AI and Clinical Practice: Spring 2026 Update

I’ve spent at least 30 hours every week over the last three months either using AI, reading about AI or asking other people about their use of AI.

So many articles on AI appear in mainstream media every day. I can only imagine how much people are talking, either with excitement or doom, about AI on social media and on Reddit.

I am particularly interested in how AI shapes clinical work and higher education, since those are the greatest areas of my professional focus.

This is a summary of the AI and clinical landscape as of Spring 2026. The environment is changing quickly and standards haven’t even been set. Regulatory and legal responses are uneven and still developing across jurisdictions. This update reflects ongoing clinical work alongside review of emerging law and literature. Its purpose is to reduce blind spots for clinicians and programs and to identify emerging risks to the profession and the public. It also serves as a record for me as I expect I will write, talk and train on these topics for much of the next decade. Future updates will incorporate international developments as relevant.

State Regulation Is Moving First

Colorado HB26-1195. This is a bill that proposes to prohibit clinicians from using AI to directly communicate with patients. It also places restrictions on AI from creating treatment plans or therapeutic recommendations with a licensed professional reviewing them.

New York S7263. This bill imposes liability for damages caused by a chatbot imitating certain licensed professions, including counseling.

New Jersey S3668. This bill requires disclosure in certain AI-driven communication.

Washington State HB2225 and S5984. This bill mandates that AI chatbots inform users that they are not interacting with a human and then requires periodic reminders.

The Colorado bill is the most aggressive about protecting the public and clinicians while New York is laying the ground for user litigation against AI companies if they get unlicensed or bad advice. New Jersey and Washington are just about AI disclosure. There is no unified Federal standard. Clinicians are operating across inconsistent legal environments. None of them go far enough.

The Courts Are Beginning to Test Harm and Liability

Google was sued in Federal Court on March 4 by the family of a Florida man who took his life. The man’s family alleges that the Gemini AI chatbot encouraged his self harm.

The parents of a girl who was critically wounded in a mass shooting in Canada has sued OpenAI in British Columbia’s Supreme Court. They allege that OpenAI failed to act on warning signs from the shooters ChatGPT account.

Liability theories are forming. Courts will shape foreseeability, duty to warn and liability. Regardless how these and other cases play out, they will influence practice, insurance and legal environments. I expect to see a significant increase in lawsuits, including families bringing claims related to harm, negligence and failure to intervene.

Clinical Risk

A new scientific review in the Lancet Psychiatry discussedhow AI chatbots can encourage delusional thinking in vulnerable people. It describes how AI can present incorrect or reinforcing content.

How I Am Using AI

I am using AI to edit some of my writing, generate counterfactuals and conduct hostile reviews of my articles. Any research that AI conducts I independently verify. When I do use AI research for an article, I cite it. I use AI to organize and analyze data and provide me with basic visualizations. I have used AI to synthesize themes and evaluate prior work in my career. I have a written doctrine about AI Use and Writing Standards available on my website that goes into much greater detail about this.

AI is not allowed to write a sentence for me. Or suggest a phrase. I write every draft of every article, note, paper, evaluation, play and book.

I created a Student AI Use Guide for my Rutgers Seniors. I will update it throughout the semester and I will provide it to my junior policy students in the fall. After two classes have used it, provided me feedback and, I expect, pushed back on it, I will post an updated version of that on my website.

Provisional Practices

Documentation and Writing: AI may assist with structure or editing. My best practice recommendation is that clinicians should not have AI write notes, treatment plans, treatment plan reviews or discharge summaries. Writing is both an act of thinking and learning. Clinicians who do all their own writing are much more likely to have a better understanding of their case, as well as keeping their skills sharp. The more one uses AI to write, the more one loses the ability to write.

Diagnosis and Clinical Decision-Making: Do not rely on AI to determine diagnoses or treatment decisions. A medical student described using AI so frequently for diagnostic support that he realized he had gone an entire day without independently thinking through a single patient encounter (The New Yorker, “If A.I. Can Diagnose Patients, What Are Doctors For?”). He deliberately pulled back after recognizing the impact on his own thinking.

Input Discipline: Do not enter identifiable client information into AI systems unless you are certain it complies with privacy laws and organizational policy. I believe there are likely widespread HIPAA violations happening all over the country in this regard.

Supervision and Consultation: AI is not supervision. AI carries no ethical duty or liability. No matter what the law or even the professional ethics state in the future, a good clinician should continue to seek human supervision and consultation. My abilities and career were shaped by my supervisors. Woe to the therapist who learns mostly or solely from a computer.

Client Use of AI: Clinicians should ask their clients about AI use. They should find out if they are using AI for guidance or emotional support. College students have told me that they have friends who spend entire weekend evenings chatting with AI. One woman I talked to on a train told me that she was getting advice about how to handle her breakup from AI. To be clear, some people are using AI as a substitute for human interaction. Clinicians should evaluate the impact of a client’s AI use on symptoms, avoidance and functionality.

Verification: Do not rely on unverified AI outputs. Any information used in clinical or professional work should be independently confirmed.

AI Agents: Do not delegate communication or decisions to AI. This introduces legal and ethical risk.

Disclosure and Risk Awareness: Assume AI-assisted content is discoverable. Check with your company’s policy on AI disclosure practices. That’s a bit of a joke, as most companies’ AI policies are outdated, incomplete or non-existent.

