Preposterous Quote – No Limits

CAUTION! PREPOSTEROUS QUOTE AHEAD!

OF COURSE there are limits on what you can accomplish! There are limits associated with the natural world, limits associated with the power you have to impact your environment, limits to your own neurology, limits to your current level of functioning and talent, limits because you can’t accomplish multiple things if they are contradictory or have to be prioritized.

Thinking you have no limits is literally delusional!

How about this? Learn your limits, and encourage yourself to stretch a little past today’s limits in a valued, valuable area.

Comment with your improved version!

Easier to believe what we fear


It’s easier to believe what we’re afraid of…


It’s easier to believe what we’re afraid of, than what we hope for. (Almost always, for almost everyone.)

I can’t tell you how much it changed my practice when I realized this phenomenon, and began explaining it to clients. Here are two ways to think about it.

 

  • Let me tell you a story about evolution. (Just a story, mind you. This isn’t the time to get bogged down in phyla and epigenetics and all that.) Long ago, there were two kinds of people. One group of people saw a coiled vine and assumed it was a coiled vine. They were promptly bitten by a sneaky snake and all died. Thus, they have no living descendants. The other group of people saw a coiled vine and jumped away, thinking it was a snake. They did a lot of unnecessary jumping, a little necessary jumping, and a lot of staying alive and going on to make babies. They are our great-great-grand-cestors. So, we’re all evolved to be a little jumpy (get it? “jumpy”? haha!).
  • If you don’t like to think about it think way, you can also think about it from a very pre-frontal cortex, literature informed stance. Humans tend to be risk averse – a loss of $5 is more distressing to us than a gain of $5 is joy-inducing. In any given situation, we’re likely to put more emphasis on what we could lose than what we might gain. Fear and aversion conditioning (under most circumstances) also happen faster than other kinds of associative learning. So, if you mistake a snake for a coiled vine once and have a near miss – you’re quick to avoid vines in the future. (But you don’t so quickly change your approach to potential snakes when just one turns out to be a vine – thank goodness!) So, it’s easier to believe what we’re afraid of than what we hope for.

 

Let me just give you a few examples of application:

I know you’re already thinking of your classic GAD catastrophizer. Good, that’s #1.  Also, this leads to exacerbated social anxiety, as clients overestimate the likelihood of negative judgment. It contributes to the ever-building cause-effect sequences in OCD, because clients misjudge the likelihood that events are related. Phobia maintenance, misinterpretation of panic symptoms, etc.

And it’s not limited to anxious clients. This is the dad who can’t listen to his teenager’s needs because of his fear for her safety. It’s the workaholic (whose husband is in therapy because she can’t squeeze it in) who doesn’t realize she has a dual income family. It’s part of what maintains the hopelessness of your depressed client, the migraines of your “under-adequate”-mom client, and even the frantic relational grabbiness of your client with BPD.

Also true in your couples – when one partner is afraid of being cheated on again – he wants to hope it won’t happen again, but it’s much easier to be afraid that it will. When sex is painful, she wants to hope that it won’t be next time, but she’s afraid it will be. That’s easier to believe, and that leads to tension, and that leads to more pain. When he has an erectile “failure,” it’s harder to hope it won’t happen than to be afraid it will, and that leads to performance anxiety, and that leads to more “failure.”

It’s the beginning of so many self-fulfilling (self-defeating!) prophecies. And while we can’t change the fundamental neurology (and maybe don’t want to), bringing our own and clients’ awareness to this little quirk of our brains can help us all to pause, and bring a little more prefrontal cortex to our otherwise limbic reasoning. Here are a few specific things that can help:

 

  • Accept their fears with gentleness, and help them to extend self compassion
  • Work on reducing the actual and/or perceived consequences of the feared event
  • Co-create strategies to gain information that will help client evaluate potentially fearful situations
  • Teach this phenomenon to help clients reduce their emotional reasoning

 

Comment below with examples of how you’ve seen this in action with your clients!

 

 

 

 

Before burnout begins


Before burnout begins…


How do I know when my client load is getting too high?

