Positive and negative aspects of shame

Shame is one of those emotions that a lot of people label “negative,” and talk about simply wanting to banish or let go of. I will argue that all emotions are useful, and only take on a positive or negative connotation in the way you’ve learned to relate to them.

What are emotions?

An emotion is an experience that puts a person in motion. It comes up in response to a situation that calls for action, and gives an intuitive sense for what type of action to take — a motive. The label given to an emotion is literally just a name for the feelings and thoughts associated with the action tendency which comes up in the body under particular circumstances.

For example, if something unfair is happening that I think I might reasonably be able to address, I’ll feel anger, which is my motivation to confront the source of the injustice, to use my strength and power to stick up for myself. If I repress all of my anger, I’ll be a doormat and let others take advantage of me. On the other hand, if I fixate on sources of rage over which I have no legitimate power, I’ll end up misapplying my strength in ways that may harm myself or others.

Each emotion is like this. An action tendency that is useful insofar as:

  1. Your appraisal of the situation is accurate, and
  2. You are able to tolerate the feeling of it.

In other words, emotions are healthy and useful when we’re able to relate to them in healthy, balanced ways.

What is shame?

Shame is the feeling that comes up when you realize that there is a gap between what’s expected of you and what you’ve been doing. It motivates you to close that gap, to do better, to live up to the expectations you hold for yourself and those that your community holds for you.

We say a person “has no shame” when they don’t seem to adhere to any community norms or values. This is not usually thought of as a positive trait, although the ability to subvert cultural norms and expectations can allow a person to show a great sense of humor (provided they’re not inclined to do so in a way that others find hurtful.)

When I notice that my house has gotten dirty, certain feelings come up automatically. I feel a sense of displeasure, because it’s not nice to be in a place that’s dirty. I also get a small feeling of shame because it’s up to me to keep up my own house and I can see that I haven’t kept up on that responsibility. So that small feeling of shame, along with a desire to be satisfied with my home and with myself, helps to motivate me to take action. My house gets cleaned.

What do poor relationships with shame look like?

On the other hand, what if I’m overly afraid of feeling ashamed? If I avoid the feeling of shame, rather than allow it, then I also block the motivation to clean. I end up in a vicious cycle, in which my house keeps getting dirtier, and so the shame feeling keeps getting stronger. I’ll exhaust myself more and more with the effort it takes to avoid the shame feeling, instead of honoring it by taking the action it is calling for. This is a phobic, or repressive, response to shame.

Shame can also go too far, if my expectations for myself are unrealistic. If I believe a good person keeps a house so clean that you can eat off the floor at all times, then I will feel the emotion of shame coming up anytime that’s not true. As a result, in order to satisfy the shameful feeling, I will either have to stop walking on my floor, or to keep washing the floor constantly. This is an obsessive-compulsive response to shame.

Healthy shame

A balanced and healthy position toward shame is a recognition of the usefulness of this feeling in motivating you to meet your own expectations for yourself. If you feel overwhelmed by shame, then you either need to adjust your expectations, or else increase your tolerance for the feeling.

Here’s the program I’ve followed to rehab my gums. I hope it helps you!

Goal 1: Address the bacterial infection. Here’s my daily routine

Step 1: Chlorhexidine irrigation & flossing

Nobody was prescribing this stuff for some reason despite it being repeatedly referred to in the literature as the gold standard for eradicating subgingival bacteria and disrupting biofilms, so I bought this veterinary solution that comes at 4%, and dilute it down to .2%. It doesn’t taste great (and has a bit of detergent in it), so I mix in some therasol to improve the taste.
I loaded that juice into a cordless waterpik with a plaque seeker tip and thoroughly irrigated into the gumline and between teeth every day for the first couple months, then gradually reduced down to a couple times a month.
I find it helps to floss even on days I’m doing the waterpik, and on days I’m not using the waterpik I put a little of the chlorhexidine solution in a small dish and dip extra thick/absorbant floss into the solution between each tooth. That way I’m delivering the solution closest to where I need it while limiting its exposure to the rest of my teeth & mouth

Step 2. Regular brushing

Next I rinse with antimicrobial Therasol mouthwash, and I brush lightly with a soft-bristled sonic toothbrush while holding the solution in my mouth to help get it into any pocket openings that the vibrations might effect.

Step 3: Ultrasound & arginine treatment

Next I do a final round of "brushing" with a genuine ultrasound (not "sonic") toothbrush, to disrupt subgingival biofilms that I may not be able to reach chemically, including any infection that may have moved into the bone, and to help stimulate gum tissue regeneration.

The ultrasound toothbrush I use is the Emmi-Dent from Germany. You don’t really brush with it, just hold it over each area for a few seconds while it does its ultrasound thing. I do it for about 5 minutes total each day, spending extra time on problem areas.

To prepare the ultrasound brush for use, I apply an arginine-containing toothpaste, which helps stimulate regeneration of both gum tissue and tooth surface.

I stumbled onto ultrasound around 2 or 3 months in to my rehab program, and discovered arginine toothpaste around 6 months in, and both of these discoveries mark major turning points in my recovery. I consider these two elements to be critical.

Step 4: Oral probiotics

I like to follow up this daily bacterial assault by re-introducing some beneficial bacteria. Oral probiotics have been shown to discourage colonization by pathogenic bacteria and decrease pocket probe depth (ref). Here’s one that should be pretty good.

Goal 2: Control and regulate inflammation

The literature is clear in depicting periodontitis as a dual problem of bacterial infection and dysregulated inflammatory response.
To this end, I eat an anti-inflammatory paleo / lectin avoidance diet. Details on this can be found in the book The Plant Paradox by Steven Gundry, MD. I also eat as infrequently as possible (currently fasting for 16-20 hours each day (ref), and eat as low carb as possible (ref).
Exercise is also helpful, particularly HIIT (ref).
A number of supplements have been shown effective for improving periodontitis and general oral health:

  • Vitamin D (ref)
  • Omega 3 fish oil (ref)
  • Aspirin (ref)
  • Bio-curcumin turmeric extract (ref)
  • Ubiquinol (ref)
  • Vitamin C & B-Complex (ref)
  • Lactoferrin (ref)

A Symbolic Therapeutic Gardening Group for Adolescents

This morning I led a gardening therapy group for my 25 residential teenagers. I introduced the group by teaching them how to work with the plants, by way of some Ericksonian metaphors:

When a baby is born, no one knows what it’s going to turn into. It’s just this bald, screaming, helpless little thing… it could grow up to be anything. And nobody can make it become anything in particular — an artist, or a scientist, or an engineer. You just have to give it the right amount of care, so you can enjoy learning what it is going to become over time. When you plant a flower bulb, you might not have any idea what sort of flower you’ll get, what color or shape or size. You have to wait, and make sure it gets the right amount of water and sunlight so that it will become whatever its true inner self is supposed to become.

Now sometimes a flower plant starts out growing in one sort of container, like this [held up a planter], but after a while it tends to outgrow that tiny plastic shell. So it’s necessary to transplant it to more suitable ground. And when you’re going to do that you have to be gentle in extracting the plant from its planter. You have to squeeze the sides gently to loosen up the root system, and then gently pull it out just slowly enough that the whole foundation of the thing will not be too disturbed. You can see how smoothly and easily it becomes ready to find its new home.

But notice that the roots have taken on the shape of their planter; they’re all bound up together. So you want to just gently pull them apart a little bit so that when it gets a little fresh soil it’ll begin to naturally and automatically reach out to find new sources of nourishment and stability. To really become established in the ground and ready to grow up into whatever its true nature may happen to be.

Now I could just stand this little plant up here and leave it [set the plant down on the ground], but it wouldn’t do very well because it needs care and support and connection. So when you’re placing it in the ground, make sure that you’ve dug out enough room for it to sit really comfortably in place. And then push enough soil in around the roots to make it nice and snug. Not too firm, but just firm enough that it will be held up securely while it works on settling its new roots into the ground on its own.

