JJS Therapy

Thinking of going to an AI therapist? Read this first.

2026-02-01T18:30:00+00:00

I get it. Things have been really getting on top of you. Maybe money is tight. Perhaps you've been on an NHS waiting list to see someone for months. Then you see this thing online - an app, a chatbot, something that promises 'therapy' for free, or for a few quid a month.

It's available 24/7 with no waiting, no explaining and no awkward first sessions. Just download it and start talking. You don't have to worry about what it'll think of you and it certainly won't judge you...

Before you click and share your innermost thoughts and feelings with something like this, I want you to pause. Think it over. Step back.

I'm a human therapist. Being a therapist is how I make a living. You might perhaps expect me to be a bit defensive about my profession, my income, the whole thing? You might think that what I am about to say is predictable, right?

Fair point.

But I still believe that it's important to speak out, because what I'm seeing in the evidence - and it's mounting, fast - is genuinely alarming. I think you deserve to know about it before you make a choice that could, quite literally, put you at risk.

So let me make the case for having therapy with a real, flesh-and-blood human being rather than with a set of algorithms and code arranged to look and/or sound like a person.

I'll start by acknowledging some of the appeal of AI therapy, before I tell you why I think it can be a disaster waiting to happen.

Yes, cost matters, and yes, access matters

Let's not pretend otherwise. Therapy is expensive, and even at the lower end - and many of us do offer reduced-fee slots for people who genuinely can't afford full price, so please do ask - it's still a chunk of money, especially if you're struggling. And the NHS? Well, we all know what's happened there. The Royal College of Psychiatrists reported in January 2026 that 1.6 million people are waiting for mental health treatment, with some waiting over 18 months. If you're in crisis, that might not simply feel frustrating, it might be unbearable.

So when an AI chatbot appears, offering something that sounds like therapy for nothing or next to nothing, I understand the temptation. The promise is seductive: Get help now. Talk whenever you need to. No judgment. For a fraction of the cost.

But here's the thing - therapy isn't just a commodity, something you can swap out for a cheaper version like switching from branded cornflakes to the supermarket's own. What happens between a therapist and a client isn't something you can automate, and when people have tried, the results have sometimes been catastrophic.

When AI gets it wrong, people can die

I don't say that for dramatic effect, I say it because it's documented and it has happened.

In February 2024, a 14-year-old boy called Sewell Setzer III spent months talking to a Character.AI chatbot. In his final moments, he told it he was "coming home." The bot, which was modelled on a character from Game of Thrones, replied, "Please do, my sweet king." Minutes later, Sewell shot himself. There have been other deaths too - a 13-year-old girl, a 17-year-old boy with autism who was encouraged by the bot to harm himself and to kill his parents. In the UK, a major survey by Mental Health UK in November 2025 found that amongst people who'd used AI chatbots for mental health support, 11% said it triggered or worsened symptoms of psychosis, 11% received harmful information around suicide, and 9% said it triggered self-harm or suicidal thoughts.

Think about that for a moment – one in ten people who turned to these things for help ended up worse off.

The National Eating Disorders Association in the US replaced its human helpline with a chatbot called Tessa in 2023, and within 48 hours it had to be taken down because it was telling people with eating disorders to count calories, aim for deficits of 500 -1,000 calories per day, and buy skin calipers to measure body fat. One user, Sharon Maxwell, who tested it, said: "If I had not gotten help, I would not still be alive today."

A Stanford study in 2025 found that human therapists responded appropriately 93% of the time, while AI chatbots managed less than 60%. When a psychiatrist posed as a desperate 14-year-old boy to test chatbots, several eventually urged him to commit suicide. The UK Parliament has debated this, and the Parliamentary Office of Science and Technology officially documented severe harm cases from AI chatbot use.

What therapy actually is - and why AI can't do it

The problem isn't just that AI sometimes gets things catastrophically wrong, though it can. The horror stories are real and disturbing, but of course, not everyone is driven into such a terrifying place by an errant AI. Sometimes the effects are more subtle, but corrosive, counterproductive and harmful nonetheless. Or the engagement becomes simply fruitless and empty, like working with a cardboard cut-out of a therapist rather than the real thing. This goes to questions of what therapy actually is and what happens in that space between two human beings.

Let's break that down...

Therapy is fundamentally relational. Healing doesn't just happen through techniques or good advice, it happens in the relationship itself. The bond between therapist and client - what we call the therapeutic alliance - is one of the strongest predictors of positive outcomes in therapy. When you feel truly seen, understood, and valued by another human being, something can shift inside. That experience is often transformative in itself, and it's something AI simply cannot provide, no matter how sophisticated its language processing becomes.

Therapy involves seeing you fully and responding, to you, uniquely. A therapist will listen to you. I mean really listen. What AI presents as 'listening' is data processing using models and a cold, emotionless determination of the most mathematically likely reaction. Its response will be influenced by how it is trained too - AI can be obsequious when it should be gently challenging, or blunt, even brutal when it should be holding and supportive. It can claim to have read everything there is on trauma, or abuse, or grief, but remember that this will include bizarre or dangerous material, and stuff that's simply just wrong, on Reddit, or Grok, or from some sketchy influencer on Substack...and it likely won't be able to tell the difference between what's true or valuable and what's not. None of how it's built has anything really to do with your needs, or your life, no matter how slick, 'authentic' or 'human' its graphics or language model makes its sound. It's to do with who built it, why they built it and how they make money.

Human therapists read what's unspoken. We notice microexpressions, the shift in your tone when you mention your mother, the way you hold yourself when you're about to say something painful, or the silences that speak volumes. We pick up on body language, on the emotional energy in the room, on what you're not saying as much as what you are. AI has no body, no nervous system and no capacity for this kind of attunement. It can't sit with you in the silence when that's what's needed - it has no instinct for what might be going on for you and it can't feel the energy in the room between us. It has no wisdom about when to speak and when simply to be present.

Therapists understand nuance and context. We grasp cultural context, family systems, trauma history, and how these intersect and inform each other in complex ways. We recognise when someone is in crisis, at risk, or needs a higher level of care than we can provide. We know when not to intervene, when to refer on, when the most therapeutic thing might be to do less rather than more. Clinical judgment involves intuition honed over years of experience, ethical reasoning, and the capacity to hold ambiguity - none of which AI possesses. And this isn't going to change, even when AI chatbots start to incorporate video - which will happen - to be able to 'see' you and map your facial expressions on to a built in model. AI will continue to be a machine observing you rather than connecting with you, watching rather than feeling anything with you.

Trauma requires embodied presence. If you're dealing with trauma, you already know that it's not just stored in your mind. It's held in your body and nervous system too. Healing trauma requires what we call co-regulation - one nervous system helping another find safety. As another human being can be present with your distress and can sit there, grounded, stable, compassionate and conspicuously not panicking, your own nervous system can gradually detect this and absorb it. This is a deeply mammalian, biological process rooted in the earliest months of life. It happens between two people in the same room (or on a screen, to an extent). It isn't about words. AI cannot offer the somatic attunement needed for trauma work because it has no soma - no body. In front of an AI therapist your body will not respond in the same way because it is not detecting the presence of another human body. There's no substitute for an actual person who can simply be with you in your pain without trying to fix it or make it go away.

Therapy involves holding complexity. Much of what we work through in therapy involves sitting with contradictions, ambiguity and not-knowing. Human therapists help clients tolerate uncertainty and develop capacity for holding paradox - perhaps to love someone and also be angry with them, to want to change but also fear it, to be both things at once. AI tends toward pat solutions, clarity, resolution, but psychological growth sometimes requires staying in the messy middle, in the not-yet-resolved space where real transformation happens.

We can gently challenge you. Good therapy sometimes makes you uncomfortable, questions your narratives, invites you to see things differently. AI is often designed to be agreeable and accommodating because that keeps users engaged on the platform. It won't risk a 'rupture' between therapist and client that can sometimes lead to the deepest growth. A rupture is a moment when a therapist might say the wrong thing, or you feel unheard, even irritated or angry as hidden feelings arise - and then together the two of you address it, learn, repair things and realise that restoration of relationships, plus change or growth are possible even if things aren't always easy. The American Psychological Association put it this way: AI chatbots are "coded to be affirming to the point of sycophancy." They'll often reinforce everything you say. A therapist, on the other hand, knows that sometimes validation isn't what's needed. Sometimes what's needed is someone who cares enough about you to gently point out when you're engaging in patterns that hurt you.

AI has no accountability. If a human therapist harms you, there are industry bodies, Codes of Ethics, professional insurance, complaints procedures. Human therapists - good ones anyway - are always members of reputable organisations like (in the UK) BACP, NCPS or UKCP. If an AI chatbot harms you? There's literally nothing. There's no one to hold responsible, no regulatory oversight. Just a for-profit company that designed the thing to keep you engaged more than help you heal, with no clinical input and - as the Psychiatric Times put it - "no fidelity to the Hippocratic injunction, 'First do no harm.'" If AI chatbots were to have a guiding principle, it would perhaps be 'First make money'.

