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

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

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

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

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

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

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

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

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

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

Understanding Triggers During Your Healing Journey

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

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

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

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

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

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

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

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

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

Exercise: Coping with Triggers

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

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

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

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

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

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

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

***

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

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In graduate school, nobody tells you that becoming a therapist means signing up for the unknown. Will any of my clients miss their appointments today? How much money will I make this month? Will my carefully planned intervention help this couple? Psychotherapy is filled with uncertainty, and there’s little guidance on handling it. Over the years, I’ve watched myself, my colleagues, and my supervisees try to navigate this uncertainty, and I’ve learned that if we want to keep doing this work, it’s imperative we develop a healthy relationship with uncertainty. Otherwise, burnout isn’t just a possibility, it’s inevitable.

I confronted my own relationship with uncertainty when it started getting in the way of my clinical work and my mental health. It made me wonder how uncertainty had become so intolerable to me and what I could do about it.

Ever since I can remember, my relationship with uncertainty felt fraught, likely the result of growing up with a chronically ill father and an emotionally unpredictable mother. What kind of mood will mom be in today? I’d wonder as a child. Is dad going to die? The uncertainty was so unbearable that over the years, I developed a defense strategy: be prepared. I studied as much as I could and planned for all possible outcomes. Even when I became a therapist, I held on to the illusion that preparation would keep me one step ahead of a potentially bad outcome.

In Letters to a Young Therapist, Mary Pipher wrote, “the answer to most questions is, ‘It depends,’” I interpreted this to mean the more you knew, the more options you had, so I read clinical books, attended trainings, listened to therapy podcasts, and consulted like my life depended on it. But I never feel truly secure in my work or in my life outside work. It felt like uncertainty was lurking around every corner.

One day, while looking for answers, I came across the obituary of therapy icon Carl Whitaker, which mentioned one of his favorite phrases: “Stay confused.” It was a lightbulb moment. Instead of running from uncertainty, I wondered, what if I embraced it? But how?

To start, I sought the expertise of therapists who’d trained under family therapy legends and whose work spoke to me. Pauline Boss had trained under Carl Whitaker, and I was fortunate to meet her briefly during my doctorate program. I also came across the work of Jean McLendon, who’d trained under Virginia Satir. I emailed both women and told them I was on a quest to change my relationship with uncertainty. Both agreed to meet with me to discuss it.

Valuing Confusion

Pauline Boss is exactly the kind of woman I hope to be when I’m older. At 90, she’s still writing, and still helps therapy students and mid-career professionals alike. She perfectly fits my image of a therapist, with a soft, calming voice, and equal parts direct and compassionate. When we finally met via Zoom, I was jittery with excitement. When I asked her about her experience with the ambiguity inherent to the field she smiled.

“I’m the child of Swiss immigrants,” she said, “and Switzerland is very good at precision work. When I went to college, I attended a seminar where we were asked to use one word to describe ourselves. I picked the word decisive—and I was proud of it. But that decisiveness was knocked out of me when I met Carl Whitaker! He valued confusion, and if it didn’t arise naturally, he’d do something to make it arise.”

The very idea of embracing confusion and uncertainty made my stomach tighten. I still desperately wanted to cling to that sense of decisiveness that Pauline once had once been so proud of. How do I let go of it? Pauline’s answer sounded surprisingly simple: companionship.

“It’s the medicine that heals,” she said. “Whitaker always said, ‘We are temporary. Our job is to connect clients with someone who will be in their life after therapy is done.’ I once worked with a woman who was living alone while her husband was deployed overseas. She had no family nearby, so she’d bring her dog to our sessions. I’m not really a dog person, but I could see that he was her companion. And in the end, she told me her dog saved her from suicide. It wasn’t me who saved her. We therapists just walk alongside people for a little bit.”

I thought back to earlier in my career, when I loved hearing clients say how helpful I was. But as I spent more time doing therapy, I noticed that clients’ big breakthroughs and insights came from small moments I hadn’t put much stock in. Pauline was right: we weren’t infallible experts with all the answers. We didn’t need to be. We were simply companions on our clients’ healing journeys.

Calamine Lotion for the Unknown

A few weeks later, I sat down for my meeting with Jean McLendon, a therapist and teacher who worked directly with Virginia Satir and continues to teach her approach. Jean shared the profound impact Satir had on her—and how she’d spent most of her first training feeling like she didn’t measure up to her colleagues. But a serendipitous conversation during that training led to a lightbulb moment that convinced her she needed to be okay with confusion. And she’d built on this insight, she told me, realizing that feeling confused meant she was learning something new, beyond her current understanding.

As I listened to Jean, I felt heartened, encouraged to move toward ambiguity as a path to insight. After all, insight isn’t something we’re born with; we have to allow ourselves to be open to it.

“I began calling my struggles ‘experiencing cognitive chaos,’” Jean said with a laugh. “And I taught myself to stay in the present. That is what I can know—the right now. I can’t know 10 minutes from now, or change 10 minutes ago. This mindfulness and knowing give me the resources I need to manage change. I can breathe, and I can appreciate that I’m alive right now. I have value, and I have tools. This is the calamine lotion for the unknown.”

What an apt metaphor, I thought. There is something itchy and uncomfortable about the unknown. It makes us squirm. Scratching that itch by seeking certainty might provide some immediate relief, but it’s not a long-term solution.

“We’re not meant to face the unknown alone,” Jean continued, “because we’re relational.”

***

Meeting with Pauline and Jean was a breath of fresh air. It felt like a weight had been lifted off my shoulders that I hadn’t even known was there. Today, I try to imagine their voices when I feel stuck—in and outside of therapy. I tell myself, I have value, I have tools, and it’s not my job to figure this out alone.

These conversations reminded me that oftentimes, the so-called problem isn’t actually the problem; it’s our tendency to struggle against it that creates the real problem. Uncertainty wasn’t the reason I’d been struggling; I’d been struggling because of how I’d been responding to it. I’d been trying to plan my work and life without acknowledging that some problems can’t be foreseen, and not all answers can be formulated in advance. I began to realize that there had been times when this thinking had caused me to try to fix my clients’ pain, rather than simply sitting with them in it.

