Psychologists often encounter clients from varied language and cultural backgrounds, which can pose challenges to the process of helping. The case of "Mary," an unmarried, 24-year-old Chinese international student in the U.S., embodies these dynamics and offers insights into how culture and language shape, and are shaped by, the therapy alliance, process, and outcome in bilingual therapy. Mary was seen in individual therapy that combined a multicultural, relational psychodynamic, humanistic, client-centered, and solution-focused approach by one of the authors (Y.X.) for 10 sessions (over a 14-week period, with four cancellations); and the therapy was supervised by the other author (J.N.F.). Mary’s presenting problems included challenges in adjusting to her new environment, including a decline in self-confidence and difficulties in her social life, which led to significant anxiety in her daily life. To enhance understanding of the course of therapy, we employed an adapted version of the Critical Incidents Technique (CIT) to analyze significant moments in Mary’s 10 sessions. We focus on the role of language use in bilingual therapy, exploring its functionality as both (a) a buffer against the intense impact of emotional and traumatic experiences, and (b) as a bridge that can foster deeper psychological engagement. We highlight the mechanisms by which the therapist, with supervision, attempted to provide Mary with a meaningful and helpful psychotherapeutic experience. The core theme in our analysis of the case includes the ways that Mary uses her primary (Mandarin) and secondary (English) languages to avoid, and then access, hurtful and traumatic experiences.
Fuertes and Xu (2026) present a case study examining the psychological roles of language in bilingual psychotherapy through their work with “Mary,” a Chinese international graduate student navigating anxiety, shame, and acculturative strain. In this commentary, I focus on two main areas: (1) clinical decision-making and mechanisms of change through treatment, and (2) the broader theoretical, training, and service delivery implications that arise from the work. In both areas, language is emphasized as a tool for affective regulation and psychological defense. I also highlight the timing of linguistic challenges in building the therapeutic relationship and the role of the supervisor in providing a supportive and reflective holding environment, and examine the complexities in interpreting outcome data, particularly when changes in symptoms do not clearly match signs of psychological growth. Institutional factors, such as the limitations of short-term university counseling and the need for supervision that responds to cultural and language differences, are also discussed. Overall, the case serves as an insightful way to understand bilingual psychotherapy not merely as treatment across two languages, but as a process that takes place through multiple emotional, relational, and language domains.
This commentary discusses the case studies of "Fran" and "Emily," treated by Sam Hamburg (2026) with Paradoxical Intention (PI) combined with hypnosis to address panic disorder and agoraphobia in Fran and aviophobia in Emily, with both patients showing a rapid positive response. Hamburg (2026) presents a compelling and novel approach to treating anxiety disorders in just three sessions, a notable departure from traditional CBT protocols that typically require 6–20 sessions to see clinically meaningful change. Drawing on our expertise in third-wave CBT frameworks, including Acceptance and Commitment Therapy (ACT) and Dialectical Behavior Therapy (DBT), we highlight strengths of Hamburg’s approach while identifying areas that warrant further clarification. We then propose an alternative mechanism of action in Hamburg’s treatment with "Fran" and "Emily," with particular emphasis on the inhibitory learning model as a process underlying PI combined with hypnosis. Finally, we underscore the importance of approaching techniques such as PI and hypnosis with both openness and caution in the treatment of anxiety disorders given the limited empirical evidence.
We provide commentary on the article Paradoxical Intention (PI) Combined with Hypnosis in the Rapid Treatment of Anxiety Disorders: The Cases of "Fran" and "Emily," by Sam Hamburg (2026). We highlight strengths of the article, including its effort to identify the active elements of treatment, as well as its use of case observations in an effort to advance the field of psychology. We also discuss several areas of weakness, including the use of unclear definitions of “success” in treatment, focus on habituation-based exposure, and lack of acknowledgement of research-supported treatments that include principles of paradoxical intention within their intervention.
Paradoxical intention (PI) is a psychotherapeutic technique that is intended to help clients become more flexible, or at least more open to thinking about their problems, such as anxiety, from a new perspective. In line with this I have developed an approach that involves a "Panic Attack Time Line" (PATL). This PATL (a) helps the client visualize and understand what is happening during the panic attack, and (b) encourages them to understand why, when they start to have panicky feelings in their body, it will be paradoxically helpful to make these feelings worse, for example, if the attack makes their heart beat faster, they might be instructed to do jumping jacks. One of the important advantages of this PATL approach is that it can typically shorten therapy for treating anxiety disorders to just three sessions in comparison with traditional CBT protocols that typically require 6–20 sessions for achieving clinically meaningful change. Two, 3-session adult individual cases, "Fran" and "Emily," are presented to illustrate the different ways that the PATL-grounded, PI approach can be combined with hypnosis to produce successful therapeutic outcomes. In Fran’s case, the PATL was used explicitly by itself with her and was sufficient to address her agoraphobia/panic disorder. Hypnosis was then used to extend the gains produced by PI. In the case of Emily's aviophobia, the PATL was not used explicitly with her. Rather, the paradoxical logic it embodies was used to create a paradoxical directive that was conveyed via hypnotic suggestion.
