms and there’s not a lot of people going back and forth. That way you can set up a play area, particularly for the child and provide privacy.

However, sometimes you have to be very, very flexible. For example, I’ve done disaster work in shelters where I’ve just had the corner of a room, where we set up chairs to make a boundary for the therapy space from the people walking by. In those spaces, our typical play kit will have the aggressive release toys and nurturing toys, as well as toys and materials for creative expression.

One time, we were using dart guns which upset some of the parents and disaster shelter folks, so we had to put them away. It was the same with the bop bag, or Bobo doll. While we knew therapeutically that these kids were releasing some aggression and gaining a sense of power and control, we had to respect the others around. After Hurricane Katrina, I was working with some children in Louisiana who were playing in a classroom with the dart gun. In that instance, people were not walking by, so we had a bit more freedom. A boy grabbed the dart gun and jumped up on the table, “okay, we’re going to shoot the monster that’s coming toward us.” He was referring, of course, to the hurricane. They played out what we would call a trauma reenactment.

They were, in a sense, shooting this monster hurricane that had impacted their community. That particular child had been at the Superdome where he had witnessed actual shootings. Had that play occurred in the corner of busy shelter rather than a private room, that group would not have been able to play out that particular scene out of concern for re-traumatizing others in the immediate vicinity. That’s why understanding and working within context is critical.

LR: that pretend play gave them a sense of power and control; a sense of mastery over this terrible thing that they had experiencedIs the play of children who have been traumatized by natural disasters different from the play of children who have not been similarly traumatized?

JB: Sometimes, yes but it a lot of it depends on the exposure they had to the particular incident and their history. Important factors include whether they were impacted by the death of somebody that they knew, being close to that person as they were dying, their own resilience, and their own history of trauma.

Many times, you will see more direct reenactment of the incident through what we call traumatic play. For example, I was working with a group of children in Florida after a major hurricane. There, because of the setting, it was not possible to have individual sessions. On their own, this particular group of children decided to make a circle and then have one kid in the middle pretend to be the hurricane. The kid would spin around while going around the group which worked together to push the hurricane back. Those kids loved that game that they created and eagerly took turns being the hurricane. That pretend play gave them a sense of power and control; a sense of mastery over this terrible thing that they had experienced.

LR: In that instance, you witnessed what I might call resilience-oriented play where the kids were working through the trauma creatively, spontaneously, and in their own way. What do you look for in kids’ play that suggests resilience and healing?
JB: For example, if the monster is coming at them and they’re shooting or something like that, I’m looking to see if they have a sense of resolution. Can they overcome this? Many times, kids will play good versus bad, kind of a cops-and-robbers type of idea. But then maybe, they will play the bad guy or the bad thing, in this case the hurricane and will get to the point where they are the superhero that comes in to rescue everyone. And so, I often look for the rescue to happen as a sign that they are working through the trauma in a healthier way.

LR: When it’s time to leave the community, how do you ensure that treatment or healing can or will continue? In other words, what seeds are you planting both with the children and within the community?

JB: That’s why disaster response play therapy often includes a group session where we teach some coping strategies like deep breathing, some self-soothing, or distraction through a song of resilience like, “I am safe, I am strong.” We teach those coping strategies so that the child feels a sense of empowerment which is a more directive approach as opposed to typical non-directive, child-centered play therapy. That . We have to give the kids actual coping strategies along with psychoeducation about what they can expect, it’s part of the trauma informed disaster response play therapy protocol. And we want them to know that they will be OK.

We also want to extend that to the families, many of whom need a more direct psychological first aid approach to help them de-escalate, to become more emotionally regulated. Some parents are just not able at that particular time to provide the care and nurturing for their children. After Hurricane Katrina, there were displaced families I saw at a shelter––people who didn’t know where they were going or how they were going to survive. I respected the fact that the parents were in survival mode; fight, flight, or freeze! They simply couldn’t attend to their children in that state.

That’s when disaster mental health responders can be helpful to their children by providing them support the parents can’t. After Hurricane Maria in Puerto Rico, in spite of the fact that some time had passed since the storm, many people were still struggling. We went to a place of worship where families came together. There was a sense of community. The church leader gathered the parents around in a circle where they held hands and prayed. I thought that was a great example of using the community structure and its own built-in sense of resilience and support.

After we worked with children whose parents were most severely impacted, we went back to those parents or caregivers to give them a debrief about the progress their child(ren) made. We were giving a warm handoff back to the parents and providing them with some support. Sometimes those parents just need to talk and get that comfort from the play therapist. But we were also carefully watching those children for signs of serious trauma so we could refer them to local counselors and mental health professionals in that area. For example, I worked with one mom whose daughter was in a community that had been hit by a tornado. It seemed that the child was okay as there were signs of resilience. But the mom was really struggling because she had been on the phone with her older daughter when the phone went dead. She was terrified that her daughter had died. While it turned out that she was okay, they were out of contact for about 24 hours. That mom needed some extra help which we were able to provide. We were also saying to that mom that she would benefit from having someone else in her community to work through this trauma. In that instance, the child was more stable than the mom.
LR: These disasters bring death, so grief is an ongoing process that transcends your presence there. Have you had the opportunity to use the play to create a death scenario or mourning activity?
JB: Yes. Many of the portable play therapy kits that we bring have a sandtray the size of a laptop computer, maybe a bit bigger, that can accommodate the miniatures kids like to place in there. That’s where a lot of kids will play out death scenes. I’ve had kids create scenes in the sand that are knocked down by a hurricane. In those scenarios there may be a burial. Some of the kids do it quite quickly, while others are almost in a trance type state while they are doing it. That’s where the play therapist comes in, so that they can process that scene with the child by reflecting their feelings and helping them to understand their beliefs through reflective feedback.

The Stress of Deployment

LR: Shifting a little bit to the clinician, what are some of the challenges you’ve witnessed to the therapist at the site of natural disasters?
JB: I’ll back up a bit to the preparation phase of deployment because we anticipate there will be challenges for the clinician. And because we know that each person will feel overwhelmed at some point, each play therapist has to do an inventory of how they will cope and what their self-care plan is; emotionally, physically, relationally, and spiritually. That is an essential part of the protocol. Before my team took off to Puerto Rico after Hurricane Maria, we talked about what each person needs to do when they become dysregulated.

If, for example, somebody says, “well, my back’s been acting up,” or that, “I’ve got a problem with my diabetes,” or “I have difficulty with some other ailment,” then that’s also not the time to go. Someone may have had a recent death in the family or be experiencing family issues, so those are also reasons for not going. And we also have to think financially, because deployment is not remunerated, and some people can’t afford to take the time away from work. And that reminds me of another disaster response protocol which is that you never go alone; you always go with the team.

At the scene, some people may get a little snappy, some people just may withdraw. Some people may just cry. So, we identify what dysregulation means for each member of the team and then the team will intervene and help the person develop what we call a “NAP” or non-anxious presence. That’s just basically getting yourself into your window of tolerance, de-escalating, getting yourself back, emotional regulation, and/or implementing your strategies. One person may say, “Look, I just was really overwhelmed by this one kid’s story of death,” so the team debriefing cuts down that sense of isolation and despair that often comes in the presence of death and dying.

LR: Eliana Gill and I wrote an article about countertransference play, or how clinicians can use the play materials to work through their own countertransference response. Have the clinicians you’ve worked with found it useful to play in order to work through the stress of being there?

JB: That’s a great point and very helpful. To the extent possible, many play therapists will do a sandtray or an expressive arts activity. One such activity is drawing a circle with words expressing feeling overwhelmed on one side of a piece of paper. On the other side of the paper, the therapist draws a circle with words through it suggesting hope or resilience. The circle provides a sense of containment for the feelings evoked by the words within it. It can even be a group play activity, where the therapists stand in a circle and hit a ball back and forth. Or it can be as simple as enjoying a meal together.
LR: One of the themes that’s run through our conversation is the importance of working through play within the cultural context. In Puerto Rico, for example, were there any indigenous healing rituals that you were able to tap into?

JB: Well, there there’s a real sense of Puerto Rican pride which was a beautiful thing to witness. There’s that deep sense of shared identity—we are Puerto Rican; we are a strong people. We would often see signs like that in peoples’ yards or common areas. Another thing that we did with a group of children was to sing songs about being safe and strong, which was similar to one of their own songs about a chicken. All across the island, there was singing, dancing, and the sharing of food.

LR: Jennifer, as we wrap up, can you offer any particular resources or organizations that child therapists or play therapists can visit to learn more about this process and perhaps how to get involved?

JB: Absolutely. As I mentioned, the Association for Play Therapy just came out with their practice briefs on disaster response for play therapists. I think that’s a very important document to see. They make it very clear that APT is not in the business of deploying people. So, for that part, therapists who are interested in disaster mental health and disaster response play therapy would need to link themselves with other entities.

he American Red Cross would be another resource, as well as many other non-governmental organization. I also did a couple videos, one of which is called Disaster Response Play Therapy. So, there are opportunities, but the play therapist needs to be intentional in making those network connections prior to the incident.

LR: Jennifer, thanks so much for sharing your expertise and experiences with our readers and for the incredible work you and your teams have done at the sites of these natural disasters. It’s been a pleasure.

JB: Thanks Larry. I enjoyed this time with you.

Bio

Jennifer Baggerly, PhD, LPC-S, RPT-S, is a professor of Counseling at the University of North Texas at Dallas. She is a Licensed Professional Counselor Supervisor and a Registered Play Therapist Supervisor with over 25 years of play therapy experience. Dr. Baggerly provides counseling and play therapy at Kaleidoscope Behavioral Health in Flower Mound Texas. She served as Chair of the Board of Directors for the Association for Play Therapy from 2013-2014 and was a member of the board from 2009-2015. She has over 70 publications and is recognized as a prominent expert in children’s crisis intervention and play therapy.

References

Baggerly, J. (2018). Children and adolescents in disasters: Promoting recovery and resilience. In J. Webber & B. Mascari’s (Eds.), Disaster mental health counseling: A guide to preparing & responding (4th ed., pp. 149–164). American Counseling Association.

Baggerly, J. N. (2013). Trauma Informed Child Centered Play Therapy. (Video). Microtraining Associates and Alexander Street Press.

Baggerly, J. N. (2006a). Disaster Mental Health and Crisis Stabilization for Children. (Video). Microtraining Associates and Alexander Street Press.

Baggerly, J. N., & Green, E. (2015). The mass trauma of natural disasters: Interventions for children, adolescents, and families. In N. Boyd-Webb’s (Ed.), Play therapy with children and adolescents in crisis (4th ed., pp. 315–333). Guildford Press

Reflections on How to Live with Hardships in Life

Posted on December 23, 2025February 24, 2026 by rezendevknowfully.com

The central question of my latest book, Shh…it Happens: So What? Reflections on How to Live with Hardships in Life is: How do we go on when life refuses to grant us peace? Some pain lingers like an old debt; some wounds never fully heal. Perhaps wisdom lies not in overcoming, but in learning to carry what cannot be undone.

Pain Isn’t Meant to Teach Us Anything

I’m not sure how this idea could serve as a therapeutic tool. But through my work with Holocaust survivors, and others who have endured severe trauma, this perspective has gradually become something I deeply believe in.

Shh…it happens is often all we can say when life falls apart, and when we recognize that some things defy response. There is no clever comeback to death, no simple answer to betrayal, no quick fix for what breaks us. Shit happens—and not just once, but again and again, in forms both visible and hidden, personal and global, trivial and devastating. No one is immune. No life is spared from it.

Our culture doesn’t like that. It wants action and solutions. There’s a constant stream of advice: stay strong, be positive, find the silver lining. But what if we can’t? What if we’re not ready to move on, let go, or come to terms with it? What if all we can do is sit with it?

This is not a call for despair. It’s a call for honesty.

For decades, I’ve sat with people in pain—clients, friends, family, and myself. I’ve witnessed how quickly we rush to make sense of the senseless. We reach for explanations, spiritual frameworks, psychological theories, anything to tame the chaos. We want to believe that suffering has a purpose. That it fits into some larger arc of redemption.

But what if it doesn’t? What if some pain isn’t meant to teach us anything? What if the most human, most courageous thing we can do is to stay with the discomfort, without turning it into something else?

That’s the heart of what I’ve come to call a “so what?” philosophy. Not as resignation, and certainly not as indifference. It’s not a shrug—it’s an act of quiet resistance. A refusal to force meaning where there is none. A willingness to sit in the shadow of what has happened and say: This is real. I don’t understand it. But I’m still here.

Lessons from Experts in Survival

We are meaning-making creatures, but not everything in life offers us meaning. Some events simply are: A child dies. A diagnosis lands. A future dissolves. No explanation makes it right. There’s only the living with it.

And in that living, there’s something else—not healing, perhaps, but presence. A kind of dignity that doesn’t come from overcoming pain, but from carrying it honestly.

The “so what?” stance is not about dismissing what matters. It’s about letting go of the pressure to be wise, composed, or productive in the face of grief or absurdity. It’s about recognizing that we don’t have to justify our sadness or spin our suffering into virtue. We can just sit with it. Let it be part of our story without needing it to be the whole story—or the final word.

There is no clean arc to follow. No perfect lesson to extract. There are only fragments—of reflection, of feeling, of thought—offered here as a kind of companionship. No system. No stages. Just a shared recognition that life gets messy, and sometimes the best we can do is to pause, to breathe, and to say quietly: So what?

Because that’s where we begin again—not by solving the pain, but by making space for it.

While working at The Israeli Center for Mental Health and Social Support for Holocaust Survivors and the Second Generation (AMCHA)—a treatment center for Holocaust survivors and their families—I was granted a unique opportunity to learn from the very experts of survival. These were individuals who had endured the unimaginable, who had lived through horrors that seemed to defy the capacity of the human spirit to endure. It was, in many ways, a privilege—a rare chance to ask the question I had long pondered: How did they do it? How did they manage to survive the unspeakable, to continue living in the face of such loss, such devastation? What I learned, however, was that survival did not come without its own unrelenting cost.

The survivors I encountered—each with their own story, and their own scars—made every effort to continue their lives without being constantly haunted by the atrocities of the past. And yet, the memories had a way of returning, uninvited and unavoidable. They surfaced with all their accompanying emotions—grief, anger, fear—relentless in their return, like waves crashing against the shores of their minds. These memories could not be erased; they lingered, embedded deeply, despite all efforts to forget them.

Most survivors, however, showed an unusual degree of psychic strength, overcoming the effects of their harrowing experiences, their losses, and their exile. Yet, there was a minority, a clinical minority, whose wounds—those invisible scars—remained raw, continuing to affect them for years, even decades, after the war. The weight of those emotional scars lingered beyond what anyone might have expected. I tried to capture these findings, these complex realities, in my 2009 book, Holocaust Trauma—a humble attempt to summarize what I had witnessed, and what I had come to understand.

Perhaps the most telling description of endurance during the war happened during the death marches of the Holocaust. Prisoners were forced to march from one camp to another under brutal conditions, knowing that those who fell behind—too weak or too exhausted—would be shot on the spot. Every step they took was an act of defiance against a fate that seemed inevitable. The advice to “take one step at a time” finds its most literal and harrowing expression here. It’s a mantra we often hear when life feels unbearable: “Take it one day at a time.” It urges us to confront today’s pain, today’s hardship, without being consumed by the unknowable weight of tomorrow.

These aren’t stories with happy endings. They don’t offer neat resolutions or triumphs to celebrate. They are about enduring the unendurable—about surviving not because there is light at the end of the tunnel, but because continuing is the only option left.

I used to visit an elderly woman who had survived the Holocaust and once asked her gently, “And how are you today, dear?”

“Oh, you know,” she replied, her voice tinged with weariness. “Ups and downs, as always.” She paused. “I had hoped to put it all behind me, to find some peace. But it seems the past refuses to let go. It haunts my dreams, a persistent shadow.”

Her words, simple yet profound, laid bare the depth of her emotional turmoil. I had heard her recount her experiences during the war countless times, and there was no need to articulate what weighed on her mind. The past, an unrelenting burden, had etched itself into her being—a scar that even time could not heal. And yet, we must continue to live with what cannot be changed, carrying the weight of the scars as we navigate forward. It’s not about fixing or erasing the pain but learning to coexist with it.

Some shit doesn’t pass. It lingers, not as trauma in the clinical sense, but as residue. A faint tension in the body. A change in tone. A silence that settles into the corners of a room. We move on, but something in us stays behind.

We learn to live with this residue, not by resolving it, but by tolerating its presence. That doesn’t mean being passive. It means not turning away.

There’s a common belief that pain must be processed, worked through, or healed. And sometimes that’s true. But more often, we simply carry it better. We learn to contain what cannot be erased.

Containment isn’t control. It’s not about suppressing emotion. It’s about holding what’s there, without being overwhelmed by it. Like sitting with someone crying—not trying to stop them, not analyzing—just staying present. That’s what we do with our own pain, too.

To “come to terms” with suffering doesn’t mean to conquer it. It means to walk alongside it, to acknowledge its presence without letting it consume us. Perhaps then, we may slowly release our futile struggle to control the uncontrollable and begin to find peace in the messiness of life. As painful as it is to admit, this struggle isn’t separate from life. It is life. Suffering forces us to confront something deeper: who we are, how we endure, and the meaning we choose to create in the shadow of the unbearable. Some people rebuild. Some collapse. Most of us do something in between. We adapt. We patch. We find new ways to carry the same weight.

That’s what I mean by recycling shit—not transforming suffering into something beautiful, but giving it a new function. Letting it fertilize something else, even if we never asked for it.

Pain leaves a mark. But it also leaves material. Emotional scraps, memories, truths we didn’t want but now can’t ignore. If we’re lucky, we find a way to use them. That doesn’t mean we’re grateful for the suffering. It means we don’t waste it.

Some people make art. Others grow more tender. Some become fierce protectors of others who suffer. Some just endure—and that’s enough. Repurposing doesn’t have to be dramatic. It can be as quiet as waking up and doing the dishes.

I’ve seen people repurpose pain into humor, into music, into silence, into stubborn survival. Not because they’re brave, but because the alternative was to fall apart. Pain, when recycled, becomes part of who we are—not a scar to hide, but a seam in the story.

There is no promise here. No redemption arc. Just a reminder: pain changes us. And in that change, something new may form—not because the shit was good, but because we lived through it.

Recycling is not erasing. It’s carrying forward what cannot be undone, in a way that no longer poisons everything it touches. It’s not transformation. It’s a continuation.

The Contained Mess

We often speak of recovery as if it were a return, but most of us don’t return. We don’t go back to who we were before the shit happened. That version of us is gone. What we do instead is re-cover—layer over the wounds, stitch the fabric of life back together, however unevenly.

This is the heart of what I’ve come to believe: we don’t get over things. We don’t transcend. We carry, adapt, and make space. We contain, not in the clinical sense, not in the tight management of emotions, but in the old sense of the word: to hold. We become the container for the life we didn’t ask for. We hold the brokenness, the anger, the absurdity, the beauty. Sometimes it leaks. Sometimes it’s too much. But somehow, we stay upright.

For me, writing has been an exercise in containment. I’ve tried to reflect, not resolve. To stay with the mess long enough to see what it might become. And yet I wonder whether the act of writing is its own attempt at control—a way of taming the chaos with sentences.

Maybe this, too, is part of my own shit.

Still, I believe in the value of sitting with it. In not turning away. In saying, even when no answers come, I am here. This happened. I’m still breathing.

The world doesn’t need more advice. It needs more truth and more people willing to say: I don’t know what to do with this pain. But I’m willing to hold it.

That’s where these reflections end. Not with clarity or healing. With a container of shit, and the quiet hope that it holds.

