Overreacting


Overreacting


So, what if I started with something a little provocative? (What’s new, Ellis?) But really, I have a thought that…

…there is no such thing as overreaction.

What’s your reaction to THAT? 🙂

What I mean when I say this, or how I follow it up with clients, is that if you think you (or your partner) are “overreacting,” let me suggest that you are simply not aware of what you are REACTING TO. 

Really, this is just simply CBT. There’s something that happens, or a stimulus of some kind. There is a perception of that stimulus and likely a thought about that stimulus, and there’s an emotional reaction to that thought/perception (not to the stimulus, precisely). And maybe that emotional reaction is “out of proportion” to the stimulus (or at least as far you’re concerned, your partner is overreacting to the stimulus – it’s just spilled milk, it’s just being a little late, he’s just a friend). And maybe that emotional reaction is even “out of proportion” to the thought that you are aware of thinking about it. 

But the emotional tone and intensity can be the information that prompts us to look deeper…

  • perception of stimulus (milk, the clock, the text message with heart eyes)
  • thought (spilled milk is inconvenient, my boss might see me come in late and fire me, that’s a weird emoji for a friend to use)
  • schema (being inconvenience is intolerable and shouldn’t happen to me, I have to overperform people will find out I’m an imposter, I am always at risk for losing my partner)
  • core belief (I won’t ever by happy or comfortable, I am not good enough, I will end up alone)

If you’re really reacting to the fear of dying alone, that’s a BIG DAMN STIMULUS and the emotional reaction is perfectly reasonable. I’ve had clients really do well with this idea, and feel both quite validated in their own experience as well opening a door to be more curious (and less quickly and globally judgmental) about their partner’s experience. 

Comment below: What are some of the ways you talk to clients about emotions, emotion regulation, and so forth? 

 

 

 

 

Telehealth Arriving Rituals


Telehealth Arriving Rituals


So, we know there are benefits to in-person work over telehealth (at least if we’re doing anything more than coaching/psychoeducation, and probably even then!). But we also know telehealth isn’t going anywhere. If you haven’t read the Teletherapy Rant, you might want to. Or you might want to skip that but look at the tip sheet for clients. 

But if we’re going to be telehealth (and we are), and some clients are only going to do therapy that way (and they are), how do we give them the best experience. One thing I’ve been playing around with lately is the idea of “telehealth arriving rituals.” 

Some therapists (and yoga instructors, LOL) use arriving rituals even for in-person meetings. In-person therapy has its own natural built-in ritual as well – the client drives someplace, they wait a bit, you collect them, you walk together to the room, maybe small talk along the way, you both enter the “sacred space,” and you settled into chairs or couches. Telehealth doesn’t get that (and often doesn’t get a sacred space at all!).

So, how might we do this? Here are some ideas, some of which I use:

  • I have one client and we show each other our coffee cups in a sort of “cheers” moment to show that we’re both “ready to begin”
  • With one client, we made mindfulness training part of the treatment plan, so we do a new (or requested) mindfulness activity in the first 5 minutes of each session
  • If you like to use a singing bowl or similar in “real life,” that’s the kind of thing that could work in a telehealth setting (but I haven’t tried this)
  • I’ve done variations on a body-oriented kind of thing, that I just started doing and then my clients have picked up on, like I stretch my arms up and then let them fall down and I say “mmmm, ok, I’m here, how about you?” (which I also sometimes do in-person, as well)
  • I’d be interested in doing some guided imagery work in one session, and creating a mental “perfect therapy space” and then inviting the client and I to enter that space as we get online (I have a client who “built” an incredibly beautiful, luscious hidden library as his therapy space and I sometimes go there by myself!) 
  • Just always starting with a homework check-in is something I do with some clients in-person and via telehealth. If agenda setting is your thing, that could work, too.
  • And maybe the thing to do is ask the client. Just explain that you’d like to make sure that the therapy time feels sacred, even if they’re in one of their many typical life-spaces, and ask “What could we do at the beginning of session to help you really get into the therapy mood/mindspace?”

As I think about it, maybe telehealth does have its own natural ritual in a way, as we ask the interminable but ethically required questions about where clients are and if anyone is also with them, and do the inevitable “I can hear you, can you hear me” rigamarole! Oy. At least I try to start that with, “Welcome, I’m so glad to see you!” 

As a side note, I also like to encourage clients to have a TINY bit of time set aside before and after their sessions, too, which they would normally get at least in the waiting room and driving. No one seems to, though. 🙁

Oh, and don’t forget your own between-session rituals when you’re doing telehealth all day! What do you normally do between sessions? This is my (preferred) regular in-office pattern – 9:50 notes and coffee refill, 10:50 notes and bathroom break, 11:50 notes and protein bar, 12:50 notes and deep breathing or a quick walk, 1:50 notes and a bathroom break, 2:50 notes and run like mad to get in the kids’ school pickup line. (Yes, I really do notes after every session!) 

 

Comment below: What ideas do you use or can you think of for rituals-of-virtual-arriving? 

 

 

 

 

Prioritizing for Numbers People


Prioritizing for Numbers People (of which I am not!) 


Ok, I don’t make decisions like this. I’m much more of a Gendlin “felt sense” kind of chooser, or I’ll use my “Verb-ed To Do List” to decide based on what kind of energy I seem to have at the moment. But, sometimes I’m challenged in session to come up with experiments or homework that work for clients who are really different from me. This is a simple one that came up in session with a pair of engineers who were feeling overwhelmed because there was a lot on their “high stress to-do list” and they couldn’t seem to choose where to get started. (Yes, this is also sort about the emotion regulation piece of procrastination, but maybe that’s a post for another day.)

This was helped by the fact that they already had a (massive) to-do list ready. So, we take the to-do list, and we add three columns out to the side, with numbers 1-10:

 

  • How EASY is this? (1 – desperately hard, 10 – super easy)
  • How MUCH use will it be? (1 – not much use, 10 – incredibly useful)
  • Sum. 

That’s it. We didn’t’ quibble about what “easy” meant, though we chatted about how it might be effort, time, overcoming resistance, etc. We didn’t quibble about what “useful” meant, either, though we chatted about how it means something like pragmatic utility, stress reduction, etc. But they didn’t have trouble with either of those. So, they got started with the item that had the highest total sum and went from there. 

Maybe it was even better that I’m not a numbers person, so I didn’t get drawn into complex formulae and overthinking the whole thing. And it was so simple, and the answer so clear, I think that helped them not tie themselves up in further knots about it.

And it’s not perfect, and if there were more resistance, I think it would need to be processed (e.g., if they tried to spend all session or all week arguing about the numbers in order to avoid doing anything). But not everything in therapy turns out to be a terrible struggle, actually! 🙂 And of course, they didn’t get through the whole list (partly because they realized some stuff on their list didn’t matter at all and partly because to-do lists are eternal). But that wasn’t the point. The point was giving them a way they could handle their decision fatigue/paralysis and get started. And they did. 

 

Comment below: This seems to work pretty well for some of my Numbers/Engineering type clients, but I’d love to hear from you if you are one of those people… Or, how do you help clients with building the skills for prioritizing (or decision making, or problem solving, or…)

 

 

 

 

Four Existential Givens


Four Existential Givens (and the implied responses)


So, Yalom (e.g., 1980) talks about the four “existential givens” or “ultimate concerns”:

  • Death (i.e., death anxiety)
  • Freedom
  • Isolation
  • Meaninglessness 

And I’m surprised how rarely (or if ever?) I find someone cogently and overtly expressing that the implied responses to each of these ultimate concerns are the bedrock principles of existential therapy (and maybe ALL therapy):

  • Approaching (rather than avoiding) anxiety (thus reducing anxiety and also the foundation for living fully)
  • Taking responsibility (and recognizing limits of both responsibility and freedom)
  • Building and maintaining connections (maybe Existential Therapy proper doesn’t do a great job of this one, but Frankl certainly talks about it at least) 
  • Defining (and then living in) valued directions 

See what I mean, though? Why is this not just a chart in all theories textbooks? Why do we always get the idea that the main things to do is SUFFER with these ultimate concerns rather than use them as guideposts?!

 

Comment below: From your own theoretical orientation, how do these play out? Is anything missing? 

 

Yalom, I. D. (1980). Existential psychotherapy. New York: Basic Books

 

 

 

Deranged, Inhuman, Disgusting


Deranged, Disgusting, or Inhuman


In other words, deserving of your contempt.

(If you haven’t read Crazy, Stupid, or Awful, you might want to read that one first. Crazy, Stupid, Awful means you probably are thinking of your partner as a “Them” instead of thinking about the two of you as a “We” or an “Us,” but some careful, attentive, open listening might suffice. Like in They Might Be An Alien)

But contempt is something a little different.