 

First, let’s define “client load.” Number of clients is part of it, certainly. Number of clients divided by number of available sessions and days at work is also a part of it. (Having 16 clients in 16 session spots over two days is way different than having 16 clients in 35 session spots over 5 days!) But clients aren’t all created equal. So, a lot has to do with combinations of clients, your own feelings of effectiveness and meaningful work, diagnoses and personality types you work with best, if you’re one of those clinicians who gets energy from couples/families vs. finds them to be energy vampires. So, how many clients we have often has very little to do with if our client load is too high.

I think we’ve been trained to notice when it’s already too late. You know the signs of burnout, right? You have trouble getting out of bed for work, you’re “phoning it in” with clients, you can tell you should care but you don’t, you are isolating from colleagues, you’re catastrophically behind in your documentation and yet not making headway, you’re emotionally numb or nonreactive.

And before burnout comes overstress. That’s when you wake up anxious before work, “bring clients home” with you mentally, begin dropping behind on documentation and feel pressured to catch up, having trouble shutting your mind off, are cranky or a bit emotionally reactive even at home.

It’s also quite good to notice this before you really get all the way to overstress and/or burnout, because if it gets that far, and you need to reduce your load, that can be another additional stressor.

I’d like to share a few ways I notice when I’m reaching my effective client load limit.

  • I’m not learning something new for a client
    • There’s never a time when I have a case load that is so low or clients who I know so well or I’m so “knowledgeable and competent” that I don’t have something to be learning outside of session. Sometimes, that’s psychotherapy theory or skills related; sometimes, it’s learning about something that’s relevant in a client’s world (e.g., the path to professional soccer, the pokemon universe, and Japanese cultural mores around drug use have been things I’ve learned about recently). If I don’t have the mental space and time outside of session to be learning something for a client, it’s a sign to me that I’m needing to use all of my non-client time for family and self-care. That means the next thing that will slip will be client care!
  • I’m bored or distracted in session (with a client I’m not usually bored or distracted with)
    • Some clients are boring, and that’s good clinical information. Some clients are distractible, because it’s part of their diagnosis. And I get distracted in a way that’s normal for me, that’s session related. But when I get bored with a not-boring client, or distracted (especially by thinking about other clients during one client’s session), that struggle to “stay present” is an early sign to me that client load, in the mental capacity way, is getting too high.
  • It’s takes more than 20 minutes at the end of the day to finish notes
    • For me, I almost never take notes in session after the intake. Also, I’m quite bad at letting clients out at the :50. So, I usually end up with about 3-6 minutes to write notes, read last week’s notes on my next client, and maybe do one other thing (this is either run to the restroom, refill my coffee, or do a super quick meditation or centering exercise). My notes include two main parts – a summary of the important session material (so I can read it next time before session), and “the boring stuff” – client name, date, session #, MSE check boxes, treatment plan updates, etc. So, I write the summary in my 3 minutes along with the client’s name right after session and then I leave the “boring stuff” for the end of the day. It’s no problem to finish the final note and 6 “boring stuffs” in 20 minutes. If I’m not able to, it’s because I mismanaged myself during the day, and that’s usually because my client load is too high. I’m keeping clients extra long and then running behind, I’m not taking time for centering, or I’ve struggled to summarize.

Noticing is one thing. Committing to doing something about it is another. Ask your favorite colleague, your best non-work friend, and the person you share a budget with (if you have one) to all help you commit to delivering excellent care by acting when you’ve noticed you’re approaching your limit, not past it!

Comment below with the ways you notice you’re approaching your limit!

 

 

 

 

Great Books Volume 1: Indispensable Psychotherapy Classics


Great Books Volume 1: Indispensable Psychotherapy Classics


By far and away, one of the most common questions I get from students and supervisees is “what should I read to learn more about xyz?” Great question! And I love answering it, as well as teaching how to identify a good source (maybe that’s a good idea for a later post!).

I love to read books in the field, and I especially love to read the founding fathers and mothers of psychology and psychotherapy. I think this might come from having my own learning influences that emphasized primary source material, and also definitely from teaching Theories of Counseling and Psychotherapy. Textbooks never do justice to the real authors.