Now I am building a more peaceful coexistence with uncertainty. I don’t know the value my clients may find in sitting in the unknown, but I’m getting more comfortable sitting in that uncertainty with them—instead of colluding with their desires to control and problem-solve. I’ve learned that a great therapy session isn’t necessarily determined by what we accomplish, but more often by how the session feels. The best sessions are the ones where we reach a flow state and both of us are fully present.

For a long time, my anxious parts told me that being a great therapist was a matter of knowing enough. But today, I know that being a great therapist really comes from letting go, trusting the process, believing in my skills and value, and being truly present with my clients.

I’m still fine-tuning my relationship with uncertainty. In fact, I’m sure I’ll be working on this for the rest of my life. But when my anxious parts seek certainty, I take a breath and remind myself that I can handle whatever comes next.

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People often ask how I do this work—how I sit with trauma, grief, and deep emotional pain day after day—and I think they’re surprised when part of the answer is: I laugh.

Not because pain is funny. And not because laughter is a good distraction. But because humor has become one of the most unexpected and powerful tools in my clinical work—especially with clients who’ve experienced complex trauma.

It’s not something I plan. It’s not a technique or a strategy. It happens naturally, in real, alive moments between me and my clients. But the fact that you can’t force humor doesn’t mean you can’t cultivate the conditions where it can arise more easily. As therapists, we can do this by allowing space for authenticity, loosening the grip of clinical performance, and meeting our clients with genuine presence rather than rigid professionalism. It’s born from attunement, curiosity, and relational trust. And when it shows up, it’s often a bridge to something deeper.

Research supports this, too—though it doesn’t get talked about enough in clinical training. Studies show that humor can help regulate the nervous system by activating the parasympathetic response. It lowers stress, releases tension, and increases feelings of safety and connection. For trauma survivors who’ve lived in prolonged states of vigilance, this can open a new door—not just cognitively, but somatically.

It also helps with relationship-building. Humor, when used with care and attunement, strengthens the therapeutic alliance—the most reliable predictor of successful therapy outcomes. Clients often relax when they realize therapy doesn’t require constant heaviness and they’re allowed to bring their whole selves, including humor, into the room. They can be fully human in therapy—and that alone can be healing.

Humor can be a form of curiosity—with warmth, humanity, and a little irreverence mixed in. I often find myself curious and leaning in, especially when a client seems to be engaging in a self-destructive pattern and I want to know more about what’s underneath. Curiosity almost always leads somewhere interesting, and when it’s mixed with playful humor, it can open what judgment closes.

At times, I’m the one who starts laughing—not at anyone, but in warm recognition of something beautifully human. A quirky pattern, a tender truth, a moment of absurdity that a client hasn’t yet seen as endearing. And then it happens: I see the shared recognition bloom in their face—a quiet “that is pretty funny” realization. And often, it’s in that moment of mutual recognition that the real work begins.

As a Brainspotting clinician, I sometimes use a pointer. Once, a client—struggling with existential depression—looked at me and asked, “What’s the point of all this?” I gently said, “I get that. Just notice that question, what’s the point, as you stare at this point,” then paused and added, “no pun intended.” It was corny, but we both burst into laughter. And in that moment, he felt a loosening in his chest. It created just enough space for something new to emerge—a softening, a breath, a possibility, and an ability to release fear.

Over time, I’ve noticed that trauma survivors have often been taught that vulnerability is dangerous, or that emotions make them weak. Humor, when it arises naturally in the room, can shift that dynamic. I’ve had clients tease their own inner critic, mock the absurdity of perfectionism, and say things like, “I can’t believe I’m paying you to point out my bullshit.” And we laugh. And then we work. And the humor not only deepens the work, it enhances our relationship.

I’ve seen many clients soften in moments of shared laughter—something lands, tension releases, and a stuck place transforms into an opening. The laugh isn’t about avoiding pain; it’s about making room for it. Sometimes, it’s that lightness that lets the tears finally come. In trauma therapy, this can be essential.

Many of my clients who carry developmental trauma or struggle with codependency arrive armored—trying to please, being overly agreeable, careful not to rock the boat. Understandably so. In many families, especially those marked by trauma, enmeshment, or emotional neglect, having needs meant being too much or not enough. So they learned to suppress them to stay safe and feel loved.

But humor can highlight blind spots in a way that joins rather than shames, like when I told a client who couldn’t say no to a coworker, “It’s really nice of you to do all their work for them.” Humor lets us slip into tough emotional places without always pushing against our clients’ defenses.

Many of us were taught to associate healing with suffering, and the belief that therapy must be heavy to be real is still pervasive. But healing isn’t just about catharsis—it’s about safety. And sometimes, safety feels like a shared laugh, a soft “I’ve been there, too” moment.

As a trauma therapist, I’ve come to recognize that joy and sorrow aren’t opposites; they live side by side. Clients don’t need us to carry only their pain; they need us to witness the fullness of their humanity. Many trauma survivors have lived through darkness in ways that make them less afraid of naming it. Some even meet it with humor—not to minimize the pain, but to stay connected to something human and grounding.

Dark humor, in particular, can sometimes be a sign that they’re not bypassing the hard stuff, but are learning to carry it with less fear. For example, one time a client said, “I got closure this past weekend by flipping my grandma off at a Chili’s and leaving her with the bill. People were staring like, Wow, that person just flipped off a sweet old lady? But honestly, that was the most empowered I’ve ever felt.” During a guided visualization, another client let out a snort-laugh and said, “Oh my God, there’s a face looking back at me. It looks as shocked as I feel.” Then she added, “Great. Even my trauma’s like, You’re still here?”

Humor has to be used with deep care and must emerge organically, meaning it arises naturally in the moment, from genuine connection and attunement, not as a technique or performance. It has to come from your own inner child—the part of you that still plays, still notices the absurd, and still knows how to be shamelessly silly. Also, we need to remember that humor is subjective, influenced by culture and all our intersecting identities. It’s never one-size-fits-all. What one person finds funny, another person may find insensitive.