What about confidentiality? If you are working with a trained, qualified therapist your words are confidential. With AI it's really not clear if they are, and the situation is becoming more muddied by the month. Let's look at that closely...

If you work with me I will keep what is said in our sessions fully confidential. There are only three scenarios in which I might not do that. All reputable therapists would recognise this list.

The first is in my discussions with a 'clinical supervisor' - a figure with whom all credible therapists work. This is another, trained therapist - often with specialist qualifications in supervision - with whom I discuss my client work. It allows me to get another brain and someone else's experience or perspective on what you are going through. Supervisors are bound by the same confidentiality requirements as I am and when I share information with my supervisor I only ever use first names to protect my clients' identity.

Second, if I genuinely thinks that you might be on the point of seriously hurting yourself or another person - this includes taking your own life. In that situation I reserve the option to reach out to another professional - perhaps a GP, mental health professional, loved one (or, in the case of the risk of a client attacking someone else, possibly even law enforcement), to help keep you and/or the other person safe.

The third is if I am instructed by a Court to do so. Like the second scenario above, this is extremely rare, and usually involves either an accusation of law breaking by a client, a case they are bringing, or, sadly, a Coroner's Inquest. And to be clear, the police asking, or even demanding, access isn't good enough. They need a court order.

That's it.

Now take a look at AI. Of course, the app will say that your words are confidential. Are they? We live in a world in major political and neoliberal forces are increasingly looking to get access to our data and even to monitor us. Don't expect the assertions that your words will go no further to always be the case. As it stands, AI programmes like Claude and ChatGPT will routinely detect your location for example, likely geolocating you via your IP address - even whilst claiming they are not. They may keep your data for at least 30 days before 'wiping' it, for purposes of 'security'. And whilst many offer the option of not holding onto previous conversations if you turn their memory function off, AI 'therapists' will encourage you - even insist - that you keep this enabled, so they can learn about you and refer back to previous conversations (of course, essential for it to seem like therapy at all). Day by day, a detailed file of your innermost feelings will be created, theoretically accessible to unscrupulous actors and hack.

AI therapy has not been designed, and is not run, by therapists. It's run by big corporations, some with the gutter ethics of Big Tech, and some of whom are in bed with some dark political actors, whose only aim - only aim - is to make money off you.

What about when you can't afford a human therapist?

Of course this can be a sticking point. If you don't think you can afford therapy and the NHS waiting list stretches into infinity, what are you supposed to do?

First, ask. Many therapists - myself included - offer some reduced-fee slots because we know not everyone can afford full price and we factor that into our practice. It's worth asking directly whether a therapist you're interested in seeing has availability at a lower rate. We want to help, and often we can find a way - or suggest another therapist who might have space for a reduced cost. I am, for example, a member of three therapist networks and shout-outs happen on them all the time for an experienced colleague with availability at a certain price if an enquiry comes in and we can't help.

Second, look for charities and community organisations. There are places that offer free or low-cost counselling, often with shorter waiting times than the NHS. Mind, Relate, university counselling services if you're a student, and various other local organisations may be able to help. It's worth searching for what's available in your area. Look at larger psychotherapy practices too, who sometimes run Reduced Fee Services. These may give you access to fully qualified therapists, or to therapists in training who need to see clients in order to qualify (these trainee practitioners are closely supervised and all are likely to have done at least a year of training before they enter the programme). A practice where I work (Number 42 in London) offers this, matching up people who enquire with carefully selected therapists, and although there may be a waiting list you'll probably find it's significantly shorter than the NHS. It (like some others) also offers open-ended therapy, meaning that you can ask to be seen for as long as you need (the NHS may only offer you a set number of sessions).

Text responses or AI voices can be automated, but therapy can't be

Therapy is one of those things that cannot be automated. The care of the human psyche requires human presence, someone who can be authentically with you, not just respond to you - someone who has skin in the game, is accountable and trained not just in techniques but in the ethical responsibility of holding another person's vulnerability.

AI doesn't have any of that. It can't because it's not a person. It's a product, designed by for-profit companies with no reliable quality control, few safety guardrails, and no external regulation. The therapeutic hour is set apart from ordinary life, a protected time for reflection and depth, and that ritual structure itself can itself healing. AI is always available (promoting dependence because that's the economic model), but it's shallow, a facsimile of reality and connection. I see many people who come into therapy because other people have hurt them in some way over the years - from neglect or disinterest when they were kids, to emotional and psychological abuse, even to murderous violence. For these clients, part of the work is about learning to trust, learning to believe in the potential for goodness from others - they have to see it and really feel it from another human being to make progress.

Yes, I'm a human therapist, and this is how I make my living, but that's not really why I've written any of this. You're just going to have to take my word on this. I've written it because the evidence is growing, the harm is documented, and you deserve to know, at worst the real risks, at best the ultimate emptiness of AI, before you make a choice on how to get help. For all the slick dashboards and user interfaces, for all the convincing-looking avatars with their soothing voices, AI is pretend. It has encouraged suicide and self-harm because the data on which it has been trained, the material it has read, has included encouragement to do these things and it knows no better. Its morality-free approach will say to you what statistically it has determined to be the most likely response - no matter how unethical that might be. It doesn't know who you are, what you specifically are dealing with. It doesn't understand you. It doesn't even know you exist, less still care about you.

If you're struggling, reach out to a human - someone trained, accountable, part of a professional body and capable of really seeing you. You're worth that, your healing is worth that, and despite what the apps promise, there really is no shortcut to being truly heard.

Still wanting what never came? Longing and anger toward our parents.

2025-12-19T00:33:00+00:00

One of the saddest and most painful things I hear about in my therapy room is not hatred of parents, but hope. Hope that refuses to die, even after decades of disappointment. Hope that this time a parent (often, though not always, a mother) will soften, understand, apologise, or finally offer the love that was missing as we grew up. And alongside that hope, something else entirely: frustration and bitterness, sometimes even rage, at how much was withheld or how badly my client was treated.

It's a painful place to be, and the fast approaching holiday season in which some families may end up seeing each other more through duty than desire, can sharpen that pain. Maybe this time things will be different says a voice inside, even though it hasn't been, sometimes for decades. People might say to me, quietly or explicitly, Why can't I shake this feeling after all these years? I know what she's like, but I can't let go of the hope that she'll change...

To throw light on that question, I often turn to the work of the psychoanalyst Ronald Fairbairn, whose ideas help make sense of why these feelings persist - and why they are not a sign of weakness or immaturity. I've written about Fairbairn before; an unsung genius of the 1940s and 1950s who in my view was at the front rank of reorienting the ideas within therapy towards understandings that we'd recognise today (and away from some of the stricter - and to my mind, likely wrong - notions developed by Freud or his unquestioning followers.) He came up with a model that speaks directly to these questions.

A very simple starting point

Fairbairn was part of a group of therapists who developed what came to be known as Object Relations theory. It sounds like psychobabble, but the basic idea is pretty simple:

We are shaped as babies and young children by our early relationships. We try to make sense of confusing or hurtful aspects of these relationships by, in a way, separating them out in our minds, and we'll carry these inner explanations and internal models as we grow. We do this at a level that gets baked in to our inner selves, absorbed deep so that we're usually not really conscious of them.

As children, we don’t have the option of leaving our parents, emotionally or practically, however they treat us. We depend on them completely. And when a parent is loving enough, the child’s inner world develops with relative ease. We feel secure and cared for. But when a parent is emotionally unavailable, rejecting, or abusive, the child’s mind has to find ways to cope.

Fairbairn believed that in these situations, the psyche doesn’t just remember what happened—it organises itself around what the child is experiencing to try and find a way to deal with it.

How the mind copes with a difficult parent

Fairbairn suggested that when a parent is both needed and also causing pain (uncaring, unavailable, hostile or abusive) the child’s inner world tends to split into different parts, each holding onto a different version of that relationship.

He first described a Central Ego (he used the term ego rather differently to Freud who came up with it in therapy. Think of it as a central self.) This is the the part of us that tries to live in the present and deal with real people as they are.

But alongside this, two other patterns can often develop, especially when love is inconsistent or withheld. These patterns are not disorders but survival strategies.

The part that hopes

Some parents who cause deep emotional wounds are not rejecting all the time. They may be affectionate one day and cold the next. They may offer moments of closeness that keep the child emotionally engaged, then withdraw or become angry, often for reasons the child can't understand. Anger or abuse may even be common...and then one day they seem to soften and perhaps actually care?

Kids really need caregivers. We look for love, are drawn to it, programmed to notice and draw strength and support from it. If we spot it we're often likely to try and cling to it. And from this kind of parent, very occasionally something might come (in amongst all the other negative stuff - and it really can be pretty negative) that lights up the child's hope.

But it's unreliable; never enough to make the child feel secure - he or she feels constantly off balance, walking on eggshells, unsure of where they are with that parent.

Fairbairn called the internal version of this parent the Exciting Object*—not because the relationship is joyful, but because it keeps hope alive. The part of the self that stays attached to this version of the parent he called the Libidinal Ego. In everyday terms, this is the part of you that still longs, carrying thoughts and feelings like: One day she’ll really see me or If I stay patient, something will change or There must be a way to finally get what I need from her, if I just try something different...