In Closing

AI is advancing faster than regulation, and only a few states are beginning to regulate AI as it pertains to the mental health field. Legal standards are going to emerge through court cases, both in the US and internationally. Many people are using AI for guidance and emotional support; there is a particular risk for people who are isolated or have delusional type thinking. Clinicians should be talking to their clients about their AI use and setting boundaries. AI can provide information and responses on a screen, but it does not replace human interaction, in-person clinical judgment or the connection that happens between two people in a room. I wrote about AI’s potential impact on social work in 2024. At that time, I had not yet used these tools directly, but was already concerned about how they might affect clinical work and professional roles. The pace and scope of change since then has been wildly geometric.

I will provide quarterly updates where I will continue to write about legal cases, proposed bills, signed laws, relevant research, summaries of significant articles and my own reports from the field.

Bad Therapy

For the third week of class this semester, my students read a story about a patient of mine that died. Bobby’s severe drug use had damaged his brain and he was painfully aware that he was diminished. At some point each session, Bobby would ask “When will my brain heal?”

I always refused to lie. I told him that he may have done permanent damage but we would never really know until he had a few years of total abstinence from substances.

That exchange shocked my students. They were uncomfortable with the concept of delivering bad news. “You didn’t soften it,” one said.

“That would be bad therapy,” I responded.

Another student softly muttered, “I need to get a new therapist.” A few others nodded. Many of my students get bad therapy. Between their personal experiences and, at times, woeful supervision, they are being trained this way.

Bad Therapy often looks like:

  • Premature reassurance
  • Incorrect validation
  • Ideological Collusion
  • Passing over key moments
  • Avoiding core questions
  • Avoidance due to clinician discomfort
  • Diagnostic inflation
  • Failure to ask foundational questions
  • Failure to review records
  • Failure to reassess diagnosis
  • Failure to recognize origin patterns
  • Forced insight and change too quickly

Some people are in therapy for three years and have not moved an inch.

A 28-year-old woman was anxious about a job she applied for. Her therapist responded, “You’ll get the job. They’d be crazy not to hire you.” The therapist promised an outcome that was actually uncertain. A temporary sense of relief dressed up as insight. This is premature reassurance.

“If you get the job, good for you. If you don’t it, we’ll discuss your next moves and apply for some other jobs.”

A 33-year-old woman often complained in therapy about her mom, boss, co-workers, friends and last three boyfriends. The therapist agrees with each complaint. This is incorrect validation.

The therapist never names the one thing they all have in common.

A right-wing client goes to see a right-wing therapist. The client complains about liberals, immigration, crimes and pronouns. The therapist agrees that America is going down the toilet.

A progressive client goes to see a progressive therapist. The client complains about MAGA, racism and the cost of housing. The therapist agrees that America may no longer be a Democracy. This is ideological collusion, where therapy becomes an echo chamber. Agreement replaces agency.

A group of high school athletes meet with a school counselor to talk about managing their time. One mentions that he is “afraid of my Dad.” The clinician doesn’t stop to address it. This is passing over a key moment.

A couple goes to couples therapy every week for nine months. They argue both in and out of session. At no point did the clinician ask, “Do you want to stay married?” The man didn’t. Nine months had been wasted. This is avoiding core questions.

Well over a decade ago, I listened as a psychologist did a case presentation on a 26-year-old lesbian who had recently left the Navy and was new to Rutgers. She was having relationship problems. I asked her how often the client and her partner were having sex. “I didn’t ask about that,” the psychologist answered. I told her that it was an important question. This is avoidance due to clinician discomfort.

A 23-year-old man goes to a therapist to deal with the death of his older brother several years earlier. The therapist never asks, “How did you find out?” This is one of the most important questions when dealing with grief early on, as finding the body is different than getting a text message which is different than someone calling you on the phone and telling you directly. This is entry trauma ignored, which is often avoidance due to clinician discomfort.

Diagnostic Errors

An 18-year-old female walked into my office at Rutgers in the fall of 2009. “I’m bi-polar and have borderline personality disorder. I have anxiety, depression, ADHD and PTSD. I am in recovery from alcohol, marijuana and hallucinogens.”

“Let’s back up a minute. Tell me your name and where you are from,” I countered.

She had walked in with seven diagnoses. Her identity was wrapped around pathology. She later told me she felt irrevocably broken. This is diagnostic inflation.

I was hired by a program in New York City to help about a half dozen clinicians improve their skills and work on their case presentations. After the first one presented a case involving insomnia, I asked, “How long has this been going on?” He couldn’t answer. Another clinician presented on about an abusive relationship. “What do her friends think?” She couldn’t answer. A third clinician discussed a client’s overly anxious responses. “Where did they grow up? Are her parents alive?” They couldn’t answer. These were blatant failures to ask foundational questions.

A parent of a 30-year-old man at a treatment program that I was consulting with in Pennsylvania contacted me with concerns about her son. Based on her description, it was clear that he had schizophrenia. Years of records were available, but the treating clinician had never obtained them. They only had obtained the records from the referring detox. Even in other areas of medicine, there is sometimes a failure to review prior records.

When I was in the Army, a 25-year-old female soldier mistakenly walked into my office. She was being medically discharged from the Army because she had been diagnosed with bi-polar disorder. She had caught her boyfriend in their bed when she came home a day early from training. She broke up with him, packed up her stuff and moved back in with her parents. She had a hard time sleeping for a few days and couldn’t get her mind to stop racing. She went to the emergency room at Hershey Hospital and the doctor diagnosed her with bi-polar disorder. Ridiculous. She wasn’t bi-polar, she was upset from a break up. I reassessed her and she was able to stay in the Army. Therapists take in clients and often just reaffirm diagnoses instead of reassess them. Diagnosis is not a permanent label, but rather an ongoing process. All too often, therapists and other medical professionals fail to reassess diagnoses.

