Harm Enlargement

The issue of drug use is fraught with stigma and strong opinions, but no topic causes such lightning rod reactions as pregnant women who use drugs or have drug-exposed newborns. Last week, North Carolina joined a growing list of states that have introduced or passed bills criminalizing pregnant women who use drugs, even punishing them with jail time if they don’t seek treatment. But while the intention behind these laws may be to deter pregnant women from using drugs, they often have the opposite effect, driving a resource-poor population away from treatment and towards behaviors that can further harm mothers and babies.

We believe that when a person is condemned by others, it is harder to make productive change.

April W. of Durham, North Carolina, was seven months along with her third child before she realized she was pregnant. Immediately, she enrolled in a methadone treatment program where she was given a daily dose of methadone to control her cravings for heroin. But stigma made it hard to keep up with the program.

“I was judged a lot for being pregnant,” she said. “In treatment programs there is a hierarchy. People who snort drugs think they are better than people who shoot them. People who use alcohol or pills think they are better than people who use illegal drugs. But pregnant women, no matter what they use, are always viewed as the worst.”

Senga Carroll is the training director at UNC Horizons, a program that provides counseling, case management and medical care to pregnant women with substance use dependency in Chapel Hill, North Carolina. She sees the practical consequences of the condemnation of pregnant women who use drugs.

“Pregnant women with substance use disorders face shaming by health care practitioners and society when they seek medical treatment,” says Carroll. “Hospital staff often condemn the women by saying, ‘The baby is having a hard time because you are a bad person.’ When women feel judged they may lie to health care providers, and [the] lack of information makes is harder to provide the best treatment for the mother and baby.”

Currently, protocols for how to respond to a pregnant woman who may be using opioids, or a baby born with evidence of dependency, vary widely from hospital-to-hospital. Some staff members may even call Child Protective Services to separate the baby from its mother, even when the mother is on medication-assisted treatment such as methadone. Fear of judgment and condemnation drives pregnant women who use drugs underground, away from drug treatment or prenatal care. Some women try to detox off drugs on their own, though the abrupt cessation of opioids can lead to pregnancy complications. Other women opt for home births to avoid hospitals altogether. Home births are risky for babies born with exposure to opiates, as specialized medical care may be necessary to relieve their symptoms.

Part of the misinformation about the effects of drugs on birth outcomes can be traced back to the 1980s when images of “welfare queens,” “dope fiends” and “crack babies” swept the media. The public was whipped into a frenzy of anger against the perpetrators, who were overwhelmingly portrayed as poor minorities. Though scientific studies later debunked the myths of the “crack baby” by demonstrating that cocaine-exposed infants exhibited few to no withdrawal symptoms compared to babies not exposed to drugs, the demonization and criminalization of pregnant women continued. Eighteen states now address drug use by pregnant women in their civil child neglect laws, some even going as far as to make it possible to take away children based on one positive drug test.

Whitney Englander, Government Relations Manager for the Harm Reduction Coalition in Washington D.C., advocates for standardized procedures to help treat women who use drugs instead of exposing them to shaming and stereotypes.

“Just because a woman is pregnant doesn’t mean she can magically overcome a chronic condition,” says Englander. “You can’t overcome diabetes while pregnant, but you can manage it. The same holds true for addiction. There is an opportunity to reach those women because of the pregnancy. We need to make sure that laws aren’t criminalizing them and pushing them further away.”   

Unlike the symptoms wrongly attributed to crack (later determined to be caused by poverty and poor nutrition), there are legitimate symptoms in many babies born to mothers who use opiates. These symptoms, called neonatal abstinence syndrome (NAS), include excessive crying, irritability, poor feeding, trembling or diarrhea and occur in about half of babies exposed to opiates in the womb. With a duration typically ranging from one to four weeks, they can be treated through non-pharmacological methods, such as swaddling, skin-to-skin contact with the mother or breastfeeding, or, in some cases, with small doses of methadone or morphine administered over a period of days or weeks.

The symptoms of NAS are manageable and treatable, especially if medical providers are made aware of the situation early. This requires a level of trust between patient and provider. As Senga Carroll explains, simply leaping to the conclusion that all pregnant women who use drugs are bad and should be punished makes the situation worse.

“We believe that when a person is condemned by others, it is harder to make productive change,” says Carroll. “The best way to be helpful is to approach from a stance of non-judgment and figure out a way to address the problem.”

