She had that same dream as always. She was chasing the blue car as it drove away, calling out for her mother, but could never catch it. —Asha Lemmie, Fifty Words for Rain

Natalie was twelve when she found the courage to tell her mother that she was being sexually abused by her stepfather. Instead of receiving support and love, she was challenged, ridiculed, and shamed. Her mother refused to believe her, instead telling her to “stop that nonsense.”

Natalie stayed silent about her experience for another three years before sharing what had happened with a teacher. Then the teacher called Natalie’s home and shared the information with her mother.

When Natalie returned from school, her mother was waiting and furious. She accused Natalie of trying to “break up” her marriage.

“It was the late sixties,” Natalie shared, as if in explanation. She sank deeper into the couch in my office. “We didn’t have the resources we have now. People didn’t want to get involved in other people’s families. I never expected that teacher would call, but I guess she did.”

Her mother had already been divorced once, “and she was lucky to remarry as a single mom,” Natalie commented—having already learned to make excuses for her trauma.

Natalie ended up leaving home at sixteen and was married a year later.

Decades later, she still lives with the effects of her experience, and her relationship with her mother was never repaired. Her mother had abandoned her in her time of need.

Natalie told me, “I thought I escaped all of this, but it keeps coming back to me. I think of all that I lost out on because my mother could not protect me—could not even believe me.” She began to cry. “My childhood, my youth, my safety—I lost all of that.”

She had finally sought therapy after the death of her husband pushed her into a well of grief. Although his death was expected, the sense of loss and abandonment triggered all of those feelings of being alone and abandoned.

Understanding Triggers During Your Healing Journey

Traumatized people chronically feel unsafe inside their bodies: The past is alive in the form of gnawing interior discomfort. —Bessel van der Kolk, The Body Keeps the Score

Many people may hear the words “triggered” or “trigger warning” and think of something that resurfaces a traumatic experience and the negative feelings that arise from it. This word crops up often on social media, sometimes inappropriately, adding to a somewhat negative stigma. But despite the way its popular use has somewhat diluted the intended meaning, “triggered” is actually a common mental health term. It refers to the activation of emotions, mental health symptoms, or other traumatic reactions by a stimulus or event. Triggers can lead to retraumatization. Let’s take a closer look, using Natalie as an example.

For most survivors, parental abandonment leaves wounds. They may feel mad at the parent who abandoned them, but the act of abandonment disallows the child the luxury of expressing such an emotion to the one who left them. When children hold themselves back from expressing their anger out of fear of losing their caregivers’ love and support, they are forced to redirect that anger and sadness inward. With no parent to direct their anger at, they may blame themselves in order to cope. This is why survivors of parental abandonment may be more sensitive to feelings of rejection and have difficulty trusting others or developing intimate relationships—triggers come up unexpectedly, remind us of this traumatic experience, and activate a traumatic response. Like Natalie, you may have gone for years thinking that, although your experience was difficult, perhaps you had moved past it. Then, much like Natalie, you may have had an experience such as the death of a loved one or a breakup or divorce that made you feel alone and brought up all of those feelings of abandonment again. This is one example of being triggered—even if unintentional or unintended, the experience brought up the negative feelings again for you.

Healing will be a different journey for each of us, but being triggered is a common element, and safely navigating your response when triggers come up is an important tool to develop on the healing journey. Sometimes triggers can happen out of the blue—hearing a familiar song playing at the grocery store, or hearing a voice that sounds like the parent who left. Triggers can be a scenario or scene, event, sight, sound, or even a specific time of year.

Some examples of common triggers include 1) seeing a family eating out at a restaurant, noticing the parents speaking kindly to their children and each other, or just being happy together, 2) messages from media during holidays that put emphasis on being with family, or images of people with both parents during holiday gatherings that reinforce what you do not have, 3) conversations with friends and family who may intend to offer well-meaning support but end up using victim-blaming language or language that might indicate doubt in the survivor’s description of their experience, 4) discussions that violate your emotional boundaries or put you in situations where you may be forced to defend yourself, such as a friend insisting that you should reach out to the parent who abandoned you, 5) seeing pictures of people with their parents or families on social media, reminding you of what you do not have, 6) looking at old pictures of you and the parent who abandoned you, reminding you either of good times or that the good times were rare, 7) seeing mutual family or friends post information about your parent who abandoned you, like information about a recent family gathering or holiday meal that they attended, 8) weddings, birthdays, graduations, or other family celebrations, 9) certain sounds or music: listening to certain genres or bands that remind you of a point in your life or of the person who left, and 10) specific food, as so much about culture and family is wrapped up in eating (a Fourth of July BBQ reminding you of when your dad used to grill for the family; eating homemade hummus or labneh reminding you of your mother’s cooking before she left, when she used to make food representing her family heritage).

For many survivors of parental abandonment, talking about the events behind their abandonment or why their parents are not in their lives any more can feel extremely stressful. Those who have not experienced parental abandonment will have a hard time understanding it, which means most of them will at some point offer hurtful questions or statements without realizing the impact of their words. When they show you pictures of their own families, or ask where a certain parent is during important events such as holidays, or urge you to “just call them—they’re your mother/father,” their well-meaning but still harmful statements can cause you to relive the negative emotions of your experience.

Someone’s seemingly simple query—“Why aren’t you going home for the holidays?”—can bring you right back to that feeling of being a child, alone, wondering why your parent has not come to see you. In this moment, the initial rush of feelings can often include the need to excuse or explain, as well as shame for being in such a position in the first place.

Some triggers are very personal and often specific to your experiences or background—seeing certain landmarks that you used to frequent as a family, or visiting an art gallery if your parent was an artist. There is no limit or criteria to the triggers that you might feel.

Whenever these triggering moments happen, try not to shame yourself. This is crucial. You are having a human reaction to a trauma you experienced that was neither your fault nor within your ability to prevent or stop. The key to managing triggers is not to ignore or even prevent them; it is knowing to expect them and empowering yourself with ways to respond when they happen.

Exercise: Coping with Triggers

Think back to the most recent time you felt triggered. It could have been while watching a movie about a parent abandoning a child, or even about a parent who loves their child. Maybe it was a familiar smell, like pine reminding you of winters during your childhood and cutting down the family Christmas tree. It’s okay if you can’t remember specifics. Often, forgetting specific events or feelings we experienced during stressful moments is our brain’s way of moving on. Have your journal handy as you go through this list. Be open to whatever comes up in your mind as you attempt to revisit that stressful moment. Follow the steps as you reexperience this feeling in practice for when these moments come up in real life:

1. Validate: Validating your feelings is a critical first step. No matter where you are, give yourself a moment of validation. This can be as simple as something like This is a triggering moment for me or It’s hard for me to see/hear that. If you are alone at home or in your car, it may help to say it out loud. If you are in a public place, speaking silently inside your head is fine.

2. Give yourself support: Keep it simple. Tell yourself You’re having a normal reaction, This is okay, or I didn’t deserve what happened to me. Go slowly for the next few minutes or hours until the feeling has passed.

3. Get curious: Ask yourself: What is this trigger trying to show me? For some, the answer may come immediately: It is hard for me to hear this song because my mom used to play it on the record player and it reminds me of happy times; or Watching a father walk his daughter down the aisle at her wedding is difficult for me, even when in a movie, because it reminds me of what I missed out on.

4. Figure out what you need to move forward: Validation is often enough for some people to move forward, but there is no right or wrong answer. Do you need to spend a couple of minutes in your office before going back out to work? Do you need to take a few minutes to look at cute kitten pictures or funny videos on social media? Allow yourself the time to do whatever you need to, to be able to move forward.

Triggers are a normal part of the healing process. So normal, in fact, that we should expect them. For each individual those triggers will be different, but the more we dig into our negative emotions and healthy ways to cope, the better prepared we can be to navigate them. Even those who have spent years working on their healing may find themselves triggered. Now, when you find yourself experiencing these or other triggers, you know to recognize these as triggers and do your best to use these steps when they happen. While the triggering events may not go away, over time we become more equipped to manage our way through them.

Remember that you have the tools to heal. Also remember that healing is not linear; it is much more like a wave that ebbs and flows. Learning to cope with negative feelings does not mean that those feelings will no longer affect you; rather, this means you have grown in your awareness and your ability to respond and are continuing on your journey to healing.

***

Excerpted from Healing from Parental Abandonment and Neglect: Move Beyond Insecure Attachment to Build Safety, Connection, and Trust with Yourself and Others, by Kaytee Gillis.

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For someone who’s about to lead a clinical workshop on racial reactivity and defensiveness, Ken Hardy looks remarkably unreactive, at ease even. Then again, he’s been presenting various permutations of the topic at the Psychotherapy Networker Symposium for nearly three decades.

In the past, these kinds of discussions about race and therapy haven’t always gone smoothly. Plenty of therapists—who are usually good communicators with advanced emotion-regulation skills—have raised their voices, sobbed into microphones, and even stood up and stormed out of the room. This year, the workshop unfolds against a political backdrop that includes a slew of executive orders promoting racial profiling and unlawful deportation, new policies criminalizing practices related to DEI, and landmarks being removed and renamed in ways that erase the history of Black Americans and other marginalized groups.

Yet Hardy is undeterred. In his role as supervisor, professor, and author of books like The Enduring, Invisible, and Ubiquitous Centrality of Whiteness and On Becoming a Racially Sensitive Therapist, he doesn’t just teach about racial reactivity and defensiveness, he actually welcomes it into the room. The tensions and intensity that arise allow for honest discussions with real feelings, which Hardy then folds into clinical concepts and tools, offering an antidote to our culture’s entrenched habit of avoidance and self-righteousness.

When Hardy first started giving a version of this workshop in the early ’90s, nearly all the participants were people of color, in part because it was the only training that even touched on their concerns and challenges around race in the therapy room. But it was also a respite—one of the few spaces where Black therapists in a predominantly white field could let down their guard. Today, it’s not just the racial makeup of participants that’s different—there are plenty of white clinicians in the room. The conversation itself has evolved. Racial reactivity used to be thought of as the rapid, inevitable escalation of anger and frustration, now we see it in a more nuanced way: as a complicated slow-burn of disengagement, defensiveness, and hopelessness.

“As you can tell,” a Black man in the front row says to Hardy when he invites audience members to express their version of racial reactivity today, “I’m not a shrinking violet. I’m 6-foot-1 and 200 pounds. When I walk into a room, I take up space. I do this from the most authentic place I can. But as Ta-Nehisi-Coates says, when simply being in my skin is perceived as threatening, I don’t have much control over what happens to my body. I know it’s my job to be aware of my own privilege as a highly educated person and a man, but I feel like that privilege sometimes puts an even bigger target on my chest.”

Several white therapists admit to trying to be “the good white person” in conversations about race, a self-protective stance Hardy says makes it difficult to move the needle. “When we as white people try so hard to be nice,” an older man adds, “that’s a stress response. We’re fawning. We’re coming from a place of fear. We’re defending ourselves rather than showing humility and openness.”

A white woman discloses, in a trembling voice, her feelings of heartache and regret about an interaction she had with a client of color she’d worked with for several years. The client had made a last-minute request to switch his session from in-person to virtual. When he’d appeared on the telehealth screen, he was slurring his words. “In the past, we’d touched on his alcohol use, but this was the first time he’d shown up drunk to a session,” she said. “We chatted for a minute or two, and then I just named the alcohol issue and said, ‘Maybe we should wrap up for today and reschedule.’ So we did. But the next morning, he sent me an email accusing me of being a ‘Karen.’ I wrote him back that I knew talking about this stuff was hard and I was here if he wanted to talk more, but he never contacted me again. After listening to you today, I’m wondering if I missed something important.”

Hardy’s response to hearing this story is to lean into VCR, which isn’t a throwback to ’90s movie nights, but an evolved clinical tool: validate, challenge, and request. It’s a model Hardy has created to help people stay constructively engaged through tough conversations where there’s high reactivity. Using VCR as a technique first requires assuming a particular worldview, though, one where the goal is to embrace complexity and resist the temptation of succumbing to reductionistic, either/or thinking. Given that a Karen has come to mean someone who’s quick to act with little data and lots of prejudicial judgement—usually based on racial stereotyping—the client’s reference to his therapist as a Karen was unquestionably a racial one.

Had the therapist been more practiced in adhering to a VCR worldview in this kind of high-stakes clinical situation, she might’ve thought to validate the client’s commitment to showing up for sessions, which could’ve included an acknowledgement of how he’s courageously defying the stereotype of Black men shying away from the challenging, vulnerable work of therapy. This acknowledgement, had it come before her comment about his intoxication, would likely have elicited a different response from him—one that was less reactive. Without it, the therapist became just another white person judging him in ways he interpreted as having racial—and possibly racist—underpinnings.

“Before you challenge, confront, critique, or correct,” Hardy says to her, “you find something to validate. We tend to skip this step. But it’s important to find the value in what another person is doing or saying before we challenge them. This is even more critical in interracial conversations because we live in a context of so much historical racial strain and harm. So I appreciate you for sharing your story. That’s a very difficult situation to be in, and you made a game-time decision. You were correct to name his impaired state during that teletherapy session, but I believe you missed a few critical, preliminary steps in the process.”

“Beginning with the validation part,” the woman in the audience murmurs into the mic regretfully. “I could’ve noticed something good about what he was doing first.”

“Once we validate,” Hardy affirms, “we can then move to the ‘C’ of VCR—challenge—which we always start with an and rather than a but, because you’re trying to hold complexity. That’s where we engage the other person in compassionate accountability. With this client, that might have sounded like ‘I really appreciate that you showed up today, and I’m worried that we won’t get the full benefit of our session time.’ Then we could have gotten to the ‘R,’ which is a request that we’re making of the other person. Your request, ‘How do you feel about us wrapping up for today and rescheduling?’ might have been experienced differently by your client had the other two steps preceded it.”

Hardy believes that when we’re willing to apply this to conversations around race—however haltingly and imperfectly—it can serve as an antidote to the reactive-defensive loop where all we’re doing is reinforcing old narratives and piling new harms onto old ones. He sees our culture’s perverse relationship with race as arising from the fact that the significance of race is regularly denied and dismissed, even though it organizes nearly everything we do, from where kids sit in cafeterias to the legacy of Jim Crow embedded in our legal, carceral, educational, and medical systems.

A white therapist in the audience asks Hardy what racial healing actually looks like. “I’ll give you the short answer,” he responds. “I don’t believe true healing can take place in a context of continual assault. It’s like saying, I’m going to create a space for you to heal in our abusive relationship, but I’m also going to keep beating you up. At the same time, I think we can find ourselves on a path toward healing, which then becomes an ongoing process.”

In Hardy’s view, racial reactivity is the outward manifestation of an inward event—one that often goes unrecognized. No matter what our race, we’re a constellation of privileged and subjugated selves. When we’re feeling reactive, it’s because one or more of our subjugated selves is experiencing a threat, and if we’re unaware of what’s happening, we can easily tip into self-righteousness. An added complexity lies in the fact that this threat can be multifaceted and experienced in one or more of four domains: as a threat to our identity, to our autonomy, to our dignity, or to our safety, security, and survival.

“Every one of us has a preferred racial self and a disavowed racial self,” Hardy says. “It’s important to notice which self our reactivity is rooted in.” He shares a story about a white woman at a university who stood up halfway through one of his talks and yelled, “How dare you talk about white people being privileged! I’m white, and I grew up dirt-poor!” This woman didn’t recognize that she had multiple selves, including a privileged white self and a subjugated poor self.

“I looked for a pearl of functionality, for a pearl of worthiness embedded in her comment, and I validated her experience as a woman who grew up poor,” Hardy says. “I applauded her for remaining present in the conversation even though she was hearing characterizations that seemed contrary to her personal experiences and circumstances. I said, ‘It makes perfectly good sense to me that the gravity of the poverty you experienced would make it impossible to think of yourself as privileged.’ I also assured her that based on class status, she was indeed anything but privileged. However, after validating her, I went on to challenge her by saying that in terms of race, being white was a privileged position. While all poor people suffer in our society, it’s a fact that those who are white and poor tend to make out better than those who are poor and racially subjugated. ‘What I’m suggesting,’ I told her, ‘is that you’ve been hurt and subjugated as someone who grew up poor, while at the same time holding privilege as a result of being white. I think your experience of growing up poor has the potential to help you be particularly good at understanding the plight of people of color because you, too, have experienced marginalization. I also hope that every person of color here can relate to the devaluation and degradation you experienced as someone who grew up poor.’”

“When I hear this story, and how you handled it,” a Black man in the audience says, “it feels like you’re asking me to level up even though I’m being beaten down. Frankly, I’m tired of that!”

“Your comment makes sense,” Hardy responds with genuine warmth in his voice. “And I want to point out that what you did just now is exactly what I’m recommending here. You had an emotional response to the anecdote I just shared. But you recognized your response, and you verbalized it. That’s what we all need to do more of. Because if that doesn’t happen, the emotional response turns into reactivity. And I respect what you said about feeling like I’m asking you to level up. For me, though, it’s not about being the bigger person. It’s about accessing your personal power, so others’ inhumanity doesn’t rub off on you. It’s about being the captain of your own ship, the author of your own story. Especially if you’ve been silenced, whether you’re a person of color or a woman or someone who grew up with a tyrannical parent, the simple act of exercising your voice constructively and powerfully is critical. Maybe it changes a social condition, maybe it doesn’t. But there’s a deeper purpose to using our voice. I want us to speak because there are just certain things our ears need to hear our mouth say for the liberation of our soul.”

“Amen!” a Black woman in her 50s calls out. A workshop volunteer passes her the mic, and she rises out of her chair. She doesn’t speak immediately; instead, she glances around the room. Then, she faces the stage. “I needed to hear what you’re saying about multiple selves. I’ve had a lot of painful experiences like what people have been talking about here, but I’m saying amen because I want you to keep preaching and teaching. And I want all of us to keep talking, interacting, and paying attention.”

Hardy nods. For a moment, it’s as though everyone in the room has been lifted up on a swell of collective emotion.

As the end of the workshop approaches, a white man shares a painful experience he had on a therapist listserv after the murder of George Floyd: the online interactions between therapists of color and white therapists got so heated and combative that the administrators decided to pull the plug, ending all communication.

“To me, that’s the worst-case scenario,” Hardy weighs in sadly. “When we go silent. That breeds hopelessness—and hopelessness is contagious. But hope is also contagious.”

Hope can come from different places. For Hardy, it begins with recognizing our personal power. Even when we don’t have what he calls “positional power,” the way—for example—a president of a country does, we’re still powerful. Hardy shares that he sometimes tells his clients and supervisees, “Try to spend more time defining yourself and less time defending yourself. I’m not saying don’t get angry. I’m saying direct and guide your anger to your advantage. Because when you’re defending yourself, someone else is controlling you. But when you’re defining yourself, you’re exercising personal power.”

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“Here’s what happens when we first start working with couples,” declares George Faller, a certified Emotionally Focused Therapy (EFT) trainer and the presenter of the high-conflict couples workshop I’m attending at the 2025 Psychotherapy Networker Symposium. Faller looks comfortable on stage. He’s unphased by the ungainly speech-to-text microphone clipped to his flannel shirt, and it’s clear from the way he holds the clicker that he’s a PowerPoint pro. He raises his hand, and a slide featuring two pictures of Nicolas Cage appears. In the first, the actor grins under dark aviator sunglasses as only Nicolas Cage can, equal parts cool and goofy above the words Of course I can do this!

“But pretty soon the couples we see change our minds,” Faller says with ominous humor, using the laser pointer to circumnavigate the second Cage picture. In this one, Cage’s hair is a mess, his face and chest are caked with dirt and blood, and he’s squinting maniacally above the caption Three months later.

From the tenor and intensity of the laughter rippling through the room, it’s clear a lot of my fellow couples therapists can identify with that dramatic progression. It’s nice to know I’m not alone in this experience, and its particularly comforting to recognize the faces of well-known, acclaimed clinicians in the audience nodding along with the rest of us, including Ellyn Bader, co-founder of The Couples Institute, and in the third row, the woman many consider the queen of couples therapy: Esther Perel herself.

“We need to be ready for things to go wrong with couples,” Faller says. “I think we’re always hoping for empathy to emerge, so we don’t plan for the moments in session when it doesn’t—when partners go into a fight or flight response, when they interrupt each other, protest, and shut down.”

Despite the number of people in this huge workshop, it still feels oddly intimate, like I’m hanging out with a few colleagues and an off-duty New York City fireman. This is probably because Faller speaks off the cuff, as though we’re all trusted friends, here—but also because he himself is a former New York City fireman. Putting out literal fires and running into non-metaphorically burning buildings appears to have shaped his penchant for action-packed acronyms for couples therapy interventions like CPR, TARGET, TEMPO, and TERROR, but what really captures my attention is his take on a couples dynamic older than Antony and Cleopatra. It’s a pairing everyone’s heard about in relationships—as ubiquitous as hot-cold, love-hate, and introvert-extravert. In both pop culture and marriage and family therapy circles, it’s referenced so often that I, for one, have stopped paying attention to it.

Until now.

The Pursuer-Withdrawer Dynamic

Faller tells us a story about a young couple. They’ve been working too much. The wife takes out her phone one morning and sends her husband a text. “Hey, just thinking about you. Really hoping we get a chance to talk tonight. I feel like we’re disconnected.” When he sees her text, her husband thinks, She’s probably right. But he’s at work and doesn’t want to get into it now. He sends a quick smiley face emoji.

Are you kidding me? she thinks. I’m pouring out my heart, and I get an emoji? She follows up with another text. “We have to prioritize our connection. It’s the oxygen of the relationship. Why is it my burden to educate you on this? It would be nice if you initiated these conversations. You’re setting a bad example for our kids.” Her text goes on and on. He doesn’t know how to reply in the moment, so he does what withdrawers do well: he compartmentalizes what’s happening and gets back to work.

She waits. Nothing. Every time she looks at the phone, she feels rejected. I can’t believe he’s not responding, she thinks. He doesn’t care. I’m doing all the emotional labor here. Finally, she can’t take it anymore and calls him. Why not deal with the problem now? she’s convinced herself. Why wait until later?

He’s eating lunch and checking sports scores when the phone rings and her name pops up on the display screen. He silences the phone and doesn’t answer. We’re going to fight when I get home, he thinks. Why fight now and later?

Her call goes to voicemail. What kind of jerk did I marry? she asks herself. This is unacceptable. How did we reach this point of such disconnection? I can’t allow it. She gets in her car. When she arrives at his office, his secretary gives him a two-minute warning. “Your partner is here, and she seems upset.”

He goes to the bathroom, locks himself in a stall, and tries to think clearly. What am I going to do? The only solution he can come up with is to drop his phone in the toilet so when she asks why he didn’t pick up, he’ll have an excuse.

“Pursuers and withdrawers live in completely different realities.” Faller says.

The slide on the screen changes to a cartoon of someone on a desert island looking up at the sky and waving their hands. A bunch of stones at the person’s feet have been arranged into the letters SOS, and a fire by a palm tree sends up smoke signals. “Help!” Faller shrieks as he channels the pursuer’s despair. “They’re building fires, sending smoke signals, making SOS signs. Their body’s mobilizing. They’re trying to engage and get the connection they need. That’s what’s happening for the woman in that couple as she’s shooting off texts, calling, and eventually driving to confront her partner.”

Faller then brings up a different cartoon of a bearded man leaning against a palm tree on a similar island. He seems to be enjoying the ocean breeze as he watches a TV half-buried in the sand. “Separation for a pursuer is agony, but for a withdrawer, it’s a break. They can exhale. So why do you all think withdrawers shut down, walk away, and put up walls? Come on, you’re all therapists here! Shout out your answers!”

“Protection!” two people yell simultaneously.

“To defend themselves!” a voice calls from the back of the room.

“They’re in survival mode!” a therapist near me says.

“Fear of vulnerability!” someone else cries out.

“Yes! Keep it coming. I love it!” Faller nods, tracking each response. “All these words and phrases around defenses and survival.” As the audience settles, though, he says something I’m pretty sure none of us is expecting to hear. “And yet what everyone here is saying also shows therapists’ bias against withdrawers.”

Inside the Withdrawer’s Circle of Hell

“Close your eyes.” Faller is about to take us on a journey, and I’m not sure I want to go. I peek at the red-haired therapist sitting next to me. Comfortably settled into her fold-out chair, she’s already allowed her eyelids to lower. I lower mine, too. Faller, the stage, the screen, and the ballroom disappear into darkness. Like Dante, he’s leading us into a place many therapists in this room probably aren’t familiar with, given that we’re largely a group of pursuers (Gottman’s Love Lab research suggests women tend to pursue and 75% of therapists are women). We’re descending, little by little, into the withdrawer’s unique, internal hell.

“As a withdrawer, all you want to hear is ‘good job,’” he says quietly. “All you want is to be appreciated. Your heart wants to smile. Nothing more. This is why you’re in therapy. This is why you’re trying, even though you know you’re probably doomed to fail.”

I flash on the faces of withdrawers I’ve worked with—and some I’m still working with. I let myself feel them in a different way, with a little less impatience and a little more humility. It’s true—they’re doing their best. They’re trying to figure out what their partners want and how to provide it. They long to be appreciated for their efforts.

“But guess what?” Faller continues. My body braces instinctively for the impact of whatever he’s about to say next. “You don’t get the ‘good job’ you need. In fact, you never get it. Instead, you hear you’ve failed—again—and the reason you’ve failed is because you don’t care. You hear the opposite of what’s true for you, and you even hear it from your therapist when they confront you about withholding feelings or not “showing up,” or fail to challenge your partner’s complaints about the walls you’ve erected.”

The face of one of my pursuer clients appears in my mind’s eye. I see her mouth moving. I hear the angry words she’s directing at her partner. Despite being a large man, he seems to be shrinking into the cushions of my couch. She tells him he doesn’t care about their relationship, because if he did, he’d try harder. He’d give her the emotional closeness she’s been begging him for. How hard can that be?

“As a withdrawer, a part of you believes that what you’re being accused of is true,” Faller says. “You’ve heard this message so many times before. You’ve heard it as a kid, and in a lot of other relationships. You’ve heard you’re not smart enough, strong enough, thoughtful enough, good enough. You’ve heard, ‘You’re a failure.’ You’ve heard over and over how much other people don’t like you; and in this place, you don’t like you, either.”

I can sense how this version of not liking oneself—the withdrawer’s version—has a different emotional flavor than what I’m used to as a pursuer. In a way, it’s worse. There’s a cold, full-bodied numbness to it. It’s voiceless and suffocating. It feels a little like being buried alive in a sensory deprivation chamber.

“If there was ever a time you needed another person’s help,” Faller says, “this would be it. You’re alone. In hell. And no one’s coming. And as a withdrawer, you’ve only got one resilient move available to you. All you can do is put up walls and get back to performing in your attempts to earn love. But here’s the kicker: as soon as you make this move, your partner will hate you for it.”

