There’s nothing quite like unwinding on a couch in front of a good movie, especially when so much of what we do (including therapy) feels like hard work. But what often makes the best movies engaging and memorable is the way a film can be two things at once—entertainment and a form of healing. We asked some prominent therapists about their favorite therapeutic movies—and here’s what we learned.

“Lion”

In 2016, I saw the movie Lion, which moved me and has stayed with me ever since. Based on a true story, the main character, a five-year-old boy named Saroo, falls asleep on a train in India and ends up 1,000 miles from home, hopelessly lost. All the while, he maintains an unfaltering connection to his family and sense of place, which stay with him, guide him, and even help him to find his way back 25 years later.

In one scene, Saroo is lying under a bridge in Calcutta, wearily moving little stones from one place to another. The scene shifts to show him listening to his mother’s soothing voice, saying, “What a good boy!” He remembers visiting her while she was working at a rock quarry. He helped her carry heavy rocks from one pile to another, until they sat together, and his mother shared a juicy mango with him. Under the bridge, we see through his mind’s eye just how his mother beams at him, repeating, “What a good boy!” Saroo also replays memories of his older brother, with his cheerful, bopping gait, who turns and smiles at him, cajoling him to skip across the train tracks together.

Saroo’s ability to soothe and self-regulate by calling on his memory of his mother brings to mind the Accelerated Experiential Dynamic Psychotherapy practice of using portrayals to invoke a natural mechanism of secure attachment. We help our patients heal what’s gone wrong by engaging the neural circuits in the brain that are active when things go right.

Later in the film, Saroo ends up in an orphanage. Despite having been separated from his family, he holds on to the certainty that they miss him, even as he enters into a new life with an Australian couple who want to adopt him. Soon, he attaches to his new parents and thrives under their love. Eventually, he travels back to India and locates his village. Body memory helps him navigate the alleyways to the door of his childhood dwelling, where he meets a woman dressed in a pink sari: his mother. She never moved from the village in the hope that one day her son would return.

So even though Saroo was lost at age five, he displayed a deep sense of confidence and faith that he’d be found. Throughout his journey, he was full of zest. He showed a playful and heartfelt capacity to engage with people and life, and to deal with both adverse and fortunate circumstances.

I like to recommend Lion to patients and nonpatients alike because it’s an amazing illustration of how secure attachment functions as the most profound life insurance that exists on this planet. Instead of being haunted by the loss of his cherished mother and older brother, Saroo is accompanied by the presence of their love, which stays constant within him. This story is miraculous and a profound testament to how secure attachment instils resilience and the capacity to deal with adversity. Healing insecure attachment is nothing short of restoring nature at its best. The mechanisms of secure attachment reside deeply in our brains, despite circumstances, and under the right conditions can be activated to set healing and transformation in motion.

Adapted from Tailoring Treatment to Attachment Patterns: Healing Trauma in Relationship, Copyright © 2025 by Karen Pando-Mars and Diana Fosha. Used with permission from W. W. Norton & Company, Inc.

Karen Pando-Mars, MFT & Diana Fosha, PhD

“Defending Your Life” and “Buck”

Every two years, I offer a four-day training in intensive experiential dynamic psychotherapy approaches to therapists. We cover a lot each day, but evenings are dedicated to fun, relaxing activities, including watching movies. This isn’t purely entertainment, though. The two films I show trainees are actually a continuation of principles they’ve been absorbing during the day.

The first movie I show is Defending Your Life, a romantic comedy from 1991. As the dead characters’ lives are evaluated by a prosecutor, defense attorney, and two judges in Judgment City, penetrating debates follow—both in the movie and between trainees, when the movie is over—about how to define “success” on earth. Is success professional advancement and financial growth? Or is it having the courage to follow your convictions, be kind and generous, live authentically, embrace values with integrity and passion, and—perhaps most poignantly for therapist-viewers—be kind to yourself?

In the movie, Meryl Streep’s character lives joyfully and spontaneously, showing us what it’s like to be relatively unconflicted. Albert Brooks’s character is clearly “neurotic” and “defense dominated.” He’s anxious, indecisive, ruminative, and concerned with appearances. He viscerally exhibits the pain of what it’s like to live at war with yourself. As a therapy client, he’d be a lot harder to get close to than Meryl Streep’s character but, I would argue, he’s just as worthwhile to get to know.

I believe this movie provides a rare opportunity for viewers to step back and consider the ways we can embrace our true nature and live passionately instead of constantly holding back and allowing fear to dominate us. As a trainer and supervisor, I enjoy how it illustrates, in an artistic format, clinical phenomena such as the relationship between feelings, anxieties, and defenses. Although my trainees like to remind me that the ending is a bit clichéd (I won’t give it away), it still speaks to our human potential for resilience and change, along with our capacity for overcoming internal obstacles that cause suffering.

The second film I show trainees is Buck, a 2011 documentary about Buck Brannaman, a horse trainer who endured severe child abuse. This movie demonstrates his unique, paradigm-shifting way of training wild horses. Instead of a confrontive, competitive “breaking” of the horse (the equivalent of a therapist having an agenda and leading too much in therapy), or passive coercion (a therapist following too much and colluding with existing self-defeating patterns), his approach is respectfully collaborative, firm, and kind. Too much following creates uncertainty and anxiety, whether in a horse you’re training or a client you’re working with. Conversely, clear leadership builds safety and trust. The trainer must be confident enough to provide clarity about the next task they’re inviting, and to do this, the trainer needs to clearly know what it is they’re attempting to do. In a misguided effort to always be attuned to clients, therapists with their own trauma may avoid the discomfort of directly challenging a client. But truly “seeing” another person means you see all of them, including their limitations. When therapists are more selectively active with clients, they can sensitively provide growth-enhancing challenges much more rapidly.

Buck’s authentic, deeply held stance provides the basis for creating trust and safety, motivating the horse he’s working with to collaboratively connect with him. His deep understanding and effectiveness, most likely due to the sensitivity he developed as a child, transcend intellectual understanding or verbal communication. Because his interactions are with animals, his communication is strictly nonverbal. For many trainees, when we discuss the film later, this is one of their biggest takeaways: that nonverbal communication is incredibly powerful. There’s an old expression: affect leads and intellect follows. Many of us tend to over rely on talk and logic with our clients. We explain, give reasons, persuade, and provide psychoeducation. But accurate empathy is expressed nonverbally far more than we realize, in a way that even wild horses can pick up on—and people, too.

Steve Shapiro, PhD

“All That We Love”

Director Yen Tan’s All That We Love (available for streaming Fall 2025) stars a luminous Margaret Cho as Emma in a tender, beautifully observed exploration of grief, connection, and transformation. The story begins with the death of a beloved pet, but soon expands into a richly textured portrait of relational loss. Not long after Emma’s dog has died in her arms, her daughter announces her plan to get married and leave the country. Emma’s subtle response to this news is layered with such raw heartbreak and desperate self-protection that I couldn’t help but identify with both her frailty and her feisty will to endure. One of the gifts of grief, after all, is its universal power to connect us as human beings.

Tan’s direction is paired with poignant performances by Cho, Jesse Tyler Ferguson as her best friend, Alice Lee as her daughter, and Kenneth Choi as her ex-husband. As in his extraordinary movie,1985, Tan uncovers exquisite beauty and laugh-out-loud humor in seemingly ordinary moments between people, the kind of everyday moments that are often overlooked. As such, he invites us to embrace life’s heartbreaks with bravery and openness, and I found myself laughing out loud much more than I expected to at the numerous idiosyncratic bits of silliness, each borne out of credible bids for connection between the characters.

But what I found most affecting are the gentle, dog’s-eye-view shots of Emma, hinting at a spiritual presence and underscoring her journey to rediscover herself through loss. For me, this served as a reminder that healing can come when we’re brave enough to let go and love with a renewed and expanded sense of self.

A lot of what we do in therapy focuses on helping clients face loss, live with loss, and make meaning of losses. Tan’s exuberant and refreshingly true-to-life film invites us to do just that with grace, humor, and imagination. All That We Love is a soulful, resonant gem—one that’s rapidly becoming my top recommendation for clients this year.

Mark O’Connell, MFA

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

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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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!

Psychotherapy Networker’s annual Symposium is a little like being on the therapeutic red carpet. For 49 years, we’ve hosted everyone from Virginia Satir and Jay Haley to Irv Yalom and Brené Brown. Many of these pioneers of modern therapy come back year after year, decade after decade. And each time they do, we ask them: What are you thinking about now? What should the field be talking about today? What do we need to be figuring out together? This issue is an invitation to experience some of the most meaningful moments that happened in 2025 with premiere thought leaders in our field, including Esther Perel, Jon-Kabat Zinn, and Dan Siegel. Join the conversation today!

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The first time a client tells me about a part of them that’s angry, I don’t jump to interpret or intervene. I get curious. As an Internal Family Systems (IFS) therapist, I want to know what that part of them is trying to do for them.

Take Maya, a client who came to therapy exhausted by an internal war: one part of her would flare up in anger at her partner during minor conflicts, while another part quickly stepped in to shut down the anger, criticize it, or rationalize it away. She described the angry part as overwhelming and “kind of scary,” and the rational part as the “voice of reason.” When I asked what she imagined might happen if the angry part wasn’t managed so quickly, she paused. “I’d be out of control,” she said. “People would leave me.”

In my work, I use IFS as a framework to help clients understand how they get stuck in the protection strategies they’ve developed to navigate the complexities of life. I often begin with a simple analogy: most of us are familiar with the feeling of having conflicting voices in our heads. As we slow down and listen, we notice that different parts of us are advocating for different things. One may be seeking comfort or pleasure, the other protection, acceptance, or belonging.

A common metaphor in the IFS community to describe this phenomenon is that our parts are like clouds, and our Self—the calm, compassionate essence at our core—is like the sun. Sometimes the clouds cover the sun, but that doesn’t mean the sun is gone. It’s just obscured. We don’t need to push the clouds away. We just need to understand them.

When a part gets activated, I invite clients to get curious about what need that part might be trying to meet. Are they reaching for safety? Autonomy? Connection? To be understood? For most of us this is a novel approach, not to just shut down any “unacceptable” feelings or emotions, but to earnestly look at the underlying reason with curiosity. I’ve found that IFS lends itself to a rich internal visual world full of metaphors and archetypes. Presenting clients with ways to visualize these internal dynamics has been a huge support for clients to move beyond self-judgment and into curiosity and understanding. One visual metaphor I developed around our needs is a reimagining of Maslow’s hierarchy of needs. It is a collection of parts, depicted as clouds, presenting a collection of our universal human needs, as they swirl around a pyramid-shaped mountain.

For Maya, the angry part had long been dismissed or pushed away, but when we got curious, she began to visualize it—a young, sword-wielding 10-year-old cloud, fiercely protecting her from shame and self-doubt. He wasn’t angry for no reason; he was trying to keep her from collapsing into a sense of worthlessness. “It’s like he’s been working really hard for a long time,” she said. When I invited her to show him her adult self and let him know he wasn’t alone anymore, her whole posture softened. “He’s dancing around,” she smiled. “He likes being recognized.”

This wasn’t about “fixing” the part. It was about witnessing it, giving it space to reveal its purpose, and understanding that the behavior—however chaotic—was rooted in a core need to feel worthy and safe.

Sometimes I’ll say to clients, “Your parts are the embodiment of your needs.” Just as hunger leads to eating, internal discomfort drives parts to act. Some parts may seek relief through perfectionism, people-pleasing, or hyper-independence. Others may rebel, shut down, dissociate, or self-soothe in ways that don’t serve us. But underneath every strategy is a need trying to get met.

Another client, Amy, came in with a deep fear of abandonment. In romantic relationships, this fear would ignite what she once called her “rageful” part. But as we explored together, she realized it wasn’t rage—it was terror. This part would explode when she sensed her partner’s attention drifting to someone else, leaving her flooded, dissociated, and ashamed. “It’s not about jealousy,” she said. “It’s like I become a baby who’s terrified she’s going to lose everything.”

When I asked her what the part needed, she paused. “Space,” she said. “I’ve never had space when that happens. I’m always shut down or judged.” As we followed her imagery, she found herself sitting in a dark room next to the part—now a baby—who didn’t want to be left alone. Eventually, the baby let her pick her up, and Amy carried her out into a sunny garden, where she placed her in a bed of flowers surrounded by spirit guides. “She likes looking at the world,” she said. “She doesn’t want to be alone anymore.”

Through this approach we are able to reframe even the most disruptive behaviors as adaptations. IFS gives us language and structure to explore these adaptations without pathologizing them. It’s not, “I am crazy” or “I have to fix this.” It’s “A part of me feels terrified,” or “A part of me thinks I need to do everything perfectly.” That shift alone can help clients unblend from the reaction and move toward understanding.

With another client, Jules, we mapped out a part that tried to do everything—overhaul her routine, fix her emotions, be productive every minute. She called it “the do-everything part,” which would kick in after periods of zoning out or emotional overwhelm. We noticed how one extreme behavior would trigger the other: hyperactivation followed by shutdown. “It’s like I swing from one extreme to the other,” she said. As we tracked it, she recognized one part trying to outrun discomfort and another trying to numb it. Both were strategies to manage overstimulation. Both were trying to meet the need for ease and control.

To help her see this visually, I shared an illustration that shows parts at opposite sides of a boat, leaning out over the rails, both struggling to keep it from capsizing. When the parts are stuck in extremes, the boat rocks wildly. When Self is present, the system finds more balance.

These images help clients feel what’s happening inside. The metaphors give shape to the ineffable. At some point, I share that I see our parts as the necessary strategies of our humanness—adaptive patterns designed to keep us safe, secure, and connected in a complex world. Meanwhile, the Self is not just a better part; it’s something more akin to our spiritual essence—our capacity to witness, to love, and to lead with wisdom. The dance between our parts and our Self is the dance between our survival strategies and our soul.

I’ve found that IFS becomes much more accessible—and even playful—when we translate psychological jargon into universal experiences of need and care. And when clients begin to see their behaviors as expressions of their unmet needs, they soften. They get curious. They stop asking, “What’s wrong with me?” and start asking, “What do I need?”

That’s where the healing begins.

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The first time I met Carson, he was buried in a gray hoodie, eyes half-shut from the heavy hand of his medication cocktail. A support staff leaned in to whisper, “He might not say much. He’s usually either sleeping or checked out.”

I sat beside him on the floor—close, but not too close—and said something simple like, “You don’t have to talk. I’m just here.”

He looked at me, expression vacant, and mumbled, “It doesn’t matter, go away.”

It was barely audible. But it mattered.

That moment was the beginning of a journey that would forever change the way I understand suicidality—not as a crisis, but as a chronic condition. Not as something to eliminate, but something to understand. Carson wasn’t a crisis waiting to happen. He was a child living in a constant state of emotional threat, misunderstood by systems and buried beneath the wrong labels and meds.