The recommended treatment for pregnant women who use opiates is medication-assisted treatment (MAT), such as methadone or buprenorphine, in the context of broader services such as screening, assessment, a treatment plan and evaluation. But MAT can be controversial. Opponents of MAT often call it a substitution of one drug for another. They point out that half of babies born to mothers who used methadone or buprenorphine treatment while pregnant still exhibit withdrawal symptoms.

For Carroll, such criticism ignores five decades of research that clearly point to MAT as the better alternative to abrupt detox while pregnant.

“Research shows that MAT is extremely important to prevent spontaneous abortion,” says Carroll. “A woman who ceases opiate use abruptly can abort the fetus. To maintain the health of the mother and fetus it is best to engage the mother in prenatal care, substance use treatment and peer support. Medication also reduces cravings for opioids and helps avoid fetal exposure to the highs and lows of active addiction.”

MAT is recommended by the Substance Abuse and Mental Health Services Administration (SAMHSA), the American Society of Addiction Medicine, the World Health Organization (WHO), and the American College of Obstetricians and Gynecologists (ACOG). The 2014 WHO and ACOG guidelines state that “pregnant women dependent on opioids should be encouraged to use opioid maintenance whenever possible.”

Even with support for MAT from scientific research and the majority of the medical community, states continue to introduce bills that punish pregnant women who use drugs. In many cases, misinformation and stigma guide policy more than facts or science.   

“This is an emotional issue for people,” says Whitney Englander. “People see babies with withdrawal symptoms and they want someone to blame. But punishing the mother is not best for the baby. A fetus can die if the mother tries to detox quickly because she is ashamed of how people will judge her if she takes methadone. We need to create a standard best practice policy for how to treat pregnant women that is based on science and decades of evidence-based research, not knee-jerk reactions and anger.”

Advocates agree that it will take time, patience and education to convince lawmakers and the public of what the medical community has known for a long time—MAT can help manage the symptoms of opioid addiction and the criminalization of pregnant women who use drugs causes more harm in the long run.

“Education is the most useful approach to changing hearts and minds,” says Carroll. “We can show the outcomes and cost savings of programs that treat pregnant women who use drugs with dignity, such as the number of children not admitted into the foster care system, the drop in number of emergency department visits or women sent to jail or prison, and the number of families kept together. When women are treated in a nonjudgmental manner and provided with services, it produces better outcomes for women and children as well as cost savings for society.”

Tessie Castillo is the Advocacy and Communications Coordinator at the North Carolina Harm Reduction Coalition. She writes a regular column for The Huffington Post on overdose prevention, drugs, sex work, HIV/AIDS, law enforcement safety and health. She last wrote about sexism in the drug war.

A growing list of states have criminalized pregnant women who use drugs if they don’t seek treatment. These laws are doing more harm than good.
By Tessie Castillo
My Way

At one point, I spent quite a bit of time on the road, giving workshops and making presentations to audiences of counselors and treatment program staffs.

I began my lecture by saying:

“I’ve never had a drug addiction or been an alcoholic, nor has anyone in my family. I’ve never worked in a treatment center. And I’ve never taken a course on addiction.”

People would shoot each other uncomfortable looks, and shift in their seats.

“But,” I continued, “no one had to teach me about addiction. I’ve thought about it every day in my conscious life. Oh, and I have been addicted.”

“When I was five years old, I lived in a row house near a man who was carried home drunk every night. Seeing him helpless and babbling distressed me as a kid roaming South Philly, when I was often accosted by roving gangs because I was Jewish. (Yes, I walked to kindergarten six blocks on city streets by myself.)”  

“I asked my mother, ‘Why does he do that? Why does he leave himself helpless, when anyone could do anything they wanted to him?’ It completely violated how I understood the world worked.”

“And so, I asked everyone I knew about it, and watched every time I came upon someone who was drunk, or observed closely whenever I encountered a street person. My mother would tell people, ‘Stanton is really interested in alcoholism. Isn’t that fascinating?’”

“I reflected on the meaning of being helpless, out of control. I thought from a very early age, ‘There’s an escape in doing that, when you aren’t expected to do anything, like I have to do my chores. What would my mom say if I told her I couldn’t do them because I was always sick?’”

“When I was 13, I read a newspaper article that described a man who had been in a treatment program for alcoholism. He came home to an apartment with boxes stacked all over the place, since his wife had moved in the interim. He immediately turned around and went on a bender.”

