Responding to responders: the therapist’s role in Critical Incident Stress Management (CISM)

From left to right, myself, Sheriff’s Department Mental Health Navigator Stephen Echols, and Assistant Clinical Director and Designated Crisis Responder Dana Milagrosa, all of Discovery Behavioral Healthcare in Port Townsend, WA. April 9, 2022.

NB: the following contains references to sexual violence and suicide.

People who become therapists want to help others, pure and simple. But we don’t get to stop very often and think about what it means to help other helpers, and that we ourselves are helpers who might sometimes need help. That’s where peer support comes in. As a psychotherapist, I’m ethically obligated to engage in supervision and consultation, and that’s where I find a lot of support. In my consulting groups with other therapists from differing backgrounds, I get to talk to others who understand and empathize with what it’s like to do this job. And I believe it is also an ethical obligation for me to continue to work with my own psychotherapist so that I never forget what it is like be on the receiving end of this service. A lot of the therapy I receive revolves around the therapy I offer to others!

But not every helping professional gets that same level of peer support when it comes to their own mental health. In fact, some helping professions, culturally speaking, are quite wary of perceived stigma around seeking mental health support. For people serving as law enforcement officers, coast guard, firefighters, EMTs, and other first responders to community distress, the culture of “serve and protect” doesn’t often come with “also be vulnerable and share your feelings.” As an officer for the Department of Corrections in my county recently put it to me, “There’s a lot of type A personalities in this line of work…”.

So for psychotherapists such as myself who work in a community mental health setting, I believe it is imperative that we take the “community” aspect of our jobs very seriously. It’s true that most of my day is spent speaking one-on-one with individuals in my office. But none of these interactions ever happen in a vacuum. Each individual I serve is usually involved in multiple areas of service, such as housing support, substance use recovery or addiction counseling, domestic violence advocacy, and/or the public schools. And if they’ve ever gone to the emergency room or been seen by providers at express medical clinics, they’re interacted already with potentially dozens of first responders and service workers. So, it is important for someone like me to understand that when I see a client in my office who has been arrested or hospitalized, or who has gone to court for any reason, or receives any kind of state aid, I am only one part of a larger network of service professionals. You might not think that a community mental health therapist has a lot in common with a firefighter or an EMT, but if you consider the kinds of helping professionals that people interact with as they navigate traumatic events and life transitions, the relationship should become very clear: when you interact with an individual, you already are interacting with them through their community.

Wanting to understand those relationships between helping professionals when communities and individuals respond to disasters, accidents, and other potentially traumatic events inspired me to volunteer for training to become part of my county’s Critical Incident Stress Management (CISM) team. A CISM team offers Critical Incident Stress Debriefings (CISD) to emergency responders. Emergency responders are personnel such as firefighters, EMTs, law enforcement officers, dispatchers, paramedics, first responders, search and rescue, and ER staff. A critical incident is any situation that emergency responders face that can generate unusually strong emotional or physical reactions that have the potential to interfere with their ability to perform their jobs. For example, a death in the line of duty, an on-the-job injury or death, any death or injury involving a child, anytime there are multiple casualties of an accident or incident, a suicide or a homicide, or a community-wide disaster—all of these could cause strong emotional reactions that could benefit from early intervention. A CISD is designed to help reduce the long-term effects of stress on responders, and are facilitated by specially trained peers in the field (for example, if a police department suffered a death of an officer in the line of duty, peers from another department in another city or county would offer that support), and by specially trained mental health professionals. The goal of the CISD is to reduce the impact of the critical incident on the emergency responders and accelerate the recovery process. As a mental health professional who might respond, it’s important for me to remember that this is not the same thing as therapy. Rather, it’s the preventative care that can help resolve problems so that things don’t get worse later on. If the initial trauma is like a cut that if not cared for can become a life-threatening infection, the CISD is like doing psychological “first aid” to prevent that infection from occurring.

If you’re a therapist reading this, I am sure you can think of multiple clients of your own who have come to you for therapy after carrying the burden of a trauma for years or decades because no one provided that “first response”. On the day before attending the first day of CISM training, I held a session with a client who, now in her mid-forties, spoke casually and dismissively of the multiple rapes she had suffered as a young teen, after we had spent many minutes exploring her desire to work on her low self-esteem. I suggested that the trauma of those rapes might continue to impact her in ways she might have repressed. It became clear that she never sought support for her violation because she didn’t believe it would do any good (and, sadly, given her context at the time, speaking out might have made her even more vulnerable), and internalized the blame for her victimization. It’s not an uncommon kind of story. How would this woman’s life be different now if someone had provided an immediate response, letting her know that her guilt, depression, and attempts to numb herself and withdraw from others were normal reactions of a normal person to a highly distressing and traumatic event? Recognizing the importance of psychological preventative care in my role as a therapist, how can I not volunteer to help my colleagues in the helping professions, especially first responders, continue to serve while maintaining optimum health?