Just before COVID, a 43-year-old cop came to see me. He was miserable at work; so much that his wife wanted him to quit after 18 1/2 years. He only needed to work another one and a half years to get his pension. He had seen a few other therapists and nothing had helped.

“Well,” I told him, “we aren’t quitting this close to retirement.” I went through his background and learned his father was an abusive alcoholic. I told him that I wanted him to go to three Adult Children of Alcoholics (ACOA) meetings in the next month. When he returned, he had gone to 20.

“After the fourth one, I called my younger sister and said, ‘it wasn’t us.'” Dealing with his family of origin issues lowered his stress baseline and he was able to survive his last few years at work. He actually lasted another four years before he retired. This was an example of failure to recognize origin patterns.

In 2010, a 25-year-old male graduate student came to me for help with his anxiety and “bitchy” girlfriend. I recognized his drinking problem within 15 minutes. I told him that I wanted him to attend Early Recovery Group on Tuesdays and check out a few on-campus AA meetings with some other students. He disappeared for six weeks.

I told my supervisor what happened.

“He left because you were forcing him to a place he didn’t want to go. He didn’t see alcohol as problem. He wanted to work on his anxiety and relationship.”

“Those aren’t his primary issues,” I responded.

She calmly smiled. “To him, they are.”

He returned after six weeks and we worked on his anxiety and romantic relationship fights. After 18 weeks, he started to see the connection between those problems and his drinking. My mistake was an example of forced insight and change too quickly.

I have worked with people who took six months to realize what I knew in 15 minutes. That used to feel like wasted time. Now I accept that it sometimes takes people a long time to recognize their problems.

Some people sit in therapy and never move. A bad therapist won’t push or challenge them, point out when their behaviors aren’t matching up with their values and often engages in going-nowhere-validation therapy.

Disclosure: Mechanical editing and risk-review assistance were provided by a large language model in accordance with my AI Use & Writing Standards. All arguments, interpretations and conclusions are my own.
https://greenagel.com/ai-use-and-writing-standards/

The Greenagel Stress Volcano

From the Greenagel Equations

The Greenagel Equations are a set of practical frameworks developed between 2005 and 2008 in schools, outpatient and family treatment settings. They were built in rooms, not in theory, and have been used with students, families, law enforcement, veterans and therapists.

Everyone has a baseline level of stress. Your baseline depends on a few factors: childhood experiences, parental modeling, adult experiences and your stress regulating behaviors. This model explains how stress builds and when it turns into a crisis.

Stress functions like a volcano. Ideally, the magma level is one’s baseline stress. As we experience stress, the pressure rises. When we experience a crisis, it is like a volcanic explosion. Ash darkens the sky and lava runs down the sides, threatening all in its path.

Some people live near the bottom. Some live near the top. Most live somewhere in the middle. The lower one’s baseline, the greater their capacity to handle stress and emergencies without blowing up. Higher baselines mean that small triggers can lead to an explosion.

As a teenager, I lived near the top and would easily erupt over petty and inconsequential things. Entering recovery at 19 and finding a variety of calming behaviors moved my baseline to the low magma level. This has helped me survive my work.

Everyone experiences increases in stress. Movement up the volcano is normal, for both small and big things. During big Vikings or Dodgers games, my stress level goes up a little bit. The key here is baseline position, not the existence of stress.

Unlike the other equations, I don’t remember the exact moment I came up with the volcano. I know it happened in a substance misuse treatment group though. Clients would talk about how they would experience stress and act out sexually or binge eat or overspend. And while it helped them temporarily, eventually the good feeling passed and their stress level would rise again, sometimes even worse than before because of their actions. They would move down the volcano when they were high, but the next day they would rise right back up to their baseline level. Eventually, I included all of the process disorders as unhealthy ways that people try to manage their stress:

  • Substances
  • Gambling
  • Video Games
  • Screens & Social Media
  • Food
  • Shopping
  • Sex & Pornography

Two consistent factors come into play here:

  1. The relief from these behaviors is temporary
  2. Engaging in these behaviors over a long period of time leads to an increase in the baseline.

Whenever I teach this, whether it is in group, class, trainings or individual sessions, I wait for someone to ask, “How do I permanently move down the volcano?”

I always smile and say, “I was waiting for that question.”

I tell people that these behaviors will help people slowly move down the volcano. They need to be consistently done over a long period of time:

  • Therapy
  • Reducing or, ideally stopping, maladaptive behaviors (drinking, gambling, overeating)
  • Exercise
  • Proper sleep hygiene
  • Healthy eating
  • Time off from work or school
  • Time in nature
  • Avoiding red arrow people
  • Participation in sports, clubs, associations and 12-step groups
  • Enjoyable hobbies
  • A sense of purpose

Consistent engagement in a number of these will move someone down the stress volcano.

For people who had a rough childhood, their baseline stress as an adult will be higher. If you have been trained on or read about ACE scores, you know that a higher ACE score predicts a vast number of physical and psychological problems. That written, ACE is not destiny. Someone can have a high ACE score and still end up being pretty low on the stress volcano. But, I can assure you, they engage in several of the aforementioned positive behaviors.

For people in high stress jobs, their baseline stress will be higher. High stress jobs include but are not limited to the military, law enforcement, fire fighters, EMTs, and emergency room medical professionals. To be clear, not all military and law enforcement jobs are stressful. The highest type of stress comes from a) your own life being in danger b) protecting/rescuing other people in danger c) seeing awful things happen to kids and d) being continually responsible for a number of people.

If you are reading this and identify that you had a rough childhood and you are in a high stress job, you should be on high alert that you are at risk for living at the top of the stress volcano. You might have figured this out already though and have engaged in a bunch of those positive behaviors for years as a way of taking care of yourself.