 

The Gottmans (e.g., Gottman, 1993) really brought the idea of contempt onto the couples’ therapy scene, a kind of relational filter that says “I’m better than you, and you don’t deserve my basic respect.” Sometimes, it looks like sarcasm or condescension (speaking as if your partner really is stupid, or worse). Sometimes, it’s withdrawal (because you believe that your partner really is disgusting and you can’t stand to be around them). Sometimes, it sounds like demeaning put-downs (because you think your partner is just a real piece of shit). It’s dehumanizing (e.g., Kteily et al., 2022). And that’s a much bigger problem than thinking they’re a decent human being who you just really don’t understand or agree with. 

 

The impacts of contempt are probably quite a bit broader than just in couples’ relationships, too. As therapists, we need to be on the lookout for contempt of partners, but also of kids and bosses, among others. And there are some pragmatic things we need to think about – when parents are using sarcasm, condescension, demeaning put downs, and/or withdrawal/neglect with their children… we need to intervene strongly and quickly to help them make changes. Eye-rolling, name-calling, and that pinched-face look of disgust need to be taken with plenty of seriousness. When it’s someone talking about a coworker, boss, friend, etc., the easiest solution might be to simply get out of that situation or relationship… contempt (like real burnout) is pretty damn hard to come back from.

 

But then, we also need to look at the underlying cognitive structures that support contempt… Contempt “implies sense of superiority over [other people], pessimistic feelings about their possibility of betterment, detachment from them, and avoidance driven by detachment (Miceli & Castelfranchi, 2018). So, I’m going to go ahead and say (maybe outrageously?!) that contempt is never rational. So, to be clear, I’m not saying that anyone should stay in contact with someone they feel contempt toward. Maybe the contempt goes along with other thoughts/feelings that are quite reasonable and dictate that the appropriate behavior is detachment (e.g., an actually abusive partner, an actually unfair and unpleasant working environment). But that sense of down-to-the-ground superiority of one (aggrieved) person over another? Mmmm… that’s a tough sell for me. Dehumanizing a human being doesn’t fit the logic I understand. 

And there are personality structures, too. It’s possible to have a contemptuous “personality” (or long term attributional style, maybe?). Sometimes, that goes along with narcissistic and antisocial stuff (esp when the dispositional contempt is typically outwards), but sometimes the contempt is directed inwardly at the self, as well! (see Schriber et al., 2017). 

 

I’m sure how you choose to work on this depends on your theoretical orientation… I just wanted to take a minute to bring it to the forefront and make sure we’re not letting some important signs pass us by! 

 

Comment below: What other markers of disgust do you see in clients? Do you ever find it easy to blow those off? How do you work with clients on these deep cognitive structures? 

 

Gottman, J. M. (1993). A theory of marital dissolution and stability. Journal of family psychology, 7(1), 57.

Kteily, N. S., & Landry, A. P. (2022). Dehumanization: Trendsinsights, and challengesTrends in Cognitive Sciences, 26(3), 222–240. https://doi.org/10.1016/j.tics.2021.12.003

Miceli, M., & Castelfranchi, C. (2018). Contempt and disgust: The emotions of disrespect. Journal for the Theory of Social Behavior, 48(2), 205-229. https://doi.org/10.1111/jtsb.12159 

Schriber, R. A., Chung, J. M., Sorensen, K. S., & Robins, R. W. (2017). Dispositional contempt: A first look at the contemptuous person. Journal of Personality and Social Psychology, 113(2), 280-309. doi: 10.1037/pspp0000101. 

 

 

 

Reversal Theory Workbook


Reversal Theory Workbook


And here’s the other reason that I was on a bit of a hiatus from blogging…

Probably if you spend any time on the Ellis Tangents blog, you know about Diligent Page Publications by now. 

Diligent Page Publications exists to give the therapy gifts that are possible to deliver just in words. None of these books will replace an awesome therapist. But they’re certain to be research-supported, practical, and affordable. They are only authored by mental health professionals with your best interests at heart. 

The Reversal Theory workbook has been quite a while in the making – I think that this little-known theory has a LOT to give the world of psychology (along with business, education, behavioral health, etc.) and I often teach it (or components of it) to my clients as part of their therapy work. 

If you haven’t read much about Reversal Theory before, check out these posts! 

Comment below: Are there any RT topics that you’d like to see blogged about? Also, consider this first edition largely a draft; I welcome all feedback about how to make it better! Thanks!

 

 

 

Start School Later


Start School Later


I know it’s been awhile since I last posted, and it’s because I’ve been working on two pretty big projects. I thought I’d announce the first one here, as it’s ready to at least begin…

Soon, I’ll be starting a public education project to share the research about the benefits of starting high school at 8:30 or later. (I even got back on Facebook for this purpose. I hadn’t been on Facebook since my 10 year old was born – HA!) 

The body of research is huge and well established – teens go through (like all mammals do!) the adolescent sleep phase shift – a natural, developmental, biological delay in sleep drive and change in circadian rhythm that means they get sleepy later and become alert later. (See… you really WEREN’T just being lazy or undisciplined!) Teens also need more sleep than adults, or even older children – an average of about 9.25 hours/night! 

So, asking teens to be alert for driving or school at 7:30 is really like asking adults to be alert for driving or work at 3:30am! 

Research shows that delaying high school start times until 8:30 or later:

  • improves academics (less tardiness, fewer absences, higher GPAs, higher standardized test scores, better graduation rates, etc…)
  • improves teen physical health (healthier BMI, less obesity, less screen time, more physical activity, better dietary choices, reduced substance use, reduced risk taking, fewer accidents, fewer injuries, etc…)
  • improves teen mental health (less depression, less suicidal thinking and planning, less anxiety, improved mood, better emotional regulation, better coping strategies, improved teen-family interactions)
  • improves teen behavior (better decision making, less risk taking, less juvenile delinquency, fewer suspensions, better classroom behavior, less risky driving and sexual behavior, etc…)

Here, you can read a research summary that I put together specifically for my district (FBISD), but that is full of research relevant to any school district. 

And here, you can watch some videos (2-12min) that I put together, fleshing out some of the research a bit more, as well as addressing myths/misconceptions and common concerns/possible solutions. 

I’m still working on finishing up one other big project, and then I’ll get back to regular posts – I have tons in my mental queue, but just don’t have time to get them written out just yet. 

Comment below: Do you know any additional research I’ve missed? What time did you start high school? What time do your kids start? What other concerns do you think parents/teachers/etc have? Is there anything else that deserves a video that I don’t have posted yet? 

 

 

 

 

 

 

They might be an alien…


They might be an alien…


If you haven’t read the Crazy, Stupid, Awful blog, go ahead and do that first. 

. . . . . . 

For fun, to help a couple who has a deeply difficult time understanding the other’s internal logic, I gave them an assignment to watch a sci-fi or fantasy movie for a date night, or even a family movie night. I requested that it be something neither of them had seen, and that they let me know what it was, so that I could make sure I watched it before we met again.

I suppose this could work with any kind of movie, but I thought the extra distance element might help. 

So, when we got back together, we spent several minutes talking about what makes sense in the movie that would NOT make sense in Real Life? And then taking it to the character level (which is why it might work with any kind of movie). When this heroine does this amazing thing at the end of the movie – does it make sense? (Yes, if the movie’s any good.) And would it make sense if any other character did that amazing thing at the end? (No, if the movie’s any good.)

And then we go through what we learn (that is, what the movie writers, directors, and editors teach us) about each character so that their behavior makes sense. In a well-done story of any kind, the writer has to give you certain pieces of information so that the characters’ actions are understandable. And because writers try to give readers/watchers at least a few different main characters (with different background, motivations, etc.), most stories will work for this exercise. 

Now, if your partner is an alien, you need them to teach you what things are like “on their planet” or “with their species.” You need them to teach you, as if they are the writer/director/editor of a movie about them, what you need to know about their biology/neurology/history/experiences/culture in order to understand why they – as a character in this story – do not behave in the same way you do. And you need to simultaneously realize – YOU are not the earthling. You are not the holder of all reality, and that’s where the sci-fi/fantasy thing helps more, I think. 

I don’t think this is specifically a lot different than any kind of empathy or phenomenological understanding or perspective taking work, but it was helpful with these clients who really struggle. And now they have a language to say to each other, “That’s not really how it works with my species” or “How is that different on your planet?” that is giving them a little more space to talk about their differences in a friendly way.

And they had a fun date night. 🙂 

Comment below: How do you help clients who really struggle with this?!

 

 

 

 

 

 

Emotions for Engineers Part II


Emotions for Engineers – Part II


I first addressed the issue of “emotion for engineers” (or for “traditionally raised men,” or for “thinking types,” etc.) here. I recently had the opportunity to expand this concept into a “flow chart for emotion regulation,” prompted by one of my favorite clients saying, “Can you say that all again, but use steps?” So, here is what I came up with. It emphasizes the need for time between a stimulus and response (rather than a quick reaction) and it pairs nicely with a discussion of how you wouldn’t implement a new project or budget at work on a whim. 