Pursuers and Vulnerability Junkies

When I open my eyes, I see the people around me nodding their heads, exhaling, and making eye contact with one another as if to assure themselves that they’re back—thank god—from the chilly, desolate landscape we’ve all just visited together. The redheaded therapist hands me a tissue. I take it gratefully and blow my nose.

“My purpose in doing that exercise with you isn’t so you leave this workshop depressed,” Faller says. “What I want you to understand is that in our field, we get withdrawers wrong. It’s not that they don’t care. It’s not that they don’t feel. As a recovering withdrawer myself, I can assure you, we care and feel a lot. But here’s the thing: why would I, as a withdrawer, want to go to therapy when even there, I’m seen in such a limited way?”

How many of us, when we see a withdrawer in our consulting room, think, If only they weren’t quite so stubborn. If only they’d try a little harder to tune into themselves, access their feelings, and express them vulnerably and openly. I don’t think I’m the only therapist who has clung to the hope that I could “heal” a withdrawer with a colorful feelings wheel and a few emotionally cathartic conversations with their inner child as their partner bears witness. Before today, I knew—however vaguely and theoretically—that for withdrawers, going to therapy was an act of courage. Now, I genuinely feel it.

“Personally, I’m not good at emotions,” Faller says. “I’m sensitive to failure, and in therapy, I’ll likely be asked to do things I’m going to fail at. Therapists see the protective part of what withdrawers do, but they don’t always see how brilliant it is. Withdrawers’ ability to turn off their emotions when they have to is incredibly valuable. And it’s often what withdrawers like most about who they are. They’ve worked really hard to stay calm under pressure. The world loves them for it, just maybe not the therapy world.”

In our field, lots of different words and phrases reveal our preference for the pursuer’s desires and worldview—going deeper, attachment, somatic, psychodynamic, right brain, bottom- up. Unless you’re a CBT therapist, you probably favor emotional self-expression as the desired result of your work with clients, but also as a moment-to-moment indicator of progress. Emotions are the pot of gold therapists look for at the end of the intervention rainbow—and understandably so! Being able to experience emotions within the context of a safe, affirming relationship is one of the most curative things humans can do for each other.

Faller wants us to consider the possibility that we’re missing the mark in subtle but significant ways when it comes to helping withdrawers feel safe enough to access their emotions and other internal experiences. “The goal isn’t to turn withdrawers into pursuers,” he says. “It’s to help them feel safer experiencing and expressing emotions at their own pace so that they can become more relationally flexible.” We’re not very good at matching withdrawers’ affect in a way they can receive. We say things like, “You must feel so lonely,” or “That must make you enraged,” instead of “That must be hard,” or “That sounds frustrating.” We use words that are too emotionally charged too soon in our work with them, and we also miss the mark when it comes to making sure they experience “wins” with us. If I can’t succeed here, they end up thinking, why even try? We’re emotionally out of tune with them because we see them through our pursuer lens, with our field’s pursuer bias.

“When you’re on the operating table, do you want your surgeon to say, ‘My partner and I had a bad fight last night, so I’m feeling pretty sad right now?’ What about the lawyer representing you?” Faller asks. “How would you feel if they said, ‘Wow, that lawyer on the other side of the table is really good. I’m intimidated.’ When I was a firefighter crawling into the flames, I didn’t want the guy next to me whispering in my ear, ‘Hey, George, it’s hot and I’m scared.’

“We therapists are vulnerability junkies!” Faller exclaims. The laughter this statement elicits is so noisy and contagious that it takes the room longer than usual to quiet down. “We’ve lost our balance in our quest for vulnerability, don’t you think? We’re the only profession that measures our worth in the number of tissues a client goes through in a session.”

Or a roomful of therapists go through in a workshop like this one. I ball up the tissue my neighbor gave me and slip it into my purse.

I’ve been guilty of excessive zeal in my pursuit of vulnerability, particularly at the start of my career. For years after I got my license, I seriously wondered if there was anyone in the world with a better job than mine. I got paid to feel connected to people! There were days when I felt sad about leaving work because it seemed like my relationships with clients gave me more uncomplicated closeness than my “real” relationships. Was being a therapist the equivalent of being an alcoholic who’d been hired to work as a beer taster at a brewery? Maybe a bit. If you’re someone who craves intimacy, there aren’t too many jobs as emotionally meaningful or satisfying. And sometimes, this can get in the way of being even-handed with couples caught in a pursuer-withdrawer dynamic.

“I’ve made it a rule of thumb that if I have a withdrawer in the room,” Faller says, “I make sure they experience success with me. I make sure they get the caregiving they need—especially when their partner isn’t able to give it to them.”

The workshop is winding down, but it’s not over, yet. We’re about to take one last guided tour, one that will reveal the inner world of pursuers. “What do pursuers want from withdrawers?” Faller asks. The audience crackles with a seemingly endless litany of responses. “Love!” “Co-regulation!” “Safety!” “They want to connect!” “They want to be valued!” “Attention!” “To be taken seriously!” “Understanding!”

My neighbor has her tissue packet out on her lap. Even though I know the landscape we’re about to visit like the back of my own hand, I relax into my chair, close my eyes, and get ready for the ride.

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Enjoy the audio version of this article—perfect for listening on the go.

How do you work with a client who’s thriving in their career and relationships, but can’t seem to make sense of their overwhelming sadness for a beloved, deceased pet? Megan Devine, world-renowned grief expert, and Leanne Campbell, internationally acclaimed EFT trainer, walk us through their different approaches to this clinical challenge.

Meet Marcus

Marcus is a successful 40-year-old lawyer who works for a Fortune 500 company. In therapy, he tells you he feels fulfilled in and outside of work. He has a loving wife, a baby girl on the way, and a handful of close friends from the local kickball team he joined last summer. Lately, you’ve been helping him find ways to manage his worries about fatherhood, especially given his rocky relationship with his emotionally distant and alcoholic father.

But in your last session, Marcus returned to discussing the event that brought him to therapy one month ago: the death of his pet cat, Snickerdoodle. You’d helped him process his initial grief, and by session four, he said he was ready to focus on other issues. But in your last session, Marcus broke down sobbing. “I can’t believe she’s gone,” he said. “Snickerdoodle was there for me through so many milestones: the law school years, new jobs, a bad breakup, and meeting my wife. I know she lived a long, happy life. I’m just having trouble with this new normal. She was like family, you know?”

Marcus has tried a variety of grounding exercises on his own to help him deal with his grief, like deep breathing and body scans. He’s also been journaling, and recently put together a scrapbook of his favorite photos of Snickerdoodle to keep as a memento. “These things help,” he tells you, “but when I think about the good times with Snick, I inevitably get a sinking feeling in my stomach, my heart races, and then I fall apart.”

“I know this must sound so stupid,” he says. “I know it’s ‘just a cat.’ But she was my cat. I just feel so alone right now.”

An Experience to Be Tended

By Megan Devine

My role as a therapist is to hold the full expression of my clients’ grief, while balancing the need for both validation and action. Marcus came to therapy to address what he felt would be a simple cure for his grief, with tools that would help him focus on the good things unfolding in his life. His returning emotions, or rather, his confusion about his returning emotions, highlight a common misconception about grief: it’s not over in a few short weeks. Although we’d discussed the realities of grief outside of what media and self-help books often describe, Marcus appears to hold himself to the ideal of “getting over his grief,” and doing it quickly.

Our culture sees grief as a kind of malady, a terrifying, messy emotion that needs to be cleaned up and put behind us as soon as possible. As a result, we have outdated beliefs around how long grief should last and what it should look like. Books, movies, and even articles on the psychology of grief often present grief as something to overcome or something to fix, rather than something to tend or support.

When we’re holding on to the idea that grief is a problem to be solved, it puts us in an adversarial position with life. Life is full of losses, large and small. Trying to force ourselves through sadness, pain, or grief in order to resume a “happy, normal life” is simply unreasonable. Grief is part of love. Marcus loved (in fact, still loves) his cat. No part of love should be rushed or dismissed like it was no big deal.

Since he uses words like, “I know it was just a cat,” I suspect Marcus thinks his grief is unwarranted. Sometimes this self-dismissal comes from the client’s own beliefs, and sometimes it’s a reaction to outside judgement. Sometimes it’s both! Because we treat grief as a temporary problem that can be overcome with the right attitude, lots of people think they’re doing grief wrong. And when you’ve lost a companion animal, not a human being, it can be harder to see that loss as valid.

Sitting with Marcus, I’m careful not to rush him through his tears. When his sobs have quieted somewhat, I ask, “it sounds like you think you should be over her loss by now. Is that true?” By adding Is that true? I’m inviting Marcus to clarify the thoughts behind his emotions. This also helps me avoid making an assumption about his feelings, allowing me to change course if necessary.

“No. I mean… yeah,” Marcus replies. “I’m doing everything right. But looking at her pictures just makes me feel worse. I know she had a good life. I have a good life!” Marcus begins crying again.

As clinicians, we’re often trained to see grief as a disorder rather than a natural response to deep loss. And this extends to the tools and practices we “prescribe” to grieving clients. Nothing is going to make a client’s grief go away. The best tools help a client understand their emotional experiences, providing insight and guidance on how to live alongside their losses.

“Doing all the right things doesn’t make it hurt less,” I tell Marcus. “She was a huge part of your life. Of course you miss her.” When Marcus doesn’t reply, I add, “Things like grounding exercises and reminding yourself of the good times aren’t meant to take grief away. They’re meant to help you stay present with it and find ways to survive it.”

“I know,” Marcus replies. “They did help a lot in those first weeks. There are just much bigger things going on, and it’s not like I lost a child.”

There are several places I might go next with Marcus. Because we’d extensively discussed the judgment attached to grieving a companion animal in our first two sessions, I’d like to bring his current emotional state into relationship with the big changes in his life, rather than inquire more deeply about that judgment. At the same time, I don’t want to ignore the way he dismisses his grief.

“It’s hard to give up that habit of downgrading your grief, isn’t it?” I say. “You’re facing big life changes without the one being that helped you through all the big milestones in your life.”

Marcus nods and reaches for a tissue. “I don’t want to worry my wife, you know? And it’s not like I can call my dad for guidance on how to not screw up. I don’t know…. I could tell Snick anything, and I’d feel better. Without her, I don’t know how to do any of this.”

“She was your constant,” I affirm. “It makes sense that you’d feel sick thinking about becoming a father without her.”

Acknowledgement is a powerful intervention. Clients often present with an internalized narrative detailing all the ways they’ve done things wrong. So much of our clients’ suffering is simply being out of alignment with their true emotional experience. It’s as if there’s a tug-of-war happening inside of them between how they’re “supposed” to feel and how they actually feel. Because we don’t talk about the realities of grief (or really, any emotional pain), many clients think they’re the only ones struggling, and view their grief as a personal failure.

Helping Marcus see his unrealistic expectations about grief—and his internalized judgment—is not a one-and-done thing. Habits learned over a lifetime can be hard to break, especially when the outside world reinforces the idea of bouncing back quickly. We need to help clients learn to recognize their own emotional judgments and the actions they take when trying to manage their emotions rather than accepting them. For Marcus, his grief over Snick’s death intersects with his fears of becoming a father. Facing this big unknown without a major emotional supporter sets off feelings of insecurity; knowing his own father didn’t set a good example has made Marcus feel doomed to repeat those mistakes. And that comment about not wanting to worry his wife isn’t a throw-away statement either—it hints at internalized gender roles about being “strong” and fears that sharing his feelings is a burden to others.

Helping Marcus see the connection between all of these different elements without reducing Snick’s loss to a “life lesson” is a tricky process. So often, a typical therapist statement like, “new losses can show you old grief that hasn’t healed” inadvertently causes harm: it positions the current grief as a mere portal to the past, and shames the client for their previous lack of healing. We don’t mean it to come across this way, of course, but given that grief can make people sensitive to even perceived judgment, the language we use matters.

Instead, I want Marcus to make those connections. I want him to decide what Snick’s loss brings up, and how it relates to both his fears and his longing.

“There’s so much in that statement,” I tell him. “You don’t want to bother your wife, you can’t rely on your own father for guidance, and without Snick, you feel like you have to do all of this alone. It’s not really how you want to enter fatherhood, is it? I know it might not make sense to jump from Snick’s loss to fatherhood, with all its pressures, but it sounds like Snick was really an anchor in uncertainty for you. What feels most daunting about what’s ahead?”

Marcus is quiet for a moment before replying: “I miss knowing what to do.”

After another few moments, he adds, “and then I start to feel sick. And then I instinctively reach for Snick because I always did when I felt lost. And then I remember she’s gone.” His eyes begin to well again. “And then I feel helpless and overwhelmed because I can’t rely on her anymore. I don’t know what to do when that happens, so I’m just stuck feeling screwed and alone.”

This is another choice point in my session with Marcus. I can help him feel less alone by exploring communication tools and ways to feel safer sharing his feelings with his wife and friends. We could address concrete ways to increase his parenting confidence and lessen his anxiety. But this time, I’d like to use that emotion-response cycle in a different way, almost as a precursor to those interventions.

“I’d like to try something with you, Marcus,” I begin. “You know, when most people feel something uncomfortable, their impulse is to stop feeling that way, like they try to talk themselves out of it. Or maybe you tell someone you’re feeling overwhelmed, and they tell you why you shouldn’t feel that way. I could tell you that by coming to therapy, you’re already doing something your father would never have done. But that stuff doesn’t actually work, it just makes people feel more misunderstood. So instead of talking you out of discomfort, I’d like you to try noticing it when it happens.”

Therapy tools like mindfulness and awareness can feel vague for both clients and providers. Becoming aware of an emotion isn’t about making it go away. When you recognize a feeling state as familiar—and normal—it opens up new ways of responding to those feelings. When Marcus notices that sick feeling in his stomach, he might say something like, “Oh, I’m feeling overwhelmed and helpless again. Right. It makes sense that I feel this way—fatherhood is a huge unknown. And I don’t have Snick to lean on. Feeling sick is a cue that I’m feeling alone and unprepared.”

“Snick gave you a consistent action to take when you felt this way,” I tell Marcus. “Without her physical presence, you need to find something else to lean on. This isn’t always easy. So when you notice that sick feeling in your stomach and say to yourself, ‘Right, this happens when I feel alone, and then I panic,’ you can add, ‘What do I need when I’m feeling this way?’”

There’s no one right answer to this question—not for Marcus, and not for anyone. It’s the practice of recognizing feelings and physical symptoms as needs, not problems that helps shift things. After Marcus thinks about this question, he says, “I think what I need is comfort. Just sitting quietly with Snick calmed me down. So what you’re saying is I need to look for new sources of comfort instead of winding myself up.”

“Exactly. Notice that helpless feeling when it shows up in your body, and use that as your cue to ask yourself what you need. Sometimes the answer is clear, like I need to go for a walk or I need to ask for help. Sometimes it leads to more questions, like What the heck brings me comfort? That’s a great question to carry with you today. This is really about stepping outside of the feelings to ask yourself what you need.”

Marcus takes a deep breath, and exhales. “And if what I need is Snick?” he says with a half-smile.

I smile back. “Then you lean into missing her, thinking of her, carrying her with you.”

Grief is not a problem to be solved, it’s an experience to be tended. My work with Marcus helps him get into the right relationship with all of his feelings, especially the uncomfortable ones. Learning how to respond to his emotional needs with kindness and skill will serve him well in the years to come, as a parent, a partner, and a friend.

Emotion Lights the Path Home

By Leanne Campbell

In working with Marcus, I begin to wonder, Is he moving through the grief process and successfully navigating his transition to fatherhood as he considers his relationship with his own father, or is he somehow stuck?

What does stuck mean from the perspective of Emotionally Focused Individual Therapy (EFIT), an attachment-based, humanistic, experiential, and systemic approach to therapy?

From an EFIT perspective we are hard-wired for connection and intrinsically motivated to grow, and emotions are the motivating force that move us. When we get stuck, it’s most typically because we haven’t moved through the emotions associated with some key event, such as a trauma or loss event, or a relationship event. In some cases, there have been longstanding protective strategies in place, like turning emotion up or down as a means of managing intolerable distress, developed amidst emotional overwhelm and interpersonal isolation. In other circumstances, suppressing or intensifying emotion is temporary, later countered with a template for secure attachment that brings people home to themselves and their loved ones, and through the emotions they might have temporarily blocked or tempered.

In EFIT, we look for the rationality, not the pathology. If clients are stuck, we assume it makes sense in context. I listen closely as Marcus tells me how Snickerdoodle was a significant source of support during important developmental transitions in his life, moments of joy and celebration, and challenging times. Now about to embark upon another significant developmental milestone, fatherhood, Marcus’s relationship with his own father is understandably on his mind, as well as the loss of a longstanding source of solace, Snickerdoodle.

Holding an attachment frame, I would anticipate a period of disorientation and disorganization following the loss of a key source of security, and I would expect Marcus to be on his own unique grief journey. I would also expect his grief to come and go, with waves of emotion punctuated by periods of reprieve. In short, I’m not concerned about Marcus’s grief reemerging, but I am struck by his comment that he feels alone, despite saying he has a positive relationship with his wife and feels fulfilled in and outside of work. Marcus’s relationship with his father is relevant, of course, but I wonder whether there’s more here to be discovered. Are there other relationships—perhaps with his wife, mother, or other family members—that might be instrumental in helping him move forward through grief and embrace fatherhood with some of the same confidence and competence he feels in other parts of his life?

In trying to answer this question, I start by tracking, reflecting, and validating as I listen to Marcus share his experience with me. I offer summary reflections, which focus our sessions and offer openings for discovery. “I hear you, Marcus,” I say. “Snick was an important part of your life during pivotal, defining periods—your law school years, new jobs, a bad breakup, and meeting your wife. Of course you miss her. She was there when perhaps others weren’t or couldn’t be, and now, during another very important time of life, the void is palpable. Am I getting this right?”

“Yes, that’s right,” he replies. “I could never depend on my dad—or my mom for that matter. My mom was and remains in denial about dad’s drinking and his absence as a father and a husband.”

“More loss,” I quietly reflect. As we maintain eye contact, I feel myself become teary as Marcus’s eyes fill with tears. I can feel the same sinking feeling in my stomach that he referenced earlier. I remain silent. As Marcus uses the space I’ve provided to embody his felt experience, more grief emerges. He sobs—and I encourage him to do so.

Secure attachment offers the therapist a beacon, as typified by clients’ capacities to tune into their internal experiences (needs, fears, longings, and vulnerabilities), share those directly and coherently with key people in their lives, and give and receive love. Emotion lights the path home to self and inner experience, and offers the opportunity to share that with others.

“That’s good, Marcus. It’s good to cry.” As Marcus begins to breathe and looks up, I respond with a soft and slow voice. “This is good. There’s much to cry about—Snick, and your parents. From what you’ve said, your parents provided in some ways but were absent in others, especially emotionally. And now, as you embark upon your own family life with a child on the way, it makes sense that all this would be emerging, especially given the recent loss of Snick.”

As Marcus catches his breath and looks up, I maintain eye contact. “What are you feeling now, Marcus?”

“Some relief,” he replies.

“What was it like to share those deep feelings of loss with me?”

“Good,” he says. “I’ve felt so alone.”

“Maybe say more about that. I think I understand, but perhaps not fully. Help me understand more. You feel alone. . . .” I wait for Marcus to fill in the blank.

He pauses. “I really don’t know.”

“That’s okay,” I respond gently. “This is a lot.” Then, I reflect and summarize. “Do you see what just happened?”

Marcus nods.

“As you get close to the feelings of loss surrounding Snick, this also puts you in touch with the sense of loss surrounding your parents. What you didn’t have and don’t have are poignant now as you prepare for your own role as a parent.”

“Yes,” he quickly replies, “and I’m so worried about messing it up.”

“I hear you. Yeah, being a parent is an important job, and you want to be the best you can be, of course.”

I turn my attention to Marcus’s wife, Tara. A positive response from Tara would offer a corrective emotional experience—an opportunity to share his inner world and be met with safety and security from a central figure in his life. Blocks to growth are dissolved and change occurs through a new experience and a new relationship event.

“Have you shared your fears with your wife?” I ask.

“No, she has enough to worry about.”

Using myself as an instrument in this process, I wheel my chair a little closer to Marcus. Making my voice soft and slow, I invite Marcus to tell me about his wife in more detail, with the goal of bringing this key attachment figure into focus and moving him deeper into the felt experience he has now accessed. Marcus closes his eyes and describes his wife: her blonde hair, her eyes soft and locked on his. He tells me he can feel her soft hands and the ring he gave her on her index finger.

Backing away slightly, I invite Marcus to stay still in his inner experience, to be guided by it, using it as a compass for life and love.

“Let’s stay really still in this moment, Marcus,” I say, closing my eyes as well. “Your wife is here. I’m here too, in the background, and I can also see her. Beautiful. If you stay really still, what do your eyes want to say to hers? From your body, not from your brain? From deep inside of you?”

“I’m so scared of disappointing you,” he says, clutching his knees with both hands. “I’m so afraid of letting you down, of letting our child down.” As tears roll down his cheeks, I remain attuned, intervening after a few moments when I see his breathing begin to change.

“What did Tara’s eyes say to you?” I ask. “What did you hear, feel, see from her—from her eyes?”

“Reassurance,” he says, smiling. He opens his eyes, and they look brighter now. His voice lifts a little. “She said we’ll be imperfect, but we’ll be imperfect together.”

EFIT is a bottom-up process, so I proceed by summarizing for Marcus what happened in the session, highlighting what he has discovered as he tunes into his inner experience more deeply, as well as the contrast between being alone with his inner experience and sharing it with someone else. The goal is to help him cognitively integrate and consolidate the gains he’s made on an experiential level.

A few months later, Marcus comes to our session reveling in the joy of his baby and his new role as a father. His insecurities have been gradually fading, and when he’s felt them more palpably, he’s felt comfortable enough to share them with his wife, leading to heartfelt conversations about the enormous responsibility they share, but also their gratitude for the opportunity to parent their beautiful daughter together.

So what happened here? How do we make sense of what happened with Marcus through the lens of EFIT and attachment? In essence, Marcus was able to more fully connect with the sense of loss he felt, not only surrounding Snickerdoodle, but his parents as well. Having grieved what was lost in his relationship with his parents, Marcus was later able to embrace what they could provide, this time with their granddaughter: snuggles during dinnertime and strolls in the park. He was able to grieve these layers of loss, and in doing so, was able to make space for something new. In this case, it was a deeper relationship with himself and his wife, the birth of a baby, and a new identity as a father.

The post When Grief Is a Soft, Grey Animal appeared first on Psychotherapy Networker.

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Our magazine has won awards not only for its insightful articles, but for its beautiful design. Check out the digital magazine on your e-reader or any favorite device—and dive in from cover to cover!

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Memories aren’t just sepia-toned snapshots that live in our minds and occasionally crop up to evoke certain emotions; they serve an even bigger important purpose. Although we aren’t often aware when it happens, when a new experience triggers an old memory, our minds spring into action to make sense of it, as if to say, Oh, this is familiar! You’ve dealt with this before, and here’s what you need to do now! As we all know, memories can also be a valuable resource for us therapists; when we explore them with clients, we gain greater insight into their self-narratives and why they behave the way they do.

But sometimes, we can get so absorbed by a client’s memory that we assume it’s an absolute truth—and we get locked in it, right alongside our client. For psychoanalysts like myself, who often search for some connection between clients’ current struggles and a formative past experience, an old memory may be a red herring that keeps us from focusing on what’s really relevant: what’s happening for the client in the here and now. Not long ago, I fell into this trap with one of my own clients, John. But by helping him let go of his attachment to an old memory—and gradually letting go of my own tendency to focus on old memories in therapy—we both turned a corner.

Taking a Wrong Turn

John walked into my office and sat down on the couch looking especially flummoxed. He’d called me a week earlier to tell me he needed help processing some insecurities in his relationship with Lisa, his girlfriend of almost three years.

John started talking right away about his concerns. He told me he cared deeply for Lisa, but added that he was having trouble taking the next step. “She wants to get married,” he said flatly, “and I do too. But I’m not ready yet, and I’m afraid she’s going to get tired of waiting and end things. I really don’t want that to happen.”

John told me that he loved Lisa and wanted to commit to her, but that he’d been badly hurt by an ex-girlfriend, Marianne, which was making it hard for him to completely trust Lisa. “I trusted Marianne,” he said, “and look where that got me! I’d bought her a ring. We’d been planning our wedding—and then she dropped me.” He folded his arms across his chest and shook his head. “I’ve never felt so betrayed or hurt in my life. I don’t ever want to go through that again.”

As I listened to John’s story of rejection, I thought about what psychoanalysts once called a screen memory—an event that represents another life experience. Developmental theorist Daniel Stern called memories tied to a specific event “representations of interactions generalized,” meaning they become part of a personal narrative that influences our sense of who we are and how we expect other people to behave toward us. These memories can also get in the way of processing new experiences, due to the conscious or unconscious belief that closing ourselves off from them will protect us from further pain. I began to wonder: Was it possible that John’s fear of commitment was a result of being abandoned by someone he’d trusted to care for him when he was younger? Perhaps a parent?

With my prompting, John willingly explored this with me. He shared how his parents’ marriage had fallen apart and how he’d learned that his father had been having an affair with a much younger woman. He’d admired his father, he told me, and was angry and disillusioned when he realized his father wasn’t the man he’d believed him to be. We’re onto something! I thought. We spent the next several sessions unpacking this experience.

“Do you think I should tell my dad how much his behavior affected me?” he asked me at one point.

“That depends,” I replied. “How do you think it might help?”

“I don’t know,” he said. “Maybe I just need him to know.”

I wondered what John thought he could accomplish by confronting his father. Did he simply need him to understand his confusion and anxiety about relationships? Did he need an apology? I encouraged him to imagine how this conversation might play out.

“I don’t know what I want out of this,” he finally concluded. “My dad wouldn’t take responsibility anyway.”

“Is that what you want?” I asked. “For him to take responsibility?”

John nodded.

“And what if he can’t?”

“You mean what if he won’t,” John muttered.

“Either way, what if you can’t get what you need from him?” I asked.

John shrugged. “I’m not sure how I’d feel.”

I was beginning to question my own focus on John’s parents. Would John get anything out of this conversation with his father? Would it have any impact on his relationship with Lisa? Something didn’t quite line up.

The Here and Now

As I sat with this dilemma, I remembered a moment from early in my training. I’d been seeing a psychoanalyst before switching to a different one who was certified by my institute. My first therapist had helped me contextualize childhood experiences I’d long overlooked, and I’d expected my new therapist would do the same. But when I told him about the pain of feeling in competition with a classmate, his response surprised me. “What do you mean by competition?” he asked.