“I thought, ‘I know people like that.’ My father was a very anxious man. When faced with any upsetting or chance event, he blew up in rage. He never struck us, but he was unrestrained in expressing his anger and anxiety.”

“At the University of Pennsylvania, then a fraternity school, I associated with both athletes (I played intramural club basketball) and hippies (I lived in the hippie section of Philly), and witnessed young adults who got drunk nightly, and others who smoked marijuana around the clock. I had a girlfriend who lived downtown with heroin users, and I shot up with them a few times. They held jobs, had non-using girlfriends, and were healthy, riding their bikes everywhere."

“At Penn, a group of us were close friends. My roommate, who was an isolated person, started dating a high school girl. He told me, ‘Now that I’m together with Claire, I won’t be seeing you guys anymore.’ They got married in our senior year, and she accompanied him to his grad school, where she went to college.”

“I meanwhile went to grad school at the University of Michigan. While I was there, Claire came home and left a tape recording for my friend saying things weren’t working, and she was running off with another man. I had an epiphany: ‘That wasn’t love, it was an addiction. They were together to fill a need for each other (she was from an abusive home). When they no longer filled that slot, they were replaceable.’”

“At the same time, I was familiarizing myself with the addiction literature at Michigan. I was especially fascinated by an article in the New York Times quoting Charles Winick (Winick was the first to identify that people frequently outgrew, or matured out, of heroin addiction). Winick was quoted as saying that ‘opiates are usually harmless, unless they are taken under unsatisfactory conditions.’ This, of course, confirmed my own experiences with heroin.”

“So, you see, I don’t think of addiction as something outside of normal human experience. I think of it as a variation of what people ordinarily undergo, that anyone can experience, that I have experienced myself with girlfriends and lovers. For, you see, it wasn’t only my college friend who was addicted to love. I am an anxious-attachment kind of person—can you guess why?”

“I knew what it was like to become desperate in an involvement, to start clawing at your surroundings, flailing and acting out in ways that only make your situation—and feelings—worse. And then you need more of the addictive experience—even if, in the case of a girlfriend or a lover, she was the source of your anxiety and pain. More hair of the dog that bit you, with predictable results.”

When I described this inner experience of addiction, people often responded to me in terrifically emotional ways. Archie and I first wrote a preview article for Love and Addiction for Psychology Today in 1974. A man named Lee Silverstein who was active in the recovery community came to see me at my office at the Harvard Business School, where I taught after grad school. He said that he had been reading passages from the article aloud in his group, and that they often burst out in tears of recognition.

Still, people didn’t know what to make of Love and Addiction. It was a mass-marketed paperback. It wasn’t a book about my recovery, although there was a lot of me in it since I have been a love addict, both before and after my long marriage.  

Love and Addiction’s publication brought me into contact with grassroots people in the field, who often reached out to me. For instance, when I was living in California, I was invited to speak with drug counselors at the Haight-Ashbury Free Clinic. They were very reinforcing and appreciative about how my writing illuminated people’s inner experiences of addiction.

Once I was giving a talk with LeClair Bissel, the founding director of Smithers. She told the audience that "Nothing Dr. Peele says makes sense to me. But an alcoholic medical student of mine gave me his book and told me 'This meant more to me than anything else I have read in the field.' So he must have something of value to say."

More recently, a long-time addictions counselor and researcher in Scotland, Rowdy Yates, said about rereading the book 35 years after it came out:

This book I read as soon as it was published. A friend had recommended it and she wasn’t wrong. Peele and Brodsky view addiction as a normal behavior that has veered out of control and they compare it with dysfunctional human relationships. I think it was probably the first book I ever read which analyzed addiction in a way that made sense to me and echoed what I knew from my work. Years later, I undertook a study looking at recovered addicts who had been sexually abused as children. One of the researchers we used was a psychotherapist and remarked to me that the relationship they described with their drug(s) of choice sounded exactly like their relationship with their perpetrator. I remembered Peele and Brodsky and pulled it off the shelf. It still reads absolutely true as an understanding of addictive behavior all these years later.

Of course, reactions like these confirmed my feelings that all human beings have had addictive experiences, although in some cases they become more life-defeating than others. This reality shows our shared humanity, and also holds the promise that anyone could overcome addiction in service of larger life goals and rewards.