A couple of years ago, I taught my stress volcano at a State Police Forensic Lab and I later learned that a number of the attendees weaponized it. “Your stress volcano is super high” and “you are making me move up the stress volcano” were phrases employees threw at each other.

I don’t want people doing that. This is not for you to label others or criticize them. It is designed for self-assessment.

Now, if you are in the early stages of a relationship and recognize that your romantic partner lives at the top of the volcano and you are tired of dealing with the explosions, then by all means, leave.

Where is your baseline?

What raises it?

What lowers it?

The goal is not to eliminate stress. The goal is to lower where you live.

The Substance Misuse Spectrum

From the Greenagel Equations

The Greenagel Equations are a set of practical frameworks developed between 2005 and 2008 in schools, outpatient and family treatment settings. They were built in rooms, not in theory, and have been used with students, families, law enforcement, veterans and therapists.

Substance misuse exists on a spectrum from non-use to severe disorder, defined by behavioral, physiological and consequence-based criteria.

I was running a group at Integrity House in 2004 when a client exploded in anger, “I’m tired of all these people telling me I have a problem. You an addict. You an alcoholic. You need treatment. And they keep sending me away to these bitch ass programs.”

“Has anyone ever explained to you how we diagnose someone with substance abuse or dependence?” I asked him.

He immediately calmed down. “No.”

I listed out the criteria from the DSM IV-TR on the board and broke down what each one meant.

Group members started saying what they did and didn’t have. Some confronted each other on their denial. It was a wildly effective group.

I didn’t like how substance abuse had four criteria and substance dependence had seven with only role failure in both. I explained that role failure meant that substance use caused a problem at work, school, with family, with friends, with a romantic partner, legal issues, financial difficulties or health complications.

“All of those?” someone asked.

“No, just one life area needs to be affected.”

I created a spectrum, starting with non-use on the left and then use, abuse and dependence as it moves right. I used role failure as the anchor. Both people who used and those who didn’t use substances were united that they didn’t have any role failure caused by using alcohol or drugs. They may have problems, but they weren’t caused by substances.

For the next nine years, I taught substance misuse as a spectrum, rather than two separate diagnoses. In 2013, DSM-5 came out. It threw out the terms abuse and dependence, got rid of legal problems for diagnosing and listed a clean set of 11 criteria. The APA had come around to seeing this as a continuum, or spectrum. They came to see it my way.

I wanted to include percentages for each group. I looked up data and crosschecked it. For years, it was roughly 20% of adult Americans who do not use alcohol or drugs at all. That about 50-60% use without having any problems and 20-30% meet criteria for a substance misuse disorder. In the 2020s, various data sets place those numbers at 20-30%, 50-60%, and 15-20% respectively.

I have trained and assisted staff and students on the RU Sure Campaign for just about two decades. Their research at Rutgers states that

2 out of 3 students drink 3 drinks or less

and that

1 in 5 don’t drink at all

This breaks down to 20% non-users, which is consistent with my aforementioned data. Whenever I have presented these numbers, especially to people in treatment, correction settings, lawyers, cops or military, I am inevitably met with some version of this comment: “Yo man, your numbers are bullshit.”

People who drink heavily often cannot conceive of that 20% of adults don’t drink at all. “You ever hear the phrase birds of a feather flock together” or “You are identified by the company you keep?”

People nod.

“When I was 15, I was on juvenile probation. My father was horrified. I told him that over half the kids I knew were on probation.”

He responded “juvenile delinquents hang out with other juvenile delinquents. Behavior doesn’t happen in a vacuum.”

Two rules to consider with the spectrum:

  1. If I take 1000 non-users and 1000 users and then look at them in ten years, there will be more people that meet criteria for a substance misuse diagnosis from the using group than the non-using group. This holds true throughout the spectrum. So, the further along you are, the more likely you are to continue.
  2. One of the first people I ever treated was a 53-year-old white female who was a middle school music teacher. She met three of the four criteria for substance abuse. She was unhappy, but didn’t have any work or legal or health problems from her drinking. About a month later, I was treating a 15-year-old boy who also met three of the four criteria. He was having problems in school, had been arrested and his parents were both furious and worried about him. His life was already upended and it was very likely that it was going to get worse if he didn’t stop. So, if someone is young and already meets diagnostic criteria, it is much more likely to get worse than someone who is older.

This is the single lesson I have taught more than anything else in my life. I have taught this in high schools, universities, jails, prisons, hospitals, in-patient and out-patient settings, community centers, Army bases, with individual clients and a number of other settings.

Substance misuse exists on a spectrum from non-use to severe disorder, defined by behavioral, physiological and consequence-based criteria.

This is how I explain the criteria in group settings.

Role failure – One challenging aspect is how people define failure. Some students are good with a C, while another student may view a B+ as a total failure. I think it is a good idea for someone to come to a consensus with a counselor on a fair definition of role failure.

Use despite problems – Healthy people cut down or stop when their substance misuse has caused a health, legal, financial or any other type of problem. A doctor tells you to stop drinking and you counter with reducing your drinking for the time being. A counselor tells you that the anti-anxiety medication will be less effective if you use marijuana and you smoke anyway.

Tolerance – It takes more of the substance to get the same effect, or you experience a weaker sensation with the same amount. People will often use a harder version of the substance (80 proof alcohol instead of beer or 74% THC content in a vape instead of 15% THC in the marijuana plant) or combine substances.