A volunteer firefighter and professional EMT attends the CISM training to learn how to support other first responders.

The acute distress that first responders face is often overlooked, especially when the outcome of their actions is discussed in a positive light: they are brave heroes who deserve our special thanks and respect. But being held in positive regard as a “hero” by their community doesn’t necessarily attend to the psychic wound caused by a traumatic experience; in fact, it might distance the person suffering the trauma from their own pain, because it lionizes them, rather than allowing them to process the adverse reactions they might still be having. Our CISM instructor, Dr. Daniel Clark of Critical Concepts Consulting, gave an unforgettable example. In 1987, 18-month-old Jessica McClure fell into a well, becoming wedged into a casing pipe. A team of rescue personnel worked for 45 hours to free her, an operation that involved numerous setbacks as they attempted to dig through rock and cut the pipe while keeping Jessica safe. Paramedic Robert O’Donnell crawled through the tunnel parallel to the pipe and ultimately rescued the baby. The event garnered nationwide attention, even inspiring a film. While Jessica herself went on to live a full life (she is now 36, with children of her own) O’Donnell suffered effects of acute traumatic stress and developed PTSD. Apparently, when O’Donnell learned of the Oklahoma City Bombing in 1995, he watched first responders working tirelessly in the news coverage on television. “They [the first responders] are going to need a lot of help,” he said to his family. He then walked away and was found to have completed suicide with a shotgun not long after. Granted, many other factors could have played into O’Donnell’s decision to end his life, but lack of response and support for his ordeal with baby Jessica, and the displacement of his distress into narratives of bravery and heroism—that is, the invisibility of what became post traumatic stress disorder—could not have helped, whereas early intervention certainly could have. The first step is simply recognizing that first responders may be psychically wounded by acute stress, and that this is not a failure, but a human reaction. CISM provides that first recognition, which can then get the process rolling for further preventative care.

Dr. Daniel Clark shows an image of a NYPD sergeant leaning his head against his patrol car as victims of the 9-11 attack on the Twin Towers enter a bus behind him. Dr. Clark began this segment of his presentation by asking, “What’s wrong with this picture?”

After completing the introductory CISM training, I came away with a renewed understanding of myself as a helping professional in relationship to other professionals in my community who, like I do, respond to individuals in distress, pain, and crisis. This in turn affected my understanding of what it means to serve a community as an individual counselor who works one-on-one with individuals. In an interview, the famed group psychologist Irvin Yalom said, “I think all kinds of meanings in life transcend yourself. They’re linked to other generations of people around us, to our children and our family. We’re passing on something of ourselves to others. I feel that’s what makes our [lives] full of meaning.” I feel that what makes my work as a psychotherapist full of meaning is that the work I do with an individual transcends that single encounter. Like the rings spreading across the surface of a pond when you toss in a single stone, an encounter with an individual touches and reverberates within all of their context. And I am constantly being enveloped by those waves of connection when my clients interact with others beyond the confines of my office. We’re all in this together, all the time.

Trainees from Clallam and Jefferson counties in Sequim, WA in April of 2022 with their CISM instructor Dr. Daniel Clark (second from left, bottom row).

“What is solitude?” and “Responsibility and vulnerability”

Instagram is an unexpected place to find brief philosophical offerings, which is maybe why I’ve been enjoying creating these “insta-essays”. The format keeps me focused and honest, since I can only upload ten images at a time. I guess I’m looking to turn self-obsession into self-reflection, one Instagram post at a time. 🙂

You don’t need an Instagram account to view these posts. If you find anything thought-provoking or worth mentioning, I’d love to hear.

Losing the Religion of Thin: beginnings in becoming anti-fatphobic

Apple Mirror Images – Browse 4,861 Stock Photos, Vectors, and Video | Adobe  Stock

It’s been nine months since I stopped counting calories and macros for good, and I’m steeling myself to make it to a year. Disappointingly, despite successfully fighting the urge to wrap a measuring tape around my waist for all this time, I seem to keep in reserve in the back of my mind the possibility that I can diet again, if I need to—that is, if my body decides, against its best interests, to exceed itself, and if my habits, against my best interest, need to be brought under control. I can wrest this control back and make myself submit to a regimen which will, if I do it correctly and with enough focus, result in reduction of my weight and size. I’ve done it before and I can do it again, I remind myself, if I need to. If I get too fat. As if getting fatter is some sort of crime or sin, which it is not. As if being fat is contiguous with failure, which it is not. As if fat people are somehow to blame for some sort of shortcoming, which they are not. As if fat can’t be healthy, comfortable, normal, natural, and beautiful, which it can be and absolutely is. I find myself still considering dieting even though I have read the research that proves that diets don’t work and are injurious to health—physical, mental, and spiritual—and even though I truly desire the liberation of all bodies from the cruel regime of diet culture and the sneaking prejudice of fat-phobia (cruelties and prejudices that go hand in hand with racism, ablism, and heteronormativity). But making that final step to achieve a cognitive shift so that I actually believe that I don’t need to ever diet again is the hardest part of all.