Definitely, in some later posts, I’ll talk some about specific books in more detail. Here, I’d like to give you a list of what I think are the best primary source books for psychotherapists. I’m defining “best” here as a combination of most foundational and most useful (so you’ll notice that Freud doesn’t make the list, even though he’s FREUD. And other favorites like William James’ Principles of Psychology. Sigh. Another day.) I’m also going to (painfully) limit myself to one per author.

 

  • On Becoming a Person (Carl Rogers)
  • What Life Could Mean to You (Alfred Adler)
  • The Undiscovered Self: The Individual in Modern Society (Carl Jung)
  • Your Many Faces (Virginia Satir)
  • The Gestalt Approach and Eye Witness to Therapy (Fritz Perls)
  • Focusing (Eugene Gendlin)
  • I’m OK, You’re OK (Thomas Harris)
  • Warning: Psychiatry Could Be Hazardous to Your Mental Health (William Glasser)
  • Strategies of Psychotherapy (Jay Haley)
  • The Doctor and The Soul (Viktor Frankl)
  • Life Without Fear (Joseph Wolpe)

 

Ok, I can already tell that future lists are imminent! There are SO many books that I’m having trouble not listing! But start with these. You’ll be glad you did!

Comment below and let me know the book you think I missed!

 

Seven +/- Two


The Power of 7 +/- 2

(How Working Memory Works in Therapy)


How many things can you remember to get from the grocery store without writing it down? Well, never mind, I guess I already gave you the answer. Obviously, it’s 7+/-2. Or it is for most people.

And you probably learned about this in your intro psych class in college. But how is it meaningful in therapy, you ask?

It’s meaningful because your brain, and your clients’ brains, are pinball machines. You can really only hold about seven pieces of information in your brain at a time, and relatively small pieces of information at that. And they just “bounce around in there,” ad infinitum, unless we do something intentionally to get them out. And here are three ways that we can capitalize on this quirk of our brains in therapy.

 

#1: Journaling

I know that you already know that journaling is awesome. I know you could extol its benefits to almost any client, I know that you’ve seen it work its magic, maybe in your own life, and (because I’m a therapist, too) I also know that you sometimes recommend it for clients as homework just because you don’t know what other homework to give them. (We all do it!) And that’s OK, because journaling is pretty safe and, let’s face it, it sort of is magic. What you might not realize is how the 7+/-2 function of the working memory plays into the effectiveness of journaling, and how you might be able to use it even more intentionally and beneficially than you have been. One of the ways that we can get those bouncing pinballs inside our brains to get out is to write them down. I’m sure you’ve given this assignment to your anxious clients who have trouble getting to sleep at night because their pinballs are all the worries that they have about the next day. And you encourage them to put a pen and paper next to their bed, so that they can write down any anxious thoughts that they have or anything they need to remember for tomorrow, temporarily letting it go so they can sleep. Great!

Occasionally, that has unintended consequences. And you have a client who, instead of staying up for two hours thinking about the same five worries over and over, stays up for five hours writing down all the worries that came up after they wrote down the first five. And while they don’t like that very much, that’s part of the magic. When those five, seven, or nine thoughts keep bouncing around, they don’t leave any space for anything new. They don’t leave any space for other worries or concerns, and then those get kind of trapped, unexpressed, maybe even living inside and wreaking havoc on the client’s body. (More on this kind of thing in another post.) So they are not aware of, and cannot make you as their therapist aware of, all of their legitimate concerns. Journaling helps them to flesh all of those out. As if that weren’t enough, those seven pinballs also keep other new thoughts from coming in. Hopeful thoughts, new solutions, brilliant ideas, etc. So, one of the ways that we can take advantage of the 7+/-2 principal in therapy is to use journaling in a targeted way, whenever we want to give clients freedom to explore both the true breadth and depth of their concerns and also open them up to new possibilities.