Then me, another therapist, and a few staff counselors all worked together with the kids to turn a broken down fountain into a big flower planter, to plant some fresh vegetables in the neglected garden boxes, and rejuvenate the walkway with lots of beautiful flowering plants.

An old broken fountain becomes a beautiful flower garden


Vegetable garden

Hypnosis is the most effective way to stop smoking

I regularly provide counseling to help people stop smoking, and often use hypnosis as a part of my approach. One of the first questions I hear from people is: Does hypnosis really work? Can it really help me stop smoking?

I’m not an advertiser — I’m a clinician and a scientist, so I tend to be a little bit conservative about telling people just how much more effective hypnosis actually is than all other available treatments. So I’ve compiled this brief review of the scientific literature on methods to stop smoking so that you can make the comparison for yourself and really see the difference in effectiveness. In putting this together, I’ve focused strongly on rigorous, meta-analytic studies — which are studies that combine the results of many other smaller studies in order to get much more comprehensive results.

Here are the major interventions currently being used to help people stop smoking:

  • Hypnotherapy
    • In a major meta-analysis of 633 studies on smoking cessation, including 48 studies which examined hypnosis on more than 6,000 participants, hypnosis showed a 36% success rate when no distinction is made between different types of hypnotic intervention (Viswesvaran & Schmidt, 1992). This is important to note, because there are many different ways that hypnosis can be used, and they are not all equally effective. Previous studies have shown, for example, that custom-tailored hypnosis is much more effective than the standardized, scripted variety typically used in scientific studies (Lynn, Green, Accardi, & Cleere, 2010). So with this study we can see that even when most of the treatments use a standardized, one-size-fits-all approach, more than 1/3 of participants still achieve and maintain abstinence from cigarettes.
    • An extremely rigorous, randomized controlled study in 2006 found that intensive (8-session) hypnotherapy resulted in 40% of patients being free from cigarettes at 6 month follow-up, as confirmed by measurement of carbon monoxide levels in their blood (Elkins, Marcus, Bates, Rajab, & Cook, 2006). Not a single person in the control group had managed to stop smoking on their own for this length of time.
    • New procedures for enhancing hypnotic responsivity and reinforcing treatment gains may provide even greater effectiveness for the use of hypnosis to stop smoking (Lynn, Green, Accardi, & Cleere, 2010)
  • Counseling
    • A recent systematic review published in the journal Addiction found that behavioral counseling is superior to treatment with medication (Hartmann-Boyce, Stead, Cahill, & Lancaster, 2013)
    • Another meta-analysis showed that a type of counseling called Motivational Interviewing is also effective in enhancing smokers’ ability to quit successfully. (Heckman, Egleston, & Hofman, 2010)
    • However, counseling is substantially more effective when hypnosis is used (Lynn, Green, Accardi, & Cleere, 2010)
  • Acupuncture
    • A meta-analysis of alternative smoking cessation aids published in the American Journal of Medicine found that acupuncture is an effective treatment for smoking — more effective than medication or nicotine replacement — but not as effective as hypnotherapy (Tahiri, Mottillo, Joseph, Pilote, & Eisenberg, 2012)
  • Nicotine Replacement Therapy
    • Nicotine replacement is the most popular method to try and quit smoking, because products such as nicotine gums and patches are readily available over-the-counter, and people believe that replacing the nicotine from cigarettes will help them to break the habit before they have to deal with the physical effects of detoxification from nicotine. A 2008 meta-analysis found that nicotine patches and nasal spray were roughly as effective as other medications (Eisenberg et al, 2008), while nicotine tablets and gum were slightly less effective.
    • In total, only 7 to 9 percent of people succeed in stopping smoking by using this method (Shiffman et al, 2002).
  • Medication
    • A meta-analysis published in the Canadian Medical Association Journal compared 7 popular medications used for smoking cessation including buproprion (Wellbutrin) and varenicline (Champix), as well as nicotine replacement products such as the nicotine patch, gum, or nasal spray (Eisenberg et al, 2008). While each of these medications was more effective than a placebo in helping smokers kick the habit, the overall effectiveness is not very good. All told, less than 10% of patients receiving any of these medications succeeded in remaining abstinent from cigarettes for 6 months.
  • Aversive Smoking
    • This is the method of intentionally making yourself sick by smoking many cigarettes very quickly. This creates an intensely unpleasant experience which causes many people to feel a subsequent aversion to cigarettes. This method is actually slightly more effective than anti-smoking medications (Eisenberg et al, 2008), but not anywhere near as effective — or enjoyable — as hypnotherapy (Tahiri et al, 2012)

From reviewing the literature, my conclusion is that New Scientist was correct when they declared hypnosis “the best way of giving up smoking.” Particularly when used in a personalized manner, in conjunction with motivational interviewing and behavioral counseling, there is simply nothing that comes close to matching its effectiveness.

In 2011, I worked with Dr. Edward Frischholz, Ph.D., ABPH on further developing a brief hypnotic treatment for smoking originally developed in the 1960s and under continuous refinement since that time. The method’s effectiveness has been confirmed in numerous studies. In the most recent published study, from the American Journal of Psychiatry, this method achieved 30% success at a six-month follow-up (in a single session!) — measured by complete 100% abstinence for the entire six month period (Spiegel, Frischholz, Fleiss, & Spiegel, 1993). If a participant smoked even one cigarette at a party a single time during the entire six months, it was counted as a failure.

By studying the real-life circumstances associated with both successful and unsuccessful outcomes, we were able to modify the technique in order to achieve an additional 8% success at 6 months follow-up. I presented these findings to the Society of Clinical and Experimental Hypnosis at their annual conference in 2011.

And as we continue to update and refine this method, we find that more and more of our patients are finding it easy and enjoyable to become non-smokers… permanently.



  • Eisenberg, M.J., Filian, K.B., Yavin, D., Belisle, P., Mottillo, S., Joseph, L., Gervais, A., O’Loughlin, J., Paradis, G., Rinfret, S., & Pilote, L. (2008). Pharmacotherapies for smoking cessation: a meta-analysis of randomized controlled trials. Canadian Medical Association Journal, 179(2), 135-144.
  • Elkins, G., Marcus, J., Bates, M., Rajab, J., & Cook, T. (2007). Intensive hypnotherapy for smoking cessation: A prospective study. International Journal of Clinical and Experimental Hypnosis, 54, 303-315.
  • Hartmann-Boyce, J., Stead, L.F., Cahill, K., & Lancaster, T. (2013). Efficacy of interventions to combat tobacco addiction: Cochrane update of 2012 reviews. Addiction, 108(10), 1711-1721.
  • Heckman, C.J., Egleston, B.L., & Hofman, M.T. (2010). Efficacy of motivational interviewing for smoking cessation: a systematic review and meta-analysis. Tobacco Control, 19, 410-416.
  • Lynn, S., Green. J., Accardi, M., & Cleere, C. (2010). Hypnosis and Smoking Cessation: The State of the Science. American Journal of Clinical Hypnosis, 52(3), 177-181.
  • Shiffman, S., Hellebusch, S.J., Gorsline, J., Gorodetzky, C.W., Chiang, Y.K., Schleusener, D.S., & Di Marino, M.E. (2002). Real-world efficacy of prescription and over-the-counter nicotine replacement therapy. Addiction, 97(5), 505-516.
  • Spiegel, D., Frischholz, E.J., Fleiss, J.L. & Spiegel, H. (1993) Predictors of Smoking Abstinence Following a Single-Session Restructuring Intervention with Self-Hypnosis. American Journal of Psychiatry, 150(7), 1090-1097.
  • Tahiri, M., Mottillo, S., Joseph, L., Pilote, L., & Eisenberg, M.J. (2012). Alternative smoking cessation aids: a meta-analysis of randomized controlled trials. American Journal of Medicine, 125(6), 576-84.
  • Viswesvaran, C., & Schmidt, F. (1992). A meta-analytic comparison of the effectiveness of smoking cessation methods. Journal of Applied Psychology, 77, 554-561.