And our job wasn’t to save him. It was to see him.

The Misdiagnosis of a Life

When Carson arrived in his last residential facility, he came with a file thick enough to flatten a small tree. The diagnosis section looked odd but had followed him for years. Each entry came with its own medication. Antipsychotics. Mood stabilizers. PRNs, to be used when needed for agitation and insomnia. Some were redundant. Some contradicted each other. All of them dulled him into a trance. I took Carson’s case on after he had been in the facility for several months because his previous therapist was leaving the organization, and they wanted someone with expertise in his symptomology to help.

The first few weeks of therapy were… quiet. Carson didn’t speak. He groaned. He slept. He ignored my existence.

And the records didn’t match the kid. Something felt off. There were flickers of intelligence behind the fog. Glimmers of social interest. A complexity that wasn’t captured in the notes that described him as “dangerous,” “manipulative,” and “noncompliant.”

One day, during a routine consultation in my office with Carson’s parents, I asked his mom what he was like as a boy—before the chaos. She teared up and gave me so many details of this smart, sensitive kid who had a favorite stuffed animal that as a teenager, he still kept.

That detail stuck. It was one of many pieces that didn’t fit the current puzzle but seemed critical.

I recommended a full psychological evaluation. I shared my observations with both parents—how what I was seeing didn’t align with the clinical picture he’d been painted into. And when the results came back, they hit like a tidal wave.

Autism Spectrum Disorder. Level 1. High functioning. Undiagnosed until age 16.

When I read the report, something in my chest tightened. It wasn’t just the numbers or the diagnostic language, it was the quiet, aching pattern that showed through between the lines. Soon after, I sat down with his parents to share what I’d uncovered. The moment I finished, his mother began to cry. Silent at first, then with a kind of grief that had been waiting many years to be named. Everything shifted in that moment. Not because we had all the answers, but because for the first time, Carson’s parents felt seen.

When Crisis Isn’t Crisis

What we’d been calling “manipulative outbursts” were meltdowns tied to sensory overload. What we’d labeled “oppositional behavior” was actually a trauma response from years of being misunderstood. What we saw as suicidal threats were not cries for help but expressions of internal overwhelm. Often, they weren’t indicators of a desire to die but of an inability to cope with the sensory and emotional chaos around him.

Carson wasn’t in an acute suicidal crisis. He was living with what I’ve come to call baseline suicidality—a persistent, underlying ambivalence about living that existed not because he wanted to die, but because life simply felt too hard to manage in his body, brain, and environment. He wasn’t impulsively unsafe. He was chronically exhausted. And our clinical model had been trying to extinguish a fire that wasn’t actually a fire—it was just the temperature of the room.

Human Before Risk

We began the long, messy process of titrating down Carson’s medications. It wasn’t a decision we made lightly. The psychiatrist was on board, the school team prepared, and most importantly—Carson and his parents were with us every step. We didn’t rush. We watched with the kind of careful attention usually reserved for miracles. Each taper wasn’t just about symptom management—it was about space. We were making room. Not for chaos, but for something far more powerful: for Carson.

The first time his eyes lit up during a session—really lit up—his mother covered her mouth, tears brimming. His father leaned forward, as if afraid the moment might vanish if he moved too quickly. I felt it too, that electric pulse of recognition. He was still in there. What we were hoping to see wasn’t a perfect child or even an easy one. We were hoping to see him. His preferences. His quirks. His voice. We were hoping for emergence. And slowly, he began to arrive.

I implemented what I called a Baseline Understanding Plan (BUP). A BUP is a treatment planning tool that is designed not just to respond to crisis, but to understand the whole child. Unlike traditional behavior support plans that activate once a youth is in distress, the BUP focuses on identifying what baseline functioning looks like for that specific youth, even if that includes behaviors like withdrawal, passivity, or flat affect. Instead of a traditional behavior support plan that only kicked in when Carson was in “crisis,” the purpose of this plan was to help the team identify  what “normal” functioning looked like for Carson (even if it included passive suicidal talk), what signs indicated escalation toward actual risk for him, and what interventions worked to soothe him that didn’t rely on physical containment or medication.

We created almost our own language that was unique to him because feeling emotions were not something he was used to and that made talking about them uncomfortable and awkward for him. We didn’t label him as angry, sad, or other feeling states, we spoke in a language that met him where he was. His version of “safe” still included some intrusive thoughts. That was important. His “safe” wasn’t the same as another child’s.

We trained staff to stop asking “How do you feel? Are you angry?” in a clinical tone and start asking, “What’s the volume in your head today?” This small change allowed Carson to talk about his experience without fear of being immediately placed on constant observation. We moved away from the binary of “safe or unsafe” and stepped into a spectrum of emotional tolerability. And in doing so, Carson finally began feeling like he had some agency.

Trusting the Process

It wasn’t all smooth. A few months into our work, after a hard family therapy session on grief, Carson ran from the room, slammed a door, and screamed, “I’m done with this life, no one will care! They don’t care!”

The staff froze. Old habits kicked in. They called for assistance. I gave him his space, because I believed in that moment it was most important for him to feel the emotions he was currently experiencing. I found him an hour later, curled up and crying on his bed, with his hoodie strings pulled tight.

“You said they’d understand,” he whispered. “But they didn’t.”

That moment gutted me. Because he was right. Our systems are wired to panic. And we had panicked at the first opportunity of him being expressive.

I brought the team together. We reviewed the situation, not to assign blame, but to recalibrate. Carson had screamed, “I’m done with this life!” and it rattled everyone. The team had responded with panic, thinking it was an immediate suicide risk. But when we stepped back, we realized the true trigger wasn’t a desire to die, it was his desperation to be understood, his frustration boiling over after being repeatedly redirected without being heard.

We updated his plan again. We named the real trigger: feeling dismissed and emotionally cornered. And we made a commitment, no more punishment for expression. Only redirection grounded in empathy, curiosity, and connection. Because sometimes, a child isn’t trying to end their life. They’re trying to end the loneliness in it.

Family, Freedom, and Flourishing

Over the next few months, Carson began to wake up. Not just physically but emotionally. The emergence was underway.

He started asking questions. He initiated games. He asked to help decorate the therapy room for the holidays. He wrote a poem about what it feels like to live in a body that doesn’t match the world. He shared that he wanted to try medication again—but only one, and only after reading the label.

His family work flourished. His parents were committed and were willing to read all the articles on emotional validation, autism, and trauma-responsive parenting, and do just as much work as their son.

We kept working from the same framework: support the baseline. Honor it. Understand it. Don’t panic when old language resurfaces. Instead, anchor yourself in connection.

We celebrated subtle victories. Not just the absence of any incidents but the presence of things like Carson advocating for a break instead of fleeing the room, Carson naming his internal state without shame.

By the time he was discharged, Carson was primarily taking vitamins, attending school full-time, and—his words—“not so scared of myself anymore.”

What Carson Taught Me

I’ve worked with hundreds of kids in residential care. But Carson changed the way I practice. He showed me that suicidality isn’t always a scream. Sometimes it’s a whisper, a hum, the static underneath the skin. And if we only train ourselves to react to fire, we’ll miss the people who are quietly drowning in plain sight.

He taught me that what’s “normal” for one child might be a red flag for another—and vice versa. Neurodivergent kids are especially vulnerable to being misdiagnosed, overmedicated, and misunderstood. The greatest intervention we can offer isn’t a protocol—it’s a pause. A pause to ask not, What’s wrong with you? but What happened to you? and What’s it like to be you?

***
Baseline suicidality won’t show up neatly on your risk scales. It won’t always trigger your alarms. But if we listen closely, it speaks. It says, “Help me stay, even when I don’t know why I should.”

Carson is thriving now. So is his family. He still has hard days. He still has maladaptive thoughts. But he also has tools, language, autonomy, and trust. And that trust didn’t come from saving him. It came from sitting with him, even in the storm, and believing that the storm didn’t define him. And he just recently successfully graduated from high school!

Sometimes healing doesn’t look like “all better.” Sometimes it looks like real. And Carson reminded me that real is enough.

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How do we support our clients in moving beyond limiting stories? How do we help them experience life’s rich complexity in the midst of what can feel like a never-ending barrage of emotional burdens? How do we help them focus on hard-to-face issues and make meaningful changes?

Here, some of the wisest souls in the world of psychology and psychotherapy share their answers to the biggest, most slippery questions we face—as therapists and humans.

***

TARA BRACH: How Do We End Suffering?

Clinical psychologist and renowned Buddhist teacher sheds light on the shadow sides of therapy and the spiritual path.

IRVIN YALOM: How Do We Live Our Best Life?

Psychotherapy’s most famous storyteller believes we should focus less on symptoms and more on the great, timeless issues of freedom, meaning, and mortality.

EUGENE GENDLIN: How Do We Cultivate Wonder?

The developer of the mind-body approach Focusing highlights the value of tapping into the dynamic experience of the “felt sense.”

DANIEL KAHNEMAN: How Do We Change Bad Habits?

Nobel Prize-winning cognitive research psychologist explores the role of automatic responses in human thought, and just how instinctively unwise we can be.

***

A version of this article was originally published in March/April 2013.

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The starting point for much of my work is the recognition that the body isn’t what we always thought the body was: a thing, a mechanical object, like an automobile that we drive or manipulate. A simple but powerful way to shift your experience of life is to take your attention and deliberately put it on your body.

At first, you may not get anything, but if you just stay there for about 30 seconds or a minute—or if you keep coming back there—pretty soon you develop what I like to call a “felt sense.” That’s a body sense of the whole situation: not just one feeling, not just that you’re angry or happy, but the whole Gestalt of what’s going on for you at that moment.

It’s comforting to be in touch with a felt sense. It’s like now you know in some immediate way that our experience of life is always an interaction of both the body and the environment. That doesn’t mean only interaction with another person. It’s how you’re sitting, what you’re inhaling, and the whole situation surrounding you. It’s the past; it’s what led up to this present moment. Most of us are still stuck in one spot or another in the past, and all of that’s in the body.

Focusing vs. Mindfulness

Mindfulness, at least as I see it being practiced by many people today, is like sitting at the head of the stairs and looking out at everything that comes up the stairs and saying “Oh, I see anger. Oh, I see impatience. Oh, I see this. Oh, I see that.” But I say, “Go downstairs. Don’t just sit there and be the passive observer. Go downstairs and see where everything is coming from.”

For their part, the mindfulness people say, “Make sure that you regularly go back upstairs so that you don’t get caught by every different emotion and every different feeling.” To which, I’d say, “Yes, but the focus needs to be downstairs, in the body.”

It’s also important not to consider the body as being somehow opposed to the conceptual, cognitive ability we have as human beings. To me, it’s a dialogue: the conceptual gives us an understanding in the body that’s important, and the felt experience of our body leads us further than we’re able to go just with what we can put into language or from our concepts about the world. So analyzing is important, but it needs to be in dialogue with the rest of our experience.

Wonder

The body has a natural tendency to say, “What’s next?” and to go forward. So when you’re working with someone in therapy who’s experienced something horrible, there’s always a part of the person that wants to move forward. It’s like when the picture is hanging crooked on the wall and something in your body tells you to get up and straighten it.

In this life, we regularly discover that there’s all this crap—the difficult experiences we try to avoid—but there’s also magnificence that we can sense. In animals, in trees, and in the rocks, there’s a magnificence that’s obviously there, and you can find it if you look out the window. But sometimes it seems far away over there, and it often comes mixed up together with the horror. That’s one of the biggest things to learn in life. The wonder of the whole thing is so much bigger than anyone can see. At this stage in my life, it’s more important to me to take it all in and not get distracted by trying to invent too many fancy phrases to describe it.

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I entered psychiatry as many people did in the 1950s, seeing a traditional, Freudian psychoanalyst four times a week. She was older and had a suite of five offices, all of them rented by therapists she’d once analyzed. She was like a grandmother analyst, and I guess you could say I spent 700 hours being psychoanalyzed by my grandmother.

Looking back, it’s clear it wasn’t 700 hours well spent. In fact, it offered a good instruction on how not to do psychotherapy. Despite all the time and expense, we never dealt with any of the issues that came to seem to me more and more the central concerns of life in later years: mortality, freedom, the search for meaning, and our ultimate existential isolation.

Then in 1958, psychologist Rollo May came out with his book Existence and, suddenly, I saw there was a third way for psychotherapy—something that wasn’t biological or psychoanalytic, but a way of grappling with the great existential challenges of life. I decided to write a textbook to further explore this new, alternative pathway for therapists. To do that, I felt I needed to do something bold that nobody else was doing at that time: I needed to talk to people facing their own mortality close up.

My ordinary patients weren’t prepared to do that, so I asked the other professors at Stanford and the faculty in the medical department to send me their dying patients so I could talk with them. By then, I had quite a bit of group experience, so I started seeing these patients in groups.

That experience was extremely anxiety provoking, for me and my students. It was so poignant and moving to listen to people trying to cope with the idea that they were going to die shortly that I actually developed night terrors, and many of my students watching these group sessions from behind a one-way mirror often ran out of the room in tears.

Psychotherapy’s Biggest Challenge

The thing that’s most troubling to me about our field is the demise of training in the kind of psychotherapy that I’m familiar with. These days, I feel that I’m a bit of a dinosaur. I’m in a group of 11 other therapists, a bunch of white-haired therapists, all with full practices who have more patients than we can see. But there aren’t going to be people like us in the future. If somebody wants a referral to a good psychotherapist now, I’ve got to really strain to find one. I find myself thinking, “They’ve got to see someone with gray hair, because the young psychiatrists aren’t being trained to do depth psychotherapy—or really any kind of psychotherapy.” Cognitive-behavioral therapy has taken over.

Recently, I met with a bunch of group therapists who each led, on the average, five or six groups. That meant there are about 80 therapy groups represented in our little seminar, almost all of them short-term, behaviorally oriented. The emphasis was on imparting knowledge, teaching people about subjects like panic attacks or other anxiety symptoms, giving them exercises to work on, and doing manualized treatment. None of them was interested in helping people focus on how they came across interpersonally or how to solve other interpersonal issues. That’s sad to me.

Being 82

I’m a little bit mellower about facing my own mortality at this point. I don’t have the uprising terror and anxiety that I used to feel. The other day, somebody sent me a picture of the Stanford faculty in 1963. It was wonderful seeing all my old friends. I thought, “Oh, I’ll e-mail this to some other people.” Then I realized that almost everybody else in the photo was dead. That was a sad moment for me.

At this stage of my life, I’m finding that once you get your mind around the idea that death isn’t so far off, you can actually learn to live a little bit differently. My wife, Marilyn, is slightly younger—a half-year younger than I—and we’re enjoying our times together very much. Recently it’s been warm weather, and Marilyn doesn’t want to do anything but sit outside in the sun and read the newspapers with me. It feels so good. We keep making jokes saying, “I guess these are the Golden Years,” and they really are.