This essay is a condensed version of the full book: Shh…it Happens: So What? Reflections on How to Live with Hardships in Life. The full version explores each of these ideas in depth, with stories, personal examples, cultural reflections, and philosophical insights. It’s not a manual, but a companion. A place to pause, to reflect, and to feel less alone in the shit we all face.

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.

A Neurodivergent Clinicians’ Personal and Professional Journey of Self-Discovery

Posted on November 25, 2025February 25, 2026 by rezendevknowfully.com

My journey of self-discovery is probably similar to those of many others, with the exception that becoming a therapist, at least to me, is unlike any other career. The things I witness, hear, and experience, have no comparison. For the sake of myself and my clients I must continue to evolve, grow, and remain a lifelong learner. The space of shared stories and experiences is the one from which therapeutic connections can, and have, been made; where I join fully as a human being, and can bring together the various intersectional elements of my own identity. And just like my clients, I have my own story.

Recently, a student asked me about working with neurodivergent clients who have not experienced trauma. I thought it was a great question. In my experience as a neurodiverse therapist and citizen of the world, society is not set up for neurodivergent people and this binary of trauma or no trauma must yield to a more fluid, continuum-based way of thinking. Simply existing can feel traumatic for those who are neuroatypical.

In researching this topic through the scientific lens of my academic identity, I’ve simply not been able to keep pace. There is so much! Through another lens at the intersection of my identities, that of practicing clinician and neurodivergent, I have come to recognize the limitations of purely empirical investigation and have begun visiting social media sites in order to better understand the autistic and neurodivergent community through the lens of experience. I learned more from direct, and very personal narratives, than I did from any textbook or any clinical training.

Working with Bee: An Answer Deferred

Years ago, I worked with an older teenager, Bee, in a rural community who identified as queer. She initially came to see me because her gender fluidity and sexual orientation created conflict with her mother and her mother’s belief system. I want to emphasize the conflict was not between her and her mother, per se, but with the mother’s religious beliefs. This is not an uncommon experience where I practiced. While Bee had social anxiety and low self-esteem, she did have a good support system with her family and friends.

I worked individually with Bee and did some relational work with the family as well. Throughout our time together, she was able to build self-confidence and find employment. By her senior year, she was doing all kinds of things including taking on leadership roles as she fully embraced the trajectory into adulthood. It was for all intents and purposes, an effective therapeutic relationship in which we met the goals of treatment, individual symptomatology diminished, and her relationships improved, as did her attachment experiences and communication skills.

I remember one point during our time together when Bee asked me if she “could have ADHD or be autistic?” I said I wasn’t sure, so I did an ADHD screener, which was diagnostically inconclusive, after which we had several discussions about the results. I even talked about referring for a more comprehensive psychological evaluation, but did not really see the need for it. I talked about some traits but nothing within the clinical range. To support this, I pointed out to Bee that she was doing well socially, involved with extracurricular activities, had friends, and an active social life. At that point, we ended our work.

Through some happenstance around 2-3 years later, Bee’s family reconnected with me to share all the positive things that had occurred in their lives. I met this invitation with openness and curiosity. After the update of Bee going to college and studying a topic of her choice, I immediately shared my need to apologize. Bee asked what I meant. I remember asking, “do you remember when you asked me if you were neurodivergent and I said I really do not think so?” She quickly replied affirmatively.

I went on to tell Bee that I had spent the last several years learning about autism and ADHD, and that in retrospect, she was right. I admitted to her that I was neurodivergent, and that, “I believe you are too.” We shared a laugh about the experience. I was glad she was not angry and that she didn’t feel dismissed but said that “it would have been okay if you had been upset with me.” She knew back then that I genuinely did not think she was on the spectrum, but she was personally unsure. She knew I was not trying to dismiss her and reminded her of my recommendation for a comprehensive evaluation. But those evaluations were not as accessible or affordable as they later became. This was where the field was at that time, and it is where I was along my own path of self-discovery. Statements like the one I made back then, “You have some traits but don’t really meet criteria,” were likely very common before the idea of spectrum was more fully embraced. A few observable traits no longer mean that deeper pathology is being masked, awaiting a full assessment followed by a definitive diagnosis. Neurodivergence means just that…divergence, or variation on a theme. And that variation extends to race, gender, culture, and age.

I am glad I could repair, at least from my perspective, what I considered a therapeutic rupture, although Bee did not experience that rupture in a traditional way to the point that therapy hits an impasse or ends abruptly. The version of myself that spoke with Bee that day knew that she presented with all the “usual” observable symptoms that accompany autism, and that had I dug deeper, the diagnosis would have been clear. I missed or perhaps had resisted the diagnosis because I had not yet found a place for that label in my own identity. I could have let Bee’s narrative lead the way rather than the dictates of my formal training and that of impersonal scholarly investigations. Just as I now have a far clearer understanding of the complexity of my own intersectionality, I now more fully embrace the importance of honoring my clients’ narratives.

Postscript

Quite a while after my work with Bee and her family, I had taken my son at age 7 for an ASD evaluation. The psychiatric resident looked at him and said, “he is not autistic, you see this is the autistic bible––” he slapped his book on his desk––“I can tell by looking that he is not autistic.” My son returned to the room with blue cupcake icing on his face. I felt flooded with embarrassment and rage. I wanted someone to tell me why my son was struggling in so many ways in his life. I firmly said, “I want to see my attending physician.” She subsequently met me with compassion and kindness; however, not even an ADOS was performed.

The irony, or better yet, outrage I felt was because my son had classic symptoms of autism–– hand flapping, lining up toys, and a host of other stereotypical stuff for most of his early childhood, some of which reduced somewhat by age 7. Maybe the resident, and my attending, thought he was too old to be first considered for the diagnosis. But then again, I really don’t know the basis for their preemptory conclusion. I do know that the experience left me angry, feeling rejected, and dismissed, and like there was no help.

To have personally attended a state university that provided evaluations, only for the doctor to not even ask me any questions about my son was so disturbing, if not insulting. I am sure the progress note read something like, “Mother was emotionally unstable and reactive.”

I knew from that moment on I never wanted anyone else to feel that way. At the time of that visit with my son, I had been working on my PhD which paved the way for my own self-study and re-orientation to the whole experience of autism and neurodivergence. The research is clear, at least to me, as a citizen, parent, and clinician.

The field is failing neurodivergent people––kids, teens, adults, families, and couples. Social media has become a substitute, or perhaps a primary place for validation because they can’t receive it from the professional world. When clinicians and the medical community correct clients and dismiss the importance and validity of self-diagnosis, what can be expected? I view this very differently since social media was the source of my own self-discovery of neurodivergence, and a tool for assisting my clients on their own journeys. The entire experience, from my work with Bee to the evaluation of my son to my own self-acceptance, has awakened a deeper awareness that has highlighted the importance of embracing and advocating for the evolution of the professional landscape.

Christoffer Haugaard on Collaborating with Clients Who Hear Voices

Posted on November 12, 2025February 24, 2026 by rezendevknowfully.com

Lawrence Rubin: I’m here today with Christoffer Haugaard, a Danish Narrative clinician who has a particular and fascinating interest in working with clients who hear voices. Welcome, Christoffer.

Christoffer Haugaard: Thank you, Lawrence!

The Multiplicity of the Mind

LR: I know there are a lot of clinicians who will be reading this and want to know simply, how do I work with clients who hear voices? But I don’t want to start there. Instead, I’d like to start in a somewhat different place by asking what you’ve learned or are learning about the human experience by working with clients and their voices?

CH: I think what I’ve learned is that, based on the phenomenology of what voices appear to be and how they behave when you interact with them, the mind doesn’t seem to be unified. There seems to be multiple agencies, multiple perspectives that at least can be present and seem to have their own existence and are in some way tied to a particular person.

You can interact with these agencies or entities or whatever you want to call it. And, from my experience in working with people who hear voices, they respond favorably. The voices respond favorably to being treated as some kind of person, to being respected as having a perspective and their own agency, their own opinions, rather than being dismissed or rejected or taken to be not real, or only a symptom or a representation of something. They tend to appreciate being treated as if they are people too.

LR: Have you had to shed any preconceived notions along the way or divorced yourself from any common ideas about voices in order to reach that place where you recognize the multiplicity of the mind.

CH: That’s complicated. In a way it wasn’t a stretch for me because personally, I was already quite familiar with other ideas about reality of the mind, other ontologies. I’ve always been interested in indigenous societies, shamanism, animism, that sort of thing, where people experience entities or agencies outside themselves or related to the world and interact with them.

So, that way of thinking was actually quite familiar to me, but I didn’t connect it to my work as a therapist at all. I thought of psychopathology as being something distinct from that. Or at least I didn’t have any particular interest in connecting those two things. So, I regarded voices as being dissociated thinking patterns that were on repeat in peoples’ heads.

My change in view happened because we made a discovery about it by coincidence. I was working with one of my patients, named Max, whose story has been published. He considered that maybe his voices had good intentions to begin with, and I just took that idea at face value. I suggested that I try to address these voices and tell them that we had these ideas about them, that maybe they had good intentions, and tried to explain to them that Max needed them to behave in a different way so they could assist him in life.

Max thought that was a crazy idea because you can’t talk to a mental illness, but he was kind enough to not tell me that. He just said, “yeah, sure, go ahead.” So, I spoke to the voices, and they responded very favorably to that. They enjoyed being respected and acknowledged for their good intentions, and they actually changed their behavior.

From that point onwards, Max was able to appeal to them using my words in the form of a letter. In five minutes, he could quiet them down. They had terrorized him for years but responded to this immediately. That required me to change my thinking. This certainly didn’t seem to be some thinking that was dissociated and stuck in his head on repeat like a broken record.

This was something living that was responding with an opinion, and had feelings that were different from Max’s feelings. I brought that idea with me to other patients where we were stuck and we found that treating voices in this way, acknowledging them as having their own perspective, their own opinions, being persons of some kind was very effective. We then collaborated with more and more people where we were able to confirm this.

And of course, that required me to dissociate myself from normal psychological and psychiatric thinking. I was working in a psychiatric hospital where the general idea was (and still is) that voices are false. They are hallucinations, and people should not involve themselves with them. They should reject them and not listen to them, and they should be medicated to go away. I had to dare to step completely outside of that idea. I think maybe I was willing to do that because I was familiar with that way of perceiving the world already. I just never connected it to my work as a clinician before. I had a predisposition, you might say, to think that way.

So, it wasn’t a big leap for me personally, but it was something I had to dare to do in a psychiatric context, where that was not how you thought about things. I had to deal with the possibility that other clinicians would think that I was indulging people’s insanity or entertaining their delusions. But to think that that helped me to not be persuaded by such doubts or such ideas was the fact that it was just very effective.

There was just a very immediate response from these voices and nothing else had worked. I was sitting with patients who had been medicated, sometimes heavily, and who had tried many different kinds of psychotic medication for years and years; and tried psychotherapy for years and years, and it hadn’t worked. It hadn’t made any difference to these voices. And now these voices were responding in ways that were entirely novel to these patients.

They were immediately surprised that the voices were responding like this. It was useful. They could suddenly find ways to deal with these voices so that they stopped being a menace to them. Their need for hospitalization decreased, and some of them even stopped needing it. The voices ceased to be a threat to them, something they could live with. Even in some cases, they came to appreciate the input of these voices. They changed their behavior, became more reasonable, more kind, stopped going on and on about people killing themselves and stuff like that, and becoming more constructive when they were engaged in a dialog. And that was very persuasive for me and for my patients that this happened.

And when I saw that happen and the difference it made to my patients, it was it was a no-brainer really. I did have concerns about how honest I should be about what we were doing. Should I tell my patient’s psychiatrist what we were doing? But that became easier along the way because it was working.

LR: I need to dissociate myself from the popular conception that voices are equivalent to psychopathology, just as you had to. I’ll go so far as to channel Travis Heath here by suggesting that for you, accepting the reality of, and working with, voices was an act of rebellion.

CH: Yeah, and I already had a rebellious mindset. That’s why I became interested in Narrative Therapy to begin with. I was dissatisfied with how these peoples’ experiences were pathologized and just rejected as being just wrong and not worth listening to, not worth understanding, and just something that should be medicated until it stops. I was dissatisfied with how these people were not engaged in a more equal dialog about meaning and what might be helpful for them.

I had already been creating a group therapy format and participating in psychoeducation, where you tell people about diagnosis and treatments and all that. I’d become dissatisfied with being a clinician telling these people what to think about their experiences and describing it as something that was wrong with them. In the group format I developed, I invited patients to participate and interviewed them about their experiences and then together, reflect on what might this mean.

It was important to not privilege a psychiatric understanding. I wanted these people to participate in understanding their own lives and their problems instead of having to listen to yet another psychologist tell them stuff out of a textbook. I’d already done that before making these discoveries about voices. So, yeah, I definitely had that kind of rebellious mindset about it.
LR: Have you found colleagues who have attempted to adopt your philosophy about working with these clients, and have failed because they’re not you?
CH: As far as I’m aware, none of my colleagues had tried it out. It’s sort of just became a thing I did. Sometimes they would bring along a patient and ask if I could “talk to this guy or can you talk to this woman and see if you can do your thing?” So, it was more a thing I did after having published some of these accounts, circulating this knowledge, and making it available to people who hear voices. I have been contacted by people who have tried it out and found it to be effective. Not a lot. I hope there are more people out there using it that I’m not yet aware of.

A Relational Framework for Understanding Voices

LR: My guess is that because of Western culture’s hyper-emphasis on pathology and our dependance on insurance companies for greenlighting treatment, this might not find as welcome a home here as it does in Europe, or outside of Narrative Therapy circles. How does the traditional notion that voices are simply split-off and projected unpleasant or unwanted parts of ourselves fit your model?
CH: Mostly I’ve been dealing with this in a very pragmatic fashion and haven’t worried too much about that, really. Treating the voices as people was just very effective. Trying to work out what voices mean in terms of ontology or psychology has not been a concern. My patients didn’t care about that, and it wasn’t necessary to figure that out in order to do the work with them. To my mind, people are free to make sense of their voices in whatever way works for them, you know? Some people will think “this is probably a part of myself in some way,” even though that’s actually not how the voices appear.

They actually appear and behave like something of their own. But, you know, a patient who prefers to interpret that as being parts of themselves, of course, is free to do so, and it doesn’t seem to actually be important what people think of it. Voices respond to it, no matter what the host human might think of it. Right? But it doesn’t seem to depend on what the patient believes, and we don’t have to figure out what to believe about it. We have to pragmatically make the assumption that voices are people — they have their own perspective, their own desires and intentions, and we treat them that way. As soon as people have the experience that voices respond to this, they really stop caring about how crazy it might seem. It just doesn’t matter when it works. I, of course, have been interested in trying to get some idea of how we can make sense of that

I think the more traditional psychological idea that these voices must be “split-off” parts of the self presumes that the self is supposed to be unified and that this splitting is not how it’s supposed to be. Thinking that way doesn’t lend itself to acting the way we did .

You know, it becomes sort of pretending. The therapist is pretending that the voices are persons, but they really think they’re not. So, if we want to develop an idea about what voices are that actually supports literally treating them as persons, we might need a different idea about voices. It seems to me that psychology, and certainly psychiatry, is not a very good place to look for that, because these ideas are very tied to a Cartesian way of thinking about the mind and very tied to particular notions of what’s normal that are really based on industrial Western societies in the last t couple of centuries.

Basically, much of psychology doesn’t take other societies into account, or how Europeans thought just 300 years ago, which was in many ways radically different. This idea of a self-contained subjectivity is quite recent, and historically not very normal, actually. Psychology and psychiatry are very tied to such a notion of what a mind is supposed to look like. But when you start looking at the history of religions as well as anthropology and ethnography, very different ways of how the mind operates begin showing up. And a concept that has become more popular and recently redefined in anthropology is animism, which seems to be a way of understanding the world and the mind, which is pretty much universal.

All societies that have been studied either are or used to be animistic.Animism used to be considered an erroneous attribution of mind to things that actually don’t have minds. Like the “so-called” primitive belief, for example, that trees are alive or that a stone is alive. That was the original notion of animism in anthropology. And it was used rhetorically to demonstrate that religiosity in general is a primitive, irrational thing that should basically be rejected, and that the religions of civilized societies are just refined versions of this primitive animism. that was the idea back at the beginning of anthropology.

But animism has since been redefined as being an epistemology that takes the subject to be the starting point for knowledge of the world. To interact with the world socially is a way to know the world, which is different from the rationalist scientific idea of taking the object to be fundamental. In scientific, rational thinking, we want to divorce subject and object from each other, such as in Cartesian mind-body dualism. And in this vein, we then want to remove subjectivity as much as possible from the object of study, because real knowledge is supposed to be objective, independent of perspective, independent of context. It seems that many societies, indigenous societies, assert just the opposite; to know something is to invest subjectivity in it, to interact with it, to be socially engaged with it.

To know the forest then, the forest must become a person. It must become a subject. We must see through the eyes of the forest to know the forest. . As such, a spirit is not an irrational belief in a non-empirical entity. A spirit, then, would be the subjectivity of a relationship with something in the world. And in that sense, it’s a way of knowing. Instead of regarding the world as consisting of a bunch of particles in causal relationships with each other, the world can be understood to be a set of social relationships, and that the world is fundamentally social, not just between humans, but between humans and trees and animals and so on and so forth.

In this sense, animism, may be an ontology and an epistemology, a way of engaging the world that makes a different bet to rationalism and modernity. I think these notions of subjectivity, where the mind is not closed but porous, relational, and elastic, seems to be actually a very universal way of operating for our species.

And in that light, hearing voices isn’t that difficult to understand. You can look at voices as a way of understanding your life. When something in your life begins to speak to you, it’s a personification and investment of subjectivity in some aspect of your life that is problematic that you need to deal with. That’s why it begins to talk to you, so developing the right relationship with it is the road to healing. These voices mustn’t be rejected. They must be listened to because they’re trying to tell you something, and you must establish good relations with them instead of rejecting them or ignoring them or battling them.

In Relationship with Voices

LR: It almost sounds like people who don’t hear voices are at a disadvantage in some way, or that they’re not living fully in the world, as are those who are open to the experience of voices.

CH: I guess you could say that the process of modernization has been closing human beings off from the world. In making the distinction between subject and object and presuming that humans are exceptional and separate from the natural world, from our bodies, from other beings—we are asserting that we’re somehow entirely different and that only we possess minds, and the rest of the world is sort of dead and has no inherent meaning. From a historical perspective, you can certainly make the argument that modernization has operated like that; a rejection of being in relationship with the world.

LR: You’ve used the word spiritism, so is the experience of hearing voices and sitting with someone who is hearing voices, a spiritual experience?

CH: The older understanding in anthropology is that a spirit is a non-empirical entity that people believe has causal powers. That would be the old understanding of animism. The new animism in anthropology says that a spirit is a personified relationship with some aspect of the world, a relationship with something other than another human. So, when humans enter into relationships with a particular tree that may be important to them, this tree is personified by being related to in a social way. There’s an investment of subjectivity. The relationship becomes a hub of subjectivity in itself. That is what a spirit is.

LR: So, you might work with a client in relationship to the voice?

CH: Yeah, but mostly with the voices I’ve met. It’s not trees that they have problems with. It’s usually some aspect of existence. It can be aspects of our culture, for example, certain social norms that act in a personified way, and very often it’s a kind of helper. It’s like a companion entity of some kind that is trying to help people deal with something in their lives.