“It’s something I felt toward my younger brother most of my childhood,” I explained, adding that my brother had been born when I was 18 months old, and my family often joked about how upset I’d been at his arrival.

But before I could finish my story, my therapist interrupted me. “Tell me about that competitive feeling that’s coming up now, with your classmate.”

I kept trying to address the historical context for these feelings, but the therapist kept insisting that I focus on my present emotions. At one point, I summoned the courage to confront him about it. “Aren’t you supposed to be an analyst?” I asked. “Aren’t you supposed to be interested in the past?”

He laughed. “I’m supposed to be interested in analyzing your experience,” he said, “and in understanding why and how you feel the way you do. Talking about the past seems to take you away from what you’re feeling right now, and that makes it hard for you to process those feelings or find ways to understand or manage them right now.”

I was struck by the truth of his statement. Recounting old memories had become a way for me to blow off steam or redirect distressing feelings. As I thought about that moment in my session now with John, I began to wonder whether he was doing the same. Was it possible that focusing on his frustration with his father was leading us astray? Was comparing his relationship with Marianne to that with Lisa was his way of avoiding something difficult happening right now? I thought about the story he’d told me about the breakup with Marianne. There’d been warning signs, he’d said, like Marianne being less affectionate, but when his friends brought this up, he’d brushed them off. Were there warning signs now too, or was John simply afraid of being rejected again because he’d been rejected in the past?

“You mentioned that you’re having trouble trusting Lisa because of what happened with Marianne,” I said. “But I also suspect you’re having trouble trusting yourself because of that experience.”

John looked puzzled. “I’m not sure I understand.”

“You told me there were signs that something wasn’t right with Marianne, but that you didn’t listen when your friends pointed them out, which you regret now. Maybe you didn’t listen to your own doubts either.”

“But I didn’t have any doubts,” John replied. “That’s why the breakup was such a surprise, why it hurt so much.”

“And this time you have lots of doubts,” I said.

“Well, not lots of doubts. I do have some. But mostly I just don’t want to make the same mistake again.”

“Some doubts are normal, you know. In some cases it’s helpful to ignore them, which I’m guessing was what you did, maybe without realizing it, with Marianne. But it’s better to confront them so you can decide which ones are realistic and which ones aren’t. What do you think might happen if you acknowledge that some of your doubts are normal, but that not all of them may be realistic, and that some of them are getting in your way?”

“I guess it would be helpful to talk to you about those doubts,” he said. “But what if you think they mean I should break up with Lisa?”

I could’ve told John that we were looking at his internal conflicts and confusion, but I suspected he felt my opinion was important, just as he felt paying attention to his friends’ opinions would’ve helped him in the past.

“Do you feel like you wouldn’t be able to ignore my opinion, the way you ignored your friends all those years ago?” I asked.

“Probably,” he replied. “I learned my lesson the first time around.”

“Well, are your friends expressing concerns about your relationship with Lisa?”

John shook his head. “No, but I worry maybe they’re keeping them to themselves. I got upset with them last time.”

“So what would it mean to you if they—or I—had concerns?” I asked.

John shrugged. “I’d have to take them seriously,” he said.

I could see that John was putting a lot of stock into what others thought about his relationship, leaning on what he felt, mistakenly, was something that could’ve saved his relationship with Marianne, or at least saved him some pain. It was here that I realized how we could break free from the clutch of John’s memory of that pain—and it had nothing to do with his father.

A Turning Point

To counteract the power John’s memories of the breakup with Marianne were holding over his current relationship, I knew I needed to put the power back in his hands, to show him, somehow, that it wasn’t his friends, or anyone else for that matter, who could protect him from future pain: it was him.

“Rather than run your doubts by your friends or me to find out whether other people have concerns about your relationship with Lisa, what if you asked yourself some of those questions,” I suggested.

John took a deep breath. “Well, first of all, Lisa is nothing like Marianne.”

“That’s an interesting way to begin,” I replied. “It sounds like you’ve chosen a partner who wasn’t anything like your last.”

John furrowed his brow. “Wait, aren’t I supposed to be telling you what I’m thinking?”

I laughed. “Well, yes,” I replied. “But how about if we focus on what you’re thinking and feeling about Lisa, without comparing her to Marianne?”

This was hard work for John—and I’ll admit it was hard for me, too. John had to catch himself when he’d periodically return to the memory of his breakup with Marianne, and I had to resist the urge to look for some connection between his relationship with Lisa and that with his father. Those relationships were certainly significant, but I knew they mattered less than his present relationship with Lisa. As we continued to work on focusing on his present-day anxieties, those old memories began to fade into the background instead of creeping into the story of what was happening now.

“I’m starting to realize there was nothing I could’ve done to save my relationship with Marianne,” he said in a later session. “It was doomed to fail. I want to be with someone who shares my values, and ours were just too different.” Gradually, John was able to put into words his deep love for Lisa. “Lisa just gets me,” he said. “She loves me, but she also understands me in a really profound way. It feels like we can talk about anything.”

As our sessions went on, John began to acknowledge that maybe his thinking about relationships had been romanticized, and that even the best relationships have some degree of conflict. “I know that Lisa and I will have arguments and disagreements,” he said, “especially when we start a family.” He looked out my office window and fell silent, as if imagining that future. “But we have some arguments now, and we’ve worked them out. I think we’ll be able to get through difficulties in the future,” he said decisively. “Our connection is strong enough to weather the ups and downs.”

***

Memories can guard against future challenges and pain we may encounter. But leaning too heavily on them to try to make sense of current experiences can make keep us trapped in the past, shut off from fully engaging in life in the here and now. As John discovered, when we’re able to catch our automatic, self-protective tendencies to use past experiences to inform present ones, we open ourselves up to possibility, and to some of the most wonderful pathways in our most important relationships.

The post When Memories Get in the Way appeared first on Psychotherapy Networker.

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When a new client arrives late to sessions, it can be a stumbling block to establishing therapeutic rapport. Gabor Maté—bestselling author and creator of Compassionate Inquiry—and Janina Fisher—world-renowned Sensorimotor Psychotherapy trainer and developer of Trauma-Informed Stabilization Treatment (TIST)—are about to show you how they’d turn this clinical challenge into an opportunity.

Meet Lorelei

Lorelei, a woman in her late 30s, wants to learn relaxation techniques to reduce her stress. In her initial email and call, she mentions a lack of social connections, financial problems, and a host of medical issues including fibromyalgia, migraines, ulcers, and IBS. A contentious legal battle with her former girlfriend over ownership of their small event-planning business has worsened her symptoms.

At your first session, Lorelei arrives 20 minutes late because there was a lot of traffic. She expresses excitement about working with you and getting her life on track. You validate her overwhelm and help her clarify her goals. When you mention you’re approaching the end of your session time, she begins rocking in her chair and says, “I think I’m having a panic attack.” You go 10 minutes over time to help her get regulated enough to leave your office.

At your next session, Lorelei apologizes for again arriving late and says she hopes you can give her the full 50 minutes anyway because the parking lot was full and she has a lot to discuss after a bad week. You express empathy; then, you gently ask whether there might be a pattern developing of late arrival and extended session time. She appears angry and stunned.

“What?! Are you saying it’s my fault there was traffic last week and I couldn’t find a space in your parking lot today?”

You invite her to explore this strong reaction to your intervention, but she avoids eye-contact and responds to you in monosyllables for the rest of the session.

Accepting Your Client

By Janina Fisher

Next session, as I wait for Lorelei to arrive, I plan a reset. I suspect she’ll arrive late again, though I’m ready to be surprised. I’ve realized that I made a mistake last time, and that I need to do things differently today. We hadn’t yet developed a relationship in which we could have a meaningful conversation about a pattern of lateness—I’d jumped the gun, and she’d felt confronted rather than curious. To develop a trusting relationship, I need to start by accepting Lorelei as she is while still holding time boundaries. And I need to do this gently, but firmly.

When Lorelei rushes into my office discombobulated and out of breath, I notice that she’s only 15 minutes late today—an improvement over last week. I greet her with a warm smile. “So glad you made it—good to see you! You probably have lots to tell me.”

She says she does, and updates me on her physical problems and the legal issues she’s facing. As I nod, smile, and communicate my support verbally and nonverbally, she begins breathing more easily, and I can see her body relaxing.

As our session time wanes, I take a deep breath. “I realize we have to end in just about three minutes. Would you like to go through a quick relaxation exercise before you go? Or did it help you just to vent today?”

She’s surprised and appears disappointed that I’m not giving her the full 50 minutes. “I was hoping to share about an issue I’m having with my ex,” she says.

I empathize but explain that unfortunately, I have to be on time for my next client. “It’s always safest to come 10 minutes late, if possible,” I say. “I build a 10-minute time buffer into my sessions. This means that if you come 10 minutes late, I can give you the full 50 minutes of your session time. Unfortunately, anyone who arrives later than that needs to make do with whatever time we have remaining before my next client session begins.”

I’m no stranger to being late, and because I’m habitually late myself, I’ve built this way of working into my practice. If I’m five to 10 minutes late, we start the 50-minute clock then. If a client is late within 10 minutes, they still have 50 minutes to go. Given that an hour has 60 minutes, we can play within that window and give each other more grace.

Lorelei gazes at me skeptically. “Okay,” she says with a shrug. “Hopefully I can leave work a little earlier next week.”

I reassure her: “But now we’re covered if you can’t.”

My plan to accept her lateness goes a bit awry in the fourth session. She arrives only 10 minutes late as I’d suggested, just as I’m in the middle of sending an email. But I’m happy to see her, and I close my computer so we can begin our work.

“I’m so glad we’ll have enough time today so you can vent, and I can show you some ways of relaxing and regulating—if that’s still what you want, of course.”

“That’s exactly what I want,” she says. “I’ll just keep talking your ear off unless you remind me about what my goals are here.”

“Well, you have several choices in terms of goals,” I say. “We can work on managing your symptoms through relaxation techniques—that’s one option. Or we can explore what’s at the root of the difficulties you’re having and see if we can heal them. Or we can do both! Which sounds best to you?”

“I think I want to do both,” Lorelei says hesitantly. “But I want to relax first.”

“Then let’s focus on that,” I say. “Start by just heaving a big sigh.” I model the sigh so we’re sighing together. “Does that feel better or worse?”

“A little bit better,” she says, “but then I start worrying again.”

“Of course your mind keeps going back to the anxiety, and every time it does, just sigh again. And again . . . and again.” I sigh with her. “Now your mind will go back to the worry, and you’ll have to sigh again, but let’s sigh before the worry gets here!”

A few mutual sighs later, she’s calmer and ready to leave the office.

As Lorelei’s therapist, my goal is to build a relationship with her that acts as a container for whatever emerges over the course of our time together. Because my primary focus, particularly when we’re still getting to know each other, is the relationship, I’m unlikely to address her lateness as having any particular meaning. If I address it at all, it’ll be when she raises it as an issue.

Although verbal exploration and insight may provide a context for understanding a client’s thoughts and perceptions, I’m far more interested in what triggers Lorelei and how she responds to triggers. When Lorelei is triggered, it means she’s experiencing feelings and body memories related to some wounding or trauma in her past. By helping her sit with her distress and understand it as an emotional memory, rather than a present-day reality, I’m helping her regulate her overwhelm and develop a friendlier relationship to the emotions she’s always struggled with.

I remember what happened in the first session when she was so badly triggered by the end of the session. She’s much more fragile and easily dysregulated than she presents. Over time, a clearer picture will emerge. She might believe that I’m teaching her to relax, but what I’m really doing is helping her befriend herself.

My approach is to work with whatever feeling or issue is “up” for her because change can only take place in the present moment—we can’t change the past or the future. I ask questions like, “Is this feeling familiar? Is there an image or memory that goes with it?” These somatic questions from Sensorimotor Psychotherapy help clients to deepen without stimulating defensive responses.

My goal is to approach our work with playfulness, acceptance, curiosity, and empathy, to quote Dan Hughes. Together, Lorelei and I will get to those deeper places with less pain and more interest in whatever we discover together. Hopefully, we’ll laugh as well as cry, and if she continues to be late, that’s okay with me. The lateness is not a statement about me or the therapy. It says something about her brain and her executive functioning that we can discuss when organizational problems arise. In the meantime, I plan to enjoy her.

Honoring Boundaries

By Gabor Maté

I perceive two issues here or, to be more accurate, two sets of issues: The clinical problems Lorelei presents with—fibromyalgia, migraines, IBS, ulcers, social isolation, and an inability to regulate her stress responses—and her self-identified solution of “relaxation techniques.” The client’s repeated tardiness for appointments and expectation that the therapist go overtime to accommodate her, and her apparent resistance to taking responsibility for her lateness. The two sets of issues are clearly linked, because they both have to do with boundaries—I’ll come back to that. Having said that, the first set cannot be approached before addressing the second.

The initial and essential step is to establish a mutually respectful working relationship. Here the therapist’s job is not to make Lorelei understand anything about herself, e.g., that there might be “a pattern of lateness and expectation of extended session time.” That may be the case, but we cannot force insights on people, no matter how accurate. In fact, in that potentially valid insight there may lurk an element of passive aggressivity on the part of the therapist.

The real question is, How does the therapist feel about this recurrent situation and how do they wish to handle it?

If the therapist feels some anger, which would not be surprising, it’s their issue to deal with. The client isn’t causing any feelings on the part of the therapist—triggering them, perhaps, but not causing them. Still, it’s important to come up with a strategy to deal with the practical problem of the client’s lateness and unrealistic expectations of being accommodated with extra time.

It would be honoring both the client and the therapist to agree on a clear boundary. This might sound like the therapist saying: “I understand and respect your intention to heal, which is what impelled you to consult me. In that spirit, we need some working rules: We begin at the agreed time. And that means leaving enough space for our appointments. I understand that on occasion unexpected circumstances may intervene. Traffic or difficulty parking are not unexpected circumstances. Therefore, if you’re late, I’ll still charge you full fees and must end at the required time, out of fairness to myself and to my next client, as well. If we can’t agree on that, I’m not the right person for you to work with.”

Such an approach is respectful to both therapist and client, because it honors the therapist’s requirements and it gives complete agency to the client. It recognizes her as capable of taking responsibility for how she approaches the therapeutic process. If a clear agreement is achieved, we can then move to resolve the clinical issues. The client presents wanting “relaxation techniques.” She likely doesn’t recognize that the real problem is not a lack of stress-reduction techniques, but how she unwittingly generates stress in her life. Relaxation techniques, useful as they can be, only reduce symptoms. They do not deal with fundamental causes. So, in that sense, they function like the cup with which we ladle water out of a leaky boat. Until the leaks are discovered and addressed, the boat will still keep taking on water.

Fibromyalgia, migraines, IBS, and ulcers have all been related by voluminous research to childhood trauma. For readers wishing to learn more about that, I recommend my books When the Body Says No and The Myth of Normal. The title of the first sums it up: people who develop such chronic conditions have perennial difficulty saying no to the demands, judgments, and expectations of other people and of the culture in general. Because they do not know how to say no, their bodies say it for them in the form of illness. They do not know how to set boundaries. That’s why they are so stressed. It’s not their fault: it’s how they adapted to their childhood’s traumatic environment, by suppressing their own needs to serve those of others. So, resolving problems like Lorelei’s is never simply a matter of learning new “techniques.” It’s a matter of connecting with one’s authentic self and learning how to set firm boundaries. Then one won’t be so stressed.

Lorelei’s presenting difficulty in recognizing the therapist’s necessary boundaries has to do with her lifelong, trauma-induced failure to honor her own. In setting the boundaries that will support their work, the therapist will have taken the first step towards helping Lorelei develop the essential boundaries she needs to take better care of herself in her own life.

The post The Case of the Late Client appeared first on Psychotherapy Networker.

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Penny and Rick came into my office on a sunny Friday afternoon, chatting about the nice weather. But their smiles quickly dissolved into frowns after they sat down and started telling me about their issues. It was clear to me that they loved each other, but they bickered regularly and were struggling to connect. They were both unhappy with the state of their marriage.

According to Rick, Penny was a methodical neatnik. “Well, I do hate surprises,” she admitted. Rick, on the other hand, was fun and distractible. “She gets so upset about socks on the bedroom floor,” he said. “I don’t even notice them! I prefer to focus on interesting things.” From this brief exchange, I had an inkling about their Enneagram temperament styles.

“So, do you have conflicts about the socks?” I asked. Understanding what they fought about and how it related to the different ways they approached the world would help me get a sense of their Enneagram temperament differences.

“It’s kind of embarrassing, but yes, we fight about socks nearly every day,” Penny said. “I mean, we fight about other things, too. We have three kids between the ages of two and eight, and they leave toys all over the house. It drives me crazy. I can’t relax till they’re put away.”

Rick, who’s seated on the couch next to Penny, braces for what’s coming next.

“Yesterday, when I got home from work, Rick told me he had a big project and needed me to play with the kids so he could do it.”

“It didn’t seem like a lot to ask,” Rick muttered. “I’d been watching them all day.”

“I’m happy to play with the kids,” Penny interjected, “but then why can’t he pick up the toys and finish the dishes before I get home? If he’d just do that one simple thing, I’d be able to relax. I can’t relax if the house is a mess.”

“Why do toys and dishes affect her so much?” Rick asks. “Honestly, I don’t get it. Just take the kids outside and play in the yard if you have to!”

Rick and Penny, like many couples, find themselves in constant conflict, not because they’re not a good match, but because they have different sensitivities, priorities, and temperamental styles.

Opposites Do Attract

How is it that people who are so different fall in love and choose each other for a lifetime of frustration? This question has always intrigued me. In my 30 years of working with clients as a certified couples therapist, I’ve experimented with many different theories, frameworks, and perspectives in search of answers. What I’ve discovered is that very few partners have the same temperament. Instead, those who enter romantic relationships seem drawn to a person who exhibits the part of themselves that’s undeveloped or nonexistent. Partners feel more complete with someone who possesses their missing attributes, however alien they may be. The risk-taking entrepreneur finds a partner who grounds them. The over-the-top emotional type finds a quiet, serene partner. And likewise in reverse. Yet, having yearned for a mate who has ready access to emotions, and isn’t shy about expressing their feelings, the quiet, introverted person in a couple then shrinks away from their partner’s emotionality.

The Enneagram is a system of nine inborn temperaments set forth over 2,000 years ago. The Ancient Greeks wrote it down, and because “Ennea” is the Greek word for nine, they named it the Enneagram. Each style represents a gift, motivation or drive that can lead to a burden or challenge. For instance, the gift of the Enneagram One is to see all the details around them with the need to correct what they perceive as wrong. This causes tension with friends and family who don’t want to be corrected. Thinking about their relationship conflicts through an Enneagram lens can open a couple’s eyes to hard-wired differences by helping them explore their distinctive inborn temperaments. As they understand one another with less judgment, their motivation to collaborate grows.

Since 1995, I’ve been teaching the Enneagram system to my clients in semi-annual seminars with groups of 20-30 participants, sharing my view of the nine temperaments as a system that encompasses behavioral, emotional, and cognitive styles common to humans. In my work, I’ve found the Enneagram offers a simple and practical way of making sense of our tendency to partner with people who possess seemingly opposite traits. This doesn’t mean we all fit easily into the nine categories, or that these styles don’t express themselves in a wide variety of ways. Our nature and the expression of pre-born traits are shaped by early experiences. We process trauma differently depending on our temperamental style. This adds to the Enneagram’s usefulness in psychotherapy since we can anticipate the kind of developmental trauma each Enneagram style likely encountered in childhood. The Kind-Hearted Two in a dysfunctional family, for example, often experienced some degree of parentification. It’s not unusual for Kind-Hearted Twos who’ve been parentified to marry grandiose or narcissistic partners. Each temperament has a strength that can be distorted or nourished, depending on childhood experiences and the Enneagram style’s downside.

After sharing with Rick and Penny how I draw on the Enneagram in my work and how it might be helpful to them, I handed them a copy of a small booklet I created several years ago for couples like them that summarizes the nine styles.

“Take a minute to read through this,” I suggested. “Let me know if you resonate with any of the types.”

Although I tend to have a sense of couples’ temperament styles early on, I believe it’s important to allow partners to resonate with the adjectives and descriptors without feeling swayed or pressured. Based on conversations I’ve had for three decades with several thousand clients, I’ve come to believe that the online tests are only around 50% accurate. For this reason, I don’t believe taking the tests online is worth the time or money. Looking at gifts and burdens in the different Enneagram styles is usually enough to jumpstart my clients on their journey of self-reflection regarding their temperamental differences.

Nine Temperaments

Each temperament outlined in the Enneagram comes with a particular ability, which can be thought of as wired into the brain. That ability, when overused, leads to challenges. After reading through the Enneagram booklet, Rick identified with the Enneagram Nine. As a Nine, the thing that frustrated Penny most about Rick is also one of his gifts. He has an easy-going temperament, and he rarely notices details. As a result, tensions can arise with Penny, who identified with the Enneagram One, the characteristic style of those who care a great deal about details.

Here are the nine temperament styles with their abilities and challenges.

One. The Detail Oriented has the gift of noticing the details in life and the burden of needing to correct what seems wrong. Ones say, “I love making every detail perfect.”

Two. The Kind-Hearted are gifted with tuning into others’ emotions, interpreting their needs with a desire to help them. The burden of the Two is not to be aware of their own needs. Twos say, “I am more comfortable giving than receiving.”

Three. The Goal-Oriented are gifted with focus, which they use to achieve, and problem solve. The burden of the Three is fearing failure and missing relational cues. Threes say, “I am what I do. Don’t just stand there, do something.”

Four. The Individualist has the gift of deep emotions, creativity, and a sense of the extraordinary. The Four has the burden of wanting to belong and individuate. Fours say, “Sometimes I feel isolated, even with my friends.”

Five. The Observer is gifted with perception and objectivity. Their burden is their detachment and need to withdraw. Fives say, “Having my private space is very important. I dislike large groups of strangers.”

Six. The Guardian/Doubter is gifted with a keen sense of what can go wrong. They’re always on alert for security and safety and burdened by worry. Sixes say, “When I feel threatened, I’ll either withdraw or put on a tough act.”

Seven. The Joyful is gifted with adventurousness and enthusiasm. Their burden is avoidance of pain, theirs or others. Sevens say, “I let go of grievances much faster than others.”

Eight. The Take-Charge has the gift of leadership, management skills, and a big picture view. Their burden is insensitivity to those who follow, and an aversion to vulnerability. Eights say, “Some take offense at my bluntness.”

Nine. The Easy-Going has the gift of being a peacemaker, patient, and good-natured. Their burden is being distractible, stubborn, and preferring procrastination to action. Nines say, “I often feel connected to people and nature. When people try to control me, I dig in my heels.”

Gifts and Burdens

Penny’s gift of noticing details and homing in on what’s right and wrong makes her uncomfortable with anything that’s out of place. She’s driven internally to correct what’s incorrect, and to be helpful. One downside of this gift is that she’s often perceived as critical.

Rick’s gift as an Easy-going Nine is to be fun-loving, calm in a crisis, and good at sidestepping conflicts. He doesn’t notice the odd sock on the floor or where he left his keys. The burden of the Enneagram Nine is that—as Rick himself admits—he often forgets things, doesn’t like planning, and digs in his heels when he’s challenged. Recently, Rick had been diagnosed with ADHD. Nines tend to have many interests and be distractible. They have difficulties with focus and organization. Nines are the opposite of Ones who easily plan and see every detail.

Shortly after Rick married Penny, he was dismayed to discover that she was different than he’d thought. Penny was also dismayed when Rick exhibited traits she hadn’t noticed. Many couples interpret these apparent changes in their partner as “they don’t love me enough.” Penny’s perennial complaint about Rick was, “If he loved me, he’d pick up the toys at the end of the day and follow my directions, so he doesn’t lose his keys, again.” Rick’s complaint about Penny was, “If she loved me, she wouldn’t dismantle the Lego creation I built with the kids because she’d recognize that having fun is more important than a neat house.” My goal was to help them join forces and recognize that each of them carried strengths and gifts the other lacked.

The work of couples therapy is often to help partners accept differences and experience them as assets rather than as problems to fix. Clients can grow within their relationships by accepting and understanding the gifts and burdens that come with their own and their partner’s particular temperamental style. By becoming more self-aware, and accepting the reality of their temperamental tendencies, they can grow to appreciate each other more.

Temperament and Refrigerators

For both Rick and Penny, their childhood histories revealed attachment and alienation issues affecting and affected by their Enneagram temperament styles. Penny’s detail-oriented One temperament had helped her through an unhappy childhood. She’d grown up with a raging father for whom nothing was good enough. Eventually, she’d left her hometown and gone to college to get away from him. Rick’s easy-going Nine neglect of details and penchant for quick solutions to immediate problems helped him feel confident and self-sufficient in a home environment where his parents were often distracted by Rick’s brother, their acting-out son. The downside was, Rick had always fended for himself with his Nine distractibility and unrecognized, untreated ADHD.

Penny’s history of being raised by a critical father dovetailed with her detail-oriented One style, amplifying her fault-finding tendencies with Rick. Though he’d learned to defend himself against his acting out brother, it stung to defend himself against Penny over things he viewed as insignificant. He felt he could never get things right with Penny. Most of their conflicts were over who was right and who was wrong. Penny thought it was right to put the toys away before she got home. Rick thought it was right to leave them out overnight so the children could continue their games the following day. The power struggles that emerged from their opposing perspectives left each of them feeling defeated and alone.

At the beginning of therapy, Rick and Penny had told me that making decisions together had always led to battles that remained unresolved. For example, when choosing a refrigerator, Rick wanted to explore every option, while Penny cared mostly about being practical. She measured the space in their kitchen for the refrigerator. “Why would you even look at a refrigerator that won’t fit in our kitchen?” she’d said. Rick had said, “I don’t care about the measurements at this stage, I just want to see all my options.” This had led to a stalemate. Rick had refused to pay the slightest attention to Penny’s measurements, and Penny had refused to look at refrigerators without taking measurements into account. But through our work, Rick and Penny began to see good intentions in each other. Slowly, they implemented behavioral changes. A few months into couples therapy, they reported having finally chosen a refrigerator.

“Rick had the opportunity to look at all the options,” Penny said.

“Then she came in with her measurements and we narrowed them down,” Rick said. “She asked the salesperson about the icemaker, the lighting panel, and other details.”

Thanks to the work we’d done on understanding their distinctive temperaments, Penny said she’d been less worried about having to look for the refrigerator the “right way.” As a result, she was able to trust that they’d be joining forces in their final decision on which refrigerator to buy. Rick also recalled aspects of our work that related to Penny’s Enneagram type. He reminded himself that it was okay if Penny followed up with questions after he expressed his preferences, and if his favorite refrigerator was too big, or lacked some necessary feature, it didn’t make his choice wrong. Together, they’d narrowed down their choices to several refrigerators that fit both of their requirements.