I even gave it an acronym (by client request!): DEER

Define, Evaluate, Express, Respond. Check it out here: Emotion Regulation Process

(As always, free to use, please don’t sell.) 

Comment below: How are some ways that you talk about emotions with people who aren’t already well-versed in emotions? 

 

 

 

 

What’s Not Gaslighting?


What’s NOT gaslighting? 


I’m a little bit alarmed with how this word is so quickly changing in meaning. And especially because we only have one word for gaslighting – to cause a person to doubt his/her sanity through the use of psychological manipulation. (You’ve heard of the play for which the term is named?) So, it’s using your power to actually change the other person’s ability to experience the world with reality, and then to lie to them about reality so that they question their own ability to function in the world.  

Here are some examples of gaslighting proper: 

For example, if your partner secretly took money out of your account, and then you overdrew it not knowing the money was gone, and they punished you for not managing your money well, and you pleaded with them saying that you were sure the money was there, and then they lied and blamed you, saying if you didn’t do it then your wicked mother/corrupt employer/secret lover/etc. must have taken the money, that would be gaslighting.  

If you drugged your partner’s dinner, and then you went to a kickboxing lesson, and got a bunch of bruises, then told your partner the next day “Look what you’ve done!” and your partner denied it, and you told your partner that they did it in a manic, alcoholic rage and just didn’t remember, and pointed to the empty bottles you hid in the trash, that would be gaslighting. 

(Granted, they’re a little extreme, but that can be helpful for clarity’s sake in the definitional stage.)  

But we have lots of words for the other things that gaslighting is beginning to be used for, like lying, manipulation, misuse of power, dysfunctional communication, etc. So, in the interest of reserving the utility of the vocabulary for as long as possible, let’s talk about what gaslighting is NOT.  

 

  • When the other person actually perceived, experienced, or remembered something differently than you did 
    • Given the outrageous amount of research literature on these topics, along with everyone’s actual experience of the world, it puzzles me so much that we all STILL think that we perceive the world “correctly,” that our experiences are “the valid ones,” and that we remember things with ANY degree of “accuracy.” Because we don’t. Brains are not made to perceive the world accurately or to remember accurately – brains are made to predict the future, and they consciously process only a tiny fraction of what’s experienced, and that is always affected by their own history, their language, their biases, their mood at the time of the experience, and about a thousand other things. This is compounded when it comes to memory, because it’s not just the error in encoding reality accurately… but all the same issues come again when memory is retrieved, so the problem is at least doubled (and more than that if you’re remembering something more than once!) (Let me know in the comments if you want a post on the perception or memory literature.)  
    • So, most of the time, what’s called “gaslighting” has at least something to do with the fact that people are different, experience the world differently, remember the past differently, and are pretty sure they’re the ones who are right.  
  • When there is a misunderstanding or miscommunication 
    • As bad as we are at experiencing the world accurately and remembering it accurately, we’re worse at communicating it accurately to another person (or perceiving accurately what they intend to communicate). We lose almost all of the richness of an experience when it has to be boiled down into language, and then we almost all use language differently than everyone else. Oh, and all that stuff that gets in the way of accuracy when perceiving or remembering something gets in the way AGAIN when we listen, and not necessarily in a predictable way!  
    • Try this… imagine, REALLY imagine, in all the detail you can – your own bathroom. How it looks, smells, is configured. How it feels to be there, both physically and emotionally. Get a sense of the whole thing, including how it is different at different times of day or depending on your purpose there. Remember when it’s been steamy, and notice how the experience of reading the word “steamy” changed your memory of your bathroom in this exact moment, either bringing a new image or new emphasis to your steamy bathroom. And realize how much more likely you are to think of your bathroom as steamy next time you think of it. Paint it in your mind and let yourself see it like it’s in a movie and let yourself move through it like virtual reality and then fill in all the little details of how it  REALLY is. Now, with as much accuracy as you can… write down or say out loud everything you can about someone else’s bathroom. HA! Oh come on, try it! It’s hard enough when you’ve actually BEEN in someone else’s bathroom, but also try it with whatever you know that you’ve just been TOLD about someone else’s bathroom. If you can’t think of a bathroom you’ve talked about but not been in, call someone and ask them to describe their bathroom to you! Do it! It’s a really fun way to experience this difference between what we experience and how little of that we can communicate, and even more the lack of richness and accuracy we are limited to when hearing something from someone else! 
    • So, a lot of the time, what’s called “gaslighting” has a lot to do with how poorly we are able to communicate with each other about our internal and external experiences.  

I think those two bullets cover most of what comes up in therapy around “gaslighting,” but here are two more things that come up occasionally, that also are not gaslighting.  

  • When the other person is lying or manipulating and you know it 
    • If you KNOW the other person is lying, you have not been gaslit. Implicit in the concept of gaslighting is that the other person has enough power over you and your circumstances to convince you that you are the crazy one, and that they are trustworthy arbiters of reality. So, if you still have enough agency to know or even believe that they are lying or manipulating, then what they are doing (at most) is lying or manipulating, not gaslighting. 
    • That’s actually something that can be worked on in therapy, even if the first response is still denial!   
  • When you rely on the other person for reality testing and you trust them because they’re trustworthy  
    • This one comes up occasionally, and I actually like it. We are all relying on each other to do reality testing all the time. “Do you hear that sound?” “Oh yeah, it’s someone’s car alarm going off outside.” And things like that.  And it’s really good and useful. And it’s helpful when there’s more than one person to rely on. That’s another key to gaslighting – it’s really difficult to do if the target of the gaslighting isn’t completely isolated from other sources of potential information about the world.  
    • Sometimes, you might know you’re not great at a certain part of reality testing. For example, I’m really bad at remembering what I’ve said in the past. I rely on my husband a LOT for that. Is he always right? I’m sure he’s not. It’s just that he’s better at it than me! COULD he gaslight me if he wanted to, at least in that way? Oh yeah. But I don’t think he is…everything keeps turning out ok.

Here’s a potentially controversial thing to say (what’s new, Ellis!?)…  

Gaslighting, by definition, seems to include an intention on the part of the gaslighter. Can we compare it to sexual harassment? Sexual harassment has some clear behavioral definitions, but in any ambiguous situation, it is defined by the person who “feels harassed.” (There’s a topic for another day… is it possible to “feel verbed?”) Because the gaslighter has to change reality, because they have to “psychologically manipulate” – doesn’t that imply that they have to intend to gaslight someone?   

Can you “feel gaslit?” If you feel gaslit, does that mean you WERE? This is why I want to make sure we have a good variety of language around relational communication… Once a person feels gaslit, there’s no way for the other person to be part of the conversation anymore. If they were actually gaslighting, they’d be trying to explain how they weren’t. If they weren’t gaslighting, they’d be trying to explain how they weren’t.  It leaves no room for the other person’s experience, and then what? That’s a 100% power transfer to the person who feels gaslit. Maybe that’s what they want? But it doesn’t work in the therapy room, at least. 

Look, I’m usually a BIG proponent of using client’s the language. I’m a champion of the idea that it is the therapist’s job to mirror, tailor, and otherwise adapt their own presentation in order to build a comfortable and usable space for the client and facilitate empathy and connection! (Rather than this new notion of “authenticity” that seems to mean “do and say everything exactly the way it makes sense to you, and if other people don’t accommodate you, that’s their problem” – hmmm, maybe a rant on this in another post! Ha!) 

I also know that increasing the granularity and specificity of language helps improve cognitive flexibility and emotional recognition and regulation! So, I will absolutely offer new vocabulary to clients when it might be helpful and/or help them to clarify their vocabulary to increase their ability to communicate clearly both with others and inside themselves!  

 

Comment below: When has vocabulary shown up in your sessions as something important? In what ways? As always, especially comment if you disagree!  

 

 

 

 

Introducing Diligent Page Publications


Introducing Diligent Page Publications


So, if you’ve read the blog for awhile, you know I can get ranty about some stuff in our field. And nothing gets me on a soapbox faster than talking about how EXPENSIVE therapy is and how much that prohibits so many people from accessing good resources.  

I love therapists. I am a therapist. It’s not that I don’t want us to make a fair wage and maybe even have nice things. I do. 

(Side note: Here’s a little experiment for you to try. First, go to the bank and get $150 in one dollar bills. Then, find a therapist-colleague. Set a timer for 60 seconds. Now, every time the time goes off, give them three $1 bills. Or have them do it to you, or both. Do it for the WHOLE 50 minutes. Just notice what that’s like for you. And discuss.) 

So, I’ve been channeling that rage-energy that gets worked up in me sometimes (usually when someone at my office says something like, “But can’t they pay the full rate?” or “We’re increasing everyone’s rate by $5”) into writing. So, I started Diligent Page Publications as a place to publish low cost, super high quality, empirically-supported resources for clients. (It’s just in its baby stages; don’t get TOO excited.)