Often they turn out to be quite right about what people need, but because people have been rejecting this voice and been afraid of it, the relationship has gone sour. Sometimes it turns into a war. Sadly, sometimes psychiatry contributes to creating this state of war because they encourage people to reject their voices and in telling them that this voice is a sign that there’s something wrong with your brain. That’s a very scary thing to come to understand. This element of fear and rejection tends to lead to a conflict with the voice, and then the constructive aspects of what a voice may be trying to tell people is completely lost in this war. What I’ve often done is try to be on a diplomatic mission to create a peace and to try to understand what the voice wants. Often the voices are able to communicate when you interact with them in a respectful way. Very often, they want something. When the person comes to understand this and finds a way to satisfy the voice in an acceptable way for the person, the war ends.

LR: Have you found any commonalities in the origins of patients’ relationship with the voice(s)?

CH: There’s often trauma. The first appearance of voices is often in the context of a traumatic event, but not always since some of the people I’ve collaborated with have been able to hear voices for as long as they can remember. Just seems to be an ability, something that they’ve just always had.

LR: It made me think of an interview I did a while back with an ecopsychologist, who talked about the proliferation of ecological anxiety and dread as the planet is attacked from so many different sectors. Our planet is experiencing trauma which makes me wonder if some people who hear voices are afraid of the annihilation of our world.

CH: I have collaborated with one among other voices that was extremely angry about how the world was being treated by humans and wanted the person hearing the voice to try to annihilate humanity. I wasn’t able to, to work with that person in a very consistent way. A certain reason I haven’t collaborated with this person was due to the circumstances in their life, and of course, wanting to annihilate all of humanity is not a desirable or constructive thing to do.

It was not sensible to agree with this voice about that but to appreciate the anger of this voice was certainly relevant. Of course, I would see that as the fury of this voice. You know, wanting extreme things. And we need to channel that into something that’s acceptable for a human being to actually do, and killing people wasn’t it.

LR: Can you bring to mind a client with whom you’ve worked where there was this negotiation?
CH: There is my collaboration with Alice that has been published. She heard a multiplicity of voices operating in a unified way that she called “the others.” They were very aggressive and wanted her to harm herself and other people. They enjoyed gore, suffering, pain, and things like that and wanted her to do them.

Of course, she didn’t want to do anything of the kind. Then they would torture her in various ways when she would not comply with them, and try to convince her to kill herself. Once she started talking to the others, she discovered that they had all this aggressive energy that they wanted to express through her.

Alice resisted that, but because of this, they felt trapped. They could not exercise their own being in any way. They were just trapped inside her. That caused suffering for them. They were in pain from not being able to express themselves in the way that they wanted, and therefore they didn’t want to exist anymore. The voices were trying to get Alice to kill herself, hoping that that would also put an end to their painful existence.

We found out by coincidence that they enjoyed having smoking breaks. One day, we were talking about something that they didn’t appreciate, and it seemed like an attack was coming on from them. To avert that, I said, “sure, you get it your way. We’ll talk about something else for now. You just take a break for a smoke or something.” And that was just a joke. I was trying to lighten the mood and as it turned out, that averted the attack. Alice then told me they liked that. They liked being offered a smoking break, this was after having made this discovery with Max that I mentioned earlier. After that, I brought cigarettes for them and we put them out on my desk.

They really liked that. Otherwise, they would want her to kill herself. The voices didn’t like me talking to Alice and trying to help her get better because they wanted her to die, but now they had to admit that I offered the cigarettes. No one else in the world had ever offered them anything, but I did, so they couldn’t thoroughly hate me. We also gave them coffee. We could avert attacks like that, and begin to teach them to behave more kindly and in a friendly kind of relationship instead of an aggressive one based on power, which was all they knew. They started becoming familiar with being friendly and what that meant, so we tried to accommodate them.

They also wanted all this blood and gore and aggression. They liked that but of course, Alice didn’t. I suggested putting on gory movies for them. I didn’t want to look at it. Alice certainly didn’t. So, I put them on my computer and turned the monitor away from us, up where the voices were receiving their cigarettes and coffee.

I chose something comical, something funny like Peter Jackson’s old gory comedy movies he made before the Lord of the Rings. Later on, Alice decided to start practicing martial arts and they really liked that too. She was doing something that had something aggressive in it, but which was socially acceptable and acceptable to Alice. The voices calmed down more and more. And in the end they became quite friendly and liked me and wanted to be friends with me. They eventually stopped bothering Alice, and she stopped being afraid of them. So that was this kind of negotiation, you know? Can we give you something that you’ll appreciate, but which is also acceptable for Alice?

Narrative Therapy and Working with Voices

LR: Christoffer, what is it about Narrative Therapy that’s helped you in your work with clients and their voices?

CH: I think externalizing conversations already has some similarity with working with voices where there’s a practice of personifying problems. It has this animistic element to it. The leap isn’t that big. And then there’s the element of Narrative Therapy that’s called co-research. David Epston calls it co-research when you’re in a situation where you don’t know what to do, or how to deal with a problem. You relinquish your professional identity as the one who’s supposed to know stuff and invite the patient to explore. You work from the premise of “let’s explore this together.”

Narrative Therapy has roots in anthropology and ethnography, so this idea of collaboratively exploring the world without knowing in advance is essential. That is certainly what we did because we were in a situation where the usual stuff wasn’t working and we had to recognize the fact that we didn’t know what to do. It was a matter of just going with it to see what we could find and try it out and see what works. What we found with voices was that they responded well to this, so we did this consistently with one patient after another.

LR: Are the written elements of narrative practice like letter writing and journaling particularly useful here?

CH: Yes. When I spoke with Max’s voices that first time, he had a positive experience because the voices responded and calmed down immediately. Max then asked me to write down for him what I had said to the voices. That became a letter that he would then use whenever the voices got worked up about something in his life. He would simply read this letter to them, and they would stop attacking him. I have also used letter writing with some of my other patients when we were trying to figure things out, and as a way of documenting our discoveries. In those instances, I would write to them and some of them would also write to me to explain to me what they had discovered, or what the history of the voices was like.

Lately, I’ve been writing letters, not to my patient, but to the problem, a personified version of that problem. In one case, I wrote a letter to a dream entity of a patient with PTSD who had reoccurring nightmares. In one of those nightmares, he saw a dead man who had committed suicide. The patient had been the first person on the scene.

In the nightmare, they had a conversation where the patient was extremely angry with the dead man for the impact the suicide had on his life. The dead man told him that the suicide was his decision to make and that it didn’t concern other people. That made the patient even more furious. This conversation would happen every week in a nightmare. I decided to treat this as if it were a voice and appealed to the dead man in the nightmares as a person. This person was a personification of the trauma the patient was living.

I wrote a letter for the dead man from me said to the patient, “please read this letter right before going to bed.” As with Max, the patient thought this was a crazy idea which was not going to work. But since he had been having the nightmare for two years, he was willing to go along with the plan. He liked me enough to try. The nightmare with the dead man stopped as did the other trauma-related dreams. He later told me that when I suggested this plan, he didn’t think it was going to work. But it did.
LR: He was willing to try. A long shot at hope!
CH: I’ve had quite a few patients when I read these letters. I’ve been writing it while they were there, and just wanted to read it to them to make sure that I had all the facts right. And they would cry, because it just hit something apart from their own sense of themselves or their own minds. But something else, seemed to just appreciate it.

LR: The way you describe it is very consistent with Narrative Therapy’s focus on freeing people from systems of oppression.

CH: Yes, but with the twist that what seems to accomplish this work is the assumption that the problem is a person with good intentions. So it’s important not trying to resist the problem or undermining the problem, but to actually listen to what the problem is saying. I’m trying to acknowledge the good intentions of the problem, and then explain to the problem the effects of how it is going about its work of helping the person. I ask the problem to consider that the way it’s been behaving is having all of these negative effects. And then I just ask people to read this letter on my behalf to the problem every day. I say to the person that all they have to do is read the letter to the problem. And that’s been very effective.

LR: Do you ever introduce voices into your work with clients?

CH: In what sense?

LR: Such as with a client who has no history of hearing voices other than their own, where you might invite them or invite a voice into the conversation. Or is that a crazy question?

CH: No, no, no, I get what you’re saying. Yes, I do sometimes try to relate to the problem as a person when people are not hearing voices, and that that’s often very effective. I don’t usually explicitly introduce that or explain that. I allowed the person to wonder, like I might say, “I wonder if this depression might be trying to tell you something.”

I might also wonder aloud if “the depression has come at the time that it did in your life for some reason”. And then, based on what people have told me, I consider “well, maybe this depression has been looking at you and has been looking at how your life has been unfolding and how you’ve been dealing with your life. And perhaps this depression is aware of the things that are important to you, and therefore this depression is dissatisfied. It has been dissatisfied with what you have been doing, how you have been compromising with the things that are important to you, the things that matter to you, that you have been sacrificing yourself for the boss at work or whatever.” I might add, “maybe this depression has decided to make an intervention to stop you from living your life the wrong way.” The thing is with depression, at least in my experience, they tend to be like a sawn-off shotgun. When they fire, they fire all over the place.

I might continue, “Maybe this depression is, in fact, trying to dissuade you from living in a way that isn’t right for you, but in interfering with your life, it’s just hitting everything, putting you completely at a halt with lots of negative consequences. But maybe this depression wants something for you. And maybe we need to try to hear that message. Maybe you need to try to satisfy the depression with what it actually wants, its intention, not all the negative effects it’s also having, but it’s intention for you; what’s actually important to you, how you’re supposed to live. Maybe you’ve been compromising with something essential in the way that you’ve been living up to the point where this depression stepped in and interfered with your life.”

Often I worry that people think I’m crazy when I say these things, but I’m surprised that they don’t. They tend to be on board with that quite immediately, actually.

LR: So, in a sense, and regardless of the emotional valence of the voice(s), you consider them always on the side of the patient.

CH: Yeah, I make that assumption or at least try out that idea very carefully that the voices have good intentions before assuming that the problem has only bad intentions. Voices tend to respond quite well to the assumption that they have good intentions

LR: Even when a patient’s voices are instructing them to kill their parent? In cases like this, is it a safe assumption that the client has rageful feelings, or that there are rageful feelings toward the parents?

CH: They may or may not have those feelings, but I would try to invite the patient to explore the voice’s intention with me and also directly with the voice. The voice may have different reasons for wanting that. To become a teacher here in Denmark, you have to learn how to how to teach, how to communicate in a way that’s conducive to learning. I have the impression that voices have not had this course. Sometimes they’re very angry at their host human because they think the person hasn’t been taking care of themself, such as “Back when you were raped, you should have killed that rapist. I’m so angry with you because you didn’t and because you didn’t, I think you’re useless. You should die.” When what you’re hearing is just, “you should kill yourself, you’re useless,” It’s very difficult to see the good intention, but it is often possible to actually unravel it.

What the voice wants is for this person to stand up for themself, but that communication needs to be translated into something that’s acceptable for an actual human being to do. We don’t want to kill anyone, but that may be the voice’s way of expressing a desire for protecting the person, or demanding they defend themselves. In Alice’s case, the “others” would say, “kill him,” whenever they were angry with me because they thought I overstepped my bounds or talked about something they weren’t comfortable with. There, I would say something like, “I’m sorry that I have offended you. Please take another sip of coffee or let me give you another cigarette, and I’ll be more careful to not offend you in the future. That certainly wasn’t my intention.” And then they’d calm down.

Sometimes voices can have these very violent and graphic ways of expressing themselves, and that language may need translation. It shouldn’t necessarily be taken at face value. It may be an expression of extreme frustration and desperation on the voices part. And that’s what we need to understand so that we can respond to it in the right way; saying something like,“We don’t want to kill anyone, but there’s someone you want to blame. There’s someone you’re angry at, and you want something else for this person you’re talking to. Okay, let’s see if we can solve that, because I certainly get that. I get being angry at that. Right? I get wanting to defend yourself.

But, you know, voices, this person wasn’t able to do that back then. She was a child. She was powerless against this person. We have to find other solutions here. And I invite you voices to participate in that because I appreciate your good intentions. I wish she was able to defend herself back then, but she couldn’t. I understand why you want the rapist dead, I get that. But we can’t do that. We have to find another solution. But I want to collaborate with you to find that something that this person needs , something that they can do.”

Expanding the Subjectivity of Voice Hearers

LR: Christoffer, we’re nearing the end of the hour, but may I ask a question about cultural healing practices?
CH: That’s a very big issue. We talked about spirits and animism and all that, but my point is not to say that voice hearing and spirit encounters in various cultures are necessarily the same thing, and that people in other cultures are all hearing voices and or that people in our society who hear voices would be shamans in other societies. That’s not necessarily the case. The point is more that animism provides a different way of understanding subjectivity and a way of handling subjectivity that fits quite nicely with what works for voice hearers. So, I can be agnostic about how voice hearing relates to spirits. It’s more about the commonality in the subjectivity.

You know, we might learn something from the spiritual practices in other cultures without it necessarily meaning that what we call mental illness is the same as the experiences that shamans deal with. I think that would be a conflation and an oversimplification.

But there’s a common structure of subjectivity around voice hearing and the practices and understandings in other cultures. It’s a better fit if we don’t view what I do through the lense of traditional, Western theories and practices. These don’t lend themselves very well to doing what I have done with voice hearers, because it would be very difficult to go from a traditional psychological model to offering cigarettes to a disembodied voice.

From an animistic perspective; however, it makes a lot of sense. These are offerings. We’re making an offering of tobacco that’s found in many indigenous groups in the Americas. To make an offering is to appease spirits by making a gift. And when you receive a gift, you enter a moral community of mutual obligation. That’s the logic of an offering. Alice’s others responded to that.

LR: Lastly, and speaking of community, can you say a word about the Hearing Voices Network. Is their work and philosophy consistent with what we’ve been talking about?

CH: There’s a lot of similarities. When we set out to do this co-research, David Epston and I along with these patients decided to not engage with the literature of the Hearing Voices Movement to just start from scratch and make discoveries. But a lot of what we found is very similar to some of the discoveries of the Hearing Voices Movement. And of course, the Hearing Voices Movement doesn’t have one unified idea or one unified practice. They have this idea that people should be allowed to find their own way, but certainly some of the discoveries that they have made are very similar, like for example voice dialog. So, we have arrived at practices that are like what they have arrived at. I find that very encouraging, that without trying to do the same thing, we have arrived at similar practices, working from scratch. And that expands that notion of subjectivity across continents, across borders—not just ideological borders, but geographic borders.

LR: without trying to do the same thing, we have arrived at similar practices…and that expands that notion of subjectivityI think that will be a good place to stop. Thanks so much for this fascinating conversation, Christoffer.

CH: This has been a very interesting conversation. Thank you very much. I’ve enjoyed it.

Links to Christoffer Haugaard’s JCNT (Journal of Contemporary Narrative Therapy) articles

Respecting Voices: A Report on a Co-research Project Concerning Voice Hearing

The Ring in the Well: Psychosis as a Crisis of Identity

Rose and the Whispering Voices

Sitting through it with the Voices: Victoria’s story by Christoffer Haugaard & Victoria

Why Trauma Recovery Isn’t a Straight Line

Posted on October 1, 2025February 19, 2026 by Psychotherapy.net Team

When clients begin trauma therapy many hold onto the hope that healing will follow a clear path. They picture a beginning, a middle, and an end. A moment where the past stops hurting, their relationships feel easier, and their bodies finally release the tension they’ve carried for years. But as therapists, we know it rarely unfolds that way. Healing is not linear. It comes in waves. Progress can be followed by regression. A moment of insight might be lost in a fog of overwhelm. A good week can lead to a hard month. It’s not a step-by-step climb. It’s a spiral. Clients return to the same emotional terrain again and again, but each time, hopefully, with a little more clarity, a little more stability, and a little more strength.

Clients Might Not Recognize Themselves at First

One of the earliest shifts I’ve witnessed in my trauma work is a client beginning to question long-held coping strategies, survival instincts, and automatic responses. These were the very tools that kept them safe in environments where safety was uncertain. They may start setting boundaries and feel a wave of guilt they can’t quite name. They may say no and spiral into fears of abandonment. They may feel anger surface for the first time in years and have no framework for how to manage it.

This stage can be disorienting. Clients often wonder if they’re regressing or doing it wrong. In truth, they are beginning to do something radically new. The nervous system often perceives unfamiliar experiences as potential threats, even when those changes are healthy. That is why growth frequently shows up as discomfort.

As a therapist, I have found it to be essential to help normalize this phase and support clients in tracking these shifts as evidence of progress. What once felt unsafe begins to register as tolerable. And over time, it begins to feel like safety. This is not failure. This is the nervous system recalibrating.

For clinicians interested in exploring the neurobiological foundations of this process, resources like Bessel van der Kolk’s work, and that of the National Child Traumatic Stress Network offer helpful frameworks for understanding how neuroplasticity supports recovery. I keep reminding my clients and myself that discomfort is often a sign of meaningful change. With time, what feels unfamiliar now can become a source of strength and stability.

The Nervous System Has a Story to Tell

Trauma doesn’t just live in your client’s memories. It lives in their bodies. It often shows up in the form of chronic tension, unexplained exhaustion, or a racing heart in situations that seem calm on the surface. I have noticed how a client becomes anxious in safe environments, withdrawn when connection is offered, or goes numb during moments that would typically bring joy. These aren’t signs of resistance or dysfunction. They are adaptive nervous system responses developed to survive past experiences.

The body carries what the mind may no longer recall. My client’s nervous system often reacts before their conscious awareness catches up. These responses made sense in the context of trauma, even if they seem confusing or disproportionate now. As a therapist, I can help clients begin to recognize these embodied patterns with curiosity and compassion. The healing process often starts with noticing—subtle shifts like shallow breathing, clenched jaws, or emotional distance in the room. These cues are the nervous system’s way of communicating safety or threat.

Rather than encouraging clients to override these sensations, I guide them toward listening to their bodies with gentleness. When I help create space between sensation and reaction, I offer a new way forward. That space is often where integration and healing begin. In learning about how the nervous system holds trauma and how regulation begins with awareness, I have found the Polyvagal Institute to be a particularly useful resource.

In one session, I have found that a client may speak with clarity and confidence. The next, they might come in feeling discouraged after falling into old patterns. Maybe they people-pleased, avoided conflict, or ignored their own needs. They begin to question whether any of their progress was real. It was!

Healing is not linear. The strategies that once helped a client survive can resurface, especially when they are tired, anxious, or uncertain. These moments are not evidence of failure. They are part of the natural rhythm of recovery. What begins to shift is their awareness. They notice the pattern more quickly. They pause before reacting. They ask themselves what they truly need in that moment. These subtle changes are meaningful. They mark the growth of resilience.

I have also found it important to help clients see these moments for what they are. Not as regressions, but as opportunities. This is where change begins to deepen. When someone catches themselves repeating an old behavior and chooses even a slightly different response, they are practicing something new. There is also something powerful that happens in these harder moments. Pain and struggle often reveal where care is still needed. They slow things down. They invite both the client and therapist to listen more closely to what is underneath the reaction.

This is where the deeper benefits of pain and suffering begin to emerge. These experiences have the potential to strengthen emotional awareness, deepen empathy, and reconnect a person with their values. Suffering, while never sought out, can become a guide that point to unmet needs, long-held beliefs, or unresolved grief that is asking to be seen. These moments help build presence, not perfection. Setbacks are not the end of healing. They are woven into the work. I have supported my clients in seeing these experiences not as detours, but as part of the path forward.

Healing Can Disrupt Your Relationships—And That’s Okay

As clients begin to heal, their relationships often start to shift. They may stop over-functioning. They may begin setting firmer boundaries or expressing their needs more clearly. Behaviors they once tolerated may no longer feel sustainable. These shifts, while healthy, can create waves. Not everyone in the client’s life will welcome or understand the changes. And that can bring grief, confusion, or even guilt.