I’m a forty-year-old, white, (mostly) female-identifying person. I’m educated. I don’t want to think of dieting as some sort of back-up plan, but somehow I still do. It wasn’t until this last year that I began to pay deep attention to the way my ingrained, internalized attitudes toward body, size, and shape play out in patterns of interactions with others that sometimes reinforce the harm of the thin ideal. It’s such a mind-twist to realize that even though I don’t want to be fat-phobic, my attitudes toward health might still harbor the prejudice of fat-phobia. It’s similar to the work of undoing white fragility in learning to be (more and more) anti-racist. I may want to be anti-racist, but unless I continue to confront my own white fragility (and this is a process that has no end—so get comfortable with being uncomfortable), I’m not going to get very far. As with racism, so it goes for fat-phobia too: I need to directly confront any attitude that conveys the message, whether explicit or implicit, that fat is somehow bad, lazy, immoral, or lacking in any way. I am what’s known as “straight-sized”, a person who, in general, benefits from “thin privilege” that results in social advantages, from being able to buy off-the-rack clothing without much trouble, to not having my health concerns overlooked or dismissed. I can’t heal the damage I have suffered from “the religion of thin” unless I work to undo the cultural and social prejudice that has not only harmed me but given me privilege. This is a messy intersection, and it’s all real. My experience in the world is not the same as a fat person’s. I have not had to endure the same violences. Fat-phobia harms everyone, and it harms fat people most of all[1]. I think what needs to be said out loud in the community of straight-sized people who want to work for body liberation is this: I can’t heal my own relationship with my body without addressing internalized fatphobia, which means learning about and committing to a social and political ethical stance. Body work is justice work.


“I know you don’t believe in diets, Claire,” says my best friend, a doctor; “but then there are the rest of us.” She had just declared that she was “staying away from sweets”, and I had asked her why. I stayed silent at her retort. Not wanting to believe in diets and actually not believing in diets are two different things. I am working to deprogram myself from an ideology so pervasive that its most harmful precepts have grown cheek and jowl together with beliefs about the good, the healthy, and the right. The way we blindly reinforce the ideology of thinness and diet culture within the medical system and “wellness industry” is like feeding a parasite we don’t know is draining our most precious resources before we can even taste them. My friend is a brilliant woman, and she knows and understands these things, but that does not simply translate into release from the shame and sadness of constantly believing your body is betraying you.

“I lost five pounds!” my mother whispers conspiratorially, turning to me with an expectant smile. I know she wants validation, but I can’t even muster a “good for you”. I can’t bring myself to reinforce the self-abasement and anxious self-critique that has been my mother’s constant companion since I don’t remember when. She carries around “need to lose weight” like an albatross and a badge: she’s good for doing it, and she’s already guilty for having to. The odd and confusing mixture of “self-care” and punishment literally pains me. How did she learn this, and what have I learned from her? During the work week, my retired parents provide free child care for my five-year-old, and every day I wonder about the implicit lessons she is soaking up from media and casual conversation. I come get her one day and my mom and daughter are talking about making cookies. “Make sure you don’t eat too many, grandma,” chirrups my little one. “That’s right, sweetie,” says my mom approvingly. I know I need to say something, and soon, before the bodily distrust and unease settles itself into my daughter’s bones, and she starts to think of this disease as a friend. But how do we unwind ourselves from a way of thinking so familiar and seemingly comfortable that it feels like the way things are and should be? Getting someone who already thinks this way to believe they can live without dieting is like trying to convince someone they can breathe without air. We’re addicted to bodily self-control through weight loss like a substance that we so depend on that the withdrawals could kill us. Or so we believe.


I had an idyllic early childhood, the summers especially. Warm sunlight on fragrant tomato vines in the burgeoning backyard garden, dark loamy soil that smelt of rich goodness, squinting up at a deep blue sky, a scratchy tire swing on a hairy rope, grasshoppers tickling your palms, the satisfying thunk-thunk of wooden spoon in a pitcher full of some icy Kool-Aid. My barefoot mama making bread in the old farmhouse kitchen, the snap of a juicy green bean being prepared for dinner. I crawled around between wooden table legs in the warm shadows, exchanging stares with our dusty-whiskered black cat. I was selfishly unconcerned with my baby sister sitting in her highchair happily reducing a banana to mush, and I had no idea how perfect it all was: an early childhood remarkable only by virtue of the fact that it was unremarkable. I was so safe and happy it never occurred to me to think it could be otherwise. This childhood is the greatest gift I’ve been given in my life, because it laid a foundation of security and confidence in the world around me. And while I have experienced a fair share of shame, disappointment, rejection, exclusion, dysfunction, and some discrimination in my life, this foundation has enabled me to dig my toes deep into inner resources that have helped me return to steady. I love myself, and I believe in the essential goodness of being alive and being together. I have my parents to thank for that.

