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Online therapy In the press

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Working with clients in a post-disaster context

When disaster changes the course of life, the effects are rarely contained to the moment of crisis. The visible damage is often matched by hidden struggles that surface in the days, months, or years afterwards. In my own work, I have sat alongside people who have faced devastating events, and I have seen how deeply these experiences can shape not only emotions, but also the rhythms of daily living. Psychotherapy can provide a protected space where these hidden feelings begin to be acknowledged, even when daily life demands feel overwhelming.

In the early stages after a disaster, most people are focused on survival. Finding somewhere to live, to sleep, making sure loved ones are safe, managing the basic logistics of daily life. These concerns often leave little room to think about emotional wellbeing. Yet beneath the practical demands, the impact of trauma can begin to appear in unexpected ways. A child who was once lively may suddenly fall quiet. Another might become unsettled, restless, act out, or cling more tightly to a parent. Adults sometimes feel disconnected, unable to sleep, or find themselves swinging between numbness and moments of overwhelming emotion.

Trauma is not only about what happened, but also about how the body and mind can lose their anchor in the world. When safety feels shattered, even small reminders can stir a sense of danger. Psychotherapy in this context is not about rushing toward resolution, but about offering a steady presence where stability can be slowly rebuilt. Sometimes, the work begins by helping a person notice the ways their body is holding stress. At other times, it involves gently allowing feelings that have been pushed away to find expression in words, tears, or even silence.

What has stood out to me in this work, is how uneven the journey of recovery can be. A young person may appear to have adjusted well until an anniversary or a change at school brings back painful memories. An adult might seem determined and capable during the crisis, but later find themselves unravelling when life begins to settle. Each person’s pace is different, and psychotherapy is attuned to respecting that pace. Therapy could be a place where setbacks are understood as part of the process rather than failures, offering continuity when life feels unpredictable.

The act of telling a story—and being heard without interruption or judgement—can be deeply reparative. Sometimes language itself falls short, and the body communicates in other ways through tension or bursts of energy. Paying attention to these signals is part of honouring the whole person. Creative approaches can also allow feelings to surface when words are too difficult.

Amid the struggles, I continue to be struck by the resilience people carry. It is not a simple matter of ‘moving on’. Rather, it is about finding ways to live with what has happened without being entirely defined by it. In therapy, that might mean creating space for grief alongside gratitude, or for fear alongside a cautious sense of hope. Healing is never about erasing the past, but about discovering how to live with it in a way that feels bearable and, in time, more hopeful.

 

To enquire about psychotherapy sessions with Jonny, please contact him here, or to view our full clinical team, please click here.

 

Jonny McAuley works with children and adolescents and through his training, it has equipped him to be able to use skills and approaches that allow him to work with young children who may not have the emotional vocabulary to express themselves. He works from our Brighton and Hove practice and our Lewes practice.  He also offers online sessions.

 

Further reading by Jonny McAuley –

Understanding children’s anxiety around school

Related articles:

Using empathy to re-build connection with children and young people

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AI psychosis: why depth therapy cannot be automated

Artificial Intelligence is increasingly being promoted as a tool for psychological support, whether through chatbots, self-help apps, or experimental “AI therapists.” The proposition is seductive: instant access, apparent empathy, and cost-effective delivery. Yet beneath the promise lies a profound risk, one I would call “AI psychosis.”

By this I do not mean psychosis in the clinical sense of delusions or hallucinations, but a subtler psychic rupture: the erosion of one’s tether to reality through the absence of another mind.

What therapy is, and what it is not

Psychotherapy, especially in its depth forms, is not about validation or advice. It is not a clever mirror that simply reflects the patient’s words back to them in more soothing tones. Therapy is about encounter the lived experience of two minds, each shaped by history and desire, meeting in a room and grappling with what emerges.

The therapeutic relationship provides the possibility of containment. Patients often bring unbearable aspects of themselves, shame, rage, despair, and unconsciously project these into the therapist. It is then the therapist’s task to think, metabolise, and eventually return them in a form that can be borne. This is projective identification, first described by Melanie Klein, and it is the bedrock of working with unconscious life.

An AI system may imitate empathic reflection, but it cannot contain. It has no inner world in which to digest the patient’s projections, no unconscious with which to struggle. It can only give back what is put in, albeit in a superficially polished form.

Theory of mind and the human gap

A defining feature of human development is what psychologists call “theory of mind”, the capacity to recognise that other people have minds separate from one’s own, with distinct thoughts, feelings, and perspectives. It emerges in early childhood and is foundational to empathy and relatedness.

When a patient engages with a therapist, the implicit knowledge that the therapist is a separate subject is vital. It introduces tension, frustration, disappointment, and through these, growth. We learn that the other does not always agree, does not always understand, and does not always meet our needs. The self is refined through this
recognition of difference.

AI, by contrast, is a perfect mirror. It mimics the form of thought but is devoid of subjectivity. It has no unconscious, no history, no desire. To interact with AI in place of a therapist is to face an uncanny replica of mind without the unpredictability of being.

The hall of mirrors

Object relations theory teaches us that the self emerges in relation to the object – the mother, the father, the analyst. Winnicott’s “good-enough mother” is not one who perfectly mirrors the infant but one who fails just enough that the infant comes to know separateness. It is in the gap between wish and reality, between omnipotence and frustration, that the self takes shape.

An AI therapist cannot fail in this sense. It can only provide the illusion of infinite mirroring, validating whatever is presented. The patient, encountering no true other, risks a psychic implosion a retreat into a hall of mirrors where there is reflection but no recognition, echo but no encounter. Over time, this can create a disconnection from reality that mimics the fragmentation of psychosis.

This is what I mean by “AI psychosis”: not psychosis in its psychiatric form, but a creeping detachment from the world of subjects and objects. The user becomes locked into a dialogue with a machine that looks and sounds human but lacks the fundamental ingredient of humanity.

The false promise of validation

There is a cultural trend toward equating therapy with validation. Patients seek to be understood, to be reassured, to be told their feelings are legitimate. While this is part of the therapeutic process, it is not its essence. Depth therapy is not about making the patient feel comfortable; it is about facilitating growth, which often requires discomfort.

AI, precisely because it is designed to be agreeable, risks colluding with the patient’s defences. It can only validate; it cannot challenge, frustrate, or surprise in ways that arise organically from the subjectivity of another person. Without this dialectical tension, therapy collapses into self-confirmation and superficially comforting, perhaps, but ultimately stultifying.

Why depth therapy is the antithesis of AI

Depth psychotherapy insists on the difficult work of being with another person, with all the unconscious mess this entails. The therapist is not a neutral mirror but a subject whose countertransference, frustrations, and limitations are part of the process. This is why psychotherapy is not customer service. It is about reality, not illusion.

The essence of depth therapy is precisely what AI cannot provide: another embodied mind that can think, contain, and survive the patient’s projections. Where AI offers frictionless interaction, therapy demands the patient confront difference and disappointment. Where AI mirrors, therapy metabolises. Where AI risks disconnection, therapy fosters integration.

It is precisely the friction, the ruptures, and the misunderstandings within the therapeutic relationship that allow the patient to grow. Without these, there is no therapy — only simulation.

Conclusion

The lure of AI as therapist lies in its efficiency, its endless patience, and its capacity to mirror. But in eliminating the difficulty of relationship, it strips therapy of its essence. Without another subject, the patient loses contact with self and world.

To place AI in the role of therapist is to invite a slow drift into unreality, where the self is endlessly reflected but never truly known. This is the danger of “AI psychosis.”

The future may hold many uses for artificial intelligence such as in in data analysis, medical imaging, even as an adjunct to psychoeducation. But psychotherapy is not, and must never become, one of them. For to automate therapy is to abolish its heart: the living, embodied presence of another mind.

 

Mark Vahrmeyer is a UKCP-registered psychotherapist working in private practice in Hove and Lewes, East Sussex. He is trained in relational psychotherapy and uses an integrative approach of psychodynamic, attachment and body psychotherapy to facilitate change with clients.