Clients may feel lonely even as they move toward what’s best for them. They may grieve connections that once felt familiar, even if those dynamics were rooted in dysfunction or emotional distance. Letting go of old patterns often feels like loss, even when it is progress.

At junctions such as these, it’s important to normalize these growing pains. Healing doesn’t always feel good at the moment. It can challenge long-standing relational roles and bring uncertainty to familiar bonds.

These disruptions also signal movement toward something more grounded, more honest, and more self-respecting. Support clients in recognizing that discomfort in relationships is not a sign of regression and can be a sign of emerging authenticity. Healing doesn’t always preserve the old. Sometimes, it clears space for relationships that are built on emotional safety, mutual care, and respect.

It’s Normal to Feel Tired and Take Breaks of Healing

There have been moments in my clients’ journeys when the work feels like too much. They may grow tired of telling their story, tired of tracking every trigger, tired of examining old wounds. The weight of self-reflection can feel heavy. They might withdraw for a while. Maybe they spend more time scrolling, bury themselves in work, or cancel a session or two. These behaviors are not necessarily resistance. More often, they are signs of fatigue.

It is particularly important to name and normalize this part of the process. Healing is demanding. It takes emotional energy, and it does not always move at a steady pace. Help your clients understand that needing rest is not failure. Taking a break is not giving up. Slowing down does not erase progress. Sometimes the most meaningful work happens when clients step away and give themselves time to integrate what they’ve already uncovered. Growth needs room to breathe. It needs softness and space. When clients return, whether next week or next month, I acknowledge that return. Remind them that showing up, even imperfectly, is still showing up. That, too, is healing.

Clients often come into therapy carrying unspoken pressure. They want to get better quickly, move on from the past, and prove they’re strong by needing less. Some may feel shame for still struggling or frustration that their healing is taking “too long.”

There’s No Deadline for Healing

Therapeutically, it’s important to gently challenge this mindset. There is no prize for speed. No gold star for needing the least amount of help. Healing is not a race, and there is no finish line.

What matters is consistency, not perfection. It’s the willingness to return to work again and again, even after a setback. It’s the slow rebuilding of trust within themselves. I invite my clients to move at a pace that honors their body and nervous system. I help them see that slow progress is still progress. I let them know that taking the time they need is not only acceptable but it is wise. Therapy is not about rushing toward resolution. It is about creating a space where healing can unfold naturally, with patience, care, and room to breathe.

Postscript

If your clients’ healing journeys feel slow, confusing, or filled with setbacks, that doesn’t mean they’re getting it wrong. In fact, it often means they’re doing the hard, necessary work of integrating change. Recovery from trauma is rarely a linear process. It moves in spirals, detours, and pauses because that’s part of what makes it real.

As therapists, we can support this process by holding space for grief, for uncertainty, and for the parts of healing that take time. We can remind our clients that it’s okay to move at their own pace. That healing isn’t measured by speed but by presence, consistency, and the courage to keep showing up.

Nancy Haug on Psychedelic-Assisted Psychotherapy

Posted on September 24, 2025February 11, 2026 by Psychotherapy.net Team

Lawrence Rubin: Hi Nancy, thanks so much for joining us today. You are a professor in the department of psychology at Palo Alto University, and an adjunct clinical professor in the department of psychiatry and behavioral sciences at Stanford University School of Medicine. You have ongoing collaborations with and a teaching role in the Stanford Psychiatry Addiction Medicine Program, where your current research interests include implementation of evidence-based practices in addiction treatment, harm reduction for substance use, cannabis vaping, and psychedelic-assisted psychotherapy. Welcome!

Nancy A. Haug: I would add to that that I do have a small private practice where I treat clients, some for addictive disorders, but I am mostly a generalist.

LR: I didn’t know that you also have a private practice. Do you practice psychedelic assisted psychotherapy?

NH: I do a little bit of that work, but it’s a very small percentage of my clients, and it’s mostly limited to the preparation and integration phases of psychedelic therapy. I’m not doing any kind of administration of psychedelics in my office or in my practice. My clients will get that elsewhere. And then I’ll help them integrate the experience into therapy. We can get more into that later.I’d like to start by acknowledging the indigenous peoples and practices, because many psychedelics are derived from sacred plant medicines that have been used for millennia by many cultures. This isn’t something new, because much of the work we’re doing with psychedelics comes from thousands of years of cultural shamanic traditions.

Psychedelics as Medicine

LR: Thank you for that acknowledgment. I think it’s important that clinicians appreciate the broader cultural and historical context of psychedelic use.So, there are practitioners of psychedelic medicine, and there are practitioners of psychedelic assisted psychotherapy—two distinct but overlapping applications.

NH: Sure. I think the medicine piece would be more in the context of something like Ketamine treatment and/or the administration of psychedelics in a more medicalized setting. Clinical trials are being conducted right now that are looking specifically at psychedelics as medications. But as a psychologist, I’m more focused on the therapy piece which I really believe is an important component. It is about the way that psychedelics can be therapeutic for psychological healing.

LR: much of the work we’re doing with psychedelics comes from thousands of years of cultural shamanic traditionsSo, you might have a client presenting with symptoms of depression or anxiety or trauma going exclusively to a medical professional and receiving one of the psychedelics, but not necessarily being referred to a mental health professional for integration into therapy?

NH: Exactly.

LR: Is there a turf battle between medical and mental health practitioners in the realm of psychedelics over who gets ownership over their use? A battle in which psychotherapy is considered a diminutive form, and the integration of psychedelics into therapy as an encroachment of sorts?

NH: I believe that a lot of the providers of Ketamine treatment would support integration into psychotherapy as part of that workIt depends on who you talk to. We can certainly get into the differences between the various psychedelics, but at this point, there are many clinics where people can receive Ketamine infusions for various conditions that don’t involve psychotherapy. But I believe that a lot of the providers of Ketamine treatment would support integration into psychotherapy as part of that work. I actually work with a psychiatrist who runs a ketamine clinic, and he is always asking me if I’m taking referrals or if I can give him referrals to other therapists. He does have some therapists built into his clinic, but there’s not enough of them to meet the patient needs. So, I think there is recognition that the therapy component is helpful and that it can improve outcomes.

LR: Which chemicals are most often used in this line of research and intervention?

NH: Ketamine was used as an anesthetic in veterinary clinics and given to soldiers in Vietnam in the 1970s as a field anesthetic. It’s also been used off-label for the treatment of refractory depression and suicidality.The classic psychedelics are LSD, psilocybin, DMT, which is dimethyltryptamine, ayahuasca, and mescaline, which comes from the peyote cactus. Of the hallucinogens that have been studied and are in current trials, I would say psilocybin has probably been looked at the most. And then we have MDMA––ecstasy or Molly, methylenedioxymethamphetamine, which is a serotonin, dopamine, or epinephrine agonist, It’s sometimes called empathogen or enactogen, which produces a heightened sense of connectedness or openness. It’s characterized by the person becoming very empathetic and compassionate. MDMA has stimulant properties, but it’s different from classic psychedelics, which affect more perception, cognition, mood, and sense of self.

LR: if someone is going to do this work, it’s very important to be familiar with the different compounds, their effects, and what conditions they’ve been applied toI would think that mental health professionals would really need to know their way around pharmacology to venture into this realm of practice.

NH: I really agree that if someone is going to do this work, it’s very important to be familiar with the different compounds, their effects, and what conditions they’ve been applied to—just knowing the research. Most training programs for therapists who are interested in integrating psychedelics into their work will include the history of psychedelics, and then there’s always a psychopharmacology piece that is addressed. I don’t really endorse one or the other training programs, but I think most of the established ones are pretty good. Psychedelics are classified as Schedule I drugs by the FDA, meaning they do not have an accepted medical use.Some states, including Oregon and Colorado, have initiatives supporting psilocybin use in therapy, but they do require therapists to go through training programs. I think they get certified or licensed somehow as being psychedelic providers, which I think is a good thing—just to put some controls around it. And this isn’t just limited to psychologists. Anyone who’s a licensed therapist can do this work and can get training. That includes licensed marriage and family therapists, and clinical counselors.

LR: Is there a national certification that is available, or is it currently a state-by-state affair?

NH: Not that I’m aware of. I think a lot of the training programs developed in the context of clinical trials, and now pharmaceutical companies that are doing drug development, like Compass Therapeutics, have developed their own kind of training protocols for doing this work, and there are a few manuals, like Deliberate Practice in Psychedelic Assisted Therapy, which is one of the volumes in APA’s Essentials of Deliberate Practice series.

Integrating Psychedelics into Psychotherapy

LR: Is there a standard definition of psychedelic assisted psychotherapy?

NH: psychedelic medicine may or may not involve therapy as it’s more focused on the administration of the psychedelic. I do have a definition of psychedelic assisted psychotherapy that I like to use which I pulled together for a presentation with one of my colleagues. Psychedelic assisted psychotherapy is a clinical intervention that combines preparation, psychedelic administration, and integration of experiences to facilitate psychological healing in the context of a therapeutic environment.All of these pieces are important components of psychedelic assisted psychotherapy. There’s also an umbrella term called psychedelic medicine, which you’ll also hear a lot, and that I simply define as applications of psychedelics or hallucinogenic drugs to the treatment of psychological conditions or psychiatric disorders. Psychedelic medicine may or may not involve therapy as it’s more focused on the administration of the psychedelic drugs. But I know you wanted to talk about the therapy piece.

LR: Am I correct in assuming that there are randomized controlled trial studies comparing psychological treatment with Ketamine alone and psychotherapy with a psychedelic?

NH: We’re still in the early stages of this work. There was a review paper that came out recently looking at the different types of therapy that have been implemented, but there’s not a gold standard at this point.

LR: if I’m going to do this work, I’m working closely with a physician or a psychiatrist who’s administering the medication in a controlled settingWould a psychologist need prescription privileges if they wanted to use psychedelics independent of a licensed physician?

NH: I don’t think that would really be part of our domain as psychologists. Our role is to provide the therapy! It’s important to work with other providers, so if I’m going to do this work, I’m working closely with a physician or a psychiatrist who’s administering the medication in a controlled setting. There is a treatment model where the patient will be prescribed sublingual Ketamine lozenges that they can take at home and then work with a psychologist or licensed clinician to do the therapy.

LR: I don’t know anything about half-lives of the various psychedelics, but must the client be in an active substance-induced state, and how do you know if they are?

NH: I think again it depends on which psychedelic medicine and on the particular model of treatment. With the IV Ketamine infusion, the person typically isn’t conscious, so you couldn’t really be doing the therapy while they’re under the influence. But you could afterwards, because there’s research suggesting that because of the brain’s plasticity after psychedelics, the patient may be more receptive to therapy within 24 to 48 hours after they’ve ingested the medication.Like I said, we really don’t have a gold standard. And I think there’s been some challenges in disentangling the effects of the psychedelic drugs from the therapy itself. Some trials have tried to incorporate evidence-based treatments like Cognitive Behavioral Therapy or Acceptance and Commitment Therapy. There is some evidence that this might promote better clinical outcomes. I think ACT specifically, and mindfulness therapies lend themselves really well as interventions because of the psychic or psychological flexibility that they target. So, combining that with the psychedelic might create synergistic effects. But again, we haven’t standardized it, so it’s really hard to even compare across studies. You asked earlier what I thought the mechanism of action was, so I did want to say that we really think that it’s a result of the interaction between the medicine, the therapeutic setting, and the mindset of the participant. People might take psychedelics like ecstasy at a rave, or mushrooms at a festival; but that doesn’t necessarily lead to them being cured of their trauma or depression. Because it’s a different setting that is not necessarily a therapeutic context, they don’t have a guide with them really exploring underlying processes. We really want to help the patient become clear about their intention, such as addressing their fixed beliefs or getting more in touch with certain emotions. The therapy can help loosen some of that up, which will allow for greater flexibility.

LR: there’s been some challenges in disentangling the effects of the psychedelic drugs from the therapy itselfWhat do you hope to tap into or capitalize on when applying psychedelic assisted psychotherapy?

NH: I think it’s different for each patient and depends on what they are coming in with. Are they coming in with an unresolved trauma? Are they coming in with existential depression? I try to determine where they’re stuck and what it is that they’re trying to get insight about. And if they have cognitive expectancies, which refers to what they expect might happen during the psychedelic experience, or their mindset. And that does require some preparation work.One of the things I would want to be clear about with my patients is what they are looking for and not overselling this therapy as a magic bullet or that they’re going to be cured of their depression. That’s not how it works, and so I would actually be hesitant to do this work with someone who came with the notion that psychedelic therapy is the end all, be all, and that they’re going to be fixed. That’s probably not going to be helpful for them. I might even want to temper those expectations by providing a more realistic picture of what could happen, which starts to get into some of the ethical issues around this, particularly with informed consent, because we don’t know what’s going to happen. How do we obtain informed consent when we can’t even explain the psychedelic experience? I can’t tell what’s going to come up, and sometimes there are even personality changes where the person becomes more open or has altered metaphysical beliefs. So, it’s important to provide a lot of education and information about what could happen, including some of the subjective effects. There are just so many possible outcomes.

LR: one of the things I would want to be clear about with my patients is what they are looking for and not overselling this therapy as a magic bulletIs there any solid research about how the brain actually changes under the influence of psychedelics that make it easier for the clinician to access conflicts, or to get through resistance, or for the clinician to more directly intervene on a particular issue? In other words, is there anything proven about what happens in the brain that allows for that?

NH: Absolutely. Psychedelics enhance neural plasticity. One model that’s been put forth is the REBUS model by Robin Carhart-Harris, which is about relaxed beliefs under psychedelics. The idea is that the psychedelics relax what they call priors, or prior beliefs, or assumptions to allow bottom-up processing in which information flows more freely, where the mind can really open. Psychedelics have also been referred to as “disruptive psychopharmacology” because they disrupt boundaries among brain networks, allowing for greater communication across the whole brain.Psychedelics are also considered nonspecific amplifiers of human experience. In other words, whatever the person is going into the experience with – their particular mindset and setting – is going to be amplified during the psychedelic-induced state of consciousness.

LR: one model that’s been put forth is the REBUS model by Robin Carhart-Harris, which is about relaxed beliefs under psychedelicsHave there been any randomized controlled trial studies involving the use of placebos?

NH: It’s really hard to come up with a placebo that is comparable to psychedelics because people usually know when they’ve been given a placebo. That’s actually been one of the most difficult pieces of doing this research is that we can’t actually blind people. I know with some of the Ketamine studies they’ve tried to use Midazolam, which is a benzodiazepine. Usually, people know the difference.

LR: Circling back a bit; you mentioned that ACT lends itself particularly well to psychedelic integration.

NH: I think that because ACT emphasizes mindfulness, anything–psychedelics in this instance– that allows for fuller contact in the present moment, can help the client more fully and deeply navigate the therapeutic experience including any states that may arise. As another example, I believe they’ve used Internal Family Systems model in the MAPS (Multidisciplinary Association for Psychedelic Studies) trainings; and while I’m not trained in IFS, some people report that it’s useful because it helps the person look at different parts of themselves that they might not otherwise.In general, I would say that the therapy that occurs while the person is under the influence of the psychedelic tends to be more nondirective. In this context, the clinician and the client can respond in the moment to what is coming up. If the clinician is using a somatic tool or some other type of cognitive reprocessing, you don’t want to try to direct them in a particular way. It is important that the client’s inner wisdom, rather than the clinician or any particular technique, be the guide.

LR: it is important that the client’s inner wisdom, rather than the clinician or any particular technique, be the guideYou describe the presence of the psychedelic drug or experience as a co-therapist; a therapeutic ally or resource. The disinhibiting or loosening helps the person to get more in touch with their somatic experience. Whatever intervention you use may be enhanced, accelerated, or deepened. So, the therapist is a facilitator or guide.

NH: Exactly! You’re a facilitator or guide. In the MDMA trials through the MAPS program, they actually have two therapists, male and female. They have various reasons for doing it that way, one of which is perhaps to facilitate projection that could take place as the client reflects on their relational experiences. But it gets very expensive to have two therapists in the room for eight hours doing this work. I’m not sure how they could scale that.

LR: we have a lot of evidence that MDMA really does work with veterans who have been in combat; but also with survivors of sexual abuse and traumaYou mentioned that Ketamine has been successfully used for clients with depression. Do you have a sense of what the mechanism of action is in this case as well as with PTSD?

NH: Typically, MDMA is going to be the psychedelic of choice for PTSD. My understanding is that it promotes emotional processing, and reprocessing of the memories in a way that the person feels safe, less threatened by the memories or the images which allows to experience a deeper contact with those emotions or memories so can work through them.We have a lot of evidence that MDMA really does work with veterans who have been in combat; but also with survivors of sexual abuse and trauma. MDMA was recently reviewed for approval by the FDA but was rejected for various reasons including lack of supportive research. It’s hard to quantify and standardize psychedelic therapy, and since the FDA is not in the business of approving therapies, more research will have to be done. I do know that this outcome was very disappointing to the psychedelic community because we’ve been working hard at this for a long time and thought there was sufficient evidence, especially with PTSD, where clients with PTSD improve more with MDMA than with other behavioral therapies.

LR: I’ve seen an acceleration in progress for those clients who try psychedelic therapiesSince you spoke earlier about the role of client expectancy in treatment outcome, I’m wondering if you’ve noticed a difference in your own therapeutic presence or expectancy when doing psychedelic assisted therapy?

NH: I think I am more optimistic because I’ve seen clients who’ve really benefited from this work. I am hopeful that they will have breakthroughs because I’ve seen an acceleration in progress for those clients who try psychedelic therapies. They kind of get to the heart of their issues and dig into the meat of where they’re stuck a lot faster than they would with regular psychotherapy. I try to go in without any expectations and just let it unfold like I have no idea what’s going to happen.

LR: There’s so much research these days comparing the efficacy of various therapies, but I wonder how much emphasis you place on the role of the relationship in therapy outcome, especially when psychedelics enter the frame? Are you a technique-oriented person or relationship-oriented person, if such a simple binary even makes sense?

NH: I think I would call myself both, but it’s a really interesting question. I recently had an expert speaker come into my class to talk about CBT for addiction. He was talking about how we have all of these branded therapies, but that all good therapy really comes down to common factors and the therapeutic alliance. We need to foster a sense of safety and trust with clients, irrespective of intervention. In using psychedelics, a lot of fear can emerge, so they really need that safe space, which is where the therapeutic relationship becomes all the more important.

A Few Challenging Issues

LR: I’d like to circle back to the beginning of our conversation where you mentioned the importance of psychedelics with indigenous cultures. I don’t know the extent to which indigenous people reach out to traditional [white] therapists, but is there research on the use of psychedelic assisted psychotherapy within specific cultures?

NH: I don’t know that we’ve done enough of this. There’s a movement to try to be more inclusive, particularly in developing our approaches by consulting with indigenous communities. MAPS was doing some training to be more inclusive of therapists and clients of color. There was a paper published suggesting there are very few therapists of color or researchers in the field who are doing this work, so there’s definitely a need for more of this. We do know that MDMA and other psychedelics can be helpful for racialized trauma. Monnica Williams has done some of this important work.I have a student who did a dissertation on this topic where she interviewed clinicians in the community who were administering psychedelic assisted therapy. She asked them about motivations and workplace values in serving diverse communities. She had therapists of color and from marginalized groups, including one indigenous therapist. It was a qualitative study, and she had some interesting findings around the values that were being incorporated into their training, their identities, and then in their work with clients, and how countertransference reactions came into play. We definitely need to do more of this kind of research and perhaps even studies that look at therapy performed by clinicians who are given the option to use psychedelics like Ketamine so they can understand what the experience is like, although there would be challenging legal parameters there, especially around some of the Schedule I psychedelics.