There are many moments when saying something that might be humorous wouldn’t enhance therapy—when it would be a deflection, or misattuned. But when it’s spontaneous, grounded in the relationship, and respectful of the client’s experience, it can invite a deepening rather than avoidance. Motivation is everything.

As clinicians, we can understand our own motivation for injecting humor into our interventions by asking ourselves questions like, “What’s my reason for bringing this up now?” When our clients say something humorous or make a joke, we can consider saying, “I noticed you laughed when you said that, and I’m wondering if there’s something more behind that laugh.” It’s not the humor itself that matters most but what it’s doing in the room.

Healing doesn’t always start with crying. Sometimes it begins with a snort-laugh in a quiet office. Sometimes it starts with the nervous system relaxing just enough to say, “Maybe I can let someone in.”

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You’re about to hear a discussion between Dr. Ramani Durvasula, a leading expert in narcissism and narcissistic abuse, and Kory Andreas, a leading expert in autism and neurodivergent couples.

Some of you are probably wondering why we’re even exploring autism and narcissism in the same conversation. Other than both being words that are growing more and more ubiquitous in our culture, they have nothing to do with one another: one is a neurotype that exists on a spectrum with vast presentations of its challenges and strengths, and the other is an antagonistic personality style that’s hugely damaging to relationships.

So why are these two experts, with such very different clinical specialties, coming together to meet today? The answer is that they’re both concerned about the confusion they’re seeing around certain behaviors that can be damaging for relational partners but can have very different root causes and have very different prospects for change.

In her neurodivergent couples therapy practice, Kory Andreas is seeing a lot of partners of autistic adults feeling helpless and hopeless, maybe thanks to social media, because they’ve misunderstood some of their partner’s behaviors as rooted in narcissism rather than autism.

And in the groups for survivors of narcissistic abuse that Dr. Ramani runs, she’s seeing that actual narcissistic partners are falsely claiming that their harmful behaviors are rooted in autism, not narcissism, which can really complicate the healing process for someone struggling to make sense of a narcissistic relationship.

Today, we’re going to discuss why this is happening, why it matters, and what we can do about it.

This is a tricky conversation, and frankly it was tricky for me to facilitate, so before we dive in, I want to make a few things clear.

First, the presentation of autism we’re focusing on here is in high-masking autistic adults, or individuals with low support needs, many of whom probably weren’t diagnosed until late in life and as a result may carry a lot of trauma from being misunderstood and unaccommodated for so long.

Second, just because we’re having this conversation does not mean we’re implying that every high-masking autistic adult exhibits harmful behaviors toward their partner. That is not the case at all. Rather, we’re exploring certain behaviors that can show up in neurodivergent relationships that may look similar to certain behaviors that do show in narcissistic relationships and therefore are often misunderstood by partners—and sometimes therapists. Correcting that misunderstanding can make a dramatic difference in people’s lives. And that’s what we’re attempting to do here.

Most autistic adults have a strong sense of justice and fairness—they are not looking to control a partner or shut down emotional conversations or put up walls or erupt in anger at seemingly small things. They may not even be aware of how much they’re masking at work, and how that affects their nervous system when they come home to a partner. But when both partners in a neurodivergent couple are committed to learning about the autistic brain and making accommodations, there’s a lot of room for growth and change—and that’s what Kory Andreas focuses on in her practice.

However, when these same kinds of behaviors are rooted in narcissism, there’s very little chance of change, and making accommodations only gets a partner deeper into what can be a soul-crushing cycle of abuse. And that’s what Dr. Ramani focuses on in her practice.

So you’ll be hearing us discuss things like: the misconstrued question of empathy, extreme rejection sensitivity, trauma, and controlling vs. rigid, pattern-seeking behaviors.

As we get started, keep in mind that we’re opening the door to something nuanced and complicated, and it’s an ongoing conversation we hope you’ll engage with.

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

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

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

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

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

Until now.

The Pursuer-Withdrawer Dynamic

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

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

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

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

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

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

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

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

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

“Protection!” two people yell simultaneously.

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

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

“Fear of vulnerability!” someone else cries out.

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

Inside the Withdrawer’s Circle of Hell

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

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

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

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

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

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

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

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

Pursuers and Vulnerability Junkies

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

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

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

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

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

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

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

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

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

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

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

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

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

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For many people, trauma isn’t just a singular experience—it’s something they were born into, so ingrained in their day-to-day life that they don’t recognize it for what it is.

This is the kind of trauma therapist Linda Thai would like you to know about. Thai is especially well-versed when it comes to trauma treatment, having worked with organizations like the Trauma Research Foundation, the Asian Mental Health Collective, and Fairbanks Memorial Hospital. She’s keynoted for the U.K.’s Royal Society of Medicine and the National Education Association, as well as at the Oxford Trauma Conference and the Psychotherapy Networker Symposium. As a therapist, author, educator, coach, and storyteller, Thai is candid about her journey as a survivor of the post-war Vietnamese Boat People diaspora that dropped her at the intersection of trauma, addiction, attachment wounding, and grief.

Thai found healing and recovery in yoga, which helped her process the trauma stored in her body. She studied Somatic Experiencing, Brainspotting, Internal Family Systems, Trauma-Informed Stabilization Treatment, Havening Touch, and Flash Technique. She also caught the attention of renowned trauma expert Bessel van der Kolk, with whom she’s partnered to lead workshops aimed at healing attachment trauma. And along the way, she traveled the world, bringing her expertise to thousands.

Thai’s unique approach draws from the “wisdom portal” of her ancestors. After settling on the traditional lands of the Tanana Athabascan people (modern-day Fairbanks, Alaska), she learned to live off the land with a combination of “mutuality, reciprocity, kindness, and collective responsibility.” She and her husband live in a 550-square-foot cabin they built by hand, heated by firewood they cut themselves. They pick wild berries, raise animals, fish, and hunt.

No, not everyone needs to take up woodworking to process trauma or combat the traumatic forces of sexism, racism, homophobia, and colonialism that exist in our systems and institutions. But some of the most profound healing, Thai says, comes from time-honored cultural practices, like a reverence for nature and community. She believes we must buttress our mainstream therapy approaches and techniques with an acceptance that at the heart of healing is something more innate—instinctive practices that may feel more elemental than intellectual.