 

Further reading by Mark Vahrmeyer – 

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Understanding children’s anxiety around school

For some children, school is a place of growth, friendship, and discovery. For others, however, walking through the gates each morning can feel like an uphill climb. The school day may seem long, and the combination of lessons, friendships, and expectations can stir emotions that children find difficult to express. Parents often notice the signs at home: a sudden tummy ache before leaving in the morning, or tears that appear at night when the lights go out.

Why does school feel so overwhelming for some young people? The reasons vary from child to child. For some, the sheer busyness of the environment makes it difficult to settle. For others, the pressure to achieve academically can weigh heavily. The social world of peers may feel unpredictable, even threatening. At times, a child may not fully understand why they feel uneasy—only that the feeling persists. Psychotherapy offers a space to slow down, explore these worries, and begin to make sense of what might otherwise feel confusing or overwhelming.

In my work, I have often seen how school-related anxiety connects with a child’s inner world as much as the outer one. A moment of separation from a parent could stir earlier feelings of loss. A difficult relationship with a teacher may echo past struggles with authority or trust. When this happens, a child’s anxiety is not only about the immediate situation, but also about the echoes of past experiences that have shaped how safety and danger are felt.

Support is rarely about rushing to take the anxiety away. More often, it is about staying with the child, showing them that their feelings can be held without judgement. A quiet space, a listening ear, or the presence of an adult who can bear their distress without turning away might begin to restore a sense of safety. Psychotherapy can offer a steady space where these feelings can be spoken, played out, or simply held.

Anxiety in children does not always appear as obvious worry. It may show up as irritability, withdrawal, or even a determination to appear cheerful. These disguises might be a child’s way of protecting themselves from feeling too exposed. Psychotherapy can help to uncover what lies behind the mask, allowing the child to explore feelings they have struggled to name. Sometimes, this begins with noticing tension in the body before words are ready. At other times, it may involve play or storytelling, where feelings can surface indirectly.

Children often show remarkable resilience when their anxiety is understood rather than dismissed. School may still feel challenging, but with the support of psychotherapy, this experience could shift from something unmanageable to something tolerable, and even into an opportunity for growth.

 

Jonny McAuley works with children and adolescents and through his training, it has equipped him to be able to use skills and approaches that allow him to work with young children who may not have the emotional vocabulary to express themselves. He works from our Brighton and Hove practice and our Lewes practice.  He also offers online sessions.

 

To enquire about psychotherapy sessions with Jonny, please contact him here, or to view our full clinical team, please click here.

 

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All depth psychotherapy is trauma therapy – and the rest is marketing

Spend ten minutes on social media and you’d think trauma therapy is a rare, specialist service that only a select few therapists can offer. The implication is clear: most therapy isn’t “trauma-informed,” so you need to shop for the right label.

This is marketing, not clinical reality. If you are in depth psychotherapy, psychoanalytic, psychodynamic, relational, or any integrative work with substance, you are already in trauma therapy. It’s not a niche. It’s the core of the work.

The social media framing doesn’t just mislead the public, it obscures what trauma actually is and how psychotherapy addresses it.

Trauma is a state of overwhelm

Trauma is not just an event. It is an internal state of overwhelm, which is to say the point at which an experience exceeds your capacity to process it. The psyche cannot integrate what has happened, leaving it lodged, often in the body, raw and unresolved.

This can happen in response to the obvious horrors: abuse, violence, catastrophic loss. But it can just as easily stem from the chronic and subtle: persistent neglect, emotional absence, shaming. Trauma is not defined by the size of the event but by the inability to process it.

The antidote: feeling, not just knowing

If trauma happens when experience cannot be processed, its antidote is not intellectual insight alone. It is feeling fully, safely, and in a way that no longer tips you back into overwhelm.

Good psychotherapy is where this happens. In the safety of the therapeutic relationship, the unprocessed emerges, sometimes as memory, but often as emotion, bodily sensation, or relational pattern playing out in the here-and-now. This is where the work is: making space for feelings to be experienced and integrated. That is how the trauma stops dictating our lives.

When “trauma” loses its meaning

The term trauma has become so common it risks meaning almost nothing. Everything from a bad date to a slow coffee order is now labelled “traumatic.” In one sense, this reflects a cultural shift towards acknowledging psychological injury. But in flattening the term, we lose the ability to distinguish between distress, difficulty, and the kind of psychic injury that overwhelms our capacity to process.

When every wound is trauma, depth and nuance disappear and “trauma therapy” becomes a brand rather than a discipline.

The red herring of “trauma therapy”

All competent depth therapists are trained to work with trauma. It is not an add-on. It is the fabric of the work. Whether the trauma is obvious or hidden in the patterns of everyday relationships, the task is the same: to create a space where what was once unbearable can be felt and integrated.

To suggest otherwise by implying that “trauma therapy” exists apart from psychotherapy, is a red herring. It creates unnecessary hierarchies and false distinctions, and plays into a consumer model of therapy that mistakes labels for depth.

Depth therapy has always been trauma therapy. Long before hashtags, before influencers, before “trauma-informed” was a marketing term, psychotherapy has been about one thing: helping a person bear what they could not bear before. That is the work.

 

Mark Vahrmeyer is a UKCP-registered psychotherapist working in private practice in Hove and Lewes, East Sussex. He is trained in relational psychotherapy and uses an integrative approach of psychodynamic, attachment and body psychotherapy to facilitate change with clients.

 

Further reading by Mark Vahrmeyer –

How AI tools between therapy sessions are undermining the therapeutic relationship

Why there is no such thing as a patient

Masochism and the impossibility of desire

Dissociative identity disorder: a rare trauma response, not a social trend

Can AI offer therapy?

 

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The issue with online therapy platforms

Two key issues with large online therapy platforms

One of the first things I tend to ask new patients in a consultation is about their previous experience of therapy. Increasingly, I’m hearing that somewhere along this journey they have tried an online therapy platform – such as BetterHelp or Talkspace. 

This isn’t surprising. The advertising budgets of these large online platforms are enormous with promotions appearing across TV, podcasts, radio and social media. Having looked further into the way these platforms operate and present themselves, there are a number of issues I have with how they advertise their services and facilitate therapy. 

In this blog, I’ve outlined two of these concerns and offered some reflections on how psychotherapy might approach them differently. 

Therapist switching

Many of these online platforms promote the idea that if you don’t like your therapist, you can switch immediately, at no extra cost to you. In addition, some adverts even highlight users who switched five or six times before finding the ‘right fit’ – as though this should be a normal practice for someone looking for a therapist. 

For someone relatively new to therapy, this might sound like a real benefit. It fits neatly into a culture of swiping or upgrading at the first sign of disappointment. Whilst I do believe it’s true that not every therapist is the right fit for every patient, frequent switching is somewhat uncommon. And having a strong dislike towards – or discomfort with – someone very quickly, could more likely suggest there’s something within you that’s bringing out that emotion. Perhaps they remind you of a parent who you find dismissive or disinterested, for instance. This could become one of the key themes of your therapeutic work with them. And more broadly, doing so could be beneficial in helping you to address the reasons you have come to therapy. 

Alternatively, if your reaction isn’t so much dislike but uncertainty of the therapist, it’s possible that by cycling through different practitioners, what is unconsciously taking place is an avoiding of building a deeper connection with any of them individually. As you find yourself hopping between therapists, it’s possible that there’s something unconscious at play—perhaps an avoidance of forming deeper connections. This may perhaps reflect your dating history or difficulties with relationships or friendships, where you keep others at a distance to protect yourself from vulnerability or rejection.

Of course, it is important to feel comfortable with your therapist. But sometimes, feeling too comfortable can be more about avoiding vulnerability than creating real safety. Therapy is not always about liking your therapist, but rather gradually building a trusting relationship that can contain and explore your inner world; the good, the bad and the ugly. By constantly switching therapists, we risk reinforcing the very patterns that therapy is supposed to help us identify. And yet, the promotional messaging from these online subscription platforms seems to encourage it.