My favorite piece of this is a little ebook that teaches clients how to do therapy efficiently, saving them time and money and making more space for new clients, while not reducing therapist rates! 

And then I have a few guided journals that I made for clients and decided could be a useful resource for people who are doing life transitions (instead of therapy or as an adjunct to help therapy go faster/less expensively), because it turns out there really aren’t good, inner-world-focused books for people doing life transitions! 

I have a few other projects in the works, and of course I’ll post about them when they’re ready. But I want to share Diligent Page with you, because there’s a chance as a continued reader of this blog, you might share some of this desire with me!  

 

 

 

 

 

 

The Most Important Question – The Scrubbing Bubbles Story


The Most Important Question – The Scrubbing Bubbles Story


Sometimes, therapy is REALLY easy and short.

But first, let me tell you a story. 

So, I was cleaning the kitchen tile grout when I moved into my new house. (Yes, those are my actual kitchen tiles, in progress. ACK! And it is beige grout, not white, just so you don’t get all judgey on me! Haha! ) This is how that went: Squat, Spray, Wait, Scrub, Spray, Wait, Scrub, Rinse, Heave-off-of-creaking-knees-to-move-two-feet, Squat, Spray, Wait… for FIVE HOURS. And then, something happened that I thought was a complete disaster. … Halfway through my kitchen, I ran out of spray. 

“Oh no!” I thought to myself. “Now I’m going to have to change sprays and use the crappy spray under my sink that is not the special spray I bought for cleaning tile grout and it’s going to be so much more work and so much more time… WAAAAAAAH!” But I decided to do that (rather than, I realize now, going to the store and buying more, which possibly could have saved me a bunch of time, but I was messy and sweaty and cranky and didn’t want to.) So, I huffed out a breath and got the other spray out from under my sink. 

It was a miracle spray. WHAT?! NO squatting – the spray stream was awesomely direct and I could spray every grout line standing up. NO waiting – by the time I got back to my initially-spray tile, it had already done its work. Almost no scrubbing – this spray was amazing effective! I finished the rest of the kitchen in under an hour.

So much pain and effort and time saved, by just trying something different that was already at my disposal, even though I thought it wouldn’t work.

Some of the ways this has shown up in therapy:

  • How’s your sleeping?
  • Have you recently changed medications? 
  • Are you sure that’s necessary? 
  • Did you tell them that out loud? 

I probably could have titled this “The Most Important Question – What have they tried so far?” But then, that would have been too easy and short, right? 

Comment below: What have been some of the wildly easy “fixes” that have made a big impact for your clients? 

 

 

 

 

Real Solutions to Boredom


Real Solutions to Boredom


So, there’s regular boredom. Kids waiting in line, or into the 7th week of summer kind of bored that often turns to mischief. And adults struggle with that, too, although now our phones can usually hide the feeling of boredom from us! And, in general, kids and adults seem to think that the solution to boredom is finding more stimulation… and it’s most definitely not! 

And then there’s the deep, soul-boredom the Existentialists call ennui.  Meaninglessness, purposelessness, a barrier to full engagement with the present… Erich Fromm even suggests that boredom might be the single most important factor in aggressive behavior because of the search for stimulation to reduce the unpleasant bored feeling.  

Will it surprise you if I suggest that the solutions to the fleeting, childlike boredom and the bone-deep sense of listless purposelessness are actually THE SAME? Here you go: 

 

  • Meaning-making: Emotions are often signposts that there is an action sequence that’s needed (e.g., sadness -> resource/support seeking; anger: restitution of justice). Boredom may be a signpost that the action sequence needed is meaning making
  • Introspection: Is boredom your primary emotion, or is it covering up something that might be unpleasant? Opening up and looking inward when feeling bored may unveil some very important material, if you’re willing to engage with it!
  • Imagination: Even if boredom is primary, and it’s a reasonable emotional reaction to a highly stagnant outer-environment, your inner environment is never stagnant! Boredom can give you a nudge toward going inside to your imagination, an eternal spring!
  • Mindful awareness: Is the outer-environment actually stagnant and boring? Or might there be a whole world being missed because our focus is narrow? Consider bringing a mindful awareness to what’s going on around you, noticing things you might not normally notice. 
  • Body/self awareness: Failing that (plundering the outer environment for its hitherto unnoticed treasures), tuning in mindfulness to the body is always an option, and one that often bears fruit in the form of pleasant feelings of being calm and centered, or interesting information about the messages the body is carrying. 
  • Body engagement: A second source of boredom-management that your body can give you is movement. Even a gentle walk, if available, can both energize the body (and thus help focus the mind) and may bring you into contact with other parts of the environment to engage with. 
  • Connection: Boredom is much more common when we’re lonely – in fact, it might actually be one of the primary differences between being lonely and being alone!  Boredom may be a request for the action sequence of connecting with others!
  • Rest: Contrary to popular conception (and outside the context of an apathetic depression), boredom may even be sending the message that you haven’t gotten enough rest! If you’re tired, all of the focus and energy required to engage meaningfully (and interestingly!) in the outer or inner world might just not be available! Take a nap! 
  • Stoic Acceptance: Allowing the bored feeling to exist while you choose to carry on with your needed life obligations is a kind of gentle discipline that can make the dreary moments of life more tolerable!

Comment below: What other healthy and effective alternatives can you think of for managing boredom, without giving in to the often-problematic strategy of stimulation-seeking? How have your clients struggled with boredom and what has worked for them?

 

 

 

 

Alfred Adler and Taylor Swift


What do Alfred Adler and Taylor Swift have in common?


Shockingly, in this case, the answer might be…. relational wisdom?

Adler, describing the psychotherapy relationship says, “A tactless truth can never be the whole truth; it shows that our understanding was not sufficient.” 

And Swift, describing one of many terrible breakups calls her lover’s communications “casually cruel in the name of being honest.” 

I think – and this might be controversial, though I wish it wouldn’t be – that the culture has a thought brewing that authenticity means doing exactly what you want and saying exactly what you think without regard for the audience. But, you know what? It doesn’t really work. 

The clearest, most honest communication you can make with yourself still has to cross at least 2 barriers – the experience, history, filters, schemas, current nervous system functioning, etc. of the listener and everything that fills the space between you and the listener, which might contain the larger culture, personal history between you, effects of the time and location, and more. Without considering those factors, your ultra clear and honest communication is going to get all distorted. You can communicate MORE truth by taking the other person and the situation into account than by tapping into this new (problematic) kind of “authenticity.” 

 

Comments below: What do you think? Do you see this in therapy, especially with couples? But also in your communications with clients? Or not? If this feels controversial to you, talk about that, too! 

 

 

 

 

 

CLEAR thinking


C.L.E.A.R. Thinking


 

Oh dear. If you know me, you know one of my pet peeves is “made to fit” acronyms. Ugh. I am familiar with the research about how that makes things easier to remember, yes. And I’m the first one to criticize, let’s say, Yalom for making the (would-be) “acronym” for the curative factors of group therapy AIIIIUECCCS. Not helpful. But, maybe it was just too many years of church sermons forced onto artificial acronym scaffolds that gave me a bad taste about it. I especially don’t like when the concept has to be twisted or something has to be grafted on to make the acronym work. 

That being said, this one sort of made itself in a therapy session one day, so I’ll share it. Blerg. 

CALM – brains that are all geared up don’t think very clearly. Or rather, they might think clearly, but they think in very limited ways – limited to RUN, FIGHT, APPEASE, etc. Useful for predators, not so much for the rest of life. This goes along with other bodily things that can get in the way of clear thinking, like hunger, exhaustion, and pain. 

LOOSE – really good thinking is flexible. It’s structured enough that it’s coherent, but it’s not so structured that it loses its openness. Like any high-functioning system, clear thinking is semi-permeable. 

EFFECTIVE – clear thinking prioritizes effectiveness. That means both recognizing potentially multiple goals and prioritizing them. Effectiveness over winning, unless winning is the only goal. Effectiveness over comfort, unless present comfort is the only goal. Etc. 

ACCURATE – it’s got to happen in a reality-based way. Distortion is unavoidable, but the more we can be aware of our biases, the typical tricks of cognitive distortions, our own fantasies, etc., the clearer our thinking will be. 

RELATIONAL – there’s no escaping that we exist in relationships, all the time, even when we’re alone. Keeping thinking relational means we’re better at taking others’ perspectives, more likely to consider real systems that are at play, and keeps our feet out of our mouths (pretty often).

 

Comment below: Ok, lay it on me. Should I give up the acronym? Is it forced? Could it be useful? Can you improve on it?! 

 

Blocks provide you with everything you need to build a larger page. They contain a variety of content elements, such as images, buttons, headings, and more. These elements are arranged in rows and columns, which provide a useful structure, as well as a sense of balance within the overall composition. You can modify this structure using our intuitive drag and drop interface, which allows you to rearrange content to your heart’s content.