Motivational Enhancement Therapy

Many times the most difficult thing about making a change is deciding to. It is the terrible ambivalence that keeps us from taking steps to improve our health, to strengthen our relationships, and to break free from patterns of behavior that damage and hold us back. Many people take the first major step of coming to therapy for addictions, or depression, or marital discord — only to find that they are fighting an internal battle about whether or not they really want to take action. Sometimes that conflict doesn’t even really show its face until you’re sitting in a therapist’s office being told what to do in order to get what you want. And a part of you, just… doesn’t want to.

Motivational Enhancement Therapy is like the therapy before the therapy. Before you can really dig into the work of making change in your life, you have to make that critical decision — that this is the time. Not with part of your mind, but with all of it.

The Motivational Enhancement procedure takes about four sessions, which are spent examining the situation as it is, the changes you’d like to see, and the reasons why you’d like to see those changes. Most people are surprised at how low-pressure these sessions are. There is no point during a Motivational Enhancement session at which I will try to convince the patient of anything. My job in these sessions is just to ask the types of questions that help a person understand their own reasons for wanting to change. The final decision about how to proceed rests squarely in the hands of the patient.

The way this is done is using the techniques of motivational interviewing:

  1. Open-ended questions – This type of questioning naturally leads into the issues most pertinent not to the therapist, but to the patient.
  2. Affirmations – When we’re feeling ambivalent, it’s often because we’re having trouble recognizing what strengths we can bring to bear on a situation. By helping you recognize the things you’re already doing well, this technique provides a feeling of encouragement and stimulates problem-solving.
  3. Reflective listening – The client’s own ideas and experiences are reflected back in a way that facilitates momentum toward a logical conclusion.
  4. Summaries – Periodically, the therapist provides a summary to help bring it all together and show how each of the ideas discussed connect.

So the purpose of this therapy is not to persuade the client that they should make a change — after all, if they didn’t already want a change, they wouldn’t have showed up. The purpose is to help draw connections between personal experiences and strengths, so that a natural, progressive course of action will become clear.


Incorporating Mindfulness Meditation into Psychotherapy

Mindfulness meditation is a deceptively simple technique with a wide range of benefits and a growing body of research support. It’s become the basis for popular psychotherapies like Dialectical Behavior Therapy (DBT), Acceptance and Commitment Therapy (ACT), and Mindfulness-Based Cognitive Therapy.

General Benefits of Meditation

From a neurological perspective, regular meditation practice has been associated with structural changes in the brain — long-time meditators experience a thickening of the cortical tissue (which manages executive functions like attention and concentration), and an increase in the functional connectivity between adjacent cortical regions (meaning that important parts of your higher brain have stronger, faster lines of communication.)

Meditation has been shown to relieve stress and inflammation, thereby reducing risk of a whole host of diseases and improving overall quality of life. I think the evidence is more than sufficient to say that there is a general benefit to meditating, and would recommend it to pretty much anyone.

But as a therapist, I’m interested in helping people get what they want out of therapy — achieving specific treatment effects — in a reasonable amount of time. And for that reason, I incorporate mindfulness meditation into psychotherapy where it’s appropriate for a particular patient, and in a way that supports other parts of the work.

Benefits of Using Mindfulness in Therapy

The clinical benefits of mindfulness practice fall under two related umbrellas: cognition, and emotion.

For cognitive control, think about problems like Adult ADHD,  age-related cognitive decline, mild dementias, or even just problems focusing at work. Mindfulness meditation is all about learning to concentrate, and it works like exercise — the more you use your ability to focus your attention, the stronger that ability becomes.

However, in each of the scenarios I mentioned, it’s important to note that there is likely to be a contextual component to the problem, where your social environment and inner emotional life come into play. Oftentimes patients suffering from anxiety disorders or addictions complain of problems focusing, and it’s necessary for the therapist to look very closely to see how that issue plays into the larger clinical picture. There are also many more cognitive rehabilitation techniques which can be utilized in therapy to achieve optimum results based on an individual patient’s needs.

On the other end of the spectrum, people suffering from things like depression, bipolar disorder, or complex trauma are generally having difficulty regulating their emotions. They feel overwhelmed or find themselves acting in ways they’re not satisfied with. As a framework for building up a calm, centered state of mind, mindfulness meditation can be very helpful in gaining more control over your emotional experience. Over time, you learn to accept emotions as they arise and continue on with your life in spite of them. There are a lot of ways to expedite that process in psychotherapy, and so I generally introduce meditation as just one component of an overall program for psychological health and well-being.

Varieties of Meditation Experience

It’s also very important to consider the manner in which meditation practice is framed, as this will influence the way it’s experienced and the types of benefits that are achieved. Anyone can listen to a guided meditation CD or read my tutorial on the subject and experience certain benefits. But who knows whether those benefits will be exactly what is needed for a particular individual to feel better? Depending on what a person is really looking for in therapy, I might help them develop a meditation practice focused on cultivating acceptance, forgiveness, compassion,or positive emotions. In other cases, it’s more beneficial to concentrate on disconnecting from negative thoughts, memories, emotions, or experiences. Or to build up associations to positive experiences, like an improved relationship to the body, or to other people. Or for spiritual grounding.

Because so much of psychotherapy revolves around gaining control over mental states, I end up teaching most of my patients to use some form of relaxation, meditation, or self-hypnosis. But I think it’s important to emphasize that those practices are not a one-size-fits-all cure. It’s the way they’re applied, and the purposes they’re applied for, that make these techniques useful adjuncts to psychotherapy.

Relaxation & Stress Management

Are your mind and body working against each other?

Psychological stress is so powerful that it can practically tear your body apart.

Studies correlate stress with chronic pain, heart disease, stroke, diabetes, cancer, dementia, infections, and just about every other medical problem you could possibly experience. Why? Because stress causes inflammation.

And inflammation inhibits your body’s ability to repair itself, causing ordinary problems to spiral out of control — turning into allergies, arthritis, hormonal imbalance, autoimmune disease, asthma, skin problems, hardened arteries… That’s how powerful the mind-body connection is.

Worse, stress is sensitizing. Surviving a very stressful event doesn’t prepare you to handle stress better in the future. Instead, you actually become more likely to experience adverse consequences every time.

What’s the antidote? Relaxation.

In the 1970s, a cardiologist named Herbert Benson was the first to discover that when people engage in active relaxation, their physiological response to stress is reduced… along with all of its negative health effects. He called this natural healing effect the relaxation response.

A lot of people hear this and immediately think they need to spend more time kicking back in front of the TV with a cold beer. But there’s a catch — passive activities like watching television don’t do the trick. (In fact, studies show that TV can actually induce physical stress.)

If you want to trigger your body’s healing relaxation response, you need to practice a technique specifically aimed at doing so (such as diaphragmatic breathing exercises, progressive muscle relaxation, or meditation.) And these activities actually provide a cumulative benefit — they not only make you feel relaxed while you’re practicing them, but over time they bring your body’s baseline for stress down to a more comfortable level. That means that ongoing stressors in your life won’t affect you as much.

The best approach is to work at the problem from both sides.

In the course of providing psychotherapy and counseling, I end up teaching most of my clients some form of meditation, relaxation, or self-hypnosis technique that they can use to achieve these benefits. They’re very effective, and people really enjoy them.