Withdrawal – Most people think of shakes and hallucinations when they think of alcohol withdrawal. Those are late stage alcoholism withdrawal features though. More common are headaches, gastrointestinal issues, fatigue and irritability. The most common physical withdrawal feature of marijuana is sleep problems. Psychological withdrawal includes difficulty concentrating, confusion, memory issues, irritability and lack of motivation.

Confrontation (x2) – The DSM-5-TR asks if you have one person in your life who thinks you have a problem. I don’t like that, as there may be someone who has recently quit drinking and wants to change everyone else or is some kind of evangelical teetotaler. I don’t consider unified parents to be two people; I’m also looking for a teacher or coach or friend or romantic partner or the court system to state their concern.

Use of motor vehicle or machinery or other dangerous activities – The number one instinct in all creatures is survival. If you operate a motor vehicle or other machinery while under the influence, you put yourself at increased risk of injury or dying. This goes against nature. Or you get into more dangerous situations than you would when you were not using, you meet the criteria.

Reducing/changing friends and activities – If you used to play softball, sing, paint or ride horses and now you do those things a lot less or not at all, we need to examine whether your use led to this. If you gave up friends that didn’t drink like you or questioned your marijuana use, you probably meet the criteria.

More use, more time than planned – If you bought a 1.75 liter of vodka and planned it to last all of spring break but it ran out on Wednesday, you’re hit. If you acquired 90 Adderall pills for the semester and are out of them by mid-terms, you meet the criteria. If you planned on smoking until 10 pm but you didn’t stop until after midnight, you got it.

Previous attempts to cut down or quit – You once tried to give up marijuana for Lent and you got to day 15 and then said, “Jesus will understand.” You stopped drinking hard liquor and switched to beer, only to eventually get back on hard liquor or drinking an excessive amount of beer. You said only on the weekends and the weekends started on Thursdays. No more bongs, just blunts. This is my last vape. Any of these and you meet the criteria.

30 Hours or more in a week – A week is made up of 168 hours. If you have ever had more than one week (I’ll give you Jamaica 2014) where you were under the influence for 30 hours, you have it. Family members and friends are often aghast at the 30 hours number: “It’s like a full-time job.” Clients I’ve had at group often scoff at the same figure: “I get to 30 hours by Tuesday.”

Physical or psychological problems caused or exacerbated by use – If you got drunk and sprained your ankle. If you had bronchitis and smoked anyway and it lasted for two months. If you never were depressed but now you are down unless you are using, or you had anxiety and you find that since you started smoking, your anxiety has gotten worse.

How to Handle Death Anniversaries and Holidays: Make a Plan

I recently recognized that I haven’t written about how to handle death anniversaries and holidays in any of my grief articles, despite the fact that this is something I work on with all my grieving patients.

The first year after a death is a massive readjustment period. The first Father’s or Mother’s Day, Thanksgiving, Christmas, Hanukkah, Eid al-Fitr and birthdays often loom large. Common thoughts and statements include:

  • “How do I celebrate now?”
  • “I miss him.”
  • “It won’t be the same.”
  • “I don’t want to do anything.”
  • “Thinking about it makes me upset.”

You have the right not to celebrate. You have the right to not plan anything. You have the right to sit in grief.

However, I think those are very ill-conceived choices.

Without addressing grief, without addressing looming dates, people often not only struggle with holidays, but regular numerical reminders and whole seasons. Unaddressed grief intensifies and spreads.

One client’s sister took her life on March 13th. His father posts pictures and stories on Facebook on the 13th of every month. Another client’s husband took his life in October, and for almost two years, the entire Fall season was difficult.

Besides individual counseling, grief groups, writing, connecting with others and sometimes finding new purposes, I work with clients on planning for upcoming holidays and anniversaries. Here is the playbook:

  1. Make a plan to do something on the holiday or birthday or first death anniversary.
  2. Negotiate and discuss with others what that plan will be. Even if there are other grieving family members who don’t want to do anything or are indecisive, you should still make a plan.
  3. Whatever the plan is, do it in the morning. Otherwise, much of the day is spent thinking and worrying over how it is going to go, how you will feel and how others might respond. If there is a big family meal in the late afternoon or dinner, I think it is wise to say something about the departed, that you miss them and love them and, hey, remember when they said or did this at the last holiday? Give people space to laugh or cry or sit uncomfortably or run out of the room. Do not lengthen or manage it. Move on with the holiday.
  4. For the first death anniversary: installing a tombstone, visiting a grave and reading or telling stories are all excellent plans. After the first death anniversary, I don’t suggest continuing to mark the date. However, if one can find a purpose with the date, that might work. For a few years, I had my friend Eric Arauz come and talk to my high school students about addiction on my friend Frazier’s death anniversary.
  5. In January, my Mom texted me that it was her Mom’s death anniversary and that she was sad. She died in 1979. I told her that it was probably more about her brother Bryan, who died in March of the previous year, making this the first time that she didn’t have a sibling to talk to about missing her parents. I suggested that she engage in some activity her Mom liked and go do something positive. She recognized that she was grieving her brother. This is common; anniversaries often activate other losses. She ended up going to the gym and went swimming.
  6. I’ve told people to eat some food that their Dad liked on his birthday (as long as they liked it too). I’ve had others do things with their daughters that they used to do with their sisters. This shifts grief from passive recall to active behavior.
  7. If you feel overwhelmed, you can have a long cry. But, do not stay in bed all day. Do not isolate. Get up, shower and go be around other people. Even if you don’t want to. Go do something even mildly productive.

I’m currently running a grief group. During the first session, many of the participants stated that they were comforted that they weren’t alone. “I have been so overwhelmed with sadness and I’ve also been angry at the rest of the world for just moving along,” one member started, “and to hear that other people experience this makes me feel a little bit better.”