Power struggles over the right and wrong way to do things are just one part of the complex dynamic contributing to conflicts in relationships. By making sense of one another’s temperamental styles through an Enneagram lens, therapists can help partners understand key differences in a new way. Sometimes, the way we do things and see the world isn’t personal. It’s a longstanding part of who we are that can enhance how we interact as a couple, if we’re willing to work as a team.

The post Defusing Couples Conflicts with the Enneagram appeared first on Psychotherapy Networker.

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Q: Several of my heterosexual female clients have reported difficulty orgasming with a partner. I’m not a sex therapist, but I’d like to help them. Where do I start?

A: Women having difficulty with orgasm is a common, though underdiscussed, experience—and it happens most often within heterosexual relationships.

Statistically, women have higher rates of orgasm during sexual experiences that don’t involve men, including alone and with other women. A recent study found that 92 percent of women reported “usually” or “always” orgasming when masturbating, while only 57 percent said they experienced orgasms during sexual experiences with men. Studies also consistently find that women orgasm less often with male partners than with female partners.

But the difficulty many women have with orgasming during partner sex with men isn’t due to biology or something inherently wrong with men. In most cases, women’s problems with orgasm are due to the cultural messages we receive about heterosexual sexual encounters. The good news is that clinicians—even those who aren’t sex therapists—can help their clients overcome these faulty messages in surprisingly simple ways.

My own foray into sexual issues began about 15 years into my practice. After hearing many stories from female friends and clients about the loss of sexual desire—and experiencing it personally—I immersed myself in the sexual health field. Today, I teach therapists and physicians about treating sexual issues, and I’ve written two books about female desire, including A Tired Woman’s Guide to Passionate Sex and Becoming Cliterate: Why Orgasm Equality Matters—And How To Get It. My goal has been to help women become more orgasmic, aroused, and sexually satisfied, but also to help them improve their body image, increase their feelings of entitlement to pleasure, and experience less sexual pain. But my message isn’t just for women: men who become more well-versed in women’s pleasure and sexual communication have more satisfying sex as well.

Asking About Orgasms

How do we begin talking about orgasms, especially with the women who come to us feeling numb, ashamed, depressed, or broken because they’re struggling to orgasm?

Orgasm intensity varies between women. For one, it might feel like an earthquake; for another, like a sneeze. Since there’s no objective marker of the female orgasm, many women will say they don’t know if they’ve had one or not. The general thinking is if someone doesn’t know if they’ve had one, they probably haven’t.

The first step in helping your clients to experience orgasms more often or at all is simply to ask about them. Surveys report that almost half of clinicians avoid talking about sex with their clients, whether due to cultural or religious thinking around sex, mistakenly believing it’s too private, creepy, or unethical to bring up—or because they’re struggling with their own unresolved sexual issues. Regardless, avoiding the topic of sex is a disservice to our clients, since sexual satisfaction is highly related to both relationship and life satisfaction. And research shows that clients usually won’t bring up sexual issues unless asked to or given a signal that their therapist is open to discussing them.

You can send those signals early on in your work by asking about sex on your intake form or in your initial interview in a nonjudgmental, normalizing way. I might say something like, “More than 50 percent of people have problems with sex, and these problems are related to their overall well-being. Is there anything about your sex life that’s bothering you that you’d like to discuss?” Alternatively, you can ask about sex in the context of the client’s presenting concern. For example, you might say something like, “Many women with anxiety have difficulty calming their mind enough to enjoy sexual experiences. Is this something that’s bothering you?”

Even if you’re already deep into working with a client, you can still broach the subject by saying something like, “I recently read an article about the importance of sexual satisfaction to overall life and relationship satisfaction, and it made me realize that this is something I’ve never asked you about. Is there anything about your sex life that you think is important for me to know to best help you?”

If a client reports no sexual concerns, leave the door open. You might say, “I’m glad to hear this is an area of your life that isn’t problematic for you. But if this changes or if something occurs to you, please bring it up! Sex is something I’m comfortable discussing.”

Seven Strategies That Can Help

Let’s say your client does want to discuss their sexual issues. There are seven empirically supported techniques to help them orgasm (and they rhyme!): educate, meditate, masturbate, lubricate, vibrate, communicate, alternate. For women who’ve never had an orgasm, these steps can be applied roughly in this order. For those who can orgasm alone but not with a partner, they can skip some of these steps depending on why self-pleasure isn’t transferring to partner-pleasure. For example, if it’s due to fear about guiding a romantic partner to touch a certain way, communication training will be key; whereas if the client can’t quiet her thoughts enough during sex to reach orgasm, focusing on mindfulness will be key.

Before we jump into the seven strategies, be sure to rule out any underlying medical causes that may be inhibiting orgasm. Some medicines, especially SSRI’s, inhibit orgasm, as do some medical issues like vulvar skin diseases and clitoral adhesions. Many women experience decreased genital sensitivity and have difficulty orgasming during menopause. So the first step in any treatment is to send your client to a physician for assessment. Some off-label medications have been found to enhance orgasm, and a doctor may find that your client is a good candidate for them. Keep in mind that, unfortunately, most physicians—even gynecologists—aren’t trained in assessing and treating sexual disorders, so make sure you’re referring to a knowledgeable medical provider. You can find these on the websites for the International Society for the Study of Women’s Sexual Health and the National American Menopause Society.

Educate. With most clients who have difficulty achieving orgasm, I like to begin by doing a little education around orgasms. As I mentioned earlier, women have more orgasms when alone and with other women than with men. With men, they have more orgasms in long-term relationships than in casual hookups. In all situations in which women have more orgasms, they’re receiving more external genital stimulation, referred to in most writings as “clitoral stimulation.”

How many women need clitoral stimulation to orgasm? Most studies say 85 to 96 percent. In research I’ve conducted with thousands of women, only four percent have said their most reliable route to orgasm is penetration alone. These women who orgasm from penetration usually aren’t the ones who come to us struggling with orgasm concerns.

The first step in helping a woman who’s either never had an orgasm or is having difficulty orgasming with a partner is to assess the type of stimulation she’s getting. This assessment goes together with education about genital anatomy, the need for clitoral stimulation, and our culture’s faulty messages about women’s sexual pleasure.

Assessment for orgasm concerns must be explicit and direct. Asking a client if they pleasure themselves, what they do, and if they orgasm is important. Likewise, asking a client to describe a typical sexual encounter with their current partner and whether external clitoral stimulation is involved is critical.

Take my client, Andrea, for example, a 33-year-old woman who told me she’d never had an orgasm with her husband of two years. Steve and Andrea had waited to “consummate the marriage,” and when Andrea didn’t have the orgasm she’d seen in movies the first time they had penetrative sex, she began to fear that her “vagina was broken.”  When asked directly, Andrea revealed that she did orgasm during self-pleasure. However, with Steve, they usually kissed a bit during foreplay, he’d caress her breasts, and then they’d have intercourse. Andrea told me she felt that she “should” orgasm this way, and that because she couldn’t, she felt “abnormal.”

I proceeded by educating Andrea on her genital anatomy and normalized the way she masturbated. She told me she was very relieved when I informed her that less than two percent of women masturbate by just putting something in their vagina, and that the rest use external stimulation, alone or coupled with penetration. “Wow, so you mean I’m not a total weirdo?” asked Andrea. “Of course not!” I replied.

To educate clients on genital anatomy, I’ll usually use either a vulva puppet or a drawing of the vulva—the anatomically correct word for the external genitals, including the external portion of the clitoris (the hood and glans) and the inner lips. The glans of the clitoris evolves from the same embryonic tissue as the head of the penis, while the clitoral hood evolves from the same tissue as the foreskin of the penis. The inner lips are equivalent to the shaft of the penis. All these parts contain abundant touch-sensitive nerve endings, as well as corpuscles that respond specifically to vibration. They also contain the erectile tissue that’s central to orgasm.

The vaginal canal itself has only touch-sensitive nerve endings within the first third. There are pressure sensitive nerve endings on the rest, which is why something inside the vagina feels wonderful to many women when aroused. When a woman is aroused, her vagina lubricates (although many women still need external lubricant). Then, the cervix pulls up and out of the way. But if penetration occurs before such changes, it can be painful. Having penetrative sex before being fully aroused and/or not using lubricant is a common cause of sexual pain for women, which can be a driving force behind sexual problems, including the inability to orgasm. Sex should never be painful, despite the cultural message given to women that this is normal or to be expected.

Another insidious culturally instilled belief that female clients often need help eradicating is that their pleasure is secondary to their partner’s pleasure. Such beliefs are reflected and perpetuated in the language our culture uses for sex. We use the word vagina to describe women’s entire genitals, thereby linguistically erasing the clitoris and calling women’s genitals by the name that is most sexually useful to men. We refer to intercourse—the way most men reliably orgasm—as “sex,” and we refer to clitoral stimulation—the way most women reliably orgasm—as “foreplay,” implying that the latter is just a lead-up to the main event. I talk about these linguistic mishaps with my clients, and tell them that moving forward, I’ll be using specific language, like oral sex and intercourse, and that when I say sex, I mean the entire sexual encounter.

For many clients, this is an aha moment. From there, I help them internalize that they’re entitled to pleasure, that clitoral stimulation is just as much sex as penetration, and that their orgasm is just as central to the encounter as their partner’s orgasm. Research shows that women who hold these beliefs have more orgasms.

Meditate. Teaching clients to be mindful during sex is an essential part of treatment for orgasm concerns. Women often have trouble orgasming, particularly with partners, because they’re focused on their thoughts rather than on their bodily sensations. When they’re with partners, they often worry about how they look or smell, if they’re “doing it right,” or if their partner is having a good time. If orgasming has been difficult or elusive in the past, thoughts like Am I going to come? may preoccupy a woman’s mind. But to have an orgasm requires not thinking. It requires being fully focused on the sensations in your body.

When I’m working with clients struggling with orgasm issues, I’ll often have them first practice mindfulness in daily life, and then apply it to solo and partner sex. Mindfulness practices outside of the bedroom can include guided meditations like breath work and body scans. Yoga can also be helpful, as it’s been shown to improve orgasm due to the mindful body focus it teaches. Clients can also practice being focused on sensations during daily tasks like brushing their teeth or washing their hands, during which time they can learn to notice when their mind wanders and bring their focus back to sensation.

Once a client understands what it feels like to focus on sensation, practicing mindful masturbation is an excellent next step, since during self-pleasure there’s no partner to worry about. The final step, of course, is a mindful focus during partner sex. Encourage your client to notice what they feel, smell, see, hear, and taste during sex. For example, some of my clients love their partner’s scent, so they’ll focus on it during sex when their mind wanders. Another one of my clients simply homes in on her own bodily sensations and couples this with breath work.

Masturbate, Lubricate, Vibrate. Many clients present with the inability to orgasm under any circumstances. For these women, sending them home with encouragement and instructions to pleasure themselves is a central part of treatment. This is called directed masturbation, and it’s the most empirically supported technique for anorgasmia. Two of my favorite books I recommend to help women with this are Betty Dodson’s Sex for One and Lonnie Barbach’s For Yourself.

With my client Sandra, who’d never had an orgasm, I explained the research backing guided masturbation and asked if this was something she was ready to try. “Yes, but not yet,” she replied. As a preliminary step, I suggested Sandra touch herself more erotically when getting dressed and in the shower. I also directed her to the educational website omgyes.com to learn about the ways other women masturbate. I told her to buy some lubricant, as vulvas are not supposed to be touched dry, and asked her to simply enjoy applying it to herself and touching herself in various ways, simply exploring what felt good. Finally, I suggested she set aside 30 minutes to mindfully touch herself, emphasizing that the goal was to be immersed in her sensations and not focus on the goal of orgasm, since trying to have an orgasm makes having one less likely.

Sandra reported back that while she’d enjoyed herself, she hadn’t orgasmed. I encouraged her to try other things like reading, watching, or listening to erotica, fantasizing, and switching up her self-pleasure method by adding penetration when aroused and pleasuring herself when lying face-down instead of face-up. As I do with almost all clients, I also suggested she purchase a clitoral vibrator. I explained to Sandra that many women don’t orgasm until they use a vibrator—the biological basis for this being that there are special corpuscles in the vulva that respond to vibration. Sandra bought a vibrator, which I reminded her to use with lube and a mindful focus, and the next session, she came in beaming. She’d had her first orgasm!

But her joy soon turned to worry. How would she be able to do this with a partner? she wondered. I assured her that this would involve communication, a skill she could easily master.

Communicate. I proceeded with Sandra by telling her she now had to follow the most essential (but underutilized) advice for having an orgasm with a partner: she needed to get the same type of stimulation with a partner that she was getting alone. To do this, women must be equipped with the confidence and skills to tell their partners about the clitoral stimulation they need to orgasm. Clients in committed relationships can bring partners to therapy or suggest reading material like the chapter in Becoming Cliterate (written for men!) or Ian Kerner’s outstanding book She Comes First. Kerner provides a fantastic pep talk for male readers about how focusing on clitoral stimulation benefits them by taking pressure off of lasting long and thrusting hard. Along with educating partners about clitoral stimulation, clients will need skills and guidance to talk about sex with partners more generally, including outside of the bedroom, and before, during, and after encounters. The research is clear: those who communicate about sex have better sex.

Take, for example, my client Valerie, a high-powered attorney with excellent communication skills—just not with her partner when it came to sex. She’d never told him about the stimulation she needed or really communicated during sex, she told me, because she’d never seen this modeled in the movies. After learning to communicate sexually, including during sex, she told me it had been “life changing.” There are some great books and websites to help women with sexual communication, including Sex Talks by Vanessa Marin. Having couples view and discuss the videos on the website omgyes.com is also incredibly useful.

Alternate. Something couples should talk about—and most often change—is their sexual routine.  One of the biggest contributors to women not having orgasms during heterosexual sexual encounters is the routine in which intercourse is considered the main event and ends when the man orgasms. One reason women who have sex with women have more orgasms than those who have sex with men is that instead of the encounter revolving around a main event—penetration—partners take turns pleasuring each other.

Turn-taking can be easily applied to heterosexual sexual encounters. For example, a woman might orgasm from oral sex while her partner orgasms from intercourse. Or they can take turns pleasuring each other with oral or manual stimulation. Or they might have intercourse during which the man orgasms and then after, the woman uses a vibrator on herself while her partner kisses and caresses her until she orgasms. The possibilities are limitless. Orgasmic partner sex requires each person to allow themselves the space to focus fully on their own sensations, and turn-taking provides this.

For those couples who want to orgasm during the same act—intercourse—a scientifically supported technique is the woman touching herself with a hand or vibrator during penetrative sex. In this case, it’s paramount to tell the client that it is no less sex if she touches herself, and that this is the only way many women can orgasm.

***

Orgasm is considered the pinnacle of a sexual encounter. While not all sexual encounters need to include orgasm for both partners, the gendered orgasm gap tells us that we have a cultural problem that’s playing out in our clients’ bedrooms. To help our female clients experience orgasms, we need to empower them with knowledge, strategies, and tools. A client who’s never had an orgasm will likely need all of these interventions, while one who can orgasm alone but not with a partner may only need a few. Regardless, I’m confident that by following these suggestions, you’ll find helping your clients experience pleasure to be one of the great joys of your work.

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We all know that there’s no such thing as a “perfect” parent, but even so, many parents hold themselves to unreasonably high standards. Our work as therapists includes helping our clients genuinely accept their imperfections, work through shame, and repair and reconnect with their loved ones. In the process, they model what it means to take responsibility, and strengthen their relationships. Recently, I helped my client Tiffany let go of her own self-imposed requirement to be a perfect parent—and thanks to a little self-disclosure, she not only felt less alone in her “failure,” but was able to take steps toward repairing her relationships with her partner and children.

Two months ago Tiffany called to schedule an emergency session. Earlier that morning, she and her husband, Zach, had a bad argument that left her feeling hurt, angry, and guilty.

“I don’t like arguing in front of the children,” she told me. “And usually we manage to keep things under wraps until we can be in private. But this morning, I couldn’t stop myself. Zach was griping about the children not getting ready fast enough, but he wasn’t doing anything at all to help! And they were being awful, just lying in bed demanding video time before school.”

Tiffany’s voice trembled, and for a moment she was quiet as she fought to hold back tears.

“I yelled at them all,” she blurted out. “I shouted, ‘I can’t stand this!’ and told Zach I was going to work and that he could deal with getting the kids ready. But before I could walk out of the house, my littlest one tried to hug me. I told her I couldn’t, and left.”

Tiffany began sobbing. “I’m mad at Zach and feeling miserable about my marriage, but even worse, I feel terrible about what I did to my children. What kind of mother yells at her kids and walks out on them?”

She took a breath. “I know what kind of mother. Mine. It’s something my mom used to do and something I swore I’d never do to my own children. I’ve worked so hard to make sure I don’t repeat her mistakes, and here I am, doing the exact same thing! I should’ve stopped and explained that I was upset but that I still loved them. They were just being kids. I keep thinking back to their sad little faces. It breaks my heart. I want to go to their schools to make sure they’re okay. But maybe that would just make things worse.”

Like many parents these days, Tiffany was well-attuned to her children’s emotional and attachment needs. She knew that the idea of a “perfect parent” was a myth, and she generally felt like a pretty good mom. Still, she didn’t like making mothering mistakes, and she felt that this one was pretty awful.

I tried to help Tiffany accept this misstep by reassuring her that we all make mistakes with our kids, but she continued to berate herself. But as she did, I began thinking back to some of the many times I’d messed up with my own child, who’s now a grown man with a family of his own. I used to joke that I would make a list of all the terrible parenting errors I’d made so that he could save time when he started his own therapy, as he would inevitably do. It would’ve been a long list, but as I’ve learned in my own life and in my therapy practice, most of the time, what parents feel bad about isn’t even on their child’s mind.

Thinking about Tiffany’s situation triggered a particular memory for me: that the worst thing I’d done to my family wasn’t as a mother, but as a grandmother. A few years earlier, my husband and I had been staying at an Airbnb while visiting my son and his family out of state. Our three-year-old grandson had been staying with us, and we’d just finished making breakfast together. I hadn’t been paying attention to how close he was to the stove, standing on a stool, and even though the burners had been turned off, they were still hot. When he’d turned to show me something, he accidentally put his hand on the stove, and started screaming.

Immediately, I made a mistake: I put Neosporin on the burn. Then I called his mom, who told me to run his hand under cold water and said she’d be right there. She called her pediatrician on the drive home, who told her to take him to the emergency room. At least outwardly, she was calm and efficient—a seemingly perfect mom in a difficult situation. I knew she probably wasn’t feeling calm or efficient, but still, she soothed her son, took care of his physical and emotional needs, and managed to soothe me as well. “Mistakes happen,” she told me. “You’re a great grandma. This could’ve happened to any of us.”

“As a daughter, a mother, and a therapist, I know all relationships are imperfect,” wrote my friend and colleague Judith Ruskay Rabinor. “Most of us have done things we regret, and often, don’t even understand.” These behaviors may be emotionally loaded, or they may simply be accidents. But, she continues, “none of us are as bad as the worst thing we have ever done.”

One of the most important things for parents to keep in mind is that most failures can be addressed directly with our children. Psychoanalyst Heinz Kohut once pointed out that repairing these ruptures can be more important than the mistake itself. Taking responsibility for our error, recognizing and validating our children’s feelings, and expressing genuine remorse for causing them pain helps our children in a variety of ways.

Recognizing and validating their emotions when they’re upset with us helps them develop self-awareness and emotional intelligence. It also models empathy and compassion. Owning what we’ve done provides them with an in vivo example of taking responsibility for your behavior. And acknowledging our imperfections without demanding forgiveness or acting as though we’ve lost sight of our strengths shows our children how to accept, take responsibility for, and learn from their own failures.

One of the most important components of this process is its interactive quality. Taking responsibility isn’t enough. Acknowledging a child’s feelings is important, but not enough. The real goal is to repair the relationship without ignoring the impact of the offense.

I wasn’t sure whether it would be helpful for Tiffany to share my memory with her. But then, she suddenly asked me, “Did you ever do anything like this to your children?”

I laughed. “Oh, I was just thinking about that,” I said. Then I told her about the experience with my grandson.

Tiffany began to wipe away her tears. “Wow. I always thought of you as being so perfect,” she said. “Well I guess it’s good to know that you’re not perfect, after all. But it sounds like your daughter-in-law might be. I’m not sure I could have forgiven you after something like that.”

I nodded. “I’m not sure I could have forgiven my own mother for that, either,” I said. “I’m lucky. She’s a very generous woman. But maybe you and I might have eventually been able to repair the rift with our mothers if it happened with them. We both know that nobody’s perfect, and we’ve both made mistakes with our own children.”

For a minute, Tiffany was silent. “I guess the trick is also to be able to forgive yourself,” she finally said. I nodded.

In our next session, Tiffany told me that she’d spoken to her husband and apologized to him. “I told him I want to work on the ways we fight,” she said. “We’re not going to stop arguing, because we aren’t going to stop having differences of opinion. But maybe we can talk about how to disagree more effectively and less hurtfully.” Her husband had agreed.

“Then I asked him for advice about how to handle the incident with the girls,” she continued. “He said they’d probably already forgotten it, but that if I wanted to say something, maybe the best thing was to just be straightforward about it, to tell them I didn’t like what I’d done, that Daddy and I were going to work on how we talk to each other, and that I wanted to work with them on how we talk to each other, too.”

Tiffany told me she’d felt soothed and understood by her husband. Later that night, after dinner, she spoke to her children as he’d suggested, but first she’d asked them how they were feeling about what had happened. “It’s funny,” she said. “My older daughter said, ‘It’s just the way you and Daddy are.’ My younger daughter didn’t remember any of it.”

Tiffany wondered if she should try to make her little one remember. “Did she just suppress her feelings?” she asked me.

I told her that small children often let us know when something is wrong, although not always directly. Over the next few days, she could watch to see if there were signs that her daughter was upset, but if she seemed like her usual self, she’d probably just accepted that this was part of her parents’ relationship.

“So I guess the most important thing is to move on and work hard at changing those behaviors,” she said.

“And to recognize that none of us is perfect,” I added. She smiled.

“So did your son and daughter-in-law ever let you take care of your grandson again?” she asked.

“They did,” I replied. “As soon as he came back from the emergency room, he showed me his Band-Aids, covered in cartoon designs. Then my son asked him if he wanted to stay with me, and he said yes without missing a beat. I asked if they were sure they were comfortable with that, and they also said yes, and went back to work.”

It’s important not to put our children in charge of alleviating our guilt or make them responsible for letting us off the hook. When Tiffany finally spoke to her children that evening, she told them that what she’d done was wrong. She didn’t put the blame on her husband or on them, nor did she make excuses for herself. Even though her children didn’t seem to think it was a big deal, she told them she’d been upset and that she didn’t like herself or her actions in that moment.

Her children’s responses surprised her. They smiled, her older daughter patted her head, and her younger daughter asked if they could watch their favorite show. Although Tiffany worried that they needed to talk more about what had happened, their mild reactions reinforced my sense that she and her husband were doing a good job as parents. Her conversation with her husband had been more difficult, but also indicated the solidity of their relationship. After she’d apologized, he’d defended his behavior, but when she continued to take responsibility for what she’d done and reminded him that they were both working very hard, feeling overwhelmed, and needed to work together on managing their conflicts better, he’d agreed.

That agreement wasn’t the last of their arguing, nor was it the end of difficulties between them in the mornings, when getting the kids out the door for school was often a challenge. It also wasn’t the last parenting mistake either of them would make. But it was a turning point, an opportunity for both of them to experience what they were trying to teach their children: mistakes happen, and nobody’s perfect. They could care about each other and stay connected, not just in light of these mistakes, but because of the work they’d done to repair them.

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Our magazine has won awards not only for its insightful articles, but for its beautiful design. Want to flip through the pages of the latest issue? Check out the digital magazine on your e-reader or any favorite device—and dive in from cover to cover!

Although autism itself isn’t new, we’ve called this issue The New Autism because courageous voices inside and outside our field are helping us see it in new ways. Many of these voices belong to therapists and coaches who are themselves neurodivergent. As we learn from them, the standard approaches to depression and anxiety, and even to common relationship problems brought up in couples therapy, were designed from within a neurotypical framework. Using them may actually cause harm to Autistic people—including the undiagnosed, high-masking clients who may be flying under the radar in your practice or those who are part of an astonishingly large wave of adults grappling with a later-life autism diagnosis. Providing safe, attuned, and affirming care will require many more mental health professionals, even some already working within the autism community, to update their understanding of the wide spectrum of neurodivergence and the complex, vulnerable nervous systems at stake.

The perspectives you’ll find in this issue invite you to shift your mindset. For some, it may be a difficult or disorienting shift, but ultimately, making it will empower all of us to provide more people with the neuro-affirming care and validation our world needs.

Join the conversation and let us know what you think at letters@psychnetworker.org.

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Q: In the mid-sized city where I practice, I’ve become one of the “therapists who see therapists.” The problem is, I’m not sure I like providing psychotherapy to people like us. Maybe because we swim in the same waters, their defenses are sophisticated and hard to recognize. They know too much about the “backstage” of the therapeutic process. Though I like and admire these clients, I also dread my meetings with them. What do I have to offer that they don’t already know?

Part of the magic of psychotherapy is that most of our clients don’t fully understand how it works. Mystery can produce powerful placebo effects, such as the instillation of hope and the activation of the client’s own self-healing capacities. One of the reasons I find acupuncture and Chinese herbal medicine so helpful, for example, is that I have no idea how they work. When my acupuncturist explains what she’s doing and why, I nod, but really, I’m dumbfounded. My ignorance is part of what potentiates the effects of the needles and bitter-tasting herbs. I trust her because she’s kind, has a cool office with a relaxed vibe, takes her time with me, pays close attention to where I’m hurting, and is confident in what she’s doing.

Our clients who are healers themselves and seeking relief through modalities they may have received training in and know quite well, have fewer illusions—especially if they’re seeing a therapist who practices from a similar theoretical orientation. So, how do you remain confident and reclaim some of the magic inherent in the process?

Authenticity

From the polyvagal framework, we know that the focused attunement of a psychotherapist who is genuinely paying attention—sometimes called right hemisphere to right hemisphere engagement—lies at the heart of psychological healing. Psychotherapy is a process that takes place in a rich co-regulatory environment where two nervous systems join to alleviate suffering: one to tell the story of adversity with emotional authenticity and one to hold it with steady compassion; two bodies in sync. To accomplish this alignment, the emphasis on my own expertise and what I know about research and theory doesn’t matter and actually can produce an unhelpful distance.

Rather, with my therapist-clients, I’m more likely to share vulnerable facts about myself, about my marriage and parenting experiences, and my experiences as a son and a therapy client trying to get over my own carefully curated professional self to get at the real, messy issues I most need to address. I’m careful to minimize how much time I take up with self-disclosure —after all it’s their hour!—but this kind of honest, relatable sharing supports a deeper, more fearless connection. It levels the playing field, lowers anxiety, decreases feelings of comparison and competition, and increases safety.