In 1978, the provincial branch of the Canadian Addiction Research Foundation (now CAMH) in Alberta was hosting ARF’s national conference. The head of that agency came to New York, where I had moved with my wife, to meet with me. He asked me to provide my insights on addiction by delivering the keynote address at the ARF conference. After that, I was on the map of international addiction speakers.

My greatest strengths were my greatest disadvantages. I didn’t think addiction was a special category of behavior. I never regarded it as a disease. Of course, that view contradicted the dominant memes for addiction and alcoholism in our culture, and people regularly lambasted me for my views. I was viciously attacked personally, for instance, for recognizing controlled drinking as one treatment option.

I always believed that people could quit addictions on their own (including cutting back their use), since I saw that happen all the time out in the world. In particular, my old college alcohol-dependent and pothead friends were growing up, getting married, and—to take a phrase from that old folk comedian, Martin Mull—they “got normal.”  

Once I asked an old friend, who became a major star in the art world and a father of two, how he had overcome his college alcoholism (he was the first blackout drinker I knew) and pot addiction. He looked at me strangely: “I was never addicted or alcoholic.”

What could I say?

At the same time, people often noticed that I treated addicted people like everybody else. I listened and believed what they told me about their lives. I didn’t think of them as outsiders—at least no more so than I was!

My position in the addiction field has always been unique, and has given me key insights. I don’t believe addicts are different from other human beings since those I originally dealt with weren’t in AA or treatment. Of course, since then I have become engaged with treatment populations and providers. I realized that for some people it takes unusual effort to change, and that some can benefit from guidance and support that reflects the awareness of addiction that I described. 

As a result, I created the Life Process Program. It appeared originally in a self-help book, The Truth About Addiction and Recovery, which I wrote with Archie and my wife, Mary Arnold, in 1991. I converted it into a residential treatment program, and now it is available online. And people regularly write me about how one of my books (of the 12 I have written from 1975 to 2014) has made a crucial difference for them in overcoming an addiction—what a gratifying feeling!

At the same time, I understood then and now that drug use—even heroin—could be normalized. In this case, former addicts who have returned to more moderate substance use reach out to tell me how much my writing expresses their experiences. I didn’t believe that people are doomed to be addicted by their genes or their pasts. I knew they usually outgrow addiction with maturity. I believed that addiction makes sense to people in terms of their own experience.

While my ideas were initially considered crazy by many, each and every one—natural recovery, harm reduction, use of practical coping skills training in treatment, along with maturity and purpose as guideposts to recovery, and the idea that addiction occurs with non-drug involvements (e.g., gambling, sex, and electronic entertainments) exactly as it does with heroin, while heroin use is often managed within a normal lifestyle—is now recognized in the addiction field.

But there still remains so much for me, at age 69, to do.

Stanton Peele, Ph.D., is the author of Recover! Stop Thinking Like an Addict. He will be interviewed by Tom Horvath, President of SMART Recovery, in a webinar on the future of addiction treatment on Saturday, May 16, 2015, 5:00 PM EDT. He is the recipient of career achievement awards from the Center for Alcohol Studies and the Drug Policy Alliance. His Life Process Program for treating addiction is available online. He last wrote about 12 concepts of recovery that have stood the test of time and outgrowing sex addiction.

My name is Stanton, and I am not an alcoholic. But I can help.
By Stanton Peele
pro voices

In a previous piece for Professional Voices, Dr. Scott Kellogg demonstrated the power of Chairwork in the psychotherapy of addiction. Now, in what might best be described as a piece of “Historical Psychotherapy Fiction,” he engages a seminal figure in addiction, Bill W., in an imaginary therapy session focused on a traumatic and perhaps profoundly debilitating event. Obviously, we’ll never know what impact this type of therapeutic encounter might have had on Bill W., but it is a wonderful illustration of how effective psychotherapy strives to repair deep wounds that play a critical role in the formation of psychological distress that can find manifestation in addictive behavior…Richard Juman

In As Bill Sees It, Bill W., the co-founder of Alcoholics Anonymous, told a story about how he learned how to throw a boomerang. He was 10-years-old and he had been feeling depressed for about a year. In terms of life stressors, his father had abandoned the family, his mother had left him in the care of his grandparents so that she could begin her medical studies, and his school life was not going well. One day, his grandfather showed him a book about Australia and told him that the book said that only the Aboriginal people could make and throw a boomerang. This stimulated something in him. He wrote: “‘Here’s my chance,’ I thought. ‘I will be the first man in America to make and throw a boomerang.’” Set on fire by this goal, he made a boomerang and spent six months learning how to throw it. “But mine was a power drive that kept on for six months, till I made a boomerang that swung around the churchyard, in front of the house and almost hit my grandfather in the head when it came back.” His conclusion was: “Emotionally, I had begun the fashioning of another sort of boomerang, one that almost killed me later on.” (185)