Early on, grief can feel insurmountable. Looking back on it, we can remember it was painful but perhaps not even grasp how debilitating it felt. Grief writing plus therapy plus planning can help process and reduce the intensity over time.

Do not allow birthdays, holidays and death anniversaries to dominate your thinking or fill you with dread. Make a plan and follow through.

Enabling and the Cost of Good Intentions

The 93-year-old woman was waiting in her car. The passenger door opened and her 67-year-old son got in. She asked him how it went and he said fine. The word and tone were familiar, as she had been hearing it from him for over 50 years.

She was driving because her son had lost his license after another DUI.

I learned about her case because a graduate student of mine was working with her. They were working on what happens to him when she dies.

Whenever I tell that story to a room full of families, I’m met with a mixture of gasps and stunned silence. Because so many of them see the ghost of Christmas future.

This is the cost of good intentions.

Enabling is doing something for someone that they should be doing for themselves or protecting someone from earned negative consequences.

It feels like love.
It often looks like loyalty.
It functions as avoidance.

There was a woman who had been in multi-family group for a couple of months. One day, seemingly out of the blue, she blurted out “I’m the chief enabler.”

She cried.

In groups over the next few months, when new parents introduced themselves, she would say “I’m Susan. I’m the Chief Enabler.”

The psychoeducation in multi-family group, Al-Anon attendance and her own therapy helped her towards recognizing her role and behaviors. One she saw it, she changed. And her son got better. Significantly and often lost in the tumult of a son in treatment, she got better too.

Enabling behavior includes:

  • Giving money
  • Paying legal fees.
  • Defending their bad behavior.
  • Calling employers with excuses.
  • Making appointments.
  • Opening mail.
  • Listening to them gripe for two hours a day.
  • Complaining about “how others treat them.”
  • Lying to family members.
  • Taking over responsibilities.
  • Driving them after DUIs.
  • Threatening consequences and not following through.
  • Allowing them to live at home without expectations.

Every one of these lowers the cost of the addiction.

Every one of these delays their ability to see themselves clearly.

Meanwhile, the enabler often suffers through some combination of anxiety, resentment, embarrassment and identity collapse.

This is the social normalization of dysfunction. It can repeat multi-generational blue-red patterns.

It can lead to a 93-year-old woman driving her 67-year-old son around to his appointments.

Do not confuse support with enabling.

Support says “I love you and I will not help you destroy yourself.”

In Al-Anon, parents, spouses and loved ones learn the three C’s:

  1. I didn’t cause it.
  2. I can’t control it.
  3. I can’t cure it.

So, stop giving money. Stop defending their bad behavior. Stop listening to them gripe on the phone for two hours a day. Stop driving them around after a DUI. Stop threatening consequences and not following through.

If they crash, it may interrupt the illusion.

If you cushion, you extend it.

You cannot prevent all harm. You can stop participating in it.

Trust = Consistency × Time.

Short stretches of sobriety do not equal restored trust.

Boundaries are not cruelty. They are math.

If you value accountability,
your behavior must reflect it.

If you value dignity,
your behavior must reflect it.

If you value love,
your behavior must reflect it.

Live your values.

The Hobby Matrix

From the Greenagel Equations

The Greenagel Equations are a set of practical frameworks developed between 2005 and 2008 in school, outpatient and family treatment settings. They were built in rooms, not in theory, and have been used with students, families, law enforcement, veterans and therapists.

A life concentrated in one box is a life vulnerable to collapse.

The Hobby Matrix was created in an early recovery group at Hunterdon Drug Awareness in 2009 or 2010. People were there with six to 12 months sober. We were working on increasing their activities and friends. I saw that people leaned inside or outside, solo or group.

I started drawing four boxes on the board and asking people to mark where their time actually went. Most people were dominant in one or two areas. I almost never came across anyone who had multiple checks in all four boxes.

How It Works

Draw four boxes.
Ask where time goes.
Look for zeros and clustering.
Increase breadth.

I treated a 17-year-old who spent nine hours a day watching short videos. He watched all day, every day. During school and well after midnight. He had drifted away from friends and activities.

Inside/Solo – dominant and unhealthy.
Everything else – empty.

Interventions:

Reach back out to friends from the neighborhood
Reach back out to kids on the academic team
Start playing baseball again
Go to the gym
Hike with his father
Watch movies

He went back to baseball. The gym started but was intermittent. Still, a win. He hung out with friends and made some new ones. He even went to a couple of parties, which alarmed his mother, but I told her it was a good thing.

A 33-year-old woman had a breakup over different views of having kids. She had spent the last two years on relationship island and alienated her friends. Shopping was a big coping skill that had gotten her into some financial problems. I was concerned about her possibly drinking to escape or seeking rebound relationships. The breakup happened in winter.

Inside/Solo – biggest risk.
Outside/Group – rebuilding required, hard in winter.
Inside/Group – reconnect with friends, avoid bars.
Outside/Solo – exercise is an underused strength, more likely in summer.

Book a solo trip for summer that is high on physical activity. Exercise two to three times a week to prepare for it. Reach out to friends and plan a few group activities.

Mid-20s woman. Social butterfly. Easily had two to four things to do each day on the weekend. Organized canoe trips, axe throwing, escape rooms, fancy dinners, concerts and dancing. During the weekday, she just went back to her apartment and scrolled while watching television. She could not imagine going to a movie or restaurant by herself. Had no problem ordering take out almost every night.

Inside/Group – dominant, healthy.
Outside/Group – dominant, healthy.
Inside/Solo – empty.
Outside/Solo – empty.