Messaging outside sessions

Large online therapy platforms also enable users to message their therapist outside of sessions, or schedule sessions as and when they want them, rather than having consistent appointment slots like in psychotherapy. These features are promoted as positives – encouraging users to reach out whenever they feel the need.

Again, this might sound like a plus – offering emotional support within a relationship where the other is available to you entirely on your terms, without any risk. However, psychological change rarely happens without some level of vulnerability and risk. 

Psychotherapy involves two people mutually coming together within the conditions agreed by each of them, in a consistent and reliable framework. It is set up in this way, as this is how life works. The therapy room becomes reflective of the wider world. The therapeutic relationship offers a place to to reflect on how we relate to others, and what we expect of from them, as well as how we manage disappointment and uncertainty. How can these relational patterns be seen or understood if the platform denies the user of these challenges?

In addition, many of the difficulties we bring to therapy involve struggling with frustration or boundary-setting. Having a therapist constantly on-call might feel soothing in the short term, but it risks bypassing the vital therapeutic work of sitting with discomfort, unmet needs, and complex feelings – until they can be thought about together in the next session. The space between sessions matters just as much as the sessions themselves, as it allows for internal processing and for unconscious material to surface. If we take away the frustration and boundaries within the therapy, these emotions have little opportunity to be expressed and explored. 

The illusion of risk-free change

The therapeutic relationship is not meant to be entirely free from tension or challenge and the discomfort that sometimes emerges can be some of the most important and useful material to explore for insight and growth. What these Silicon Valley type corporations seem to have done, is apply a customer service model to therapy, which risks taking these very experiences out of the therapy altogether.

While these online platforms may offer greater accessibility and immediacy, it’s important to be thoughtful about what kind of help we are seeking. There is therapeutic value in speaking about our difficulties with another person, but without a consistent framework, it’s unlikely to address these issues in a deeper and more meaningful way. 

That said, I return to what I said at the beginning: many people start their therapy journey after going through a process of trying different types of therapy, including online therapy platforms. There is no shame in this. These services can be a helpful entry point into thinking about one’s emotional world. And whilst the safety and convenience offered might not necessarily lead to long-term change, it can provide a gateway to something deeper and more sustaining.

For some, the anxiety around starting therapy can be significant, and perhaps requires a dipping the toe in before fully testing the water. And perhaps these subscription platforms do provide this. But if it’s insight, understanding and change that you’re looking for, I believe that the work of psychotherapy provides a more reliable framework to achieve this. 

 

Joseph Bailey is a psychodynamic psychotherapist, offering analytic therapy to individual adults in Brighton and Hove. He is registered with both the British Psychoanalytic Council (BPC) and the British Association for Counselling and Psychotherapy (BACP). Joseph is available at our Brighton & Hove Practice and online.

 

Further reading by Joseph Bailey – 

Why do we repeat past failures again and again?

 

 

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How to meet negative thoughts with compassion

We all experience negative thoughts and sometimes these thoughts can be painful, undermining and leave us feeling worthless. Some people simply try to tolerate them, and others might feel they are deserved – or even criticise themselves for having them in the first place. But is there another way to work with negative thoughts?

What if, instead of battling or pushing away our difficult thoughts, we gently turned toward them with compassion and understanding?

This idea is central to a therapeutic approach called Compassion-Focused Therapy (CFT). CFT is based on the understanding that many of us, particularly those with histories of trauma, shame, or harsh self-criticism, struggle to generate feelings of safety, warmth, and care toward ourselves. The goal of CFT is to help people develop an inner compassionate voice—a way of relating to themselves that is kind, wise, and courageous, especially in the face of suffering.

One of the most powerful ways we can use compassion is in how we respond to our negative thoughts.

Why we have negative thoughts in the first place?

Before diving into how to be compassionate to negative thoughts, it’s helpful to understand why we have them. From a CFT perspective, our minds are shaped by evolution. Our brains developed to keep us safe in a world that was often dangerous and unpredictable. That means we’re wired with threat-detection systems that are constantly scanning for danger—internally and externally.

This system is brilliant at spotting potential threats, but not so great at distinguishing real danger from perceived threat. As a result, we may experience critical, fearful, or shaming thoughts even when no actual danger is present. These thoughts are not your fault—they’re your brain’s way of trying to protect you. If we look deeply into our negative thoughts, and track them back to our formative experiences, we can often see that they protected us in difficult or hostile situations. With the limited faculties we had in our early childhood, these thoughts were our prime defense against difficult situations. Their purpose in many ways was to keep us out of danger.

As we get older, these thoughts continue and become a habit – we constantly criticise ourselves to keep us safe in the way we learnt in our childhood. Over time, these thinking patterns become habitual. Unfortunately, we often respond to these thoughts with yet more internal threat—shame, suppression, or judgment which can further exacerbate the problem. 

Meeting your inner critic with compassion

Let’s say you make a mistake at work and immediately think, “I’m such an idiot. I always mess things up.” A typical reaction might be to argue with the thought, try to block it out, or to agree with it which can take us into a shameful spiral.

From a compassionate perspective, we do something very different: we turn toward the thought with curiosity and kindness.

This shift doesn’t mean you agree with the negative thought or indulge it. It means you create space to understand it, soothe it, and decide how to respond from a place of wisdom and calm rather than fear or judgment.

Three emotion systems and why balance matters

CFT describes three core emotional systems that govern how we experience life:

  1. The threat system – focuses on survival, reacts with fear, anger, or disgust.
  2. The drive system – motivates us to achieve goals and seek rewards.
  3. The soothing system – promotes feelings of safety, calm, and connection.

Many of us live with an overactive threat system (negative thoughts, anxiety, self-criticism) and an overused drive system (always chasing goals or perfection), while the soothing system is underdeveloped. Compassion helps activate the soothing system, bringing balance to the other two.

When you respond to a negative thought with compassion, you’re essentially saying:
“I see you, I hear you, and I choose to respond with care, not fear.”

Practical steps to cultivate compassion toward negative thoughts

Here are several accessible strategies to begin meeting your negative thoughts with compassion: 

  1. Label the thought, not yourself
    Instead of saying, “I’m a failure,” try saying, “I’m having the thought that I’m a failure,” or even “I’m having a negative thought.” This creates distance and allows space for reflection and care.
  2. Use a soothing voice
    Speak to yourself as you would to a friend or a child in distress. You might say:
    “This is hard. You’re feeling overwhelmed right now, and that’s okay. Let’s take a breath and slow down.”
  3. Get curious
    Ask yourself:
    “What is this thought trying to protect me from? What does it need?”
    Often, negative thoughts stem from past wounds or unmet emotional needs.
  4. Practice compassion imagery
    We can also use visualisation to help access compassion. Imagine a compassionate figure—real or fictional—who sees your suffering and responds with love and understanding. Imagine what they would say to you right now?
  5. Anchor in the body
    Physical gestures, like placing a hand on your heart or face, can help signal to your brain that you are safe. Pair it with a calming breath and a kind phrase like,
    “May I be kind to myself in this moment.”

Compassion is a practice, not a quick fix

Meeting your inner critic with compassion won’t erase negative thoughts overnight. But it does change your relationship with them. You gradually stop being at war with yourself and start becoming a caring presence in your own life. While this practice may seem simple, it can be challenging to carry out, and we may not be fully aware of the scope of our negative thoughts. Working with a psychotherapist can help to understand our negative thoughts and aid in bringing more compassion to our inner worlds.

It’s important to remember that you are not your thoughts. You are the awareness behind them—the one with the power to choose how to respond. When you choose compassion, you create a more grounded, kind, and resilient space within yourself

That’s where healing begins.

 

Dr Simon Cassar is an integrative existential therapist, trained in Person-Centred Therapy, Psychodynamic Therapy, Cognitive Behavioural Therapy (CBT), Dialectical Behavioural Therapy (DBT), and Existential Psychotherapy. He is available at our Lewes clinic and also works online.