Identifying Self-Protective Habits

There are a couple self-protective habits that I’ll gently identify and invite therapist-clients to explore. As children growing up, many therapists were lauded for being good, intuitive listeners and compelled to take care of others in ways that distracted them from their own developmental needs. When they attended graduate school, they learned additional skills that make them even more powerful as listeners and counselors. They learned the guardrails of the therapeutic role, the boundaries and compartmentalization of their own needs, which makes them effective professionally, and they became increasingly intentional and strategic in how they navigate relationships: expert interpersonal chess players! Unfortunately, in their personal lives, these habits of careful self-curation can distance them from their real human selves and from family members and friends. It can make it even harder to get their own human needs met. In our real social and family lives, we all want to be seen and known, but we can’t be seen behind a mask.

Often, I begin a session asking a therapist-client: “Tell me how you’re doing this week.” What often follows is a thoughtful—and interesting!—case conceptualization of her husband. I ask the same question again, curious about them—“But tell me how you’re really doing”—and this time they give a case conceptualization of their daughter. There’s a countertransference challenge here. I usually find the case conceptualization answer compelling and might be seduced to listen, but in this situation, it’s an unhelpful collegial behavior. I’ll be fooled into not paying attention to them. “Do you notice that your responses to my question are about other people, but there’s no ‘you’ in your story?” I’ll ask.

With my therapist-clients, I find it useful to discuss the ways at the end of their professional day they bring their therapist self home, case managing or counseling family members, in ways that may be helpful to the family member, may even be appreciated and lauded, but that’s ultimately dishonest and disconnecting. It’s a way they shortchange themselves in their personal relationships by neglecting their own needs. All of us do a little of this, but there can be a temptation to lean too heavily on therapist skills in nontherapy relationships to our own detriment.

The Self-Therapizing Client

Another self-protective habit I notice with therapist-clients: They tell me a story about their lives, one with genuine struggle and confusion, and then launch into what they know about how a therapist would respond to them. “Of course, I know this is a normal response when parents launch their children into college and the grief I’m feeling won’t last forever. I can use self-regulation skills to manage my feelings.” It’s almost as if there are two halves to their response: their real human story of struggle and then what they’d say to themselves if they were their own therapist.

This could make for an easy session: I could just kick back and let my client do all the work! But in reality, it shuts me out of the therapeutic relationship. The client doesn’t sit with their own vulnerability and give me the chance to accompany them. I’m simply watching them be their own therapist. “Do you want to stay with the sadness and struggle for a bit longer?” I might offer. “Do you want to allow me to be with you in the messiness of it, without having to clean it up with therapist talk too soon? You don’t have to be so alone with all this.”

Embracing Messiness

With their highly cultivated sense of interpersonal intention at work and at home, therapist-clients can struggle with a deadening lack of spontaneity and authenticity. I often encourage these clients to imagine how they’d engage in specific situations with people in their lives from a sloppier, less curated place. What would it look like to relinquish control a little bit? Or to value their irrational and confusing emotions as portals to the real? Can they tolerate raising the temperature in their personal relationships a notch or two and expressing anger, disappointment, and fear? Would it be okay to act in ways that might not feel appropriate as a therapist in a room with a client, but that could infuse their home lives with genuineness and life force energy? Can they tolerate an escalation of a personal conflict into an uncertain outcome that’s not under their total control and influence?

Our therapist-clients can be some of the most vulnerable clients we work with. Because the work they do is so taxing, physically and emotionally, it can predispose them to illness, depression, and anxiety. Their training compels them to compartmentalize their own feelings and needs. They’re far more prone than most clients to develop professional habits that bleed into their personal lives and lead to feelings of loneliness and emptiness. The therapy we provide offers them a chance to flex into a different part of their brains and nervous systems, to be messier and more spontaneous, and ultimately to feel seen and cared for in ways that benefit them, their families, and ultimately their own clients.

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For most providers, an evaluation or therapeutic relationship starts with a diagnostic interview, also known as an intake. Although there are standard questions and components of a diagnostic or intake interview, each provider has their own style and the freedom to structure these appointments in the way that works best for them.

There is no one way to conduct a diagnostic interview that is inherently superior to all others. Providers will be most effective when leaning into the approach that plays to their strengths, and clients will have different needs and preferences when it comes to engaging. We need providers with all different styles in order to fit each client’s needs. However, there are some approaches to these interviews that can be harmful, especially to neurodivergent clients.

Below are some general tips for what not to do in a neurodiversity-affirming intake appointment:

1. Assume dishonesty. Unfortunately, many providers approach evaluations assuming that a client is going to exaggerate their symptoms and difficulties or try to deceive the provider. You cannot effectively build rapport with a client if you come from an assumption that they are lying to you.

2. Assume unmasking. Masking, by definition, causes a client to present in a way that shows few neurodivergent traits. This means that a provider might not directly witness some of the traits a client experiences, and it may appear that they are not demonstrating experiences they describe in the session. Remember that masking is often an adaptive behavior developed in response to being penalized for authenticity! You cannot assume that a client will feel comfortable unmasking the first time they meet you, or that they have even begun the process of learning how to unmask.

3. Try to trigger behaviors. Sometimes, a provider will want to directly observe certain behaviors that a client is not showing in the intake session and might attempt to bring out that behavior. Clients have shared stories of evaluators attempting to induce a meltdown during an intake in order to see what the client is like in this moment. It is inappropriate and unethical to deliberately cause a client severe distress, especially in a first session when you likely do not have the rapport established to support the client in de-escalating. No, you do not need to see the behavior to believe the client’s experience.

4. Argue with the client about their experience. Similar to assuming a client is being dishonest, many providers come from the assumption that the client might be trying to tell the truth but has fundamentally misunderstood their experience. Clients rarely develop trust in response to arguments with and invalidation of their description of their experience.

Conversely, some general tips for making diagnostic interviews affirming:

1. Understand the power dynamic. Although a neurodiversity-affirming provider approaches mental health care from a place of equality with the client, acknowledging that they are the expert on their own experience, there is an inherent power dynamic to any appointment. The provider has the power to diagnose, deny a diagnosis, or misdiagnose. They can modify the client’s medical record to reflect their perception of the visit, impacting the individual’s future access to care. By acknowledging and understanding this power dynamic, providers can avoid harm to the client due to our position.

2. Follow the client’s lead. As clients are the experts on their personal life experience, following their lead in an intake can result in gathering robust and extensive information. This additionally builds rapport, making the client more likely to unmask and show their authentic self in the appointment.

3. Be transparent. Clearly explain to the client what your role is. If you are a therapist who cannot diagnose certain neurodivergences, let the client know that. If you are conducting a diagnostic evaluation, detail your diagnostic process. Encourage questions and answer as comprehensively as you are able.

4. Prioritize emotional safety. Clients who have had harmful experiences with other providers might have increased difficulty trusting new providers. Be patient, and make efforts to create an emotionally safe place for the client to open up to you.

5. Collaborate. Remember, the provider is the expert on the mental health field, and the client is the expert on their unique personal experience. When we approach intakes from a place of collaboration, we are likely to get better information about the client, their needs, and their experience.

***

Reprinted from Neurodiversity-Affirming Therapy: What Every Mental Health Provider Needs to Know Copyright © 2025 by Amy Marschall. Used with permission of the publisher, Norton Professional Books, a division of W. W. Norton & Company, Inc. All rights reserved.

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When my oldest son, Cooper, was four, he largely stopped speaking, eating, and wanting to leave the house or move his body. He refused to do most activities—putting on his own socks, walking up the stairs, playing with toys, drawing pictures, even answering simple questions—and pushing him to do any of these things resulted in explosive meltdowns that regularly lasted anywhere from 30 to 60 minutes. No traditional forms of soothing or parenting helped.

On the occasions he did speak, it was often to tell us his legs weren’t working so he couldn’t walk where we were going, even a block away. Or to scream “No,” yet again, to a suggestion of something most other four-year-olds would do happily, like walk out the door to get ice cream.

We saw specialist after specialist, and in countless fields, only to be dismissed or blamed for what was happening. The blame was often paired with a reprimand to be more consistent—code for strict—in our parenting. He needs to know who’s in charge, they said. You must extinguish this behavior, they insisted. Because our son had always been challenging, this was advice we’d often heard and had already been doing our best to implement.

Like the type-A, traditional parent I once was, I followed the rules and instructions I was given. I used 1-2-3 Magic and Positive Discipline with the support of pediatricians. The former called for time-outs, and enforcing them were some of the most traumatic moments I’ve had as a mom. I remember putting our four-year-old in a bedroom, and my husband or I would try to ignore his screaming while we closed the door and held it shut while Cooper pounded on it, first with his fists, then with his writhing legs from down on the floor.

What I now know is that these were full-on panic attacks. But the experts I met with then did not. When Cooper escalated to the point where I couldn’t manage anymore, I didn’t know what to do, and it seemed no one else did either. “Next time a meltdown lasts that long,” our pediatrician said, “take him to the children’s psychiatric emergency room.”

Instead, I left my career. At the time I was leading Pew Charitable Trust’s research quality team, but because my son could no longer attend daycare, and we feared the possibility of drastic medical intervention like implanting a feeding tube, it didn’t feel like I had a choice.

Without a diagnosis or structural supports, and unable to live on only one income in Washington, DC, we moved to a small town in my home state of Michigan. The changes jarred all of us, including Cooper. A few weeks after we arrived in Michigan, he could only eat Honey Nut Cheerios, out of one specific bowl, and never with milk.

The confusion about why this was happening was no clearer in Michigan than it had been in DC. Our new environment, daycare providers, and medical team had no new suggestions. The lack of insight and understanding left us feeling utterly alone—and in many ways, we were.

Then, as we began feeding therapy for Cooper, an astute occupational therapist (who saw that the traditional strategies weren’t working) suggested I look into Pathological Demand Avoidance (PDA)—also referred to as Pervasive Drive for Autonomy. As soon as I read about it, it was like a veil lifted. I finally began to feel like I understood my son.

This was in 2020, and I spent the next two years—and the pandemic—providing around-the-clock care to Cooper. The main “accommodation” I provided was my own nervous system: giving him undivided attention. When I didn’t, I risked him exploding into a meltdown or lashing out physically at his one-year-old brother. My only reliable reprieve were screens. As my own nervous system frayed, I increasingly allowed Cooper to indulge in these distractions—but even then, he’d sometimes control my line of vision by requiring me to look at whatever he was watching with him.

What I now know is that both Cooper and I were experiencing nervous system burnout. Those were the hardest, most soul-crushing years of my life, but they also gave me the opportunity to truly understand my son’s challenges with the correct logic. And it was from there that all my decisions, creative problem-solving, ideas for accommodations, and strategies flowed.

Now, as a parent educator for thousands of families with PDA children and teens, and a researcher conducting empirical studies on PDA with the University of Michigan Medical School, I have both an intimate and a bird’s eye view of the mechanisms of PDA. I believe clearly defining PDA as a neurotype and nervous system disability will enable us all—parents, pediatricians, teachers, and therapists—to vastly improve the lives of PDA children, teens, and adults.

A Nervous System Disability

If you’re a clinician or a parent who’s taken an info-dive into PDA online or on social media, or gone deeper into the peer-reviewed research, it’s probably for a reason: there’s something familiar about stories like mine. But you might still be confused. After all, much of what’s been written about PDA focuses on whether it even exists. And when it is acknowledged, it’s often broadly defined as an “anxiety-driven need for control” or confused with other diagnoses like generalized anxiety disorder, autism, ADHD, ODD, bipolar disorder, or other personality disorders.

This is especially confusing for professionals because it suggests that CBT and exposure-based approaches would be effective treatments, when in reality, these cognitive and behavioral treatments are rarely helpful for PDAers. In fact, they often make things worse, especially when a PDA child, teen, or adult is in burnout.

A more accurate conceptualization of this unique brain-wiring is as a survival drive for autonomy and equality that consistently overrides other survival instincts—like eating, sleeping, hygiene, toileting, and maintaining physical safety toward oneself or others—either in a single moment, or as nervous system stress accumulates.

This is what happened to Cooper, and what I’ve seen play out in thousands of families. Over time, as PDAers perceive threats invisible to others, they experience acute nervous system activation that eventually disables them. The challenging behaviors we see as a result are a subconscious attempt to regain control or equalize back to nervous system safety.

Whether from a five-year-old or a 40-year-old, these “equalizing” behaviors can look like controlling, manipulating, trying to be “above” another, correcting, or acting aggressively toward a safe or “weak” person. With a more internalized expression of PDA (more freeze/fawn than fight/flight), we tend to see these behaviors aimed at the self in the form of self-harm, or the destruction of one’s own things.

Equalizing, or the need for control, often coalesces around one or more basic needs (for my son, it was eating). The physiological impact of all the accumulated stress PDAers experience often leads to medical issues like insomnia, toileting regression, encopresis, UTIs, restrictive eating, compulsive eating, and the inability to engage in physical hygiene. All this tends to get separated out from their behavior challenges.

An Autonomy Focus

Another way to think of this subconscious cycle is to imagine you’re being held up at gun point in a dark alley. Without thinking, your nervous system reacts with “fight” behavior, and you swear, hit, bite, and punch the assailant. Your adrenaline is coursing, your muscles tense, your pupils dilate into laser vision, your digestion slows, and you feel no hunger. Or maybe you “freeze” in front of the assailant, are unable to move, go mute, or even collapse, allowing the thief to take whatever they want from you.

Either way, what your nervous system did saved your life. And even though you may question it afterward—where did that violence come from in me? or why didn’t I defend myself or run?—you know you did it without choosing to do so. Your body reacted to a perceived danger and life threat.

Now imagine that this is what your nervous system perceives every time you experience a loss of autonomy, freedom, and choice. And every time another person is “above” you in stature, authority, or posture, or you’re in a situation that seems to require submission. Every day when your parent tells you to get dressed, sit up straight at breakfast, or pack your backpack, your metabolism slows, your adrenaline courses, you get tunnel vision, and you go mute. If you had these types of physiological responses day in and day out to what appear to be ordinary daily expectations, tasks, and situations, then we might expect you to lose the ability to consistently eat, go to the toilet, sleep, make your legs carry you, or even speak.

This conceptualization of PDA as a nervous system disability impacting both behavior and basic needs is what we’re conducting research on at the University of Michigan. Our first study surveyed more than 700 parents who considered their child or teen PDA and found that in addition to behavior (equalizing, dysregulation, fight/flight, and avoidance), the impacts on basic needs (sleeping, eating, hygiene, and toileting) were also statistically significant factors that can be used to develop a better measure of PDA. While this research is incipient, it’s enough to move us beyond the theoretical debate on whether or not PDA exists. It also helps us formulate a more accurate picture of the challenges of PDA. Our hope in submitting our study for peer review and publication, along with the PDA-Q (a questionnaire for identifying PDA), is that it will eventually ensure that PDA is included in a future edition of the Diagnostic and Statistical Manual, so that families don’t have to go through what I and so many of my clients have gone through to get the support they need.

Once families identify that their child or teen is PDA, and are then equipped with a clear understanding of what that means and how they can make accommodations, they make enormous gains. For example, within six months of identifying their child as PDA, many parents I’ve worked with have reported that their teen is no longer attempting suicide after previous hospitalizations and more traditional approaches failed to stop the attempts; their child has gained much needed weight (even moving from 1 percent BMI to 21 percent BMI) after all previous feeding approaches and strategies failed; their teen is leaving their room for the first time in a year and engaging with their family again; their child is asking to go to the park, after refusing to leave the house for months; their child, diagnosed with selective mutism, is using more new words and speaking more than ever.

We consistently see transformative success in treating PDA as nervous-system driven and using autonomy-focused accommodations. This is also true for families who’ve previously tried—to no avail—applied behavioral analysis, other types of behavioral conditioning, “teaching skills” or “correcting behavior.”

My own family’s experience is one of these success stories. My son, now in fourth grade, loves being back in school—a private one, where children’s autonomy is encouraged. He has strong verbal and social skills and countless friends through school and athletics, and will soon graduate from feeding therapy.

Through the PDA Lens

Although our understanding of PDA is still evolving, therapists don’t have to feel lost when it comes to working with PDAers or their parents. The skill I believe will most quickly and effectively help therapists integrate their own methods and clinical frameworks in their work with PDAers is what I call the PDA Lens.

I imagine the PDA Lens as a pair of glasses that we can put on and take off. We put them on when we want to experiment with the idea that the challenges our client (or their child or teen) face are driven by PDA. In other words, when we put the glasses on, we assume that the client’s nervous system is perceiving mortal threat at every loss of autonomy or equality. They may be able to mask this in less “safe” scenarios—at school, with grandparents, or for an adult at work—but the nervous system activation they experience in these environments builds and may eventually disable them from feeling safe and emotionally regulated enough to attune to their body’s needs.

Then, with our glasses still on, we think through how we can best support this client. How do we demonstrate compassion, patience, and flexibility for a person with a disability that’s out of their control—one they may not even understand—but that we believe (or are willing to experiment with believing) is driven by their nervous system’s need for autonomy and equality?

Each therapist will answer that question differently, depending on their professional training, creativity, and the specific circumstances and challenges the client is facing. Regardless, if the client consistently responds positively, this could be evidence that they are indeed PDA. And knowing that, and what it means, can open up a world of possibilities.

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Enjoy the audio version of this article—perfect for listening on the go.

Early in my career, before I’d developed Internal Family Systems (IFS) into the approach it is today, I (Dick Schwartz) had many clients who struggled with addicted behaviors, and I believed what most of the addiction field still believes. Since addictions are biological drives that need to be controlled, recovery is one long fight.

My reeducation began during an outcome study with bulimic clients, who taught me to listen to their inner parts (or subpersonalities) rather than lock them away. When a client asked her bingeing part what would happen if it didn’t make her eat that way, it would explain that other parts that felt sad, worthless, empty, or terrified would take over. Beyond that, the bingeing part often feared suicide. If I stop bingeing, it would say, she could die. As we soon learned, the motives of the suicide part were also protective. On perpetual standby, it was always ready to take the client out if the pain got too intense. In short, we could not deter or control the bingeing part because it was on a mission to save the client’s life. For me, this was a novel view of addiction.

When therapists don’t listen to addict parts or ask about their fears, these parts feel alone, misunderstood, and defensive. When we fail to recognize their primary goal of protecting clients from prolonged emotional pain, they ramp up. As addictive behaviors become more heedless and disruptive, therapists get sidetracked. A need to control whatever crisis is underway eclipses the underlying, fundamental problem of vulnerable parts feeling shameful and unlovable. As I saw how judging and trying to control these parts harmed clients, I committed to developing a parts-based treatment approach, which I’ve been doing for the past 30 years.

However, as IFS lead trainer Cece Sykes—who has advocated for using IFS with addictions for decades—can attest, IFS psychotherapy for addiction has been a tough sell. Therapists are often skeptical or afraid of welcoming parts who are known for causing harm and have typically been seen as the enemy. They argue, understandably, that traditional residential treatments and 12-step recovery groups help desperate people and save lives. Even so, therapists and addiction specialists can agree that too few people get treatment, too many drop out, relapse is a continual threat, and it would be great to have better options. We propose that IFS is tailor-made to bridge the clinical gap between the psychotherapy and recovery communities.

Exposing Fragile Parts

Looking pale and tired, Georgie rushed through the door, plopped onto the sofa, and let out a huge sigh. “Sorry I’m late,” she said. She had warm, brown eyes, an easy laugh, and a headful of curly dark hair.

I (Cece Sykes) nodded, thinking, Okay, no big deal. She was in her mid-30s, taught theater in a public high school, and had started therapy with me a few months earlier after a painful breakup with her longtime girlfriend, Delia, which fueled near-constant rumination about what she’d done wrong as a partner. She had also started focusing on the personal lives of her students in an attempt to help them make wise decisions in their own relationships, but these attempts drained her and were often unwelcome.

“How are you?” I asked.

“Bad. I feel like crap,” she said. “I was out drinking last night with friends and got home late—very late.”

I nodded, encouraging her to continue.

“I hate that I’m getting hammered on a Wednesday night. And I brought some woman I just met home with me, too. Honestly, I’m sick of myself.”

I felt her pain, self-disgust, and fear and made a note of what she was implying: there’d been bouts of late-night drinking in her past. A part of me immediately wanted details: How many drinks? Any drugs? How often? But probing for specifics at this point would probably have shamed her. Mentally, I asked my worried, hard-working therapist parts to step back, freeing me to simply offer Georgie Self-energy-warmth, clarity, and an open heart.

Clients are especially vulnerable when they work up the nerve to talk about risky behaviors with sex, gambling, food, or substances in therapy. Georgie was exposing fragile parts of herself, and I was glad we could learn more about her addictive process together. I said, “You sound miserable, Georgie. I’m glad you trust me with this. It’s a hard thing to bring up. Let’s take a moment to appreciate your courage.”

“I guess,” she said. “Delia and I used to party a lot—like, a lot. I haven’t gone out much since we broke up. But last night I couldn’t stop myself. I drank way too much and then hooked up with someone I barely knew.” Georgie paused and grinned ruefully. “I prefer drinking and sex to crying. And, hey, at least I got to work on time!”

Along with her bravado, I noted how quickly she shifted to minimizing her pain and the costs of drinking. “Sounds like partying with Delia was a regular thing,” I observed. “But a lot has changed. I hear relief that you made it to work today. Sounds like you’re feeling hungover, regretful, disgusted, and maybe ashamed of how much you drank.”

A Seat at the Table

I wove IFS principles into Georgie’s therapy from the start. She’d taken to the idea that her psyche was a system of interrelated parts quickly: protectors (managers and firefighters) and the more vulnerable exiles, each with unique feelings, thoughts, and agendas. She’d also learned that protectors who escalate in response to each other become more extreme over time yet have good intentions and are trying to maintain systemic balance.

When we’re stable and functioning well, our proactive manager parts help us accomplish basic work, school, and relationship tasks. They ensure that we’re safely embedded in various social groups and negotiate well with the protectors who advocate for an even-handed distribution of shoulds versus wants in daily life.

Georgie knew that her well-meaning manager parts could become extreme, depleting and exhausting her with criticism, caretaking, and shaming. She understood that her firefighter parts (those advocates for rest and recreation) could also become extreme and were motivated to depressurize when the inner shaming got intense. Sometimes, they told her to stay in bed all day, binge TV shows, and eat junk food. Additionally, we’d explored the needs of her tender, open-hearted parts who felt abandoned and alone after the breakup. She knew how easily they got silenced—and exiled from consciousness—by protective parts who were allergic to their pain.

But banishment is never fully effective. Out of sight is not really out of mind. Like steam in a sealed pot, the pressure of an exile’s longings and sense of worthlessness build. In response, managers—who crave control and stability—double down on shaming and self-improvement projects. These behaviors amplify the exiled part’s pain, which, like heat from flames, sets off the alarm that calls in firefighter parts with their single-minded, short-term goal of putting out the fire. They have many tools at hand (think of the whole array of possible addictive processes) to distract or soothe emotional pain.

Although proactive managers and reactive firefighters generally work at cross purposes, they do align on one thing: a need to contain the innocence, vulnerability, and negative feelings of wounded exiles. When these feelings break through to consciousness, the power struggle between protectors who shame or soothe kicks off again. While all protectors focus on the short-term goal of suppressing emotional pain, their polarized methods—inhibition (shaming) versus disinhibition (e.g. using addictive substances)—inevitably cause trouble over the long haul.

In Georgie’s case, I knew her managers would double down on criticizing her when she drank so much and hooked up, which would frighten her exiles and motivate her firefighters to act again. I didn’t expect this vicious cycle to end until we addressed the underlying pain of her exiles.

“Let’s explore what you just shared with a parts-based visualization,” I suggested. “Imagine you’re sitting at the head of your kitchen table.” I chose a table, but a campfire, classroom, or meadow would have worked just as well. “Some part feels nervous about mentioning what you did last night, right? And a part who was upset about the drinking kept yelling that you messed up.”

“True,” Georgie replied.

“Let’s invite all the parts who don’t like drinking or hookups to sit on one side of the table,” I said. “Then invite the parts who like to drink and hookup, along with the ones who eat junk food and watch Netflix all night, to sit on the other side.”

At first, Georgie’s manager team was indignant. “They don’t want to include the drinking and hookup-seeking parts!” Georgie reported. “They say they’re bad and make everything worse.”

“I know they feel that way,” I said. “Assure them that we’re not endorsing what those parts do, but we need to understand their perspective.”

Reluctantly, Georgie’s managers agreed to let the drinking and hookup-seeking parts take a seat. One good way of helping clients organize inner chaos is to call a meeting in a safe space, hosted by the client’s Self. In IFS, the Self is our core essence—curious, present, accepting, and accountable. As the client notices their parts and vice versa, the parts are more likely to cooperate. They want validation. They want to be felt, seen (if the client is visual), heard, and understood. When they get into intense disagreements, they also need help depolarizing.

While people like Georgie can visualize internally with ease, people who are not internally visual can feel, hear, or somatically sense their inner community of parts with equal facility and success. The IFS therapist facilitates this process until the client and their system can do it without help. The essential relationship between parts and the Self develops as parts separate (or unblend). Once the Self has witnessed (sensed, felt, heard, seen) a part’s experience from the part’s perspective, the part becomes willing to also see its problems and dilemmas through the adult, fully resourced perspective of the Self.

It turned out that Georgie’s drinking and hookup-seeking parts were equally unenthusiastic about sitting at the table with her critical managers, who routinely attacked them for causing relational, physical, and emotional problems. The drinking part absolutely did not trust Georgie to protect it. “Would the drinking part be willing to meet with you separately, away from these critics?” I asked. “Maybe in a separate room?”

When they were alone, the drinking part said, “Without me, you’re weak and alone.”

Georgie recalled hiding in her bedroom closet when her mother was angry. “Okay,” she said. “I get that. Now I have a question for you, okay?” The part nodded. “How old do you think I am?”

“Six,” the drinking part promptly replied.

Georgie sensed this six-year-old part within her, feeling what she’d felt when she hid from her mom in a bedroom closet. She invited this young part to sit next to her and then asked the drinking part to look at her again. The drinking part was surprised to see that Georgie was actually a grown up. “I want you to know that I appreciate all you’ve done for me. You’ve helped me have a social life, made sure I had fun, and distracted me when I felt desperately alone.” When the drinking part felt appreciated and understood, Georgie asked it, “Can we go back and talk to the parts who’ve been critical of you now?”

They returned to the table, and Georgie took the lead, “Does everyone see me? I’m here to help. And I’m grateful to all of you. Would you like my help?” Slowly, they all nodded. “Who needs my attention first?”