 

#2: Healthy Conflict

Ok, how often have you had a couple in therapy and they’re discussing their latest argument, and the one of them who remembers everything perfectly (because there’s usually one) pulls out some exact quote from the other person that was really hurtful, and then the other person says, “ok, yes, but I was mad, I didn’t mean it!” And naturally this never satisfies the hurt partner, and they don’t believe them.

(Let’s be very honest, how often have you said that? And you know you didn’t really mean it, and your partner doesn’t buy it. And how often has your partner said that, and you didn’t buy it? Hmmmm?)

Let’s put this in the context of 7+/-2. When we’re upset about something, we ruminate. It’s one of the easiest times to see 7+/-2 in action. One thing that our boss/mother/partner/kid/etc. says – we just repeat it over and over along with a refrain of “how dare they,” and a chorus of “I didn’t deserve that.” That’s it. Over and over. And that’s bad enough by itself, right?

But then, we actually bring it up with the other person. And as we are “having our say,” we start with all of those things (pinballs) that have been bouncing around. After we say them out loud… That’s right, they’ve made a way for brand-spanking-new thoughts. Brand new thoughts with brand new words that we haven’t taken the time to decide whether or not we want to say. And because all of those pinballs have just made space, in the heat of that moment, all of these new, unfiltered, unevaluated, and probably regrettable words just fall out. That’s what’s happening a lot of the time when we say “I was mad; I didn’t mean it.” And you know what? It’s pretty much true.

We really don’t want to base our jobs on an unedited report that we threw together at 2am without really thinking about it. That’s not our “real work.” Our real work is composed, thoughtful, edited for appropriateness, thorough, concise, and clear. That’s what we want our bosses to judge us on. Our best. And that’s what we want to give to our partners, and what we want them to judge us on as well. So, you can teach this to couples along with other techniques for conflict management (more on this in another post), and help them to keep their pinballs from falling out and rolling all over the floor.

 

#3: Person Centered Therapy

PCT is just magic right? Right. But seriously, past the humanistic underpinnings, have you ever wondered-in a technical sense-how person centered therapy works like magic? I think I have an idea. Just an idea of mine, mind you. But it’s based on the 7+/-2 principle. And it goes like this:

What are the main techniques of PCT? Silence, reflection, paraphrasing, summarizing. (Remember, in honest-to-goodness Rogerian PCT, even questions aren’t very present.) So, what do these techniques to do? First, silence allows clients space to get the first seven pinballs out of their heads. Then, reflection allows them to know that their pinballs are safe, not going anywhere, and you create a holding space inside the session for those pinballs to live for a while, almost like little sticky notes. Lo and behold, the client suddenly has more access to their own genuine thoughts and feelings that have been locked up behind those first 7 thoughts. Great! So they can put even more pinballs out into the session with you – emotions, ideas, etc. – that they may not have had access to before. Like journaling, that might be therapeutic enough on its own.

But PCT goes further. When several of those pinballs/sticky notes get out into the space between you, it’s time to paraphrase. When you paraphrase, it’s like taking a couple of sticky notes, condensing them, and putting them together on one index card. Imagine, just by paraphrasing, you might take 30 of your client’s sticky notes and turn them into 15 index cards. Then what? Summarizing. When we summarize, and draw together common themes, it’s sort of like taking those index cards, condensing them even more, and maybe stapling them together. So, by the end of one session, you’ve let a client have access to much more of their internal experience, maybe even some of their inner wisdom, you held all of it safely in the session with you, and you’ve condensed it and given it back to them in packages small enough and few enough that they can make a new 7 +/-2 and they can re-organize their internal experience. That gives them more “brain space” for knowing themselves well, entertaining new ideas, in essence… space to grow.

 

Now, go do magic with the power of 7+/-2. Comment with how it works out for you!

 

Making Homework Count


Making Homework Count


Your kids don’t want to do homework. You don’t really want to do homework. Clients don’t either, most of the time. But it’s important…clients who are compliant with homework do better in therapy – the effect size is .36 (according to a meta-analysis by Kazantis, Deane, & Ronan, 2000). For comparison, the effect size for therapy as a whole is usually reported at between .7 and .8.