 

 

 

 

Online Resources Vol 5


Online Resources Vol 5


 

Of course, if you haven’t seen Volumes 1, 2, 3, or 4, check them out!

 

  • An online intro psyc textbook – fun reading for therapists to catch up on new developments in the basic areas (the knowledge half life of psyc (apparently about 7 years) is getting shorter all the time!). Good for helping savvy or “book smart” clients who feel empowered with more knowledge. 
  • A good written resource for Autogenic Training produced by the VA. I can’t ever find a good YouTube version – they’re all so “meditative” and awash with harps and binaural beats and stuff. My experience has been that people who want to do autogenic training want that because meditation feels too “woo woo” for them and they consider themselves to be practical, no-nonsense folks. I was going to make one, and I might still, but this is not a bad substitute for now. 
  • Here’s a great little workbook a colleague of mine found (Thanks, Sana!), and it references Gendlin’s Focusing as a primary tool in emotional work! It’s written more like a flowy graphic novel, or kind of like a series of infographics – easy to read! 
  • This is just super fun, and I can imagine it having therapy homework possibilities, too. Make mandalas!  
  • A resource for clients (and maybe clinicians, depending on how much this was a part of your training!) in reading scientific studies when you’re not a professional scientist! 
  • I have a sad update on the Reveri App (mentioned in Volume 4) – it’s no longer free. It’s now subscription-based. And it’s still worth it. I will tell you, though, if you have clients who can’t afford it, and they write to the Reveri folks, they’ll usually still offer a free year! 

Comment below and add any free online resources or apps that you use! 

 

 

 

 

 

Big Pharma & Non-conditioning Shampoo


Big Pharma & Non-conditioning Shampoo


 

I’ve been promising a “Big Pharma Rant” for a long time, and today I’m really inspired. Well, I’m inspired enough to start – I think it’s going to end up being a few mini-rants, which is probably better anyway. 

 

Here we go. See this conditioner bottle? (Yes, this post is born from an honest-to-goodness “shower thought.”) These folks did research, so that they could print the results on their bottle and get you to buy it. 

97% less breakage*

With an asterisk. Geez, at least they put an asterisk and then tell you right then and there what it’s compared to…. the mega-super-ultra-anti-breakage-shampoo-plus-conditioner-used-as-a-system vs. a non-conditioning shampoo. 

Listen, that’s not a super fair comparison. Using a non-conditioning shampoo is probably actually even worse for breakage than using no shampoo at all, but does anyone who is looking for super-ultra-mega-anti-breakage conditioner not already use conditioner? Don’t you really want to know if this conditioner is better than your regular conditioner?! 

(Side note: They pretty much all do this, and so I’m not really calling out a specific brand. If you recognize this bottle, I actually happen to love it and would highly recommend.) 

Ok, how does this relate to Big Pharma? Well, pharmaceutical companies often will compare their active medication product to a placebo. And that’s certainly better than not doing that. But that’s not REALLY what you want to know, is it? Don’t you want to know if an antidepressant (with all of its attendant side effects) improves depression more than, say, a 10,000 lux lamp that costs $40 and you only have to buy once? Or more than walking 3x/week? Or 16 weeks of CBT? Or, heaven forbid – a course of psychodynamic therapy?! Don’t you really want to know that before you spend thousands of dollars out of pocket getting transcranial magnetic stimulation? Or before they add an antipsychotic medication to your regimen? (This isn’t even getting at things like how long the benefits of medications vs. therapy last and how much they cost over time. Spoiler alert – therapy’s better on both metrics!)

But they’ll never do that. In the same way that the Uber-Fancy-Conditioner won’t ever make a comparison to The-Other-Uber-Fancy-Conditioner… because they know they won’t come out on top, or they know the differences will be so small that it won’t be worth the money they put into the study. So, we have to go find that research ourselves (I’m back to pharmaceuticals, btw – I don’t imagine you’re actually going to find conditioner-research!), and sometimes help our clients evaluate it, too. 

There are at least 4 more mini Big Pharma rants to come, so stay tuned! And, believe it or not, I’m not actually against the use of effective, well-prescribed, thoughtfully-considered psychotropic medication. Maybe I should I do a post about that, too.

 

Comment below: It would be awesome if you were to post here any additional research you come across about non-pharmaceutical treatments for depression and how they compare. There are just way too many for me to include today! Or any other comments, as always! 

 

 

 

 

 

 

Trees and Taproots


Trees & Taproots


You know how I like to have metaphor-ready stuff in my office. (See the other Office Supplies posts here, here, here, and here.) This is a drawing of a real tree that exists and even thrives, despite a meager attachment to its later (non-primary) supports. 

And this is a remarkable tree. And I think that’s honestly more the purview of motivational speakers – “You too can be THIS tree!!” I don’t think most clients resonate with that kind of thing, because it’s to o easy to say, “But I’m not that strong, special, etc…”

I often talk about plants, trees, nature, etc. in therapy with clients (and, myself having a black thumb in real life, I do sense the irony.) I have a few current clients who are pretty established gardeners and out interactions have led me to at least a lot more successful reading about plants! 

And something I learned recently is that most trees and plants start out life with a “taproot” – a long, primary source of nutrients that tends to head straight down wherever the seeding begins to grow. Some plants keep their taproot forever. Some vegetables, like carrots, ARE taproots! Some plants never establish a taproot. But most trees and plants start out with a taproot and, once they are established in their environment, stop using the taproot for nutrition in favor of their lateral roots. Like this extraordinary tree. 

Certainly, a healthy taproot in a young plant is a great thing. (I am talking about the early childhood environment here, in case that isn’t yet clear!) But a strong taproot isn’t always a great thing – it makes transplanting more difficult and overreliance on it can make plants vulnerable in ways that a strong lateral root system can compensate for. And I think that can sometimes be a really important thing for clients to learn – because most clients didn’t have or don’t have a perfect “taproot” family-of-origin experience. And that’s not the end of their thriving. 

Comment below: How (and how often! ha!!) have you used gardening/planting/growing things/plants as a metaphor in therapy? And as always, share your own metaphors!

Photo Source: This gem was drawn for me by my best friend! Thanks, Lisa!!

 

 

 

 

 

Productive Purposeful Pleasant


Productive – Purposeful – Pleasant


After ending last week’s blog, I realized I haven’t ever posted about this little language-based motivation/behavioral activation technique that I sometimes use with clients. Probably because I really don’t like it when people make (or especially seem to force) alliteration or acronyms, and I don’t want you to think I did that! Haha! This actually just popped up in a session one day, fully formed (fully P’d!) and it has been useful several times. 

This little technique seems to be sometimes beneficial with clients who have mild/moderate depression, the kind of anxiety that keeps them sort of paralyzed (not catatonically paralyzed! Just keeps them from moving forward effectively), and some who deal with procrastination. (Although straight mindfulness is good for all of these, too, especially procrastination.) 

The technique is really simple – it just involves (Step 1) taking the things on the client’s to-do list (whether that is take a shower and check the mail in the case of depression or the long list of household chores or whatever), and dividing them into these categories, or labelling them… is the task Productive, Purposeful, or Pleasant? (or some combo?)

*Wouldn’t it be nice to have lots of things on the list that are all three?!*

Step 2: Just take anything else off the list! What’s it doing on there, anyway?! This can sometimes bring a sense of relief and permission to clients who need it. 

Step 3: Make sure there are items in every category, especially the pleasant category! (This is a kind of sneaky way to measure anhedonia and sometimes to figure out distress tolerance ideas!) 

Step 4: Invite clients, in session if it’s possible or as homework, to choose items from anywhere on the list.

I often start with Productive… is there anything on there that they have the motivation/energy/etc. to do right now? If they can, they often feel a sense of accomplishment and also relief from “checking something off the list.” It’s ok to make use of session time to get this started! Do they need to make a dr’s appointment – just have them call, right now! Do they need to update their credit card information on their bill pay? OK, do it! 

If not, how about something purposeful (meaning tied to values, even if it doesn’t “get things done”)? Is there a value of relationships or being a kind person – choose text a friend from the list (add it right in the moment if it comes up!) Is there a religious/spiritual value – choose read a scripture verse. Is there a value of being a good parent – write a sticky note for your kid and put it in their room. Is there a value on making progress in therapy? Listen to your affirmations, read a few pages in the homework book, etc. Make sure that plenty of these are easy, low energy, low cost options. (This is a kind of sneaky way to get to identification of values, as well, which can be helpful in most cases.)