I learned a long time ago from my group of cancer patients that there are many people, even in the midst of this awful illness, who actually start to change in a positive way. They grasp that they’re going to die and begin to say, “Why am I spending time doing what I don’t want to do? Why am I seeing people I don’t want to see?” They begin to reexamine what’s really meaningful and what’s trivial in their lives; they start saying no to things they don’t want to do.

Once you fully realize that you really are mortal and that you’re going to die, you can come to appreciate life more fully. You don’t waste quite so much time striving for material goods. As German philosopher Arthur Schopenhauer said, if you strive for objects all the time, eventually, you don’t have them: they have you.

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One of the things that distinguishes therapy from a purely spiritual path is the engagement with one’s personal story. The therapist collaborates with the client to look at the personal patterns that play out in daily life and discover what might help in coping more effectively and finding more ease and happiness. On the spiritual path, suffering arises from any identification as a separate self. The key inquiry on the spiritual path is how is this identification being fueled and what awakens us to our wholeness. In other words, therapy’s main concern is the story of the personal self. Spirituality includes that story but emphasizes who we are beyond the limiting notion of self.

In Western psychotherapy, sharing one’s personal story creates rapport and intimacy and serves as a portal to discovering where experience lives in the body and in the heart, but many people can get fixated on the story and never go beyond it. So that’s the shadow side of psychotherapy. The shadow side to what’s called spiritual practice is sometimes a dismissal of the story and the poignant constellation of feelings and emotions that surround it. So I think it’s important to find a middle way, where you honor the story, but don’t get lost in it. The Tibetan teacher Tsoknyi Rinpoche talks about our beliefs, stories, and emotions as “being real, but not true.”

That means we need to acknowledge that our beliefs feel real in our bodies and hearts, but don’t actually translate into the truth of reality itself—just like our thought of an apple isn’t the same as biting into and tasting it. If we can recognize that, everything starts opening up. We can honor the portal, but we keep reentering the real, living, dynamic reality that’s here.

The Power of Intentionality

When clients come to me for help, right from the start, I want to hear about what their deepest intention is. I invite them to go to the most sincere place in them and say what it is they’re really wanting. That lets me know how large a view they have of what’s possible, and it helps me say, “OK, this is where you are right now. Let’s take the first step.”

The first thing I’m doing is in some way asking, “What’s your hope? What’s your aspiration?” When we aren’t aligned with our deep aspiration, we suffer. There’s a question you can use to get at this that’s pretty straightforward: “What’s asking for attention in your life right now?” Suffering is a way of calling attention to a certain part of us that needs attention.

My assumption is that something in them is longing for what I call refuge, or for really coming home to a place of inner peace and a loving heart. I think that we’re all longing for that. I sometimes think of William James, who said “All religions begin with the cry for help.” We all sense the uncertainty of this existence, so everyone of us on some level is looking for what will allow us to feel more at home in our own being. Becoming conscious of our longing for refuge—for peace, for freedom—is an essential part of what energizes our path.

Opening to the Larger Self

There’s a wonderful teaching from Carl Jung that says that whatever within us that is unlived controls us. When we’re traumatized, we’ve got unlived fear in our body that needs to play itself out, and unlived grief that needs to be grieved. When we live the unlived life, that very process opens us to a larger sense of wholeness. The process of emotional and spiritual healing is one of living the unlived life.

Viktor Frankl wrote that between the stimulus and the response there’s a space, and in that space is our power and our freedom. When there’s unlived life, we’re caught in a chain reaction that keeps us from contacting what might feel raw or intense. By pausing and becoming present, we can tap the inner resources that give us our power and our freedom. We’re able to open to the unlived life and integrate this vital energy into the larger whole of our being.

Self-Compassion

The practice of self-compassion trains us to let ourselves be touched by the suffering in our own bodies and hearts, and actively offer care. In this culture, that’s radical, because we’re taught to pride ourselves on being rough and tough on ourselves, always trying to be in a self-improvement project. I often use the gesture of the hand on the heart because it deconditions that inner armoring and helps us discover this vast feeling of tenderness that can offer care inwardly.

Our survival-oriented brain makes it hard for us to stay with the places that are difficult inside us. We don’t want to be with unpleasantness. But there’s a very wise spiritual equation: Pain x Resistance = Suffering. We perpetuate our suffering because we have all sorts of clever strategies to resist emotional pain. Whether we busy ourselves or distract ourselves or judge ourselves, we just keep away from that pain. So the practice of self-compassion means training ourselves to quiet our minds, stay with our experience, and remind ourselves to come into the body and heart.

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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!

The terrain that therapists today are navigating is full of surprises, some of which could seriously trip them up, or worse, pull them under. If you’re regularly crossing boundaries between therapy and life coaching, how do you make sure you’re doing it ethically—in ways that won’t jeopardize your license or land you in court? If you want to grow your public-facing media presence, how do you successfully build your “brand” as a therapist without sacrificing your integrity? (Nine of today’s most successful therapists told us how they did it.) How do you avoid becoming a line item in a venture capitalist playbook if you join a mental health startup?

Join the conversation today!

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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.

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One key thing I did to enhance my “brand” as a therapist was share my own story publicly.

I’ll be honest—this wasn’t an easy thing to do, nor was it supported by all my colleagues. As therapists, we’re trained to hold space for others, to listen, to be safe and nonjudgmental. The unspoken rule is that we should maintain a bit of mystery about who we are and what we’ve gone through.

Before becoming a therapist, I’d worked in media/journalism, so writing about myself didn’t feel particularly difficult. However, I was told early in my graduate program by an older professor to delete everything I’d written online about myself and even forgo building Brown Girl Therapy, the first and largest mental health community for adult children of immigrants (now at a quarter of a million people!), which was born of my early struggles as a child of immigrants.

Early in my counseling career, I was faced with difficult questions: What if being honest makes me seem unprofessional? What if I’m not allowed to be a therapist and share my story?

Thankfully, I had professors and mentors who supported my work and believed in what I was doing. After all, I’m a community member first, who identifies as bicultural, who’s navigating many firsts in my immigrant family, and who’s been in therapy on and off for a decade and takes antianxiety medication.

As a narrative therapist, I firmly believe that storytelling shapes the way people make sense of their lives. We all have a story we tell ourselves about who we are, where we’ve been, and where we’re going. But I’ve also realized something else: the stories we don’t tell, the parts we hide or skip over, often hold the key to our healing.

My vulnerability is what’s created connection in the enormous online community I’ve built, one that’s a bridge for so many of us who’ve been left in the margins when it comes to mental health care.  When I shared my story, beyond the confines of an individual therapist’s office, it became a conversation and a shared experience between lonely humans who didn’t see themselves—or their experiences—represented in the culture at large.

Since then, I’ve continued to be open about my mental health journey, most recently in my book, But What Will People Say?. Turns out, the parts of myself I thought were too raw or messy to share were what resonated the most with others. And far from being a hindrance to building my career, it’s made me a more authentic, relatable, and effective therapist.

For me, success hasn’t been about “branding,” but about showing up honestly and truthfully, and meeting the community—my community—where they are. The process has been humbling. I’m not the expert of other people’s lives, but by being more forthcoming about my own experiences, I’m able to help others live a little more well.

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I welcomed my second child into my life eight months ago, and it’s reshaped my relationship not just to my work, but to the way I think about “brand development.” We often hear that parenthood helps us develop the capacity to say no and get clearer on the things that are a wholehearted yes. That’s been true for me. Parenthood has helped me reshuffle priorities personally, socially, and professionally.

Branding and visibility have become less about numerical growth (such as getting more followers on social media platforms) and more about nurturing the people already in my life and practice, encouraging them to deepen their interest in the work I’m putting out into the world. Instead of chasing expansion, I’m focusing on depth and fostering richer engagement with the community I’ve already built—the clients I still see; the people who’ve read (or will read) my book, The Origins of You; my current followers on Instagram, and the people who’ve subscribed to my newsletter.

This shift has meant making some big decisions. I’ve said yes to fewer things, and been deeply intentional about what I take on. Now, I only step onto stages with people I respect and admire, recognizing that part of building your brand or your business is about allowing yourself to be influenced by others and to collaborate with those where reciprocal elevation is available.

One way I’m doing this is by co-creating a course with a friend and colleague called “Secure and Thriving: A Nervous-System-Based Path to Healthy Love.” This project feels expansive and aligned with my values, but also my bandwidth. There’s hard work involved, of course, but because I’m doing it within the context of a richly nurturing friendship, there’s also laughter, play, and fun. These kinds of sustainable collaborations have taken center stage for me, right now.

I’ve also made the difficult decision to see fewer clients. I adore working with people one-on-one, and in an ideal world, I’d still see 25-30 clients per week. But this chapter of my life requires something different. Instead of pouring all my energy into the therapy room, I’m channeling it into work that reaches more people while also allowing me to be present for my family.

This change hasn’t been easy. Friction accompanies shifts in identity, but friction and tension contribute to growth and expansion. I remind myself that evolving my brand doesn’t have to mean losing what I love—instead, it can mean reshaping it. Right now, my brand isn’t about more. It’s about meaning. It’s about creating with intention, collaborating with care, and building something that sustains not just my career, but my life.

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When I think back on what I’ve done over the years to grow my work as a therapist and my business—which includes my couples therapy practice, my writing, and my social media presence—I realize that I often did the opposite of what many influencers tell people to do.

Many influencers encourage therapists to grow their income and build their practice by charging for almost any service, including speaking engagements and consultations. But as my online presence has grown over the last decade, I’ve taken an approach that might be counterintuitive. I don’t charge for everything, and this has helped me grow my income. Even now, after writing books, cultivating a large online following, and creating a successful practice, I still agree to free speaking engagements, offer consultations to other practices at no cost, and do pro bono sessions.

Of course, we all need to make a living. However, I’ve found that there are often opportunities—like connecting with others and lifting them up or taking a meaningful speaking engagement—that are priceless in many ways. In fact, it’s often the unpaid events that have had the largest impact for my career, even years later.

When I first started my practice years ago, I sold almost everything I owned so that I’d have the money to rent an office space and buy a new computer. I spent many nights cobbling together a website and learning the nuts and bolts of SEO. I also did a ton of networking to grow my clinical skills. I reached out to supervisors I admired (paying for their services with credit cards I knew I wouldn’t be paying off for a while), and drove all over the country to learn from experts I felt drawn to and maybe take them out for coffee, just to pick their brain and share a little bit of who I was.

I also held free workshops for churches and universities and shared my therapy knowledge on Instagram (before it was a thing). I knew many people didn’t really understand what couples therapy entailed, and I wanted to demystify it. Since then, my Instagram account has grown to nearly 300K followers. I’ve founded A Better Life Therapy, a group practice dedicated to helping people improve their mental and relational health. I’ve also written several books for couples and developed my signature couples weekend intensives aimed at helping couples get through crisis.

There’s a lot of noise out there claiming that therapists wanting to grow need to brand quickly so that eventually they’ll create an easy life for themselves where they’re simultaneously doing important work, enjoying lots of free time, and making loads of cash. But I’ve found that when it comes to growing professionally, that’s the exception, not the rule. Instead, I think we should be willing to make sacrifices and stay open to opportunities. Fortunately, that’s been the formula for success for me, and I’m grateful for where I’ve landed.

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Not long ago, my heart leapt the moment I saw the email in my inbox from my talent agent. “Please be a TV show, please be a TV show,” I whispered to myself as I clicked. It was! A network was looking for a therapist … yes … for a new television series … yes … on a major network … yes … about nude psychotherapy … no.

I’ve been building my brand as a public-facing relationship educator and clinician for many years, and I’ve had to learn how to practice discernment regarding partnerships. At the start of this journey, I was so grateful for any opportunity to get my name out there that I said yes to everything.

“Want to be a guest on my podcast?” Absolutely!

“Can you write a 500-word article for my website?” Of course!

“Can you come speak to my group of 30 people? We don’t have the budget for compensation, but it’ll be great exposure.” I’ll be there!

As my platform grew, so did the number of inquiries I received. Soon, I was feeling overscheduled and on the road to burnout. I quickly realized that my inclination to say yes to everything was going to lead me to a point where I’d have to say no to everything.

To prevent this from happening, I use a simple formula to rein myself in. I like to visualize the formula as a triangle with a question in each corner. Corner 1: Is it financially lucrative? Corner 2: Does it expand my audience? Corner 3: Is it an inherently fun, rewarding, and/or meaningful experience? To qualify as a potential yes, it needs to hit two of the three corners.

You should know that I have a love-hate relationship with this formula. Just like a budget keeps you from buying everything that looks cute at Nordstrom, and just like a portion keeps you from eating a full sleeve of Thin Mint cookies, this formula keeps me from straining my neck from nodding yes too much. This formula is both good for me … and a total buzzkill.

The nude psychotherapy show was a clear no, but another opportunity I recently had easily hit all three corners: creating a new series for MasterClass, called MasterClass In Practice. My yes wasn’t just about their enormous audience (4.2 million on Instagram?!) or the fact that I’d be one step closer to meeting my icon, Gloria Steinem. It was also about an opportunity to do what I’m passionate about—teach people how to practice Relational Self-Awareness—on a scale I can’t possibly reach on my own. Being part of the MasterClass faculty is a BHAG (Big Hairy Audacious Goal) for sure, a peak experience built atop thousands of my Instagram posts, blogs, talks, books, and podcast and media interviews.

Had I not implemented this formula years prior, I wouldn’t have had the bandwidth to say yes to this incredible opportunity. I wouldn’t have had the time or the mental energy to put together a quality curriculum. Saying yes to too many okay things would’ve forced me to say no to the really big, incredible thing. As I continue to grow as a public-facing clinician and thought leader, the triangle formula ensures that I keep moving forward and let go of things that no longer serve me.

Still, it’s never a perfect journey. Each next step is a risk. You may say no to something that takes off, leaving you feeling like you missed the boat (been there!), and you may say yes to something that ends up being largely a dead-end. What I try to come back to again and again is that each risk is a learning experience that teaches me and readies me for what’s next. Regardless of what happens, I feel sure I won’t regret saying no to nude therapy.

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The healthcare field needs intensive care.

Not only is it a field filled with high-stress workdays, legendarily rigorous training programs, sparse staff-to-patient ratios, and mountains of bureaucracy to navigate at every turn, but it’s also a field where exposure to physical and emotional trauma is as regular as the sound of beeping machines on an ICU unit. Nonetheless, doctors and nurses are expected to remain calm and dispassionate. Feelings aren’t simply discouraged: they’re seen as a job hazard.

And yet these health care professionals, however heroic, are also human. The work they do impacts them. They need help processing difficult experiences and coping with stress just like the rest of us—or maybe even more than the rest of us. Which begs the question: Who heals the healers? And how?