Thai recently sat down with us to share how we can all cultivate more wholistic healing practices, with characteristically honest reflections on her own journey and the spiritual act of finding your way back home.

Ryan Howes: What drew you to somatic treatment for trauma?

Linda Thai: Quite simply, yoga and meditation saved my life. I was in addiction recovery, and these practices helped connect me with my body in real-time. So I started teaching them in addiction and trauma recovery settings. I also got into Bessel van der Kolk’s work, IFS, Sensorimotor Psychotherapy. I was learning all of that even before I started studying to become a therapist. I’ve also benefited a lot from studying attachment theory and applying attachment-based principles to my work.

But I’ve never felt any of it truly captures the fullness of what it means to be human: interdependent and in inter-relationship with the world. Psychotherapy hyperfocuses on dyadic relationships: between two partners, between parent and child, between therapist and client. We may see families; we may even facilitate groups—but we’re still only focusing on human relationships.

As a society, we’ve been severed from the holistic, expansive experience of our relationship to nature, to our bodies, to our ancestors, and to time itself. You could say we have an insecure, avoidant, anxious, disorganized relationship with all those things.

I immigrated to the United States as an adult. But as a toddler, I was a refugee, first in Malaysia and then Australia. Home ceased to exist long before we left it, and there was no home to go back to. I then became a refugee from a country called The Body. It put me in close proximity to all kinds of loss, including the embodied experience of secure attachment and the full experience of being human.

This is common for all refugees—religious refugees, people fleeing domestic abuse, trans youth fleeing their families, abducted and enslaved Africans, transracial and transnational adoptees. They’ve all experienced forced displacement and disrupted relationships with themselves and their sense of home. Disrupting the relationship between a people and their home is the first act of disembodiment, and once people are disembodied, they’re easier to make compliant. That’s colonialism: the trauma of colonialism is the trauma of disconnection.

This process of colonialism happens with all waves of immigrants that were othered and all indigenous people who were invisiblized. Speaking as an Asian-bodied person, my people have colluded with the model-minority myth, because it gives us more proximity to whiteness and separates us from other Black and Brown bodies. You can learn about this process as information to put it into your head, but there’s a metabolic process of grief that also takes place within the body.

RH: Much of your work focuses on intergenerational trauma and grief. How are those connected?

Thai: In graduate school, I learned that the dynamics of a dysfunctional family are “don’t talk, don’t trust, don’t feel.” Not naming your losses, not naming your sadness, not crying: those are survival strategies, especially when our rituals and ceremonies for embodied grieving have been taken from us.

As Resmaa Menakem reminds us, when trauma is decontextualized, it looks like culture. It looks like stoicism. It looks like sucking it up, or stuffing it down, or rubbing some dirt on it. And it also looks like the shaming and blaming of emotions in others and in oneself.

Parents with unresolved losses and traumas aren’t able to be there for their children in developmentally appropriate ways. And then the children learn not to cry, not to feel. You see the individual informing the family system, which informs the culture. And now we have a society that, as Francis Weller says, is replete with mechanisms for amnesia and anesthesia.

RH: Which leads to addiction for a lot of people, right?

Thai: Exactly. When I worked in addiction recovery, we’d do a timeline of our drug use alongside a timeline of our transitions, losses, and traumas. It showed how unresolved losses often become the platform for using. Some losses, like moving schools as a child and losing friends, may not have registered as a trauma, but if your parents didn’t acknowledge the losses or provide resources for support, then it most certainly was traumatic.

In the absence of an embodied way to grieve, and in a culture of patriarchy and unhealthy masculinity, the acceptable go-to emotion is anger. In my work, we often looked at fury and rage as indicators of unresolved grief and trauma. And we bring mindfulness awareness to the physical sensations of those emotions, because that’s what emotions are: physical sensations.

RH: What does healthy grieving look like for you?

Thai: Grief is a primal human need, and it’s a solitary journey that we can’t take alone. To grieve, you need to be in community, some sort of group, where the fullness of your body’s need to express grief is welcomed. It’s important we reclaim cultural rituals that make space for song, story, movement, silence, togetherness, and aloneness. You can see these elements in African American funerals, Vietnamese funerals, funerals with people who are hired to wail—professional keeners—which come out of several European traditions.

Once we expand our conceptualization of what it means to be securely tethered and have a sense of place in the world, we can then get curious about the things that were taken from us (that we may not have realized shouldn’t have been taken from us) and the things that were given to us (that we may not have realized shouldn’t have been given to us). That applies within our family systems and on a societal level. In the latter sense, collective trauma requires collective healing.

We need to come together every new moon, every full moon—something to give us a sense of rhythm. We need to be in community as a witness, as a container. And when the fruit of grief ripens in the moment, we need to know it, to carry it. Just like how we metabolize food, when we metabolize grief, we create fuel for our growth, for our humanity.

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

Meet Marcus

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

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

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

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

An Experience to Be Tended

By Megan Devine

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Emotion Lights the Path Home

By Leanne Campbell

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

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

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

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

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

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

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

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

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

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

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

“Some relief,” he replies.

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

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

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

He pauses. “I really don’t know.”

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

Marcus nods.

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

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

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

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

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

“No, she has enough to worry about.”

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

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

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

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

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

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

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

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

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

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

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

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.

The post Baseline Suicidality in Neurodivergent Kids appeared first on Psychotherapy Networker.

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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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It’s generally recognized that there are two ways in which thoughts come to mind. If I say “two plus two,” something instantly comes to your mind. If I say “seventeen times twenty-four,” probably nothing comes to mind immediately. You can produce a solution if you know how to do it—it’s 408—but computing that’ll take you some time. Clearly, different operations are involved in the response to different kinds of problems. That’s what I call System 1 and System 2.

System 1 is associative and immediate. In System 1, things just come to our mind. System 2 is different. We feel that in System 2, we’re the authors of our own thought. System 2 requires attention, effort, and mental work.