But it’s also important to work on directly improving the stress in your life. That’s why I rarely stop at relaxation. Some of the other important ingredients for maintaining a positive, relaxed state are:

  • Assertiveness: Learning to communicate clearly, authentically, and effectively — so you build deep connection, minimize resistance, and get what you want more often
  • Organization: A good organizational system can relieve stress while allowing you to accomplish more
  • FocusAttention and concentration are strengths that can be exercised and improved over time, using techniques like mindfulness meditation.
  • Acceptance: Worrying uses up valuable time and energy without contributing anything positive. By learning to accept the uncertainty and chaos of life, you can increase your resilience and respond more effectively when stressful events actually occur.

Transpersonal Therapy & Spiritual Counseling

Your spiritual beliefs can be your most powerful tools for positive transformation.

Psychotherapy based on the integration and amplification of spirituality is referred to as “transpersonal” — because the nature of spirituality is that it helps to bring us outside of ourselves, and to connect us with higher powers and higher realities. Transpersonal therapy often incorporates aspects of Jungian analysis, which focuses on understanding the archetypal forces playing out… not only in your unconscious mind but in the external world.

These concepts are not very popular with today’s science-minded psychological community. There are few studies, and few testable hypotheses or techniques. Regardless, I believe that spirituality is the original form of psychotherapy, and it still may be the most powerful.

Even when I’m explaining what I do in terms of scientific tools and medicalized interventions, in my own mind I think of what I do as shamanism. But, in a world where spirituality has become personal and individual — rather than the deeply shared beliefs of our collectivistic past — a shaman’s job is to work with the very personal myths and symbols that have taken root in each individual mind. Peer-reviewed science is only the current mythological system of our culture. For those who subscribe to it, I use empirically based treatments (with just a dash of magic).

But for those who follow the old religions, I prefer to use a more traditional style of treatment.

The induction and utilization of trance states has played a central role in treatment for thousands of years. The explicit practice of hypnosis goes back to the sleep temples of ancient Egypt and the shamanic rituals of all tribal cultures. Judaism, Christianity, and Islam, with their emphasis on prayer, study, and meditation, have been no less reliant on trance.

Even the designs of churches and temples evoke states of consciousness congruent with the spiritual values of the sect they represent — from the humbling grandiosity of mosques and cathedrals, to the wooden stoicism of Lutheran chapels, walking into a place of worship generally triggers a sense of spiritual presence even for those who do not usually subscribe to the beliefs of that particular sect.

Spirituality is about finding a sense of meaning in life. And that sense of meaning, as told in the myths of every religion, imparts a supernatural ability to overcome life’s difficulties.

Every generation has numerous examples of miraculous healings by faith. Descriptions can be found in nearly every spiritual text and — although they are repeatedly discounted by reasonable, scientifically-minded people — they continue to take place all over the world. I believe that this type of healing is at least as accessible to us today as it was thousands of years ago.

For example, I recently worked with a double-amputee who was experiencing phantom leg pain. As he described his strong Christian beliefs, I realized that they were his strongest and most ready tool for overcoming his symptoms. As we talked, he came to trust in my openness enough that he was willing to share his faith with me and to show me how he prayed. After a month or two of working with him to strengthen his prayer by digging more deeply into his own most closely-held beliefs, his pain disappeared.

People usually seek help when they can’t understand the meaning of what is happening to them.

As their lives change, their beliefs no longer seem sufficient to explain their experience and connect them with the unknown. They experience depression, anxiety, obsession, darkness, and longing. I find that I am able to work easily with such people, because I have no beliefs of my own. A part of me believes everything.

I grew up steeped in fundamentalist Christianity, in which the deep symbolism of the Christian Bible was taken as literal truth. And a part of me still believes it is. But other parts have come to similarly subscribe to the truths of Buddhism (that all of life is an illusion to be transcended), of Hinduism (that life is a grand drama playing out between fragments of a single consciousness), of Catholicism, Wicca, Druidism, Spiritualism, Scientism, Illuminism. Parts of me have become initiated in secret magickal societies and experience the power of imagination to act upon the outside world. Parts of me experience the universe in ways that have not yet been named — as a series of quantum fields which can be consciously traversed.

So when a person comes to me for help living in a different kind of world, I create rituals that call that world into being. I help them experience trance states in which they can travel there — and realize that they have the power to choose which world they will live in.

Creativity Coaching

Powerful psychological techniques to unlock your full creative potential.

There’s a big difference between being a creative person, and being a creative professional. The pressure to produce fresh ideas can interfere with your ability to tap into your deepest creative resources.

By taking the time to really nourish your creative abilities, and develop a richer relationship with your unconscious mind — you can begin to enjoy easier access to your natural creative energy.

I use an innovative combination of relaxation, visualization, hypnosis, and explorative Jungian therapy techniques to help my clients balance and enrich their inner lives… allowing a smoother and more satisfying flow of inspiration.

  • Actors: Develop a deeper understanding of your character, and connect to the script as though it were your own life
  • Directors: Leverage all your mental resources to broaden your creative vision (and relieve the stress of managing large productions)
  • Writers: Allow the best parts of yourself to naturally spring to life on the page
  • Choreographers: Imagine fresh, rich, natural patterns and communicate them effortlessly
  • Dancers: Bridge the gap between mind and body so your movements flow like brilliant liquid
  • Musicians & Composers: Harness the deep rhythms that run through every part of your life
  • Singers: Feel the soft luxury of your breath gliding naturally to new levels of emotional expression
  • Chefs: Learn to connect all your senses, and draw fresh inspiration from all around you
  • Designers: Free your mind to conceptualize in new, exciting, and cohesive ways
  • Marketing and Advertising Professionals: Dig deep to connect emotionally with your market’s most closely guarded motivations

Are you in a creative rut?

There are two basic types of problems with creativity. The first is the creative block — like writer’s block, for example — where you just can’t seem to grasp an idea. You know you have the creative resources somewhere inside yourself, but you can’t bring them up to the surface. It’s like the artistic equivalent of the tip of the tongue phenomenon.

The second type of problem is a loss of inspiration. This is the feeling that maybe the creative talent that previously surged from your unconscious might have finally dried up. You can still produce things, they just aren’t as good. They lack that creative life-force. Your work is uninspired and uninspiring.

Creative blocks are usually caused by deep-seated anxiety.

When you feel a deep need to prove yourself, it doesn’t only mean that you need the world to recognize your ability — it means that on some level you also doubt your own worth. That feeling of basic self-doubt, is what blocks access to the unconscious riches that informed your previous creative work.

In order to get past this problem, we’ll explore the source of the anxiety — how does the pressure you feel now relate to the basic challenges of your life? We all replay our early relationships and developmental struggles in the back of our minds, over and over, until they are finally resolved. Dynamic psychotherapy can help you to achieve this resolution much more quickly.

Once the inner conflict is resolved, most people are surprised to find that not only is their creativity restored… they also experience a renewed enthusiasm for life, relationships, and fun.

Loss of inspiration often results from a slow descent into a comfortable, but uninspiring, lifestyle.

You have achieved a kind of psychological victory. You have overcome those same anxieties described above… not by mastering them and harnessing their creative energy, but by locking them in a dungeon in the back of your mind. Perhaps the walls are so thick that you can’t even hear their dull roar, day and night, ceaseless.

Creativity comes from the uncertainty of living. The loss of creativity is not just a loss of some skill or ability — it is a loss of the penetrating thrill of living. In order to reclaim it, we’ll examine strategies you’ve devised to protect yourself from chaos and fear. Then, we’ll work together to slowly open up your windows to the infinite. To re-invigorate your connection to the source of life… to reclaim your childhood innocence… to feel that excitement again.

Depression Treatment

Depression is extremely common, and extremely treatable. More than 1 in 5 adults will experience a diagnosable mood disorder at some time during their lives, with major depressive disorder being the most common (this is what some counselors call “clinical depression.”) If you’re suffering from depression, you already know how many different kinds of problems it can cause… problems with work, relationships, health. And it steals your ability to feel joy, enthusiasm, or even simple pleasure.