Jessi Gold, a popular psychiatrist who’s been featured in The New York Times, HuffPost, Time Magazine, and Forbes—and is also the chief wellness officer of the University of Tennessee System—started asking herself these questions during the pandemic. Gold’s recent book, How Do You Feel? One Doctor’s Search for Humanity in Medicine, chronicles her experience helping physicians, nurses, and medical students through that challenging time—along with what she discovered while seeking balance amid intense professional burnout.

Recently, she and I sat down to talk about the state of the healthcare field and how to best help our fellow providers in the medical profession.

Ryan Howes: Why is the medical profession so hard on medical professionals?

Jessi Gold: Medicine has long been one of these fields in which having feelings and being impacted by our work is seen as weakness. Vulnerability isn’t a goal doctors and nurses are supposed to strive for. Rather, it’s seen as a barrier to moving forward in your career. Having feelings is seen as selfish. For example, if I’m your doctor, and you tell me you’re dealing with something hard that strikes a chord in me, or if I see a patient die and it affects me emotionally, then it takes away from you. We learn that’s not what a good doctor does.

RH: So there’s a belief that you’re serving the patient by denying your own humanity.

Gold: The field values hard work and putting other people before oneself, which is understandable. But it often leads to healthcare professionals not feeling, not taking days off, not sleeping, not eating, and not peeing. There are things to admire about selflessness, but absolute selflessness isn’t sustainable. You can’t just give and give. After a while, there will be nothing left to give.

RH: Obviously, we don’t want brain surgeons to be immersed in their feelings in the middle of surgery. But when surgery is done, how can they switch their feelings back on?

Gold: You can detach from your feelings and reactions in the moment to do your job well. The danger arises when your job becomes your existence.

There’s a false assumption that we can detach from our feelings all the time and somehow come out okay. We start that way because we have to, and then it feels like that’s the only way to function because that’s what’s modeled all around us. We worry that if we don’t do that, we won’t be able to handle our jobs. In my book, I share about a time when I was very excited because I didn’t cry in front of a patient, and my therapist was like, “Why is that a good thing? Why are we high-fiving over this?”

I also tell a story about a patient of mine who was an ER doctor who went to an opera, and someone in the audience died. Everyone else was horrified, but she just wanted to get back to the opera. For her, it was like, “Oh, here’s death again.” We become really detached from normal human reactions to things that most people would find very disturbing.

RH: Is it true that going to therapy can have negative career repercussions for medical professionals?

Gold: It is really not true anymore, but you’ll always find someone with a story about a doctor who tried to take care of their own mental health and was somehow punished for it by having their license revoked. This may have happened a lot in the past, when medical licensing boards didn’t understand mental health conditions or how they played out in the workplace. But over time, most of them have changed their mind about the value of mental health treatment. Organizations like the Dr. Lorna Breen Heroes’ Foundation are pushing to change the wording
on some licensing applications, so it doesn’t inadvertently punish people for going to therapy. After all, it’s supposed to evaluate whether you’ll hurt a patient based on your mental health, not whether you’d benefit from therapy. In fact, I was told to go to therapy during my training as a psychiatrist.

Sure, someone can say, “You shouldn’t be practicing while you’re depressed.” But all that means is that it’s in your own best interest—and the best interest of your patients’—to notice signs of depression or burnout early and address them.

Right now, we tend to take a stop-the-bleed approach to care. Also, we tend to overwork to compensate for all kinds of other feelings, because when we overwork, we get praise. It’s the culture we live in. However, we can help people recognize that the more they take care of themselves, the better they are at their job. Taking care of themselves shouldn’t be viewed as a last resort, the way it is in the medical field.

In this culture, we’re all starting at 50 percent burnout, so chances are you can look around and say, “Jimmy looks sadder than me, and Frank isn’t sleeping either, so I think I’m good.” But your measurement scale is out of whack.

RH: How do you distinguish between regular workplace stress and burnout, particularly for healthcare workers and therapists?

Gold: Stress, in general, is a physical response that helps you get stuff done. If you have a test, the stress boosts your adrenaline, and you finish the test. The stress is temporary. Burnout, on the other hand, tends to stick around and decrease your sense of personal accomplishment. You feel ineffective, emotionally exhausted.

RH: What advice would you give a therapist who’s starting to treat a nurse, physician, or other healthcare worker?

Gold: First, I wish there was a certificate program for treating healthcare workers because we’re a weird subculture. Healthcare workers don’t like to talk about how they got to where they are, so knowing a little about their training and what they do in residency—sort of like with any cultural competency—avoids putting them in a situation where they have to educate you or re-explain stuff. What I hear a lot from healthcare workers is that the therapists they like are the ones who don’t give them suggestions that make no sense given their workplace. For example, you can’t tell them to sleep. That’s not helpful. You can say, “What’s your sleep look like?” But you can’t say, “My recommendation is you find a way to get eight hours of sleep a night.” They can’t do that. It’s more important to figure out what they can do.

Teaching quick skills is helpful—deep breathing or other relaxation tools or tips for self-compassion at work. CBT-based exercises are often quick and helpful. It also helps to recognize this population needs you to have some flexibility when scheduling sessions, because their schedule can be erratic. When I was in residency and on night float, my therapist saved me a morning time slot, and if I couldn’t make it, she understood and waived the missed session fee. Recognize that your healthcare worker clients want to come to therapy, but might need an after-hours time, or a weekend slot.

If you want to see healthcare workers, put that on your therapist profile and on your website, even though it’s not an official specialty. Also, understand that healthcare workers are coming from a field that doesn’t talk about mental health often, so it’s hard for them to even be in therapy. Be patient with them. They’re usually not comfortable with feelings, so you’ll get a lot of alexithymia, avoidance, and intellectualization. They might be uncomfortable with the process of therapy for a while. I was—and sometimes still am!

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Lately, I’ve been noticing an emerging trend—one that may be flying under your radar but reflects conversations I’m having each week with therapists. More and more colleagues are expressing a desire to move beyond the constraints of insurance and geographic limitations, or to shift away from a constant focus on trauma and suffering. They’re not looking to abandon their current caseloads or stop being therapists, but rather, they want to add something new—something different.

They’re desperate for a change, much like my client Ari, a therapist who’s been operating a solo private practice for the past decade and is beginning to feel a pervasive sense of fatigue. During a rare summer break at the beach, she read a book on resilience that encouraged her to assess all areas of her life to identify what was draining her energy. This led her to reconsider her caseload, full of complex trauma cases. Of course, she could adjust her schedule of 25 sessions a week, but was that really the source of her exhaustion? She dug deeper and realized that while the number of clients she was seeing might play a role, it was the constant focus on abuse-related trauma that was wearing her out.

“I’m burning out, Lynn,” she told me during our first business coaching consultation. “I have a full caseload and a wait- list of adults who were abused in early childhood—I do trauma work. The work can get complicated and dense at times, for my clients and for me as their therapist. I’m not going to stop being a trauma therapist: I feel called to do it. But I want to add a different type of service to my practice . . . a really different type.”

“What would that look like?” I asked.

“I’m the parent of an Autistic child. He’s finally launched, in his first year of college, but getting him there taught me a lot about parenting neurodivergent kids and how to navigate the resources available. I think I can give other parents ideas, hope, and guidance—but not as a therapist, more like a partner who supports their journey.”

“You want to be their coach,” I said.

“Yeah,” Ari responded, smiling wryly, “but every time I mention the idea to my colleagues, they either shake their heads in disdain—like, ‘Oh no, not you too’—or they cringe—like, ‘Why would anyone want to be a coach when you have a license to practice therapy?’ I hope you can help me figure this out. What’s the difference between a coach and therapist these days anyway?”

Two Professions Colliding

I identify primarily as a therapist, but I’ve also worked as a coach in various capacities for over 30 years. Given my diverse background, transitioning into coaching as a therapist wasn’t difficult. After all, therapy was my second or third career, following an undergraduate degree in art, managing the family scrap metal business, running a small side business, and eventually returning to school for an MSW. I quickly built a private practice; and while my work as a therapist was deeply fulfilling, I missed the strategic mindset I’d used in business.

Despite having a full therapy caseload and being a single parent, I made time to complete a two-year coach training program. At first, I wasn’t sure how I’d apply what I’d learned, but as managed care began to stir anxiety among therapists, I began teaching small groups of therapists in my office how to navigate the business side of their practice. Over time, I began writing, presenting, and consulting to translate business concepts for therapists—all within a coaching framework. Eventually, I joined the faculty of a large coach training school, and I wrote books and articles about coaching to help therapists—my home team—better understand the newcomers on the field.

When asked about being both a therapist and a coach, I’d explain that my work as a therapist informed my coaching. But as coaching developed into an established field with its own body of knowledge, I found the reverse to be true as well: coaching informed my work as a therapist. Integrating both professions enriched the entire spectrum of my work.

Therapy and coaching have always been kissing cousins. From its inception, coaching looked at many professions for content and wasn’t shy about borrowing from the arena of personal growth. No wonder therapists initially dismissed coaching as a fad or therapy-lite, a lesser version of therapy. But in the last decade, coaching has begun to push the boundaries of mental health services even further. Established therapeutic methods are transforming themselves into coaching methods. A quick internet search shows providers offering “narrative coaching,” “acceptance and commitment coaching,” and “ADHD coaching.” Some find the blurring of solidly therapeutic mental health treatment methods into coaching programs disconcerting, and I agree that trying to make sense of these blurred lines is an example of the challenges within the unregulated coaching profession.

Most coaching training is offered via for-profit, individually owned, non-university-based centers. Without regulation, many public offerings from coaches can be misleading in tone and content. Perhaps most concerning, anyone can call themselves a coach without requiring formal training or certification. This is why Ari’s colleagues had scoffed in disdain. Coaches can be an unregulated, overpromising, and underperforming bunch. While this creates a “buyer beware” market for those seeking coaching services or training, coaching remains in high demand. Why, despite the lack of regulations, is coaching so popular?

One reason is that coaching fills an unmet need. It bridges the gap between therapy and proactive self-improvement. Many people want help, but don’t consider themselves in need of psychological “treatment.” Instead, they’d say that they want to improve life skills, gain confidence, or set and meet specific personal and professional goals. But they’d like to do this with guidance and help, one-on-one. The upside for therapists is that now, because this gap is defined and coaching is widely accepted as another avenue for personal growth, it provides therapists with an opportunity to expand their services.

Taking this one step further, I believe therapists often make the best coaches. A coach with a master’s degree or higher in mental health can be incredibly reassuring to clients. Not only does this background add credibility, but it brings a deeper understanding of human behavior—something that can significantly enhance the effectiveness of coaching. Evidence bolsters the need and place for coaching. Current research suggests coaching can be an effective, available, low-intensity intervention, offering an alternative to traditional clinical treatments for depression and anxiety.

Defining the Differences

When Ari asked for my help to clarify the difference between therapy and coaching, I was reminded of a plenary discussion I attended back in 1996, sponsored by the only coaching certification organization at the time. I listened with growing concern as a panel of coaches tried to differentiate coaching from therapy. One panelist said, “Coaching focuses on the present and future, while psychotherapy focuses on the past.” Another added, “Coaching is about achieving goals, while therapy is about developing insight.” Others chimed in, “Coaching is short-term, while therapy can take years,” and “A coach listens and talks back to you like a real person, while a therapist is a silent, blank screen.” As the only therapist in the room, I explained that these definitions were overly simplistic at best and inaccurate at worst. We therapists know that psychotherapy, a profession that has existed for over a century and includes hundreds of methods, can’t be neatly summed up in one sentence.

Still, there are distinctions—and an important one lies in the populations served. Therapy is designed for those dealing with varying levels of vulnerability and need; while coaching is appropriate only for those who are functional enough to take action steps, even if those steps are small at first. Another is the setting: Therapy sessions must be confidential and contained to support treatment objectives and methods. Coaching sessions should also be confidential; however, coaches often work in informal, less restricted settings—such as meeting with a busy executive in a local coffee shop.

Although there are differences in the purpose of therapy and coaching, there’s also overlap. The extreme examples of each—say, psychoanalysis versus sports coaching—makes it easier to see. But modern cognitive therapy and life coaching often aim to achieve similar objectives, such as helping clients feel self-actualized and productive, or building confidence, self-awareness, and better relationships.

When the goals of therapy are comprehensive—to help a person gain insight, heal emotional wounds, eliminate self-destructive behaviors, or bring about characterological development—therapy again becomes distinct from coaching. Therapists take a long view of progress and therapy is typically process-oriented—a dynamic, ongoing treatment that delves into both conscious and unconscious drives. A therapist might consider the therapy successful if, after treatment, a client has made subtle internal shifts in thinking, feeling, and behaving, even if the client is functioning in the world in a low to moderate range. Part of the purpose of therapy is wrapped up in its developing, emergent process.

In contrast, coaching is typically more structured and focused on cognitive development, with a clear, time-bound framework designed to help clients achieve specific goals. The hallmark of coaching is action, which serves as the primary measure of its effectiveness. Key questions to assess progress include: What specific changes have occurred as a result of coaching? What actions are planned next? Can the coach and client quantify progress in observable terms?

The major coaching schools, to their credit, have also been working hard to define what coaching is by identifying a set of eight, detailed core competencies, known as the “coach approach.” Those who are certified and trained in accredited schools are expected to adopt this approach, sometimes also referred to as “pure coaching.” The core competencies have evolved over time, but in my opinion, four factors remain central to coaching. The first involves the locus of control. In the coach approach, it’s understood that the client holds the answers and is the source of their own transformation. Coaches are there to facilitate change, but the client is the one who owns and directs the results.

Pure Coaching

This distinction between therapy and coaching is why coaching presumes the client will be “coachable”—functional, with minimal mental health issues, emotional challenges, or psychosocial complexities, trauma-free with readily available problem-solving skills to find their own answers. Along with this client-based locus of change, there are three more keys in the pure coaching model:

Partnership. Coaches, particularly life coaches, engage with clients from an informal, nonhierarchical position. They aim to be collaborative and authentic, “leveling the playing field” to motivate and encourage clients. They’re less distant or removed than a therapist might be. This positioning helps support the next element: action. (In contrast, therapists take on many roles. At times, we need to be blank screens or avoid self-disclosure to keep the client central to the treatment. Occasionally, we must take a more hierarchical stance, making difficult decisions like recommending hospitalization or providing expert guidance to move forward with a treatment plan.)

Action. Achievement is the hallmark of coaching. Trained coaches use a toolkit of skills to help clients do more and go further, assuming the client is already functional. (In therapy treatment, action is not always a prescribed or welcome outcome. For example, it must be balanced with awareness, insight, emotional regulation, or developing new and better cognition prior to taking next steps.)