Real trust is something you don’t think about. At three or four years old, I didn’t think about whether or not to trust that my parents loved me, that I had a home, that I would be cared for, that I had enough to eat. We should celebrate those privileged selfishnesses of childhood, if we’ve been lucky enough to have them. Because of that foundation in security I was so lucky to have, it’s difficult for me to remember when I had my first experiences of questioning whether or not I could trust my own body, let alone whether or not I could control it. Like so many other unremarkable stories of growing up, it was a mixed stew of religion, culture, education, and family dynamics that eventually taught me the wayward awkwardness of my own flesh. These unspoken lessons were in the pale, oval, and thin face of the Virgin Mother, a willowy blue-eyed beauty, gazing beneficently at my little Catholic congregation, as well as in the visible ribs of a bony crucified Christ I also stared at every Sunday (no wonder Jesus needed the magical process of transubstantiation to feed us all, since there was so little of him to go around…). It was in the long rubbery legs of the one Barbie doll I was allowed to have, a gift from a grandfather who professed ignorance in the face of feminist protests from my mother. Nobody explained to me why she was both so beautiful and so bad; I just remember the sighs of giving in to a little girl’s demands for what every other little girl already had, and my father’s admonishment to keep her dressed—a lesson I never forgot. It was in the leotard and tights for my ballet lessons, and the angelically blonde child stars that dominated mid-80s sitcom programming: there was a way to be good, beautiful, liked, and accepted. There existed a magical formula of privilege, money, and genetics (i.e., white, rich, thin) that would unlock lifelong happiness and success. That was something I should want. That was something I should get. And if lack of privilege, money, or the right genes prevented access, then I should beg, borrow, steal, or cut my foot to fit the shoe, like Cinderella’s sister[2] with the glass slipper right in front of her, but maddeningly out of reach. Such were my tacit lessons in racism, sexism, and fat-phobia.

Suzanne Sommers and her Thighmaster, and the TV aerobics classes against a seafoam green studio set (I still love me a good pair of leg warmers), health food from the co-op, and Richard Simmons with his disturbingly shiny shorts, and …Weight Watchers. I think Weight Watchers came into our home sometime in the early 90s, not too long after the birth of my youngest sibling. There was a three-ring notebook and a food scale on the counter, inscribed with a hot pink cursive font that somehow connoted both competition and success. Adorning the front of the fridge, right at adult eye-level where the mayonnaise jar might be, was a blue ribbon, much like the kind you could win at the county fair, that said “I lost 10 lbs!” in cheap, flaky gold paint. A contest was on. Who was winning? Who was competing? Was it me? Was I part of this race?

For many of us, perhaps healing is a process of learning to regain the trust in our own bodies—which means in our very selves—that we intuitively understood as children. I’m aware that this “return to paradise” trope has is problems; not everyone has memories of an idyllic childhood to return to. All I mean to suggest is that, as Lindo Bacon and others in the Health at Every Size (HAES) movement have been saying for years now, the trust that we can have in our own bodies is something that we don’t have to scrounge up out of nothing, but something we are already primed for. As a colleague recently reminded me, our bodies are “elegant things” fully capable of managing themselves, and it is when we intrude into our bodies’ natural processes that problems arise. Our bodies are not the problem; our bodies are the promise of integration and balance.

I believe that the very fact of our embodiedness is something that we can return to with trust[3]. Even if that body is a body in pain, and even, and maybe especially, when that body does not cooperate with our desires. The key is learning to desire myself. I am my body, for better or worse, and my body is me. But good old Cartesian dualism, that time-honored split between the body and the mind or “spirit” that is still so pervasive in this culture, makes us doubt that our bodies are anything more than meat-machines designed to steer our craniums around, and that consciousness is somehow independent of our biology (we’re seeing this fantasy playing out in biotech anti-aging research and the excitement around CRISPR for extending human life). But our lives and our persons are deeply entangled—molecularly, behaviorally—in our physical, material context. I can’t lift my consciousness whole-cloth from this context and expect it to live. My consciousness without my context would be like an organ without a body. An organ is the function it performs in intimate concert with the organism. That’s a humbling thought. It destroys the notion that my ego is sacred unto myself, instead implying that without the warp and woof of life’s grand tapestry, my little threads are pretty meaningless. Returning to my body with trust means letting go of ego in a pretty serious way.