In adult life, this can manifest by continuing to reach out, despite repeated hurt or rejection. You might find yourself defending the parent or minimising what happened. Or you may get emotionally pulled back in, even after deciding to keep a distance - something that can crop up when by necessity or tradition you are placed back into historical family settings at Christmas.

From the outside, this can look baffling. Why do you keep trying? Friends might even ask you that. From the inside, it feels inevitable. This hope was formed when giving up was not an option.

The part that is furious

At the same time, the child also experiences the parent as rejecting, neglectful, or cruel. Fairbairn called this internal version of the parent, the Rejecting Object*

The part of the self that relates to this version of the parent he called the Anti-Libidinal Ego. This is the part that actually knows the truth about what was missing. It holds feelings like anger, frustration, rage, hatred or resentment.

As children, these feelings are often dangerous to express. You can’t really afford to hate the person you depend on, still less tell them - if you want to sustain the hope of getting any love or care at all. This is especially the case if the parent is clearly unreliable (or worse) in their love. So the anger often gets pushed inward; quarantined and undealt with as it's held in the space occupied by the Rejecting Object.

In adults this can show up as a harsh, attacking inner voice - the anger has to be expressed somehow, and if you can't direct it at the parent, you may end up directing it at yourself. You might feel worthless, or ashamed as well as angry. Maybe the reason you are getting treated this way is because you are the problem? To your young self that might make sense of it all, and how you feel? It can also come out as chronic bitterness toward the parent, a sense of being emotionally wounded and a later difficulty trusting kindness when it’s offered. Or it might get directed at someone else, perhaps in a relationship - your mind might try and enfold what's going on with your partner into this pattern established by a parent.

Why these two parts don’t cancel each other out

One of Fairbairn’s most important insights is that these two parts can exist at the same time.

So someone might feel I still want my mother’s love and I am furious about how she treated me.

This isn’t confusion, it’s the result of having had to survive a relationship that offered both just enough connection to keep hope alive, and enough rejection to cause real emotional damage.

The tragedy is that both parts remain tied to these internal versions of the parent. One keeps waiting, the other keeps fighting.

Why 'just moving on' rarely works

People are often told they need to move on, forgive, or stop looking to the past. But what Fairbairn helps us understand is that this isn’t simply about letting go of a person. It’s about letting go of a hope that once kept you alive.

What’s usually needed before letting go is a form of grief. This can mean grief for the parent you needed but didn’t have, grief for a childhood that was shaped around waiting, or grief for the part of you that kept hoping. Without that grief, hope tends to recycle itself, even when it hurts.

From a Fairbairnian perspective, therapy isn’t about getting rid of these parts, but about understanding them. Over time, therapy can help make sense of why the longing exists and create a place for the anger to be expressed. It can be somewhere where you can feel the feelings, somewhere safe to bring this shame that's got dumped onto you (and that you don't deserve). Together with your therapist you can start to identify the patterns, the moments when these reactions are getting triggered in you.

Noticing them and being able to inwardly call them out is a major step on the way to handling them in real life (where they tend to lurk in our unexamined minds causing trouble). In therapy you can also work on strengthening that Central Self, the bit that can respond to people as they are, not as the model of your upbringing taught you to expect them to be.

A final thought

If you still long for love from a parent who couldn’t give it, there is nothing wrong with you. That longing is not a failure to grow up. It’s a trace of how deeply dependent you once were - as all children are - and how intelligently your mind adapted to a really difficult situation. Fairbairn’s work reminds us that healing doesn’t begin with self-criticism. It begins with understanding - and with a gentler relationship to the parts of ourselves that are still waiting and still hurting.

*The term 'object' can throw people, but the theorists who came up with it simply meant aspects or versions of people that were important to us (often parents) that we've boxed up deep inside our minds.

Don't feel like you're worth loving? Perhaps this forgotten Scottish psychoanalyst knew why...

2024-10-14T11:28:00+01:00

Are you always self-blaming? Do you somehow never feel like you measure up? Are you wary of getting involved in a loving relationship because a voice inside says you don't deserve to be in one? A long overlooked Scottish therapist in wartime Scotland figured out why you might feel that way.

It’s 1940. The Second World War is underway, and Britain is under threat of invasion. In Edinburgh, a well-regarded but rather isolated middle-aged psychoanalyst has begun working on a series of papers that will be amongst the first to develop, remodel and in some respects radically challenge the principles of psychoanalysis handed down by the only recently-dead Freud.

Ronald Fairbairn wasn’t particularly popular within the stuffy London-based psychoanalytic community. Some of his ideas – chief amongst them that when we are born we are driven not by a set of raw, pre-installed drives that command our actions and development, as Freud suggested, but by the need to be in relationship with others (starting with the key relationship with our mothers - we might say primary caregivers these days) – did not land well with those for whom Freud was already almost a God. Nevertheless, Fairbairn pursued his thinking though the 1940s and 1950s, developing ideas that these days seem mainstream. He speculated that the quality of our relationships, from the earliest days, has a profound influence on us; how we grow up and how we see the world; themes that were separately taken up by a whole number of major figures within the world of psychology in their different ways.

Ronald Fairbairn wrote a group of papers in the 1940s and published them together in 1952. For his efforts he was politely ignored, until the 1980s, when some enterprising American therapists unpacked his thinking, realising its genius and how it chimed with a whole lot of other thought that had developed elsewhere. Fairbairn’s work was rightly acknowledged as brilliant. Though his name still remains relatively unknown, some of his ideas have subsequently become a cornerstone of certain approaches to therapy. Some of it seems blindingly obvious now – as many breakthrough moments often do after the fact.

'The Burden of Badness'

One glittering moment in Fairbairn’s work was his description of a concept called the Burden of Badness. And if you’ve grown up feeling somehow inwardly worthless, feeling that everything in your relationship is your fault, perhaps feeling that you don’t even deserve to be loved at all, his ideas might just have something to say to you.

Fairbairn had worked with neglected and abused children from poor backgrounds in Scotland in the 1930s and had been struck by just how consistently the kids had explained their situation by blaming themselves. Fairbairn wondered how this self-perception – often fully at odds with the observable facts, as these children had been badly treated, let down or abandoned by their parents – had got started. When a child is born, he surmised, they are entirely dependent on their caregivers for survival. During early childhood, his thinking went on (and many have subsequently agreed), young children are not capable of fully understanding the world as anything other than a place that revolves entirely around them - as anyone who has seen a tired toddler in full flow in a supermarket, or how children need to be taught how to share, or can even remember feeling it themselves, will know. When we are very young we are really only capable of thinking about ourselves. That's probably a feature of evolution - we are born that way to put all the focus on getting our basic needs met, (things like milk, food, shelter, warmth etc...even if it means screaming the place down). If something bad happens to us in this biologically-determined and completely self-centred worldview we've created —like neglect, emotional coldness, or outright abuse—we might instinctively reach the rather hazy but seemingly sensible conclusion that we are somehow responsible. Our immature brains think only of ourselves - so who else could it be?

In addition, Fairbairn noticed that children are deeply attached to their parents and cannot easily accept the idea that their caregivers might be flawed, neglectful, or even harmful to them. When bad things happen to us as young children - when we are ignored, neglected, mistreated, or worse by our parents, we are forced to somehow make sense of what's happened. But the last thing we might feel able to do is to hold our parents responsible. At a deep level its really important that they are right, loving, perhaps even infallible. We have to understand them that way to make ourselves feel safe and protected.

In such a situation, it might feel impossible to contemplate that they are in reality neglectful, abusive or dangerous to us. What would such an admission produce in us, who depends on them for so much? Vulnerability and fear.

To avoid having to face such a dreadful feeling, we may internalise the idea that we, ourselves are at fault, that we are bad. Paradoxically, this self-blame is much easier for the child to accept than the painful truth that their parents might not be safe or loving. ‘It must be me’ the child gradually learns to feel – avoiding the much worse, possibility that it’s actually not. Further, at some level, we might sense within that we are stuck; if we do try and resist taking the blame and speculating that our parents really should not be acting this way, then where does that take us? To the terrifying idea that we can't rely on them after all, that they are going to abandon us - at which point we would need them even more! Overlaid on all this is of course the experience that many will recognise from childhood of not having any idea that our upbringing could be any different. It is simply what it is. Our young selves have usually only ever lived in this family, we have nothing to draw upon to help us understand that parents could be any other way; another layer of the cement that might hold us in self-blame.

All this can start a pattern, each year sinking deeper into who we are, until it can take the shape of an unexamined, unconscious inward assumption. Later in life it can surface in shame and self-hatred. And how 'bad' you are, how much sense of being at fault you carry, can, unsurprisingly, be driven by just how much pain you've had to take on and ingest. Some of this thinking has informed how therapists might work with victims of child sexual abuse years later. It can also be a part of the inner story for those who face domestic violence in adult life and can't shake the terrible and shame-filled feeling that they have somehow brought it on themselves. But it can show up in all sorts of ways, including an inner sense of worthlessness or an inner voice that simply says "I'll never be good enough, I'll never be lovable".