Now, here’s where things get tricky: depression isn’t really a single thing

There’s no medical test that can definitively diagnose depression — and anyone who tells you that depression is caused by a “chemical imbalance” is either misinformed, or has some medication to sell you. Even the psychological tests for depression are really just lists of symptoms that you check off, or questions that other people who are depressed have been found to answer in a similar way.

The truth is, there are many different causes of depression, many different ways that depression might affect you, and therefore many different types of treatment that might be effective for your particular case. Some examples:

  • Major Depression – already mentioned, this is the diagnosis for people feeling sad, guilty, tearful, and withdrawn
  • Atypical Depression – tends to be reactive to external events, and is characterized by overeating, oversleeping, and an inflamed sense of rejection
  • Dysthymia – a form of low-grade, chronic depression (they used to call this depressive personality disorder)
  • Adjustment Disorder – this situational depression occurs when external events overcome your ability to manage the emotional stress of what you’re going through
  • Postpartum Depression – depression after giving birth, or occasionally during pregnancy
  • Premenstrual Dysphoric Disorder – depression which follows a woman’s monthly cycle
  • Seasonal Affective Disorder – “winter sadness”
  • Bipolar Disorder – where depressive episodes alternate with periods of hyperactivity called mania (this pattern used to be called manic depression)

Depression treatment is very effective. But…

One-size-fits-all treatments are only going to be effective for people that they are actually a good fit for. The treatment should not only be a good fit for your symptoms, but also for you as a person. Your personality dynamics determine what types of psychological problems you might have, how they’ll present themselves, and how you can find your way back to feeling better.

That’s why I like to take a holistic (Adlerian/Ericksonian) approach, creating a customized treatment for each patient. This may incorporate any of the following:

  • Behavioral prescriptions – Targeted action plans can help gradually break the inertia of depression, so you start regaining a sense of yourself as a person who can accomplish things. In the scientific literature, this is referred to as “behavioral activation,” and it is actually one of the most effective techniques — especially for severe depression.
  • Lifestyle modification – I help my clients examine their style of living to identify simple, powerful changes they can make to help support a positive mood — things like exercise, sleep, relaxation, stress management, nutrition, and time  in nature. This ties in with behavioral activation, but goes beyond mere activity for it’s own sake, into choosing activities that will have specific physiological and psychological effects.
  • Cognitive restructuring – This central aspect of cognitive behavioral therapy involves learning to recognize and change the automatic thoughts and mental images that support the depressive symptoms, as well as the core beliefs which make a person susceptible to depression in the first place.
  • Psychodynamic therapy – Many people who are “cured” of depression remain susceptible to experiencing the same thing all over again later on. Through the use of insight-oriented or psychoanalytic techniques, you can discover the source of this susceptibility and develop strategies to help ensure that the rest of your life keeps getting better and better. Research shows that patients who receive this type of therapy continue to improve for years after the treatment is done.
  • Clinical hypnosis – By tapping into your deepest, unconscious resources, hypnosis can enhance and accelerate all of the other therapy techniques I’ve mentioned. Many scientific studies have shown that psychotherapy with hypnosis is more effective in the treatment of depression than psychotherapy alone.

Rape Counseling: The Sooner The Better

After a traumatic event, most people feel a little bit like they’re losing their minds.

Because rape challenges your basic sense that the world is a safe place to live. The feeling of being violated causes such a huge rush of emotion — everything from anger to fear to guilt to sadness — that it is a really disorienting thing to recover from.

Some of the most common things that people experience as they recover from trauma are:

  • A looming sense of fear and anxiety
  • Avoiding people and place that are normally comfortable for you
  • Insomnia, jumpiness, being startled easily
  • Nightmares, and even flashbacks
  • Lack of focus and concentration
  • Depression
  • Emotional numbness
  • Irritability, feeling like you’re not yourself

These experiences are normal, and won’t last forever.

However, I recommend that anyone who has experienced a traumatic event like rape seek counseling immediately. Because the earlier you get into counseling, the better the results will be — you want to treat the psychological injury before it has a chance to set.

Here are some statistics about the natural healing rate for psychological trauma after rape.

  • Intrusive symptoms such as nightmares and flashbacks are strongest in first few weeks after rape, and usually diminish after 3-6 months.
  • Fear and anxiety, however, frequently persist beyond 1 year.
  • 1 in 4 women feel they still have not fully recovered from the trauma after 4-6 years.
  • Anxiety symptoms tend to diminish over time, but somatic symptoms (such as unexplained aches, pains, and stomach upset) can actually get worse over time.

As you can see, some of the problems caused by this type of trauma can be long-lasting if they’re not properly treated. And worse, it can sensitize you to future stress, causing ongoing mental instability. Rape survivors are more likely to report future nervous breakdowns than any other group, and 1 in 5 rape victims make a suicide attempt in the 9 years following the event.

Trauma is treatable.

As I said at the beginning of this page, traumatic events can shatter a person’s basic trust in the world.  They can disrupt not only your life, but the person living it — your sense of self.

Therefore, the first step in treatment is to re-establish a basic sense of safety. From there, you can begin to rebuild a positive sense of self, and to re-engage in the important relationships that give you strength.

Weight Loss Hypnosis & Counseling

Here’s what the scientific research says about the effectiveness of hypnotherapy for weight loss:

  • One study took an existing 9-week behavioral therapy program for weight loss (something like Weight Watchers or Jenny Craig), and added hypnosis to it to see whether patients receiving the hypnosis-enhanced version would get better results. At the end of the 9 weeks, both groups had lost weight… But the patients who got hypnosis were more likely to achieve and maintain their personal weight goals. In fact, unlike the patients who got regular behavioral therapy, the hypnosis group actually kept on losing weight. Two years after the treatment, they were still losing weight and maintaining their target weights. (“Effectiveness of hypnosis as an adjunct to behavioral weight management”, from the Journal of Clinical Psychology, Bolocofsky, Spinler, & Coulhard-Morris, 1985)
  • A meta-analysis looked at 6 studies comparing cognitive behavioral therapy (CBT) for weight loss with CBT + hypnosis. The patients who got the psychotherapy alone lost weight, but patients who received hypnotherapy along with it lost twice as much weight. And, just like in the previous study, the hypnosis groups continued to lose weight after the treatment was over. (“Hypnosis as an adjunct to cognitive-behavioral psychotherapy: A meta-analysis”, from the Journal of Consulting and Clinical Psychology, Kirsch, Montgomery, & Sapirstein, 1995)

A number of studies have looked at the benefit of hypnotherapy as a stand-alone solution for weight loss… And they have generally found that while it is effective, it’s not as effective as hypnosis used in conjunction with psychotherapy.

That’s why I use and recommend hypnosis as just one part of a comprehensive, individually tailored weight loss program.

There are no legal requirements for calling yourself a hypnotherapist or a weight loss counselor, and so a lot of people end up paying the same amount of money to see someone with no special knowledge of psychological or physical health.

I have years of intensive training and clinical experience helping people understand and improve their mind-body relationship to overcome problems like diabetes, obesity, and food addiction (as well as the problems with self-esteem, body image, and relationships that often come along with them.)

So, when I meet with a patient for the first time, I take the time to really get to know them — their background, beliefs about life, and style of living. Then I use that information to develop a personalized weight loss plan that is designed to play to their unique, individual strengths. This is the difference between seeing a credentialed mental health professional, and seeing someone who may have only taken a weekend workshop.

Of course, motivation only gets results if you’re taking the right kinds of actions.

Most therapists who offer weight loss counseling services are trained to provide psychotherapy, but have no specialized knowledge of how the body works. So… they’ll go to all the trouble of psychotherapizing you only to have you… eat less and exercise more. An approach that has roundly failed to produce lasting results, despite hundreds of researchers actively trying to prove that it works since the 1970s. So it’s really important to find a qualified mental health professional who also has special training in mind-body medicine.