In System 1, we’re more aware of feelings, wishes, or vague intentions. In System 2, we’re often aware of not doing everything that comes to mind, but System 2 mostly engages and endorses what comes to mind from System 1. I sometimes describe System 2 as the relationship between a newspaper editor and a journalist. The journalist (System 1) writes stories, while the editor (System 2) looks at them to see whether there’s a major problem; if not, it just goes to print. Only if there’s a problem do you slow down and try to do something that doesn’t immediately come to mind.

In psychotherapy, you’re often trying to get System 1 and System 2 to relate to each other in a somewhat different way. It may be that System 1 is running the show in someone’s life, and their System 2 is trying to talk back to System 1, but without a lot of success. Just as being aware that you’re addicted to something doesn’t enable you automatically to get out of that habit, System 1 is the associative machinery of our mental processes, and it’s typically very hard to change it. While you can teach System 2 new tricks to some extent, System 1 is difficult to reeducate.

Strategies of Change

Still, there are many ways in which System 2 can influence the operation of System 1. In the first place, you can make decisions about the context of your life, and then the context will take over. So if there are no cigarettes in your home, you’re less likely to smoke. If there are no cookies, you won’t eat cookies. The easiest form of self-control is to restrict your environment in a way that’ll reduce temptations.

I’m not an expert on therapy, but much of what therapists seem to do is help people re-image the situations in their life and acquire new mental habits. What can make that process difficult is that while System 1 is quick to change responses to context, it’s slow to learn new habits. Nevertheless, we do learn to drive and acquire other everyday skills in life and, to some limited extent, we can acquire different mental skills, or we can overcome some habits of mind that bring us misery. For example, it sometimes happens that people find new ways to label what’s happening to them, and that new label may have different emotions associated with it. So by labeling situations in a new way, you can sometimes change your response to them. So insights in therapy, to the extent that they lead you to a different labeling of situations, can change people’s emotional response. Actually, relabeling isn’t all that different from acquiring a new habit.

The Power of Story

Our associative memory is organized to maintain an ongoing narrative of our life. This happens automatically. We don’t have to deliberately construct stories: our associative machinery is built in such a way that it tends to produce interpretations of the world, stories that are more coherent and simpler than reality. If something happens, we tend to look for a possible cause and, without deliberate effort, typically link two events to make up a story to “explain” what happened. The halo effect, attributing positive qualities in one context to someone who’s impressed us in some other way in another context, is an example of a simple associative story. If somebody is good at something, we tend to see them as good in everything. Black and white is simpler than recognizing shades of gray.

Our tendency toward believing our own stories is important in determining how we think about our lives. If you ask somebody, “How was your vacation,” as opposed to asking in a given moment of the vacation “How are you now?” you’re asking different questions to different aspects of the self. The first question is addressed to what I call the “Remembering Self” and the second question is addressed to the “Experiencing Self.” In fact, the Remembering Self doesn’t necessarily take into account what the Experiencing Self has actually been through.

The Remembering Self tends to be sensitive to the structure of a story, especially how things end. If an experience ends well, then it casts a different coloring on what went before. So it turns out that we tend to control our life by anticipating how we’ll remember something in the future. It’s the Remembering Self that’s really in charge, and it drags the Experiencing Self along, frequently imposing experiences on the Experiencing Self that aren’t necessarily the best ones.

Here’s a thought experiment that highlights the difference I’m talking about. Think of your next vacation and then imagine that at the end of the vacation you’ll be given a drug that causes you to forget the whole vacation. Would you go to the same vacation, even if you knew you wouldn’t remember it? Would you go on vacation at all? Would you go on a different vacation? Thinking about that’ll give you the idea that there’s a lot that you do because you’re creating memories, and knowing that there are going to be no memories changes our attitude about what we’re doing.

What Really Matters

Wisdom, as I understand it, is an ability to look at complex situations and distinguish what’s important from what’s not important. It’s the wheat from the chaff. Wisdom is about determining the things that really matter and what’ll make a difference in the long run. Wisdom might be thought of as our ability to allow our System 1 and System 2 to have regular conversations with each other, to be aware of all the automatic errors we make in coming to our judgments because of the built-in biases of our cognitive machinery.

I’d like therapists to think about themselves and their own reactions in terms of System 1 and System 2. I’ve spent many years studying these systems, and, with all that, I still can’t say that I’ve been successful in changing many of my own bad mental habits. The best we can often do is to just be aware of how unreliable our mental machinery can be.

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

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

Taking a Wrong Turn

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

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

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

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

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

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

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

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

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

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

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

John nodded.

“And what if he can’t?”

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

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

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

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

The Here and Now

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

A Turning Point

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

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

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

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

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

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

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

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

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

***

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

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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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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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Sandra feels a sense of pride and accomplishment as she wraps up a telehealth session with Roy, one of her long-term therapy clients who’s finally begun seeing the benefits of two years of weekly psychotherapy. He’s set some boundaries with his emotionally abusive ex, and he recently received a hard-earned promotion at work.

“See you in a week?” Sandra asks, more as a formality than a question.

“Absolutely,” Roy beams. Then, as an afterthought, he adds, “I’ll be in California hosting a networking event, but we can still meet. I’ll just be three hours behind you.”

“That works.” Sandra smiles, imagining Roy traveling around the country in his new leadership role. He’s come a long way from the depressed man who was too anxious to leave the house after his divorce. But the pride she feels in his progress is quickly eclipsed by a prickly insecurity. Is it legal for me to see him as a therapy client when he’s out of state? I’m not licensed in California. Can I still bill his insurance? Another voice pipes up: Just call it a life-coaching session. That’s what half the therapists in your peer-supervision group are doing. 

“See you then,” Sandra says.

“Sounds good. And thank you.” Roy waves goodbye.

After closing the telehealth window, Sandra makes herself tea. The warmth in her chest has returned. It’s gratifying to see clients like Roy do well. What was she supposed to say to him when he mentioned traveling for work—”Oh, sorry, I can’t see you next week”? It’s fine, she reassures herself. I’m a therapist who does life coaching with a few out-of-state clients, just like thousands of other therapists. That’s not a crime. If others are doing it, why shouldn’t I? It’s not my fault the whole state-reciprocity thing is such a mess. What matters is I do good work. I help people.