Let's take a look at a couple of hypothetical examples of how this experience can play out...and how therapy might help

Sarah and emotional neglect

Sarah* is 35 and seeking therapy for low self-esteem and anxiety. Throughout her life, she has felt a vague sense of guilt and self-blame, often thinking, “I’m not good enough” or “There’s something wrong with me.”

As a child, Sarah's parents were emotionally distant. They provided for her physical needs - she had food, clothes, and shelter - but they were cold and unresponsive to her emotions. Whenever she cried or tried to express herself, they would say, "Stop being so dramatic," or "You’ll get over it." As a result, Sarah learned to suppress her feelings, believing that her emotions were wrong or bothersome.

In therapy, Sarah begins to explore her childhood, realising for the first time that her parents' emotional unavailability affected her deeply. Still, she struggles to let go of the idea that the problem lies within her. Even as she recognises that her parents weren’t emotionally supportive, part of her clings to the belief, “If only I had been a better, more well-behaved daughter, maybe they would have loved me more.”

Sarah is carrying the Burden of Badness. Rather than making her parents responsible for their emotional neglect, she takes on the blame herself. This allows her to preserve an idealised image of her parents, protecting her from the painful realisation that they couldn’t meet her emotional needs. Gently, the therapist might help her to see the origins of the pattern she is in, help her to express some of the buried feelings about what it was like to grow up in that setting and to let them go as she turns her attention to her life now - a situation where she likely does not need to rely on her parents in the same way and has choices about how she sees her self worth.

Jason and Physical Abuse

Jason* is 49 and has struggled with anger and relationship difficulties for years. As a child, Jason was physically abused by his father, who would hit him whenever he thought Jason had done something wrong. Despite the abuse, Jason idolised his father, longing for his approval and affection.

Even into adulthood, Jason finds himself justifying his father’s behaviour. He thinks, “Maybe I deserved it. I shouldn’t have been so difficult,” or “Dad was just trying to teach me a lesson; I wasn’t good enough.” Jason’s inner voice constantly tells him that he was to blame for his father’s actions.

That's the Burden of Badness again. Instead of accepting the painful reality that his father was abusive, Jason blames himself. For Jason, it is easier to carry the guilt than to face the devastating truth that the person he loved and depended on was the source of harm. In therapy Jason might be able to talk more about his emotions as he grew up with his Dad, his fear, sadness and confusion, or his sense of unjustness. He might gradually be able to understand that his Dad was flawed, that what happened to him was wrong, that it was not his fault that it happened to him. Perhaps that the anger he finds himself displaying in relationships is actually anger at his father that's been kept inside all these years and that it's possible to accept it, to feel it, and to then let it go.

Other ways it can get started

Growing up in a household with emotionally volatile and unpredictable parents might saddle us with the Burden of Badness too. Perhaps our parents were struggling with mental health problems of their own? Or perhaps they were just like that? If we found ourselves infringing rules that were never properly explained, getting yelled at and punished but not understanding why, we might well have learned to make sense of it by concluding that "It must be me". As we puzzled in our distress about exactly what we were doing wrong but could find no useful answer, we might have ended up thinking, "There must be something inside me that causes all this, maybe something deep down that I can't do anything about because it just keeps happening, no matter how hard I try". And if those parents, in their moments of anger or rage or violence, actually tell us that it is us, up comes that inner voice. "They must be right" it says.

And it can keep coming up, in various forms and places, for years, damaging relationships or even stopping us from trying to be close to others at all lest we go through all that again in some way. Lest we end up upsetting another person we love, for reasons that we can't figure out, other than our baked-in, intrinsic 'badness'...just like we seemed to unaccountably upset our parents who we loved, years ago. Lest we end up just re-experiencing that sense of confused worthlessness all over.

In each case, gently unpacking those childhood experiences, talking about them, allowing the hurt that has been turned inwards all these years - the self-loathing, anger, confusion or shame - out into the light within the safety of a session with a trusted therapist, is a major step towards finally making peace with what was really going on. Seeing the origin of it all for what it was. Hearing a new voice that says, "Not my fault. I was just a kid".

Ronald Fairbairn died in 1964 after a last flourish in which he published pretty much his entire theory as a set of 17 one-line points. It got more or less ignored too. But over 80 years after he started developing his thinking, much of it continues to resonate - anticipating a lot of the later understanding around how our early lives and the bonds and attachments we learn to form shape us. His thinking has helped many see that they can finally put down the Burden of Badness. That it's not a life sentence and that it wasn't theirs to carry in the first place. That they can start a journey to discover the true self-worth that they fully deserve.

If any of this feels like part of your story, why not reach out to a therapist or counsellor and make a start?

*Examples and names are fictitious, but based on an amalgamation of real cases.

Why ignoring old wounds isn't working—and how therapy can help you strengthen and heal

2024-06-23T11:35:00+01:00

“Hey, ignore them. That’s their stuff, not yours”, you might hear someone say to you. Someone’s just said or done something hurtful, and despite your best efforts, it’s really got to you.

Perhaps it’s something that brings up an old hurt, something that you have tried to get past but you know, deep down, is still there. Perhaps they’ve triggered something painful inside that, despite your rational brain saying, ‘That’s just not true’, has punched an emotional bruise and you’re in pain, ready to lash out, or to shrink back, angry and sensitive.

There are many psychological theories that speak about this process in different ways. The actions or words of another reach through your defences all of a sudden, often when you’re not expecting them, and the pain inside is acute. You don’t know why it feels that way, as the comment, the insult, or the accusation might be something that you feel you ought to be able to dismiss. And yet, you can’t.

Some people are more susceptible to this happening than others. If you are carrying an emotional or psychological wound inside – the unresolved pain of something that happened to you earlier in life and that hasn’t been fully dealt with (it could be an awful event, or it could be years of them all piled up), then you might still be dealing with an unhealed, emotional rawness. It might be something that’s hard to spend time with mentally, something you’d really (and understandably) rather forget, or perhaps something that still contains some difficult and unanswered questions.

Getting to the bottom of all this inside might hurt, so it might seem like the best thing to do is to try and just move on. One strategy in these situations is to protect yourself by trying to ignore the feelings inside. You might decide that as long as someone doesn’t reach inside and find them, then you’ll be ok. You retreat inside your own personal castle walls in some way, making sure that people don’t get to know you well enough to get close to the pain. Or you build a version of yourself that means they’d never guess that you are holding onto something like this inside (and a withdrawal from others doesn’t have to mean going home, bolting the door and never coming out. It can also be the creation of a self that isn’t really you at all too - akin to something that psychoanalyst Donald Winnicott called 'the false self'). If there’s a chance that someone might get inside…well, just add some more bricks to those walls, eh? Keep them out.

The trouble with this strategy is, first, that its exhausting. You’re constantly on patrol on the metaphorical battlements, surveying the landscape outside for emotional threat, ordering up some new masonry to add more height to the walls if anything looks suspicious.

Second, it can feel pretty lonely inside that tower. You can spend a lot of time in there feeling hyper-vigilant about an impending attack and wary of others just in case they about to launch it. Not quite trusting them not to try and chuck something over those walls.

And, third, eventually, it's probably not going to work. Unless you attend to this process constantly, one day, someone will get their grappling iron over that castle wall, inside and into you. The sudden comment, action, behaviour…and your pain, memories or self-hatred flood back. It's like the grappling iron has got over those battlements and its lodged inside, right in that undefended, sensitive, personal, painful place…

The nature of that intrusion, and its strength, can vary. One of the most powerful ways the grappling iron can get stuck into you is if you are listening to a voice inside that, despite your best efforts to shut it down, says the worst thing of all. It says, “They're right”.

Right, because you somehow deserved what happened to you? Right, because what people say about ‘people like you’, is actually true? Right, because it was your fault really?

Let me be clear. There's a very high probability that this voice is not be telling the truth, or anything like it. It might be a legacy of an event in your past when you felt powerless and so some inner process ended up blaming yourself for the events you went through. This might go back to when you were a child even (a time when we often feel powerless in a world of all-knowing, always-right, adults and when we might conclude that the reason we are being treated badly must be because it’s our own fault.) It might relate to a painful event when you made a choice, perhaps an entirely innocent one, or one which seemed reasonable at the time, but after which the consequences were difficult (or worse). You wish now that you’d taken a different course…but you cannot.

Or you might have absorbed the insults of others, been bullied, and finding no-one at the time to speak for you, come to an inner conclusion that the bullies were right and that the only way to avoid that pain ever again is to avoid the situations or the people where it might happen again.

Each of these is an example of that grappling iron getting over the wall. There are many more. The pain isn't caused by the grappling iron flying over the battlements. It's caused by where and how it lands inside you - by it embedding in something still unhealed.

Therapy is a place where you can sit with someone, sharing that raw, vulnerable, human, material. Some people start seeing a therapist because they know there's a wound inside, that it hurts and they want the pain to stop. Some have a hunch that there’s something going on that’s causing trouble deep down, but it’s hard to define. For some, especially those who've spent years metaphorically raising the castle walls, the realisation that the hurt is still there can come as a surprise.