Possibility. Coaches are an optimistic bunch. They don’t pathologize problems. They work in the realm of what’s possible and focus on vision, purpose, mission, success, and effectiveness—future-oriented, affirming concepts that drive action and motivation. (Distinct from this, therapists learn to hold an honest, unsparing and at times diagnostic view of a person or situation, to help heal trauma, suffering, grief, and loss in ways that coaching is not designed to tackle.)

In a pure coaching approach, all four of these elements must be present in each and every coaching session. While therapy sessions may include some of these aspects at various times, most therapy models don’t require this exact formula to be present in every session. Coaching, at is most pure expression, is a different method.

The Business of Coaching

How does a therapist pivot to be a coach? I have a business mantra I learned early in my coach training: integrity first, needs second, wants third.

Now that Ari was ready to focus on the logistics of setting up a coaching program in an ethical and professional way, the integrity question meant protecting her therapy license by reviewing her state licensure and code of ethics to determine whether offering coaching as a separate service would affect her professional standing. When she found nothing that would prohibit it, I encouraged her to purchase additional liability insurance specifically for coaching if it wasn’t already covered by her existing malpractice insurance. Ari was exploring membership with the International Coaching Federation, the leading global coaching certification and accrediting organization, which would provide her with a clear coaching code of ethics to follow. To further protect her licensure, we also discussed:

No dual relationships. Given that therapist and coach are separate roles for a therapist, Ari would decide whether to take on the role of therapist or coach for a particular client and stick with that choice. She would not see a client for therapy and then later agree to be the client’s coach.

Maintaining existing therapy policies. In her therapeutic role, Ari already had a social media policy, billing policy, informed-consent packet, and signed contracts for new clients. I recommended she maintain these same policies with her new coaching clients in order to protect her therapy license. Why? Many licensing boards consider a therapist’s primary role to be that of a therapist, and any complaints lodged could result in the therapist being held to the ethical standards of their licensure—even if they’re acting as a consultant, teacher, presenter, or coach.

Identifying a coaching platform. Ari was no longer limited by geographic boundaries when it came to seeing coaching clients, giving her a national platform to reach out to parents across state lines, so when she thought about what to charge, I recommended she look at several criteria: her potential population, the results her services could convey, the market of coaches working in a similar way, and, with my help, a business plan. We decided that her fees for coaching would not match the insurance or fee-for-service model she currently used for therapy services. Instead, she decided to price coaching fees in packages of 10 sessions to encourage parents to see her coaching as a valuable set of strategies and tools, similar to a highly customized course that one would take. Once she finalized her new coaching fees, she set up a system for her coaching notes and administrative record-keeping that would be distinct from the practice-management system she used for therapy sessions (which handled insurance billing, note-taking, and diagnostic coding.) Keeping her coaching administration separate provided an added layer of protection, ensuring that her coaching services wouldn’t be questioned as another form of therapy.

Transparency. Ari worked to clearly define her coaching services, pricing, packaging, and programs on a separate coaching website, as her focus on parenting was distinct from her therapy practice. Since a website is a relatively low-cost way to advertise and gain online visibility, she believed that having two separate websites—each with its own focus—would reduce confusion for potential therapy or coaching clients. On the coaching website, she included a detailed explanation of what coaching entailed and, in the FAQs section, used clear language to differentiate coaching from therapy.

Then, she considered her business needs: finding coaching clients, which required a basic marketing plan that I helped her put together. Finally, she got clear on her business wants: hosting a podcast with her son, so that he could talk about his lived experience as an Autistic person. Despite her excitement about the idea, after evaluating the time and effort she’d need to expend to start her coaching practice, she decided to hold off on the podcast until everything else was in place.

My continued coaching support helped Ari cope with her early unrealistic expectations that her business would take off immediately and find the tenacity to stick with her plan. At each session, I encouraged her to appreciate what she’d already achieved, rather than just lamenting what was left on her to-do list. Our motto was: small steps count. After six months, Ari was ready to space out our sessions with some breaks, and I readily accommodated her.

Coaching Ari meant trusting her judgment to set the pace of our work, while I offered partnership, structured action steps, and a steady focus on possibilities—ensuring she could experience the kind of coaching she might one day offer others. My coaching style incorporates a strong element of business consultation, so Ari also received practical guidance as needed. Over time, she naturally embraced a new coaching role, skillfully balancing the unique demands and approaches of both professions.

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“I’m worried I’m going to disappoint you,” Jade says quietly. I take a deep breath and notice my heart aching for the young supervisee in front of me. I suspected something was brewing from Jade’s backlog of unwritten session notes and unanswered emails. This cohort of prelicensure therapists, some of whom I’ve known since their internships, has gone through many things graduate school didn’t prepare them for: a pandemic, which meant learning how to be a therapist via telehealth before they even sat in a room with a client; a national uprising for racial justice and Black liberation that had been sparked by a brutal murder in our own city of Minneapolis; and the hardships of becoming a therapist. Some of them have gone through all of this while holding marginalized identities that are too often met with micro- and macroaggressions not only from outside the field, but from professors, clinical supervisors, and colleagues.

“You can’t disappoint me, Jade. You’re an excellent emerging therapist. I know you have a lot of notes to write, but that’s not uncommon for people at your stage of professional development. We can figure out some strategies, unless there’s something else . . .?” My voice trails off as I leave space for their answer.

Jade sits up a little straighter. “I’ve decided not to pursue licensure. If I can’t make it in a practice as supportive as this, I’m not sure being a therapist is for me.”

My supervisor’s heart breaks just a little for another therapist lost to our field while my words explore the reasons behind Jade’s decision. I provide them with reassurance that I’m not disappointed, just sad that our field could not do better by them.

When I first became a supervisor several years ago, this kind of conversation was fairly rare, but it seems to happen more frequently nowadays. What’s changed, especially for minoritized supervisees? While our field has been somewhat successful in attracting a more diverse range of students, we haven’t adapted to meet their needs or the challenges presented by these politically turbulent times.

Every week, I witness the consequences of an ever-increasing allostatic load—amplified by the impact of the climate crisis, multiple genocides, late-stage capitalism, and an openly transphobic, ableist, racist and xenophobic cultural environment—pressing on the shoulders of prelicensure and licensed colleagues alike. But for the former, especially those who’ve been marginalized, this impact seems far greater since they haven’t yet developed the tools or networks that might help them bear it. And it’s causing them to burn out prematurely or to leave the field altogether.

This is, in many ways, understandable. Alongside my disabled supervisees, I’m deeply affected by the current attacks on many aspects of the Americans with Disabilities Act. With my trans and nonbinary supervisees, I fear what devasting news will come across my screen on a daily basis. What new hate crime, traumatic event, or executive order will lead us and our loved ones to wonder whether any of us can ever truly be safe, even in refuge states? Those of us who are immigrants have been triggered by the countless ICE raids. Indigenous communities continue to be devastated by ongoing genocides, while Black and Brown people keep experiencing never-ending cycles of racism and anti-Blackness. This is not the world graduate school prepared me or many of my supervisees for.

Given the small number of minoritized clinical supervisors in mental health, minoritized supervisees often experience supervision that’s culturally misattuned—even harmful—on top of everything else. How do we guide the minoritized prelicensure and early-career therapists in our care through this landscape that seems full of land mines at every turn, especially if we’re impacted by the same systems of power, privilege, and oppression? I don’t have any magical formulas, but I do have some guiding principles.

First, it’s important to acknowledge the current cultural climate, as well as the challenges faced by minoritized supervisees, without denying or minimizing the increased allostatic load they carry. This might seem simple, but it can often be a missing element in the supervisory relationship. Reducing the obstacles our supervisees share with us to individual problems only reinforces a sense of moral failure in them. To avoid doing that, we need to honestly and critically look at the messages we’ve internalized in our training and professional development. For example, we might have unrealistic expectations about the number of direct client-contact hours a prelicensure clinician might be able to provide, especially via telehealth, while dealing with significant systemic issues or the low levels of pay we expect early-career clinicians to unquestioningly accept. It’s important we educate our supervisees about how insurance reimbursement works and the hidden costs of running a therapy practice, as well as support them in deciding which direction to go in their career.

Another vital element of supervision, often sacrificed due to time constraints, is our self-of-the-therapist work—reflective, personal healing that’s essential for us to become more self-aware and address any unresolved or lingering issues that might impact our clinical practice. This work is especially critical for supervisees who are minoritized and face micro- and macroaggressions on a daily basis. They need us to directly ask about mental health issues that commonly occur in the face of systemic oppression: depression, anxiety, substance use, and suicidality. Sadly, those issues are often considered taboo in supervision or are approached in a punitive manner, like when a supervisor says, “I think you should stop seeing clients immediately,” rather than addressing them in an open, supportive way. This can lead many early-career clinicians to hide their struggles from their supervisors until it’s no longer possible, and in some cases, until after they’ve been significantly harmed.

Those of us who are supervisors are ultimately responsible not just for our individual supervisees or mentees, but for the legacy we leave in the field of mental health. Are we committed to creating and nurturing spaces in which minoritized supervisees can more safely and effectively practice and grow as clinicians? Are we advocating not only for more diversity in the field, but also for just practices in education, employment, and clinical supervision? Are we ready to bring the shadow aspects of our field, especially in clinical education and supervision, into the spotlight?

Until we do so, promising therapists like Jade—exactly the kinds of therapists we want to attract—will prematurely burn out and leave the field. How many people like Jade are we willing to lose before we’ll face the reality that our field needs to change to provide a healthier practice environment for minoritized prelicensure and early-career clinicians? While Jade is doing just fine and is much happier using their skills for coaching and dedicating more time to their artistic career, the field of mental health is poorer for their absence.

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As a therapist, you work hard for your money. But did you know that you have multiple options when it comes to saving for your retirement? From simple plans like traditional IRAs and SEP IRAs to more complex investment options like 401(k)s and Cash Balance Plans, there’s plenty to choose from. But how do you know what choice is best for you?

As the managing partner of a CPA firm specializing in supporting mental health professionals, I’ve spent over 20 years helping therapists just like you maximize your bookkeeping, tax strategies, and financial clarity, so that when the time comes, you’ll be ready for retirement.

First, some basics: why do retirement plans matter? As a therapist, you know how important it is to help others plan for their future. But what about your financial future? Whether you’re a new therapist, starting your own practice, or considering transitioning from a solo therapy practice to a group practice, choosing the right retirement plan is crucial for your long-term financial security, and the earlier you begin thinking about retirement—whether you’re solo or have employees—the more you can take advantage of tax benefits, compounding growth, and peace of mind.

Beyond just having “a place to put your money,” retirement plans provide major tax advantages. With the exception of Roth IRAs, which offer tax-free withdrawals later, most contributions to qualified retirement accounts work like any other tax deduction: they lower your taxable income right now. Imagine your practice pays $1,000 in rent each month. That $1,000 is a straightforward tax deduction—but that money goes straight to your landlord. Now suppose you put $1,000 into a qualified retirement plan. You get the same $1,000 deduction, which lowers your tax bill, except now you get to keep that money in your own account, helping you build long-term wealth. Because that money is still in your possession, you’ve essentially created a tax write-off out of thin air.

This dual benefit of lowering your taxes in the current year and increasing your retirement nest egg is the central reason why setting up a proper retirement plan early can dramatically impact your future financial security.

To demystify the major retirement plan options available to private practice owners, I’ll give you a breakdown of how seven different major plans works, what kind of practice owner benefits the most from each type, and how to know when a particular plan no longer fits your financial needs.

The Seven Major Plans

SEP IRAs. A SEP IRA (Simplified Employee Pension) is a popular choice for solo practitioners, thanks to its simplicity and tax advantages. A SEP IRA lets you make tax-deductible contributions on behalf of yourself, and possibly your employees. Its key benefits include no administrative costs or annual maintenance fees (unlike many 401(k) options) and high contribution limits (for tax year 2025, you can contribute the lesser of $70,000 or 25 percent of your self-employed income—or W-2 if you’re an S-Corp). You can also change your contribution amount or percentage annually based on your practice’s performance, giving you great flexibility.

Solo therapists who decide to bring on full-time W-2 employees (who are non-owners or a non-spouse) should consider switching from a SEP IRA. If you hire employees, you must contribute the same percentage to their retirement as you do for yourself, which can become prohibitively expensive if you’re contributing a high percentage. In this case, you’ll often roll your existing SEP IRA money into another plan, like a 401(k), and close out the SEP plan.

401(k) Plans (Solo and Traditional). When people think “retirement plan,” they usually imagine a 401k, and for good reason: 401k plans are versatile, widely recognized by employees, and can significantly reduce tax liabilities through deductible contributions.

Solo 401(k)s are for owner-only practices, ideal if you’re the only full-time employee in the business, or you employ only your spouse. Its key benefits include high contribution potential. Because you’re technically both the employer and an employee, you can contribute more (via elective deferrals plus employer profit-sharing) than SIMPLE IRAs and Traditional IRAs. The contribution limit for tax year 2025 is $23,500 on the employee side and up to $43,500 on the employer side. Combined, that’s $70k, which is the same limit as a SEP IRA. If you’re over 50 years old, you can contribute slightly more. Solo 401(k)s also offer flexibility, allowing you to change your contribution amount each pay period if the need arises.

Traditional 401(k)s, meanwhile, are best for growing or larger practices. Once you hire employees, you’ll need a group 401(k) structure if you want to continue with a 401(k)-type plan. Key benefits include the fact that these plans are very appealing to employees, given that they usually include an employer match—an attractive benefit when you’re competing for talented therapists. This plan also offers customization, as you can work with a Third-Party Administrator (TPA) to design employer matching formulas, vesting schedules, and more. It’s important to note that with the traditional 401(k), you can expect to pay some administrative fees for annual filings (IRS Form 5500, for example) and compliance testing, especially once you have non-owner employees.

SIMPLE IRAs. The SIMPLE IRA is often described as a “lighter” version of a 401(k) for small businesses. Just like a 401(k), employees can make salary-deferral contributions, and employers provide either a matching contribution or a mandatory nonelective contribution. However, even though these plans are “simple,” in my opinion, they put too much administrative burden on the practice owner. Although a SIMPLE IRA is generally cheaper to set up and maintain than a full-fledged 401(k) and offers a straightforward employer match (you can choose between matching a percentage of your employees’ contributions—commonly up to 3 percent—or contributing a flat 2% of salary for each eligible employee), there are several downsides: more administrative burden for business owners, who will be coordinating pay payroll deductions and ensuring compliance, and lower allowed contributions than 401(k)s (contribution limits for SIMPLE IRAs are set at $16,500 for tax year 2025 compared to $23,500 for 401(k)s, although in both cases, employees 50 and older can contribute slightly more).