Making Informed Choices

Sandra’s right. It’s not a crime to do life coaching with out-of-state clients—well, not exactly. And it’s not her fault the whole cross-state thing is complicated. And it absolutely does matter that she’s doing good work with people like Roy. And thousands of therapists across the country are in fact doing precisely what she’s planning to do in a week’s time: providing a nebulous, unregulated service called “life coaching” to out-of-state clients.

But Sandra is also wrong. Even if it’s not necessarily a crime to provide life coaching instead of psychotherapy to Roy when he travels to California, there are a number of legal and ethical complications that many well-intentioned therapists don’t fully understand. And although the majority of seemingly minor ethical and legal violations therapists commit go unnoticed, there are times when these violations balloon into larger problems, even morphing into complicated legal situations that are harmful to clients (and therapists!).

Clients who feel slighted or angry, or who become upset by a firm boundary (like being told they need to pay full fee for a missed session), may come to resent their therapist over time and decide to file a complaint with a licensing board. In some cases, clients have been known to file a malpractice lawsuit if they feel wronged. The consequences can be dire for the therapist—from having their license revoked and livelihood upended to being slapped with hefty fines, or having to pay for damages as a result of a malpractice suit.

For years, I’ve been teaching therapists about ethical, legal, and practice issues, providing those in our field with the information they need to make informed choices and decisions. So when it comes to therapists reflexively dipping their toe into the life-coaching industry or moonlighting as life coaches to hold on to clients who travel or move, it’s my job to shine a light on the potential dangers.

Therapists are usually not licensed in more than two or three states, yet more and more of them are being asked by itinerant clients for teletherapy. In my ethics workshops, therapists are now wondering, Can’t I do life coaching with a psychotherapy client if I tell them that’s what we’re doing? I’m already results-oriented in my practice, and I like giving advice, so can’t I just rebrand my therapy practice as a life-coaching practice? Can’t I bring my expertise as a therapist to life coaching and avoid all the complicated laws, rules, and limitations that come with practicing psychotherapy?

Because coaching as an industry has exploded alongside teletherapy, not too many people have hard-and-fast answers to these questions. In providing them, my goal isn’t to rain on anyone’s parade or be the bearer of bad news: it’s to empower them. Informed therapists make better decisions.

A Risky Mix

Let’s return to Sandra. She’s made herself a cup of tea, and the nagging insecurity about turning Roy into a coaching client for a session kicks back in. Luckily, this is all happening in a futuristic time—maybe even a week from now, given the rapid pace in which technology moves—and I’m able to appear in her office as an AI 3-D hologram, beamed in because an app on her phone has somehow overheard her silent inner musings.

“Hi, Sandra,” I say. “Listen, I’m going to cut right to the chase here. This is a very common dilemma you’re in, and there are some important things you need to know.”

Sandra sits back in her chair and appears open to listening.

“Life coach and psychotherapist aren’t the same thing,” I tell her. “The most important difference is that psychotherapy is a regulated health care service whereas life coaching isn’t regulated or even defined by the state. Also, let’s make the distinction between providing life coaching, possibly as a licensed mental health provider, and identifying as a life coach. Someone who calls themselves a life coach might have more freedom than a psychotherapist, but it also means anyone can call themselves that. There’s no required training or licensing: no rules, laws, or regulations to govern it. Life coaches can’t diagnose or treat mental health disorders. Although the International Coaching Federation has in fact outlined a code of ethics for coaches, whether or not coaches follow it is optional. Therapists, on the other hand, can face serious legal consequences if they don’t follow ethical codes as required by their licensing rules.”

“I get all that,” Sandra says. “But I’d just be providing life coaching to this client occasionally, when he travels. Things are going so well for him. I don’t want to interrupt our work. I could do life coaching when he’s out of state, and psychotherapy when he’s back.”

I shake my head sadly. I’ve heard many therapists say things like this. “There are quite a few problems with that,” I reply.

“Like what?” Sandra says, a little defensively.

“First, it confuses clients. As a licensed psychotherapist, you’re ethically and legally bound to avoid misleading the public. You need to properly inform your clients about the benefits and risks of your services before you begin working with them, and to continue informing them of changes you make to the treatment you provide throughout the therapy process. Which means you’d need to inform Roy about the benefits and risks of life-coaching before offering it. You can read up on this under the advertising or public statements sections in most codes of ethics and licensing rules for mental health professionals.”

Sandra waves her hand in front of her face, as if she’s trying to swat away a fly. This is a lot for her to take in, but I decide to continue. I’d be doing her a disservice if I withheld what I know.

“If you’re providing services associated with your license or clinical practice, including life coaching, the service must be provided in keeping with the laws, licensing rules, and code of ethics in your state. When providing mental health treatment, like psychotherapy, across state lines you must be even more careful. It’s legally essential that you be licensed, or another legal provision of some type exists, both in the state where you’re located and in the state where your client is located when the psychotherapy session occurs. After all, you are in fact practicing in another state—a separate jurisdiction that gets to determine what’s legal there.

“Whenever you claim to be providing life coaching but are actually providing some type of psychotherapy, you’re relabeling a regulated mental health treatment as something it’s not. A rose by any other name is still a rose! Doing so is not in keeping with codes of ethics, state laws, or licensing rules, or consistent with the standard of care.”

“This is more complicated than I thought,” Sandra says.

I have a lot of compassion for therapists trying to figure out what to do in situations like the one Sandra is facing with her client. Like many of them, she’s struggling to accept a difficult truth: her I’ll-do-coaching-for-just-one-session workaround isn’t as convenient or failsafe as she’d hoped. I know she’ll need a little time to wrap her mind around this new information. Even though I’m an AI hologram, I walk over to her kettle and pour myself a cup of tea.

Have Your Cake and Eat It, Too?

Then, something I wasn’t expecting happens. Sandra’s face lights up.

“Wait!? What if I created a separate service on my website that’s just ‘life coaching?’”

“Not a bad idea,” I say, careful to keep my voice measured. I don’t want to invalidate her or overwhelm her, and she’s actually heading in the right direction, ethically and legally speaking. “Keep in mind, however, that if a clinician did what you’re suggesting and then claimed that the life-coaching services they offer are in no way associated with their therapy practice—and that therefore, the same laws don’t apply—a host of other issues would arise. For example, you’d need to keep your coaching records someplace entirely separate from your clinical records. And you couldn’t bill through your clinical practice. Oh, and also remember not to confuse or mislead your client.”