After some discussion about their cycle (the shaming causing the drinking and hookup-seeking behaviors), Georgie asked if they’d be willing to allow her to help the little girl who was still hiding in her bedroom closet. When they agreed, Georgie called on the little girl, but she wouldn’t make eye contact or come out of hiding. When Georgie asked why, the girl said, “Where have you been? Why did you leave me alone?”

Georgie apologized, “You didn’t deserve the bad things that happened to you. I’m sorry I wasn’t there to protect you… But I’m here now and I want to help. What do you need?”

At this, the little girl came closer and began to show Georgie some painful, shaming memories. When she felt sad and fearful after being ridiculed at school for having short hair and “boy clothes,” her mother had been impatient and dismissive. Then, the girl showed Georgie times when she’d felt alone and confused because she loved her best friend. Georgie listened with an open heart and expressed understanding. After a while, the little girl said she was ready to leave the past with Georgie and come into the present. She wanted a hug. Georgie held her and asked if she was ready to let go of the belief that she was bad and unlovable. Looking at me, Georgie reported, “She says it’s good to be with me. She’s relieved.”

After the little girl unburdened those toxic identity beliefs, we asked her protectors how they were doing now. They were relieved, too, but not ready to go off and do something else. They wanted to see how this would go. Would Georgie be reliable? Would she be able to keep everyone safe?

Georgie validated their concerns and asked them to make a deal with her. “If you see a problem, tell me. I’m here to help. You don’t have to be sneaky or do things impulsively without me knowing. Come to me directly and I’ll help us find a solution.”

As we wound up the session, Georgie emanated a newfound calm and tenderness. I was moved by her sweet, affectionate tie with the little girl. Going forward, I knew her critics and partying parts would need more attention, and I suspected we’d find more exiled parts burdened with both family and cultural legacies. But I also sensed that Georgie’s big leap today would ricochet through her whole system beneficially.

***

Georgie’s story is typical of clients who struggle with compulsive, high-risk, distracting or numbing behaviors. IFS links the inner focus of trauma treatment with the behavioral focus of addiction treatment. Since clients in the grip of addictive processes often require a lot of support, they may need to attend a residential program, an intensive outpatient program, a 12-step peer support group, couple therapy, or family therapy. Additionally, they may need medical interventions and medication. IFS, which treats a system rather than a symptom and anchors clients in the knowledge of their essential goodness and capacity to revive, is well-suited to be the hub of this treatment wheel.

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As a trauma therapist, long-time EMDR consultant, and registered art therapist, I’ve found that art and collage-making offer a low-barrier, effective way to work through blocks to entrenched trauma memories. In fact, my clients often tell me the sessions they remember most are ones where we’ve made art together, images they could take home and work on between sessions. As a therapist, I can relate: although I may forget what clients say after a few months, I always remember the imagery they create.

But even highly creative clients sometimes balk at using traditional art therapy tools in conjunction with EMDR because they feel shame or self-judgement about painting or drawing. Plus, using AI art therapeutically is still a novel idea in the field of art therapy, and many art therapists believe it’s risky and may dampen creativity. Initially, I too had doubts. Then, a middle school principal I was working with brought an AI image he’d created to one of our sessions and it changed everything. The image was of a man standing inside a hollowed-out heart, shoveling pieces of it into buckets being held by a long line of people. “When I showed this to my wife,” he told me, “she got how I was feeling about my job, and my life, for the first time.” I too was moved.

Since then, I’ve been experimenting with AI art as a therapeutic tool to do what all forms of expressive art therapy do: help clients access their imagination through metaphors that reflect blocked emotional experiences. In bypassing their analytical thinking, they can foster deeper emotional insight and experience a more accessible, visual, and intuitive way of healing.

Here are a few of the benefits of using AI art to help clients generate these metaphors. It’s efficient. Clients can work quickly, saving time and getting a dopamine hit within a few minutes. It can boost creativity by allowing clients to quickly create unexpected elements, enhance ideas, and combine different concepts. Customization allows clients to quickly create a visual representation of a problem or situation they resonate with, adjusting the particulars of images to fit elements of their identity that are important to them, such as skin types, gender, and any other elements unique to them. Finally, it’s cost-efficient. The availability of so many free AI tools makes this method well-suited to projects inside and outside of therapy.

Needing to Be Perfect

Harper, a female client in her late 30s felt alone and misunderstood. “I don’t have the words for what I’ve gone through,” she said, referring to her childhood trauma and the way her family had always dismissed it. “My heart hurts constantly.”

When I asked if she might be willing to try to create an image of what her heart feels like, she dismissed the idea. “I can’t do art,” she responded. “It’s too frustrating. I get pictures in my head, but they never come out right on paper.”

“I hear you,” I said. “And I have an idea. Maybe using AI could help you create what you have in your mind—and feel in your heart. Would you be open to that?”

“Maybe,” Harper sighed. “I guess I just like getting things perfect.”

Her response didn’t surprise me. Trauma clients can present with self-protection in the form of perfectionism, which can block their creative process. At the same time, what initially appears to be resistance to creativity can be a helpful metaphor in healing. So, I asked Harper, “Where else do you feel blocked by this perfectionism?”

“Everywhere,” she said. “I grew up needing to be perfect, so I wouldn’t add to the problems in my family. I only felt loved when I looked and acted a certain way. Mostly, when I picture my childhood, I see myself alone in a desert with no horizon.”

“If your heart was in this desert, what would it look like?” I asked, trying not to sound too enthusiastic, as I suspected we’d just co-created her first image—a lonely desert—where I could meet her and she could meet herself.

“My heart would be crying. It needs those tears—that precious water—to survive, but they keep spilling out from loneliness.” As she described this image, tears welled up in her own eyes.

“Would you be willing to pause?” I asked. “Just take a moment to close your eyes and place your hands on your heart as you breathe into this image.”

After a few moments, she opened her eyes. Her features had softened. “So how do I use this AI thing?” she asked.

I clicked on the OpenArt tab in the browser of my laptop then handed it to Harper. “Jot down whatever’s bubbling up for you,” I said. “Then press enter. It’s that simple.”

Harper began typing a few words onto the screen. A few minutes later, her face lit up. “Wow,” she said. “That’s it. That’s how it feels.”

The simplicity of discovering images by typing in keywords and layering one image over another gave her the power to hide things that needed to be hidden and magnify others. She was in the driver’s seat as she traversed—and redesigned—her desert in a way that helped her heal. Click here to see it.

A Golden Eagle

With my Mexican American client Lucia, our EMDR work had stalled after several months. She lived with her aging father, and believed it was her duty to care for him no matter how abusive he was toward her. Some of this aligned with her cultural values, but at times, his degrading treatment of her reawakened the childhood trauma of witnessing him inflict physical violence on almost all of the intimate partners he’d had over the years.

Her goal for therapy was to find ways to set better boundaries in her life and have a healthy family of her own someday. First, I encouraged Lucia to create images of her most persistent negative beliefs, such as “I’m trapped and don’t deserve freedom.” Then, I asked her to create images of the beliefs she’d rather hold like, “I’m not trapped and can trust myself.”

In our sessions, I showed her how to use a free AI program called DALL-E. The first image she created was of a dad holding chains beside a young, crying girl. Click here to see the image. Over time, as therapy progressed, she developed a second image with words between each broken link of the chain, each emphasizing the benefits of being her own person. This image served as a reference point for exploring the emotions, sensations, fears, and hopes connected to setting boundaries with her father. We used slow bilateral movements with EMDR to enhance this resource.  Click here to see the image.

Over time, Lucia created an image of her future self and what she wanted. She used words like “I am courageous, bold, strong, and fearless. I have the ability to choose emotional maturity over feeling trapped.” We were able to solidify these thoughts and feelings about her future into a concrete image of a golden eagle breaking heavy chains and flying out of a storm. Click here to see the image. Since then, she’s created many collages to process traumatic memories. She plans to put them together someday and make a book about her healing experience with EMDR and collage art with AI.

***

Unfortunately, as we get older, many of us disconnect from our natural expressivity and innate imaginative powers. As an art therapist, I see this clearly in the contrast between what happens when I guide a roomful of kids through a creative exercise versus a roomful of adults. With kids, a sea of hands rises into the air when I ask, “Who wants to share their art?” In a roomful of adults, I’m lucky if I get one or two tentative fingers.

Bringing AI art into therapy can help reconnect “unartistic” clients to the imaginary realm of metaphor, helping them unearth feelings and ideas that need attention and compassion. Not all our clients are artistic, but they’re all creative.

AI Art Resources

OpenAI

Account required: Easy to create via Google

Cost: 1000 free credits (500 prompts), subscription plans start at $1.99/month

Features: Generates 2 designs per prompt, images are around 300 KB, downloadable without watermark; automatically saves created images and allows for organization in folders; creation time varies from 15 seconds to over a minute

Craiyon

Account not required: Optional account for saving work.

Cost: Free (ad-supported)

Features: Generates 9 low-quality images per prompt (about 1.5 MB total); allows upscaling of images for better quality; image generation can take 1-2 minutes per prompt

Picsart

Account required: Easy to create via Google

Cost: Free for AI image generation; additional features may require a subscription

Features: Generates up to 4 designs per prompt, with options for more; images are around 100 KB and can be downloaded without watermark; fast generation time, typically under 20 seconds

Google’s ImageFX

Account required: Google account needed

Cost: Free

Features: High-quality, realistic image generation; quick generation times, good for beginners

Microsoft Designer’s Image Creator

Account required: Microsoft account needed

Cost: Free

Features: Powered by DALL-E 3, offering high-quality outputs similar to ChatGPT’s image generation

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How do you approach a first session with a client who’s tried all kinds of different therapies and yet continues to struggle? Steven Hayes, cofounder of Acceptance and Commitment Therapy (ACT), and Steve Shapiro, Intensive Short-term Dynamic Psychotherapy (ISTDP) trainer and adjunct faculty member of the AEDP Institute, are about to show you how they’d work with this client.

Meet Billy

Billy is a stylish, 50-year-old man who lives with his long-time girlfriend in her brownstone. He’s written a couple of successful screenplays and has recently started working on a novel. “I know I can write,” he tells you in his first therapy session. “I just don’t have much motivation. Mostly, I feel numb. It’s been like this for years.” He used to teach screenwriting but has been unemployed for a while now. “I’ve never gone through any major tragedies, and I had a truly happy childhood,” he says. “My parents divorced when I was eight, but they were both deeply kind, thoughtful people who coparented amicably. If anything, they were too good—they always made me a priority and made sure I felt loved and supported.”

Billy has seen several therapists before you—all of whom had been “great people who offered great therapy that just hadn’t worked.” He’d done EMDR, CBT, IFS, SE, art therapy, and psychodynamic therapy. “I’ve also done some couples therapy with my girlfriend,” he adds. “Six months ago, I did three sessions of psychedelic-assisted therapy, and it was interesting for sure, but I still have trouble getting out of a bed every morning, and my anxiety gets the better of me sometimes.” Billy has seen neurologists and doctors to rule out biological issues, and he’s had a couple of psychiatrists. “I’ve tried virtually every medication for depression under the sun. A few helped for a month or two, but mostly the side-effects outweighed the benefits, and getting off them was a huge ordeal.”

“I really trust the friend who referred me to you,” he says, a hopeful look on his face. “She says if anyone can help me, you can.”

A Case of Motivational Paralysis

By Steven Hayes, cofounder of Acceptance and Commitment Therapy (ACT)

Billy’s case is a good example of motivational paralysis, one I’d approach through the lens of Acceptance and Commitment Therapy (ACT), a process-based approach I originated a bit over 40 years ago. ACT is based on Relational Frame Theory, a research program on human language and cognition, and it’s designed to help people develop the ability to accept their thoughts and feelings without being overly influenced by them, allowing them to act in line with their values even when facing difficult emotions.

Sitting with Billy in this session, I pay close attention to his actual words, wanting to see how he describes emotions, motivation, and action. I notice that as soon as he acknowledges his skills, he dismisses his capacity to use them, attributing his inaction to a lack of motivation, which he contrasts with feeling numb.

Billy’s words reveal an unworkable relational network in which his ability to act is determined by his motivation, which hinges on him feeling a certain way. The hidden problem, fostered by our culture, is the empirically false belief that only certain feelings can result in healthy actions. This way of thinking traps clients and therapists alike into believing that the therapist’s task is to alter the client’s emotional state first so they can then live better and have a sense of well-being. Of course, when this doesn’t happen, the client’s mood takes a hit, leading to another round of motivational paralysis.

I like to think of feelings as echoes of the past contacting the present. We need to help clients like Billy learn to observe and describe these echoes, not suppress them, because our awareness of our present feelings (informed by our past experiences and the current context) is how we develop wisdom. But the moment we act as if only certain emotions pull us forward, like magical sled dogs, we’re basically saying that we have to control our emotions in a point-to-point way for a life worth living. Living according to this doctrine does not make for a happy life, and running from a lack of confidence, as Billy seems to be doing, is the least confident action we can take.

Where does Billy’s numbness dominate him so that he’s waiting for life to start? I think it comes from the erroneous belief that we must avoid so-called negative feelings and cling to so-called positive ones, even though we all know deep down that we can’t control feelings this way. Letting go of this agenda, of course, is easier said than done. People with motivational paralysis, like Billy, feel frightened, helpless, hopeless, and frustrated—and in desperation, they suppress these feelings too. Many, like Billy, will seek out therapist after therapist, looking for relief to no avail.

Rethinking Treatment Goals

Billy mentions that his past therapy experiences, aimed at getting rid of his depressed mood and anxiety, have not shifted things for him. Seemingly, for him, successful therapy involves eradicating his numbness, depression, and anxiety before any real action can be taken. There’s an expectation that feeling better is a prerequisite to living better. But this approach to life isn’t just ineffective, it forestalls what Billy truly needs: to learn how to open up to his past and feel the discomfort and pain that comes with life’s challenges. Ironically, the undesirable feelings Billy is currently experiencing could be motivating if he allowed them to be. Instead of focusing on feeling good, he needs to learn to feel good —to do a good job of feeling.

ACT’s concept of creative hopelessness is pivotal in Billy’s case. It involves acknowledging the futility of trying to control one’s internal experiences to control life’s outcomes, and abandoning the agenda to change them. Billy has invested decades, six forms of therapy, and myriad medications in this pursuit, yielding little progress.

When is enough, enough? When Billy allows himself to let go without knowing what comes next, his actual experience will have a chance to be let in. Helping Billy carefully and non-judgmentally see the rigged game he’s playing can help him see that his approach to problem-solving is itself the problem, and he can begin to imagine a different path toward healing.

Engaging the Body

To bypass Billy’s cerebral approach, I try to help him focus on his body. I ask him to spend some time in session feeling numb, in a very physical way, and explore whether this numbness is indeed such an enemy when purely thought of as a feeling.

I ask him to show me, using only his body, him at his worst when he feels numb. I notice, predictably, that his head moves down, his eyes close, and he draws his arms and hands inward. When I next ask him to show me, using only his body, him at his best when feeling that same degree of numbness, I see his head rise, his eyes open, and his hands and arms extend.

A 2022 study published in the Journal of Clinical Medicine reports that 95 percent of people show postures that are more open, aware, and ready for active engagement when they are “at their best” when dealing with emotional challenges. This suggests that, intuitively, we know that our mood and outlook aren’t determined by what we feel, but how we relate to what we feel.

With Billy, I draw out the paradox that he’s following an agenda his mind is giving him as he avoids and withdraws, even though his own body knows better. I ask him if he’s ready to trust his own hard-earned wisdom within by learning how to open up rather than closing down in the face of difficult emotions. Haltingly, he says he is, but that he doesn’t know how.

Tapping into Values

I notice a significant gap in Billy’s current narrative: there’s no mention of his values nor what he truly wants his life to be. By shifting his focus to ways of being that might tap into his embodied knowledge, I open the possibility for therapy to be transformative.

To get here, I follow the most apparent piece of vitality in his description of his situation. I ask him to explore what he felt while writing his screenplay. And as he does, we find that what he’s been running from is actually in alignment with living a life of purpose.

“You’ve written screenplays that touched people,” I say to him. “Would you be willing to focus on a moment when you were in the flow and writing? Just think of a specific memory when writing felt like that.”

Billy nods, closes his eyes, and begins to visualize.

“In this moment you’re remembering, did you feel a sense of purpose?” I continue. “What were you giving voice to in your writing back then? What did you care about?”

Billy takes a deep breath and opens his eyes.

“I wanted to show that life doesn’t have to be perfect to be meaningful,” he says. “In the moment I remembered, I was working on a story  where my character’s life was a total tragedy, but I also wanted the reader to see that he was still a loving person, yearning to make a difference. I thought there was something worthwhile about that. Noble, even.”

“Wow,” I reply. “That’s such a powerful statement. And at your best, while you were writing, did it feel like you were able to help the reader see that deeper message? It sounds like it was important to you that they see it.”

“Yes, it was very important,” Billy replies. “I was damn good at it.”

Billy pauses as his eyes begin to well up.

“I can’t believe I’ve stopped writing.”

“Well, maybe you somehow bought into the idea that you have to wait for the right feeling to write,” I offer. “But if life doesn’t have to be perfect to be meaningful, why wait? Your life isn’t perfect now. Nobody’s is. What if, instead of waiting to become someone else with different feelings, you could give voice to what’s meaningful to you now, with your thoughts and feelings and memories and sensations as they are?”

Billy wipes away his tears, and nods.

“I wonder what else you could express in your writing,” I continue. “Not just this idea that life doesn’t have to be perfect, but other things that are important to you.”

***

The goal of this approach is to uncover Billy’s values and motivation hiding in plain sight. By asking these questions, I find that his values are already present—and inherently motivating. He has bought into an idea that he needs to meet certain emotional standards first, but that fused belief just hides these motivating values from view.

When we shift from passively waiting for some foothold to actually exploring Billy’s capacity for creation, we see things that he holds dear, things he can own. Who knows what else will show up as therapy continues. Creativity? Love? Connection? I’m eager to find out. These kinds of explorations could positively influence his relationships with his girlfriend, his family, with his therapist, and others.

Billy’s case shows that sometimes therapy needs to take a radical turn, to move from helping clients try to control the uncontrollable to helping them embrace the full spectrum of life’s experiences and uncover meaning and purpose. Shifts like these are the key to helping our clients unlock their full human potential.

A Case of What’s Absent

By Steve Shapiro, Intensive Short-term Dynamic Psychotherapy (ISTDP) trainer and adjunct faculty member of the AEDP Institute

Sometimes during our initial session with a client, what’s absent is just as important as what’s present. During my first session with Billy, I notice the absence of any “negative” feelings toward others. I’m also struck by his denial of childhood difficulties. Considering Billy’s significant suffering and poor treatment outcomes, it seems unlikely that he grew up without challenges or difficulties.

Psychotherapy isn’t all about feelings. It’s about the therapist hypothesizing what the client is doing with those feelings, which the client then either confirms or denies. The goal is to allow an increasingly complex and accurate picture of the client to emerge.

When I first meet Billy, I don’t know the reasons for his presenting problems—and neither does he!  A good therapist acts as a guide to collaboratively explore the unknown. As therapists, we need to understand the division of labor accurately. The therapist guides the process, and the client reveals the content: their thoughts and feelings.

As Billy and I work together, he continues presenting as excessively positive, cheerful, and complementary. He denies almost all negative feelings, thoughts, and impressions. This makes me curious about two key issues:

Directionality. I use this term in my experiential dynamic therapy trainings to convey where our feelings are directed within our minds and bodies. Do we focus on the other’s role and direct them outward? Do we tend to repress them and turn them inward? Where we direct our feelings will influence our symptoms and how they manifest. “Externalizers” will have more interpersonal conflict, whereas “internalizers” will have symptoms like depression and anxiety.

By his own description, Billy showed little evidence of outwardly expressing emotions like anger, sadness, or fear in his life, something I also observed in his sessions with me. I hypothesized that these emotions were being repressed and directed inward. This reflected an intrapsychic structure that was well integrated and syntonic (meaning he himself wasn’t aware of it). A syntonic defensive style is like being on automatic pilot, which keeps emotional conflicts and anxiety at a tolerable level, but at a cost. For Billy, the cost was feeling numb and disconnected from others.

Emotional physics. This term refers to the range of fundamental processes governing our internal experiences and how they interact to maintain a homeostatic balance. For example, through the lens of emotional physics, emotions don’t create difficulties—emotional conflicts do. I begin to wonder about Billy’s emotional conflicts. What’s getting in the way of him experiencing and expressing “negative” emotions? I wondered. What makes it risky or anxiety provoking to be anything but cheerful and pleasant?

The Fork in the Road

In our fourth session, Billy walks past me and sits down without looking up from his cellphone. He indicates with a raised hand that he’s busy, then taps his phone for nearly five minutes. When he’s done, he puts his phone away, meets my gaze, and smiles. “Sorry,” he says. “I just had to text my girlfriend about something.”

Contrary to many therapists’ fears, a direct but respectful exploration of what arises in the here-and-now of the therapeutic relationship can improve our working alliance with clients. Rather than accepting Billy’s apology and moving on, I address his texting. “Are you aware you just spent five minutes of a 45-minute session doing something different than what you’re here to do?” I ask, my voice warm and curious.

An irritated look flashes across Billy’s face, but the smile returns quickly. “Well, I wasn’t trying to offend you.”

“I’m not offended,” I say. “But I am curious because you said one of your goals in therapy is to feel connected with others and aligned in your life. I also noticed that in our last session, you spent nearly 10 minutes in the restroom. Again, you were here, but not here.”

“True,” he admits with a sheepish smile. “But I did have to go to the bathroom.” He pauses. “And maybe a part of me didn’t want to be here last week . . . and today. I know I’m paying you to help me, but sometimes you pry, and I guess I want to be left alone.”

“There’s a healthy side of you that wants to be here and do the work so you can feel better,” I say, “and another side that wants to be left alone.” I was highlighting what I call the “fork in the road”—Billy’s choice between defensively excluding unacceptable emotions and accepting his own complex humanity.

“Yeah,” Billy says, his leg bouncing. He sighs. “Now that you bring up last week, I guess I try to distract myself when I feel uncomfortable.”

For most clients, their motivation to do psychotherapy and their resistance to doing it are constantly fluctuating. This is because the focus of the work is on exploring their characteristic ways of thinking and feeling as well as how they relate to others—things that are deeply personal and often vulnerable and painful. For our exploration to be productive, I need to help clarify his defensive patterns, such as the tendency to have one explicit intention (getting better through therapy) while anxiety-reducing behaviors reveal a different intention (maintaining a cheerful façade). My work is to familiarize him with hidden parts of himself, not abolish them, while helping him regulate anxiety in new ways.

“So the feelings you have toward me are hidden behind texting or bathroom breaks,” I say.

“I’m not hiding things from you on purpose,” he says quietly. “I hardly ever let myself feel what I feel. It’s sad.”

“It is,” I murmur in agreement. “And it’s also not like you do it on purpose.”

“I don’t want to do it anymore,” Billy says.

Over time, a fuller range of feelings, memories, emotional conflicts, and insights emerge from beneath Billy’s cheerful protective barrier. “It’s totally new for me to sit and talk with someone and feel like it’s okay to be angry, sad, scared, whatever,” he tells me. He begins learning to express “negative” reactions toward people he cares about rather than simply behaving the way he thinks others expect him to.

***

The focus of effective psychotherapy needs to be on destructive internal patterns evident now, not events from the past. It’s the way these past events influence how we relate to ourselves and others now that causes suffering. In my work with Billy, we didn’t need to dwell on his feelings about his parents’ divorce because the way he coped during that time in his life was still evident in the “numb” way he related to himself and to me. One thing that makes the challenging task of changing lifelong patterns easier for therapists is that clients inescapably exhibit automatic and unchanging coping patterns without the therapist’s deliberate intervention. Healing isn’t all about facilitating a dramatic, cathartic breakthrough of feelings with clients. Only with increased awareness of his destructive coping patterns was Billy able to see the problem clearly and decide to risk making different choices. Increasingly, he chose the vulnerability of responding authentically over the protection of hiding behind his defensive coping patterns. Over time, he reported feeling happier and more relaxed, as well as increased intimacy with others.

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Q: One of the most entrenched types of trauma I’ve worked with is emotional or physical abandonment by a parent or caregiver. How can I best help my clients heal from it?

A: As a therapist who’s spent over a decade helping survivors of parental abandonment—and as a survivor myself—I’ve found that this kind of trauma is often misunderstood, largely due to a combination of cultural and social stigma, lack of awareness, and internalized shame that keeps many survivors silent about their experiences.

When a caregiver makes a conscious choice to remove themselves from their child’s life, no matter the reason or form their absence takes, the result will have long-term consequences. I’ve seen parental abandonment in the form of a parent rejecting a child who gets pregnant or comes out. I’ve seen it occur when a parent grows emotionally distant after a divorce or remarriage. It can occur when a child suffers abuse and a parent refuses to believe the abuse happened. And it can manifest when a parent believes their child’s disability, or even personality, is too burdensome to handle.

As with many traumas, abandonment traumas can deeply influence attachment patterns with friends and romantic partners. They have a profound impact on self-perception and sense of belonging. Survivors often internalize a message of unworthiness, and resort to reflexive self-blame, and as a result, may constantly seek new relationships or avoid intimacy altogether.

Understandably, people who’ve experienced parental abandonment often have issues with trust, including in the therapeutic relationship. Many also struggle with people in perceived positions of authority, meaning they may see us therapists as intimidating, no matter how hard we try to create a collaborative and welcoming space. Since these can be daunting clinical obstacles to overcome when working with survivors, I’ve developed a five-step process for working with survivors of parental abandonment that helps mitigate self-blame and build trust with the therapist.

Karalina’s Story

Karalina had experienced parental abandonment after getting pregnant when she was 17. Now in her 40s, she was finally realizing the severity of that trauma through our work.

“I always felt different from my siblings,” she told me in our first session. “My younger sisters were well-behaved and brought home perfect grades. But because of my anxiety and ADHD, I’d always struggled at school and often skipped class. At night, I could hear my parents arguing about what to do with me through the thin bedroom walls.”

When Karalina found out she was pregnant, she hid it for a few months before coming clean to her mother. “I’ll never forget the look on her face,” she told me. “Shock, shame, disappointment—all at once.”

“I have to call your father,” her mother had said flatly.

Instead of yelling at Karalina, her father had started working longer and longer hours. He’d go on weeks-long work trips, even though her due date was approaching. She was scared, plagued by her father’s absence and the idea that all of this was somehow her fault. After she gave birth to a healthy daughter, her mother helped out with the baby but with a distant expression on her face. Her father would come home occasionally, his loud boots echoing in the hallway, but he barely acknowledged her or his new granddaughter. Eventually, he moved out.

“Dad left because you shamed the family,” her sisters would hiss. Karalina didn’t want to believe it, but deep down, she believed it was true.