LR: we do know that MDMA and other psychedelics can be helpful for racialized traumaAre there any counter indications for the use of psychedelics in psychotherapy?

NH: Absolutely! I would say clients who experience depersonalization, derealization, and intense existential struggles. There can be personality changes and long-term negative effects. I think it’s a small percentage, but there’s always a risk. I would say the same risks you would have with other medications and with therapy, right? There’s a percentage of people that can be harmed in some way, or for whom it can make their symptoms worse. It’s not going to be a positive experience for everyone.I think particularly along the lines of existential struggles. Some people might even encounter a higher consciousness or spiritual or mystical experiences that they weren’t expecting which can be disturbing. A person’s outlook on the world can change or they can wind up with a totally different perspective. For some people, that can be helpful, especially around end of life anxiety, where they can begin to feel more connected and safer around their own death. But sometimes, people can feel like they’ve died when using psychedelics, and that can be very unsettling. It can take a long time to integrate these kinds of experiences and to process things they didn’t necessarily want to see.

LR: some people might even encounter a higher consciousness or spiritual or mystical experiences that they weren’t expecting which can be disturbingSort of seeing someone for good old cognitive behavioral therapy and ending up at some existential cliff, looking at an abyss that they didn’t anticipate.

NH: Exactly! There’s another model I wanted to mention called the FIBUS model, or the False Insights and Beliefs Under Psychedelics. We know that psychedelics can promote therapeutic insights, but a person may experience misleading beliefs and insights that feel like they’re profound and true but might actually not be. So, one role of a therapist would be to help guide them in distinguishing what’s helpful, what’s harmful, what’s real, and what’s not.

LR: In that vein, I can see that psychedelics might not be useful with clients experiencing dissociative disorders, delusions, or cognitive impairment where they can’t rely on their own cognitive processing.

NH: Right, right! So, this isn’t for everybody. I think the clinical trials have done a really good job screening people by using strict inclusion and exclusion criteria. But in clinical practice, we could do a better job at looking at who might and who might not benefit from this, such as a person with a history of serious mental illness like schizophrenia or bipolar disorder.

LR: Are there any particular resources that you would direct readers to if they wanted to learn more about psychedelic assisted psychotherapy.

NH: There are some professional practice guidelines for psychedelic assisted therapy, like the American Psychedelic Practitioners Association and the Ketamine Research Foundation. There was also a paper published on ethical guidelines for Ketamine clinicians. I know the VA provides Ketamine therapy for treatment resistant depression in some of the Ketamine clinics they’ve set up where they have established protocols. Yale University has a program for psychedelic science and published an article on the use of ACT with psychedelics. But, I would say the training piece is always of critical importance.

LR: many of my students come into the program really clear that they want to be psyche

Redefining Strength: A Black Woman’s Journey to Healing

Posted on September 10, 2025February 11, 2026 by Psychotherapy.net Team

Redefining Strength: A Black Woman’s Journey to Healing

Kayla sat in my office with her arms crossed against her chest—a familiar shield against the world. At 23, she had grown accustomed to protecting herself, whether necessary or not. She avoided eye contact with me like the plague, guarding herself as hard as possible. “I don’t even know what I’m doing here,” she said, her eyes fixed on the floor. “This is so awkward.”

“That’s normal,” I said.

As a therapist, I have heard many clients share that they are unsure of what has led them to therapy. What was always different for me was tonality. I have heard people voice uncertainty about therapy with anger and even sadness. Kayla’s voice was filled with exhaustion.

“I feel so out of control as of late. I feel like I’m in a loop of the worst days of my life. I go to sleep thinking about my mistakes. I always wake up feeling worse than I did the day before. I’m eating and spending like crazy. I’m so tired.”

Kayla’s specific wording and my clinical judgment led me to believe there was more behind what she shared. So, I asked her, “What is weighing on you?”

Kayla burst into tears, and for the first time, she looked into my eyes, hers filled with anger and sorrow. “My mom died! I finally tell her how much I hate her, and she dies!” Kayla sobbed as her words lingered in the air. It had been a year since her mother passed, but as we know, there is no time limit on grief. Grief moves at its own pace and intensity. For Kayla, grief was feeding off her deep-rooted trauma.

“I keep replaying that argument with her over and over. Maybe what I said caused her too much heartbreak. Maybe she’d still be here if I had kept things unspoken.”

I leaned forward slightly.

“Kayla, your mother’s passing is not your fault.”

Kayla shook her head as tears continued to roll.

“Then why does it feel like it is?”

A Childhood Built on Survival

Kayla’s childhood was a lesson in what love wasn’t. She realized early on that her mother was not like the mothers she saw on television who supported their children and told them they loved them at the very least.

“My mom wasn’t like Clair Huxtable or anything. I didn’t get hugs or life lessons. She just wasn’t that kind of woman,” Kayla said. “I can’t recall her ever saying she was proud of me. When I would make good grades or clean my room, she would say,‘That’s what you supposed to do.’”

For Kayla, affection was nonexistent, validation was rare, and she never felt safe displaying anything other than strength. Kayla felt sympathy for her mother as she knew her mother faced hardships as a child herself. Kayla’s grandmother shaped her mother into the woman who raised her—distant and emotionally unavailable.

Over time, Kayla began to convince herself that she was the one who needed to change.

“I just stopped asking for things that she couldn’t give me. I consoled myself. I taught myself. I protected myself. I didn’t want to rock the boat with her because she was always extremely irritable. It annoyed her whenever I was in need, so I stopped needing her.”

By age ten, Kayla had perfected the art of being invisible. She didn’t ask her mom for love. She didn’t ask for affection. She didn’t ask for help. In turn, she saved herself from disappointment.

The “Strong Black Woman”

Kayla’s experience growing up was a complex one due to the emotional neglect and also the unwritten rules of what it takes to be a Black woman (1). She grew up being told to be strong and keep going no matter what. There was not enough room for anything else. Kayla comes from a family of Black women who embodied these qualities as armor against the world. Growing up in a space that offered little empathy to Black women, Kayla’s mother taught her how to survive, and that was her act of love.

“She used to tell me that if I think anyone cares about me crying, then I have a lot to learn,” Kayla stated angrily. “Like crying made you weak or something. In a way, she was right. I had to make sure people knew I was nothing to mess with!”Even after Kayla’s mother died, she felt like she had no space to grieve. “My aunt told me everything happens for a reason, and we can’t spend time crying. So, you mean to tell me I can’t have time to be sad about my mom’s passing? Even in death, do I have to push on? That’s a lot for anyone. If my family knew I was here, they would wonder why. After everything I have endured, they would still wonder why. Because we don’t do this.”

In addition to her trauma and grief, Kayla was struggling with knowing that she needed help but feeling uncomfortable while seeking it. There has been an undeniable stigma in the Black community when it comes to mental health. As a Black woman myself, I resonated deeply with her.

“My aunt would probably be like girl, you need to talk to God, and not no therapist! Talk to God, and you will be all right. Like I haven’t been talking to God. Talking to you is my last hope at this point.”

Kayla was plagued by wondering if she should even be here as a Black woman and also hoping that therapy would “work” for her.

“You know you can do both, right?” I asked. “You can talk to God and spend time in therapy.” Kayla arched her eyebrows as if she were in deep thought. I continued, “James 2:14 says, ‘Faith without works is dead.’ Kayla, you are doing the work right now.”

“Wow, I’ve never thought about it like that,” she smirked. “I like that!”

Naming the Wounds and Breaking the Cycle

Kayala learned to survive from an early age, and her defensive tactics served her well. Now, it was time for her to thrive. I discussed clinical diagnoses with her, and her mood instantly changed. I could tell she was not fond of labels.

“What is Post Traumatic Stress Disorder and Borderline Personality Disorder? Are you saying I’m crazy?” she asked, irritated.

“Absolutely not!” I said sternly. I swiftly disputed Kayla’s thoughts so she didn’t disengage with me. “A diagnosis is not about calling you crazy; it’s about creating a roadmap. Knowing your diagnosis helps us understand what’s wrong and how we can fix it.” I continued while I still had her attention, “Right now, your mind still seems to think that you are in danger, and it is responding accordingly. Kayla, you are safe now, but your experiences in life have wired your brain into a constant state of fear. When this happens to us, it is hard to regulate our emotions or trust new people because that is not a priority; safety is. That is why we are looking at Post Traumatic Stress Disorder or PTSD. We need to look at the research for what has been proven to work with your symptoms.” (2)

Kayla’s jaw tightened, but I saw a flicker of understanding.

I continued. “Now, some traits of Borderline Personality Disorder or BPD concern me. Again, this does not mean that there is something wrong with you. It simply means that something happened to you that is causing patterns similar to BPD to arise in your personality.”

Kayla previously reported mood swings, fear of abandonment, and impulsive choices that she wished to cease. I wanted her to understand that these symptoms made sense when one has endured the trauma that she has. Giving it a name only serves as a guide to addressing her symptoms.

“But here is the most important thing,” I said. “None of these things mean you’re crazy. They mean your brain did what it had to do to survive. And now, we’ll teach it a new way of looking at life.”

She nodded slowly. This time, she was really hearing me.

The Work: Using DBT to Rebuild Control

Kayla discussed feeling out of control when she first sat on my couch. She said she was tired and had exhausted all options. She wanted to feel different. Therefore, we had to try something different. Kayla was stuck in a cycle of emotional dysregulation, intrusive thoughts, and impulsive behaviors—trying to numb a pain that never seemed to dull. As a result of her trauma and grief, she had become avoidant. She had cut off her family in an attempt to forget her past and her unfavorable memories of her mother. She had also distanced herself from friends, convincing herself that being alone was the safest way to be. However, the isolation only compounded her sadness.

“I like to be alone. I don’t have to worry about anything…or anyone,” she said.

It was clear that avoidance had become a comforting survival mechanism for her, blocking her pathway to healing by dismissing the very things she needed to address. That is why Dialectical Behavior Therapy (DBT) was the chosen approach for Kayla—she didn’t just need to talk about her pain; she required structure. She was new to managing her emotions and grasping concepts of healthy communication. As someone who always “just dealt with it,” Kayla needed practical tools to help her regulate her emotions, tolerate distress, and rebuild her broken relationships with family and friends (3). DBT would allow Kayla to accept her past and present circumstances while learning tangible ways to help her approach her overwhelming emotions less detrimentally.

Kayla’s case and the use of DBT demonstrate its flexibility beyond its original purpose for borderline personality disorder for managing trauma and grief as well. Unlike traditional talk therapy, DBT provides tangible solutions to change. It was designed for people like Kayla—individuals who felt emotions so intensely that they often became destructive. With some culturally adapted tweaks, I knew DBT would be life-changing for her.

DBT Treatment Sessions: A Step-by-Step Process

Reframing Emotional Regulation Through Radical Acceptance

“So, what? I just breathe through my feelings? That’s not gonna do anything,” she snapped when I introduced emotional regulation techniques. Kayla came to therapy with the belief that any emotions outside of anger made her weak. She had been taught to be a strong Black woman. For her, that, unfortunately, meant suppressing pain and keeping her composure no matter what she faced—crying, asking for help, or expressing vulnerability felt like weakness. Regulating emotions meant giving in and giving up. We needed to reframe that thinking. I knew I had to introduce something concrete that would challenge this belief in a way that made sense to her lived experience.

That’s when I introduced Radical Acceptance.

“To radically accept something means acknowledging our reality no matter how much it hurts. It doesn’t mean you like it. It doesn’t mean it was fair. It simply means it happened and is out of our control.”

She narrowed her eyes.

“So, I just roll over and accept what happened to me? That sounds like letting people run over me.”

“It’s the opposite,” I assured her. “It means you stop wasting energy on what has happened and can’t be changed, then you can focus on healing and moving forward.”

We practiced this with a powerful exercise. I asked Kayla to create two different lists. On the first, I asked her to list everything she wished had been different. On the second, I asked her to write down the reality of what happened. Kayla hesitated, as if putting the truth into words would finally make things real for her. But eventually, she did it.

When she finished, I asked, “Which one is true?” She looked at them for a long time before responding.

“The second one.”

“And which one are you living in?”

She tearfully stated, “the first one.”

“That’s why it hurts so much.”

There was silence. I saw Kayla arch her brows again, as she always does when thinking.

“I guess I can’t change the past, huh? Being angry about it isn’t going to change it for me, either. I need to focus on what I want to be different now and make a plan to change my now.”

Managing Impulsivity Through Distress Tolerance

In our next session. I wanted to focus on Kayla’s binge eating and spending. These weren’t random actions. They were her mind’s way of coping with her trauma and grief. These behaviors were a quick way for Kayla to feel something other than discomfort, if only for a brief time.

“I don’t think—I just do it,” she admitted when we explored her excessive spending and binge eating.

I introduced distress tolerance skills to teach Kayla to sit with her uncomfortable feelings. One of the most valuable techniques for this was the STOP Method:

Stop – Pause before you react.
Take a step back – Create space to think before deciding.
Observe – Notice your emotions without judgment.
Proceed mindfully – Act with awareness.

At first, she was skeptical about being able to control her urges. But then, one evening, I received a text from her: “I almost spent $500 online on something silly, but I stepped away from my phone and did that STOP thing instead. So… yay, I guess.”

It was a small victory for Kayla but a critically important one. Over time, she began to master interrupting her impulsive urges. We were replacing her self-destructive behaviors with healthy coping skills.

Processing Trauma Through Mindfulness & Exposure Our next session was challenging as we addressed Kayla’s most potent and longest-held form of self-protection; we addressed her avoidance. I felt that Kayla had enough coping skills at this point to start to touch on some of her trauma that impacts her today. She shut down and cut off anyone who was a reminder of her trauma, further isolating herself and feeding her negative behaviors.

“I just don’t have time to think about any of that stuff. It feels bad,” she told me once.

But avoidance doesn’t erase trauma—it only buries it deeper.

I introduced mindfulness-based exposure therapy, where she slowly confronted the memories she had been running from. We spent half of one session just looking at a picture of her mother and addressing the emotions that rose from that. Eventually, we reached a point where Kayla was listening to an old voicemail her mother had left her shortly before her passing. Her mother called to check on her as she had not seen her since their argument. Kayla’s hands began to tremble; her breathing became shallow.

“This hurts me so much,” she whispered.

I nodded.

“I know. Just go with it.”

As she let the tears roll, she didn’t dissociate. She sat in how she felt. That was a breakthrough!

Breakthrough Session: Onward to Healing

Months into therapy, Kayla no longer felt like she was spinning out of control.

“I still have my bad days,” she sighed. “But I don’t feel like I can’t do anything about it anymore.”

Her progress was never about curing her pain. It was about living with it more healthily. She was still grieving, still processing, only this time around, she had the tools to cope. As she stood up to leave our session today, she paused. “You know,” she said, “I think my mom would’ve liked you.”

I smiled, and said, “I think she would’ve liked you too.”

Kayla walked out of my office that day, not healed, but healing. For now, that was enough.

Reflections from the Therapist’s Perspective

My experience with Kayla has grown me in ways no training or manual could. After some time sitting across from her, I realized that I was doing much more than simply applying interventions to an issue. What I was providing Kayla was a safe space. As big as the world is, many people do not have the space to be truly vulnerable and seen in their pain. In that space, it was not about how much I knew academically, but how deeply I could listen, be present, and make it safe for her to unravel.

Therapy is often misunderstood as something people do to “fix” an issue. However, healing does not come from quick fixes. Healing comes from connection when I can help carry the weight someone shouldered alone for far too long. Kayla reminded me that everything I do matters. My patience, validation, and commitment to her healing mattered so much. These small and consistent actions are the most powerful tools a therapist can implement during therapy. Most importantly, I learned I cannot validate what I do not acknowledge.

Kayla’s life experiences, beliefs, and values all stemmed from her upbringing. They stemmed from her identity as a Black woman in her home and the world. As a Black woman myself, I resonated deeply with the themes around mental health that Kayla had come to know as truth. As a Black therapist, I am even more grounded in my belief that therapy must make space for cultural humility and the intersectionality of the people we sit across from. Their identity, history, and experiences make them unique. That said, we must see our clients for all that they are.

References

(1) Carter, L., & Rossi, A. (2021). Embodying strength: The origin, representations, and socialization of the strong Black woman ideal and its effect on Black women’s mental health. In WE matter! (pp. 43–54). Routledge.

(2) Bremner, J. D., & Wittbrodt, M. T. (2020). Stress, the brain, and trauma spectrum disorders. International review of neurobiology, 152, 1-22.

(3) Prillinger, K., Goreis, A., Macura, S., Hajek Gross, C., Lozar, A., Fanninger, S., … Kothgassner, O. D. (2024). A systematic review and meta-analysis on the efficacy of dialectical behavior therapy variants for the treatment of post-traumatic stress disorder. European Journal of Psychotraumatology, 15(1), 2406662.

Understanding Sexual Reenactments and How to Eliminate Them

Posted on August 13, 2025February 11, 2026 by rezendevknowfully.com

In general, reenactments are an unconscious attempt to reconcile, reframe, or repair a trauma that occurred in childhood. Sexual reenactments are no different. Most sexual reenactments originate due to childhood sexual abuse or sexual assault in adolescence or adulthood. Although not every former victim of sexual violence will have a need to reenact their trauma, many do. This is because most sexual trauma goes unprocessed. Most sexual abuse victims don’t talk about it due to feelings of shame and the fear that they will not be believed. Many try to put it in the past the way friends and family encourage them to do. Unfortunately, this doesn’t work, and they end up reenacting the abuse in some way. As it is with other forms of abuse, typically, former victims tend to either reenact their trauma by continuing to be victimized or by becoming abusive.

It is common knowledge that victims of child sexual abuse have a tendency to reenact their trauma by being re-victimized throughout their lives, by repeating what was done to them and thus becoming an abuser, or by becoming promiscuous or sexually addicted. In this article I will discuss all of these types of sexual reenactment.

Patterns of Re-Victimization

Research over the past decade has consistently shown that women who were sexually victimized as a child or adolescent are far more likely to be sexually assaulted as an adult than other women. One study found that former victims of CSA are 35 times more likely to be sexually assaulted than non-victims. (1)

In addition, reenactments often lead to re-victimization and with it, related feelings of shame, helplessness, and hopelessness. For example, it has been found that women who were sexually abused as children are more likely to be sexually or physically abused in their marriages. Therefore, helping clients gain an understanding and control of reenactments is a primary way to help them avoid further victimization and shaming.

Why are victims of child sexual abuse more at risk of being re-victimized?