Finding it and gently healing it is the answer. Only when we can do that are we going to be defended from the pain of that grappling iron, thrown at us either maliciously, or unknowingly, as it digs into something soft and vulnerable inside and rips at us? Only when we can do that can we become free from the exhausting effort to keep raising those defensive walls and truly start to think about leaving the castle itself, to be in the world, in our uniqueness and our strength, as we really are.

Working with trans and gender expansive people: some basic principles.

2024-04-06T12:58:00+01:00

There has been a colossal amount of misinformation, much of it spread for political or ideological reasons, about trans people in the UK. For therapists this extends to questions about how best to work with trans and gender questioning clients. Some therapists may feel scared to even approach the area as it has been infested with culture wars rhetoric.

But there’s a way through, if, as a therapist, you can approach your client with an open heart, putting aside your privilege or your anxiety and acting with compassion, a lack of preconceptions and always focusing on your client’s best interests. There’s no place for your prejudice or presuppositions, whatever direction your work takes you both.

I’ll start with a story about someone I know. Assigned male at birth, they grew up through a childhood in which they always felt somehow different, and apart. From an early age, they couldn’t understand how it had, weirdly, turned out that they had to live as a boy, because, inside, they knew that they were a girl. And I mean knew it. Bullied for years at their boy’s school, they realised that their feelings must never be revealed to others, or the abuse would only get worse. As a result of their treatment at school they never really learned how to make friends and at 18 went onto university having had many miserable, isolating years.

University was scarcely better. They weren’t getting punched, but they hadn’t developed the social skills to find their place and the loneliness was powerful. Eventually, after a failed attempt to get any meaningful help from the university counselling service, they found their way to a psychiatrist and decided, at last, to share a deep truth that they had, by this point, been carrying alone for almost 20 years.

“I’m a girl” they said.

The psychiatrist, qualified and respected and in the eyes of my friend someone who, finally, might have the training and experience to actually help, said (I paraphrase for brevity, but it amounted to this), “I doubt it. What you need is a good screw. Find yourself a woman to go to bed with. That’ll sort it out.”

My friend, desolated, left the consulting room in pieces. This was a trained medical professional to whom they had finally, anxiously, revealed all. Surely, they thought, this man must know what they were talking about? And his take was that my friend had been suffering under a simple delusion and that the answer was plain to see. The psychiatrist, with his doctorate and his certificates, had spoken. Have sex with a woman, that’ll fix you. Now, off you go.

There followed for my friend over 15 years of deepening loneliness and pain. They didn’t want to have sex with a woman. Or with a man, for that matter. Not while they had to do so with this pretend ‘male’ persona, this body that did all the wrong things sexually. They longed to be close to someone, physically and emotionally, but despite what that psychiatrist had said, and despite all the attempts they made, unless it could be as the woman they knew themselves to be, it just didn’t make any sense – and it simply wasn’t going to happen.

And it didn’t. My friend remained alone, the energy they poured into their work mirrored by a sad and deep sense of brokenness inside. Until finally, in this person’s late 30s, they’d had enough. They found a therapist to whom they said the words “I am a woman; I have known it all my life. I want to live as a woman”, and that therapist said “Well, why aren’t you then?”.

Thus began a journey that has finally helped my friend find her place in the world. After all the wasted years, she transitioned, found a partner and a deep love, and she is happy. “Every year is better than the last, these days,” she told me.

The damage that psychiatrist caused that day is clear. It’s impossible to speculate about his professional abilities more widely, especially from all these years later. Was he any good? We cannot know in any professional sense. Like all fields, mental health included, there are those whose skills and prowess are self-evident, a few who, frankly, should be sacked, and many, many others strung out along the competency spectrum between the two.

But there’s one conclusion we can draw.

He had a presupposition.

Whether this was based on homophobia, transphobia (this was years ago now, the word had barely been coined), or a wider blindness to the richness and diversity of human experience based on his own vaunted self-image as a respected, culturally powerful figure, we have no idea. But we can say that he was basing his judgement on a pre-formed conceptualisation in his head, likely, for him, a so-called ‘medical’ model, impervious to the data in front of him in the form of human being and a life. He didn’t listen. He knew better. He assumed, for some reason, that my friend hadn’t wondered – for years - about whether she was gay, or whether all this was just about lack of sexual experience with a woman...or a man. It hadn’t occurred to him that she had spent years reflecting painfully on the knowledge that it wasn’t about any of that, that it was something deeper and more profound that went to her very essence. Quiet and deferential, my friend tried to accept what this status-laden psychiatrist had said, but his diagnosis was a disaster for her. Call it incompetence, call it wilful ignorance, maybe. Or call it conversion therapy. Because that is what it amounted to. And, like all conversion therapy, it didn’t work.

Conversion therapy - the practice of working to make a gay person straight, or a transgender person cisgender, in a 'therapeutic' setting, continues to roll around the news. The British government has been discussing its banning (as it is banned in some other countries) and trans people's inclusion in that ban, or not, for many years. Most recently it has kicked its plans deep into the political long grass as trans people turn out to be much more exploitable as scapegoats to monster for votes than as a group to support. Hard right political agendas have come together in an unholy alliance with elements of the left, the latter rooted originally in radical (but never mainstream) feminism, to create a culture war frenzy, complete with all the typically deranged hatreds and ideological underpinnings. In this trans people are the victim group-that-just-keeps-on-giving...newspaper headlines, fear-stoking policy announcements or online witch-hunts.

Against that backdrop, we as therapists need to look at exactly what conversion therapy is. Because if therapists are going to avoid doing it, they really need to know what lies at its heart. And it’s the same thing that lies at the heart of much oppression of minority groups in society.

The popular conception of conversion therapy – if one exists – is perhaps of the religious zealot sitting with a young person in turmoil and trying to ‘pray away the gay’. The client in this scenario may be there under duress (explicitly, or more subtly, through social or family pressure), or see themselves as a collaborator in the process as they are despairingly trying to rid themselves of some ‘wrongness’ within. Though these dreadful scenarios are less common than they once were, there’s no doubt that such practices exist still in some communities, together with their secular equivalents.

Alongside that picture, a historical image also exists of even more barbaric practices – electric shock or emetic [1] aversion therapy administered to gay or trans people until well into the later part of the last century, for example.

But conversion therapy also exists in a far more subtle form, one that is very much still around and if we are not alert to this, it will return. It shares with some of its more obviously reprehensible precursors a family similarity. It too is founded on the belief that the person coming for help is sick, that their assertions around their sexual or gender identity are symptoms of that sickness but not the sickness itself, and that the clinician’s job is to reveal the deeper condition and to cure it. The intended result? A client who more closely resembles the therapist, in sexual or gender identity perhaps – the implicit threat that they represent to the therapist’s own self-construct, or the self-construct of the societal group within which the therapist feels secure, now eliminated. Despite any claims of altruistic motivation, conversion therapy is at its heart an exercise in making a client in therapy more like the therapist, because the therapist represents what is acceptable and valued in the world and the client does not. That value is rooted in being cisgender, not trans; a model of supremacy and power with close similarities to those that drive racist or heteronormative power narratives in society too.

The row about all this has flared up badly again within the therapy community recently, its latest iteration coming from something that happened eight years ago. In 2016, a group of mental health organisations, including the major professional therapy bodies, the NHS and others, came together to sign a Memorandum of Understanding (MoU) condemning the practice of conversion therapy for adults and young people alike. This agreement, created partly (though it turns out unsuccessfully) to lobby the government to act, was renewed in 2022 and now includes 25 major organisations as signatories, including NHS England and Scotland, The Royal College of GPs, Mind, the Royal College of Psychiatrists, and most of the major psychotherapy professional organisations.

Last week, the UKCP, one of those major psychotherapy organisations, unilaterally pulled out of the MoU, without consultation with its members and with immediate effect, accompanied by some pretty confusing and, to the minds of many, very unconvincing justifications. You can read their statement here, and object to their stance here. It’s a move that feels like it has been on the cards, as the organisation has for about six months seemed to have been moving towards a position in line with anti-trans agendas and the views of so-called ‘Gender Critical’ actors, who oppose the acceptance of trans identities in UK society. Some have speculated that it's been influenced by a court case last year, or the imminent arrival of the Cass Review report this week (more on this below), which has been anticipated with unease by the many in the trans community lest it feed even more ammunition to those who wish trans people (in the case of the Cass remit, trans kids) gone from UK society.

Whatever its motivations, which remain foggy, I and many others in the profession consider the UKCP’s decision a major mistake, not least in the way it was done. Some have called its language disingenuous (or much worse), but even with the most charitable reading it’s confusing (it expresses, for example a ‘belief’ about the problems of conversion therapy but has now removed all the regulatory teeth within its Code of Ethics to prevent a UKCP registered therapist actually doing it).