As both an addiction psychologist and as a father, this story disturbs me. I believe that this was a traumatic experience for Bill and, as is often the case with traumatic experiences, I believe he drew the wrong conclusions from this event. The decision to try to master the boomerang was an attempt to shore up his fluctuating self-esteem—but the story is more than that. It is also a story about drive and ambition, about choosing a goal and pursuing it with dedication and perseverance. These are character traits that most parents would be proud of. When his throwing of the boomerang goes wrong, Bill made a global and negative assessment of himself. I believe that his sense of ambition became tainted and intertwined with traumatic fear and guilt. What he really needed was some more practice and some fine-tuning of his technique (and, possibly, some parental supervision). “Let’s go into that big field over there and throw it in a place where it will be safer,” I wanted to say. Tragically, it seems that no one did that. 

I recently wrote an article for The Fix on Chairwork. Following up on that, I want to explore how I might have used Chairwork dialogues to treat Bill’s trauma, if I had been given that opportunity. In reality, it probably would have taken several sessions and a number of different Chairwork approaches; nonetheless, I believe that the example provided here would have been a central part of the healing project.

Dr. K.: Bill, I’ve been thinking about that boomerang story that you told me last week.

Bill W.: Yes, it is quite a story.

Dr. K.: If it is okay with you, I would like to revisit it and do some work with it.

Bill W.: Fine.

Dr. K.: To start, I would like us to have a Chairwork conversation with your grandfather about what happened.

Bill W.: Hmm…okay, I guess.

(I move to a place in the office where there are two identical chairs facing each other. They are about three or four feet apart.)

Dr. K.: (Pointing at one of the chairs) I would like you to sit here. (He sits down. I bring over another chair and sit to his left. I am about two feet away and I am sitting at a diagonal so that I can see both Bill and his grandfather.)

Dr. K.: (Pause) I would like you to imagine your grandfather sitting in that chair (pointing to the chair opposite). Take a moment to settle in and then let me know when he comes into view.

Bill W.: (He sits in silence for a minute or two—looking at the chair opposite.)  Okay. I can see him.

Dr. K.: Please describe what you see. What he’s wearing. How old he is. What the expression on his face is and how you are feeling as you see him.

Bill W.: (Pause) He’s in his early 60s. He’s dressed the way he used to dress back then. He looks serious but I sense some warmth in him.

Dr. K.: How are you feeling as you see him?

Bill W.: I’m happy to see him. I haven’t seen him in a long time.

Dr. K.: Good. (Pause)  I’d like you to speak to him about the boomerang incident and how it has been bothering you. 

Bill W.: (Pause) Grandpa, I’ve been thinking about that day with the boomerang. It has stayed with me for my whole life. Dr. Kellogg says it’s a trauma. I don’t know if that’s true but I do know that I’ve never forgotten it.

Dr. K.: Tell him what you remember.

Bill W.: I remember that I’d been practicing with the boomerang. I had been working on it for months. I was excited. I thought I was finally getting it. I was hoping that I could be the first American to throw a boomerang.

Dr. K.: What happened next? Tell him.

Bill W.: I remember throwing the boomerang toward the churchyard. I can still see it in my mind. It made this beautiful arc and it was heading back toward me. (Pause)

Dr. K.: Then what?

Bill W.: And just then, you came out of the house and it went right toward you.

Dr. K.: What were you feeling? Tell him.

Bill W.: I was terrified. I couldn’t move. I was afraid it was going to hit you.

Dr. K.: Say that again. I was terrified. I thought it was going to hit you.

Bill W.: I was terrified. I thought it was going to hit you.

Dr. K.: Good. What happened next?

Bill W.: At first it seemed like you didn’t see it. Then I yelled. You saw it and you ducked.

Dr. K.: It missed him.

Bill W.: It just missed him. (Pause) I was so scared. I ran over to make sure you were okay.

Dr. K.: Was he angry? How did he react? Speak to him about this.