Generally, I don’t recommend SIMPLE IRAs. While materially similar to 401(k)s, the administrative burden falls on the practice owner instead of a third-party administrator (TPA). My personal philosophy is to take as much of the financial side of running a practice off of the owner’s hands, and in my opinion, managing a SIMPLE IRA is in direct opposition to that goal. They are less expensive though, so whether you choose this plan will be based on whether you’re willing and able to manage the extra work involved.

Cash Balance Plans. A Cash Balance Plan is a type of defined benefit plan, functioning more like a traditional pension and usually implemented alongside a 401(k) plan. Setting them up is extremely complex and they’re expensive to administer, so they’re only suited for extremely high-earning practice owners who want to accelerate retirement contributions to the highest possible degree. Key benefits include, being able to potentially contribute over $400,000, based on your age and income—which is more than five times the amount you can contribute in any other plan. But there are important considerations, like expensive administration costs and complexity. You’ll need an actuary—usually supplied by a Third Party Administrator (TPA)—to calculate minimum funding requirements. They’re also a long-term commitment: Ideally, you should maintain a Cash Balance Plan for at least three to five years, as shutting one down prematurely can lead to extra fees or IRS scrutiny. Still, these may be good plans for established practices with very high incomes or owners looking for large tax deductions or the chance to significantly catch up on retirement savings.

Traditional and Roth IRAs. Traditional IRAs and Roth IRAs exist independently of your practice. These are individual accounts you contribute to personally, rather than through your business. Key benefits include simplicity: these accounts are easy to open at most financial institutions, usually have zero ongoing costs, and no complex paperwork. They’re also very accessible, as anyone with earned income under certain IRS limits can contribute.

Whether you choose a traditional or Roth IRA depends on how you’d like to pay your taxes. With the traditional IRA, your contributions may be tax-deductible, and you’ll pay taxes on withdrawals in retirement. With the Roth IRA, contributions are made with after-tax dollars, and qualified withdrawals in retirement are tax-free.

These plans do have some limitations, however, including lower contribution limits (annual caps are much smaller than SEP IRAs and 401(k)s—only $7,000 for tax year 2025, slightly more if you’re over 50 years old) and income restrictions (traditional IRAs and Roth IRAs have income phase-outs that may limit or prohibit contributions if you or your spouse are above certain income thresholds).

Choosing the Right Plan for You

So now that you know about the seven major retirement plans for therapists, how do you decide which is right for you? If you haven’t made up your mind yet, here are my recommendations.

For solo practitioners who want to keep their administrative tasks simple and plan to remain solo long-term, a SEP IRA or solo 401(k) might be ideal. If your income is modest, just opening a traditional or Roth IRA can be an easy, no-hassle way to start saving.

For practices expecting to grow, a solo 401(k) can convert into a traditional 401(k) when you hire employees. If you have employees already, a 401(k) is often the most popular, versatile, and recruitment-friendly choice.

For ultra-high earners who need big tax breaks, consider adding a Cash Balance Plan alongside your 401(k). This advanced strategy can help you put away substantially more each year—but again, it does come with additional costs and complexity.

For brand new practices or “side hustle” practices, consider making retirement plan contributions at the personal level, not through your business. Traditional and Roth IRAs have the lowest contribution limits, but are more than sufficient in many cases.

Regardless of which plan you’re leaning toward, there are also some practical tips and next steps to consider. First, it’s always a good idea to first consult with a CPA, Accredited Retirement Plan Consultant (ARPC), or financial advisor. Retirement plans involve nuanced tax rules and contribution limits that change annually. A knowledgeable professional can guide you to a plan design that fits both your current and future practice structure.

Second, make sure you’re staying compliant with employee eligibility. If you’re running a Solo 401(k) but hire full-time W-2 employees, you’ll need to convert your plan promptly. Non-compliance can lead to penalties and corrective contributions. Again, working with a competent professional can save you loads of stress and time.

Third, mind the paperwork. 401(k) plans require annual filings and tests like IRS Form 5500 and nondiscrimination testing (unless you have a solo 401k or certain “safe harbor” plans). These filings are usually handled by a TPA, but double-check before signing on the dotted line. Cash Balance Plans require an actuary to certify funding levels each year.

Fourth, review your retirement plan annually. As your practice grows or your personal financial situation changes, reassess your plan. You can adjust contribution amounts, add more tax-advantaged layers like a Cash Balance Plan, or switch structures entirely.

Fifth, make sure you’re thinking for the long-term. The most effective retirement strategy is consistently saving over time. Thanks to compounding interest, even smaller contributions early on can lead to significant growth.
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Selecting the right retirement plan for your private practice can make a tremendous difference in your short-term tax situation, long-term financial health, and peace of mind. Whether you’re a solo practitioner looking for a straightforward solution like a SEP IRA, aiming to expand with a robust 401(k), or in a position to leverage a high-contribution Cash Balance Plan, you have options. Each plan offers unique benefits and responsibilities, from the administrative load to tax advantages and contribution flexibility.

By choosing wisely and staying compliant, you’ll not only secure your own financial future, but also create a sustainable work environment, one that can attract and retain quality employees if you decide to grow. Pair that with consistent guidance from CPAs and financial advisors who understand the nuances of private practice ownership, and you’ll be well on your way to a prosperous, less stressful retirement. Best of luck!

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Anne, a mom of two, corporate executive by day, spinning and yoga instructor by night, joins me in my virtual therapy room for her third session of an adult autism assessment. Her ocean-blue eyes meet mine just long enough to exchange pleasantries before shifting away to look somewhere just offscreen. The relief on her face was palpable a few weeks ago, when I assured her that eye contact wouldn’t be necessary during our sessions.

Divorced twice, she’s overwhelmed by the social dynamics of her high-powered job and struggles with the nuanced communication expected in adult relationships. Anne greatly values her time with her childhood best friend, who makes her feel like she can unapologetically be herself, but few other relationships seem worth the effort. Parenting comes naturally to her, but these days, Anne finds her marriage unfulfilling. She quietly admits that she prefers solitude and the company of fictional men in books and movies to the reality of her husband.

The best, and sometimes most frustrating, part of my autism is how my pattern-seeking brain tends to replay sessions on a loop, cataloging my clients’ words and filing them away by themes or phrases. Early on, I recognized Anne’s narrative in the experiences I’m accustomed to hearing from so many of my late-diagnosed Autistic clients. This “modern” autism isn’t the visible, predictable version that once led parents of stereotyped young boys to question vaccine schedules. It’s the neurodivergence of high-masking adults hidden in plain sight—in boardrooms, art studios, tech meetings, and academia. And it continues to elude many mental health professionals in 2025.

In the final moments of our session, Anne jumps off script, “I’m not even sure if this is relevant,” she says, “but I feel like I should tell you that I’ve struggled with some eating issues since middle school.” This is the fourth disclosure of disordered eating I’ve heard from a neurodivergent woman this week, a pattern that, by now, feels both unsurprising and deeply personal.

Anything but Neurotypical

Anne’s complicated relationship with her body began at age 11, when her “extremely rigid,” fat-fearing mom enrolled her in Weight Watchers. “I developed an unhealthy interest in dieting, calorie counting, and exercise practically overnight,” she recalls. “I tend to take things and run with them.”

She quickly memorized the points, calories, and nutritional facts of every food she encountered. Within days, Anne showed a startling aptitude for gaming the system of food intake to uphold the rigid structures her mother valued. She recounts years of struggling with body image issues, obsessive eating and exercising, and failed attempts to manage compulsions to control a body that never seemed quite right.

In her 30s, Anne says she’s “obsessed with wellness, but not always well.” She explains, “I don’t enjoy going out to eat because I’m consumed by the fact that I don’t know how many calories are in the food. I try to teach other women how to listen to their bodies, but honestly, I’ve never been able to trust my body. I don’t know when enough is enough, with food, exercise, anything. I can’t do anything in a small way. I become obsessed with any exercise I do. The numbers on the scale, the calories, the structure, it all feels like information my body doesn’t know how to provide me with.”

Anne’s words land on me as a full-body tingle, born of validation and shame. I’ve also been a walking encyclopedia of nutritional facts since my first diet and my first encounter with “points” and food-counting apps. There’s an irony here: autism, which so often isolates us, has brought Anne and I together in this moment of shared interests neither of us wanted. I shift in my chair, feeling the connection as well as a familiar sense of sadness. Beyond the difficulty of disordered eating and autism, there’s the deeper tragedy of a system that continues to fail us.

Although I’d love to claim absolute peace with my body and my neurodivergence, we’ve all been steeped in a culture that teaches girls—however they look and process the world—to hate themselves long before they can even vote. Everywhere you turn, there are books, apps, programs, and workouts that promise to help you fit impossible cultural standards, and those tools happen to bring a sense of order and fleeting relief from the chaos of not being able to “simply know” what your body needs.

Years ago, a 5 a.m. Pure Barre class became my daily ritual. Missing even one class felt like it threatened to the entirety of my human balance. Before that, the Whole 30 diet transformed food into a system of “good” and “bad,” a structure my neurodivergent brain clung to. The diet reshaped my body in weeks, but more than that, it offered the illusion of control. Eliminating choice felt like freedom—from digestive issues, bloating, discomfort from binging, and the constant burden of feeling like I was “wrong” in my body. But these frameworks, no matter how soothing in the moment, only intensify my obsessive tendencies and the unhealthy relationship between my Autistic brain and my never-quite-right body.

I explain to Anne that the intersection of autism and disordered eating, though common, is often misunderstood in therapeutic spaces. Themes of identity struggles, generational trauma, rigidity, and black-and-white thinking are factors of the Autistic experience that tend to get overlooked by well-meaning helpers. Unfortunately, many eating disorder specialists aren’t prepared for the unique challenges of eating disorders paired with neurodivergence.

Because Autistic bodies are so sensitive to their environments, stressors, and even medication, treatment must first focus on finding nervous system equilibrium before addressing their relationship with food. Attempts at behavioral change in an unregulated nervous system can predictably fall flat. In addition, not all eating behaviors need to be changed: after all, just as Autistic people have different but valid ways of socializing, many of us have different but legitimate ways of eating.

Middle School, Maturing, and Masking

One key detail that’s critical to our understanding of both high-masking autism and eating disorders lies in the social demands of the teen years. The collision of mounting social pressures with sensory sensitivities emerging from awkward, maturing bodies often result in an intense struggle with confusing identity expectations. Without support, Autistic middle schoolers can experience a rapid, downward spiral with long-term, dangerous consequences. For Autistic trans teens, the stakes are even higher, as gender dysmorphia adds additional layers of complexity to their struggle to assimilate.

Xander, a 27-year-old transmasculine Autistic PDAer exemplifies how these struggles can persist into adulthood. PDA (Pervasive Drive for Autonomy) is a profile of autism characterized by intense nervous system responses to a perceived loss of autonomy. For PDAers, being forced to eat can activate dangerous fight, flight, or freeze responses preventing meaningful engagement in treatment. Outward behaviors may mirror avoidance, defiance, or unwillingness to participate in treatment, but at the core, the dysregulated nervous system is in desperate need of support.

Prior to his autism diagnosis, Xander cycled through four inpatient and two outpatient eating disorder programs. These treatment programs all labeled him “noncompliant” and documented his “refusal” to eat, “refusal” to share his feelings, and “refusal” to participate in groups as his refusal, not ever recognizing that his nervous system was resisting, not him. The overwhelming social and sensory stressors of forced group therapy and rigid protocols ignored his needs as an Autistic, trans man with trauma. During my collaboration with his treatment team, I suggested that the factors at play for Xander were far more complicated than their assumption that his avoidance was “his eating disorder talking.”

For therapists to support clients in the margins of multiple at-risk groups, we need help recognizing the factors shaping their particular clinical picture. Characteristics of autism, such as sensory sensitivities, interoception challenges, a reliance on “data,” a need for predictability, and family histories of undiagnosed neurodivergence influence disordered eating experiences. Comorbidities like avoidant/restrictive food intake disorder (ARFID), PDA, and OCD complicate these cases, making standard treatment approaches ineffective and even harmful.

To innovate new ways of supporting neurodivergent people, we must take into account how their brains and bodies work, what their nervous systems need to stay regulated, and what healthy eating looks like for each individual (which may be atypical).

Why Traditional Treatments Fall Short

Food is experienced through the senses, and sensory sensitivities are common for Autistic people. Many cling to the “beige foods” like chicken nuggets, boxed pastas, snack foods, and processed foods, which offer a perfect score in predictability despite falling short in the nutrition department. A cracker never surprises you like a sour blueberry or a chicken finger that’s “too chicken-y.”

But the sensory experience doesn’t stop at taste. Foods have textures, smells, sounds, and sliminess. To eat is to experience all the senses, which is why many Autistic individuals struggle with varied eating, and some may even be diagnosed with ARFID. Autistic people with ARFID will often reflexively refuse new foods before they’ve attempted to try them. Even the suggestion of new foods can lead to a full-body nervous system reaction. In cases of ARFID, we often have to rethink standards around eating and nutrition and accept that, as they say with infants, fed is best.

Many Autistic people also struggle with the ability to sense internal bodily cues like hunger, fullness, or thirst. This is due to a breakdown of interoception, the ability to sense and make meaning of body sensations. For some, a migraine is the first signal of thirst, lightheadedness the first clue of hunger. This disconnect can lead to eating past fullness, forgetting to eat altogether, or being unable to recognize what’s enough. “Being full or hungry only happen in the extremes,” Tina, a 29-year-old teacher, explains. “I’m either starving and feel like I’m going to die, or so full that I feel like I’ll explode. There’s no in between.”

Elle, my 35-year-old client, once said, “To me, intuitive eating isn’t real. I don’t feel full. I’d eat whatever was on my plate because that was the rule as a kid. People were constantly commenting on how much I ate, but I thought I was following the rules. Even now, I’m like, just tell me what the hell to eat, and I’ll do it. My body is no help in that area.” Teaching Autistic people to “listen to their bodies” only reinforces the traumatic reality that the instincts most people take for granted don’t align with their neurodivergence.

The act of eating is physically demanding, but for Autistic people with sensory sensitivities, it can be emotionally overwhelming. Textures, tastes, smells, and temperatures intensely shape how Autistic bodies experience food, turning mealtimes into stressful events. Predictability can help create a sense of safety, but that may mean eating the same foods, adhering to strict mealtimes, or following specific preparation methods to soothe an otherwise overwhelmed brain. Disruptions to these routines, such as skipping a meal or encountering an unexpected menu, can feel catastrophic. Plus, the sensory needs of Autistic people can change unpredictably, easily turning “safe foods” into “unsafe foods” and creating rigidity around food that’s often mistaken for disordered eating when it’s actually a form of sensory accommodation.