So what does this have to do with weight loss and diet culture? When we constantly do battle with “gaining/losing weight”, we reinforce the notion that the body is a thing that needs to be disciplined by a more reasonable mind. There’s an underlying, tacit theology to this too: just as humanity is innately flawed and partial because marked by “original sin”, always looking for wholeness through union with a higher power who “forgives” these transgressions if we commit to a life of faith, so too is the body approached as already errant and deviant, and we can only “forgive” our own bodies for being so offensive by committing to a life of faithful discipline through diet and exercise. This is the contemporary, secular equivalent to more medieval practices of the mortification of the flesh. Michelle Lelwica argues in her 2011 book The Religion of Thinness: Satisfying the Spiritual Hungers Behind Women’s Obsession with Food and Weight that striving for a slender body serves a “religious” function, providing a set of ritual practices, dogmatic beliefs, and sacred iconography that give adherents a sense of purpose and belonging. This spiritual warfare is not only gendered; it’s racialized as well. It has always been the bodies and the lives of women, queer folks, and racial and ethnic minority that bear the brunt of these demands for conformity, forced to reduce themselves to fit the margins.  At these intersections, fat people are often the most marginalized of all. Living out this faith means a life of detachment and dissociation from the body, from life itself. To denigrate the body—especially the fat body—through this attitude of discipline and control means, very literally, the depersonalization of one’s very self. Depersonalization, in extreme states, can become a mental disorder wherein one feels distant and separate from one’s own body, as if you’re on the outside looking in.  People who engage in self-harm, have suicidal ideation, or attempt suicide very often report experiences of depersonalization. I believe that following the faith of diet culture that results in this detachment is a form of self-harm. Insidiously, it hides in things like health and self-care, masquerades as quasi-spirituality, and drains from the inside.

And what does this have to do with battling fat-phobia? In the same way that my consciousness is nothing without my embodied experience, so is my individuality nothing without my social experience. In popular psychology, the idea that you have to start with yourself and “learn to love yourself first” or “fix yourself first” gets tossed around a lot. It’s true, to an extent, but it’s also a chicken-and-egg kind of circularity. There is no “first”, there is no linearity to the time that relates me to all that is other than myself. Instead, we need what philosopher Emmanuel Levinas calls “anarchy”—not only the disestablishment of hierarchies that institutionalize prejudice and violence, but the destruction of the assumption that my identity, my being, begins in myself. I begin in the Other. Which is to say that my beginning is beginningless, without foundation. The only substance I know is my response to the Other—my crying out for comfort, warmth, and food as an infant; my grasping for belonging throughout my life.  Levinas wrote, “When human existence interrupts and goes beyond its effort to be […]—there is a vocation of existing for the other stronger than the threat of death”[4]. When I am interrupted by ethical responsibility to others, I am called beyond my own effort to be a self. My vocation, my calling, is to be for something more than just myself. This is why any honest to goodness effort to heal my relationship with my own body will call me beyond myself to the work of social justice. My body isn’t just me; my body is the experiencing of my relational world. Because of my body, I am never alone.

A life lived in diet culture is damagingly lonely. Subscribing to losing weight as a lifestyle means living life in a state of wounded attachment with myself as well as the world around me. Research in attachment styles and patterns clearly shows that disruptions in attachment with caregivers in infancy can have a negative impact throughout one’s life. Fortunately, attachment styles can change, and while change is slow and effortful, people can recover from childhood traumas. But attachment styles can shift toward the negative as well. Even with the security of an idyllic childhood, later trauma events and/or the sedimentation of diffuse negative messaging about the self (such as the microaggressions that people of color, gender non-conforming folks, and fat people encounter daily) can result in ruptured attachment patterns with others, and with one’s self. The benefit of secure attachment is that the child gains the confidence and the trust necessary to leave the arms of its caregivers and learn to care for itself. In other words, with secure attachment, we are given the best shot at becoming good parents to ourselves, and eventually our own children. Healing internalized fat-phobia will not only heal my attachment with myself, but also allow me to be present to others in secure states of attachment as ally, friend, coworker, partner, and colleague.

In my mid-thirties, while working full-time as a research academic overseas (translation: I was already super stressed out), my partner and I suffered three miscarriages. These were brutal lessons in the fact life does not bow to our commands, and I battled the depression and sorrow by running as hard as I could in the opposite direction. I was damned if I was going to let my body fail me so horribly again. A hobbyish interest in strength training and body building became an obsession. After the third miscarriage I signed up for a kick-boxing gym; the swollen shins and bloody toes felt like a kind of penance, if not quite the redemption I was looking for. And I exerted control all right. I got ripped, but also unhealthily thin. Achieving thinness gave me a high that felt so good it almost made the hunger migraines worth it. At the height of my dysfunctional and disordered relationship with my own being, I was so detached from my own body that my brain was literally screaming out for food. But I had a six pack, and nothing and nobody could touch me. Even writing this now, I can feel the pull of that seductive elixir of achievement and elitism. If I just took on this talisman once more, it would protect me from all other pain. I wanted to believe that I achieved the unachievable in the exercise of self-control. But I couldn’t, and no one can, sustain the unsustainable. I no longer have a six pack (no surprises there), because our bodies expertly resist reduction; instead, we are primed for survival. That’s why dieting becomes a chronic “life-style” for so many. We bounce back and forth within a certain weight range, trying to make our bodies behave, and our beautiful, blessed bodies keep returning us to the size we are meant to be for optimum health. Our bodies themselves return us to the invitation to trust something other than our egos, our ideals, our ideologies.