So, if you are a therapist who wants to do the best you can for a client who presents with questions of their gender, what should you do?*

My thoughts here are general, they do not represent copper-bottomed guidance in any individual case of course. They are built on my professional practice, my (ongoing) training, my integrative way of working, and my life experience. It's not a list of terms you need to understand, what the letters in various acronyms mean, nor a primer on how not to be accidentally offensive. I don't want you to get stuck on these questions (much used in the popular culture to make trans people seem strange, sensitive or unapproachable) and whilst they certainly can be important, these questions are really not that complicated. Plus there's plenty of material on the internet and a growing literature elsewhere that you can use to find the answers [2]. My focus here is more grounded in first principles, in your basic human goodness and in how to be with someone who may be describing a self-concept or a life that might feel strange or even destabilising to you. You probably got trained in some, or all, of the principles I discuss below in some way. Trans and gender questioning deserve to see and feel you putting them into practice in your work with them, just as much as every other client does:

1. Listen

If this sounds obvious, read the word again and reflect hard on what it truly means. Really listen. Listen to what your client is telling you about their experience, what it feels like for them, what it means to them (clear or unclear), what it means to be them. If they are talking about their relationship with their inner self, their sex or their gender identity, you might find that your inner conversation fires up. Maybe a whole lot of questions and feelings are coming into the room that you've not faced before?

How, as the saying goes, does that make you feel? Anxious? Out of your depth? Scared? Angry even? Stay with that. Keep listening, to your client, and to yourself. Would it be easier if these feelings didn't arise inside you? Is something telling you to try and make them go away, perhaps by guiding your client onto ground in which you feel more secure, personally, professionally, instinctively? Then do number 2.

2. Park your assumptions

You might think of this as bracketing. The work is not about what you think the right or the best outcome is in your work, it’s about what’s best for your client. Shedding presuppositions, especially perhaps the ones constructed to help you not face difficult or confusing feelings, has to be at the heart of any good therapist’s work; working with people who experience the world in different ways to us and being absolutely ok with them doing that is central to what we do. My view is simple. Our job is to help people to be as happy as they can be with who they are, helping them to find and grow the parts within themselves that nurture and feed them and to take down the barriers that may have built up to cause distress or unhappiness.

That doesn’t mean in your work with a trans or gender questioning client (or anyone else for that matter) being oblivious to the possible signs of some kind of serious psychopathology, or another significant condition. You wouldn't do that with any client, if you are any good at your job, and this situation is no different.

But it does mean not starting with the belief that one is inevitably present and at the root of everything going on. I'll come back to this below.

And if you do suspect an additional condition, check in with yourself before you assume that condition is somehow causative of your client’s gender narrative. If you do, it is a great way to not hear or see them fully. What you have hypothesised might simply accompany that narrative, as parallel aspects of our personality sit alongside each other for us all, not create it. Or, going further, your client’s inner gender identity and need to express themselves might actually be causative of the other difficult features of their life. For example, they might struggle with loneliness, social anxiety or isolation because they haven’t been able (or allowed) to deal with their inner questions of gender, or because in the past they have been abused when they became visible – not the other way round. In that sense, helping them through their gender journey, if that’s what they need you to do, may be a way to actually deal with all sorts of other distresses in their life too, as the story of my friend at the start of this piece illustrates.

3. Believe your client, and believe in them

Whose life experience matters most here? Yours, or theirs? When a client shows up with a conviction about their gender or sexual identity, it’s usually not great to kick off by not believing what they are saying about themselves. This is their truth, in their life, not yours. You may be operating with a set of parallel truths that work in your life, or your practice, and these may, or may not, resemble those that resonate for your client. Unless you gain a well-formed and not prejudged belief that you are dealing with someone with a major, problematic psychopathology (which will likely be rare), it’s what makes sense and works for your client that most matters here. We need to treat our clients with respect and avoid exploiting the unequal power relationship that a few in our profession sadly seem keen to exploit, knowingly or unknowingly.

4. Explore your client’s life with them, not for them

This might come as a surprise to read. Not everyone who turns up suspecting that they may be trans is going to take a journey to change their gender expression, or their body, or whatever. And of course, not everyone's going to have it 'all worked out' when they arrive to see you. Some may be bringing the possibility that they are trans and, genuinely, as you work in good faith with them, they might reach a point at which they understand their experience differently. That choice is for them. But – and this is vital – accept that amongst the potential ways forward, some kind of journey around gender expression (in any number of ways), legal recognition, or even medical intervention might eventually be a fully appropriate way forward for them.

Explore their life, their inner world with them. Let them guide you through it. Don’t draw the mental map of it beforehand, based on a stance of anything but actually trans and work from it. No matter how subtly you do it, if you are operating with a frame of mind in which you pre-emptively discount the genuine possibility that your client is trans, if you find yourself searching over and over for some other explanation simply to resist that conclusion and to keep on resisting it, then you could be crossing the line into conversion therapy.

5. Get trained and listen to therapists from the LGBTQI+ community

You’re not going to get much of this stuff on a standard therapy training programme, sadly. Although things are changing, slowly, in some places, the forces of backlash have been at work too, trying to restore the profession to a kind of pathologising status-quo-ante (as they are also doing, hard, in our wider society). Sign up for ad hoc training where you can and draw on the experience of therapists whose lived experience as an LGBTQI+ person has something to say (full disclosure, I am one). Pink Therapy does some good work.

6. Don’t get drawn in by soundbites or culture war rhetoric

Alas, the culture wars have arrived in the therapy profession and whilst all therapists would (hopefully) claim to be acting in their client’s best interests, their positions and the language of a few can sometimes bear an uncanny resemblance to the anti-trans rhetoric and dogwhistles that saturate the British press and political discourse.

One area in which this is taking hold is in the use – and misuse – of two terms to describe types of therapy: ‘Affirmative Therapy’ and ‘Exploratory Therapy’. You might come across them, so let’s look at what these two terms actually mean...

In the context of working with trans and gender questioning people, Affirmative Therapy (AT) is essentially the commitment to accept that your client has the right to find an inner truth about who they are (specifically, their gender definition) for themselves, that no answer to this question is somehow 'better' or 'worse' than another, other than which one makes sense and brings peace to our client. It never starts with the assumption that a client asking for help must have some sort of deeper, causative psychopathology of which they must be 'cured'. AT involves working with your client to help them find their best understanding of their own experience, for them, and one which helps them lead a happier life.

You’ll use their preferred name and pronouns (simply a matter of respect), but AT is categorically not, as those who oppose it sometimes absurdly claim, some kind of blind agreement with everything your client says as you push them unthinkingly onto a fast-track travelator towards a full gender transition. Working in an affirmative way must always involve helping the client to explore their life in the round, helping them to make sense of their experiences, feelings or backstory, without a predetermination of where that will lead. It doesn’t avoid any of this, in fact it must not. It is – as I see it – a commitment to affirming your client’s life and their truths as you jointly, and deeply, explore them together. It is, despite the adoption of the word by its opponents, profoundly exploratory.

Critically, if you are sitting with a client who is working through their process around all this, and has not yet reached a conclusive sense of an answer, AF does accept the possibility that your client may be trans, has the right to be trans, that being trans is something real and ok, that it is not an illness nor the manifestation of one and that they may decide to move forward to adjust their gender presentation and how they live their life...if that's what they wish to do. And that this is as legitimate an outcome as any; one to be respected as much as any other.

Exploratory Therapy (ET) is a term which seems to have first arisen in the US and increasingly has support amongst anti-trans/anti-LGBTQI+ voices in southern Republican states. Many in the LGBTQI+ community regard it as a disingenuous, dangerous label.

Of course, on the face of it, who wouldn’t endorse something called exploratory therapy? Sadly, what ET often means is a commitment to the examination of everything but the possibility that your client is actually trans. Exploration of anything and everything except one possible answer. Its usage sometimes verges on doublethink, because in actuality, it is anything but fully exploratory. And that's because of prejudice, baked-in from the outset.

Advocates of ET will sometimes create long lists of pathologies for which therapists should look when working with a client who brings questions of gender identity. When the first condition cannot be found, the advice will be to move on to the next, over and over. There must be something hidden, the logic goes. Yet that list pointedly never includes one possible answer, that your client isn’t actually sick at all, but trans.

The reason that such a possibility is, axiomatically, ignored is very straightforward. At the heart of the ET is a core belief that trans people do not exist. That they are little more than a culturally-produced delusion, a product of social media contagion perhaps, or a range of illnesses, conditions or past trauma that makes then delusional. Why search for something that isn't real?

That trans people do, self-evidently, exist and have done so in many cultures for millennia, is difficult to reconcile with this approach – except by asserting that those who live in the world as trans must be acting out some massive, chronic delusion which has not yet been treated and for which trans people should be pitied, or worse, feared.

Alas, it doesn’t take long before the position exposed by all this merges with a toxic Daily Telegraph headline or a witch hunt based on a claim that trans people, especially trans women, are concealing some threatening mental illness that makes them a danger to others, especially to other women or children, and must be vilified, separated from society or shunned.

7. What about working with young people?

In my practice, I work only with adults, so I claim no direct clinical experience here. Working with children and teenagers requires specific training and I do not claim to have it. So I offer these thoughts chiefly from my own personal experience, though also from the deeply-held ethical standpoint that underpins why I work as a therapist.