“I have an entire cupboard of food I won’t touch,” 23-year-old Sam tells me. “I’m supposed to eat a variety of things each day, but I can’t do that. The foods I eat have to be the right texture. If I have it in my mind that I’m going to eat ‘something else’ and don’t succeed, I sometimes kick, scream, and even hit myself in the head. I know I should be able to just eat ‘something else,’ but my brain was expecting pancakes. The shame of being an adult who has meltdowns over pancakes consumes me. The only option I have is to sleep it off and try again the next day.”

Numbers provide a sense of control and certainty in an otherwise unpredictable world, but for many Autistic people, data points like calories, macros, weight, or meal schedules can quickly shift into rigidity or obsession when those numbers become the only way to feel safe. Rather than forcing intuitive eating or eliminating these frameworks altogether, therapists can focus on helping Autistic clients create healthier relationships with data, introducing adjustments to how they can track numbers in ways that allow clients to put their efforts in the right places. Tracking weight fluctuations many times a day can halt progress, whereas a visual badge system for movement each day can adjust the data points to a healthier focus while allowing data collection and planning to continue.

To truly support high-masking Autistic adults requires providing them with increased autonomy, freedom to accommodate sensory and food preferences, and a move away from rigid adherence to neurotypical norms around food and body image. Helping clients trust themselves, rather than simply expanding their “beige diet,” is a key step in fostering meaningful change. For Autistic clients in treatment, accommodations are key, like accommodations to opt for individual reflection over groups, writing over talking, and safe foods over food challenges. Above all, nervous system safety and sensory needs should remain the focus. With support and understanding of the ways that Autistic brains crave predictability and data seeking, we could offer a realistic pathway to success for clients in the intersection of eating disorders and autism.

From Black and White to Balance

Anne has taken the last six months to digest her autism diagnosis. She arrives for a Friday morning check-in session with wet hair and matching athleisure. “So I’m guessing you can tell I just got back from the gym.”

“I see that! Spinning today?

“No, Pilates.”

The tab next to Anne’s video chat blinks red on my computer: it’s a message from a gym owner offering me a “deal” on an overpriced, professional Pilates machine. I try not to laugh at the timing.

Underneath the healthy and unhealthy eating, the overexercising, the counting, intensity is the familiar thread for both Anne and I. Seeing this as a feature of our neurotype, not a bug, is the beginning of learning to trust our brain, accept our body, and find a way to “feed” intense interests in ways that serves us. Anne is excited to update me on her progress.

“Tonight, I’m going out to dinner with friends. I picked the restaurant and the table in the back, where it’s quiet. I’ve really been trying to enjoy the social time with friends, and knowing where we’re going and what I’ll eat helps. I’ve already planned my dessert.”

“You know I love this plan, Anne,” I tell her. “It sounds like you’re accommodating what your brain needs to enjoy this.”

“Yeah, and I decided no more than two gym classes a day. Exercise is my favorite special interest, but two classes does feel better than five now that I’m checking in with my body more.”

Anne and I also catch up on her other efforts to unmask, including her request to telework more, and her disappointment in friends who’ve been less than interested in her new Autistic identity. Unmasking isn’t easy.

“I’ve been spending a lot of downtime reading the autism books you recommended. It’s been validating to learn about my brain, and I’ve gotten pretty obsessive about it. Maybe that’s helped me chill with the exercising a bit,” she jokes.

I’m proud of Anne. She has a glow about her today beyond her post-gym, rosy face. She’s working on accepting her intensity and “portioning it out” among all of her interests. When we say goodbye, I hit the big, blinking x on the adjacent tab. Let’s be honest, I don’t need a Pilates machine.

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Kay walked into my office dressed in a baggy hoodie, light-wash jeans, and clunky sneakers. She slumped into my office sofa with a soft thud and sighed. I’d seen many clients like Kay over the years: teens who are withdrawn, searching for their tribe of peers, seeking independence from their parents, spending lots of time online and on social media, and cautiously looking forward to the next stage of life at college. And like so many of these teens, Kay was suffering immensely.

Two months earlier, when her previous therapist had called to refer her to me, he’d told me about her recent psychiatric hospitalization and her history of self-harm by cutting. “I’ve taken Kay as far as I can,” he’d said. “Our work keeps stalling. I think she just needs someone new.”

Kay’s chart showed that she’d tried several different therapy formats: group, individual, and DBT. She’d worked with many skilled clinicians, too. Despite it all, Kay was still hurting. Over the phone, her parents had listed the trail of diagnoses that had accumulated in the wake of her treatments: ADHD, depression, anxiety, and mood disorder. I suspected these diagnoses were attempts at explaining why Kay was feeling the way she was. But something was missing.

“My friends bailed on me again,” Kay said forlornly when I asked her about the week. “We had plans to see the new Transformers movie, but then everyone said they were busy. I know I must have done something wrong, I just don’t know what.” Tears formed at the corners of her eyes.

“I see you, Kay,” I whispered. “Would you like to share what’s happening for you right now, in this moment?”

She shot me a reflexive look of mistrust, then paused. “I don’t know….” she said, her voice catching in her throat. “It feels like I’m in an abyss. Just living is so draining for me. And everyone else is doing it so easily.” Kay swallowed then dropped a question I hear a lot from my teen clients these days: “Do you think I might be Autistic?”

The New Autism

Over the last several years, whenever I’ve met up with fellow therapists, one topic comes up again and again: neurodivergence. Obviously, the thinking around autism today is very different than it was just a few years ago. A huge range of thinking and behavior now falls under the umbrella of neurodivergence. It can be hard to keep up.

But there’s something else that comes up in these conversations: across the board, those of us who work with teenagers hear more and more of them saying they feel like they’re Autistic. And they want to feel seen and heard as members of the neurodivergent community. This can be a tricky thing to unpack, especially since most of us aren’t experts on the subject. How do you respond when a client like Kay asks you such a direct question—one where the answer is invariably complex?

Today’s teenagers have spent considerable time researching autism online, scrolling through social media, and chatting on Discord with neurodivergent peers who’ve experienced similar life challenges to them. They see reflections of themselves in these new friends. And finally, after so much time feeling misunderstood, they feel like they can let their guard down, like they belong—which can bring them a tremendous amount of relief. But that’s not where the work stops. It’s just the beginning—for them, of course, but also for the adults in their lives struggling to keep up with what their kids seem to have figured out.

The fact is, when we work with teenagers, we’re also working with their parents in some capacity, and many parents are concerned about how society will regard their child once they’ve been labeled “Autistic.” They’ve consulted with multiple professionals and been given many recommendations about “managing” their teen’s behavior. They want reassurance, answers, a calmer baseline at home, but there’s no pat, simple solution to the challenges neurodivergent kids like Kay face. Even when kids find solace in a neurodivergent identity or community, the pressures and biases of a society shaped around neurotypical needs are constant and unavoidable. Our job as therapists is to educate ourselves, so we can better support and advocate for these teens, as well as help their parents, teachers, and others support and advocate for them, too.

Though some parents initially express shock at hearing their child believes they’re Autistic, I’ve found that once the shock subsides, parents want to learn more. Eventually, they may even whisper things like, “Actually, I’m kind of like that, too,” or “This reminds me of how my mother was.” We can make it clear that neurodivergence isn’t something to be feared. It’s an aspect of a person’s identity that can allow them to make sense of who they are.

Digging Deeper

Before answering Kay’s question, I thought back on the work we’d done so far. Had Kay shown any signs of being Autistic?

I’d learned from Kay that she has lots of friends, but she seemed to cycle through new friendships every few months; and each time one ended, was left with a crushing sense that she’d said or done something to end them. Kay is highly intuitive. She feels energetic shifts between herself and others acutely—which I see in our sessions a lot—but she’s often unable to articulate these emotional experiences. Over the weeks we’d worked together, she’d told me stories of excessive texting and ruminating over her social missteps. “I feel like I’m constantly overthinking every exchange,” she’d said at one point. In the past, this had led to cutting and thoughts of suicide.

Kay is very bright—gifted, even—though her performance in school doesn’t always reflect this. According to her parents, she doesn’t “try hard enough” and spends too much time alone in her room scrolling on her phone.

“After school, I’m totally exhausted,” Kay explained. “I feel spent, like my body’s been hit by a train. It won’t move.” It was clear that Kay enjoyed learning, but procrastinated on assignments that didn’t immediately grab her attention, and when she’d finally get around to them, she was short on time, which was paralyzing and stressful.

“I know I should go to college,” she had said one time. “But I don’t know if I can handle it.” Do you think I might be Autistic? Kay’s question hung in the air as I deliberated for a moment. I could see the trepidation on her face—an expression that seemed to be asking, “Do you see me?”

I smiled. “What do you think, Kay? I’m sure you’ve done your research, and I’d love to hear your take first.”

Kay’s eyes lit up. “I started reading some kids’ stories on a Reddit message board about finding out you’re Autistic,” she said. “When I read their stories, I was like, Hey, that’s me! And when I told them what I was like, and all the stuff I worry about and do to keep from collapsing every day, it felt like they got me. They were cool and weird, and it got me thinking about all this autism stuff.”

I’ve worked with enough young adults to know Kay wasn’t really looking to understand the official diagnostic criteria for autism. She was looking for validation. She was looking to see that I cared.

Our Mission

I’ve been in too many consultation groups with therapists who’ve said things like, “I’ve ruled out autism because my client doesn’t act Autistic,” or “My client makes eye contact and wants friends, so I strongly doubt they’re neurodivergent,” or “They’ve had multiple neuropsych tests and never came back with a formal diagnosis.” Each of these statements shows outdated thinking or bias around autism.

Getting up-to-date training on neurodivergence is critical to supporting all our clients in living full, authentic lives. The truth is, you’ve likely been working with Autistic clients all along—they’ve just been undiagnosed. And maybe you always sensed there was more going on than just depression, anxiety, or whatever other diagnoses they’d been given. Our clients are the experts on their own experiences, but we can help them better understand their strengths and challenges so they can better navigate a world that defaults to neurotypicality.

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“You never talk about your assault or your depression with me,” my father blurted unprompted as we were driving up Interstate 295 between Portland and Bar Harbor, Maine.

It was 2015, I was 26 years old, and we were on day two of our first-ever father-daughter trip. My dad, a stoic immigrant with a slight Indian accent and, almost always, a blue or purple pagri on his head, was sitting next to me in the passenger seat, wearing a baseball cap and tapping his fingers on his knee along to the radio’s song. He was unusually casual, and oblivious to the fact that he had just knocked the breath out of me.

We’d set out on this trip because a few months prior, my mom had mentioned in passing that she thought my dad was depressed.

“He isn’t acting like himself,” she’d said. “He is quiet when he gets home from work. He seems sad.” Though my mom had shared all of this nonchalantly, the weight of her words had still hit me like a ton of bricks. The word depressed—or any term even remotely referring to mental health—wasn’t used in my household.

Was papa depressed, or was he just stressed at work? Was he tired? Was he in a stage of reflection and transition in his own life as his children became increasingly independent? Why had my mom used this specific word to describe his behavior? Did it reflect her fear over his changed behavior or her own inability to understand his thoughts and feelings? I was overcome with questions, but as per usual, I knew that it would be up to me, the family mediator—a burden I embraced and am still unlearning—to do something. I decided that spending some time with my dad in a neutral environment where we could get to know each other better would make the best opportunity to get to the bottom of things.

You’re probably thinking, Um, he’s your dad—don’t you know him? Well, no, not really, sadly. Conversations with my dad had always centered around school or work, the news, religion, and, until 2019 (when I married my now-husband), my future marital status. In other words, as I have found similarly among friends, he was a typical immigrant parent: laser-focused on the future rather than the past. For most of my life, my dad had exerted control and stability by keeping his kids at arm’s length: far enough that we couldn’t see his vulnerability, but close enough that he felt like he was taking care of us. For that matter, I had never talked with my parents about anything emotional, let alone things that were heavy and terrible. This meant that aside from the basic facts of my life, they didn’t really know me, either. We put our energy into keeping up appearances within our community and our family.

And now we were driving up and down the coast of Maine together, sharing a hotel room and every meal. I came fully prepared with a list of questions jotted down in my Apple Notes app, but never in a million years did I imagine that we’d discuss my trauma. My whole life, I’d been accustomed to hiding from my parents fragments of myself that could be considered “bad” or “unacceptable” in my family or culture, leading me to live a double life.

I questioned my cultural and religious identity in secret. As an adolescent, I snuck onto the now outmoded AOL Instant Messenger at night to gossip with friends and flirt with chat room strangers in secret. I learned to explore my body and its needs in secret. I giggled at inappropriate things in secret. I struggled in secret. I was used to it, but now my dad was slowly opening a door between us that had been shut throughout my life. This trip—the first of many we would take—was meant to be about him, but he demonstrated curiosity and an interest in my life experiences that was so novel I didn’t know how to respond.

Sure, I had a desire to know my papa better, but I also feared him getting to really know me. I worried about being able to maintain my own facade and his idea of who I was.

Straddling Cultures

For as long as I can remember, I have felt on a daily basis that push and pull between who I am around my family and who I am alone with my friends—a feeling ultimately rooted in something called bicultural identity straddling, which is defined by researchers as an “ongoing process of adaptation resulting from living within two different cultural influences.” I know firsthand the suffering, the questions, the inconsistencies, and the inner torment that come with trying to occupy two spaces at once, with having no sense of belonging to one or the other and needing to chart a path forward anyway. And I know I’m not alone. Children of immigrants are often straddling (at least) two cultures, two value systems, and usually two sets of differing societal expectations. Many of us are walking a tightrope, trying to steady ourselves so as not to get devoured by the abyss below.

If you played home movies from my childhood in the suburbs of central Virginia, you’d see that I did have some semblance of a quintessential American upbringing—school dances, league sports, Friday-evening binges of Nick at Nite. (Binge-watching did in fact exist before Netflix.) But along with my adoption of the American lifestyle came long, and recurrent, discussions and arguments with my parents over the fact that I was “too American”—that I was losing my traditional Indian values. They felt that sleepovers and school dances were threats to my focus on education and community obligations. Male friends, meanwhile, were a threat to my purity: discussions about love weren’t even on the table until I was old enough to suitably marry.

Despite my parents’ best efforts, I did attend those dances and sleepovers, where friends and I—including other immigrant kids in the Sikh community—spent our nights talking about boys and eating fast food. We had dance parties in front of our dresser mirrors, swaying unabashedly to the American music we were usually discouraged from listening to. I even experienced first love and devastating heartbreak in high school—all behind my parents’ backs, of course. We were all unified in our secret rebellion.

Bicultural Identity Development

Years later, it was through building my online mental health platform and community Brown Girl Therapy while starting a career in mental health and navigating my own bicultural identity as a newlywed that I recognized how cyclical our identity development is as children of immigrants. We don’t go through consecutive stages in order or on a certain timeline; instead, I theorize, we grow through many different bicultural identity crises. Research suggests that identity development tends to happen during the adolescent years, as we move through the fear of embarrassment, the need for approval, the need to belong, and the experience and resolution of normative conflicts. This is why many of us have some version of the “stinky lunchbox” story or can recollect the painful pause before our names were stumbled over during roll call in grade school. It’s the same reason why I spent my early high school years trying to fit in by attempting to alter my skin and eye color.