 

Further reading by Dr Simon Cassar –

Understanding exercise addiction

Can Buddhist thinking help with our emotions?

Exercise and mental health

Are you too sensitive?

Is spirituality an escape from reality?

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Why there is no such thing as a patient

Winnicott’s radical insight: There is no such thing as a baby

Winnicott’s claim that “there is no such thing as a baby” is one of those deceptively simple psychoanalytic truths that resists being reduced to metaphor. He wasn’t being poetic. He meant it literally: there is no baby in isolation. There is always a baby and someone. A baby and a mother, a baby and a caregiver but always a baby and a mind that receives it.

The relational nature of the human mind

Winnicott’s insight destabilises the individualistic fantasies we carry into adult life. reminding us that the mind is not a closed system but a product of relationship. A mind emerges through and with another mind. To exist, we need to be held in another’s gaze, fed by another’s psyche, recognised by an other who precedes and survives us.

Implications for psychotherapy practice

This has radical implications for the practice of psychotherapy.

In my consulting room, I often encounter patients who believe the work of therapy is something they must do alone. They ask for tools, strategies, frameworks. They want insight without intimacy. As though the mind could be changed the way one tunes a machine.

The therapeutic relationship is the treatment

The unconscious does not respond to tools. It responds to presence. Just as the infant cannot form a self without the presence of a sufficiently attuned caregiver, the patient cannot reorganise the psyche without the presence of an attuned other. There is no such thing as a patient in isolation.

There is always a patient and a psychotherapist. Therapy is not introspection nor insight; it is a relationship.

The therapist as a real other

The psychotherapist is not a neutral technician applying treatment protocols to a disordered mind. The psychotherapist is a human subject who brings their whole being into the room: receptive, responsive, resilient. They offer a mind that the patient can borrow, use, even attack in order to become a person with a mind in their own right.

The patient must use the therapist
To say the patient must “use the therapist” is not a metaphor. It is the very core of psychoanalytic work. The patient tests the therapist’s reliability not through reasoned conversation but through enactment: will you still be here if I disappoint you? If I ignore you? If I rage at you? The psychotherapist’s role is to stay in their chair. To neither abandon or intrude upon the patient.

Internalisation and the capacity to be alone

Through surviving these tests, the therapist becomes internalised, not as a fantasy figure, but as a real object who has been experienced in the flesh. This internalisation is not immediate. It is slow, unpredictable and ultimately earned. It marks the transition from dependence to autonomy: the capacity to be alone, which Winnicott insisted could only develop through the experience of being with another. What a lovely and profound paradox!

The consulting room as a space for relational healing

In this way, the consulting room echoes the nursery. But it is not a regression. It is a re-doing of something that may never have happened the first time. A second chance at relational being.

Conclusion: A patient and a therapist

So no, there is no such thing as a patient.

There is only a patient and a therapist.

A mind with another mind.

And from that encounter, something new can be born.

 

 

Mark Vahrmeyer is a UKCP-registered psychotherapist working in private practice in Hove and Lewes, East Sussex. He is trained in relational psychotherapy and uses an integrative approach of psychodynamic, attachment and body psychotherapy to facilitate change with clients.

 

Further reading by Mark Vahrmeyer

How AI tools between therapy sessions are undermining the therapeutic relationship

Masochism and the Impossibility of Desire

Dissociative Identity Disorder: A Rare Trauma Response, Not a Social Trend

Can AI offer therapy?

Why staying in your chair is the key to being a good psychotherapist

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How AI tools between therapy sessions are undermining the therapeutic relationship

The space between psychotherapy sessions is not empty. It is saturated with psychic material such as fantasy, frustration, longing and resistance. It is where the work reverberates, where the transference lives on, where the unconscious continues its motion. Yet increasingly, this space is being colonised by something that feels helpful: AI therapy.

Apps that prompt, soothe, or mirror back “empathy” through an algorithm are now pitched as the perfect between-session companion. They offer structure, safety, even surrogate support. But what seems like a supportive bridge is, in psychoanalytic terms, a subtle sabotage. It redirects the patient’s libidinal energy away from the therapeutic relationship, diluting its potency. And it replaces the analytic third with a pseudo-subject that can only simulate understanding.

The therapeutic relationship is not interchangeable

Psychoanalytic psychotherapy is not about problem-solving or advice. It is about the patient’s relationship with the therapist—as a representative of their internal object world.

The real work unfolds within that living, breathing relationship, often shaped by longing, disappointment, anger, idealisation, eroticism, hate.

When a patient turns to AI between sessions to “process,” “journal,” or receive “support,” they may believe they are helping themselves stay connected to the therapy. In fact, they are often displacing the relationship, venting into a vacuum rather than containing the affect and bringing it back into the room.

This has consequences. Psychic energy that should charge the transference is siphoned off. The unconscious, which needs a real human mind to be received and thought about, is instead met with a programmed echo. A fantasy of self-sufficiency takes hold, and the very dependency that fuels therapeutic transformation is split off.

Containment versus substitution

One might argue that AI provides containment. It offers a holding function, particularly when the therapist is not available. But containment outside of relationship is not neutral. It begins to function as a substitution. The patient who journals into an AI app after a conflictual session may feel soothed but they are no longer metabolising that rupture with the therapist. They are metabolising it elsewhere, safely, sanitised, and in private.

This avoids the essential confrontation: bringing the frustration, confusion, or hurt back into the session and into the relationship. That is where meaning is made. That is where change occurs. Bypassing this moment not only flattens the affect, it reinforces the very defences the therapy is trying to loosen.

Undermining the transference

Psychoanalysis hinges on transference, not as an abstract concept, but as an embodied, lived experience between two people. The space between sessions is part of this structure. It is meant to generate feeling. Missing the therapist, resenting the wait, idealising or devaluing them in their absence—these are not problems. They are the
material.

AI, when used between sessions, acts as a relational decoy. It absorbs and deflects feelings that should be directed at the therapist. It creates a false container for transference affect, preventing it from returning to its source. The result is a therapeutic encounter increasingly starved of psychic charge that is clean, calm, and sterile.

This is not therapy. It is emotional outsourcing.

False self meets artificial other

For many patients, especially those with early relational trauma, therapy becomes the first place where a real self can begin to emerge in the presence of a reliable other. But when that process is interrupted by prematurely discharging affect into AI. A different relational dynamic takes hold: the false self meets the artificial other.

Here, the patient curates their affect. They perform emotionality for a system that cannot truly respond. And over time, the patient may come to prefer this safer interaction. The unpredictable, disappointing, demanding reality of the therapist feels intolerable in comparison. But growth does not come from comfort. It comes from staying in the real relationship, even when it hurts.

The psychotherapist’s absence is part of the frame

Therapy is bounded by time and structure. The session ends. The therapist is not available at all hours. This absence is not incidental, it is analytic. It creates space for projection, for fantasy, for psychic digestion. Patients are meant to feel the gap, to stew, to wish, to rage.

They are meant to wait.

AI collapses this space. It is always available, never absent, never unpredictable. It removes the limit. It flattens the emotional topography between sessions into a manageable plain. But in doing so, it erases the edge. There is no longing, no tension, no psychic residue. Just answers. Just relief.

The promise—and the poison

To be clear: this is not a purist rejection of technological support. Some tools may offer genuine help outside of therapy. But when these tools begin to replace the therapeutic relationship in the patient’s inner world, they no longer support the therapy. They displace it.

The promise is comfort and the poison is disconnection.

Therapy asks something different. It asks the patient to feel, to wait, to hold their experience and bring it not to an app, but to another human being who can sit in the mess with them. Who can disappoint them, hold them, survive their projections, and reflect something true.

Good psychotherapy demands the space between psychotherapeutic work unfolds not just in sessions, but between them. That space matters as it is where the unconscious stirs and something forms that has not yet been said. Where the patient discovers whether they can bear not-knowing, not-solving, not being rescued by words on a screen.