Bill W.: Grandpa, you looked upset. I remember you telling me to be more careful; that I could have killed someone.

Dr. K.: How did you feel?

Bill W.: I was so upset. I couldn’t stand it.

Dr. K.: What did you do next?

Bill W.: I was so angry with myself that I broke the boomerang. I never threw a boomerang again.

Dr. K.: After all those months of work, you broke it and never tried again?

Bill W.: No. I was so upset that I wanted nothing to do with it.

Dr. K.: (Pause) How are you feeling as you say these things?

Bill W.: I am feeling agitated. It’s still very disturbing to me.

Dr. K.: Did you love your grandfather?

Bill W.: Yes.

Dr. K.: Did you want to hurt him?

Bill W.: Of course not.

Dr. K.: Was this an accident?

Bill W.: Yes. Although I blamed myself for a long time afterwards. I think I still blame myself.

Dr. K.: I would like you to look at your grandfather and say this, "Grandpa, I loved you and it was an accident."

Bill W.: Grandpa, I loved you and it was an accident.

Dr. K.: Again.

Bill W.: Grandpa, I loved you and it was an accident.

Dr. K.: Again.

Bill W.: I loved you, it was an accident, and I never meant to hurt you.

Dr. K.: I loved you and I never meant to hurt you.

Bill W.: I loved you and I never meant to hurt you.

Dr. K.: (Pause) How is that resonating inside of you?

Bill W.: It feels true…I wish that I had been able to say it to him when he was alive.

Dr. K.: He’s sitting over there now. Do you think he heard you?

Bill W.: Yes. I have some sense that he did.

Dr. K.: I would like to do something. I would like you to move into that chair (pointing at the chair opposite) and I would like you to be your grandfather. I would like you to channel his energy and speak from his perspective. Is that okay?

Bill W.: Okay. (Bill switches chairs; I stay next to Bill’s original chair.)

Dr. K.: Grandpa, do you remember this experience with the boomerang?

Bill W. (as Grandfather): Yes, I do.

Dr. K.: Would you speak about your memory of it?

Bill W.: (as Grandfather) Sure… well, Bill had just come to live with us.

Dr. K.: Would you speak to him and tell him directly? Use his name.

Bill W.: (as Grandfather)  Sure. Bill, your father had already left the family and your mother had just entered medical school. I remember that you weren’t very happy. You seemed to be having difficulties in the new school. It was tough for you. You were 10 and everything was a mess.

Dr. K.: Talk to him about the boomerang.

Bill W.: (as Grandfather) Yes. I showed you that book about Australia and you really got the bug for learning how to throw a boomerang. I remember that you were really excited about the idea that you could be the first American to do it.

Dr. K.: It sounds like this memory gives you some pleasure.

Bill W.: (as Grandfather) It does give me pleasure. I remember you making a boomerang in the shed and then going out after school and trying to get it to work. You worked on that for months.

Dr. K.: Talk about the day when you almost got hit.

Bill W.: (as Grandfather) Yes. I was coming out of the house and I heard him yell…

Dr. K.: Tell him directly. Use his name.

Bill W.: (as Grandfather) Bill, I was coming out of the house and I heard you yell and then it was right there. I ducked and it went right by my head.

Dr. K.: What happened next?

Bill W.: (as Grandfather) I was stern with him. He scared me because he took me off-guard. That boomerang was made out of a nice, hard piece of wood.

Dr. K.: Bill told me that he never threw the boomerang again after that.

Bill W.: (as Grandfather) That’s right. I was sad to see that, actually. He had worked so hard at it and then he suddenly gave it up.

Dr. K.: It sounds like you wanted him to throw it, like you didn’t want him to stop?

Bill W. (as Grandfather): No. I didn’t. He had worked so hard; I was sad to see him stop.

Dr. K.: Grandpa, tell him that directly. Tell him that you know it was an accident, that you wanted him to keep throwing the boomerang.  

Bill W.: (as Grandfather) (Looking at the chair opposite) Bill, I know it was an accident. I know you weren’t trying to hurt me. I wanted you to keep working with the boomerang. I was sad when you stopped.

Dr. K.: Grandpa, would you tell Bill that you love him, that he’s important to you, and that you want him to be happy and successful.

Bill W.: (as Grandfather) Bill, you know that Grandma and I both love you. We felt bad about your parents leaving you and we were happy that you came to live with us. We were proud of you. I know that you had some pain later on in life, but I want you to be happy. I want you to be successful. We both do.