Most former victims of child sexual abuse experience a lot of shame and self-blame. These two factors are by far the most damaging effects of CSA and increase the likelihood of re-victimization more than any other effect. This is partly true because victims of sexual abuse develop certain behavioral problems, such as alcohol abuse, that make re-victimization more likely. Victimized women, in particular, believe that they have brought any abuse they’ve experienced on themselves and that they do not deserve to be treated with respect or loved unconditionally. (2) Furthermore, shame is related to an avoidant coping style, as the person who is shame-prone will be motivated to avoid thoughts and situations that elicit this painful emotional state. A victim who is experiencing avoidant symptoms may be prone to making inaccurate or uninformed decisions regarding potential danger because of the fact that the trauma has been denied, minimized, or otherwise not fully integrated. (3)
They tend to have alcohol and drug problems. Former victims often numb their re-experiencing symptoms with alcohol and drug use, which can serve to impair judgment and defensive strategies. According to research, former victims of child sexual abuse are about 4 times more likely to develop symptoms of drug abuse, and adolescents who have been sexually abused were 2 to 3 times more likely to have alcohol use/dependence problems than non-victims CSA has also been identified as a significant precursor to alcohol abuse. (4)
Certain factors increase the likelihood of re-victimization. Factors such as the severity of the abuse, the use of force and threats, whether there was penetration, the duration of the abuse, and closeness of the relationship between victim and offender are associated with higher risk of re-victimization. (5)
Certain kinds of abusive men target women whom they perceive as vulnerable. These men can easily spot a vulnerable woman just by observing their posture, the way they walk, and the way they speak.
Former victims tend to have sexual behavior problems and oversexualized behavior. Children who have been sexually abused have over 3 times as many sexual behavior problems as children who have not been abused.
They tend to have low self-esteem and poor body image. Obesity and eating disorders are more common in women who have a history of child sexual abuse. Girls and women who have a poor body image are more likely to feel complimented by male attention and are more vulnerable to men taking advantage of their need for attention.
They may feel powerless because the abuser has repeatedly violated their body and acted against their will through coercion and manipulation. When someone attempts to sexually violate them as an adult, they may feel helpless and powerless to defend themselves.
They don’t tend to respect their bodies. They may feel stigmatized, suffer from a great deal of shame and feel like they are already “damaged goods,” and there is no point in protecting their reputation or their body.
They don’t tend to be attuned to warning signs that a person may be a sexual perpetrator.
They don’t tend to have good boundaries. Former victims often allow other people to have too much access to their body, to take direction and advice too readily, to have difficulties saying “no.”

My client Ellen was re-victimized many times, by several different men and for many of the reasons stated above, specifically, shame and self-blame, being targeted by abusive men, feelings of powerlessness, a lack of respect for her own body, and poor boundaries.

“Starting when I was seven years old, my uncle began grooming me. My parents had just divorced, and my uncle started taking me places—supposedly to make up for the fact that my dad stopped coming to see me. He’d take me to the zoo, the park, and to the movies. He bought me candy and popcorn and sodas. And he bought me comics—I was really into comics. He was always very affectionate towards me, and I welcomed it because I missed my father so much.

“His affection gradually turned into sexual touches. It felt good so I didn’t resist. He progressed from touching my vagina to inserting his finger and then inserting other objects. At that point I didn’t like it. I didn’t get any pleasure—in fact when the objects got bigger it began to hurt. But I couldn’t say anything. He’d done so much for me, and I loved him so much that I just took it. Sometimes it hurt so much that it made me cry. He just ignored my crying and kept on doing it.

“I realize now that I have been reenacting the horrible abuse I experienced at the hands of my uncle for quite some time now. I’m so embarrassed to even tell you what I’ve allowed men to do to me. I was involved with one guy who was deep into BDSM (Bondage, Discipline, Sado-masochism) and I ended up letting him tie me up, drop hot candle wax on my vagina, insert objects into my anus. You’d be shocked if I showed you the number of scars I have because of that relationship. At the time I convinced myself that I loved him and because of that, I wanted to please him. But in actuality, I was just blindly repeating what my uncle did to me.”

Abuser Patterns

Just as not every former victim of CSA develops a victim pattern, not every former victim becomes an abuser. But unfortunately, many do. There is quite a lot of controversy about the extent to which males victims, in particular, repeat the abuse they suffered. Collecting reliable data has been difficult since subjects are not always willing to reveal their earlier childhood experiences, nor their own perpetrator behavior.

It appears that the type of sexual abuse one experiences can be a factor in the likelihood of becoming an abuser. For example, the evidence shows that only 21% of incest victims become sexual predators, whereas being a reported victim of pedophilia is strongly linked with being subsequently a perpetrator of pedophilia, alone or jointly with incest, with the combined rate being 43%. (6)

Several studies were conducted assessing the rate of child sexual abuse reported by 1717 male perpetrators of sexual assault who had admitted their crimes. The researchers were able to determine that, overall, 23% of the perpetrators had experienced sexual abuse with physical contact in childhood. (7) More recently, other studies have indicated that child sexual abusers are much more likely to have been sexually victimized as children compared not only to people who sexually assault adults, but also to non-sexual criminals and the general population.

Several studies have examined the factors that may increase the risk that male victims of child sexual abuse will go on to commit sexual assault. The key factors are:

In childhood:

Severity of the sexual abuse (more than one perpetrator, use of violence, greater frequency, longer duration, significant relationship with the perpetrator, etc.)
Sexual abuse committed by a woman
Positive perception of the sexual abuse experienced (positive affection for the perpetrator, perceived pleasure, poor understanding of the negative effects of the abuse, etc.)
Limited emotional support from family and friends during childhood
Intimidation and few meaningful social contacts during childhood and adolescence
Maltreatment
Lack of parental supervision
Adjustment difficulties and mental health problems in childhood and adolescence

In adulthood:

Limited awareness of the difficulties associated with having experienced sexual abuse in childhood
Low self-esteem
Antisocial behavior (8)

What Do These Findings Tell Us?

Experts maintain that, in the case of males, being sexually abused in childhood is an important risk factor for committing sexual assault later on in life, but that it is not the only risk factor that plays a role in the perpetuation of sexual assault.
Most victims of child sexual abuse will not become perpetrators of sexual assault, and a history of sexual victimization is neither a necessary nor a sufficient condition to sexually offend.
Personal and family factors in childhood that have been identified as increasing the risk that a sexually abused child will go on to commit sexual assault suggest that children who obtain specialized treatment, sufficient support from family and friends, and grow up in an environment where they do not experience maltreatment are less likely to develop a number of problems, including sexually aggressive behavior.
Individuals who do offend had, among other things, more problems in childhood and were unaware of the negative effects of the sexual abuse they suffered.

The bottom line is, if someone was sexually abused in childhood or adolescence, they need to:

Admit the abuse to themselves.
Learn about the possible effects it can have on someone, especially in terms of their sexual attractions, their sexual relationships, the amount of anger they still have toward their perpetrator and how they act out this anger sexually.
Learn what their specific triggers are—those reactions that can cause them to not only remember the abuse but to act out in a negative or even dangerous way.
Focus on what their unfinished business might be so that they are not motivated to reenact the trauma.

What’s at the Core of Sexual Reenactments?

Reenactments are always an attempt to manage unprocessed trauma. But in addition, sexual reenactments can be the following:

An unconscious attempt to come out of denial and face the truth about what happened to you
A cry for help
An attempt to take back a sense of power and control
A reaction to being triggered
An attempt to understand what happened to you

Let’s discuss each of these reasons one by one.

An Unconscious Attempt to Come Out of Denial

As I’ve have been discussing, reenactments are caused in part by powerful unconscious forces that must be eventually verbalized and understood. These patterns of behavior are often unconscious attempts to reconcile, reframe, or repair the abuse that occurred in childhood. Unfortunately, they do not always accomplish this task and can result in perpetual psychological and emotional damage. The primary reason why it is important for former victims to acknowledge the sexual abuse is that those who are in denial are particularly vulnerable to sexual reenactments.

One of the main reasons why victims of CSA continue to be re-victimized is that they are either in denial about the fact that they were sexually abused, they have minimized the damage caused by such abuse, or they convince themselves that they are not at risk. Let’s return to Ellen, the woman who was frequently sexually mistreated by men and who allowed a boyfriend to repeat what her uncle had done to her. In Ellen’s case, she had never denied that her uncle had molested her. But she did struggle to believe that he never cared about her, that he was just using her. “Even though he did terrible things to me sexually, he had originally been so good to me that I tried to excuse the other stuff. I continued to believe that if I let him do the bad stuff, he’d become the “good Uncle” again. I must have had the same thinking process with all those men who did horrible things to me. By reenacting the abuse by my uncle, in a weird way I was actually forcing myself to admit that he never really loved me, something I needed to face.”

It’s critical to help clients acknowledge whether they were sexually abused as a child or not. Child sexual abuse includes any contact between an adult and a child, or an older child and a younger child, for the purposes of sexual stimulation of either the child or the adult or older child and that results in sexual gratification for the older person. This can range from non-touching offenses, such as exhibitionism and child pornography, to fondling, penetration, incest and child prostitution. A child does not have to be touched to be molested.

Many people think of childhood sexual abuse as being an adult molesting a child. But childhood sexual abuse also includes an older child molesting a younger child. By definition, an older child is usually two years or older than the younger child but even an age difference of one year can have tremendous power implications. For example, an older brother is almost always seen as an authority figure, especially if he is left “in charge” when their parents are away. The younger sibling tends to go along with what the older sibling wants to do out of fear or out of a need to please. There are also cases where the older sister is the aggressor, although this does not happen as often. In cases of sibling incest, the greater the age difference, the greater the betrayal of trust, and the more violent the incest tends to be.

Many former victims do not realize that what happened to them as a child or adolescent was considered abuse because their image of child sexual abuse is limited to an older man abusing a child of the opposite sex. But this does not take into account males who are victimized by another male, those who were abused by a female, victims of sibling abuse, and victims of clergy abuse.

Also, in addition to the actions that we normally consider to be childhood sexual abuse, there are many other behaviors that fall into this category. You may wish to provide your clients with the following questionnaire, following questionnaire, from Put Your Past in the Past: Why You May Be Reenacting Your Trauma and How to Stop.

Questionnaire: Were You Sexually Abused?

Did a family member, a caretaker, a sibling or other older child, an authority figure or any other adult or older child:

1. Lie or sit around nude in a sexually provocative way?
2. Walk around the house in a sexually provocative way (nude, half dressed)?
3. Frequently walk in on you while you were getting dressed, while taking a bath or while using the toilet?
4. Flirt with you or engage in provocative behavior such as making comments about the way your body was developing?
5. Show you pornographic pictures or movies?
6. Kiss, hold, or touch you inappropriately?
7. Touch, bite, or fondle your sexual parts?
8. Make you engage in forced or mutual masturbation?
9. Give you enemas or douches for no medical reason?
10. Wash or scrub your genitals well after you were capable of doing so on your own?
11. Become preoccupied with the cleanliness of your genitals, scrub your genitals until they were raw, tell you that your genitals were dirty, shameful or evil?
12. Force you to observe or participate in adult bathing, undressing, toilet, or sexual activities?
13. Force you to be nude in front of others? Force you to attend parties where adults were nude?
14. Peek at you when you were in the shower or on the toilet, insist on an “open door” policy so they could walk in on you at any time in the bathroom or in your bedroom?
15. Make you share your parents’ bed when you were old enough to have your own bed (assuming other beds were available)?
16. Have sex in front of you after you were old enough to be upset, confused, or aroused by it?
17. Tell you details about their sexual behavior or about their sexual parts?
18. Take photographs of you nude or engaged in sexual activities (once again, after you were old enough to be embarrassed by it)?
19. After you reached adolescence or older, ask you to tell them about inappropriate details about your sexual life.
20. Allow you to be sexually molested without trying to stop it?
21. Deliver you to other people so that they could molest or rape you, or bring people over to the house who would molest or rape you?
22. Make you into a child prostitute?
23. Continue to make sexually inappropriate comments, or to touch you in sexually provocative ways even after you reached adulthood?

A Cry for Help

Often, without realizing it, former victims of CSA put themselves in dangerous situations as a way of letting others know they need help. They behave recklessly, get in trouble with the law, drink too much, take drugs, and/or associate with dangerous people. Coming back to Ellen, another reason for her reenactment was that she was crying out for help—not on a conscious level of course, but on an unconscious one. Although she was ashamed of all her “battle scars,” they too were cries for help. In fact, she later admitted that she often wore short sleeves so people would see her scars and ask her about them.

In most situations, if you were to confront former victims about the risks they take, they will deny it, but there is no doubt about it, in spite of their protests to the contrary, they are desperately crying out for help. This was the case with my client, Caitlin:

“When I was a teenager I got into all kinds of trouble, from shoplifting to overdosing on drugs. My parents were exasperated—trying to control me, trying to make me understand the danger I was putting myself in. But frankly, I just didn’t care. I didn’t care what happened to me.

“Now I understand that I was calling out for help. I wanted my parents to know how much I was hurt and why. I was being molested by my grandfather, a man my parents adored, and because they adored him, I couldn’t say anything. I didn’t want to break their hearts if they realized what a monster he actually was, and I didn’t think they would believe me anyway. It was like I was waving a giant red flag saying, ‘Hey, look at me. See how much I’m hurting. Try to figure out why.’ But they never did, and I just got worse and worse.

“Eventually, I got involved with a guy who was basically a gangster. He and his friends robbed liquor stores, but he pretended to be a nice guy. He’d come to my house to pick me up and be all nice and polite to my parents. He had them fooled completely, just like my grandfather had them fooled. Talk about a reenactment.”

An Attempt to Take Back Power and Control
Another common reaction to child sexual abuse is to attempt to regain a sense of power and control over one’s sexuality. Perhaps the best example of this is when former victims of CSA become prostitutes or strippers. There have been numerous studies showing that a majority of prostitutes were sexually abused as children or adolescents (8, 9). One of these studies (McClanahan) interviewed 1,142 female detainees at the Cook County Department of Corrections found that childhood sexual victimization nearly doubled the odds of entry into prostitution throughout the lives of women. The other (McIntyre) noted that 82% of the sample had been “sexually violated” prior to their involvement in the sex trade, while three-quarters had a history of physical abuse.

Many researchers have interviewed prostitutes who freely talk about the fact that they feel empowered selling sex to men because they feel like they are turning the table on them. They feel that they are now the ones in power. Of course, the sad truth is that they are no more in power than they were when they were being sexually molested. Please note: these studies primarily studied and interviewed prostitutes in the United States, Canada and Europe. Those that studied prostitution in third world countries such as in Asia and Africa found that other factors, such as poverty, were primary motivators for prostitution.

In addition to becoming involved with prostitution and stripping, former victims of CSA or sexual assault in adolescence or adulthood get involved with other activities, such as BDSM in an attempt to gain power and control. Ellen always took the passive role in her sexual reenactments but others take the aggressive or active role. This was the case with my client Tanya.

“I got involved with BDSM because it gave me a chance to be the one in power. I got to call the shots—I had all the control and it felt great. I got so good at it that I actually became a dominitrix for a while. Men paid me to humiliate them and make them feel powerless—like how I felt when I was being sexually abused. For a long time, this felt really good. But that was before therapy, before I figured out what I was actually doing, before I processed my feelings about being abused. Once I did that it turned my stomach to treat men the way I had been treated. It took all the pleasure out of it for me. I began to see them as helpless victims like I had been because who knows what had happened to them, you know? They were pathetic really and I no longer wanted to participate in their need to be punished.”

Another common way that former victims attempt to take back power and control is by becoming abusive themselves. By becoming an abuser, former victims can play the role of the more powerful person in the relationship in an attempt to overcome the powerlessness they felt as a child. My client Jake is a good example of this. This is what he shared with me when we first started working together.

“I guess the average guy can watch porn and not get triggered like I do. But what happens to me is I start feeling agitated. I feel like a caged animal—trapped in my own home, in my own skin. I immediately find some excuse to tell my wife I have to go out. Then I just drive. I drive until I see an opportunity. I might see a woman walking alone on a road, or I might see a Strip Club or bar that looks interesting. My goal is to have access to a woman, any woman, as quickly as I can. It doesn’t matter how old she is or what she looks like. She just needs to be available.

“I find a way to get the woman alone and then I try to convince her to have sex with me. I’m like a hungry animal; I have to satisfy my hunger. If the woman doesn’t cooperate, I become more and more aggressive. I do whatever I have to do to get her to give in to me—I lie, I manipulate, whatever I have to do. Sometimes I just need to coerce her to go with me to a secluded place. But if she ends up fighting me off, I get physical. I slap her, punch her—whatever I need to do to make her stop resisting.”

As Jake and I continued to work together we discovered the reason pornography was a trigger for him. When he was 12 years old, he was sexually abused by a neighbor who used pornography as part of his grooming process. The neighbor had groomed Jake by playing video games with him, providing him with sodas and later on alcohol, and by showing him pornographic films. Most of the films were about gay sex and afterwards he would molest Jake.

We then needed to understand the connection between his sexual abuse and his aggressive behavior toward women. Jake was finally able to make the connections we were looking for—the explanation for his abusive behavior after watching pornography. As it turned out, Jake felt compelled to watch pornography, even though he didn’t like how it made him feel. The reason he felt compelled to go searching for a woman after watching porn was that he unconsciously needed to prove to himself that he wasn’t gay. Another motivation: he needed to assert the power and control he had lost to the molester. And the rage he felt toward the women he forced to have sex with him was actually the rage he felt toward his perpetrator—the neighbor man.

A Reaction to Being Triggered
Often a reenactment is caused by being triggered. If you noticed, Jake mentioned being triggered by the pornography he felt compelled to watch. The most common triggers for those who experienced child sexual abuse are:

Sounds, smells or tastes that remind you of the abuser or the environment where the abuse took place
The smell of alcohol, someone being drunk
Being in the dark
Someone reminding you of your abuser
Someone coming too close to you physically
Someone wanting to be emotionally close to you before you are ready
Being alone with someone
Being alone with a stranger in a small room
Being around pornography or someone who is watching pornography
Family get-togethers (especially for those who were abused by a family member)
Being touched
Someone flirting with you or making sexual comments
Being seduced
Being manipulated (if you do this, I’ll do that)
Being pressured (Oh come on, I know you’ll like it if you just try)
Secrets/clandestine activities
Feelings of betrayal
Lies and cover-ups
Blackmail, threats
Being “bought”
Cameras and video cameras

An Attempt to Understand What Happened

Ongoing reenactments often indicate that a survivor is emotionally stuck. Some are attempting to work through an aspect of the trauma by repeating it with another person hoping that this time the result will be different. Others refuse to believe that someone they loved and/or respected could harm them in such a selfish way. Still others blame themselves for the abuse or have identified with the aggressor, and cannot admit to themselves what really happened. In this case, their reenactments are often unconscious ways to try to understand what happened to them, or their unconscious trying to force them out of denial. This was the situation with my client Monica who explained her situation this way:

“I love my fiancé very much but whenever I am at an event or party without him, I almost always get into trouble. If a man comes on to me, I just can’t seem to push him away, especially if he comes on strong. I mean, I want to get away from him, but it is like my feet are in cement. I’m ashamed to say that I let these men touch me in places they should never have access to. Even worse, on several occasions I have let men pull me into a bathroom to have sex with me. I even have haunting memories of being slammed against a wall in a dark hallway. I’m so ashamed of my behavior. I just don’t understand myself.”

I explained to Monica that it is very common for survivors of sexual abuse or sexual assault to respond in the way she does when men approach them. There is a trauma response called “freezing” in which a person cannot defend themselves or even move when they are being attacked. Many describe it as a feeling like their feet are in cement. This explanation opened the door to Monica talking about the fact that she was attacked by a much older boy after choir practice at church when she was 13 years old.

“He started talking to me after choir. At first, I was flattered to have a boy so much older than me take interest in me. But then he tried to kiss me several times and I pulled away and told him to stop. No matter how often I pushed him away he just kept trying. I ran away and tried to avoid him from that time on.

“I thought I’d dealt with the problem, but I guess it made him angry that I pushed him away because one evening he waited for me and pulled me into an empty room and raped me. I tried to call out but there was no one around to save me. I’ve blocked out the details, but it was a horrible experience for me.”

“Did you tell anyone about it?” I asked.

“No, I was too embarrassed. I knew I shouldn’t have been talking to him in the first place. My mother has always warned me about talking to strangers, but I was flattered that an older boy took an interest in me, and I ignored her warning. I thought she’d get mad at me for being so careless. And I didn’t think anyone would believe me. After all, why would a boy so much older than me, a good-looking boy for that matter, bother with such a young and unattractive girl like me?”