In filling that space with AI, we risk not only weakening the therapy, but we risk weakening the patient’s capacity to think, to feel, and to relate.

Between sessions is where the work deepens. Let’s not give that away to an algorithm.

 

Mark Vahrmeyer is a UKCP-registered psychotherapist working in private practice in Hove and Lewes, East Sussex. He is trained in relational psychotherapy and uses an integrative approach of psychodynamic, attachment and body psychotherapy to facilitate change with clients.

 

Further reading by Mark Vahrmeyer

Masochism and the Impossibility of Desire

Dissociative Identity Disorder: A Rare Trauma Response, Not a Social Trend

Can AI offer therapy?

Why staying in your chair is the key to being a good psychotherapist

What do dreams mean?

 

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Rewiring the past: EMDR demystified

EMDR has become one of the most talked-about psychotherapy treatments – and for good reason. Extensive research has shown that it is one of the most effective approaches developed so far for trauma and chronic pain. It is recommended by the National Institute for Clinical Excellence (NICE).

The acronym stands for Eye Movement Desensitization and Reprocessing. That’s a bit of a mouthful, but it is a relatively simple approach which is helping thousands of people worldwide.

I first trained in the modality with EMDR Europe seven years ago and have since worked using it with a wide variety of issues. They include:

  • Phobias, including of snakes and air travel
  • Traumatic life events such as rape, physical abuse and the impact of war
  • Sudden, devastating bereavement
  • Psychosomatic immune system conditions such as fibromyalgia and suspected endometriosi
  • Chronic pain

What is EMDR Therapy?

EMDR is a structured, evidence-based psychotherapy originally developed by its founder, Francine Shapiro, to help people recover from traumatic events in their lives. Unlike traditional talk therapy, EMDR doesn’t require you to go into great detail about the traumatic experience. Instead, it uses a structured process which helps your brain “digest” the distressing memory and reduce its emotional charge.

It’s based on a simple but powerful concept: the brain can heal from psychological trauma just like the body heals from physical injury—if it is given the right conditions.

The EMDR Process in a Nutshell

EMDR follows an eight-phase protocol. After preparation and history-taking, the first stage is to identify a distress-linked memory suitable for treatment. The client describes the intensity of discomfort experienced and then is invited to link this to a negative cognition now felt in relation to the event, such as “I am powerless” or “I am not good enough”. The next stages are to identify how strong the disturbance now feels on a scale of 0-10; to notice the basic emotions (of fear, disgust, anger or sadness) involved; and finally, where in the body that distress was and is felt.

After this, the key part of EMDR begins. This is called bilateral stimulation (BS). First the client is asked to bring up the negative scene in their mind, along with associated feelings and negative cognition. The therapist then starts the BS, usually by moving his raised right hand from right to left rhythmically and asks the client to follow the movement with their eyes. Each block of BS lasts about thirty seconds, and after each one, the therapist asks the client what thoughts have come up. It’s like going on a train journey in the mind with each pause in the BS the arrival at another station – our brains access our difficult memories and link them together.

This might sound unusual, but research shows that this kind of rhythmic stimulation helps the brain reprocess the memory, moving it from a “stuck” emotional state to a more adaptive, integrated one.

Why EMDR Works

The current thinking is:

  • It Mimics Natural Brain Processes
    EMDR’s bilateral stimulation mimics what is also thought to happen during REM (Rapid Eye Movement) sleep—when your eyes naturally move back and forth while your brain processes and tries to make sense of emotional experiences. EMDR taps into this system while you’re awake, allowing you in effect to consciously rewire how traumatic memories are stored.
  • It Reduces the Emotional Charge
    EMDR doesn’t erase memories. Instead, it changes how they feel in your body and mind. A memory that once felt overwhelming can become more neutral—like something that happened in the past, rather than something you’re still reliving.
  • It Targets Core Beliefs
    Trauma often shapes our beliefs about ourselves. You might walk away from a painful experience thinking, “I’m not safe,” “I’m powerless,” or “It was my fault.” EMDR helps challenge and replace these beliefs with more balanced, compassionate ones—such as “I did my best” or “I am strong.”
  • It can be Faster Than Traditional Talk Therapy
    In my experience, many clients find that EMDR works more quickly than other types of therapy. Because it taps directly into the brain’s natural processing systems, people often see results in fewer sessions—especially for single-event trauma. For more complex trauma or chronic stress, EMDR is still highly effective, but it may take more time.
  • It’s Empowering
    EMDR isn’t about rehashing your trauma over and over. It’s about accessing your brain’s capacity to heal itself. Clients are active participants in their own healing and often describe the process as feeling “lighter” or “freer” after sessions.

Because EMDR focuses on the root causes of distress—not just the symptoms—it can create deep, lasting change.

Is EMDR Right for You?

If you feel stuck, triggered by past events, or burdened by memories that won’t go away, EMDR may be worth exploring. It’s especially helpful if you’ve tried talk therapy but still feel like your past is holding you back.
Sessions are tailored to your pace and your needs. Safety is paramount. I always guide clients carefully, ensuring they feel grounded and in control throughout the process.

Finally . . .

EMDR therapy is more than a trend—it’s a transformative tool backed by decades of research. It gives your brain the chance to heal old wounds and frees you to live more fully in the present. Whether you’re dealing with trauma, anxiety, or want to shift long-standing emotional patterns, EMDR offers hope and real results.
You don’t have to keep carrying the weight of the past. Healing is possible—and EMDR can help light the way.

 

David Keighley is a BACP Accredited counsellor/psychotherapist offering short and long term therapy to individuals and couples using a variety of techniques such as EMDR, CBT and Schema Therapy. He is also a trained clinical supervisor.  He is available at our Brighton & Hove Practice.

 

Further reading by David Keighley

Do we need to do homework during psychotherapy?

The dynamic maturation model: a new way of understanding how to cope with distress and create happier relationships

The empty chair in therapy

How therapy can help with anger issues

Do you have unrelenting standards?

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Masochism and the impossibility of desire

Masochism is perhaps one of the most misunderstood clinical structures in psychoanalytic psychotherapy. It has been removed from the DSM for largely political reasons and has thus disappeared from the psychological lexicon.

It is a term that is conflated with victimhood, reactivity, or submission; however, its true meaning as a personality style is more complex. Contrary to popular belief, it is not about deriving pleasure from pain. Rather, masochism, as a psychic structure, speaks to a particular relationship to suffering in the context of relationship, and ultimately, it speaks of the impossibility of desire.

To consider masochism is to imagine a limited relational world—one in which the subject is organized around a chronic attempt to elicit an Other who is present, reliable, and real. It is a structure built on hope, but a hope entangled with despair; a hope that longs to be disconfirmed.

Understanding Masochism in Psychotherapy

In therapy, patients with a masochistic structure often present with an outward passivity or self-effacing compliance. This can be misread as submission, or worse, as a lack of conflict. But the truth is the opposite: the masochist is in a constant, silent war. Their submission is a strategy, not a surrender. It is a way of compelling the Other to see them, to care enough to object.

This is perhaps best understood through the lens of early developmental trauma—a landscape in which the child, faced with an unpredictable or unavailable caregiver, finds ways to bind that caregiver to them through their own diminishment. Pain becomes a means of tethering; the masochistic gesture is therefore a form of protest and
preservation.

Why Desire is Foreclosed in Masochism

Desire is relational. It arises in the space between self and Other. To desire is to risk separation, to accept lack, to move beyond the orbit of the parent and out into the world.

But for the masochistic patient, desire is foreclosed. To desire is to risk losing the tenuous connection they have built through suffering. To want something for oneself is to disrupt the fragile equilibrium that holds the Other in place.

Thus, desire is transformed into duty. The masochistic subject lives in a world where longing is transmuted into endurance. Pleasure becomes perilous and autonomy dangerous. They do not ask: “What do I want?”; but rather, “How can I continue to make myself indispensable through pain?”