For example, my training included three years of supervised clinical work focused on working with the mind-body relationship. I also have a personal passion for health, and have followed the scientific literature on this topic for more than a decade. Based on this research, I strongly advocate for a paleo-style, whole food approach to weight loss and health improvement. The modern, high-sugar, grain-based diet is a major cause of weight gain, inflammation, diabetes, cardiovascular disease, and a host of other problems. By eating (and exercising) more like our ancestors, we can reverse these effects and allow our bodies to reach their optimum genetic potential.

As I work with patients to help them develop customized programs of diet and exercise, I think it’s important to also help them to understand not only what kinds of actions to take, but why those actions will work and how they will affect the body. We look at:

  • How to fit the right kinds of dietary changes into your lifestyle (so it becomes easier to eat healthy in every situation)
  • Whether — and which — dietary supplements might help to achieve optimal health, fitness, and longevity
  • What kinds of exercise will help you achieve your ideal physique, in as little time as possible and with maximal positive health effects. For example, if your body is inflamed, a lot of high-intensity cardio will probably only make things worse.

As these details fall into place, hypnosis can be really helpful to cement them in — to start forming new habits of mind, which will translate into automatic habits of behavior. Because when people have to spend all day thinking about what they’re not supposed to eat, they fail. Our behaviors follow naturally from our beliefs, so we won’t really be able to change our lifestyles in sustainable ways until we have developed beliefs that support those changes. In many cases, the limiting beliefs run deeper than just what food or exercise is best, into beliefs about self and about the way the world works. In these cases, psychotherapy is needed to overcome the limiting beliefs and open up new possibilities for health.

Psychotherapy & Hypnotherapy for Irritable Bowel Syndrome

On this page I’ll explain how and why psychotherapy and hypnotherapy are safe and effective treatments for IBS symptoms. I’ll explain some of the causes of IBS — how it relates to diet, lifestyle, stress, and even relationships. And then I’ll explain some of the techniques that I use to help my clients achieve lasting relief from the pain, bloating, gas, diarrhea, and constipation that disrupt their lives. This page is long and contains a lot of information, so I won’t blame you if you want to just go ahead and call or email me to set up an appointment right away. If you’d like to learn more first, keep reading.

There are so many neural connections in your gut, researchers are calling it the “second brain.”

There are literally about a trillion neural connections in there. And each one of them responds to all the same sorts of things that the ones in your brain do. You probably already know that neurotransmitters like serotonin, dopamine, and GABA affect your brain in ways that control your thoughts and feelings… but did you know they do exactly the same thing inside your intestines?

Emotional experiences have a direct effect on our guts, and this is something we recognize intuitively:

  • When we describe a troubling experience as “gut-wrenching”
  • When excitement causes that feeling of “butterflies in the stomach”
  • When nervousness makes us feel queasy
  • When stress triggers heart-burn

The connection between the gut and the brain, which scientists refer to as the gut-brain axis, works in both directions.

Just thinking about food causes your digestive system to start producing and releasing the acids and enzymes needed to digest that imaginary food. This starts in your mouth. Just imagine sliding your tongue across a big, juicy, sour slice of lemon… feeling the sting of the acid as that strong sour flavor fills your mouth — and it’s likely you can feel the saliva starting to well up in your mouth to neutralize the acid of your imaginary lemon. This is happening all the way down your digestive tract, all the time.

And the gut sends strong signals to the brain as well. All the way back to the Ancient Greeks, the stomach has been thought to be the seat of emotion, and new studies are showing that gut health plays a profound role in psychological well-being. A number of studies have shown that the natural balance of bacteria in your intestines plays a large role in this, with probiotic supplements used to alter that balance causing changes in both brain neurotransmitter activity, and in behaviors related to anxiety and depression.

This two-way communication means that gastrointestinal disruptions like those seen in IBS bring about a lot of emotional problems. It also means that we can use psychological treatments to improve not only the emotional correlates, but also the actual disorder of the gut.

The standard of medical care for IBS is to attempt to simply address the symptoms without discovering or correcting the root causes. I find this completely unacceptable.

There are four main strategies that I use in the treatment of irritable bowel syndrome

1. Lifestyle change & skill building

Skills like relaxation, stress management, assertiveness, dietary enhancement, and meditation can have a major impact on IBS symptoms by balancing your physical, emotional, and social well-being.

I use my scientific training to help patients conduct a personal experiment, discovering what aspects of your behavior have a real effect on the way you feel. And, through ongoing counseling, I help you maintain your focus and motivation to take control.

2. Cognitive therapy

The way that you think about your symptoms affects the way that you perceive them. Most people think that the amount of pain or discomfort that a person feels is proportional to the amount of tissue damage or inflammation. But that’s not actually the case — every person has their own level of tolerance for pain and discomfort. And by restructuring your mental approach to discomfort, you can actually increase your level of tolerance. That means you’ll perceive less discomfort, and won’t be as bothered by the discomfort you do feel.

This component of treatment, combined with the behavioral elements described above, comprise cognitive-behavioral therapy, which a number of clinical studies have shown to be effective for relieving the symptoms of IBS.

3. Insight-oriented psychotherapy

I’ve also found that certain kinds of people are more prone to this type of condition. They generally fall into one of two groups: people who have difficulty controlling their emotions, and people who control their emotions too tightly.

In either case, it is necessary to understand the origins of that predisposition, in order to reshape the dynamic way a person processes emotions. This type of therapy has a way of not only improving symptoms — but producing positive changes across many, often unexpected areas of life.

4. Hypnotherapy

Hypnosis is a highly undervalued psychological technique that makes it possible to achieve big changes quickly. It is renowned for its ability to bridge the mind-body gap, allowing for direct control of involuntary physiological functions. It’s also the single best, most empirically supported treatment for IBS.

The type of hypnosis used for IBS is called gut-directed hypnotherapy, which means the types of imagery and suggestions employed are focused very intentionally on influencing the inner workings of the gut. I generally adapt the University of North Carolina model of hypnosis for IBS, developed by Dr. Olafur Palsson, which has a very high level of scientific support for its effectiveness.

Mind-body psychotherapy is simply one component of your care that can help to enhance your body’s resilience, response to treatment, and rate of healing… as well as your emotional well-being. When you schedule your first appointment, I’ll ask you to sign a release form that will allow me to communicate with your physician, so I can coordinate with them to provide you the best care.

The Problems With Evidence-Based Psychotherapy

There has been a tremendous movement toward evidence-based treatment in clinical psychology over the past decade. On its face, this is a good thing — the idea that we should use scientific findings to make sure the types of treatment we’re using in psychotherapy actually work. My own clinical training included a wide array of these empirically based treatments, and I happily use many of their key techniques. I also continue to pay close attention to new clinical research, and frequently review the literature in the course of formulating treatments for my patients.

However, I see some really serious problems with evidence-based psychotherapy, problems that I believe are actually harmful to the patients, and to the credibility of clinical psychology:

The studies use unrealistic exclusion criteria

In an effort to eliminate confounding variables that could interfere with study results, research psychologists try to exclude patients suffering from any ailments outside of the single diagnosis that the treatment protocol is designed for. This is in line with the medical model of psychology, which attempts to isolate discrete psychological disease processes and treat them directly, much the same way that a physician might take a throat culture and then prescribe antibiotics to treat strep throat.

The problem is that psychological issues don’t really work that way. The diagnoses used in clinical psychology are generally not isolated disease processes the way viral or bacterial infections are. Most people don’t present with a single discrete disorder, but rather a spectrum of symptoms, personality characteristics, and social factors which can all be considered a part of the syndrome which has led them to seek treatment. This requires holistic treatment that identifies and addresses the underlying causes.