Nothing doing there, either? Well, no problem! Because you have a list of activities that are for nothing but pleasure! Encourage clients that choosing something from the pleasure list is OK! (There might be a little bit of cognitive work to do here, about being “allowed” to do something for pleasure when there are things on the productive list. And one of these days I need to do a post on how “laziness” is just a really good energy management strategy! HA!) But remember – doing something is better than doing nothing, and often increases motivation and productivity in the long run. Even if the pleasant thing is doing “nothing,” like taking a nap, sitting quietly, etc., doing it mindfully is a positive step! 

Comment below: What do you do to help clients with behavioral activation? 

 

 

 

 

Preposterous Quotes – Worry

 

Actually, worry is a PERFECT use of imagination. In fact, it may be the most evolutionarily sound reason to have an imagination at all! The ability to “predict the future” accurately as it relates to potential dangers and obstacles is incredibly valuable, and that’s what imagining is! How else could we planfully navigate the world? 

Of course, lots of other wonderful and more pleasant uses for imagination. And overusing imagination to predict dangers/obstacles that are highly unlikely can be problematic. (That does happen quite a bit – in fact, in clients with GAD, 92+% of worries don’t materialize!) And catastrophizing… usually not helpful. 

But I have found that it can be helpful to clients who struggle with worry to both learn why their worry (in realistic quantity) is valuable, as well as learning to harness their imaginations for other productive and pleasant purposes! 

 

 

 

 

Preposterous Quote – New Years

 

New year’s day – or any day of our lives – is not the beginning of a new book. It might, maybe, possibly be the beginning of a new page or a new chapter (although why that would happen exactly on this particular day of the year baffles me!). But we can’t escape the fact that pages, and chapters, and VOLUMES have already been written (in our own lives, yes. And we are also chapters and pages in the lives of many other books, past and present!). We are the same characters that we were on the last page, and thank goodness for that continuity! Otherwise, how would we actually learn, grow, and change?

You can’t be the hero of a story that starts today. But you ARE the hero in the story you’re a part of. Take all those pages, read them carefully, then author your next pages well.   

 

 

 

 

Keys to Wellbeing from an Accountant


Keys to Wellbeing from… an Accountant? 


I was reading an article about managing personal finance. And, as often happens, it just kept ringing in the resonance of therapy instead. Here’s what I learned about self care from an accountant:

 

  • Live on less than you make
    This is message so many of us need to hear. We are so over-extended that sometimes even self-care seems like one more thing on our plates or something we can’t even cram into our schedules. You only make so much money per month, and there are only so many hours in a day. It’s ok to scale back, so that you are living in a way that is sustainable in terms of your time, energy, relationships, and mental health. Don’t worry – having a meaningful, satisfying life isn’t measured in quantity.

 

  • Pay yourself first
    This is related to the first one, and it’s meant to be a way to help people make sure they have savings at the end of the day – have it taken straight out of your paycheck so you never see it at all! This is a hard one to do with self care, though. Maybe it looks like scheduling all of your physician and dental appointments a year in advance. Maybe it means setting all the house lights on a timer so that it gets dark in the house by 9p? What about prioritizing your self care before you get into a serious relationship, or working that out with your partner before you have kids, so that the expectation is already there? It’s not that you can’t draw on those savings if you need to, it’s just that it’s easier to save when you don’t have to choose to do it every day.

 

  • Build your credit if you can
    If you manage to “live on less than you make,” maybe you can even go one better… what does building credit in terms of energy, time, or relationships look like? It looks like paying IN to valuable experiences, as long as you can afford to. Once your self care is in hand well enough that you have extra energy, what can you invest that energy in that will pay you back ultimately? And here’s an interesting piece of this – when you ask others for help or favors (going into “debt” with them), that can actually solidify a bond as long as the debt doesn’t get out of control and you’re in a position to be able to extend them a loan, as well.

 

  • Don’t rely on willpower
    When it comes to saving rather than spending, willpower is NOT our friend. Some people can manage ok, but most of us don’t make great decisions when something pretty or fun is in front of us. And when we’re struggling, it’s even more important. Put that credit card in the freezer and take cash to the store. Start taking care of your own pool if that poolboy is a yummy distraction to your marriage. Block that friend who always needs a loan who pulls your heartstrings. Move your phone to the bathroom if you can’t stop reading the internet when you should be asleep. Set your grocery app to order only the foods you feel great about eating, then fork over the $5 to keep yourself away from the candy aisle. Use willpower only when you don’t need it, to take small steps that make willpower unnecessary.

 

  • Good investing means NOT listening to your heart
    Emotional investing almost always means poor investing. People get afraid and sell when they shouldn’t; they get excited and buy something that turns out be nothing. When it comes to long-term decisions, even if you’re a feeling-type person, gather as much data as you can. Ask experts. Be conservative. And lead with the prefrontal cortex.

 

  • Never finance a depreciating asset
    “Buy now, pay later” is the always devil talking. And how do we do that with our time and energy? Don’t say yes to something unless you can reasonably predict that it will be worth more to you in twelve months than it is now.

 

  • Never gamble what you aren’t happy to lose
    Actually, this tip is usually worded: “Don’t gamble what you can’t afford to lose.” But in a monetary and an emotional/relational way, I prefer the stronger position. IF you’re going to gamble… make sure it’s truly a game. Can you afford to lose your job? Maybe you can. But don’t take the gamble on dating your coworker or telling off your boss unless you’re *happy* to lose your job. Can you afford to lose your marriage? Maybe you can. But don’t gamble on that flirtation or call your partner something you can’t take back unless you’re *happy* to lose your marriage.

Comment below: What do you think? Any others come to mind for you?

 

 

 

 

Dingbat & Darling


Dingbat & Darling


 

Let’s get real about self talk for a minute. Whether or not you’re into the IFS craze, we almost all at least treat ourselves as if there are multiple little versions of us inside. And pretty much everyone has a readily accessible part that will berate and punish us for any perceived mistake. (Critical parent, anyone?) And they NAME CALL. Because that inner critic often has the vocabulary of a 9th grade bully, some of that name calling is really awful. In fact, I won’t even write some of the terms my inner critic has at the ready!

I don’t share my personal experiences that often, but I think it’s worthwhile here. So, being the good little girl that I sometimes have inside, I did my self compassion work and changed some of my internal language. I gave myself a name for that sweet little kid who sometimes needs nurturing, teaching, or encouragement – she’s “Darling.” But let’s face it – there’s still a part in there that does dumb stuff, and needs something a little more corrective – and in my effort to be self compassionate, I renamed her from Those Awful Things I Won’t List to “Dingbat.” Maybe that’s not the ultimate perfection of internal parenting, but it’s a heck of a lot better. And I can interact with Dingbat in a much sweeter, bemused kind of way. It makes a big difference!

And I don’t think that we need to pretend that everything gets completely smoothed over inside, even with good therapy work. And honestly, I think there’s a space for a critical parent in there, too. But she doesn’t have to be a Raging B*tch. (Oops! did that come out?!)

Comment below: What is some of the really harmful inner language you’ve heard clients use? And how have you helped them turn it around into something that keeps the purpose without keeping the vitriol?

 

Side note: Image above is of an actual “dingbat,” which is apparently decoration on a page to make bland text more inviting! ha! 

 

 

 

 

“Untangling” Couples/Family Dynamics


“Untangling” Couples/Family Dynamics


I just love it when a metaphor shows up in real life in all its glory – slaps me in the face or lands in the palm of my hand…

Untangling these actual, real-life necklaces, the metaphor of “untangling” family dynamics in session just couldn’t be ignored:

 

  • Too much stress on the system locks everything up!
  • Sometimes you can see the problem knot right from the start, often you can’t
  • Work on whichever place is most ready to move
  • Be patient, and willing to pause and come back fresh
  • Opening up space takes a gentle “massage” of the whole system
  • Focus on all the strands, but know that the change usually happens in one small spot at a time
  • The main work is a lot of observing the same territory over and over, with gentle optimism
  • Consider small pushes along with pulls, movement can happen in more than one direction
  • Don’t drop it in the middle of the work! haha!
  • Small progress can feel like no progress, or moving backward, but it’s not
  • Anything that promotes space and movement is progress, even if you can’t see the end yet
  • Once things are moving, don’t go too fast – hold the spaces open and go gently
  • A misstep isn’t the end of the world – what gets tangled can get untangled
  • Every once in a awhile, loosen the tension on the whole mess
  • Continually look at the whole system from different angles
  • Be aware…pulling on one strand can cause tightness in others
  • When things are moving, keep an eye on every strand to see what’s happening, or new snarls might pop up in seemingly untangled areas
  • Be close enough to work, but keep your distance – you can’t untangle if you become a strand! Or even if you get too stressed while working on it.

Comment below: Can you flesh out that metaphor even more? What therapy metaphors have “jumped out” at you in the past?

 

 

 

 

 

Office Supplies Volume 3


More Useful Office Stuff (Vol 3)


I don’t have infinite space in my office, so I like to make everything count. I’ve written about some of my office treasures before here and here, if you haven’t seen those.