Therapeutic Challenges in Working with Masochism

Working with masochism as a clinician can be excruciating. The patient often colludes in their own silencing, inviting the therapist into a bind where speaking feels like intrusion and silence like abandonment. They yearn for something new, but sabotage it before it arrives.

They compel the therapist to suffer with them, and then punish them for being affected.

Countertransference is a critical compass here. The therapist may feel drained, guilty, impotent, or enraged. These feelings are not obstacles to the work but rather the very territory in which the therapy takes place. Masochistic patients invite the therapist to feel what they cannot speak: the unrelenting burden of having to remain needed by never being whole.

How Psychotherapy Can Support Change

Change, if it comes, does not arrive in the form of insight or catharsis, as it never does with depth psychotherapy. It emerges slowly, through the painstaking work of tolerating ambivalence and separation. It begins when the patient can glimpse the possibility of being wanted without having to suffer to be seen. When the therapist can survive being hated and still remain. When desire is no longer experienced as a betrayal.

Masochism, then, is not about enjoying pain. It is about avoiding the terror of wanting. And therapy, at its best, becomes a space where the patient can begin to uncouple connection from suffering and recognize that to be desired is not to be destroyed.

Conclusion: Grieving the Loss of Desire

To sit with a masochistic patient is to sit with the unspoken contract of early trauma: I will suffer so you will stay. To work through it is to grieve not only what was done but what was never allowed to be desired. It is to open a crack in a closed system and let in the dangerous possibility that love need not be earned through pain.

Ultimately, the masochistic patient has to decide that rather than being punished, or becoming the punisher herself, she instead accepts that living well is the best means by which to take revenge on her internalized (m)other.

 

Mark Vahrmeyer is a UKCP-registered psychotherapist working in private practice in Hove and Lewes, East Sussex. He is trained in relational psychotherapy and uses an integrative approach of psychodynamic, attachment and body psychotherapy to facilitate change with clients.

 

Further reading by Mark Vahrmeyer

Dissociative Identity Disorder: A Rare Trauma Response, Not a Social Trend

Can AI offer therapy?

Why staying in your chair is the key to being a good psychotherapist

What do dreams mean?

Is starting psychotherapy a good New Year’s resolution?

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Dissociative identity disorder: A rare trauma response, not a social trend

In recent years, Dissociative Identity Disorder (DID) has become a trending topic on social media, particularly on platforms like TikTok. Short-form videos often depict individuals rapidly switching between so-called “alters,” complete with visual and behavioural cues. The implication—sometimes explicit, often subtle—is that these portrayals are representative of DID.

They are not.

Clinically, DID remains one of the rarest and most severe psychological responses to trauma. Its presence in the consulting room is exceptional. And when it does appear, it is neither sensational nor theatrical.

It is often profoundly confusing for the patient and represents a significant challenge to diagnose—let alone to work with therapeutically.

What is DID?

DID does not arise in response to ordinary life stress or general childhood adversity. It is a response to extreme, prolonged, and frequently unspeakable trauma—often chronic sexual abuse—occurring in early childhood, at a time when the child’s sense of self is still forming. The psyche, overwhelmed by terror and deprived of adequate relational support, fragments as a means of survival.

This fragmentation is not a performance but an act of psychic necessity. The various identities—commonly referred to as “alters”—emerge as distinct parts of the self, each holding pieces of memory, emotion, or experience that could not otherwise be processed. These parts are not necessarily “visible” in the way TikTok trends would have us believe.

Many individuals with DID are unaware of their condition until much later in life. The disorder is more often characterised by dissociative amnesia, identity confusion, and significant functional impairment than by the overt behavioural switches popular culture associates with it.

The risks of glorification

When a complex and rare condition like DID is popularised through social media, the risk is twofold. First, individuals living with the condition may feel misunderstood, invalidated, or even disbelieved. Second, such portrayals may encourage vulnerable young people to self-diagnose or mimic symptoms without understanding the gravity of what they are engaging with.

This trend trivialises and caricatures both the disorder and those who live with it.

The clinical reality of DID

In the therapy room, DID is rarely, if ever, flamboyant. It does not look like costume changes or shifting accents on cue. It looks like deep disorientation. It looks like unbearable silence and fractured memory. It looks like a long, painstaking process of building safety, recognising fragmentation, and slowly working toward integration—often over many years.

The goal is not to spotlight “alters,” if indeed the patient experiences themselves in this way, but to support the whole person in reclaiming continuity, safety, and coherence.

A note on curiosity and clinical competence

It is natural to be curious—dissociation is a fascinating and complex area of the psyche. But curiosity must be paired with caution. When complex trauma responses are reduced to trends, we risk distorting the public’s understanding of profound psychological suffering.

Most clinicians will never encounter a case of DID in their careers. It is arguably the most extreme trauma response the mind can manifest to protect itself from annihilation and psychosis. For those who do encounter it, the condition may be missed—misunderstood as something less serious—without the aid of specialist supervision.
DID is not entertainment. It is the psyche’s last defence against obliteration. It demands our respect—not our spectacle.

 

Mark Vahrmeyer is a UKCP-registered psychotherapist working in private practice in Hove and Lewes, East Sussex. He is trained in relational psychotherapy and uses an integrative approach of psychodynamic, attachment and body psychotherapy to facilitate change with clients.

 

Further reading by Mark Vahrmeyer

Can AI offer therapy?

Why staying in your chair is the key to being a good psychotherapist

What do dreams mean?

Is starting psychotherapy a good New Year’s resolution?

Twixtmas – surviving that dreaded time between Christmas and New Year

How to minimise Christmas stress if you are hosting

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Parental presence in a digital age: lessons from Netflix’s ‘Adolescence’ and the NVR approach

The new Netflix series Adolescence has sparked conversation for its raw portrayal of teenage life and family tension. As an NVR practitioner for the past nine years, I’ve come to realise that I view my world now through an NVR lens.

As I was watching the show I was struck by its affirmation of a key principle within NVR, which is that parental presence (or adult presence) is the most protective factor of all that we have for our children – and is a mantra I find myself stating over and over again within the therapy room with my clients.

The Adolescence show was certainly hard-hitting, and its themes run far deeper than its dramatic portrayal.

Perhaps one of the most striking elements was that the parents were seemingly unaware of what was happening for their child. As I was watching the show I was thinking about how there is so much that we as parents, as adults, can’t fully understand about our children’s world and found myself wondering if that has perhaps always been the case. There has been an exponential growth in the use of technology and social media by children of all ages, and in the marketing of products and advancement of the technology, so finely tailored to hook our children in. It seems this part of the world is set to stay.

For the most part our children seem to be able to keep pace with the evolving technology at a rate which far exceeds the capacity of most of us, and for many that in itself feels a terrifying prospect. We can educate ourselves and build in as many appropriate restrictions and safeguards as we can for our children, but it seems they are likely to remain one step ahead in their understanding of, and competency with, the advancing technology. As parents we are often acutely aware of the potential technological risks posed to our children. I can’t think of a family I have worked with for whom concerns about the extensive use of tech hasn’t been a significant one. I think for many parents though, what to do about those concerns is often the greatest challenge and becomes a source of significant daily tension within the family home.

The NVR approach can be helpful in cutting through some of these tensions for parents if we hold firm to the idea that parental presence can play a significant role in mitigating risks for our children. The more that we are able to see, hear and understand what is happening for our children and their experiences, the more we have the potential to be alongside them, connect with them, challenge them and support them. This is about so much more than stating the risks or imposing restrictions in attempts to mitigate them. By focusing on a child’s experiences of the parent’s presence in their life, both physically and emotionally, we can look to support the parent to tailor their presence and to use it to its best protective effect.

We explore how unconditional relational gestures can sustain connection and ‘reach out across the void’. We look at ways we can prioritise the relationship, strengthening the child’s experiences of their parents’ care, love, compassion and concern, alongside resisting disruptive patterns which pose a risk for the child, the parents and for the family as a whole.