In many ways, mental illness is similar to metabolic syndrome — another problem for which the medical model is proving inadequate. All day long I see patients with separate diagnoses of diabetes, hypertension, hyperlipidemia, cardiovascular disease, obesity, sleep apnea. Each one of these identified problems are then treated by suppressing the symptoms. For diabetes there are pills to lower blood sugar, for apnea there is the CPAP device, for high blood pressure there are pills to lower the blood pressure. Even the preventive advice that is rendered is symptom-focused: switch to whole grains so the sugar will enter your system more slowly, take less salt to reduce blood volume. But all of the symptoms are actually related. They all result from the same underlying problem of metabolic dysregulation, and until that total syndrome is addressed, all of the symptoms will continue to get worse over time no matter how well they are managed.

Mental illness is like that. There are genetic, social, and cultural predispositions that contribute, but in order for the syndrome to be expressed a disruption in the management of psychological resources — such as emotions, thoughts, internal imagery, relationships, etc. — must take place. A cascade of compensatory actions are then set in motion, resulting in the symptoms we see on the surface: depression, anxiety, nightmares, panic attacks, hallucinations, substance abuse, etc.

I’ve treated substance abuse, and rarely seen a case where depression or anxiety were not also present. I’ve treated PTSD, and it’s the same story. Would you believe that most sufferers of severe, adult-onset, chronic pain are survivors of some form of childhood abuse? Even your basic top-level disorders, anxiety and depression, actually share many symptoms and frequently develop simultaneously. And many patients’ suffering simply doesn’t fit any currently available psychiatric diagnosis.

So what happens when you pick a single disorder, cherry-pick patients who don’t meet criteria for any other problem, and study their response to an intervention? They get better! In fact, they mostly get better even when you just put them on a waiting list. Because these are the easiest, most uncommonly uncomplicated cases. They are not a good representation of the patients that actually come in for treatment. Therefore, the studies are not generalizable; they tell us very little about how well a treatment will work in the real world.

The studies aren’t repeatable

Because there are so many potential confounding factors in research with live humans, you can never read too much in to any one study. Once a study has been repeated a few times, preferably by different researchers under different conditions, then we can start to get a little more confident that we’re seeing a real treatment effect and not just an artifact of some unpredictable condition of the study. But that’s not happening very much in the field of clinical psychology. Most psychotherapy outcome studies are simply never replicated.

Part of the problem is publication bias: for a variety of reasons, papers describing a failure to replicate previous studies don’t get published as often. Many of the findings could not be replicated regardless, because they are false positives — the study designs do not adequately discern between treatment effects, placebo effects, and random effects. There is tremendous pressure on academic researchers to produce positive results, and this leads to both conscious and unconscious bias in the way research is carried out.

Finally, psychological treatments, like medical treatments, are subject to decline effects. Over time, They get less effective. Later studies find lesser effects than earlier studies, even when the research design is sound. This could be due to changes in researcher enthusiasm, changes in the patient populations that the treatments are being tested on, or changes in the cultural context in which treatments are being administered. Regardless, most published research findings are false. It is therefore highly problematic to make those findings the basis of clinical treatment.

Here are some excellent articles about these problems:

The studies often ignore therapist effectiveness & the treatments fail to utilize therapist skill

A large number of controlled and naturalistic studies have found that the therapist providing treatment is more important to the outcome than the type of treatment being provided. This makes a certain kind of natural sense to most people, yet psychologists remain resistant to the idea and the reasons for it have not been adequately studied. We don’t really know what makes the difference between a really great therapist, a mediocre therapist, and an ineffective therapist. Treatment adherence does not explain the difference.

So what do psychological researchers do? Rather than try to isolate the factors that make a therapist great, they try to eliminate them in order to study the effects of specific treatment protocols. The therapists studied must comply with manualized treatments in ways that often contradict their own highly trained clinical instincts, and then statistical methods are used to cover over any remaining differences.

The result is rigid treatment designs that do not provide therapists with information about how to get the greatest clinical effect out of them. In practice, psychotherapy is fluid and must be adapted to the individual client on a moment-by-moment basis. But because these manualized treatments are supposed to be “evidence-based,” clinicians are obligated to go through a process of supervised practice during which they must comply with the manual at the expense of therapeutic effectiveness. Then, once they are certified to administer this evidence-based treatment, they can go back to doing the things they have found actually help people, while adhering only to the basic structure of the manualized treatment. In my experience, clinicians do their best to pick very “easy” and compliant patients as test cases for certification, since these types of patients are the ones who will generally get better no matter what you do with them.

Significant results in studies are not good enough to be considered clinical success

Even if we ignore the methodological problems and take these studies at face value, the results they achieve are generally insufficient to indicate a treatment effect that I would be satisfied with in my own practice. A “statistically significant” effect just means that whatever happened probably didn’t happen by chance. So with this type of result, we know that the treatment had some effect, but we know nothing about how much of an effect it had.

For that, we need to look at effect sizes. Even a “large” effect size (0.8) really only means that the average person in the treatment group ended up better off than 79% of people who didn’t get the treatment. We’re not talking cures here, we’re talking about less than half of the people getting somewhat better than people who got nothing.

Of course, “better” depends on the measures used. In most studies, outcomes are measured using symptom questionnaires that patients are asked to fill out before and after the treatment. The symptoms on the questionnaire will relate only to the specific disorder being treated, so for most studies we never know how well patients ended up in terms of overall quality of life. The broader the disorder, the bigger this problem becomes.

For example, Dialectical Behavior Therapy (DBT) is widely recognized as the best and most empirically supported treatment for Borderline Personality Disorder. And the studies have shown that DBT does, in fact, reduce self-harm and increase treatment compliance in sufferers of borderline personality disorder. They have not, however, shown DBT to cure borderline personality disorder — and not for lack of trying. So here you have a widely promoted intervention that does not bring about a reversal of the diagnosis for which it is prescribed. There are interventions which have been shown to do this, such as Mentalization-Based Treatment. But, for a variety of reasons, that treatment does not seem to be gaining traction in the evidence-based psychology community. As more money gets thrown at DBT studies, the likelihood increases that someone will eventually manage to get a positive result for reversal of borderline personality disorder, and then that finding will be used to solidify DBT as the mandated choice among healthcare systems using evidence-based treatments.

Study funding and treatment implementation tends to be theoretically aligned

Cognitive Behavior Therapy (CBT) is far and away the most widely studied form of psychological treatment. Let’s set aside for a moment the fact that “CBT” has gradually expanded to include the most widely-used interventions from all theoretical frameworks, as well as longer treatment periods for complicated or difficult presentations. It has been shown effective for a wide range of psychiatric disorders, with more added all the time. Based on its impressive base of literature, many researchers, educators, and clinicians assert that it is the most effective form of psychotherapy. The problem is, it’s not.

Studies comparing CBT to other types of therapy have found similar effect sizes between treatments for decades, with psychodynamically-oriented therapies showing more lasting treatment gains. So why is CBT so much better represented in funding and implementation? Essentially, politics. The cognitive-behavioral theoretical camp got a strong foothold at NIMH and held on for dear life. There are more studies showing that CBT is effective simply because there have been more studies funded for this type of treatment.

The same is true with exposure-based therapies for trauma. Therapies which focus on exposure are the most heavily promoted and widely held to have the best empirical base. However, at least five other types of treatment show equal treatment effects, and a couple of them contain no exposure elements whatsoever. There are underlying factors that are getting lost in the politics. As a clinician I have absolutely no interest in the politics — I’m interested in figuring out what works for each patient. From that basis, we may be able to start to extrapolate ingredients that make treatment more generally effective for all patients (this is the idea of practice-based evidence.)