Here are a few things I keep in my office that are especially good when it comes to client homework (and we know how important homework is, right?!) 

 

  • Homework “Rx Pad” – One of the things that clients get from therapy is permission. Permission to act differently, have a tough conversation, give themselves a nap, go someplace strange for social anxiety work, etc. Sometimes, that’s implicit, and the client just needed that permission for themselves. But sometimes, it really helps them enact their homework if they’re able to tell members of their system that “my therapist told me to!” To facilitate that, I made up a little prescription-size notepad that says “Therapy Homework” and has my name on it. I don’t use it all the time, and honestly sometimes it just gets used because clients forget homework if we don’t write it down, but when it works, it works! 
  • Brown envelopes – Somewhere along the way, I realized that I often assign homework that involves communicating in a written way with someone else, or with the future self. Because part of what helps therapy work is how special/sacred/novel it is, I like to have some plain (but special!) envelopes to give clients when I assign a homework like that. Kind of a way to take the sacredness home with them, but also nothing obtrusive that’s going to alert family members.  
    • And Red envelopes! I keep a separate set of red envelopes that I use sometimes when I give couples sexy homework. I have no research-based reason to do this, I just like to and feels extra fun! Sometimes, I’m giving them “secret” instructions and sometimes I just give them the envelope(s) to use to communicate with each other.
  • Cheap journals – I assign tons of different kinds of journaling homework. The classic Expressive Writing homework, worry-time journaling, dream journaling, ego state journaling, etc. And I have found that clients really enjoy receiving a little journal from me to start their work in. Not that they necessarily have to do it there! I just find it helps with investment, and frankly, clients like receiving gifts the way we all do! I use these – they’re lined and they have a nice, clean look. I think they’re 50 or 60 pages (which is usually plenty), and because I have a bunch of colors, clients can choose one they like. And they’re under $1 a piece! 

Comment below: What’s the most useful stuff in your office? 

 

 

 

 

Online Resources Vol. 4


Online Resources Volume 4


If you haven’t seen them, here are Volumes 1, 2, and 3!

  • The Reveri app  – It’s free (of course!) and the BEST actual hypnosis app I’ve ever come across. (And I’m ASCH certified in clinical hypnosis). I’ve previously recommended Comfort Talk, and stand by it, but Reveri is also excellent and covers a lot of great, specific topics – e.g., sleep, anxiety, chronic pain, smoking cessation – the kind of stuff it’s probably ok to work on by yourself without a therapist. 
  • Greater Good Magazine – Honestly, this isn’t a great resource for therapists, as far as I can tell. But I think it’s one of the better lay-accessible internet resources.  It’s mostly research-based and comes out of Berkeley, and has lots of different kinds of content, all focused on well being. Worth a look. 
  • Andrew Huberman Podcast – For nerdy therapists (and maybe clients), Huberman is a neurobiologist and does a lot on mental health related topics – sleep, depression, addiction, stress, etc. – as well as some stuff that’s more like “optimizing wellness.” Easy to listen to, extremely knowledgeable, great sources, smart occasional guests. Honestly, his mental health series was not my favorite, but when it’s outside my direct area, I learn a lot. 
  • Kardia Deep Breathing App – FINALLY!!!! I finally found an app that lets you control the timing of the breathing! Remember the cardinal rule – breathe out longer than you breathe in. The end. But finally, there’s an app that will let clients personalize that, rather than putting them on a strict 5-minute, 5 seconds in, 5 seconds out, rigid program! THANK YOU! It’s $0.99 for the full functionality, but the free version works perfectly well for my personal use and for how I use it with clients.  
  • Spanish & Mandarin relaxation tracks – offered by the University of Texas Counseling Center, There’s a 3-minute breathing and a body scan available in both Spanish & Mandarin – I have a hard time finding resources for clients who, even though they may do their therapy with me in English for various reasons, might prefer or better utilize resources in their native language. These are free and you don’t need to be a student to access them. 
  • Various Downloadable Workbooks – The Govt of Western Australia has a resource that includes free, downloadable self-help workbooks on lots of issues – body image, depression, procrastination, distress tolerance, panic, health anxiety, etc. I haven’t gone through the whole workbook on all the topics, but the ones I have looked at are pretty legit. Maybe a good option for clients who want to work outside of session, or for your own use as smaller handouts or in-session activities if you break them up.

Comment below: As always, if you know of great, free, online resources, let us know, too! These things are out in the world to be shared and used!  

 

 

 

 

More than Five Love Languages


There are More than Five Love Languages


I don’t love the “five love languages.” I don’t love the book because it stresses me out when books about mental and relational health aren’t grounded in research. I don’t love the concept, because I find it very limiting and prescriptive. There are clearly more than five love languages! (Although when couples have already read it/heard about it, I won’t put it down, I’ll just try to “stretch it out.”)

I do like that the idea that couples are made of two people who are different from each other, and I do like the idea of shared vocabulary for shared understanding. One of the most important things for couples to learn in this kind of empathy work is understanding that the other person might experience something differently than you do – maybe even oppositely! 

That being said, here’s a slightly more comprehensive list of ways that one person might feel loved/validated, that the other person might not understand well – or might understand in a completely opposite way! (Note especially the blank bullet points at the bottom. I like the visual assumption that clients will add their own!) 

 

  • Being helped (my partner assumes I’m worth helping/ they assume I’m not capable)
  • Being asked for help (my partner needs me because I’m worthwhile / they don’t want to do their fair share)
  • Being complimented (my partner thinks nice things about me / they’re flattering and they want something)
  • Being given gifts/money (I’m valued / they think they can just buy my love)
  • Being sexually pursued (I’m desirable / they’re just using me for their own gratification)
  • Hugs/cuddling (they love to be near me / they’re clingy and smothering)
  • Doing things together (they like spending time with me / they can’t stand being alone)
  • Introducing to friends (they think others will like me / I’m too much for them to handle alone)
  • Giving advice (they care and want to help me / they think I’m stupid)
  • Monitoring behavior (they care and want me to be safe / they’re invading my privacy and autonomy)
  • Inviting to share interests (they think I’ll also enjoy that / they don’t care what I like)
  • Letting me make decisions (they trust me / they don’t want any responsibility )
  • Making me part of their FOO (wants to include me deeply in their lives / wants to take away my individuality)
  • Encouraging me to grow in xyz way (wants me to be my best self / thinks I’m garbage and wants to change me)
  • Emoting strongly (I’m a safe place for them / they can’t handle their anger, etc)
  •  
  •  
  •  

This kind of thing can help couples do that work of perspective taking and empathy, like when they realize they didn’t marry someone Crazy, Stupid, or Awful.

Comment below: Any others you can think of or that have come up in session? How have you used the “love languages” concept to good effect in couples’ work? 

 

 

 

 

Sleep Lesson from my 8 Year Old

 


Sleep Lesson from my 8 Year Old


I have to share this amazing sleep tip from my kid!

 

(Side note: Let me say we do prioritize sleep in the household, but we don’t follow every perfect sleep hygiene prescription because, well, we’re human people. But we do have a nighttime routine and a regular waketime even on weekends! I have a sleep hygiene handout for clients that I really like and you’re welcome to use it if you like – find it here.)

 

Back to my kids: here is what she told me, completely unprompted:

“Can I tell you how I put myself to sleep? (Yes, of course!) First, I lay down  comfortably. Then I yawn. If I don’t feel like yawning, I do it anyway and then it becomes a real yawn. Then I close my eyes. Then I find the place in my body that feels the warmest and I think about it until the warmth goes to the rest of my body and then it’s relaxed and then I’m asleep.”

What an awesome technique!! I told her I would share it with the therapy world and also with clients who might be helped by it. So, there you go. 

 

 

Comment below: Any favorite sleep strategies that you use or teach to clients?