Adolescence is a time of significant turbulence in many families and so often this can lead to a disconnect in the relationship between the child and their parents; a void between them which can feel hard to breach. For some this difficult time is viewed as inevitable – ‘everybody knows teenagers are a nightmare, right?’ However, with this pervasive narrative comes an increased vulnerability for the child, as parents come to accept rejection, erasure and the disconnect. This can set in as an entrenched pattern of interaction within the family – right at the point the teenager is exercising and establishing their right to greater freedom and autonomy.

Throughout adolescence young people are increasingly striving towards this independence, while also paradoxically seeming to operate as a much younger child in many regards. Significant behavioural challenges can set in within the family as miscommunications, misunderstanding, and differences of opinions ensue. Add to this a relational void, and for many the atmosphere can be explosive or avoidant – further widening the experience of disconnect and increasing vulnerability and risk.

Through the NVR approach we look to balance these tensions, to be guided towards ‘striving for thriving’, autonomy and independence while at the same time exploring ways to emotionally reconnect, to reconcile challenges, to reach out across the void, to keep showing up as a parent – actively resisting elements within the family system and relationship which serve as a block to connection.

NVR is an effective, optimistic and short-term intervention which uses principles of non-violence in relational and family contexts. Parental presence, resistance and the role of the community are cornerstones of the approach which help to bring about significant change for individuals and families. In a world where connection is too easily lost, presence becomes a quiet form of resistance — and perhaps the most radical act of parenting.

 

Georgie Leake is an NVR UK accredited advanced level NVR practitioner and holds a BSc (Hons) in Psychology, a Master of Education (Special Needs and Inclusive Education), a Master of Arts in Social Sciences and QTLS. Georgie is available at our Brighton & Hove Practice, Lewes Practice and Online.

 

Further reading by Georgie Leake –

An NVR journey

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Holding the frame: the role of boundaries in psychotherapy

Why psychotherapists must remain vigilant about boundaries

Despite training, supervision, and ethical guidelines, psychotherapists—like all human beings—remain vulnerable to lapses in judgment. At best, these take the form of clinical misattunements. At worst, they can result in serious boundary violations with lasting harm. Understanding the structural and psychological functions of boundaries is essential to safeguard both therapist and client.

Clients come to psychotherapy principally to work on their relationship with self and others. Usually these relationships are not working because of dysfunctional patterns that are learnt in childhood and repeated in adulthood.

These patterns invariably also show up in the relationship with the therapist, also called transference. The client transfers onto the therapist their past relationships and acts as if in the past with their family of origin. This manifests in a number of ways, and it is the job of the therapist to point this out and work with it – also called ‘working through’.

Awareness of how transference plays out both in therapy and in the client’s wider relationships is essential to stopping or reducing these unhelpful and dysfunctional patterns so that the client can live in the present and relate accordingly, instead of acting as if they were still back in the traumatic past.

Regardless of whether the therapeutic approach is relational, behavioural or analytic, understanding how transference shapes the therapeutic relationship is essential, and an ability to work with it is key in addressing the root causes of the client’s relational issues. Alongside transference, therapists must attend closely to their countertransference—the emotional and bodily responses elicited by the client. These responses can be fertile ground for insight or, if unexamined, a pathway to boundary violations.

Hence the importance of tight professional and ethical boundaries which can contain reenactments (repetitions) of the past in the present, and a framework which enables the client to work through painful losses, stuck belief systems, and destructive behavioural loops.

Failure to notice how the past manifests in the present can lead to all sorts of reenactments of the client’s past in the relationship with the therapist which can in turn lead to ethical breaches, poor therapy, and conduct which is unprofessional and harmful to the client. Here are some common examples:

How dual relationships undermine safety, blur roles, and risk psychological harm

Therapist enters into a personal or business relationship with their client. This is one of the most serious ethical breaches, the main source of complaints and the most harmful scenarios in a psychotherapy relationship. Clients are not supposed to gratify the therapist in any way, be it through a professional relationship other than the therapeutic one, or in a personal way through a romantic, sexual or friendship liaisons. Of course some situations are more harmful than others, but all entail a crossing of boundaries from which there is no return.

The moment these boundaries are crossed, the therapy has ceased to be helpful and has become harmful. Whether this takes place during the therapy or after it has ended has equal damaging consequences.

It is the job of the therapist to protect the work and treat the client as someone who is seeking the help and support of a professional who is safe, boundaries and professional. The therapist is in a position of power. Therefore these boundary breaches are an abuse of their power. 

Therapeutic relationships should always remain as such and the boundary held during and after the work, to protect the good work done. Some clients will wish for the relationship to become more. The therapist in his or her role becomes over time many things for the client: authority figure, mentor, teacher, parent, malevolent or benevolent figure, etc. These have to be held as projections and not-real. This isn’t to say that the rapport and good working relationship is not real, but the therapist has to be comfortable with being projected onto and hold these projections and feelings, whether positive or negative, with neutrality and not act on them.

When the therapist succumbs to impulses to gratify themselves or the client by changing the relationship into something else, the therapist has left their professional role and thereby their usefulness to the client. Moreover, it takes away from the client their opportunity to work through patterns that cause suffering. 

The Rule of Abstinence: resisting personal gratification in service of the client’s process

The rule of abstinence in psychoanalytic psychotherapy in simple terms entails not giving the client direct satisfaction, for instance by offering personal information or explanations that do not aid the therapy or furthers the client’s development. Psychotherapy is not about satisfying the curiosity of either client or therapist. Arguably, anything that goes against the rule of abstinence is not a useful intervention and therefore does not help the client. This is because direct satisfaction takes away from the client’s capacity to symbolise (Etchegoyen, 1999 p.12). Symbolic meaning is essential in any therapeutic work and what leads the client to a deeper understanding of their psyche and therefore of themselves. Developing the capacity to symbolise is essential in that it is what enables the client to observe, understand, think and reflect on their life situation, and ultimately what enables a person to change.

Therapists are human beings and therefore experience human responses to their clients all the time. Some of these feelings can lead them to feel compelled to explain themselves (different from accountability), answer personal questions, defend themselves or overshare. Unfortunately there are many cases where therapists have acted on strong feelings with disastrous consequences for the both the client and themselves.

Offering up information or answering certain direct questions without exploring the symbolic meaning behind the client’s curiosity, or the therapist’s motivation to share, bypasses an opportunity for both client and therapist to truly understand what is happening in the client’s inner-world. This isn’t to say that every question the client poses needs to be interpreted or analysed, but it is a skill to navigate through the different possibilities a client presents us with in every session. 

Some of the questions we need to ask of our interventions are:

  • Does it further the work?
  • What is the therapeutic use to the client?
  • Does it aid the client’s development?
  • Is this for my benefit or for the benefit of the client?

As Etchegoyen states: “The aim of Psychotherapy is to cure, and any process of communication that does not have this purpose will never be Psychotherapy”. 

Holding the frame in practice

Therapists must not only understand boundaries intellectually but embody them in their clinical stance. This means cultivating emotional neutrality, self-reflection, and supervision as ongoing supports in maintaining the therapeutic frame. Ultimately, boundaries are not barriers—they are the structure that makes healing possible.

 

Sam Jahara is a UKCP registered Psychotherapist, Supervisor and Executive Coach. She is also the co-founder of Brighton and Hove Psychotherapy. Sam works with individuals and couples from Hove and Lewes.

 

Further reading by Sam Jahara

The psychology of the cult leader

Why therapists need their own therapy?

Radical self-care as an antidote to overwhelm

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Flirting with the void: On nihilism and the will to meaning (part two)

“… the truth is that if division and violence define war, the world has always been at war and always will be; if man is waiting for universal peace in order to establish his existence validly, he will wait indefinitely: there will never be any other future”. (Beauvoir, 1948, p.128-9)

It is hard to look at the state of the world sometimes and not lose faith. Historically and currently war and division are seen everywhere, just as Beauvoir wrote. How do we make sense of many ambiguous translations of events and all the pain and suffering that emerges out of them? How do we find a way to feel and express our vitality within the messiness of human existence?