The inability to eat alone is the key behavioral marker. Try going to a restaurant by yourself. Don’t scroll. Bring a book.

A 57-year-old retired cop. No friends, no hobbies. “When I was on the job, people contacted me all the time. Now I know it was because they wanted something. I worked nights and weekends and crazy amounts of overtime. I gave up hunting and fishing in my 20s.”

Pre-retirement:

Inside/Solo – empty.
Inside/Group – co-workers.
Outside/Solo – gave up activities in 20s.
Outside/Group – built-in contacts, built-in structure.

Post-retirement:
Everything – empty.

Interventions:

Start fishing and hunting again
Look into fishing and hunting clubs
Consider volunteering. Ex-cops like to feel useful.
Consider return to religious services
Won’t do gym; would try swimming. Good for winter exercise.
Open to getting a dog
Suggested reaching out to other retired cops to start a breakfast group

He joined a hunting club. The following year, he went on a hunting trip to Montana. He went back to Church and found volunteer work with them. Another ex-cop organized a breakfast group and he went.

A life concentrated in one box is a life vulnerable to collapse.

It is not about hobbies.

The Hobby Matrix does not require equal time in all four areas.
It does require at least one viable activity in each quadrant so one can be engaged in any environment.

Which quadrant is empty? Which one dominates?

The Math of Trust

From the Greenagel Equations

The Greenagel Equations are a set of practical frameworks developed between 2005 and 2008 in school, outpatient and family treatment settings. They were built in rooms, not in theory, and have been used with students, families, law enforcement, veterans and therapists.

Tr = C x Ti

Trust = Consistency x Time

If consistency is low, trust remains low, no matter how much time passes.

If time is short, trust remains low, no matter how sincere the behavior is.

Only when both increase does trust rise meaningfully.

Multiplication matters. Not addition.

I developed this in an outpatient group. Clients in early recovery complained

  • “I’ve been sober for three weeks. Why don’t they trust me?”
  • “It’s been six months. What else do they want?”
  • “It’s been two years. Why are they still cautious?”

They confused improved mood, verbal remorse, insight, intentions and sobriety with trust.

The equation cut through it.

I originally wrote it as consistency over time. A client corrected me. “Divided doesn’t work. It’s multiplied.” He was right.

Trust is behavioral. Not emotional.

Hope. Love. Guilt. Fear.

None of these belong in the equation.

Only

  • What do you consistently do;
  • over how much time

Trust is rebuilt over small repeated behaviors. Over long stretches. Without drama.

You don’t earn back 10 years of broken trust in 90 days.

A client at three weeks sober:

  • C = high
  • Ti = extremely low

Multiplication keeps trust score low.

This helps families see they are not cruel or unforgiving. It shows they are rational.

A husband who has been caught texting other women three different times over an eight year marriage:

  • C = low
  • Ti = high

It shows she is rational.

Trust is not repaired by apology. It is repaired by predictable behavior over time.

I had a client who, in his addiction, burned his parents’ house down.

He talked about it in our first group. That was about ten years ago. His family came to multi-family group. It was his mother and stepfather – which added its own layer of tension and history. We didn’t go near the fire. We worked on the basics: staying sober, going to group, telling the truth, no drama.

The family kept coming.

At nine months sober, during a three chair exercise in the middle of the room, he apologized for burning the house down. It was touching and slightly funny at the same time. Every witness had the good grace not to laugh. There is no small way to say a sentence like that.

Over time, he was allowed to visit the new home. Trust was not restored because of the apology alone. It was rebuilt because of consistent behavior over consistent time.

  • C = high
  • Ti = medium

Trust returned slowly.

Students at Elizabeth once described a male social studies teacher as being “on the rag.” I was writing at the board when I heard it. I turned around.

“That is not appropriate.”

“Mister, he is. Some days he is easy going. Other days he comes in and it’s like his wife told him she wanted a divorce at breakfast. We never know what we are going to get.”

“Well, that’s a better way to put it,” I said.

The male social studies teacher:

C = low

Ti = high

“With you we know what every day is going to be like,” they said.

C = high
Ti = high

Blue-Blue, Blue-Red, Red-Red

From the Greenagel Equations

The Greenagel Equations are a set of practical frameworks developed between 2005 and 2008 in school, outpatient and family treatment settings. They were built in rooms, not in theory, and have been used with students, families, law enforcement, veterans and therapists.

Every relationship you have ever had fits into one of three sets: Blue-Blue, Blue-Red or Red-Red.

Romance, family, work, strangers.

The Blue represents healthy behavior. The Red represents unhealthy behavior. Red behaviors include but are not limited to yelling, insults, breaking promises, public humiliation, lying and cheating.

Which relationship type is stable?

Blue-Blue is stable. I’m healthy to you, you are healthy to me.

But Red-Red is also stable. And stability does not equal health.

One cold December day I was walking in Elizabeth. I came up on an old couple. They were shrunken and slow moving. They were dressed neatly. I thought “what a cute couple.” As I got close, I heard one sharply say, “you didn’t send the fucking Christmas cards!” I was horrified and rushed passed them. I wanted to get away from them as fast as possible.

They were Red-Red. And, I’m speculating here, they had probably been Red-Red for fifty years. This can last decades. In fact, it can be passed down from father to son, grandmother to granddaughter.

Both parties operate on the same rules. Escalation is mutual. Neither expects regulation. The chaos is normalized. It’s a truly awful way to live.

What about Blue-Red?

It’s unstable. It can’t stay this way forever.