Deciding to let go of control has been extremely difficult, but I couldn’t go on living a divided life, especially as I began to see my attitudes mirrored in my daughter, and especially as I began to counsel others who have also been wounded by the pervasive and damaging ideology of diet culture and the religion of thinness. It is greatly disheartening, now working as a mental health professional, to see behavioral modalities that were developed to help people heal and cope twisted toward dieting and “lifestyle change” (these are the strategies behind not only the new version of Weight Watchers but also lifestyle apps like Noom[5] and other “no-diet diet” approaches to weight loss). The idea is that if you change your habits and behaviors you’ll achieve a better body, you’ll be happier. But “healthy habits” are doublespeak for that same division between unruly, bad body and disciplining, moral mind. It prevents the wound from healing. Dieting as a lifestyle is like living within an attachment wound, divorced from our very selves, and so from each other. Dieting as a lifestyle is a cry for nurturance, just as our starving bodies cry out for sustenance.

What would it be like to be released from the chains of fatphobia, so that when I look in the mirror I don’t judge myself and when I see other bodies it never enters my mind to judge them? What would it be like to drop the burden of an internal scale that always weighs myself and others against an impossible, harmful ideal? What would the freedom of full self-acceptance really be like? It would be a decolonization of the mind from the empire of prejudice.  It would truly mean loving others as myself; it would mean a meaningful life lived not only for myself, but for a community. Is that an impossible dream? I try to remind myself what I already know. In the glimmer of an early memory of childhood satisfaction and happiness, I knew what it was like to be innocent. I knew what it was like to trust myself and the world around me. I love myself, and I believe in the essential goodness of being alive and being together. I can lose this religion of thinness. It is work that falls squarely on my own shoulders, but I don’t do it alone. By listening and lifting up others in response to the call that shatters the shell of my own ego, I can break the chains of my own fragilities, link by link.

I extend gratitude to members of the Eating Disorders Training Network through Seattle Children’s Hospital, especially Dr. Cynthia Flynn, and others who have generously provided their perspective and feedback, especially Miriam Gnagy.

These essays, books, and websites have been the most helpful to me in beginning to understand anti-fatphobia:

Bacon, Lindo. 2008. Health at Every Size: The Surprising Truth about Your Weight. Benbella Books. See also the HAES community at

Gordon, Aubrey. Nov. 4, 2019.  “How to support your fat friends, as a straight size person.” Human Parts;

Mollow, Anna. May 10, 2013. “Why Fat is a Queer and Feminist Issue.” Bitch magazine. “Micro/Macro”, issue #59.

Strings, Sabrina. 2019.  Fearing the Black Body: The Racial Origins of Fatphobia. NYU Press.

Taylor, Sonya Renee. The Body is Not an Apology. (book, workbook, website)

…and many, many more. Engaging with others who are actively anti-fatphobia, asking about their experience, but not expecting to be taught, is an effective way to lift up others, especially if you are coming from a place of privilege.


[2] In the older, un-Disnified versions of this tale, the sisters slice off heels and toes to fit the shoe, but the dripping blood gives their ruse away.

[3] Many of us struggle with disease, chronic symptoms, disability, pain. As a person who has been in good fairly health all my life (so far), I am open to the real possibility that I don’t quite understand the implications of what I’m saying here for people of disability or with extreme body dysmorphia. This is a place of continuing learning for me.

[4] Emmanuel Levinas (1998). Entre Nous: Thinking of the Other, Bloomsbury, p. xii.

[5] For a whip-smart critique of Noom and other “no-diet diets”, see “The Dieter’s Diet” by Virginia Sole-Smith at

Why in the world become a therapist? (letter to a student intern)

Photo by Allison Shelley/The Verbatim Agency for EDUimages

My alma mater, Seattle University, offers a brilliant course for masters-level therapists-in-training in the Existential Phenomenological Psychology program. It’s called “The World of the Clinic”, and students take this course at the same time that they begin their practical internships. The course encourages students to think broadly and critically about the social and political forces that shape the work of therapy. So, for example, just as you are learning to actually diagnose someone for the very first time with a potential mental “disorder”, you are learning about the disturbing and sometimes violent history of psychiatric treatment, and you are challenged to place yourself within that history as an active agent. Just as you are learning to work with someone suffering because of their mental health, you are simultaneously being introduced to the inner workings of a medical establishment that sometimes contributes to that suffering by pathologizing marginalized experiences, such as homelessness, poverty, neuroatypicality, or gender diversity. Just as you are struggling to integrate this whole new field of knowledge into an hour with someone who might simply need someone to listen to them and validate them, you are also tasked with questioning the very assumption that this kind of work “knows” anything at all. It’s an amazing course. One of our assignments, conceived by the equally brilliant Dr. Erica Lilleleht, was to write a letter to a student who will come into the program the following year, for them to read as they begin their own practical internship. I had the great honor of speaking with the student who read my letter, and the conversation that ensued inspired me to share what I had written. So here it is, in slightly edited form. Enjoy.

