Psychotherapy Articles

The Face with No Expression

Tuesday, September 10th, 2013

Expressionless FaceAs I continue to read Tomkins and Nathanson, focusing on the human face as the seat of our affects, I’m reminded of clients from long ago whom I didn’t fully understand at the time. In particular, I think of Noah and the completely deaded facial expression he presented throughout every session. If I were still working with Noah, I would say to him, “You’re terrified that I might read your shame in your face, so to stop me, you keep your expession flat and fixed, immobile so it won’t give anything away.”

Vanessa, one of my current clients, begins her sessions with a flat facial expression that conveys indifference. I don’t think it’s about hiding shame, not in the way Noah used to do, but it’s related. Allowing her face to reveal that she’s glad to see me, that she might have been looking forward to our session, feels unbearably vulnerable. She’s afraid to smile. What if I didn’t smile back? In a microcosm, it’s the problem of unrequited love, once again. Core shame results when mother repeatedly fails to reciprocate the baby’s joy in her. Could anything be more excruciatingly painful?

Book Review: Cinderella, A Tale of Narcissism and Self-Harm

Sunday, June 2nd, 2013

Cinderella Cover

Since Adrienne’s snake dream, we’ve been making gradual progress in tapping into her unconscious anger. I’ve helped her become more aware of the rage often lurking behind self-pity and on several occasions now, she has been able to detect the hidden rage herself. In discussing her repeated insistence that I’d rather get rid of her and take on a less difficult client at my new (higher) fee, I’ve pointed out the hidden insult, the hostile suggestion that I’d drop a client to make 25 bucks more an hour. It’s a complex message, of course, reflecting her sense of worthlessness, the conviction that no one could truly care about her for who she is. At the same time, she’s angry and I feel it. Adrienne’s anger feels closer and closer to the surface as time goes on.

Online vs. In-Person Psychotherapy — One Major Difference

Sunday, January 27th, 2013

online therapyWhen I first began working with clients by Skype, I was surprised (and relieved) to find how similar it is to working in person. Once I began learning more about affect theory and how facial expressions communicate feeling states, I came to understand why I’m still able to empathize so well with my clients.

Now that I’ve been practicing via Skype for over a year now, I’m also understanding one important way that it differs from conventional face-to-face work: psychotherapy relationships via Skype tend to be much more transient. I suppose it’s a feature of many “virtual” relationships that are quickly formed and easily ended. Despite all the caveats in my disclosure statements, no matter how clearly I state that I don’t do short-term work and believe it takes time for a psychotherapy bond to develop, I still have clients who come for a few weeks and decide to quit because they don’t feel they’re making sufficient progress.

New Discussion Forum

Sunday, November 4th, 2012

Over on my personal website After Psychotherapy, I’ve now opened the first topic thread on a new discussion forum. In this first thread, we’ll be discussing the Introduction and first chapter of my new book, Why Do I Do That?, then in subsequent threads we’ll take up each of the chapters individually. I view this forum as a place for site visitors who are reading the book to ask questions about what they’ve read and to share their experience of engaging with the exercises. My book adapts the methods of psychodynamic psychotherapy to a guided course in individual self-exploration, for people working alone, but I’ll be available in this new forum to help.

I hope you’ll consider buying the book and joining our discussion group going forward. I expect to open a new topic thread each week, one per chapter, so we’ll be working our way through the book together over the next few months. I hope it will be a rewarding experience for everyone who participates. I’m not sure I’ve ever heard of a self-help book that you can tackle in the company of its author and other readers. Online group therapy anyone?

It’s Launch Day for My Book!!!

Monday, October 29th, 2012

My new book is now available for purchase on Amazon in both print and digital versions:



Please help me make my book’s launch a success! There’s a detailed synopsis below.

From Shame to Self-Esteem

Wednesday, October 10th, 2012

shame to self esteemMelissa continues to struggle with the challenges of her new job, vacillating between fear that she won’t be able to master the new skills and contempt for how “stupid and trivial” it all seems to her. We talked about her scorn as a defense: when she can’t bear the fear of failure, when it all seems so overwhelming to her, she take flight into contempt. The indifference she sometimes expresses is, in fact, a variation on this theme, where “not caring” reflects an underlying scorn which is equally defensive. The challenge, as we often find, is believing that she might grow little by little over time and gradually get better at something; she usually believes that she must know everything already or she’s a hopeless failure.

The Narcissistic Father

Wednesday, September 26th, 2012

narcissistic fatherDuring a session yesterday, I was shocked when Jeff told me that his former pastor and friend was charging him for their “sessions,” calling to tell Jeff when he needed a session, and going so far as to ask Jeff to pay off his credit cards. It seemed unethical, and a betrayal of trust.

This got me thinking about relationship dynamics, and what happens when the person who’s supposed to be the one giving — in a kind of parental role, so to speak — becomes the needy (and exploitative) one. It stirred up thoughts about Jeff’s aged father who’s been calling him 10-20 times per day. It’s become clear to me that during Jeff’s childhood, his father was a highly anxious man who relied upon his children to help manage that anxiety. Jeff talks repeatedly about the pressure he felt growing up to become a lawyer as his father had wanted to do, and his feeling that he wouldn’t be loved if he didn’t do so. Yet Jeff always insists that he “for some reason” misinterpreted reality and came to the mistaken view that he wasn’t lovable.

The Indifference Defense

Friday, September 21st, 2012

indifference in therapyIn our first session following last week’s break, Julian began by speaking about a feeling of pointlessness at his job and went on to question the value of therapy: what had been accomplished so far, and was it unrealistic to believe he could really change? It’s not unusual for clients to minimize the importance of the work during breaks, as a way to cope with feelings of unbearable need or “abandonment” when the therapist takes a vacation, but I didn’t have the sense that Julian was devaluing me. I asked him what he thought had been accomplished, if anything. He acknowledged he had developed a deeper understanding of himself: “Of course, it’s nice and all, but does it really make any difference?” His manner and tone of voice seemed very flat.

Fight or Flight

Friday, August 17th, 2012

fight or flightRyan was telling me about the rage he sometimes feels when people get into his space, or “impinge” on him, linking it to the trauma of a forceps birth and spending his first weeks of life in an incubator, tubes stuck into his head.

He also feels enraged when he enters a crowd with too many people around him. Upon entering Walmart, and seeing all the other shoppers, the thought will come into his head, “I’d like to kill someone.”

The rage seems to come up in response to an impingement from the outside that feels threatening.

The Make-or-Break Moment

Friday, July 6th, 2012

Since the beginning of our work together, I’ve noticed that David escapes from being a client by becoming the person who instead “dispenses wisdom,” as he has described it. I’ve tried to talk to him about how he uses this posture to keep me at a distance, becoming a sort of therapist himself.

I’ve been watching cautiously to see where this would lead us. His difficulty bearing need and dependency seemed clear, but I’ve also wondered whether feelings of envy for me as his therapist might also be in the background.

Last Friday, the envy came to the fore – although I didn’t quite see it coming. During session, I was focusing on the way he goes from feeling unbearably small to becoming too big, all at once. He took issue with every remark I made; he became increasingly angry and contemptuous in his manner toward me until finally, by the session’s end, I had become a worthless, incompetent therapist he despised.

Only at the end did I realize I should have been focusing on this process all along. I did what I could in the final minutes to describe what had happened between us. Later that day, I received an email from him, extremely hostile and contemptuous in manner, telling me he wanted to take a month off to try something different.


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