The Blue person here often wonders if they are crazy. They are playing by Blue rules. The Red partner is not. The Blue partner assumes fairness. The Red partner assumes dominance or chaos. That destabilization creates anxiety, self-doubt and hypervigilance.

What does the Blue want?

For the Red to become Blue.

It’s the least common outcome.

What is more likely to happen?

Blue becomes Red.

At some point, Blue cracks. They say something awful. They yell. Maybe they act out by drinking, gambling or cheating. The point is, by staying in the relationship where they keep living with bad behavior, they slowly morph into Red. This is the most common outcome.

There is a third outcome though.

Blue leaves.

In couples or family therapy, I try to help Blue figure out if they are turning Red, they should try to set boundaries or leave.

I usually try to get Blue to leave. But if Red shows some willingness to work on themselves to change, they can wait around a bit longer, if they want. It depends on a few factors, including safety, how long this has been going on and how much damage has already been done.

I was treating a cop. His wife wanted a divorce after 18 years. He was devastated. He tried to save it. No. So he did everything she asked, hoping he would win her back. She was mean. He thought he was Blue-Red. I told him he was Red-Red, because he was unhealthy too. Not unhealthy mean, but unhealthy accommodating. He eventually got better. Then he started dating Mary. Mary really liked him and wanted to settle down. He liked her, but not as much as she liked him. And he didn’t want to settle down. From his perspective, she was Red and he was Blue. I told him because he was leading her on, knowing that she thought he would change but he never would, he was in fact Red. He saw it clearly. And he finally broke it off.

Red and Blue are behaviors, not fixed identities. The same person can be Red in one relationship and Blue in another.

Red doesn’t mean evil. It doesn’t always mean cruel. It just means unhealthy. Excessive accommodation. Self-erasure. Begging for love.

Almost everyone has been Red in some relationship in their life. When we recognize it, we gain some wisdom. When we start to change from Red to Blue, that is real growth.

Once you have labeled your relationships, you can figure out which ones you want to put more time into and which ones you should cut, and which ones might be worth a little effort to save through change.

If your behavior depends entirely on how someone else behaves, you are not free.

Your relationships impact who you are and who you will continue to become. I eventually removed myself from all the people who engage in red arrow behavior in my life. It can be done.

Behavior–Values Matrix

From the Greenagel Equations

The Greenagel Equations are a set of practical frameworks developed between 2005 and 2008 in schools, outpatient and family treatment settings. They were built in rooms, not in theory, and have been used with students, families, law enforcement, veterans and therapists.

I had a drinking problem when I was 18. It was hard to get alcohol. A friend of mine said there was an old lady in a town about 15 miles north of us that would buy it for us. She was 30. She lived in a ramshackle apartment building. The inside was dirty and sparsely furnished. She was smoking and there were a couple of pots on the stove. There were two kids, a girl who was maybe six and a boy who looked eight. There were two old people. I asked if they were her parents. “No, I watch over disabled older people. They’re nice enough,” she giggled. And then, “let’s go.”

I was startled. She meant to leave the kids and the disabled old people alone with the pots cooking on the stove. I didn’t like that. She was at the door with her bag and looked at me. “Let’s go.”

I turned and followed her out the door. I knew better and moved forward anyway. On the drive to the store, in the parking lot and on the way back, my whole body was churning. “This is wrong,” I thought. “I wasn’t raised like this. Those people should have never been left alone.”

My heart was pounding when we got back to her apartment. Everything was fine. The boy had made macaroni and cheese. Nothing had happened. It didn’t matter. It could have. I was horrified. My desire for alcohol had caused me to do an awful thing. I betrayed my values of protecting others by putting four vulnerable people in danger. I look back on that afternoon with piercing regret and deep shame.

I intentionally got blackout drunk as fast as possible. It was the only time I actually drank to blackout. The other times, it had been a side effect of my heavy drinking. This time I planned to get blotto. It temporarily helped. When I woke up, the regret washed back over.

Looking at this matrix, my values were high but my behavior was low. I was in conflict. I felt guilt and then shame. If my behavior had matched my values, I would have felt at peace, or at least comfortable. If my values had been selfish, I wouldn’t have felt anything at all.

I was working at Hunterdon Drug Awareness (HDAP) in the summer of 2005 and running groups in jail for men and women. One of the clients in there was a 19-year-old man who had been arrested eight times in the last year for marijuana possession, including twice on the same day. He was in jail this time because he tested positive for marijuana while on probation. He loved smoking weed but didn’t want to be in jail. On the spot, I drew up this matrix.

“Let’s say that saying ‘I don’t want to be in jail’ is a high value. Therefore, ‘I don’t care if I’m in jail is the low value.'” On this, he agreed. I continued, “Based on the fact that you are on probation and have been told you cannot smoke weed, we’ll put staying away from weed as a high behavior and smoking as a low behavior. Because you are on probation.” He begrudgingly agreed.

I showed him that his values were high but his behaviors were low.

“Either stop smoking weed and stay out of jail or change your values and accept jail as a consequence.”

The room went silent.

He saw it.

The fantasy he wanted:
Bad behavior + good value outcome.

That. Does. Not. Exist.

This applies to:

Career. “I value excellence.” Do the minimum.

Marriage. “I value loyalty.” Cheat.

Parenting. “I value presence.” Always on phone.

Friendship. “I value honesty.” Avoid hard conversations.

Nation. “We value rule of law.” Ignore it when convenient.

At some point in their lives, almost everyone has betrayed some value of theirs.

Behavioral change is not about:

Self-esteem. Validation. Affirmations.

It’s about:

  1. Stating your values.
  2. Recognizing your behavior.
  3. Matching behavior to your values.

No one escapes this math.

Live your values.