As we get older, however, we start making adult choices—what career to pursue, whom to marry, where to live, whether to have kids or not and how to raise them if we do—and we start to grapple with our parents’ mortality. We are flung back into the throes of questioning what’s important to us and how we should carry on.

Different researchers have created many different identity development models, trying to incorporate and pinpoint the distinctive experiences of racial and ethnic minorities. There’s truth to their racial identity models, and yet within them, cultural identity tends to be neglected. In devising an alternative, I’ve built off previous models and my professional work to theorize a bicultural/multicultural identity model with five stages. These are nonlinear and nonsequential, but helping clients assess which stage they may be in can feel normalizing and validating for them. And it can provide a framework to help therapists address issues of cultural identity.

Conformity. In this stage, you’re motivated to develop performative behaviors in order to feel a semblance of belonging and acceptance within one or both of your cultural systems. This may not be a conscious choice (especially when you’re younger), as there may be minimal awareness of how you feel about your bi/multicultural identity.

Isolation or Dissonance. In this stage, you feel culturally conflicted. You may feel a sense of displacement from one, if not both/all, of your cultural communities. This can be particularly hard, as isolation and disconnection may increase the likelihood that you will struggle with mental health issues.

Awareness and Interrogation. In this stage, you start to explore what it means to identify with a cultural group. You may start to question whether your values align with those of your culture(s). You start to unpack experiences and feelings you have in relation to your different cultures, and what it means to identify with a dominant or marginalized identity. This stage is often correlated to exposure and learning.

Appreciation. In this stage, you actively return to, or strengthen, your heritage cultural identity. By recognizing the benefits, strengths, and resilience of your heritage culture(s) and communities, you begin to unlearn narratives that the dominant society and culture imposed on you.

Negotiation and Fusion. In this stage, you critically assess how to integrate—or blend—your different cultures so that they complement each other and/or serve you in living truthfully. This can be particularly difficult when cultural values are not aligned with one another, and you might have to unlearn and question decades of conditioning and norms. You may practice new ways of being. You start to search for communities that share in your identity, and you start to feel more positively about your culture(s) and your sense of belonging within it/them. You become confident in what’s important to you and what versions of your cultural identity you choose to uphold. This is usually accompanied by a sense of self-acceptance.

On that first trip together in Maine in 2013, my papa and I began to shatter a wall, and thus the narrative in which I felt separated from my parents, that is too often built between immigrant fathers and daughters. I started to share more about what I had been going through when I was depressed years prior, and he listened earnestly.

He may not have fully understood, but he also didn’t deny me my reality. He recounted stories about living in India, stories about his dad, whom I don’t have any recollection of, and stories about his early years in America. I learned that I fear disappointing him and worry that everything I do might be a burden. We talked about the concept of happiness and some of my dreams as we sat by a fireplace sipping whiskey in Kennebunkport. And in Acadia, I observed that he’s not very outdoorsy and doesn’t like to be out of his element. I also witnessed his impatience (even while waiting for the best lobster in town), his restlessness when he doesn’t have anything to do, and his penchant for happily adding crispy french fries to just about any meal.

Though the trip to Maine brought us closer, I left feeling like there were many things that I still didn’t understand and, further, that there were many, many more I’d have to realize on my own as I pursued my generational healing and reflection. But first I had to start by making room to trust myself. As therapists, this is often where we need to start with clients, too.

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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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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.

***

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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Jacki sat in her haphazardly parked car a few blocks from her house,

seething after a tense “happy” hour with friends.

As they’d gathered together, one of Jacki’s friends had let slip some detail about a concert several of them had apparently attended without inviting her. When she heard this, she felt gutted by what she’d later recognize as a familiar ugly knot of exclusion and rejection. Driving home, alone and aided by her increasingly negative story about what happened, her mortification had transformed into rage (a more familiar and thus more comfortable feeling), and she’d impulsively pulled over to write them a text.

Jacki’s thumbs flew across the screen as she furiously typed out her case against them: They knew this was her favorite artist, yet they’d made her feel ridiculous for being upset. She was the one who’d introduced them to his music! They knew she’d been having a hard time and could’ve at least been honest with her—catching them in the coverup was humiliating.

As she paused, Jacki flashed on her friend Grace avoiding eye contact as they’d said goodbye. The image made her stomach roil. Grace was her best friend—how could she, of all people, do this to her?!

Getting her thoughts down gave Jacki a smidgen of relief and propelled her to add more grievances about the others who hadn’t come to her defense. Finally, as a feeling of catharsis took hold, she eased up on typing and a faint whisper of caution emerged. You know you could regret sending a text like this, she thought. What if they get fed up and stop inviting you to things altogether?

But no, their betrayal was too great to go unaddressed. It’s better to be real and fight than be walked on. She inhaled sharply and hit send.

Does Jacki remind you of anyone you know?

The truth is Jacki’s behavior might be regrettable but it’s not uncommon. In retrospect, she could’ve used some help slowing down and getting curious about what had happened and why it upset her before she took retaliatory action, but that’s easier said than done. Once most of us are activated by big feelings like anger and humiliation, being able to acknowledge our automatic defensive patterns and question our interpretation of events is very tricky.

As therapists, we might be tempted to boil down Jacki’s behavior to diagnostic criteria, or to identify her as having an insecure attachment and move on from there—but let’s challenge that categorical thinking. When we label ourselves or our clients as insecurely attached, or avoidant, or preoccupied, or disorganized, we inadvertently lock a fluid, dynamic activation state into something rigid and unchanging, which obscures the beautiful nuance we embody as humans.

Of course, much of the literature on attachment styles comes directly from research that requires us to lump people into categories, so the impulse to label is understandable. But when a therapist believes something about a client is immutable—like personality and temperament—what does that do to our ability to help them? How does that influence our interventions, and therapeutic outcomes?

The Modern Attachment Regulation Spectrum

Does Jacki have a history of insecure attachment? Technically speaking, yes. She was raised by her grandmother, Mimi, while her mother was in and out of addiction treatment. Mimi loved Jacki, but she struggled with depression and was rarely emotionally available to her. Jacki, who knew people could disappear the way her mother had, tracked her grandmother’s moods and became her caretaker to sustain their connection. Her ability to read others became a superpower for her later in life, but anticipating rejection and abandonment in all her relationships creates problems and often leaves her feeling humiliated, rejected, and mistreated—big feelings that seem out of proportion to others.

But there’s good news for Jacki. As her therapists, if we shift our clinical focus from secure attachment to secure functioning, we can create a clear road map for navigating daily life that will help her understand her personal patterns and what she needs to shift them.

Secure functioning is more accessible, and thus potentially more life-changing, than the larger ideal of secure attachment. It’s a state of mind we can return to after becoming dysregulated, rather than a category we either belong to or are left out of. As we learn to recognize our various states of security, we understand how to function securely more often. How?

Built on our integration of modern attachment theory and relational neuroscience, the Modern Attachment Regulation Spectrum (MARS) framework helps clients like Jacki step outside a pathologizing vision of herself. It helps her see that in the lead-up to her sending that unfortunate text, her nervous system had simply shifted away from her connection circuit (secure relating) in favor of her protection circuit (dysregulated, defensive or insecure relating). That’s what made her heart pound and her stomach roil, fueling her certainty about the cause of the problem and the sense of urgency she felt about needing to express her upset.

If we were to measure Jacki’s state using the MARS framework, we’d say she’d flashed into a “red zone.” Her neuroceptive sonar correctly detected a potential relational threat—her friends had gone out without her and her friend Grace was cooler than usual when they parted—and it had sent her attachment system automatically into high alert. Others with a different neural pattern of perceiving events may not have noticed the subtle change in Grace’s demeanor, or they may have noticed and worried about what was going on for Grace.

Notably, we wouldn’t pathologize Jacki’s reaction, nor would we necessarily attach it to any diagnosis. Instead, we’d make sure she understood that dysregulation and insecure functioning is a part of all of us. Even the most securely attached among us can shift into defensively activated, insecure relating. And conversely, those with even the most severe attachment disruptions and challenges can securely relate much of the time.

The idea here isn’t to counter the depth and breadth of over a half century of attachment research, or to invalidate the utility of attachment categories. Instead, we want to help move this research into a clinical framework that can be more useful to more people in their day-to-day lives. After all, each of us can benefit from learning about our nervous system, our interpersonal activation patterns, and the skills required for secure functioning.

The Different Colors of Attachment Activation

When we use the MARS model with clients, we simplify talk about neural circuitry by first teaching about the protection and connection system. If we can help clients notice they’ve left their connection circuit and are actually defensively activated (in their protection circuit), it’s already a huge win.

In Jacki’s case, she might initially be able to say, “Hell yes, I’m activated,” and then have a story to justify her activation. But once she’d spent some time with this framework, she may recognize “Okay, the channel is right, but the volume is too high.” This means she’s not crazy—her friends really did do something without her and others may have also felt left out—but her body is responding in full threat mode. She’s reacting as if their offense is a 10 when it’s arguably more like a 5-7, depending on the details. Confirmation that she’s right (to a degree) can help her feel safe enough to begin to explore her reaction, but scaling the reaction to the offense opens space for curiosity around the intensity of her feelings and reactivity. It points her toward self-reflection instead of self-satisfied blame.

From this vantage point, we can then begin to look at different moments of activation by placing them on a colored spectrum where an arrow shifts between the colors blue, green, and red. This fluid spectrum represents the states of attachment activation created during interpersonal exchanges.

In the middle of the spectrum is the green zone. Here we can think and feel at the same time, consider ourselves and another person, care how we come across, and be flexible and compassionate in our responses. Of course, no one just parks themselves in that secure green zone all the time. It’s more a North Star we paddle toward when we drift away from a secure state. Once clients know what their green zone feels like, it helps them differentiate that secure state from one in which their body is feeling threatened and they become lost in activation.

Secure, green-zone functioning doesn’t mean you have to be “nice.” On the contrary, when we’re in this integrated neural circuit, we can be quite powerful and more effective with our voice, or we can choose not to say something for good reason. Compassion and generosity come easily. We can allow ourselves to be influenced by others’ perspectives without losing ourselves. We can have big feelings and maintain our thinking and care for how we’re coming across to others. Also, even though we call it the connection circuit, secure green-zone relating doesn’t always mean we want or need social engagement. No brain functions exactly the same, and being alone may be the most direct path to that circuit of security for some.

When we’re not in the green zone, we can all experience times of distress as we perceive threats in our relational world. That’s when our protection circuit kicks in, and we tend to rely on the familiar defensive strategies to help us cope with our emotions and tension. Our go-to response patterns, and how often we rely on them, are shaped by our individual and cultural backgrounds, the systems we live in, and our current situation. In MARS, we call those more stable patterns our attachment maps (a slightly broader concept than internal working models).

Some of us, like Jacki, have learned to keep our attachment system on higher alert, with our attention more preoccupied than others with the fear of loss of relationships (red activation). Others can shift more readily toward blue activation in an attempt to deactivate the attachment system entirely. On the blue side of the spectrum, we are more walled off and can lean heavily on our intellect and high reason to justify our anger and actions—which helps us reduce emotional expressiveness in ourselves and shut it down in others. The design is to feel safer, but in fact, shifting blue is often problematic if we believe we’re “fine” and the issue is the emotional person over there. The further blue we shift, the more we lose contact with feelings of connection. This can leave us believing we’re secure when we’re actually in a more brittle defense state due to perceiving quite a bit of threat.

Sometimes, rather than shifting along the green-blue-red attachment-activation spectrum in the face of a relational threat, we might experience a confusing mix of activation and dysregulation. When this occurs, it means we may’ve fallen into a pocket of disorganization represented by a tie-dye puddle that lies underneath the spectrum. While in the puddle, we may recognize a confusing mix of thoughts and feelings or be dropped into numbness and dissociation. The realistic goal when this happens isn’t necessarily to move directly toward the regulated green zone, but to get less disorganized. That means getting clearer about what we’re feeling so that we reconstitute back up to the more predictable spectrum, no matter which color we land in. This puts us on track to feel safer, which is required to be able to shift toward a more regulated state of attachment activation.

MARS Sunglasses

A crucial concept in the MARS framework is the scientific recognition that when we’re dysregulated, our brains actually distort incoming relational information. Keeping this in mind helps clients like Jacki explore these perceptual distortions and the predictable patterns that cause them without the shame that so often comes with emerging awareness.

For example, if our attachment map tends to hang in the secure zone, or if we’re in a secure, green-zone state of mind, we perceive information most accurately. We can take in criticism without amplifying what the other person is saying in a way that makes it more negative than it is, see our own faults without attacking ourselves, and see flaws in others without hyperbole. Think of it as viewing life through clear glasses.

However, as we leave the green zone, our perceptual lens shifts and begins to focus differently. According to brain imaging, when we’re anxiously activated and shift red, we feel emotional communication more deeply, remember painful interactions in more detail and for longer, and tend toward negative interpretations of ambiguous events. Imagine red-tinged, large-rimmed, magnifying sunglasses.

When our attachment activation has downregulated or shifted blue, our glasses do the opposite of the large red glasses: they distort by blocking important relational information, including nonverbal and subtle emotional expressions, from getting in. The fMRI studies indicate we don’t notice and are less likely to remember negative interactions, for example. We miss cues from others and reduce our own emotional expressiveness. Think of cool, dark aviator glasses that interpersonally block in both directions.

And when we’re dysregulated enough that we’ve fallen into a tie-dye puddle, imagine that our sunglasses have been knocked off and everything is blurry. The goal, then, is to move out of disorientation and get any pair of glasses back on so you can begin to identify and organize your thoughts and feelings, a step toward feeling safer.

Here’s the important thing: red zoners aren’t drama queens; blue zoners aren’t callous; being in a puddle makes sense—and Jacki isn’t just “acting out” on the side of the road as she texts. She’s having trouble containing her feelings, is hyperfocused on what she feels is a threatening rupture in her friendship with Grace, and is attempting to move toward that friendship by expressing herself and emoting. Because she learned early on to hold tight so people won’t leave, she’s upset about the feeling that Grace might be pulling away.

For Jacki, the healing path emerged through the re-establishment of safety. In therapy, we helped her identify her actions through a lens based not in right/wrong, but in human biology that makes sense. She was able to compassionately understand her distress and feelings of victimhood. From there, she could shift to a more reflective, curious state of mind, where she was able to explore the roots of her distress in the safety of the therapeutic relationship.

By providing her with some language and a visual model for complex attachment dynamics, we empowered Jacki to recognize her patterns, understand her responses, and see how she might work toward more secure relating in her friendships.

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