The first step in working with survivors of parental abandonment is to build trust by creating a safe environment. For clients who’ve been abandoned by someone who was in a protector or caregiver role, and supposed to love them above all else, it’s the most important thing you can do. When they’re in a relationship, survivors of abandonment often wonder things like, Are they mad at me? Do they dislike me? But these questions are actually asking something deeper: Is this person safe? Am I safe? Are they trustworthy? And if I trust them, will they hurt me?

Therapists working with survivors can begin creating trust and safety from the very first session by actively listening to the survivor’s story without judgment, validating their experiences and emotions, and emphasizing that what they say will remain confidential. The therapist can also create safety and trust—and convey empathy and compassion—by telling the client they believe them.

At first, Karalina’s inner defense mechanisms—denial, self-blame, and intellectualizing—were so entrenched that she’d often make comments like “Well, I was a bad kid” or “I wasn’t hit, so I guess that means I wasn’t really abused,” as well as other statements that minimized her experience of abandonment. Once I’d made it clear that I believed her story and didn’t blame her for being abandoned, Karalina began to trust me more and made fewer statements minimizing her experience.

The second stage of working with survivors of parental abandonment is helping them acknowledge their trauma. It’s a foundational step toward fostering self-awareness, understanding the impact of abandonment on their lives, and beginning to heal. It can be difficult work since coming to terms with past trauma often involves navigating complex and fluctuating emotions, confronting layers of denial or avoidance, and contending with the fragmented nature of memory and perception. Acknowledgment often comes in bits and pieces, rather than as an open declaration of what has occurred.

“I wonder what it would have looked like had your dad been there when you needed him,” I said to Karalina, trying to help her see how this had been, in fact, deeply traumatic. “Being 17 and pregnant must have been so scary.”

She paused for a moment. “It was,” she finally said, tears welling in her eyes. “I was terrified. I really needed him,” she said before pausing again. “But he wasn’t there.”

The third stage of working with survivors is helping them recognize how the abandonment shows up in their adult relationships. After the end of a romantic relationship, for instance, survivors often experience greater distress than those who’ve had secure caregiver relationships. They sometimes cling to unhealthy relationships or disregard red flags, desperate to avoid the anguish of being abandoned again.

Many of my clients who survived parental abandonment find themselves either cycling through relationships in an attempt to fill the void left by past losses or avoiding relationships altogether to shield themselves from further pain. The key is helping clients see these patterns by saying things like, “It sounds like you’ve developed certain coping mechanisms to protect yourself from feeling abandoned again” or “How might your life have been different had your parent never left?” Once you address the connection, the client can begin to see the “why” behind these distressing relationship patterns.

Despite recognizing that her latest romantic relationship hadn’t been healthy, Karalina struggled to shake off the desperation she continued to feel about it having ended. It was clear that this desperation was an indirect result of her father abandoning her when she was younger, but Karalina didn’t immediately make the connection.

“If your dad had never left,” I asked Karalina, “especially during a time when you needed him so much, do you think this breakup would feel different?”

“I think so,” she replied. “I’d probably feel more confident in myself and in my ability to be alone and recover.” Slowly, she was developing a newfound awareness that allowed her to stop second-guessing the breakup. She got better at reminding herself that the relationship had ended for the right reasons.

The fourth step in working with survivors is minimizing shame. Clients who’ve been abandoned tend to blame themselves for what happened to them, and by helping them realize they’re not to blame, the therapist can facilitate a crucial shift in perspective. Drawing on the IFS model, therapists can help clients see and acknowledge the part of them that amplifies their shame in order to protect them. Once they realize this, they can access more self-compassion. Usually, as they shift from blaming to self-compassion, tension, anxiety, and depressive symptoms begin to decrease.

Karalina was making progress in therapy, but she still sometimes reverted to her childhood belief that she’d been responsible for her father leaving. Like many survivors, her shame amplified the fear that there was something wrong with her. Nothing sends the message to a child that they’re unlovable quite like their primary caregiver leaving them. Together, Karalina and I worked to help her acknowledge—and even thank—the parts of her that were trying to protect her by blaming for what was actually her father’s failure as a parent.

“Your anxiety serves a purpose,” I told her. “It’s trying to keep you from being abandoned again. But just because a relationship ended in the past doesn’t mean your relationships now will end.”

“I worry that my needs are too much,” she said at one point. “I feel like a burden.”

“But you deserve kindness,” I said reassuringly.

Karalina nodded. “It’s easier to believe that when I think of my own daughter,” she replied. “I’ve never abandoned her, and she’s doing so well. I suppose I deserved to have from my father what she’s received from me. In my heart, I know I’ve been getting in my own way.”

Once you’ve minimized shame, you can move to the last stage of treatment: helping the client reparent their abandoned inner child. Though reparenting is more of an ongoing process than a one-and-done experience, over time, it helps clients heal old wounds, traumas, and unmet needs from childhood. It involves working creatively with the parts of the client that hold traumatic memories, experiences, and emotions related to abandonment, as well as showing consistent patience, consideration, and care. Importantly, it involves cultivating genuine curiosity about the inevitable moments, however small, when a client feels abandoned by you. Exploring and repairing ruptures in the therapeutic relationship can be deeply healing, and model healthy repairs in relationships beyond the therapy room.

Karalina and I brainstormed tools, like journaling, that she could use to reassure her inner child she was safe when worry arose that she might be abandoned again. When the shame and self-doubt crept in, she was able to remind herself that these feelings were not hers to own; they’d been given to her by her father. Now, with greater self-awareness, she began to see she deserved and was capable of healthier relationships based on trust, respect, and shared accountability.

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Lots of people are talking about racial trauma. But how do you help clients identify it? From the very first session, clinicians now have a way of measuring clients’ anxiety-related trauma symptoms and avoidance of fears of discrimination. This tool will help you:

• Support BIPOC clients healing from racism
• Defuse shame and self-blame tied to racial trauma
• Affirm and validate different types of discrimination

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“I keep trying to change my eating habits,” says 35-year-old Lucy. “I know all this bingeing is bad for my health.”

She’s a lovely, articulate, soft-spoken, and extremely intelligent medical professional who’s once again expressing thoughts and feelings of self-loathing and shame during our therapy session. “I have a few days of success, then I feel guilty and start numbing again with food and mindless hours watching movies. I try not to take on so many extra shifts at work, but I can’t say no when people ask me to cover for them. At least while I’m working, I’m not eating.”

I invite her to pause, take a breath, bring her hands to her heart, and practice the simple rocking movement we’ve connected to self-compassion.

“I know I’m supposed to feel compassion for myself,” she responds, “but I hear my parents’ voices in my head telling me how ridiculous that sounds. I hear my church family telling me I’m in pain, not because of a lack of self-compassion, but because I’m betraying my commitment to Jesus. I’m supposed to put him first, not me. I shouldn’t complain. If anything, I should be doing more to help other people, so I don’t get so caught up in myself.”

It’s powerful for Lucy to circle back again and again to her religious beliefs. And she’s deeply loyal to the teachings of her church, having been warned throughout her life about the sin of questioning its precepts or God’s will.

As an observant Orthodox Jewish woman, I understand the role that religious beliefs, rituals, and traditions can play in providing identity, community, affiliation, stability, predictability, and comfort. As a trauma-informed therapist, I also understand that my clients’ religious experiences and observances—or lack of them—can exacerbate trauma and betrayal. Since she started therapy with me three years ago, Lucy’s had a healthy curiosity about my religion and seems comfortable with our differences. But she’s been reticent to get curious about anything connected to her own religious experiences.

Every attempt I’ve made to help her increase self-compassion and self-care while reducing inner criticism and perfectionism has been met with pushback connected to religious messaging. Interventions guiding her to reframe cognitions, ground in her body, and visualize her younger self have all been met with eyerolls, discomfort, and guilt. These go-to therapeutic strategies all seem to be ego-dystonic: incompatible with the dogmatic religious messaging of her upbringing.

Losing Yourself

Lucy had grown up in an insular, isolated religious community. She was pressured to “convert” others, even as a young child, and was encouraged to “lose herself” in service to the church. She was taught to abdicate personal needs and feelings, and went through life serving the church and Jesus without boundaries or limits. She was shamed and labeled “a sinner” if she deviated from the lifestyle she was expected to uphold.

Lucy was never told that God wanted her to thrive and be genuinely happy. Her purpose in life was to make God, Jesus, and others happy. Despite her loyalty to her parents, church family, and religious beliefs, it’s clear that following their rules has created a longstanding need to numb intense, unmetabolized feelings of rage, confusion, and disempowerment. As she’s become more depressed and exhausted by her perfectionistic worth ethic, and as her dissociative eating has spiraled out of control, church members have told her she needs to give more of herself to Jesus. And yet, religious observance, rituals, volunteer work, study groups, and liturgy have brought little comfort. In fact, these things have fueled feelings of failure.

During her therapy sessions, I often feel conflicted, as I want to communicate a genuine respect for her beliefs and practices. I never want Lucy to feel judged, nor do I want our religious differences to adversely impact our therapeutic relationship, which is, to her credit, remarkably strong. At the same time, as Lucy slowly, bravely, reveals more about her earliest childhood memories, it becomes clear that her religious experiences are connected to her subsequent struggles with self-destructive behavior, dissociation, and feelings of worthlessness.

We’ve both begun to realize that the frequent and secretive bingeing she’s engaged in throughout her life is a dissociative coping strategy, enhanced by excessive hours of watching movies or TV. These behaviors are the only viable manifestations of rebellion, individuation, distraction, and self-care that she’s allowed herself to have.

She’s never experienced the spiritual bliss she’s always hoped for, and continually blames herself for falling short and disappointing God. Therefore, it feels clinically necessary to create a safe, unconditional space for her to slowly re-evaluate some of the core religious teachings she grew up with. I know this is delicate work, but I’m still surprised by the level of anxiety and fear this initially triggers in her. She balks, physically pulling back, when I make even the smallest connection between her beliefs and her current struggles.

“You’re asking me to challenge the entire foundation of my life,” she says with a trembling voice, “You’re disregarding the fact those beliefs define who I am and the choices I’ve made for 35 years.”

“What if we don’t use words like challenge or disregard? What if you gave yourself permission to just be curious, to take a half-step back, and reflect on some of the beliefs you grew up with? At 35, you have an opportunity now that you didn’t have as a child—to decide for yourself which principles and practices still resonate for you and genuinely enhance your life, and to see if any of them no longer serve you. The goal isn’t to throw the baby out with the bathwater. And the choice will always be yours to make.”

“You don’t understand what you’re asking me to do. Do you have any idea what would happen to me if I did that?” she replies.

“What do you imagine would happen?” I ask gently.

“God would have me burn in Hell forever,” she answers, shaken and crying.

This is actually a breakthrough moment in our work, as I realize what really needs to be explored is her concept of God, and the terror it evokes. I’ve been focusing on issues related to what it’s costing her to maintain the standards her family and church have set for her. Although that’s all worth processing, it hadn’t occurred to me that her concept of God was driving her fears in powerful ways.

Whose Voice Tells You That?

At this point, I have to be mindful that while my religion encourages questioning—the myriad Rabbinic interpretations of many key concepts is an opportunity to learn, debate, and spiritually evolve—hers doesn’t. Blind obedience, acceptance, and service to others forged the “loving relationship” between a person of her faith and God. Lucy says her religious practices are designed to compensate for and hopefully overcome sin.

Over decades of clinical experience, I’ve come to see how people’s concept of God is often a direct reflection of their earliest, most important and formative relationships: the ones we have with our primary caretakers. I was blessed to have been raised by exceptionally loving and accepting parents, who always modeled and emphasized self-care, self-compassion, and self-worth. Therefore, I’ve always conceived of God as a force that embodies the ultimate in compassion and unconditional love.

Lucy imagines God to be an all-powerful, all-knowing force that’s punitive, judgmental, critical, shaming, and vindictive. Those adjectives are equally applicable to her parents, who constantly criticized her shortcomings and shamed her about her weight. If she holds to the belief that God is rigid, unforgiving, and cruel, she’ll never be able to question, re-evaluate, or redefine the ways in which she can celebrate and relate to herself. If taking care of herself is considered selfish and evokes God’s wrath, just like it did with her parents, then she’ll never be able to find joyful ways to feel whole in her religious identity.

It feels important to confront her internalized message that she’ll burn in Hell if she challenges any of her core religious beliefs. I ask her, “Whose voice tells you that?”

She seems confused. “My voice!”

“It’s become your voice,” I say, “but can we be curious about the possibility that it started as someone else’s voice?”

She seems startled and is quiet for several minutes. Then she says, “I think it’s my father’s voice, and I think it’s a message from God.”

Despite her loyalty to her parents, Lucy can see the parallel between the powerful image she holds of her parents, and her notion of God as punishing and vindictive.

The Hulk and Angels

Over time, we begin to juxtapose Lucy’s long-held childhood concept of God, with a revised, adult version that allows for more unconditional love and compassion. How? We draw. Lucy creates a series of paintings and collages that illustrate her earliest understanding of God as always enraged and disappointed. Then, she does a new series with warmer colors and words including, loving, forgiving, kind.

Lucy also works with a sand tray, juxtaposing objects like a huge dinosaur, hearts made of black glass, the Hulk, and a volcano (all representing her childhood concept of God) with objects that expand her concept and create a more loving version: pink hearts, an angel, a rainbow, a baby held by a loving parent, and a bouquet of plastic roses. The visual dichotomy is striking for her to see, and she’s moved to tears more than once in these exploratory sessions.

Lucy has always been disconnected from her body, hating it and feeling ashamed of it. As we use art modalities therapeutically, I repeatedly invite her to notice how the imagery lands physically. This reconnects her to sensations, and she slowly incorporates this burgeoning body-awareness into mindful eating, so she can learn to distinguish between actual hunger and anxiety. It also gives her important information about how the punitive imagery she grew up with impacted her physically—compared with compassionate imagery that facilitates a release of tension, upright posture, and an expanded chest that feels empowering.

Lucy loves to journal, and although she has documented many chapters in her life regarding her career, friendships, and whether she wants children, she’s never given herself permission to pose questions or capture thoughts in her journals about her religious beliefs. Now she composes written dialogues between herself and God and Jesus that include reassuring phrases like I’ll never abandon you, You are loved, and I’m here for you even if you question my teachings.

Although setting limits with church members and church obligations is challenging for Lucy, she begins to practice turning down small requests. She even starts to explore online church services, and gives herself permission to use Sunday as a day of rest and self-care, rather than helping congregants after services.

Lucy’s work with me continues to change and evolve. She’s still re-evaluating childhood messages she received growing up, some of which she now describes as “religious propaganda.” As she gives herself permission to create a new adult narrative, she reports feeling less depressed, less resentful, and more peaceful. Her dissociative eating has decreased dramatically, and her self-care habits have improved. At every step, a key question we explore together is, Are my new beliefs hindering or enhancing my sense of self-worth and inner peace? Her answer has become a guiding factor in her decision making.

And when we engage in these powerful and vulnerable conversations, Lucy often spontaneously brings her hands to her heart and gently rocks, recognizing that she deserves to bring comfort and self-compassion to her journey of healing.

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“What are you noticing now?” my EMDR therapist, Janet, asked me after the initial bilateral stimulation sequence during our first reprocessing session. “That God won’t give me any more than I can handle,” I replied earnestly. “God is in control.”

“Uh, go with that,” she said. As EMDR therapists are trained to do, she wasn’t censoring any content unless it became clear that I was stuck.

This was the summer of 2004, and the way I saw the teenagers treated in the psychiatric hospital where I interned had triggered my own unhealed trauma about having my childhood wounds denied. After two years of continuous sobriety, which I credit to working a 12-step program, it became clear that there was more work to be done. Dissociating from my own life in problematic ways remained the norm for me. I wanted to stay sober, yet in many ways I still wanted to die.

Now, I was processing one of the most significant developmental traumas of my life, and my head was filled with lines like, Let go and let God and I have to forgive them, for they know not what they’re doing. With these comforting, albeit sometimes overly simplistic, recommendations I’d absorbed from the conservative religions of my childhood, I’d learned to accentuate what’s positive to stay afloat, even at the expense of ignoring pain. And if I did notice any pain, then the solution was just to pray on it, whatever “it” was.

“Jamie,” Janet intervened, with a tone that was both direct and nonjudgmental, “You’re allowed to go there now, into the pain. That’s why you’re here.”

Then the floodgates of my tears and my trauma recovery burst open. Something about her gentle permission to do the work helped me untangle the mixed messages from a lifetime of spiritual abuse and religious trauma.

As Janet and I continued to work together, I learned that I could be a person of deep faith: a person who prayed, called herself a Christian, and put responsibility in its proper place for the things that had happened to her. I could cry, I could shout my anger out to the God of my understanding. I didn’t have to forgive on autopilot to be a “good person” in the eyes of my family or the church. I could work through what I needed to work through, and then decide what forgiveness meant to me. Ultimately, I could even decide whether or not to grant forgiveness at all in order to heal.

What is Spiritual Bypass?

Spiritual bypass, a term originally coined by Buddhist teacher John Welwood in the 1970s, refers to a tendency to lean into a religious or spiritual practice, such as praying or meditating, instead of allowing oneself to feel the feelings and engage in the emotional work that’s needed to connect with pain and experience meaningful healing. When therapists hit a roadblock in working with spiritual or religious clients on their mental health goals, spiritual bypass may be a factor.

I’m not denying that religious beliefs and spiritual practices can support a person’s mental health and recovery. Prayer, meditation, having faith in something greater than oneself, singing or chanting, and worshipping in a community can be powerfully healing. But if these practices shut down emotional responses, they can clash with a client’s goals for therapy.

In my personal experience and my work with clients, I’ve noticed three main forms of spiritual bypass: toxic positivity, using spiritual or religious teachings to justify abuse, and believing suffering is a punishment for not praying or meditating enough or with sufficient devotion. Fortunately, there are several ways therapists can work with these forms of spiritual bypass to help clients honor their mental health and their spiritual inclinations.

Toxic positivity. Positive views, beliefs, or statements aren’t inherently toxic; many can even be psychological life rafts in difficult situations. The potential for toxicity lies in what they suppress and how strongly they suppress it. For instance, in 12-step recovery, the gratitude lists I made were a helpful way of cultivating a strengths-based mindset and broad perspective, but this practice could’ve easily become problematic if it had kept my focus exclusively on gratitude at times when it would’ve served me better to set boundaries with abusive people in my life, including certain religious leaders.

My healing journey from childhood trauma shifted when the simple words my therapist said—you’re allowed to go there—gave me permission to feel things that a religious context had blocked. But importantly, these words didn’t dismiss or disrespect my belief system, which would’ve created an even bigger block to my healing than spiritual bypass had.

When a client doesn’t feel judged, therapists can more easily pivot to a motivational interviewing-style of questioning: “On the one hand, you have these beliefs about focusing on the good in everyone, and they’ve served you well in many situations. On the other hand, you’ve said your goals for therapy involve working through the pain of your ex’s treatment of you. Are you seeing the clash here?”

When good teachings enable bad things. As therapists, we can help clients identify the beautiful teachings in a religious or faith tradition while acknowledging that virtually anything can get twisted to justify abuse. “Honor thy father and thy mother,” from the Ten Commandments, is an example of a beautiful and often misused teaching. Sure, there’s tremendous value in honoring our parents by understanding who they are, how they were raised, and what led them to behave toward us as they did. But when “honoring our parents” means denying our painful childhood experiences, then we can easily become stuck in our trauma.

In addition to growing up as a conservative Catholic (from Mom) and a Pentecostal Evangelical (from Dad), I spent time studying yoga in ashrams, where I saw how beautiful spiritual teachings like ones that distinguish the capital-S Self from the lower-case self, thereby allowing us to tap into a felt sense of our universal nature, can be used by some to discourage dissent in communities. In particular, people who call out abuse may be accused of promoting division or dismissed as reacting from a “lower self” mired in the past. And in religious communities, there’s a widely held view that those who embody their Highest Self always forgive, even when abuse is involved.

Of course, it’s important to maintain a nonjudgmental space in which a client can come to their own conclusions about what serves them best. For example, my client Janelle could barely function because of spiraling depression and anxiety. In our first session, I wondered out loud how her feelings of failing her Autistic child when he was dysregulated and out of control were affecting other aspects of her life, like her ability to connect with others and meet deadlines at work.

She told me, “My feelings don’t matter, because I am not my feelings,” a way that many people interpret the yogic teaching of disidentification. When I asked her to help me understand the teaching a bit better, she replied, “Well, I might have feelings of helplessness and failure, but they don’t mean anything. They’re just an illusion, like clouds, blocking our view of our true Self. I’m trying to bring my Self to my parenting, but I get too caught up in my own stuff and plummet into the quicksand.” When I gently wondered where in that teaching it said that her feeling didn’t matter, she began to open to the work of sitting with her feelings rather than escaping them.

How we intervene matters—it can either elicit defensiveness about their spiritual teacher or tradition or deepen our client’s curiosity.

Pray on it more. Many religious or spiritual clients have concluded that their suffering must mean they’re not “enough” of what God wants. I’ve heard clients say things like, “I’m just not praying on it enough,” or “My minister told me I don’t need 12 steps; I just need one step: God.” Believing they’re falling short of a spiritual expectation can become an endless source of self-blame, and it can give them an illusory sense of control.

I often ask these clients, “Would you consider that perhaps if the greatest power of prayer lies in asking God to lead us to the help we need, then the help might arrive in the form of therapy? It might arrive in moments when we recognize and accept our humanity and vulnerability. Or it might take the form of feeling supported by others who give us permission to feel whatever we feel without judgment.”

In the therapeutic relationship, we can help people see how two seemingly contradictory things—our emotions and our spirituality—are not at odds with one another. Both can be real at the same time. We can engage in the work we need to do as humans to heal—and we can remain connected to the divine. One can help us better understand the other, if we allow it.

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Couples therapy is complex. With two people in the room, often at odds with one another, and with relational dynamics playing out quickly in real time, figuring out where to intervene can feel like a high-wire circus act. But having spent over 30 years as a couples therapist, I’ve learned that one of the most valuable tools we can bring to couples work is flexibility. When our efforts eventually stall—and in couples therapy, they often do—we need to be open to trying something different, even unconventional.

For years, I’ve used emotionally focused couples therapy (EFCT) with my clients. It’s an attachment-based roadmap that’s considered one of the most well-researched and effective approaches out there. But EFCT, like any approach, isn’t perfect. Research shows that about 70 percent of couples experience significant healing from relationship distress after EFCT; that leaves 30 percent who continue to feel stuck. With those clients, I sometimes add EMDR to our therapy, which helps many of them make the internal shifts necessary for change. But even still, some couples remain stuck in maladaptive behavioral patterns.

In 2021, I decided to try something unusual: I sought training in psychedelic somatic interactional psychotherapy (PSIP). A colleague had shared that PSIP could help clients go even deeper than EMDR to move them through particularly tough attachment trauma blocks. The training consisted of five days of experiential workshops and classroom learning, including observation, debriefs, and integration work with fellow students who, under supervision, had taken legally prescribed ketamine and cannabis. Afterwards, I completed a four-month online supervision series with the same team. I immediately loved how the approach privileged the therapist-client relationship, while also allowing a gentle exploration of wounded and well-defended places.

As I got more comfortable with the PSIP model, I wondered whether I could blend it with EFCT. Fittingly, by the time I was completing my training, a couple with whom I’d been using EFCT for more than a year presented me with an excellent opportunity to see how psychedelic-assisted therapy might complement EFCT.

Stuck, and Stuck Again

Sarah and Cole, both in their 50s, had been married for 32 years when they came to me for couples therapy. The last of their four daughters had graduated from college, and the time felt right, they told me, to address some issues that had been eroding their connection.

Cole and Sarah had different theories about how this erosion had happened: Sarah believed Cole’s failure to support her during significant moments in her life, like when her mother died from cancer, had contributed to it. As a result, Sarah said she didn’t trust Cole to show up for her. Cole, meanwhile, thought Sarah needed to be less critical and more accepting. He’d grown tired of feeling like he would never be forgiven for past mistakes. They’d also stopped having sex, which bothered both of them, but especially Cole. Despite these problems, it was clear that they loved each other and wanted to make their marriage work.

There are two stages in EFCT. In the first, the therapist helps partners learn to see their negative cycle, not the other person, as the problem. This helps each partner build a tolerance for emotion (both theirs and their partner’s) and become more aware of how once-adaptive childhood responses have become maladaptive. As couples recognize the negative cycle and begin to interrupt it, they can identify and focus on their own attachment needs and regulate their emotions more easily. With practice, they feel increasingly safe taking emotional risks with each other. Afterwards, they’re ready to move to stage two of EFCT, where they can have deep, vulnerable conversations, and uncover new parts of themselves.

Cole and Sarah were able to make significant inroads in stage one. Sarah explored how being raised by an emotionally absent, shaming father had impacted her sensitivity to Cole. In Cole’s case, he began to recognize that shutting down to Sarah came naturally. He’d long absorbed messages about the “pointlessness” of negative emotions in his family of demanding intellectuals, who believed that any talk about distressing feelings constituted “wallowing.”

In EFCT lexicon, Sarah was a pursuer, who preferred to address relationship issues head-on and resolve them quickly, and Cole was a withdrawer, which meant he needed more time to process emotions. As a withdrawer, Cole would frequently pull away from Sarah during difficult discussions, and as a pursuer, Sarah found it difficult to table conversations when they got too heated for Cole. When a couple is made up of a pursuer and a withdrawer, they can negatively influence one another: the more the pursuer pursues, the more the withdrawer withdraws, and vice versa.

Although they certainly experienced moments of improved communication and were learning more about their negative cycle and maladaptive practices, eight months into treatment, they remained stuck in stage one. Even when Sarah was trying to express vulnerability, her tone inevitably became sharp. She bristled easily. Too often, Cole responded cooly and transactionally to her pleas for closeness or consideration. To make further progress, I knew they’d have to push through a lifetime of learned defensiveness and get in touch with something deeper: the core struggle of their unmet attachment needs.

The Experiment

A possible foothold emerged when Sarah told me that at a friend’s recommendation, she’d talked with someone who had a medical background and was trained as a psychedelic journey guide. The friend and her partner had done a couples MDMA journey with this guide and felt profoundly changed by it. Sarah was excited by the prospect and had already talked at length with her about how their safety would be prioritized if she and Cole did it, too. Although MDMA isn’t legal, they knew of practitioners guiding journeys all over the country.

Since I’d recently wrapped up my own training in psychedelic-assisted therapy, I knew that in a safe and supported space with a knowledgeable and well-trained guide, psychedelics might help Cole have a lived experience of the absence of performance anxiety so that he could fully show up for Sarah. And I hoped that for Sarah, they’d lower the protective barrier that had been keeping her so vigilant and made her appear controlling, enough to allow her softness and longing to come through. Although I remained neutral about their choice, I let both Cole and Sarah know I was here to help them explore their goals and misgivings about a journey, and to do the integration work afterwards.