“So what you’re saying is my good idea is a bad idea,” Sandra laments.

“My job is to make sure you’re aware of the hazards and pitfalls,” I say. “It’s up to you to assess the risks and decide which ideas are good or bad. One concern I’d have with a therapist who provides life coaching through a separate life-coaching business is that the life-coaching clients’ privacy would be affected. Within the context of a life-coaching business, federal privacy laws and state privilege laws wouldn’t protect the client anymore, which might put them at risk.”

“Really?” Sandra looks horrified. The last thing most therapists want to do is risk their client’s confidential information getting into the wrong hands or being subject to random subpoenas. Most therapists would never intentionally want to mislead clients into believing sessions with them are HIPAA-protected when in fact they’re not.

“In other words,” I say, “and this is super important to remember: you can’t simultaneously avoid regulatory requirements and still maintain the benefits of federal and state privacy laws.”

Sandra has started pacing. She walks back and forth through my hologram several times. Though technically, I don’t feel anything when she does this, I find it a bit unsettling.

“Sounds like you’re saying I can’t have my cake and eat it, too,” Sandra sighs.

She’s starting to get it, and I’m glad. She seems like a lovely person and a gifted clinician. I’d hate to see things go wrong for her simply because she was uninformed. “Well, you might be able to have your cake and eat it too if you want,” I say. “But there are risks, some of which may not be covered by your professional liability insurance.”

Sandra returns to her chair, raises her cup of tea, and takes a long, slow sip. “What do you mean by that exactly?” she asks.

“Liability insurance policies designed for licensed mental health professionals often don’t cover services—like life coaching—that aren’t considered part of professional practice for your license type and the policy is even less likely to cover a separate life coaching business. Either way, you’ll need to check with your insurance company before you make any big decisions.’’

Sandra stands and opens the door, gesturing me through. “Don’t mean to cut you short, but I need to say goodbye now. I can hear my next client in the waiting room. Thanks for sharing all this with me.”

“Happy to help,” I say. Feeling like Sandra needs a sense of closure to our conversation, I oblige by walking out the door—although dissipating into the air would’ve been a bit simpler.

Sandra’s Options

What Sandra decides to do from here is up to her, but her choice will depend on many factors, both personal and professional. I’ll present three scenarios, each accompanied by different risks.

High-Risk Scenario. Sandra decides to sit with our conversation for a day or two. But life gets busy, and she soon forgets the details of what I’d said. Two weeks later, it’s time for her to send Roy the HIPAA-protected teletherapy link to join their meeting the following day. Oh, it’s fine. Nothing’s going to happen. It’ll just be this once, she thinks. When Roy appears on screen, she lets him know that today, they’ll be doing a life-coaching session rather than a therapy session, for technical reasons. “It’s similar,” she says.

“Will you still bill my insurance?” Roy asks. “Because I can’t really afford to pay out of pocket right now with all the legal bills from my divorce.” Sandra responds that she’ll simply use the same procedure code for psychotherapy, but if he continues traveling in the future, they may need to figure out a different plan. As innocuous as this may seem, this is insurance fraud. Psychotherapy is healthcare treatment; life coaching is not.

Even if Sandra more accurately tells him, “I can’t bill your insurance because this will be a life-coaching session, which is a different kind of service than psychotherapy,” negative consequences could unfold. Roy may choose to forgo the session—after all, why would he want to pay out of pocket for life-coaching sessions when he has insurance that covers therapy—but as a result, he might feel confused, even disgruntled, which could have a negative impact on the therapeutic relationship.

With some clients, this confusion can increase the likelihood that they’ll file a complaint with licensing boards or even pursue a civil suit. I know of several cases where a provider’s actions were judged as not being consistent with the standard of care and resulted in their license being put on probation, as well as the provider paying thousands of dollars for damages to the plaintiff in a civil suit.

Medium-Risk Scenario. Sandra sees her next—and last—client of the day after our chat. Then, she sits down at her desk and writes Roy an email explaining that due to out-of-state regulations related to her license and other issues connected to insurance reimbursement and confidentiality, they’ll need to wait till he’s back in the state where she’s licensed to have their session.

Over the next few weeks, Sandra communicates with colleagues who suggest the best way to provide life coaching is to separate it from one’s private practice entirely. One colleague even tells her that he’s retired his clinical license and closed his practice, and now provides only life coaching: it’s simply easier and more lucrative for him, he’d explained. Sandra doesn’t want to go this route, but she does see the utility of having the freedom and flexibility to see clients out-of-state. She also starts to like the idea of not having to worry about continuing education requirements, diagnosing, and insurance claims—at least on the coaching side.

She begins making a plan to have both a life-coaching business and a therapy practice. I’ll open a second LLC, she thinks. She also makes plans to take a life-coaching course, so she’s better informed about the differences between providing life coaching and psychotherapy. I’ll provide life coaching only to out-of-state clients, she decides.

Although these are all smart moves, an old saying comes to mind when I think of the ethical risks that still linger: once a therapist, always a therapist. Here’s what I mean by that. Not long ago, a participant in one of my ethics seminars made a comment that he conducted life coaching sessions through his life coaching business in the same way he conducted psychotherapy sessions in his clinical practice. He saw nothing problematic about this. He had the therapeutic skills—why not use them? But we wouldn’t provide dental or medical services through our life coaching businesses, even if we had the skills—so why do we do this with psychotherapy services?

If Sandra opened a life-coaching business and used therapy techniques as a coach, would she be breaking the law? Maybe. State laws and licensing rules define mental health services provided by social workers, psychologists, professional counselors, and marriage and family therapists. To provide these services, an individual must be licensed by the state (or be under clinical supervision). If an individual, including a life coach, provides these kinds of services, they could be viewed as providing regulated mental health services illegally. Simply being capable of providing a service doesn’t make it legal to do so if the service is supposed to be offered within certain parameters, or in a particular context.