Dr. K.: I think that there’s a part of Bill that feels like he is a very bad person for what happened. That he’s dangerous. Would you speak to him about this?

Bill W. (as Grandfather): Bill. Don’t think that way; it was just an accident. You didn’t do it on purpose. I know you didn’t do it on purpose. I got angry at the moment because I was scared, but I knew it was an accident.

Dr. K.: So you don’t believe he’s a killer?

Bill W.: (as Grandfather) Of course not; that’s ridiculous.

Dr. K.: I think a part of him feels that he is. Please tell him.

Bill W.: (as Grandfather) Bill.  I know you loved me and Grandma.  I know you would never do anything to hurt us.  It was just an accident.  You were a kid. You were learning.

Dr. K: Again. You were a kid and you were learning.

Bill W.: (as Grandfather) You were a kid and you were learning. You were only 10. It’s okay. Nobody got hurt.

Dr. K.: I think Bill walked away from that experience with a sense that he should not act. That if he acts, bad things can happen. I think he wants to act but now he is afraid.

Bill W.: (as Grandfather) No, no. Of course he should be a man who acts in the world.

Dr. K.: Tell him directly.

Bill W.: (as Grandfather) Bill, I know you are a good man. I want you to act in the world. I don’t want you to live in fear, to hold yourself back. You need to be careful, but you need to act.

Dr. K.: I want you to act.

Bill W.: (as Grandfather) I want you to act.

Dr. K.: Say this, if it feels right. I want you to be careful and I want you to throw the boomerang.

Bill W.: (as Grandfather) Yes. I want you to be careful and I want you to throw the boomerang.

Dr. K.: Tell him again, it’s important that he hears this.

Bill W.: (as Grandfather) I want you to be careful and I want you to throw the boomerang.

Dr. K.: Be careful and throw the boomerang.

Bill W.: (as Grandfather) Be careful and throw the boomerang.

Dr. K.: Again.

Bill W. (as Grandfather): Bill.  Be careful and throw the boomerang.

Dr. K.: Bill, don’t live in fear.  Be safe. Be careful.  And throw the boomerang.

Bill W. (as Grandfather): Don’t be afraid. Throw the boomerang.  Be safe, be careful, and throw the boomerang.

Dr. K.: Throw the boomerang!

Bill W.: (as Grandfather) Throw the boomerang!

Dr. K.: (Long pause) Now I would like you to come back to this seat (points to the “Bill” seat). (Bill switches seats)  (Pause) I would like you to sit there and just take a minute and see if you can let in what your grandfather just said to you. (Long pause) What are you feeling?

Bill W.: That was powerful. I’m feeling shifted. I feel lighter, like a burden has been lifted. I’ve been carrying this for a very long time and I feel like I put some of it down.

Dr. K.: That’s great. What was it like to be Grandpa?

Bill W.: I really felt how much he cared for me. I also saw myself as a kid. I think that I have lost track of that. I have been really hard on myself.

Dr. K.: So you feel his love?

Bill W.: Definitely. I feel shifted and I feel better.

Dr. K.: Before we end for today, is there one more thing that you would like to say to your grandfather?

Bill W.: (Looking at the Grandfather Chair) Grandpa, thank you for that. Thank you for taking care of me. Thank you for telling me that I am not bad. Thank you for giving me permission to act in the world.

Dr. K.: That was good.

This is the kind of encounter that I strive to create when working with patients. Experiential encounters of this nature can be very catalytic and patients can make a great deal of progress from this kind of dialogue work. Does Bill W. have more work to do?  Most likely. I suspect that he would benefit from an inner encounter with the self-accusatory voices that are still likely to be there; nonetheless, this is a good start. It is my hope that, at some point in his life, he really did find ways to work through and resolve this trauma.

Scott Kellogg, PhD, is the author of the book, Transformational Chairwork: Using Psychotherapeutic Dialogues in Clinical Practice. He is also the President of the Division on Addictions of the New York State Psychological Association, a Schema therapist and Gestalt Chairwork Practitioner in private practice, and a Clinical Assistant Professor in the New York University Department of Psychology. Through his workshops, he has been training therapists in the United States and abroad in the Art and Science of Chairwork. His websites are Transformational Chairwork and Gradualism and Addiction Treatment. His email is

Could a powerful psychotherapeutic encounter have changed history?
By Scott Kellogg