 

So, let’s make it worthwhile! Here are some ideas:

  • Always check in on homework, first thing. Yes, even if they’re crying. (You don’t have to make a big deal about it, if you can tell that the session won’t revolve around it, but you need to mention it, even if you say “I can see you’re very upset, so we’ll check in about your homework later. What’s going on for you right now?”) Here’s a rule of thumb: the first time you don’t check it is typically the last time they do it! So, if you give homework, make sure it comes up next session.

 

  • Be a little stricter than you naturally want to be. It’s a nice idea to let grown-ups be grown-ups and trust that they’ll find the time and place to take care of the homework and make sure it’s done with intention. But they won’t. Help them by collaborating with them to set a time and place during the week for homework to get done. You’d like to believe they won’t procrastinate like a 16 year old with a girlfriend and a Netflix account…but that’s a fantasy.

 

  • Do it together, first. Think how ridiculous you would find it if your kid’s teacher sent homework home on a subject they hadn’t covered that day, or on skill building they hadn’t learned in class! Save 5 minutes at the end of session and do a practice run through with your client. Whether that’s a thought record, a communication exercise, even journaling – it’s worth it to do it in session first. Then clients have a better sense of self efficacy about the assignment, can get their questions/barriers addressed, and are more likely to actually do it.

 

  • Make sure you and they know why it’s important. Assign homework with intention. It’s so easy to get into the habit of just assigning and re-assigning the same 5 homeworks. Instead, make sure you have a clear understanding of the therapeutic value of the assignment. Be able to explain it to yourself, and be overt in telling clients why you are assigning what you are assigning, and what benefit you believe it will have for them. If clients believe the homework has value, they’re more likely to do it!

Kazantis, N., Deane, F. P., & Ronan, K. R. (2000). Homework assignment in cognitive and behavioral therapy: A meta-analysis. Clinical Psychology: Science and Practice (7)2, 189-202.

 

Comment with some of your favorite homeworks!

 

 

 

Existentialism – exercise


Existentialism Dessert Exercise


When you first learned about it, one of a few things probably happened. You either immediately threw up some kind of unconscious defensive wall because you heard the word Death or you started making plans to quit school, go to the beach, and drink margaritas because, well, Death.

(If you’re reading this, chances are you made it through, and didn’t take up your second choice career of selling snorkels. Great work!)

I’d like to clarify a little existential gem, if I could. And I’d like to do it with an experience. (Because, deep down, if you’re honoring the existential philosophy then your work and your life are inherently experiential. But that’s for another post.)

As you read this, it will help if you really imagine the process. But that’s NOWHERE near as helpful or interesting as actually doing this process, so I hope you do.

 

Ok, first you need to go procure your favorite food. I really want this to be your favorite food, and if you have to go to some lengths to get it (e.g., go to the store, call your mom and ask her to bake, drive across town to that wonderful restaurant), all the better.

Second, put one normal portion (normal for you) of just that food on a plate.

Third, divide that portion into tenths. (yes, 1/10ths) Then, throw away all but one tenth. (yes, throw away 9/10ths of your favorite thing that you just went across town for. YES, THROW IT AWAY. DO NOT put it in the fridge.)

Stop. You put it in the fridge, didn’t you? Go throw it away.

(Good, now take a moment to honor what it was inside you that wanted to keep it, and how it felt to throw it away.)

Now, approach the 1/10th that you have left. Check out how that feels.

Then, eat it. (Yeah, that’s it. No other instructions.)

 

After you’re done, take stock. What was it like? How did you eat it? Slowly? Did you pay more attention? Did you enjoy it more? Did you stay preoccupied with how much you threw away? Did you spoil your enjoyment by being angry at how little you had? (Or by feeling guilty that you actually left the other 9/10ths in the fridge? Good luck enjoying that now!) Did you have the urge to rush through or end the experience, which was somehow painful? Did you notice wanting to ration it, or not eat it at all? What was the experience like?

There you go. The finiteness of life helps us to focus our intention, live meaningfully, enjoy more fully. Feel free to practice this as often as you like, and just notice what changes.

Leave a comment if you really did this and want to tell about your experience!