Dear Intern,

I imagine that my fellow second-year students are beginning their letters in much the same way: these are unprecedented times, and it’s impossible to know what the next year will bring. It is impossible to know what situation you will be stepping into when you begin your clinical internship sometime between July and September of 2021. My class is currently experiencing the heartbreak of not getting to be with one another as we navigate these untested and uncharted waters. We had only talked briefly of telehealth in our classes sometime before the shutdown last spring, and now we are almost exclusively working over the phone or online in ways that are challenging some of the fundamental assumptions we might have brought to our ideas about the practice of therapy, and what it means to be with one another and to be present to one another. Your class is getting to know each other via distance learning, and when you do get to meet in person it will be in an unforeseen situation. I hope it will at least be somewhat familiar. You’ve jumped head-first into a new career on the wave of a global health crisis the likes of which the world has never seen before. You’ve been given an opportunity to be on the front lines of innovation and change in mental health services, but things will likely never be the same again. It’s just impossible to know. For me, there is excitement and grief, loss and hope, in all of this.

However, there are some things that you can be sure of. The first is your firm foundation in the existential-phenomenological (EP) tradition. No matter who you are working with or how, your EP foundations will orient you and steady you. For me, that has meant focusing on the existential questions of making meaning at the crossroads of existence: what does it mean to be free, to choose, to be responsible, and aware? And phenomenologically, I try to feel into the experience of space, time, the embodied, and the relational. As with Gadamer’s “fusion of horizons,” the event of understanding between patient and therapist is the co-creation of new knowledge that looks beyond the individual and has an integrity and life of its own. When I let go of my own understanding (the temptation to “totalize” the situation or the person, as Levinas might say), that is when real insight comes. I guess my first piece of advice is to remember that therapy is not psychology. It draws from that science, but it is an art. Decades of research has shown that the modality of therapy is not as important as the establishment of the therapeutic relationship. It is the event of the coming together of two or more people in the attempt to know and understand across the distances of difference that has a therapeutic effect. We can chart the data of how this happens: we can measure behaviors and to some degree moods that change as a result of therapy, but we can’t say why exactly healing takes place. We only know that it does. Therapeutic practice necessitates a kind of faith, and without that faith, I think it’s an empty thing.

I believe that when therapy is done well, it will always have a spiritual dimension, and if that spiritual dimension is honestly acknowledged, we will see that it motivates and upholds the work of justice. My second piece of “advice” is not to downplay the importance of what you are doing. The ramifications of holding someone in unconditional positive regard are enormous. I have started to see the small effects of this three months into my internship, and as small as those things are, they are breathtaking. Everyone deserves mental health care, just as we deserve universally available care for the rest of our bodies. If you continue to work in community mental health, you will have the opportunity to get to know, if you don’t already, the medical system from the inside out. And we can work from the inside out to bring us step by step closer to a more just society. To quote Angel Kyodo Williams, an esteemed Zen priest and the second Black woman recognized as a teacher in the Japanese Zen lineage, from a 2018 interview:

“To do our work, to come into deep knowing of who we are — that’s the stuff that bringing down systems of oppression is made of. And so capitalism in its current form couldn’t survive. Patriarchy couldn’t survive. White supremacy couldn’t survive if enough of us set about the work of reclaiming the human spirit, which includes reclaiming the sense of humanity of the people that are the current vehicles for those very forms of oppression.”

Not only will you be starting your internship on the wave of this pandemic in whatever form that will take (again, impossible to know!), you’ll be seeing patients whose health care will be impacted or will have been impacted in some way (impossible to know!) by the political changes and challenges we’ve witnessed over the past several years. Working as I do out in a rural area, I have people on my caseload with whom I do not see eye to eye politically. I have encountered situations where I have had to honestly speak my discomfort with an idea or an attitude, because I felt that to ignore it would have given a false impression of myself, but more importantly, I knew that to fail to address a racist comment would itself perpetuate racism, and I knew that to allow a sexist joke was to allow a kind of violence to continue. I know that some people would vehemently disagree with addressing such concerns in therapy. Truly, you must carefully consider when and how to do so. All I can say is that when I have spoken my true discomfort honestly, directly, and nonjudgmentally, it has opened up intense conversations that I believe have productively deepened the relationships.