As you can probably imagine, there was a lot going on with Monica and it explained why she was acting the way she did with men who approached her. She was so traumatized by the rape that she froze when men came onto her. She was unconsciously reenacting the trauma of being raped. Monica needed to acknowledge and process the feelings she had experienced when she was raped at 13, feelings she had tried to push away and forget. By doing so, and by realizing that the rape was not her fault, she was able to stop her reenactments entirely.

Passive and Active Reenactments

I’ve divided sexual reenactments into two major categories: passive and active (or aggressive). While those involved in reenactments are typically unaware of what they are doing, those who are involved with passive reenactments (men as well as women) are particularly unconscious when it comes to realizing they are reenacting previous trauma. They go about their lives, putting themselves in risky, if not dangerous situations, completely oblivious to their motive—replaying the trauma of child sexual abuse hoping for a different outcome.

Passive Reenactments

Passive behavior is continuing to view sex from a victim’s perspective and therefore can become a reenactment of the abuse. Behaving in any of these ways causes clients to feel ashamed and to continue to lose respect for themselves. Even more troubling, behaving in these passive ways is often re-traumatizing.

Examples of passive reenactments can include:

Not being able to say no to someone who comes on to you or to getting involved with sexual activities that you are not interested in or are even repulsed by.
Allowing someone to pressure you into sex or demand sex of you.
Being involved with domineering/abusive partners.
Being involved with shame-inducing behaviors—sexual activities that cause you to feel deep shame during or after sex. Examples: someone humiliating you sexually or saying derogatory things to you during or after sex.
Practicing risky behaviors such as drinking too much or taking drugs at bars or parties, especially when out alone or where you don’t know anyone. This includes not watching your drink or leaving your drink to go to the restroom and not insisting that a man where a condom.

Aggressive Reenactments

Those who identified with the aggressor or hid their shame behind a wall of arrogance or bravado often recreate the abuse by being aggressive sexually. This can include:

Being sexually inappropriate (standing too close to a stranger, touching a stranger in an intimate way [hand on their leg, hip, back, behind]).
Being sexually coercive or demanding.
Humiliating and degrading your sexual partners.
Being emotionally, physically or sexually abusive toward your partner.

Identifying Shame-Inducing Sexual Compulsions

Shame is by far the most damaging aspect of CSA. Former victims carry a great deal of shame, causing them to have low self-esteem, self-hatred, a tendency to blame themselves when things go wrong, and a general feeling of being “less than” other people. If things weren’t bad enough for former victims, some find themselves locked into compulsive sexual behavior that can perpetuate feelings of helplessness, a sense of being bad, or out of control, resulting in further shaming. These sexual compulsions happen outside of conscious awareness and are often characterized by dissociation of thoughts, emotions and sensations related to the traumatic event.

The list below are some of the most common shame-inducing sexual compulsions––

sexual activities that can cause you to repeatedly reenact the pain, fear, or humiliation of the sexual trauma you suffered (either as the one in power or as the victim).

Engaging in humiliating sexual practices (sadomasochism, sex with animals)
Combining sex with physical or emotional abuse or pain
Frequent use of abusive sexual fantasies (either seeing oneself as the abuser or the abused)
Engaging in promiscuous sex (many sexual relationships at the same time or in a row)
Charging money for sex
Having anonymous sex (in rest rooms, adult bookstores, telephone sex services)
Acting out sexually in ways that are harmful to others (forcing someone to have sex)
Acting out in ways that are harmful to yourself (allow yourself to be humiliated during sex)
Manipulating others into having sex with you
Demanding sex from others
Using rape or other types of fantasies to gain sexual arousal or increase sexual arousal
Committing sexual offenses (voyeurism, exhibitionism, molestation, sex with minors, incest, rape)
Feeling addictively drawn to certain unhealthy sexual behaviors (sadomasochism)
Continually using sexual slurs or degrading sexual comments to humiliate your partner or allowing your partner to do this to you
Engaging in secretive or illicit sexual activities
Relying on abusive pornography in order to become aroused

Other sexual compulsions can be less obvious reenactments of the trauma of child sexual abuse and are more likely to be ways to cope with stress or self-punishing behaviors such as:

Engaging in compulsive masturbation
Engaging in risky sexual behavior (not using protection against disease or pregnancy)
Being dishonest about sexual relationships (has more than one partner but professing to be monogamous)
Engaging in sexual behavior that has caused problems in your primary relationship, at work, or with your health

Eliminating Shame Inducing Behavior

If a client wishes to reduce or eliminate the amount of shame they feel they typically need to remove the above behaviors from their sexual repertoire. The same holds true if they wish to eliminate the likelihood that they will become involved in sexual reenactments. The most extreme, and therefore the most shaming of these behaviors include: talking to or treating your partner in degrading ways or asking to be talked to or treated in these ways; demanding sex or forcing someone to have sex; watching violent pornography; engaging in sadomasochism; and engaging in other dangerous sexual activities. These activities are all examples of extreme shame-inducing behaviors and are often reenactments of the abuse. Therefore, it is vitally important that your clients make a special effort to first identify and then to eliminate these particular behaviors from their sexual repertoire.

I’ve outlined some of the specific changes your clients can begin to make in order to eliminate these shame-producing behaviors and attitudes that may have dictated their sexual life.

Remedies for Passive Reenactors

Learning to Say No

While it may seem obvious that saying no is important and necessary, the truth is that many women and men don’t know they have the right to do so. It is also true that even more people don’t know how to say it. Practicing how to say “No!” teaches someone how to literally say “No!” in a strong, assertive manner—but perhaps even more important, it will give them permission to say it, not just with their words, but also with their actions and attitude. It will show them that they don’t have to just put up with unwanted sexual remarks or touches, and that by keeping silent, they may be giving people permission to go further than they should. It will help them to understand, on a deep emotional level, that they have a right to expect that their body is off-limits to anyone they don’t want touching them. The following exercise will help your clients become stronger in their resolve to stop allowing people to pressure them sexually.

Exercise #1 Saying No!

Think of a fairly current situation in which someone recently disrespected, invaded or abused your body.
Imagine that you are saying “No!” to this person.
Now say it out loud. Say “No!” as many times as you feel like it. Notice how good it feels to say it.
If you’d like, in addition to saying “No!” add any other words you feel like saying. For example, “No! You can’t do those things to me.” “No! I don’t want you to touch me like that!”

Practicing saying “No!” will help your clients gain the needed courage to say it when they need to—whenever someone is trying to coerce them into sex when they don’t want it.

Know what is Healthy for You and What is Off-limits

This step is an especially crucial one. In many cases this goes beyond sexual “preferences” to sexual needs. For example, if the person who molested your client fondled their breasts as a part of the molestation, they may have an aversion to having their breasts touched. This is a common scenario and is completely understandable. On the other hand, if the perpetrator did everything else but touch their breasts, that may be a “safe zone” for them, a place on their body where they are not re-traumatized and from which they can actually derive some pleasure. If the perpetrator did not penetrate their vagina with his finger, his penis, or another object, having vaginal intercourse may be their “safe zone,” and may be quite pleasurable. A fairly common scenario is for former victims of CSA to be able to enjoy having their partner touch those parts of their body that were not touched by the abuser, as well as enjoying engaging in sexual activities that the abuser did not impose on them.

Exercise: What’s Off-Limits

Make a list of the parts of your body you find uncomfortable to have touched. Don’t worry if you end up listing many parts of your body. This is common for former victims and is a reminder of just how traumatic the abuse was.
Try to find the reason as to why someone touching a particular part of your body is uncomfortable for you. It probably is due to the fact that this part of your body was involved in the sexual abuse in some way.
Now make a list of sexual activities that are uncomfortable, shaming, or triggering for you. Try to be as honest as you can, even if it means listing activities you believe you “should” like to do or have been doing.
Write about the reasons why you think these sexual activities are uncomfortable, shaming or triggering for you. The more connections you can make the more in charge of your sexuality you will become.
Finally, list the parts of other people’s body that you find uncomfortable to touch.
Think of the possible reasons why these body parts are uncomfortable for you to touch.
Now complete the following sentences:

Some parts of my body are just off-limits. These are: ___________________________________________________________________________________________________________

I am triggered by (have a post-traumatic response to) certain sex acts. These are: ___________________________________________________________________.

I am not comfortable looking at, touching, or feeling some parts of another person’s body. These are: _________________________________________________________________________.

Feel free to share these exercises with your clients but please cite the source (Put Your Past in the Past).

Remedies for Aggressive Reenactors

In the same way that many former victims reenact the abuse they experienced by being passive, many react to past abuse by being aggressive. As we have discussed, these people attempt to avoid further shaming by building a wall of protection to insulate themselves from the criticism of others. These same people often become bullies—attacking others before they have a chance to be attacked. But behind that aggression, behind that need to dominate or humiliate others, is a little child who is still shaking in his boots. Pretending to be tough and strong isn’t really solving the problem, and shaming and humiliating others before they have a chance to do it doesn’t help either. What will help is for your client to take off their mask, tear down that wall, and face the truth. They are just as vulnerable, just as hurt as any other victim of child abuse and they need to address their pain, humiliation, and fear instead of hiding it from themselves. Suggest they start by doing the following:

Instead of demanding sex or compulsively masturbating, or watching pornography, ask yourself if sex is really what you need? Young children who were sexually abused often discover, perhaps for the first time, that their sexual organs can provide good feelings. This can be the start of compulsive masturbation or a sexual addiction. The child, and later the adult, grows to rely on sexual pleasure and sexual release in order to cope with feelings of shame, anxiety, fear, and anger. When you begin to obsess about sex it may be a signal that you are feeling shame or that you are feeling anxious, afraid, or angry. Or you may have been triggered. In addition, you may use sex as a way of avoiding your feelings and staying dissociated. For many former victims, sex becomes one of the only ways they can feel worthy, or they can interact with another person. In other words, your client may be having sex to fill needs that are not necessarily sexual, such as needs for physical contact, intimacy, and self-worth. They may be seeking sex because they need to be held. Many former victims don’t feel loved unless they are engaging in sex with someone.
Ask yourself what sexual activity or sexual compulsion does for you. For example: What needs are you trying to fill when you have sex? Is sex the only way you can connect with other people? Is it the only way you think you can be loved? What painful emotions does the compulsion help you avoid? One of my clients answered the question in this way: Having a lot of sex makes me feel powerful. It keeps me from feeling how helpless and powerless I felt when I was being abused by my father.
If you discover that you are using sex, or fantasies of sex, to cope with shame, anxiety, fear or anger, find other, healthier ways of coping. This is also where self-soothing strategies come in. Instead of using sex or sexual fantasies to soothe yourself, find soothing strategies that work for you (taking a warm bath, gently touching your arm and saying something like, “You’re okay,” or “You’re safe now”).
Learn what your triggers are—what emotions or circumstances catapult you back in the past to memories of the abuse. If you haven’t made a trigger list, do so now.
Check to see if you have been triggered by shame. Shame is an especially powerful yet common trigger. For example, if you have been triggered by shame (your partner complains about the fact that you don’t make more money) offer yourself some self-compassion. Compassion is the antidote to shame so tell yourself something like, “It is understandable that I would feel shame about not making more money. But I am doing the best I can under the circumstances. I don’t feel good enough about myself to go out and try to find a better paying job but eventually I will.”
If you tend to be sexually controlling or demanding, practice taking a more passive-receptive role. At first this will likely feel uncomfortable or even scary. You took on an aggressive stance in order to avoid feeling small or vulnerable. But if you can practice being more passive a little at a time (i.e., adjusting so that you are on the bottom and your partner is on top) you will likely discover that it actually feels good to relax and let your partner, take over.
Allow yourself to be more vulnerable with your sexual partners. If a partner has opened up to you and shared information about their childhood, see if you can do the same. You don’t have to tell the person that you were sexually abused, but test out how it feels to share other information about your childhood that you don’t normally share with others. Opening up and becoming vulnerable will feel risky at first but if you choose wisely who you reveal yourself to, you will likely discover that it feels good to be more open.
Avoid exposure to things that reinforce or replicate the sexual abuse mindset. This includes television programs, movies, books, magazines, websites, and other influences that portray sex as manipulation, coercion, domination, or violence.
Avoid pornography or work toward weaning yourself off of pornography if you use it regularly or feel you might be addicted. For former victims of CSA watching pornography can be especially problematic because you are reenacting an abusive dynamic that disengages you from yourself, and opportunities for respectful sexual relationships. Pornography has aspects of sexual abuse such as secrecy, shame, and dominance—all tied up with sexual arousal. Pornography is especially harmful to sexual healing because it is often a depiction of sex as one person dominating another (usually a male dominating a female) which is a reenactment of CSA. Specific problems caused by watching pornography include:
- Those who were sexually abused are often inundated with feelings of shame and try to distract themselves from these feelings by watching porn. But ironically, after viewing pornography and masturbating to it, it is common for former victims to feel shame, disgust and failure—the very feelings they have been trying to get relief from in the first place.
- Former victims tend to keep their pornography watching a secret from their partners. This can mirror the way sexual abuse was kept a secret, and in that sense can be a reenactment. When their partner finds out their sense of betrayal can be overwhelming and can cause as much harm to the relationship as pornography itself. More than one-quarter of women viewed pornography watching as a kind of affair. (10)
- Viewing pornography is, generally speaking, not about connection, intimacy, and affection. Instead, there is a blurring of boundaries around acceptable sexual behaviors, especially where there are overtly humiliating or degrading practices. Researchers have found that over 80% of pornography includes acts of physical aggression towards women, while almost 50% includes verbal aggression. Only 10% of scenes contained positive caring behaviors such as kissing, embracing or laughter.
- Research also shows that viewing pornography can influence the viewer’s sexual interests and practices. A 2011 study found that people who watched violent pornographic material were more likely to report that they had done something sexually violent or aggressive. Another study found that men who watch violent pornography or are frequent viewers of pornography, are more likely to say they would rape a woman if they could get away with it.
Use new language when referring to sex. The way a person talks about sex influences how he or she thinks about it. Avoid slang terms such as screwing, banging, getting a piece, etc. Instead, use terms such as making love, being physically intimate. Stop using words for sex parts such as prick, dick, boobs, tits, cunt, and asshole. Instead, use anatomically correct and accurate terms such as penis, breasts, vagina, and anus.
Learn more about healthy sex. Read books and articles that can help you educate yourself more about healthy sex. Attend classes, lectures, or workshops at which healthy models for sex are being presented.
Tell someone about the abuse. The most important benefit of disclosing is that you will be allowing yourself to be vulnerable and to admitting how much you were hurt. This will help you lower your defenses and not always have to be the one in charge.
Enter psychotherapy or join a survivor’s group. This can be especially difficult for males. Research has found that male survivors are less likely to report or discuss their trauma, and more likely to externalize their responses to CSA by engaging in compulsive sexual behavior.

***

It is vitally important that clients stop blaming themselves for the ways they have attempted to cope with the sexual abuse they experienced. I’ve never met a sexual abuse victim who didn’t have sexual issues—whether it is the two extremes of avoiding sex, or being sexually promiscuous; having feelings of fear or repulsion about certain sexual behaviors, or parts of the body; or inappropriate or even dangerous sexual fantasies or compulsions. But this doesn’t mean it isn’t possible to confront and heal these unhealthy ideas and practices.

References

(1) Natalie, Tapia. (2014). Survivors of child sex abuse and predictors of adult re-victimization in the United States. International Journal of Clinical Justice Sciences. 9(1),64-73.

(2) Filipas, H., & Ullman, S. (2006). Child sexual abuse, coping responses, self-blame, post-traumatic stress, and adult sexual revictimization. Journal of Interpersonal Violence, 21(5), 652-672.

(3) Noll, J. G. (2003). Re-victimization and self-harm in females who experienced childhood sexual abuse: Results from a prospective s. Journal of Interpersonal Violence 12(18), 1452-71.

(4) Oshri, A, et. Al. (2012). Childhood maltreatment histories, alcohol and other drug use symptoms, and sexual risk in a treatment sample of adolescents. American Journal of Public Health. 102(82), S250-S257.

(5). Classen, C. C., et.al. (2005). Sexual re-victimization: A review of empirical literature. Treating Violence and Abuse.4(6), 103-129.

(6) Hanson, R. K., & Slater, S. (1988). Sexual victimization in the history of child sexual abusers: A review. Annals of Sex Research, 1:485-499.

(7) Baril, K. (n.d.). Sexual abuse in the childhood of perpetrators: INSPQ. Institut national de santé publique du Québec. https://www.inspq.qc.ca/en/sexual-assault/fact-sheets/sexual-abuse-childhood-perpetrators

(8) McClanahan, S., etal. (1999). Pathways into prostitution among female jail detainees and the implications for mental health services. Psychiatric Services, December, 50 (12), 1606-1613.

(9) McIntyre, J. K., & Spatz Widom, C. (2011). Childhood victimization and crime victimization. Journal of Interpersonal Violence, 26(4), 640–663.

(10) Lumby, C., Albury, K., & McKee, A. (2019, February 12). Problematic use of pornography – living well. Living Well – A resource for men who have been sexually abused or sexually assaulted, for partners, family and friends and for professionals. https://livingwell.org.au/managing-difficulties/problematic-use-pornography/

Getting Started as a Therapist: 50+ Tips for Clinical Effectiveness

Posted on July 16, 2025February 23, 2026 by Psychotherapy.net Team

New therapists are eager to help, which can be a strength and a deficit. To gauge the mindsets of supervisees or students, I ask, “What do you do in psychotherapy?” A common response is some form of, “People come in with problems. I need to have the solutions to make their problems go away.” It’s as if therapy is perceived as a special forces operation, picking off the bad guys.

It has been my experience that students and new therapists, when asked about their theoretical preference, express wanting to develop a cognitive-behavioral (CBT) skill set. This is likely, at least in part, because it’s what they are primarily exposed to in today’s graduate programs. Further, I’m told, “It gets right to fixing the problem.”

Upon further examination, their expanded definition is sometimes nothing more than identifying symptoms and providing coping skills. Psychotherapy is thus reduced to the fastest possible symptom reduction, as if it were a paint-by-number procedure. While seemingly efficient, there are inherent and fatal flaws in this approach, perhaps most thoroughly examined by Enrico Gnaulati in his, Saving Talk Therapy (1).

Over the years I’ve noticed an increasing assumption that therapy is not, or should not be, an exploratory process. Rather, there is an idea it should be neatly packaged solutions ostensibly remedying problems in short order. This is no doubt further fueled by the uptick in manualized, short-term (8-12 sessions) interventions, implying therapy is supposed to be short.

Despite the implication of these popular tools, psychotherapy is not a race. What’s more, it does not take long in the field to realize that it’s not unusual for any level of meaningful, lasting change to takes six months to a year, regardless of theoretical approach (2).

Sure, therapists wish to relieve patients’ symptoms as soon as possible, but it’s important to realize that ground must be broken to accomplish this. While therapists can offer immediate objective interventions, like diaphragmatic breathing to combat panic, or grounding techniques to interrupt dissociations, it is still necessary to examine the uniqueness of each person’s experience. Do we not need to get to know the person, and allow the person to get to know themselves?

Getting to understand the meaning behind people’s experiences can help unveil the foundational complication for ultimate resolution. This is not a Victorian relic. Modern psychoanalysts and existentialists operate as such, and traditional cognitive-behavioral therapists explore thought processes behind behaviors on the principle that thoughts drive feelings, which drive behaviors.

From its inception, psychotherapy was an activity in exploration and allowing the patient to unfold. By helping a patient explore their being, we help them come to realizations, make painful or shameful confessions, and share intimate details that almost certainly have a bearing on the problematic feelings and symptoms that led to seeking therapy. It is then that the more substantial work may begin of pulling up the anchor of deeply seated dilemmas, and allowing the person to work towards sailing freely once again.