Treatments studied often have poor theoretical integrity

As I mentioned, CBT has been steadily expanding over the years to encompass more techniques, such as relaxation, visualization, and mindfulness meditation. The exploration of core beliefs and schemas has evolved in a direction very similar to modern brief psychodynamic therapies. The only thing that distinguishes CBT from the less- (but still often well-) supported psychotherapies is its theoretical foundation.

However, the same expansion beyond CBT’s theoretical basis has led to the creation of treatment protocols which are essentially eclectic. Researchers have long lamented their difficulty in isolating the specific factors which lead to successful treatment, and these new ostensibly cognitive-behavioral protocols amplify the problem by introducing a technique-driven, kitchen-sink approach that renders a difficult task impossible. Instead of drilling down into the therapies to identify process variables which highly effective therapists incorporate naturally, we are building up theoretically vapid treatments that seem to work about as well as everything else, but target a specific psychiatric disorder (for which there is also little theoretical or empirical integrity.) Are you confused by all this yet?

Symptom-focused EBTs lead to modularization of treatment, increased total treatment time, reduced overall effectiveness

As this newfound glut of grant-funded “evidence-based” psychotherapies are rolled out in large healthcare systems, the result is a bureaucratization of psychotherapy. Patients are shuffled from one empirically supported group to another, and handed off from one therapist to another based on what symptoms each therapist is certified to treat.

For example, a common case is an obese veteran with chronic pain, depression, PTSD, and alcohol dependence. For the obesity, they’ll be referred to a weight loss group. For the chronic pain they’ll be referred for manualized pain management treatment, either in a group or individual format. The alcohol dependence will likely lead to a referral for a substance abuse treatment group, which will be followed by a referral to a manualized “Seeking Safety” group to transition between substance abuse treatment and PTSD treatment. PTSD treatment might be treated with either Cognitive Processing Therapy or Prolonged Exposure Therapy, either of which may lead to some relief from depression, but an additional referral will likely be needed for a depression treatment group. So in this common scenario, the patient is asked to participate in 6 separate 8-12 week, empirically supported treatments, each of which requires orientation into a separate vocabulary and set of expectations, and each of which has about half a chance of producing remission for its particular symptom. This treatment process will average about 60 weeks, most likely with gaps of 1 month or more in between the start of each treatment, meaning that the whole thing will take a year and a half, conservatively. How long do those non-evidence based treatments take again?

Moreover, decades of studies examining the factors related to positive treatment outcomes have shown that one of the most important factors is the therapeutic relationship. The model which I have described, which is currently in use within some major healthcare systems and which is being heavily promoted for implementation everywhere, simply obliterates the therapeutic relationship which would be established over the course of an 18-month, single-provider course of psychotherapy. That relationship is replaced by a series of much shallower treatment relationships with well-meaning therapists, and one major relationship, to the bureaucracy itself.

Psychological Treatment for Migraines

If severe, recurrent headaches are putting a strain on your ability to live life your own way, mind-body psychotherapy may help you regain your physical comfort and peace of mind. For over a decade, I’ve used the tools of psychotherapy and hypnosis to help people overcome debilitating medical symptoms. On this page, I’ll provide information about how that works. Feel free to call or email me if you’d like to discuss your situation and set up an appointment.

There is no single underlying cause of chronic headache pain, but rather a constellation of contributing factors. There is a genetic component, so a family history of migraine headaches does predispose you to also have migraine headaches. But even if your identical twin has migraines, there is still only about a 50% chance that you will have them as well. Hormones also play a role: women of child-bearing age are two to three times more likely than men to experience migraine headaches, and the headaches often ease up after menopause. Nerve tissue inflammation, skeletal problems, muscle tension, and dietary intolerances can all contribute.

There are also psychological factors. Chronic pain has a strong, cyclical relationship with anxiety and depression. The experience of chronic pain causes anxiety and depression, and these heightened emotional states exacerbate the pain symptoms. On top of that, most chronic pain patients are surprised to learn that certain personality types are more likely to experience chronic pain.

Headaches are complex, and require holistic treatment

Early in my career, I spent a year training at the Diamond Headache Clinic’s inpatient unit in Chicago, which provides treatment for severe, chronic, and intractable headache cases. While mild cases can often be managed reasonably well with medications, more severe cases require a variety of treatment modalities that work synergistically. These may include medication, dietary adjustments, physical therapy, massage therapy, chiropractics, acupuncture, biofeedback, hypnosis, and psychotherapy. The types of treatment used are often selected based on the specific types of headaches you are experiencing and the way that the symptoms present. Migraine headaches with aura, for example, call for a different treatment approach than tension headaches or cluster headaches.

Pain perception is psychological

Most chronic pain sufferers assume that since pain is a physical condition, there is nothing that a psychologist could do for them other than to help them process the feelings of frustration of being ill. But it turns out that pain is not as strictly physiological as you might think.

To begin with, no matter what part of the body feels hurt, the pain itself actually takes place within the brain. The nerve endings that register pain throughout your body simply send signals back to the brain, which processes the signals and decides how much pain sensation it should produce in response. The amount of pain that results is not necessarily related to the amount of nerve damage or activation, but is instead regulated by context, emotional state, beliefs and social expectations about pain experience, and the amount and type of attention the pain is given.

Additionally, there are no pain receptors in the brain itself — no tissue has been damaged in the moments leading up to a headache. Instead, the part of the brain which creates pain has been activated for some other reason. It is very significant that fMRI studies have shown that “painful” emotional experiences such rejection and loss share the same neurological circuitry as physical pain. That is why sufferers of chronic pain are more prone to psychological distress, and those experiencing psychological pain are more likely to develop chronic physical pain. So in many cases, part of the chronic headache pain is a physical manifestation of psychological turmoil.

Has your doctor recommended therapy?

There are many different types of psychological interventions that may be helpful, depending on the nature of your headaches. After a thorough assessment, I develop an individualized treatment plan that may include any combination of the following:

  • Cognitive Behavioral Therapy (CBT)
    • Behavior plays an important role in headache management. By optimizing diet, exercise, sleep, stress management and other behavioral aspects of headache management, we can help to create a relaxed physical state that encourages natural healing.
    • Identifying external triggers for headaches is another important part of psychological treatment. By managing these triggers more effectively, we can reduce headache frequency.
    • Cognitive restructuring provides tools to help you process pain differently, decreasing pain awareness and increasing your ability to tolerate discomfort.
  • Mindfulness – By cultivating your ability to recognize and manage thoughts and feelings, mindfulness-based treatment strategies can be especially helpful for people suffering from emotional disruptions related to chronic pain.
  • Hypnosis – This powerful psychological tool can make it much easier to introduce new behaviors, new ways of thinking and feeling, and to directly modify physical processes. I have seen many patients respond extremely well to treatment which incorporates hypnosis into the psychotherapy.
  • Visualization – By creating new internal representations of pain processes we can change their meaning, and this changes the way that pain is dealt with at the neurological level.
  • Depth-oriented Psychotherapy – Unconscious psychological processes contribute to chronic pain. For example, many people experience more intense and frequent migraines within the year or so following a traumatic experience or a major loss. Certain emotions can’t be expressed, so they get represented in the body. This cycle can be broken by examining and resolving psychological conflicts that stand in the way of dealing with those emotions directly.

Studies have shown that psychotherapy can be very effective for relieving chronic headache pain, with most patients being able to return to work and go back to living normal, happy lives after treatment. In my experience, the key to successful treatment of headache pain is developing a clear picture of what is happening for you as an individual, and addressing the root causes using a customized, targeted, and holistic treatment program.

Mind-body psychotherapy is simply one component of your care that can help to enhance your body’s resilience, response to treatment, and rate of healing… as well as your emotional well-being. When you schedule your first appointment, I’ll ask you to sign a release form that will allow me to communicate with your physician, so I can coordinate with them to provide you the best care.