Now on to some nuts and bolts. My third piece of advice is to remember to slow down. It’s so easy to get swept up into a situation and forget that you don’t have to do anything or decide anything now (or at least, that’s very rare. A crisis situation might mean you need to act immediately, but you should not be working with crisis clients at this point). I learned this lesson the hard way recently: I made a decision based on advice from my supervisor that ended with my client dropping me. What I didn’t remember was that the urgency I was feeling wasn’t necessarily so. I could have stopped and asked for advice from another clinician or a professor. Consult consult consult. It will never do you wrong. Take more time than is necessary, even now.

You are there to learn, and this is YOUR education. Take advantage of as many trainings as you can—they count toward your internship hours! If you want to do a group, create a group and do it! If you want to shadow a person or a process and it’s not already part of your training, just ask! That being said, it’s also easy to work a lot harder than you have to. Watch your hours, make sure you take your vacation time that is due to you, and beware the difference between an educational opportunity and being used as free labor. You’ll know the difference.

Whatever site you’re at, there will be many moving parts. The purpose of “World of the Clinic”, as I see it, is to get you to take a step back and get to know the site as a dynamic process within which you play a small but important role. The more you get to know the details of this process (for example, who empties your trash at night? Do you know? Do you know who schedules your clients? Do you know who updates the clinic’s software?), the more you’ll understand your place within it, just as we are learning the place of mental health work within the larger social, cultural, and political systems that shape our lives. Last of all, don’t worry. You’re here because you’re already doing what it is you’re becoming a professional to do. You’re here because you’ve been called, and you are needed.

Welcome home to who you are.

December 23, 2021.

It’s been almost two years since COVID-19 shut down travel, work, and school, and we all retreated to our homes, what we had of them, to shelter in place. I remember the almost festival-like atmosphere and novelty of the experience. We logged in, we reached out, we cried listening to Italians singing opera across courtyards in quarantine; we watched breathless as atmospheres cleared of smog and we saw metropolitan skylines for the very first time. I was about to finish winter quarter of the first year of the psychology program at Seattle University. We all got on Zoom, laughing and waving to one another, blinking back at one another’s faces in pixelated form. We joked about Brady Bunch boxes of talking heads, but I also saw a beautiful patchwork quilt. There I was at home, separated but connected to my peers and teachers. I held my three year old daughter on my lap while I listened to lecture, so grateful, despite the destruction that the pandemic wrought, to be home.

Who we are is who we are from. Who we are from is who we are with…that is, with whom we keep company. Who is your company? Who welcomes you home to who you are? That welcome may be internal as well as external. Whose are the voices that greet you when you wake? From whom come the ideas that shape your perceptions and your opinions? Do they nurture you? Do they support you? Do they prompt you to be truly you?

Sometimes who we are from is not easy company to keep, but authentic selfhood means being with and acknowledging the presence of others by whom you may not always feel welcomed. Maybe this is a parent who has never fully accepted you, or a former partner from whom you are now estranged, or a child who has rejected your attention and love. It’s difficult to embrace the fact that we are from pain and heartbreak as much as from joy. I hear a lot of talk about “boundary setting” in my work as a therapist. The implication seems to be that we can close ourselves in our own little shells with boundaries that protect us. But I wonder about such boundaries. Yes, appropriate boundaries are healthy, especially when we’re talking about physical and emotional safety. But sometimes “boundary setting” feels to me like a form of avoidance that rewards us with short-term emotional relief, rather than engaging in the hard work of building sturdy structures that will enable and enhance relationships. Thanks, Robert Frost: “good fences make good neighbors“. Is my home in the style of hostile architecture, attempting to shape and restrict the behavior of others? Or can it be a place of gather and welcome? Where is the hearth, how big is the table, and how comfortable am I opening the door?

In his famous essay “Of Hospitality“, Jacques Derrida explores the relationship between “host” and “hostage”. Paradoxically, it is when we are our most sovereign and powerful selves, able to open our homes to others, that we expose ourselves to the most vulnerability. In playing host, we become hostage to others. It is the mystery and the potential danger of the guest that makes hospitality hospitable. Otherwise, hospitality would be a lie! We would not be welcoming guests, but scrutinizing potential members of an elite club. How homey is that?

Boundaries do not separate us from others. Boundaries are the tangible, living architecture of our relationships with others. To go home does not mean to retreat into the self, but to find a place of repose and peace in the structures that support me. I did not always agree to each piece of that structure, but I can appreciate the totality of who I am as bound to the others who, for better or worse, shape my life. Who give me life. Who remind me that, like Derrida’s host, if I truly were in ultimate control, I would have no relationships at all.

So welcome yourself home to who you are. Don’t care about the dirty dishes or the mess. There is space here for you to rest. And there is true strength in your acknowledgment, in its simplicity and realness, of: “this is me.”