While symptom reduction is relieving, symptoms are just the fruit of a deeper-rooted conflict. I’ve yet to meet, for instance, someone with illness anxiety (hypochondriasis) who simply developed the symptoms, which in turn can simply be given replacement behaviors, and life goes on happily.

While working with patients on reducing their preoccupation with perhaps having a serious illness, I’ve many times discovered they have an unusually pervasive fear of death. This tends to be correlated with a feeling they are not living authentically and fear dying because they have not truly lived. In effect, the hypervigilance for serious illness serves as a check to catch any illness that may prematurely terminate their chance to live authentically. Clearly, helping this type of patient recover from illness anxiety also involves resolving the driving conflict.

Even in this age of increasingly popular, ultra-brief CBT protocols, icons in the CBT field have illustrated that deeper exploration provides a foundation for more substantial work to begin. For example, Jeffrey Young created the “Young Schema Questionnaire” to help such exploration. This is a standardized tool created to help patients with deep-seated maladaptive beliefs explore the troubling way they conceptualize their world and how that leads to their struggle (3). Thus, this insight becomes a springboard for patients to identify and accept what needs changing, and bolsters a collaborative intervention environment.

While people come to therapy for symptom relief, it’s not always as easy as categorical symptom reduction with intensive exposure therapy or teaching them to be responsive and not reactive through a Dialectical Behavioral Therapy (DBT) skills manual. Even DBT, considered a relatively quick and effective approach to borderline personality disorder, involves some deeper exploration for sustained success, and averages six months to one year of treatment.

While successful ultra-brief and single-session therapy does occur, it’s usually a very specific issue with a very motivated person that makes it successful. Most patients are going to need to unfold.

Perhaps the fastest way to psychotherapeutic success is taking the required time, which will vary amongst patients. Before deep work can begin, a therapeutic alliance must be forged, where patients come to trust that the therapist is interested and cares. It is necessary to establish a dynamic where patients may be vulnerable and reveal themselves to expose the conflicts to resolve that will ensure long-term symptom relief.

People in therapy are seeking lasting change. What is the point of quick symptom reduction if the therapist does not work with the person to make sure improvement is sustained, and this newfound way of being has not been woven into the fabric of their lives?

Find Value in Silence

The poet Thomas Carlyle wrote, “Silence is the element in which great things fashion themselves together; that at length they may emerge, full-formed and majestic, into the daylight of Life, which they are thenceforth to rule.” It is no different in psychotherapy, but many therapists squirm in silence, and opportunities for things to emerge can get lost.

When I was new in the field, the most anxiety-provoking encounters in a session were periods of silence. I felt I must have something to say, lest I wasn’t being helpful. Even worse, perhaps it painted me as inept in the eyes of the patient. In time, I learned this was mostly projection, or the assumption others perceived me the way I was viewing myself, as an insecure new therapist.

Today, I’m often reminded of how disquieting silences can be at the outset, as practicum students confess or demonstrate a similar fear. While reviewing student’s practicum videos, palpable discomfort may follow the briefest silence, and there’s a desperate attempt to fill the void. The follow-up supervisory meetings are always rich as the student digests their experience, only to be surprised to discover that filling the void can threaten the therapeutic process.

Once meeting their “silence threshold” a therapist might tell themselves, as an excuse to break the silence, that the patient’s momentary quiet means they no longer want to discuss the topic. Panicked, the therapist offers impulsive commentary or abruptly changes the topic to have something to say. After all, who wants to see a therapist with nothing to offer?

Upon inspection, however, silence is not always indicative of, “It’s your turn to talk.” The patient could be contemplating something the therapist said. Perhaps, while silent, they are mustering the guts, or finding the words for, something that requires attention. Can you think of a time, perhaps in a meeting, when you had something to say but weren’t sure if you should, or how to say it? Now imagine having something critical to share, such as disclosure of abuse, or revealing something one feels ashamed about, and the space that could require to confess or articulate.

With that space in mind, when it seems like the right moment for clients to bring to light an uncomfortable item, any excuse to not have to might be capitalized on. If the therapist becomes talkative during such a pregnant pause, the patient might not try to bring up the topic again, at least not that session, Clearly, providing patients with an ample silence berth is a valuable gesture. With enough silence, they are more likely to crack and use the moment. Like a buried seed, once the shell breaks, new growth begins to emerge.

Indeed, try giving the silence an opportunity to resolve on its own. This will be less of a task with some patients than others, and will become easier as you get to know them.

I frequently sat in silence for up to five minutes with Corrine, a patient I knew well. She would trail off and become contemplative, sometimes spontaneously. At the same time, she began to rhythmically draw her fingertips of one hand down her fingers of the other hand and across her palms in a self-soothing activity. I learned to let Corrine be and focused on watching her hand motions for their hypnotic relaxing effect, which broke any of the silence discomfort I may have experienced as minutes ticked away. More often than not, she would start to reflect on something poignant we touched on immediately prior.

If she did not speak after some time, Corrine would look up and produce a pained smile. This was my cue to coax her. “If I know anything about you,” I’d begin, “when you get quiet and play with your fingers this long, something is brewing inside, and you’re either not sure how to say it or are a little afraid to.” Merely getting her to acknowledge this was usually enough to spur her on. It was as if my reminder of how well we knew each other assured her it was safe to broach any concern.

Being someone ashamed of her body and who generally didn’t think highly of herself, the material sometimes related to intimacy with her boyfriend. Other times, Corrine, afraid to disappoint me, struggled to let me know she had re-engaged in self-destructive activity like drinking benders. Both items were important grist for the therapy mill, which would have been lost if Corrine was not allowed to engage in her process.

When a therapist is just getting to know a patient, it can be helpful to be especially careful not to force away silence. This might occur with an observation like, “What are you thinking about?” It could seem you want to know too much, too fast. It is less confrontational to offer an observation, like, “It’s been my experience that when someone sits quietly in here, there’s something knocking that wants out.” If affirmed, helping the patient partner with their silence can help the state of arrested expression. Posing the paradoxical question, “If that silence was words, what would it be telling me?” has been notably productive over the years.

Other scenarios that can generate patients’ silence as if they are unused to talking about themselves, or are fearful of exposing themselves and appearing weak. This could be related to cultural matters, machismo, or fear of vulnerability. They might answer your questions as briefly as possible, and offer no spontaneous dialogue. Not surprisingly, this terse presentation is a common scenario in males, who are often socialized to feel negatively about help-seeking (4, 5). Autistic people, given the inherent social deficits, can present similarly. It’s important to know your audience, for, in these cases, prolonged silences that were beneficial for others could be very difficult to endure. A therapist would do well to seize these opportunities to teach a patient to interact and communicate.

In situations like this, the patient honestly may not know what to say, awaiting the therapist’s prompts. To promote a forum of focused sharing, the therapist can be productive by blowing on the embers that have begun glowing with simple persuasion, like asking for clarification or other details. Simply being curious and using the most open-ended questioning style is invaluable. “What more can you tell me about that?” “How has that affected you?” or “What’s been helpful to deal with that?” can gain discussion traction.

Showing those prone to this behavior that we’re interested in what they have to say, or gradually exposing them to self-revelation and having them see that it is not disastrous, can work wonders.

Clearly, if someone is not good at sharing themselves, a goal of therapy may have to be improving their ability to be more articulate and willing to share, so we can better understand and address the chief complaint.

Lastly, surely there will be purely oppositional silence, like with rebellious teenagers who see therapy as “stupid,” and they feel they’re forced to be there. No amount of cajoling is likely to make them participate, and it has nothing to do with being an unworthy therapist. Patients like this take significant rapport building, and supervision is often invaluable.

Ask About Meaning

“How does that make you feel?” has its place in the psychotherapist’s arsenal, but it’s not the sharpest tool. If therapists want to cut deeper, asking “What does that mean to you?” or “What’s that like for you?” can engender more robust revelations and therapeutic exchanges.

It’s been my experience that asking about feeling can be a perfunctory activity leading to a dead-end answer. Great, the therapist knows the patient is anxious, depressed or feeling betrayed, but then what? There might be a great leap from “how does that make you feel?” to offering depression or anxiety management skills. Perhaps the therapist attempts to reason with the patient that they have a right to feel betrayed. There is then a comment that the patient doesn’t deserve that, rendering the therapist a cheerleader. Then what?

Although well-meaning, these responses miss a major point of therapy. That is, the necessity to explore the patient’s experience. Whether analytic, cognitive, or person-centered-based approaches, patients must get to know themselves if they are going to change. Thus, feelings are not always the most lucrative query.

Therapists need to be able to mine for, and work with, substantive data for clinical gains. Thankfully, a little curiosity can go a long way. For instance, talking to someone grieving a close relative or friend, their feelings of sorrow and emptiness are often palpable. Asking what the loss means to them, however, can open new therapeutic doors. The emotional turmoil is not only the effect of the deceased’s absence, but the death causes reflections that instigate anxieties about their own mortality or unresolved conflicts.

One patient with this experience offered that since her parents died, it was as if there was nothing between her and the grave now and there is so much more she wanted to do. This revelation made it clear that the loss, though more than a year prior, stirred her own existential angst. Exploration of her life satisfaction and how to achieve goals to feel she had “lived more” followed. Another individual, in therapy after losing a long-term, close friend, lamented that the friend’s absence meant they could never better resolve a conflict that lurked in the shadows. Clinical focus turned towards self-redemption for his role in the conflict.

In another example, Jackson, a 16-year-old teen, while working through his parents’ divorce, discovered his girlfriend cheated on him.

“She said she was only sticking around because she felt bad for me,” lamented Jackson, tearing up.

“What’s it been like for you the past week since it happened?” I asked.

“So angry my head spun. I’m drained. I’ve got no energy to be angry anymore. I want to scream, but I don’t have the energy.”

“Sounds like insult to injury,” I offered. “You were already dealing with so much.” He nodded.

“Jackson,” I continued, “what does all this mean to you?”

“It means I’m on my own. I can’t trust anyone. My parents are too wrapped up in their mess to care about the mess they made for me, and, I guess, I just suck. I give my heart to someone for the first time, and without warning, it doesn’t matter.”

Asking Jackson about the meaning of his experience led him to put words to his internal landscape. This inside-out synopsis provided more than focusing on feelings could provide. His description created an opportunity to examine the maladaptive beliefs that germinated from the problematic experiences, which only served to compound his bad moods. Navigating these beliefs became part of the plan to relieve Jackson of depression.

Therapists working with trauma may also find it a therapy-accelerating question to help understand how trauma affected someone. Therapists can ask about symptoms and provide coping skills and guidance for achieving goals, but wouldn’t it also be helpful to know how a patient is shaped by the meaning they assigned to their experience? Having a patient share that their traumatic experience made them feel “forever broken,” for example, is more fertile ground than an inventory of symptoms to assign coping skills to for a treatment plan.

Asking this “forever broken” patient, “What exactly do you mean by ‘forever broken?’” was crucial to our work. They described an overidentification with the role of victim, perpetuating the other symptoms. Hypervigilance soared, nightmares involved reaching for goals, only to be sabotaged. Understanding this schema helped treatment in that the focus centered on empowerment; cultivating and magnifying other components of her life that negated the role of victim.

Often the juveniles I interview for court are enmeshed in daily marijuana use, binge drinking or vaping nicotine. Problems follow like infractions for marijuana possession in school, perhaps public drunkenness, or getting caught stealing vaping paraphernalia. During the assessments I ask not only about their use history and how it affects them, but what sort of meaning do they assign to the substance use?

I’ve been given answers that it is how they identify with their family, or that they can control how they feel and when. In the cases involving drug dealing, while the money is a motivator, drug culture guarantees excitement in an otherwise dull existence.

In each instance, asking about meaning yielded more potent information than “why” or “how” was likely to. Inquiring about meaning encourages an answer that captures more of the experience. This includes revealing deeper causal factors than self-medication or boredom, or at least factors that encourage the substance use under the circumstances.

Be Attentive to Your Intuition

My colleague, Joseph Shannon, a psychologist specializing in personality, once told me that “listening with the third ear” is a top skill to hone as a therapist. According to author Lee Wallas, the term was first used by the existentialist Friedrich Nietzsche in his 1886 book, Beyond Good and Evil. Given my lack of familiarity with the term I was intrigued, but quickly discovered it’s simply an elaboration of something most people are familiar with: intuition.

While this clinical skill might sound unusual, if you have ever sensed there is more than meets the eye to what the patient is relaying, you’ve experienced it. Clinically, the third ear quietly deciphers indirect communication, helping the therapist read between lines. Just as Spiderman heeds his tingling “Spidey sense” that something is askew and someone needs help, it’s important for clinicians to heed their “Spidey sense.”

Sometimes supervisees confess to encountering situations where it seems their patient is indirectly trying to say something. However, they wonder if it’s too speculative or confrontational to heed the tingling and “go there.” Usually, they fear they may be off the mark, deeming them incompetent and pushing the patient away. Some have justified their defensive unwillingness to consider their intuition by noting, “When the patient is ready, they’ll tell me.”

Or not. Not regarding the intuition could inadvertently prolong misery and unnecessarily perpetuate treatment.

Is it not part of therapist’s duty, part of the therapeutic process, to explore and help patients learn about themselves so they may advance? Is it not poor practice to potentially be encouraging internalization of things that need saying; to not help patients discover and deal with, emerging elephants in the room?

It’s not unusual that patients are on the couch due to some such ineffectual coping strategy as internalization or denial. Thus, the very thing the therapist might be apprehensive of doing is just what they need, and perhaps are even carefully, consciously, asking for. Would you be surprised to learn that sometimes patients (consciously or unconsciously) guide us to make the observation so they don’t have to say it? Something that requires purging may be too painful or embarrassing to mouth, and it’s easier to acknowledge than to explain in order to get it out there. Consider the case of Rob, a successful 34-year-old, who entered therapy for “feeling emptier with age.”

As we explored his life, Rob disclosed an early history of social anxiety that he overcame with therapy. He confessed he was a late bloomer for dating given his teenage angst, but had managed a few, year-long relationships as he emerged from his shell in his 20’s. “As a kid, all I wanted was a nice girlfriend, but I didn’t get that young adult dating experience. The older I get, the harder it is meeting eligible ladies,” Rob lamented. Not about to let it sink him, he accepted singlehood as best he could, travelling abroad and exploring locally on his own.

Rob occasionally traveled with friends, but the ones he had traveled with began having children and were no longer available for adventures. “My friends had to go have kids,” he’d joke, “They don’t know what they’re missing!” Despite this, he regularly spoke of being “Uncle Rob” and beamed when talking about his friends’ toddlers. Other times Rob said, “I do love kids, I just like to give them back. Kids aren’t for me,” noting they’d be hang-ups for his ostensible free spirit.

Soon, my Spidey sense tickled that Rob’s emptiness may well stem from being childless, and I had enough evidence to justify exploration. In a subsequent session, I said, “Rob, we’ve met a few times now, and I’d like to review a bit deeper. Given your history of social anxiety, it’s impressive you’ve become so social and had some successful romantic relationships. It’s got to be disappointing to have progressed exponentially with social comfort, just to encounter the frustration of not securing the relationship you always wanted. While talking about your frustrations with the romantic void, though, you’ve also made some curious comments about kids that I feel deserve exploration. On the one hand, you depict how kids cramp your style. On the other, your happiness is palpable when you bring up kids that are in your life. Correct me if I’m wrong, but I can’t help wondering if there’s an internal conflict regarding kids of your own contributing to that complaint of increasing emptiness.”

Rob eventually confessed, “It’s much easier to say you don’t want kids than to admit you can’t pull it together enough to make it happen.” What followed was an unfolding of Rob’s fear he’d be like his father, plus he feared his own children could be tormented with anxiety as he was. Being in denial allowed him to save face about imperfections. As Rob reflected, he realized that while he enjoyed the women he was with, when talk of longevity and family surfaced, he invariably sabotaged the relationship. He was capable of getting what he wanted, but subconscious security guards only let romance go so far.

Rob isn’t unusual in that patients may be avoiding the truth as ego damage control when they aren’t procuring what they want. As we explored over time, it came to light that the more Rob could not find someone, the more he traveled solo to prove he did not need anyone and to convince himself of his rationalization defense that kids just complicate things. He needed an excuse not only for himself, but as deflection for appearing defective to others.

Imagine if I had not shared what was on my mind about Rob’s material? Clearly, selective hearing for the third ear could have grave consequences to patients. Further, it is important to note that, unlike therapists we might see on the screen, it’s not about trying to shake sense into someone by saying, “Listen to yourself! You’re not finding a relationship because you’re in denial about wanting kids.”

Framed in a disarming way that makes patients see it’s to their benefit, your hunch can be explored and will likely make them interested in examining the idea and weighing its merit. Even if it’s off the mark, that’s not synonymous with therapist incompetence. It demonstrates the need for curiosity about the self, urges willingness to explore, and shows the therapist wants to get to know and understand them, which only strengthens the therapeutic foundation.

***

This content is excerpted and adapted from Smith, A. (2024). Getting Started as a Therapist: 50+ Tips for Clinical Effectiveness. Routledge., with explicit permission from the publisher.

(1) Gnaulati, E. (2018). Saving talk therapy: How health insurers, big pharma, and slanted science are ruining good mental health practice. Beacon Press.

(2) Shedler, J. & Gnaulati, E. (2020, March/April). The tyranny of time. Psychotherapy Networker. https://www.psychotherapynetworker.org/article/tyranny-time

(3) Yalcin, O., Marais. I., Lee C.W., & Correia, H. (2023). The YSQ-R: Predictive validity and comparison to the short and long form Young Schema Questionnaire. International Journal of Environmental Research and Public Health, 20(3).

(4) Cole, B.P., Petronzi, G.J. Singley, D.B., & Baglieri, M. (2018). Predictors of men’s psychotherapy preferences. Counselling and Psychotherapy Research, 19(1), 45-56.

(5) Wendt, D. & Shafer, K., (2016). Gender and attitudes about mental health help seeking: Results from national data. Health & Social Work, 41(1), 20-28.

(6) Wallas, L. (1985). Stories for the third ear: Using hypnotic fables in psychotherapy. Norton.

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CE Requirements

Navigating the Terrain

The Stress of Deployment

Pain Isn’t Meant to Teach Us Anything

Lessons from Experts in Survival

The Contained Mess

Sitting with the Void

Myth-Busting as Moral Work

Philosophy in a Clinical World

A Final Note

Working with Bee: An Answer Deferred

Postscript

The Multiplicity of the Mind

A Relational Framework for Understanding Voices

In Relationship with Voices

Narrative Therapy and Working with Voices

Expanding the Subjectivity of Voice Hearers

Clients Might Not Recognize Themselves at First

The Nervous System Has a Story to Tell

Healing Can Disrupt Your Relationships—And That’s Okay

It’s Normal to Feel Tired and Take Breaks of Healing

There’s No Deadline for Healing

Psychedelics as Medicine

Integrating Psychedelics into Psychotherapy

A Few Challenging Issues

Redefining Strength: A Black Woman’s Journey to Healing

A Childhood Built on Survival

The “Strong Black Woman”

Naming the Wounds and Breaking the Cycle

The Work: Using DBT to Rebuild Control

DBT Treatment Sessions: A Step-by-Step Process

Reflections from the Therapist’s Perspective

Patterns of Re-Victimization

Abuser Patterns

What’s at the Core of Sexual Reenactments?

Passive and Active Reenactments

Identifying Shame-Inducing Sexual Compulsions

Remedies for Passive Reenactors

Remedies for Aggressive Reenactors

Find Value in Silence

Ask About Meaning

Be Attentive to Your Intuition