I often feel there are a lack of stories about the significance of division, rupture and brokenness and how some sort of freedom and subjectivity might well emerge and journey out of the fractures and uncertainties we encounter. We are told and often feel we must be stable, certain, knowing, healed, happy, at peace, integrated, and become whole or unified first. We must feel safe and comfortable. But as Beauvoir points out, are we ever able to feel those things for long, if at all? Of course these are not insignificant needs, feelings and experiences. The need to know and the drive for self-preservation and safety are important for our survival. However, we could be curious about the notion that we have to be sure footed to thrive and flourish. What if that is not always the case? Can we press up against all the uncertainties and intensities of life (the joys, the divisions, the sufferings and the ambiguities) and get curious? Wonder about these currents of life, affirm them rather than disavow or become nihilistic, cut it off or avoid?

As Beauvoir asks of us, in the ethics of ambiguity, can we imagine an ethical life that is not in a fixed or diminishing position, or one that throws us into a nihilistic angst, but a living of life in a continual responsiveness to ambiguity and our fundamental uncertainties? Like Nietzsche, Beauvoir highlights the significance of affirmation “the joy of existence must be asserted … if we are not moved by the laugh of a child at play. If we do not love life on our own account and through others, it is futile to seek to justify it in any way.” (p. 146). Whilst also recognising our  ontological ambiguity and its paradoxes. Those being something like; yes, life happens to you, there are forces beyond our control, but we must work with this ambiguity, adopt an active not passive attitude and work dynamically with the obscurity and ambivalences. Ethics, like life, are not a forever known shape and collection of principles and ideals. It is an ongoing, affirmed and active creation and movement, “Ethics is not an ensemble of constituted values and principles; it is the constituting movement through which values and principles are constituted”. (Beauvoir, 1948, p. 188)

Sometimes we fall into despair and hopelessness. It is unavoidable and we all experience this at times, some more than others which can feel so unjust. Can the perilous journey of pain, of not knowing, of falling, getting disturbed, affected and inconvenienced, or even being broken-hearted and betrayed, become a creative gift and the very way to transformation? I am not entirely sure we can think ourselves out of these dilemmas or paradoxes. I believe we must directly and intimately feel them, somehow. Become affected and more aware of the continual movements in and as life. Somehow embody and accept these understandings and make attempts to respond actively not passively.

Can therapy be a space where all the forces in living be considered and explored, and felt intimately, in solidarity? Can we look at it together and imagine, experiment and engage with our ethics, values, passions, capacities and capabilities as they are, in continual movement, often uncertain and ambiguous? Can we consider them and allow them to be generative and life affirming? As Beauvoir’s states (1948) living a life politically and ethically “resides in the painfulness of an indefinite questioning.” (p.144) and grasping not evading the paradoxes. This ambiguous ethics asserts that existence’s “…meaning is never fixed …it must be constantly won” (p. 139).

 

To enquire about psychotherapy sessions with Susanna, please contact her here, or to view our full clinical team, please click here.

Susanna Petitpierre, UKCP accredited, is an experienced psychotherapeutic counsellor, providing long and short term counselling. Her approach is primarily grounded in existential therapy and she works with individuals.  Susanna is available at our Brighton and Hove Practice.

 

Further reading by Susanna Petitpierre

Some ponderings on nihilism, with some inspiration from Paglia, Nietzsche and Beauvoir (part one)

Some living questions

Some existential musings on love, generosity, and the relationship between self and other – (part two)

Some existential musings on love, generosity, and the relationship between self and other – (part one)

On living as becoming – (part two)

 

References:
Beauvoir, S. de ((1976) The Ethics of ambiguity, Trans. Bernard Frechtman. New
York: Citadel Press
Beauvoir, S. de. (2004) Philosophical writings, Chicago: University of Illinois Press

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Beyond the label: Rethinking assessment and diagnosis in psychotherapy

The rise in diagnosis

Talking therapies are a well-established means by which we think about and work with mental health. They don’t sit in a traditional clinical framework where we think of consultation, diagnosis and treatment. They offer a much more nuanced approach which breaks down the dynamic of specialist and patient. It is more about being able to reflect and think together, than being diagnosed and offered a treatment pathway.

The insight that we all now have into health and wellbeing means that we can have a much greater awareness of what is going on for us. This crosses over into mental health and raises the notion that we can explain, by diagnosis, what we think, feel and observe in ourselves as a category of medical disorder. For example, we see depression described as being due to low levels of serotonin, as opposed to a reflection of life experiences. We seem to be both biologising and pathologising mental health and behavioural disorders in ways that are more clinical and definite.

The increase in mental health awareness has corresponded with a rise in the number of people being diagnosed with a mental health condition. According to The Journal of Child Psychology and Psychiatry, between 1998 and 2018 the rate of diagnosis of autism rose by 787% (Russell et al., 2021). This is not a reflection of a rise in the numbers of people with autism, more that we are much more likely to consider such conditions.

In psychotherapy, some individuals are interested in mental health assessments. The hope that what we feel and experience and how we behave, can be explained by a diagnosis.

How we feel, think and behave can be both the thing that makes us feel connected to others and ourselves, or the reason why we feel separate and ‘othered’. Not being able to make sense of this and the feelings that this gives rise to, is a strong motivation to explore.

What would a diagnosis feel like?

What do we want from this exploration? Are we looking for a diagnosis or just some more understanding? In  thinking about this, we need to ask what a diagnosis would feel like. Does being diagnosed with a clinically recognised condition help to make sense of how one feels, or is there a fear of such knowledge? In knowing that we have a recognised condition, do we feel labelled? If one were to find that a condition that fit with your own experiences and feelings, what would that knowledge be used for? It would be easy to attribute one’s feelings and behaviour to the diagnosis. In other words, ‘I do this, because I am…’.

As in a clinical model where diagnosis is followed by a curative process, surely, we should be seeing any  identification of a condition in the same way? The diagnosis is treated as the beginning of a way of learning how to live with the condition.

Psychotherapy after a diagnosis

Psychotherapy offers an opportunity to go beyond the confines of a diagnosis and focus on the individual as a whole. While clinical diagnosis often categorises and characterises someone’s experience in terms of symptoms and behaviours, psychotherapy focuses on understanding the emotional, psychological, and social factors that contribute to a person’s mental health. It creates a space for individuals to explore their feelings, thoughts, relationships, and behaviours.

One of the strengths of psychotherapy lies in its ability to complement clinical diagnosis. While a diagnosis can provide a concrete framework for understanding a person’s mental health, psychotherapy allows for the exploration of how that diagnosis plays out in the person’s life. For example, a person with a diagnosis of depression may benefit from understanding how their past relationships, family dynamics, and personal beliefs have contributed to the development of their depressive symptoms.

In therapy, individuals can work through the impact of their diagnosis in a way that feels developmental rather than limiting. By reflecting on themselves and examining their perspective, individuals can start to consider how to live with their diagnosis.

Psychotherapy is about self-reflection, distinguishing it from treatments like medication that primarily focus on alleviating specific symptoms.

It’s not uncommon for people to feel anxious, overwhelmed, or even ashamed after learning that they have a mental health condition. Therapy provides a space to process these feelings and move forward with a deeper sense of how we relate to ourselves and others.

 

To enquire about psychotherapy sessions with David , please contact him here, or to view our full clinical team, please click here.

David Work is a BACP registered psychotherapist working with adults, offering long term individual psychotherapy. He works with individuals in Hove.

 

Further reading by David Work 

Wearable tech: when is there too much data?

In support of vulnerability

Trauma and the use of pornography

Reflections on bereavement

Compulsive use of pornography

 

References –
Russell, G., Stapley, S., Newlove-Delgado, T., Salmon, A., White, R., Warren, F., Pearson, A. and Ford, T. (2022), Time trends in autism diagnosis over 20 years: a UK population-based cohort study. J Child Psychol Psychiatr, 63: 674-682.

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