To prepare for their experience, we reviewed what they’d learned so far from EFCT about their triggers, negative cycle, and the importance of resourcing themselves through bonding moments like the ones they’d had in our sessions. After several consultations with the guide, they made the decision to start with individual ketamine sessions and then jointly take MDMA a couple months later. Cole worried that his defenses were so entrenched that psychedelics wouldn’t affect him, but said he was willing to give them a try. Sarah was openly excited. Her hope was that it would make it easier for them to talk about things like money and sex without their usual defensiveness.

In our last session before the weekend when their journey was scheduled, they told me they felt ready. I replied that I looked forward to our next session, the following week.

A Breakthrough

When we met for our next session, Cole and Sarah greeted me and sat down next to each other, as they always did. But when they spoke to each other, I noticed that something subtle had shifted. They appeared to be more at ease in their bodies, and there were little gestures that were new—or perhaps they were simply more frequent. They leaned toward each other, held each other’s gaze, and smiled more. When they shared, I could sense that much of their defensiveness had melted. Sarah’s tone had lost its sharp, instructive quality, and Cole’s responses were noticeably warmer.

Their psychedelic journey had been positive overall, they told me. Cole had felt his inhibitions dissolve, and had found that he was able to show up more authentically with Sarah, asking for what he needed both emotionally and physically. Sarah, in turn, said she’d felt seen and appreciated by Cole, adding that she could now feel the sense of safety with him that she’d been yearning for, which allowed her to fully express her love for him.

When Cole went back to work on Monday after the journey, he told me, he’d been surprised at just how calm he felt, even during a stressful work presentation. “For the first time in years,” he said, “I experienced a profound sense of tranquility when people were expecting me to do something.”

Together, Sarah and Cole identified practical ways they might sustain insights from their journey through daily practices like prioritizing time together and addressing moments of hurt. They began nipping conflicts in the bud and tabling contentious discussions until our sessions.

Their readiness for stage two crystallized in a following session when Cole said, “Something’s been bothering me, and I’m afraid to bring it up, but I’m going to anyway.” Sarah sat up in her chair and nodded.

“Last week, when your family visited, I took care of everything so you could enjoy time with them. I picked everyone up from the airport, cooked, and participated in activities I don’t particularly enjoy. But after they left, all you did was talk about being tired. That hurt. It felt like what I’d done hadn’t mattered.”

“You’re right,” Sarah replied. “It didn’t even occur to me to acknowledge how much you’d done to make the visit work.”

“I’m wondering how it landed when you were working so hard to get it right and Sarah didn’t seem to notice,” I asked.

“Like a rejection,” Cole replied. “Only this time, instead of shutting down, I reminded myself that this was the pattern we’ve been talking about. And that Sarah still loved me.”

In another session, Sarah talked about her maladaptive strategies, without any intervention from me. “I never realized it before,” she said, turning to Cole, “but I can see now that there were many times when I hurt you when I felt hurt instead of telling you how I felt. I couldn’t see how I was just pushing you further away.” Instead of buying into her familiar judgements of Cole, Sarah was developing a better understanding of her own maladaptive patterns.

Before their psychedelic journey, both of them had understood their negative cycle cognitively. Now, they felt the negative cycle, understood their roles in creating it, and could see the impact it had on their relationship.

“For the first time in a long time, I’m feeling seen, heard, and understood,” Sarah said in one of our last sessions. “And I see how Cole’s nervous system works, why he used to freeze up or lean away when I’d push him to share more and be more vulnerable. I was basically saying, ‘You’re failing.’”

“I feel connected to Sarah in a way I’m not sure I’ve ever felt,” Cole said. “I think it’s because I have more compassion for myself.”

I’ve long known it’s important to be nimble in therapy—to move between approaches based on what’s unfolding in front of us—but I’d never thought seriously about integrating two approaches that look so different. I’m glad I did, and was able to support Cole and Sarah’s choice to step out of their comfort zone and try something that to them, and to many therapists, still feels radical and new.

Psychedelics were the tipping point that helped Sarah and Cole lower their defenses and be truly vulnerable and empathetic. At the same time, they weren’t the sole reason for their breakthrough. The EFCT work we’d done, and continued to do afterward, helped them grow more aware of maladaptive patterns, improve their ability to regulate their emotions, identify and interrupt their pursue-withdraw cycle, have more connected conversations, and identify and communicate attachment longings.

I’ve continued to support clients who opt for psychedelic-assisted therapy because they’ve felt stuck after years of using more conventional therapy methods and treatments. There are many pathways to healing, including ones that might seem a little unusual. When we’re open-minded and follow our clients’ lead, the results are often beautiful.

Case Commentary

By Paul Greenman

Naomi Rather’s case study is a testimony to the importance of keeping an open mind and being flexible as therapists, as it seems that integrating psychedelics helped Sarah and Cole achieve what can be an elusive but crucial goal for couples in the first stage of EFCT: moving beyond a cognitive understanding of their interaction cycle and actually feeling how their own fears and longings manifest in the relationship and the impact they have on everything.

Therapists who practice EFCT often hear their clients say things like, “Yes, I know it’s about the cycle, but what are we supposed to do about it? My partner keeps behaving this way!” As long as couples’ handle on their cycle remains cognitive, de-escalation is extremely difficult. I share Rather’s view that experiencing the cycle as the problem means confronting unmet attachment needs and the feelings that accompany them, which also entails, as Rather so elegantly says, “pushing through a lifetime of learned defensiveness.”

Like Rather, I often focus on guiding clients through blocks to de-escalation. When they have difficulty feeling their cycle, I will use a great deal of repetition, reflecting that the regular conflicts they experience are responses to unmet attachment needs, and that they are only revealing a fraction of what is happening inside them. I find that constant reframes of the cycle as the problem can help them gain new perspectives of their partner, and jump-start vulnerable discussions about their role in the cycle. From this new place, a partner might say something like, “I pull away from you because I’m hurt and afraid” or “I pound on the door because I don’t know any other way to reach you, and I’m so lonely.”

I tend to favor these types of interventions over psychedelics since drugs like MDMA aren’t legally available in the U.S., and in Canada practitioners must apply for special permission to prescribe them. Last August, the FDA declined to approve MDMA-assisted psychotherapy as a treatment for PTSD, citing the need for more evidence of its safety and effectiveness. And although there is some anecdotal evidence for the successful integration of psychedelics into EFCT, there has not yet been any empirical research into its effectiveness or safety.

I’m hopeful that with more definitive research results, it will eventually become commonplace for therapists, including couples therapists, to collaborate with medical practitioners who administer and monitor psychedelics within the context of psychotherapy. After all, when Sarah and Cole took it upon themselves to experience a psychedelic journey with a trained guide, they became more accessible and responsive to each other. They felt their way through their cycle to a more meaningful emotional connection. The combination of EFCT and psychedelics might have helped them overcome the blocks to de-escalation and to proceed to stage two.

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Most therapists are taught to take an affirming, hands-off approach when clients bring up religion, which is often considered a prosocial or supportive factor, something that grounds people in a sense of identity, community, and a higher purpose.

But as a therapist who specializes in religious trauma, I’ve seen firsthand how religion can disconnect people from themselves. And many of my clients, and those of my supervisees, are quite clear about the harmful effects of experiences they’ve endured within high-control religions they were born into and never formed an identity outside of it until they made the choice to leave as adults.

Although some of my clients can point to specific instances of overt danger or overwhelm, most say there wasn’t a single event attached to their trauma. Rather, the teachings, practices, and beliefs they were steeped in simply kept their nervous system on high alert all the time. This was their normal state: they felt threatened and overwhelmed.

Does it sound like I’m describing complex trauma? I am. As I’ve learned over the course of my career, religious trauma is trauma. But sadly, when religion is involved, even trauma-trained therapists seem to have a blind spot. Recently, a client, who came to me after hitting a wall with one of these well-intentioned therapists, said, “You have no idea how painful it is to have to convince your therapist that what you went through wasn’t just a bad church experience.”

Like many therapists, my foray into my clinical specialty began after realizing how deeply I resonated with certain experiences I heard from clients. Like them, I was working to heal—physically, relationally, and psychologically—from the impact of my highly controlled religious upbringing. In fact, some days, it felt like I was just a step or two ahead of them in my journey.

Then, during Donald Trump’s first campaign for presidency, many folks on social media began voicing disillusionment with their churches and pastors for supporting him—after all, Trump wasn’t a religious man, and his actions could easily be considered antithetical to most religious teachings. It opened the door for other conversations and questions around religion. Religious trauma became a hashtag and a frequent talking point for the therapeutic community.

In turn, I started using my own social media platform to talk about religious trauma as I saw it: complex trauma. I wanted to raise awareness about the fact that even when people reject and question certain principles, practices, or structures, the indoctrination they’ve endured lives on in their bodies. As with all trauma, religious trauma is a physical, emotional, or psychological response to a perceived threat that can overwhelm the nervous system. It interferes with a person’s ability to cope and experience safety. You can’t think it away—it must be somatically resolved.

The distinction between spiritual abuse (also a buzzword) and religious trauma is that abuse can but doesn’t always result in trauma. Most people recognize spiritual abuse in egregious events like a member of the clergy sexually abusing a child. But in many cases, it’s more insidious and covert. I like psychologist Hillary McBride’s definition of it: “when someone hands you an inner critic and tells you it’s the voice of God.” This transfer can happen in seemingly unremarkable, everyday interactions, such as a parent or authority figure telling you that you’re sinning when you masturbate or feel attracted to the “wrong” people. Or it may result from being told that not accepting certain religious teachings will earn you a life of eternal conscious torment in hell.

I receive hundreds of inquiries a year from people who feel traumatized by their religious experiences, including those within cults, but can’t understand why, despite rejecting their former belief system, they’re still experiencing hypervigilance, flashbacks, difficulty in their relationships, chronic illness and disease, anxiety, and depression. The 2,500 people who responded to an exploratory survey from the Religious Trauma Institute, which I cofounded, reported lasting impacts of adverse religious experiences like feeling chronically unworthy, overwhelmed, paralyzed, isolated, distrustful, disconnected from their bodies, unsafe, tense, hopeless, and confused. The top three lasting impacts identified were fear, powerlessness, and shame.

Body-based trauma resolution modalities that center the nervous system, like Somatic Experiencing and Trauma-Informed Stabilization Techniques, are critical in helping these clients build skills around grounding, orienting, embodiment, and safety. They may also need our guidance learning about setting boundaries, communicating their needs and feelings, differentiating from other people, thinking flexibly, embracing sexuality, being a parent, and learning to reparent themselves. As therapists, we’re well-equipped to help clients do this kind of work, even those among us who’ve never set foot in a temple or church or spiritual center.

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So many of our clients come to therapy for anxiety treatment. But the term anxiety itself tends to be overgeneralized, and there’s no one model to treat all the nuances and permutations. What if we could help clients untangle their symptoms, coping strategies, and defenses, so they can get a clear picture of what lies underneath their anxiety—and what if that helped us get a clear picture of how to target our inventions?

Over many years of working with anxious clients, I’ve been struck by three common ways anxiety shows up in our lives, regardless of its origins: catastrophizing, control, and distorted beliefs. Each presentation has a distinct underlying need that drives the anxiety, accompanied by a powerful objection, or way the anxiety fights to preserve itself when challenged. A client can have one, two, or all three presentations, but by teasing them out, we can help effectively address the objections and underlying need to best explore the dynamics at play. An important component is that each also has its own interventions that target the underlying need so as to address the anxiety at its root, not just the symptoms of it.

Catastrophizing

Emily sat in my office spinning in indecision to the point of paralysis about applying to medical school. Since high school, she’d dreamt of becoming a doctor and specializing in pediatric surgery. She was scheduled to take the medical school entrance exam in two months and was avoiding studying while in a near constant state of anxiety. Her body appeared tense, and when she spoke, she spiraled from one concern to another with a look of despair on her face. “What if I don’t get a good score? Or let’s say I get a decent score, what if I apply and don’t get in anywhere? But even if I do get in somewhere, how will I pay for it? What if I can’t handle the workload? I’ll have wasted all that money with nothing to show for it.”

I could feel Emily’s tension and worry. I was aware of how little space there was in between each of her fears for me to respond, no doubt similar to how little space she experienced for herself in the midst of them.

This is catastrophizing, one of the three common ways anxiety manifests in clients. It involves imagining worst-case scenarios of future outcomes and responding to them as though they’re either happening now or are inevitable. Catastrophizing almost always begins with the words what if, and everything that follows is a story. This pattern stems from our discomfort with uncertainty, which the human brain instinctively interprets as a threat. By conjuring up all possible negative outcomes, the mind convinces itself it’s being helpful and protective. Even when therapists try to be helpful by challenging or reassuring clients who are catastrophizing, they’ll usually hear the objection: “But it could happen!” By treating every possible outcome as worthy of attention and worry clients remain tethered to their anxiety, and challenging these fears likely won’t get far.

“That’s a lot to be worried about. No wonder you’re having a hard time studying when you’re so fearful about the outcome,” I said to Emily.

“I know a lot of this is irrational, but I don’t know how to stop,” she replied.

“What do you think these fears are trying to protect you from? How might they be trying to help you?” I asked. With this redirection, not challenging her fears, but seeking to understand them, Emily settled a bit and connected with how meaningful it felt for her to apply to medical school, and how devastating it would be if she failed. With this insight, I asked, “Can you make space for your fear, and see it as a reflection of how much you care about medical school?”

After a few moments, she announced that she noticed a feeling of relief, a sense of calm.

“Good,” I smiled. “Now that you’re feeling more settled, can you tell me what you know to be true about your skills and abilities? Just the facts, no stories.”

Emily easily identified her history of success in school and her resilience in the face of past failures. Her between-session homework was to acknowledge her catastrophizing, to mindfully observe it without attaching to what-if thoughts and worst-case-scenario stories, and then to focus on what she knew to be true. She began to dialogue with the fearful part of her, developing the ability to reassure it rather than trying to force it to go away. Focusing on the facts, not the stories, enabled her to return to studying, apply to schools, make her acceptance choice from many options, and navigate medical school.

Control

Lynn was successful, capable, and chronically stressed. She experienced life as a never-ending to-do list, with little time for relaxation or pleasure. She argued for her inability to rest, noting everything that needed to be done, all of which would only compound if she left a chore unfinished. She had a supportive husband, yet she struggled to let go, routinely finding fault with his way of doing things and thus maintaining the burden on herself. Lynn’s mother had died when she was in high school, and her father—lost in his own grief—had been an absent parent. She acknowledged that her over functioning tendencies were an attempt to cope with the profound sense of helplessness she’d felt then.

Although Lynn was often rewarded for her tendency to run herself into the ground—she was considered successful at everything she did—it left her stuck in a cycle of anxiety and overwhelm. Her sense of wellbeing became dependent on external factors rather than her internal capacity to cope. Attempts to help Lynn let go, do less, and rest at “good enough” were met with an insistence that everything would fall apart without her attention. This is a common objection when anxiety is manifesting as control. “My anxious behaviors are the reason I’m successful, so they’re absolutely necessary!”

This anxiety presentation involves an imbalance: overfocusing on what’s beyond our control—such as what others think, feel, or do—while neglecting the things within our control, like our thoughts, actions, feelings, and responses to our emotions and circumstances. This imbalance can leave us feeling helpless, powerless, or even victimized. A crucial question to ask clients struggling with this anxiety presentation is: “What’s truly within my control, and how do I want to respond?”

At its core, control is an attempt to compensate for an innate, default belief that “I’m not okay” or “It will not be okay.” The unmet need here is for safety and security. Some clients seek to create safety by exerting control over their environment. They’re driven by an unconscious belief that if they know what to expect, or if things happen the way they want them to or think they should, then they’ll be okay. It often looks like inflexibility, rigid expectations of self and others, excessive preparation and research, perfectionism, and taking on too much responsibility for others. Others will anticipate everything that might go wrong and make a plan for what to do should those problems arise. The underlying belief here is, If I prepare for everything that might go wrong, then I’ll be okay when it does.

In my work with Lynn, we focused on honoring her coping response of seeking control following her mother’s death. Slowly, she was able to see all the ways this response was now a source of stress and overwhelm, reinforcing her feelings of isolation. Her controlling, micromanaging, perfectionistic behaviors blocked others from helping and supporting her. What was once protective was now harmful.

I invited Lynn to share previously unprocessed feelings of grief about her mother—something she’d “never had time for.” We also worked to shift her sense of well-being from relying on external factors to internal ones. To let go of her anxiety and the behaviors associated with it, she needed to recognize that her internal strengths, skills, and knowledge were the true reason she was successful. This required creating experiments—opportunities for Lynn to practice letting go, doing less, resting, playing, and relaxing. We began with small, low-stakes practices to build tolerance and resource her for the inevitable discomfort that came with doing things differently. As her capacity to tolerate discomfort grew, so too did her sense of ease, calm, and enjoyment of life.

Distorted Beliefs

Helen was referred to me by her long-term therapist, who was stuck in her efforts to help her disengage from her deeply entrenched anxiety. Whenever her therapist tried to challenge Helen’s distorted thinking, she argued back with two words: “yes, but…” Distorted beliefs fueling anxiety often boil down to core negative self-perceptions—such as I’m unlovable, I’m a failure, or I’m a fraud—which drive compensating behaviors.

When a therapist challenges a client with anxiety wrapped up in distorted beliefs by giving them a compliment or offering objective feedback, a “yes, but…” statement will usually follow: “Yes, but you’re just saying that because you’re my therapist,” or anything that deflects, invalidates, or minimizes the positive statement. This objection shows up outside of therapy, too, when compliments or positive feedback is offered. The more attached a client is to the distorted belief, the stronger and more sophisticated the objection will be, thereby preserving the distortion. I liken distorted beliefs to viewing oneself through a funhouse mirror and mistaking the warped reflection for reality. These beliefs often originate in childhood, as the mind of a child attempts to make sense of and cope with early challenging experiences.

In one session, Helen shared an anxiety-filled scenario: her parents visiting her apartment before they all went out to dinner. She obsessed over hosting, stressing about what snacks to serve, and even bought new furniture to create the “perfect” home. She wondered “What would a normal person serve for a snack? What would a good hostess do?” When I asked Helen about her experience with her parents, she said they’d always been kind and accepting, and that her anxieties had nothing to do with them. Rather, her attempts to improve her home stemmed from a long-held belief that she was “broken and incapable.” Hosting perfectly was her attempt to feel whole and worthy.

In the final moments of the session, Helen said, “I’m worried that I’m not broken enough for you to be seeing me. Your time is valuable.”

Disarmed by her statement, I said, “Your time is as valuable as mine and I can hear how much anxiety affects your daily life. I’m glad you’re here to work on it.” But reflecting on this later, I felt I’d responded too quickly and overlooked an opportunity. So in the next session, I asked how she’d felt after sharing her worry about wasting my time.

“Actually,” she said. “I beat myself up for saying that this whole week. I’ve been worried that you thought I’d said something stupid.”

I highlighted how her distorted belief about being broken had turned my affirming response into another judgment against herself. Her anxiety ensured she always felt “not good enough”—too flawed to host her parents but not flawed enough for therapy.

Helen, arguing for her distorted beliefs, replied, “But even if you thought it was stupid, you wouldn’t tell me.”

“If there was something about what you said that I thought we should look at, I’d find a way to do that,” I told her. “And I’m never going to say something I don’t mean. Can I share with you what I did think?” When she nodded, I said, “It was incredibly helpful you shared that worry with me. I was impressed you could say what you were thinking and feeling in the moment. That’s doing therapy at a master level.”

Helen sat in silence, looking uncomfortable. After a pause, she admitted, “You just took away my ability to discount what you said. I want to accept your feedback, but it’s hard to.”

“Let yourself feel the discomfort,” I suggested. “And see if you can make even just a little space for my view of you. It’s okay to feel uncomfortable as you consider this new possibility.”

Healing anxiety from distorted beliefs involves identifying core falsehoods, addressing the behaviors that maintain them, and helping clients internalize more accurate truths. It also requires clients to practice new behaviors aligned with reality while building resilience for the discomfort of change. Self-compassion—rooted in understanding the origins of maladaptive beliefs and accepting one’s human imperfections—is especially powerful in countering the self-loathing distorted beliefs often carry.

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It’s not easy to figure out what to focus on as we struggle to help anxious clients. We can all get caught up in their “anxiety whirlwind” of dysregulation, distorted thoughts, and defensiveness. Understanding some of the most common ways anxiety can look in therapy, the underlying needs fueling it, and the objections that accompany it can provide us with guideposts to intervene strategically and support better outcomes for our clients.

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Q: How do I respond when a client (or a client’s lawyer) requests my session notes?

A: Recently, I saw a former client’s name in my inbox next to the subject line “Divorce Proceeding: Request for Documents.” He asked for all the notes and records from couples sessions I’d facilitated five years ago, then noted that his attorney needed them by next week. Yikes! I took a deep breath. How was I supposed to handle this? Was I obligated to send the notes? What if the things I’d written were misinterpreted? Rapid-fire worries hit me from all directions. My mind raced. Would I be subpoenaed? Deposed? Was there a risk of being brought up on charges at my state’s licensing bureau, or being in contempt of court?

As I scoured the internet for information, I stumbled on an article by Steven Anderson, a lawyer who specializes in mental health law. The next day, we set up a time to talk. At the start of our conversation, he warned me that because he was based in Seattle, the specific rules and regulations governing document requests might not apply in my state. Still, he walked me through some basic principles to remember when handling document requests.

Chill out. When a client requests documents for legal reasons out of the blue, it can feel scary and important to respond immediately. But the situation is rarely (if ever) as urgent as it seems to be in the moment. Give yourself a day (or three) to wrap your mind around the request. Listen to a symphony. Go for a walk. Meditate. Eat a cookie. Talk to a trusted colleague. Let the request percolate.

Reflect on your reaction to the request. Do you feel insecure? Angry? Vulnerable? If you feel pressured, what emotions feed this sense of urgency? Are you afraid the notes will reflect poorly on you as a clinician? Are any feelings coming up about the work you did with the client or couple whose treatment you documented?

In my case, though several years had passed since I saw my former clients, I still felt sad about the way our work had ended. My bond with both partners had been strong, and we’d had some meaningful sessions; but ultimately, the therapy hadn’t made enough of a difference, and they’d ended treatment. Reflecting on my feelings helped me accept my sadness and regret about this outcome and focus on the task at hand: figuring out what to do about the document request.

Reach out to colleagues for support. Briefly let a few of your most-trusted colleagues know about your situation (while taking care not to reveal identifying client information) and get their input. It turns out that all four therapists I reached out to had been in similar situations. Though they’d each handled the document request differently, most of them had sought counsel from an attorney specializing in HIPAA regulations and client-therapist confidentiality issues in the state where they were licensed to practice, and everyone had been careful to obtain consent before communicating with a client’s attorneys.

One colleague let the document requester know she’d need their partner’s consent to release the documents about their couples therapy—and never heard back. Another colleague (who’d received a subpoena) shared his (very high) fee per day for court appearances—and never heard back. A third colleague asserted client-therapist privilege after being deposed—and the deposition was dropped. A fourth colleague advised me to communicate with my liability insurance company because chances were, they offered free advice through an attorney on their staff.

After my conversation with Anderson, I emailed the American Psychological Association (APA). They sent me three documents highlighting important things to consider, such as how to handle subpoenas, court orders, and depositions, and what to keep in mind about the difference between confidentiality (laws and ethical standards requiring therapists to protect patients’ privacy) and psychotherapist-patient privilege (the patient’s legal right to keep their personal treatment information out of court proceedings).

Respond succinctly to your client’s request. When I first opened my former client’s email, I had a brief fantasy that it would magically disappear from my inbox if I pretended that I’d never received it. Of course, ghosting a client isn’t just irresponsible, it’s unethical. You must respond to document requests; however, you can do so in an honest, thoughtful note that clarifies what you can and can’t do as you handle the situation.

There are different rules in different states about the number of days you have before you need to respond, but in most situations, you can take a week or two. You don’t have to first understand every nuance of HIPAA legalities in your state, or all the ins and outs of malpractice issues, to provide an initial response. You’re a therapist, not a lawyer. You can reply as a therapist, briefly sharing your plan. In my case, after three days, I wrote this:

I received your request for documents. I need to consult with the licensing board in my state and with my professional counseling association regarding state-specific HIPAA and client confidentiality issues in this situation. Unfortunately, I won’t be able to fulfill your request by the deadline you mentioned, but once I have more information, I’ll get back to you.

Assess your notes. The night I got the document request, I slept poorly. The following day, after I started mining various resources for guidance, I located and looked through my old session notes. Anderson had advised me to make note of anything that a lawyer or judge might view as indicative of a personality disorder, and to assess what I’d written to see if it revealed a negative bias toward one or the other partner. Certain diagnoses or biases that show up in session notes can be weaponized against a parent in a custody battle. My former clients don’t have children, so this wasn’t a concern in my case.

But I still asked myself two questions: “Are these notes general and generic, or full of specifics and revealing details?” Sadly, detailed notes—though helpful as a tool for therapists—can work against clients’ safety when they’re made public or used in legal proceedings. If notes are general—a few sentences, limited details, widely applicable statements about goals or treatment plans—a therapist may feel more comfortable releasing them to a third party. “Do these notes reflect poorly on the client, or in the case of a couple, on one partner?” It’s important to consider whether notes reflect a bias where you may have sided with one partner. When your notes detail a partner’s missteps and insensitive behaviors, they can be used to gain legal leverage. At the same time, omitting details regarding a partner’s abusive behaviors to protect them from hypothetical future court proceedings isn’t ethical. Ultimately, if you feel your notes are biased or may work against a client’s interests, it’s best to let a client or client’s attorney know.

If the requested documents are notes from conjoint therapy, it’s your ethical duty to assert privilege on behalf of both partners in the couple. This means you’re bound to protect both clients’ rights to privacy and confidentiality and you’ll need signed consent from both partners to release notes. You’re protecting them but also yourself. Disregarding your responsibility to both clients could result in one partner filing a complaint with a regulatory agency.

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A few days after my first email—after working through my reactions, doing research, and consulting with people who knew more than I did on the topic, I formulated this more detailed response:

Because you were both my clients during couples sessions, I would need signed releases from both of you giving me permission to forward these documents to you and your respective attorneys. I am also concerned that there are personal details in the notes which were revealed in trusting circumstances. These details were not intended for public scrutiny or to be taken out of context. Let me know if you or your attorney would like to discuss these concerns with me on a call.

A few days later, my former client’s attorney responded that at this time, they didn’t need the records. A follow up to this request—or a new one—may surface again in my email inbox down the road. But if it does, I’ll feel prepared.

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