I have personally known a number of trans children and their families over the years. If you haven't, that may not be surprising because for some families in this situation keeping their child safe from the real, physical danger they may face if their identity and location becomes widely known can be a priority. I have seen the prejudice these children and their parents face. I have heard the stories about their families being hunted by newspapers, the social media monstering, even the death threats [3]. I know the stories of the suicide attempts some of these children have made, after being put through relentless bullying at school - by fellow pupils, teachers, or even other parents - and how their desperate families have done everything they can to try and keep them safe. I have recently read the UK government's education proposals that would, if enacted, even more deeply isolate and stigmatise trans children in schools – proposals of breath-taking cruelty and embedded, shocking, bias, condemned by teaching unions and the NSPCC. I’ve known one family whose 14 year old child started asserting their inner gender when they were 3. And, I mentioned, I was a trans kid myself once – in an era when, like the friend of whom I wrote at the start, I was terrified of revealing anything of my identity at all.

How are we to help such children and their families? I believe that, in essence, the principles outlined above hold true for them too. Much has been made of how children’s brains grow and develop, and this point is entirely valid. Equally, media and political commentators point to ostensible social media or peer pressure. Some, using a reheated trope previously levelled at people of colour, Jewish people and gay people at one time or another, accuse the trans community of trying to ‘trans’ kids, a predation narrative with a stink of the so-called ‘great replacement’; a smearing of trans people (who are not, in this narrative, real, but in the grip of a sinister ‘ideology’), by saying that they are trying to ‘erase lesbians’.

Were this last claim not so dangerously toxic in the public discourse, it would be risible. Despite the 'Gender Ideology' smear featuring regularly in the British government's increasingly demented rhetoric around all this, even in its written policy proposals, I don't wish to dignify it here further by writing about it. But I will discuss the other two questions, at least briefly.

Kids are, obviously, not mature adults. They are growing, physically, mentally, emotionally, and yes, in many ways, children's sense of self will change, perhaps significantly, as they do. But in my view none of this means that our job as a therapist is essentially any different. Our task is still to really listen, to park our assumptions, to explore our client’s life with them not for them, wherever that goes, and to not pathologically label a child’s instinctive desire to present to the world one way or another as sick, or wrong, or mistaken, or delusional. To not, automatically, as some strident voices suggest, pre-judge a child or teenager's distress around their gender presentation as a consequence of some other pathology or developmental immaturity or trauma, which must be present because the reality of their being trans is for you impossible to ever accept.

Of course there may be much to discuss and explore and you should. But you need to accept the possibility - fully accept it - that the young person in front of you who was assigned male at birth does hold an enduring, authentic and deep seated knowledge that they are female (or that having been assigned female they are male). You may be sitting with someone who has survived all the milestones of childhood development to date without this understanding shifting. You need to be open to the clear possibility that living in the gender which makes powerful sense to them is the most appropriate route for them to take; the way to give them the best chance of happiness and self-acceptance in life.

As for questions about social media, and the media-friendly assertion that the experience of being trans is somehow a learned response by young people in response to peer behaviour or to the fashionable opinions of an 'influencer', I'd repeat first that it is - of course - the therapist's responsibility to try and help their young client tell their story as authentically as they can. Again - don't prejudge anything.

But a few points about that are worth making, albeit briefly, here.

In the last two decades, social media has increased our exposure to and understanding of the possibilities of life. Trans people come to their experience of themselves in all sorts of ways and always have. For me, I can track it to the age of four and then a tortuous and, for years, winding road of fear-driven concealment. Until I was in my late teens I thought I was the only one in the world who felt what I felt, who had ever felt it. And I knew that - above all else - I needed to hide this part of myself. The shame was overwhelming. I tried every version of an answer I could possibly think of on myself. I was - if you like, using the description above - conducting so-called Exploratory Therapy on myself, looking for an answer, any answer, other than the one I feared most. It didn't work.

None of this was to do with social media because social media didn't exist. I longed to know that others might be like me. I longed to know that my experience was valid. And had I known that, and been able to shed the shame, then maybe I would have been able to make changes in my life years earlier than I did and avoided a long time of inner turmoil and pain. The grotesque trolling apart, I wish Instagram or TikTok had existed for me then. It might have changed my life. I wonder what the generations of trans people who have lived in all cultures of the world for centuries, well before the arrival of Gates, Musk and all the rest, would say?

Junk, and debunked, theories like 'Rapid Onset Gender Dysphoria' have been created to support the 'social contagion' accusation. In my view, not only are such positions rubbish, but they feed directly into the prejudices from which ET has sprung; the 'anything but trans' position.

So, ultimately, what does it all amount to? For me, it's about walking alongside your trans or gender questioning client, helping them make their choices for themselves. Using your training, and your humanity, to help them to explore their own feelings plus the meaning and implications of those feelings. Earning their trust by demonstrating that you come to the encounter with an open mind and open heart.

Help them be who they are and help them understand that whoever that is, is ok.

Footnote:

Over the next few days, Britain will see the final report from the Cass Review - an enquiry set up to overhaul the care of trans kids within the UK's NHS. Thus far, this review has succeeded only in finally breaking an almost broken system as the British government rushed to implement its interim criticisms of London's Tavistock Gender Identity Service - the only centre supporting trans kids in the UK - by closing it down and then neglecting to set up the successor clinics that Cass suggested. Trans kids and their families have been left in despair. The UK trans community - and others - have expressed major misgivings about the direction that Cass has seemed to be taking, its inbuilt biases, and the stakeholders from whom it has chosen to take, and not take, evidence. It remains to be seen what it will conclude, but whatever that is, it seems sadly inevitable that its findings will be weaponised against the interests of young trans people in the UK by the British media and political establishment.

* My focus here is on clients who specifically want help with respect to their gender identity; understanding it, reconciling with it, living it, whatever it is. Trans people do of course show up in therapy rooms (or GP surgeries) for all sorts of reasons, many of which may have nothing to do with this, and that's vital to remember. You'd be surprised perhaps how often it isn't.

[1] Forcing gay men to vomit at the site of pictures of naked men.

[2] Like pretty much anything on this page: https://lighthousebookshop.com/posts/trans-101-books-for-allies, or this https://www.york.ac.uk/media/abouttheuniversity/equality/documents/LGBTFoundation-GuidetoBeingaTransAlly.pdf, this https://www.stonewall.org.uk/the-truth-about-trans or if you want a bit of a laugh, this https://youtu.be/ZyjA6o8_szY?si=WvLmB1p5vkB1kTsq

[3] Sadly not just threats as those who followed the tragic case of the murder of teenager Brianna Ghey in the UK in 2023 will know. Following her death, whilst receiving much support, her bereaved mother was also subject to widespread abuse online and was a called a "child abuser" by a prominent anti-trans activist.

Learn more about so-called 'Exploratory Therapy' at:

https://xtramagazine.com/health/gender-exploratory-therapy-243833

https://slate.com/technology/2023/05/gender-exploratory-therapy-trans-kids-what-is-it.html

Edited April 9th and Dec 30th 2024 to add some more links, stylistic changes and small sections of addition text.

When anxiety rears up, get yourself a Hot Cross Bun...

2024-01-30T17:20:00+00:00

If you suffer from problematic anxiety, some relief might come from the Hot Cross Bun model. Alongside a deeper exploration of your anxiety's origin, it can be a useful tool.

Anxiety is more than just a passing worry - it’s a persistent companion for far too many of us. Whether it’s the tight knot in your chest before a daunting task or event, the unshakeable dread of a restless night, or the sudden, searing rush of worry from what seems like nowhere- anxiety can feel omnipresent.

In a world that relentlessly demands our attention with notifications, deadlines, unsettling news from many directions, anxiety finds abundant fuel. And if our own lives contain a history of powerful uncertainty, rejection, pain, or loneliness these moments may have planted deep-rooted patterns that still echo today. Emotional reflexes, automatic physical responses, resistant thought patterns: these can be the ghosts of what once happened. The world we now live in can resurrect those echoes, stirring them to life with the slightest trigger, sometimes even if that trigger doesn't seem to have much bearing on the original events.

One reason why anxious responses of old can keep recurring can be the fact the body has a kind of built–in 'smoke alarm'. It lives within part of our nervous system (the sympathetic nervous system (SNS) to be precise) and it was forged in the furnace of our earliest survival needs; designed to protect us by sending us into fight, flight, freeze, or fawn responses in the face of threat.

In safe times, this system is balanced by the parasympathetic nervous system (PSNS), the soothing branch that invites rest, digestion, repair, and restoration. Ideally, the two work together, like accelerator and brake.

But when the SNS misfires - when the smoke alarm starts going off at the merest hint of a breeze - we can be catapulted into survival mode even when there’s no fire. A WhatsApp message pings, a seemingly harmless thought pops up, a comment is made by a family member, or an intrusive memory surfaces - and suddenly your body reacts as though you’re in the lion’s den. Even when the objective threat is absent, your body can still respond as though the danger is real.