Although Sandra is capable of providing the regulated clinical services that fall within the scope of practice of her license, she wouldn’t be able to legally provide these services through her life-coaching business. And although there’s no legally required code of ethics for life coaches, it would still be in her best interest to maintain appropriate boundaries with her clients and document her efforts to do so. Again, the possibility of client confusion would exist and need to be managed. And if a litigious client or disgruntled employee realized that Sandra was doing something potentially illegal, unethical, or outside the standard of care, they might exploit the situation by threatening to sue Sandra or file a complaint with her licensing board. I’ve run into this kind of scenario many times, and the provider always exclaims, “I never saw this coming!”

Lower-Risk Scenario. Sandra emails Roy that she needs to do a little research before seeing him next week when he’s out of state. She checks her professional liability insurance policy to see if she’d be covered in the event of a complaint to her licensing board or a civil suit if she provided life coaching to a psychotherapy client, and discovers she wouldn’t be. She also learns that in some states, there are licensing rules or licensing board policies that limit and even prohibit license holders from providing life coaching (because the primary mission of licensing boards is to protect the public.) It turns out that the licensing board for Sandra’s license type has a policy on its website stating that any licensee who publicly presents themselves as a life coach must comply with the relevant rules for the profession regulated by the board, as well as all ethical obligations.

Sandra lets Roy know that she’ll need to see him in two weeks, when he returns from his trip and is back in state. At that time, she’ll discuss with him the limits of providing psychotherapy across state lines, and they’ll brainstorm alternatives for future sessions when he travels.

Ethical Cheat Sheet

Given that I haven’t been able to make myself into an AI hologram who can appear in therapist’s offices at the drop of a hat (yet!), I’ve created the next best thing: an ethical cheatsheet. (I get that putting ethical and cheat together is a bit of an oxymoron, but even ethical therapists need cheat sheets). If you do decide to combine psychotherapy and life coaching, my biggest piece of advice is to familiarize yourself with the risks and proceed with caution. Here are 10 guiding principles you can refer to if you ever find yourself in a situation like Sandra’s.

Provide clients with informed consent. Have an informed consent process for the life coaching business that highlights the fact that life coaching is not psychotherapy, professional counseling, or any other regulated mental health service. And keep in mind that since there’s no legal definition of life coaching, no legal standards regarding training for life coaching, and no yardstick for competence or standard of care, you may have a tough time offering evidence that you’re competent to provide this particular service.

Client privacy. In the informed-consent process for a life-coaching business, be sure to emphasize that the privacy laws that apply to health care providers and their clients/patients do not apply to clients of a life coach. Without these protections, clients’ records and communications with the life coach are more vulnerable to access by others.

Communicate clear boundaries. On your website, in your informed consent documents, and in your interactions with potential clients, make sure they know what services you offer and their risks and benefits. Establish policies that prevent clients from switching back and forth between your clinical practice and your life-coaching business.

Keep your psychotherapy and life coaching services separate. The more separation the better. Avoid mixing life coaching and mental health services with the same client. Maintain separate websites and social media accounts. Develop a clear understanding of the differences between these two approaches—not an easy thing to do when life coaching remains a service for which no legal or recognized definition exists. Life coaching client records shouldn’t be kept in the same electronic health record or practice management system with clients’ clinical records.

Check your state licensing rules and board policies. Keep in mind that as a licensed professional you may still be expected to follow the laws and standards of your profession even when you’re providing life coaching. Also, never associate your license with life coaching (e.g., on your life coaching website) or imply in any other way that you’re using your license in conjunction with your life coaching business.

Communicate with your professional liability insurance. Determine if your professional liability insurance covers the life coaching services that you yourself want to provide to your clients, whether as part of a clinical practice or through a separate life coaching business.

Never provide life coaching in lieu of mental health treatment. If you’re providing life coaching through a life coaching business—even if you’re a licensed therapist—you need to refer life coaching clients who need a higher level of care to an appropriate licensed mental health provider.

Avoid confusing your clients. Remember, if all this is confusing to us it is even more likely to be confusing to the public. At all times be aware of the possibilities of your clinical clients being confused. It is your responsibility to take steps to mitigate these risks.

Avoid getting complacent. As a therapist, continuously ask yourself, Are my actions consistent with the standard of care that would be applied to a professional with similar education, training, and experience? If your professional actions are not consistent with laws, licensing rules, or your code of ethics then you will not be meeting the standard of care. This makes you vulnerable both ethically and legally.

Document your decision-making process. When clinicians encounter complex or otherwise challenging situations, I encourage them to use a decision-making model like my Multiple Perspective Model. Decision-making models provide a structured approach to decision-making. By documenting your decision-making process, you’re showing your thoughtfulness and care in the choices you make. This will be helpful if you ever need to explain your actions to a licensing board or in court.

A Note on Interstate Compacts. Calling psychotherapy life coaching as a workaround for cross-state practice is not in keeping with laws, licensing rules, or codes of ethics and should not be done. Fortunately, with the advent of interstate compacts like PSYPACT, the Counseling Compact, and the Social Work Licensure Compact, cross-state practice is likely to become less difficult. These multi-state agreements will facilitate therapists practicing across state lines, but there will still be compact rules to abide by.

Ultimately, therapists who want to avoid laws and regulations may continue to see life coaching as an appealing workaround. It’ll be up to individual therapists to determine the path they forge.

The post So You Wanna Be a Life Coach? appeared first on Psychotherapy Networker.

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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.

The post Are Supervisors Failing the Field? appeared first on Psychotherapy Networker.

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

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

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

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

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

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

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

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

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

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

Opposites Do Attract

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

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

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

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

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

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

Nine Temperaments

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

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

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

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

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

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

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

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

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

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

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

Gifts and Burdens

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

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

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

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

Temperament and Refrigerators

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

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

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

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

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

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

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

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

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

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

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

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

Asking About Orgasms

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

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

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

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

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

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

Seven Strategies That Can Help

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The post The Orgasm Gap appeared first on Psychotherapy Networker.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Authenticity

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

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

Identifying Self-Protective Habits

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

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

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

The Self-Therapizing Client

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

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

Embracing Messiness

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

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

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