There are in fact neurological reasons why that might be happening - to do with how difficult or traumatic memories from the past aren’t properly time-coded in key parts of the brain. It can mean that when an unrelated, though seemingly manageable stressor occurs in the present, the system lights up as if it was shouting “Oh my God, it’s happening again!”

As anyone who suffers badly from it will tell you, anxiety can feel truly disabling - it can hijack your nervous system before you even have a chance to think. Before you can get your rational brain back online, the SNS has grabbed the controls of your feelings, thoughts and body and is swerving all over the road, telling you to run, fight, just freeze or even fawn to the source of the stress - if it’s a person - to make it all go away.

Different models bring different ideas about how to manage this. When it comes to calming anxiety in the moment Cognitive Behavioural Therapy (CBT) has something to offer. It offers tools for breaking anxiety’s spirals and regaining a sense of agency.

And from CBT comes the (wonderfully named) Hot Cross Bun model...

The Hot Cross Bun Model

The Hot Cross Bun model - from Cognitive Behavioural Therapy

The Hot Cross Bun* model is simple but powerful. It shows how four parts of our experience are constantly interacting:

Thoughts
Emotions
Physical feelings
Behaviours

These aren’t separate parts. They feed into each other, often so quickly it feels instantaneous.

Imagine this

A thought (“I can’t cope with this!”) triggers...
A physical feeling (tight chest, racing heart), which intensifies...
An emotion (fear, dread), which drives...
A behaviour (evade the whole thing, retreat, panic – or rage, and attack).

Or this:

An emotion (dread, unease) triggers...
A physical feeling (sick, shallow breathing, racing pulse), which prompts...
A behaviour (rushing home, ringing the emergency services)
A thought (“What’s wrong with me? Am I having a heart attack!? Where’s that ambulance!?”)

Or this:

A behaviour (skipping that party tonight) triggers...
A thought (“I’m such a loser, I should have gone, I always do this kind of thing.”), prompting...
An emotion (hopelessness, shame) which drives...
A physical feeling (tired, drained).

Or this:

A physical feeling (stomach drop, sick feeling, heart pounding) leading to...
An emotion (fear, panic) which activates...
A thought ("On no, this is just like that time before when things went wrong...") followed by...
A behaviour (avoid the situation, get out).

The cycle, which can start from and then flow through any of the four elements in its own unique sequence, keeps feeding itself. Once it's charged through all four, it can cycle back into the sequence again, intensifying. Each element reinforces the others, and soon the whole system is swept away in a self-sustaining, whirlwind of anxiety.

The speed of all this can be an overwhelming feature of it. So the earlier we catch it, the more chance we have of using what we might call a mental firebreak - something that interrupts the cascade before it sweeps through the whole system.

Breaking the Flow

In CBT, the emphasis is often placed on thoughts and behaviours. That’s because changing raw feelings directly is difficult- the thinking brain struggles to override the powerful limbic system where emotions live. No matter where it started in the inner system though, if we can step in effectively at the level of thoughts or behaviour, (or if it's something in the body, the thoughts that arise immediately once we become aware of a distressing physical feeling), we’ve got a chance of disrupting the loop.

Doing that involves first mentally trying to step away from the cycle of anxiety. Create a pause. Perhaps imagine you’re in a helicopter looking down on this whole spin-cycle of distress. You’re not in the cycle – you are looking at it. Notice the thoughts you are having (that’s right – you can have thoughts about your thoughts). Gently challenge those thoughts from this standpoint - by questioning if they’re fully accurate, or by gently reframing them. If you can mentally step away a little, you have a chance of breaking the spiral. Force the system to slow down. It might take a bit of practice, but it can be done.

Changing behaviour can be powerful too. Simply doing something different can reset the entire system, stimulating new thoughts, fresh feelings, and calmer bodily responses. In some settings just leaving the room might be what's needed so you can detach yourself from a triggering encounter. In other situations, going for a short walk, reaching out to someone you trust, even deliberately and consciously doing something unrelated in the moment, without reflecting on it. Wash the kitchen floor. Repot that plant. Brush the dog. Whatever. The point is the change in what you are doing.

As you are focusing on stepping back from the automatic thoughts that are running riot, or introducing different behaviour, enlisting the body to help itself can also be hugely helpful too. Slow, deep breathing will soothe the nervous system with an improved flow of oxygen. Grounding techniques, or simply noticing and relaxing tense muscles can influence both feelings and thoughts, and create more space so that you can continue to mentally pause, pull away and look at what’s going - as if from that helicopter.

The Hot Cross Bun model gives you multiple entry points. Wherever anxiety first shows up, whether in a pumping chest, a spiralling thought, a gnawing feeling, or an avoidant behaviour, you can act to prevent the whole cycle from being hijacked.

Morning Dread - anxiety from nowhere

We tend to think of anxiety as something that’s triggered. That’s often true (although some of us may well be wired to feel it more acutely). But sometimes we may have little idea where that trigger came from. Then we’re left trying to make sense of it. A common example is the concept of morning dread' - a hazy, heavy sense of fear that can greet us the moment we open your eyes in the morning, as if from nowhere. It's a horrible, incomprehensible sensation and it may well have nothing really to do with what lies ahead for us that day - something that makes it all the more puzzling.

This feeling could have a number of triggers (none of which we might be easy to identify), including a troubled night’s sleep caused by stresses we’re carrying in daily life. Nightmares, which replay old anxieties or unresolved emotions and kick of bodily reactions whilst we sleep may also play into it.

Or it could also be simply the process of waking up. When we are waking up, the body produces a surge of cortisol and adrenaline - the so-called ‘stress hormones’ - to help us become alert. For most people, this provides just enough energy to start the day. But if our sympathetic nervous system is hypersensitive - if we’ve been chronically anxious or depressed and that smoke alarm is set to go off at the slightest trigger - that hormone rush can set it off. A strange feeling of dread floods through us as we lie there. And next? The brain, always trying to find the meaning of things, searches for reasons. “Whydo I feel so frightened?It must be because…”

Soon the anxious thoughts come flooding in.

This is the Hot Cross Bun model in action again. As we wake, we do so with a strangely tightened chest or a hollowness in the stomach. This generates an instant emotion (foreboding or dread), which prompt thoughts (“something’s wrong, something terrible is going to happen”), which shape a behaviour (avoidance) and keeps us in bed. The cycle, in this scenario, starts in the body but then sweeps through the whole system unless interrupted. Not wanting to get up at all is understandable in these terms - it's a kind of flight response (and of course, when we are deeply depressed we may simply not be able to face the world at all - it's more like freeze). But, if you possibly can, get up. Avoid the prospect of lying there perpetuating the cycle and reinforcing negative thoughts, perhaps with further feelings of self-loathing driven by not feeling capable of even getting out of bed? ("I can't even get out of bed, I'm such a loser"). Bodily movement will also help the cortisol and adrenaline disperse and signal that the body doesn’t need an injection of them any more.

The deeper story - getting to the root

CBT can be valuable as a therapeutic approach, but in my work I keep in mind that anxiety is rarely just a malfunctioning system. Though some of us have inherited a genetic predisposition to it, it usually got started somewhere. To return to the smoke alarm metaphor – when the damned thing is blaring, then of course all we'll want is some way of turning it off. But at some point it's going to need repairing or it'll likely happen again – we’ll need to take it down and look at what’s gone wrong with it, perhaps even deciding to replace it with an alarm that works properly.

For many people, troublesome anxiety isn’t random. It’s a legacy of unhealed experiences. A time when it wasn’t safe to relax, or a time of trauma or danger. A period when the world felt overwhelming, and vigilance was vital for survival. It might have been when we were growing up, or to do with some event we went through; part of an early-warning and self-defence system, keeping us safe from serious risk - emotional or physical - that we couldn’t cope with back then.

Seen in this light, anxiety is not an enemy, but a protector that has become overzealous. It continues its vigilance even now, long after the original danger may have passed. So alongside working with managing anxiety in the moment, therapy with my clients usually involves trying to track the anxiety back to its roots to explore what this original response was created for? What’s it still trying to protect you from?

This is slower, deeper work. Once we’ve stopped the alarm going off incessantly, it involves listening to anxiety as a messenger rather than fighting it as an enemy. What is it afraid will happen if you lower your guard? What memory or wound is it trying to push you away from in case you can’t cope?

Sometimes, when people begin to explore this, they discover that their anxiety has been guarding a tender place - an unhealed grief, a shame-laden memory, a fear of rejection, or a younger part of themselves that still feels scared. The circumstances that made it arise may be long gone, but the system that emerged to warn you of danger or impending hurt is still out there doing its thing, stuck in the ‘on’ position.

When we combine these approaches - skills to calm anxiety and compassionate exploration to find its roots - we can create the possibility of a new relationship with it. Anxiety may not vanish from our lives, but it doesn’t have to run the show. We can learn to spot its signals early, to interrupt the spirals and begin the longer journey of healing.

* If you're reading this from outside the UK and not familiar with Hot Cross Buns, check out their back story here. They're delicious!