 

Best Quick Tips Ever Volume 2


Best Quick Tips Ever (Volume 2)


Here are some more super quick, highly accessible techniques that we could be teaching clients! (Remember, don’t use these if the underlying theory isn’t already part of your clinical repertoire, please!) If you haven’t seen Volume 1, see those here

 

  • Imagine Yourself on a Hot Air Balloon (or Better Yet, Sitting on a Satellite) – This is an old Stoic notion, “Plato’s View” (more about that here) that current research also suggest can quickly reduce distress. This visualization exercise allows you to change perspective, throwing even the deepest, most overwhelming pains into relief against all the rest of what’s happening in the world.     
  • Half Smile – A DBT classic, this is possible the quickest and most available emotion regulation technique of all! The brain and body work both ways, you know! 
  • Sunlight – 5-15 minutes in the sun is enough to boost serotonin and improve mood. Add to that the fact that you’re probably removing yourself from a less pleasant situation to a more relaxed/pleasant situation by going outside (yay, behaviorism works!) and getting a little nature fix (bonus mood enhancer!), and it’s even better. 
    • Also, as a reminder, regular moderate sun exposure helps prevent depression, and if you do it in the morning, helps to improve sleep! Oh, and cognitive function! And work satisfaction!
  • Jumping Jacks (any kind of intense exercise immediately) – Even five minutes of intense exercise can improve mood in several ways – by “using up” stress hormones if they’re present (yes, that’s a gross oversimplification), by getting you out of a stressful or uncomfortable situation (unless you’re going to bust out some crunches right in the middle of the stressful work meeting), and/or providing an intense enough distraction to act as a distress tolerance skill.
    • And, over time, a really excellent treatment and prevention strategy for depression! (WAY better than antidepressants) 
  • Say the Thing, Out Loud. Even to Yourself. Especially to Yourself. – That icky feeling is more tolerable once it has words that go along with it (especially if it has accurate words that go with it). But, emotional labeling acts as an implicit emotion regulation strategy, and it’s relatively effortless. Plus, the benefits of expressive writing (decreased anxiety, depression, negative rumination, and improved mental and physical health, including enhanced immune functioning) extends to speaking aloud as well!  
  • Drink a Whole Glass of Water – not only does this just give you a tiny break from whatever stressor you’re in, it’s an opportunity to engage in basic self care and possibly to engage in a mindfulness practice. But there’s also research showing that being even a little dehydrated can contribute to fatigue, low alertness, and negative mood. So a simple glass of water might help you feel better, and help you gear up for more active coping! (Also, many of us work in environments where this is something we could even offer clients in session.)

Comment below: Your ideas for super cool, underutilized quick tips? Or have you ever used any of these with clients? 

 

 

 

Supplements are a thing


Supplements Are A Thing


And it’s worth knowing about, because your clients might bring it up.

ETHICS NOTE: Don’t recommend them! That’s outside our boundaries of competence!! If you want to help clients in other areas, become a teacher of how to recognize credible sources and read the scholarly literature!

Here I’ll give you some research about mental-health related supplements that have happened to come up from my clients recently (links attached, of course!!). Probably this will end up being a series, but who knows? 

 

Comment below: Any supplements your clients are talking about, that you’ve looked into? Share your info! Anything you’d like me to look into for a future post?  

 

 

 

Untamed Brains (ADHD)


Untamed Brains (ADHD) 


That’s a term I got from my cool, wise kids!! It just popped into our conversation, and I love it. I love it in all the ways – it speaks to me about creativity and dream work and many more things. In fact, I love it in so many ways, I’m going to start a new tag for it, because I see now that it’s going to come up a lot. Today, I specifically love it in the way that ADHD can be a GIFT, not a diagnosis. 

Now look, ADHD is not always a gift. It’s not mostly a gift. Not in this world. It can be a hot disaster, and I don’t want to diminish that experience AT ALL. It does require accommodation. It is exhausting. It’s not a “superpower,” despite some of the messaging that’s popular now, at least not all the time. (My kids also recently engaged me in an insanely well-thought-out discussion about how all superpowers seem to also be or have super-weaknesses, at least if they’re real. Like how if you can turn invisible, you should also be blind, because your retinal cells wouldn’t have the capacity to register the light because the light would be passing through them. Yes, My kids are 11 and 9.)

Ok, back on track! Once the “weakness” part ahs been managed – and YES, that’s necessary and it might also be an ongoing thing forever – and people have learned how to place themselves in environments where they can thrive and strategies to help them do so… 

Examples of some ADHD “traits” that can be a little magical (in general, or in the right light!) include (Sedgwick et al., 2019):

  • Cognitive dynamism (divergent thinking, hyperfocus, “flow,” inquisitiveness, creativity, curiosity, originality, ingenuity)
  • Courage (non-conforming, adventurousness, bravery, integrity, persistence, spontaneity, staying an indvidual)
  • Energy (“spirit,” psychological energy, physical energy, “drive”)
  • Humanity (social intelligence, humor, self acceptance, recognition of feelings)
  • Resilience (self regulation, flexibility, adaptability, sublimation/reframing of “weaknesses” into strengths)
  • Transcendence (appreciation of beauty and excellence, awe, wonder)

Personally, a supervisor once enlightened me… those “tangential thoughts” that come up in therapy sometimes – they might be tangents, and they might initially seem TOTALLY unrelated to what’s going on with the client at that moment, but give them a chance sometimes. Even if your brain is running a little faster or a little more “untamed” than the client’s, that doesn’t mean it’s actually random. You still have neurological networks, you know. So, see what comes up – it might surprise you with just how relevant it is.  (You know, and also don’t run amok with a session, please!) 

Side note, and this is not on the “untamed” side, but people who grow up with and have to learn to manage ADHD also wind up with a lot of awesome gifts from that process and struggle. Not everyone develops the same ones, but incredible perseverance, realistic self compassion, and whole host of organizational and self management skills are typical!

Comment below: Any therapists with ADHD out there? Has it ever been helpful?

 

 

 

Sedgwick, J. A., Merwood, A., & Asherson, P. (2019). The positive aspects of attention deficit hyperactivity disorder: a qualitative investigation of successful adults with ADHD. Atten Defic Hyperact Disord, 11(3), 241-253. doi: 10.1007/s12402-018-0277-6.

 

 

 

Preposterous Quote – Pain Quitting

 

Hmmm… no. Pain isn’t always temporary. Pain is often chronic, especially when we overuse our bodies in a relentless pursuit of unhealthy goals. Or when we don’t recognize and honor legitimate limitations. Or when we don’t respect the need for rest or a healing process after injury. 

Also, why would we think that quitting lasts forever? That’s such a genuinely peculiar assumption. What about going back to something you previously quit? Especially after you are well rested or better conditioned or more equipped? Also, I’m not sure it counts as “quitting” when you mindfully stop something and choose a different path? 

I’m noticing that a fair percentage of the preposterous quotes I run across have this mad (hyper-American?) theme … do more, push through, no quitting, be everything, don’t suck! I don’t like it. 

Comment below with some healthy language for encouragement to challenge oneself! 

 

 

 

Book Announcement


So… I did a thing…


Here’s a book! I wrote it. 

ROUTLEDGE published it, and the level of fanciness I feel saying that is not measurable. 

It’s a lot like this blog, only you can get it in paper and you have to pay for it. Oh, and it has no pictures. 🙂

Actually, it’s much more comprehensive and better structured than the blog, though the writing style is a lot the same and the idea is the same – let’s BE BETTER THERAPISTS. Let’s use theory and research and our colleagues to help us do that. 

Therapists, in general, I think will really like it and get a lot out of it. So will advanced practicum students and interns. 

At any rate, I’m supposed to tell important people. So, there you go! 

It is available at Routledge and through Amazon! Oh, and if you go to the new Book page on the blog, there’s a coupon code! 

 

 

Avoidance Sucks


Avoidance Sucks


Here’s what I mean by that: 

  • Avoidance of feared stimuli increases rather than decreases fear. So it perpetuates itself at your expense. This is approximately 35% of all therapy, possibly. 
  • Avoidance is painful by itself. Every time you avoid, you’re having a measure of the pain you would have in confronting. But you avoid it over and over and over… so you have a partial measure of pain over and over and over, which almost always ends up being more painful over time. 
  • Avoidance narrows your options. I mean this in small ways, but also in the very big, existential way – like the “untimely deadness of a too narrow existence” 

Some caveats, in case you’re thinking any of these things:

  • Staying away from genuinely toxic or dangerous things/people/situations isn’t avoidance, it’s wisdom. 
  • If you believe you benefit from a “change of scenery,” you need to give a good think about if it’s escaping/avoidance or something else. A lot of that is how you use that time. If you just get away from stressors and enjoy that, it’s avoidance. If you use the time away to actively work on stuff that will improve your life when you’re back, ok. 

Comment below: How have clients sometimes gotten in trouble by avoiding? How have you?? 

 

 

 

Best Quick Tips Ever (Vol 1)

 


Best Quick Tips Ever


 

There are a bunch of super effective, super-fast, super-easy techniques for stress reduction, emotion regulation, and more that therapists just aren’t teaching clients! Why?! I think it might be because people don’t know about them? Here’s a list of a few of my favorites, each with a little video. Well, except for the really self-explanatory ones. For those, I’m attaching some research because it’s hard to imagine these commonplace little tactics are actually effective! 

(Ethics moment – definitely don’t use these if the underlying theory isn’t already part of your clinical repertoire, please!)

 

  • The Dive Reflex – If you’re a mammal (and you are), and you’re stressed, put your face into cold water for 30 seconds. Instant changes in the stress response, thus calming anxiety and other dysregulated emotions. 
  • The Physiological Sigh – You do this, unwittingly. It’s that sobbing sort of thing you sometimes do in the middle or near the end of a big cry, or you at least do it in your sleep! It’s like taking 2.5 inhales and then a long exhale, repeat 3-5x. The end. Really good for quick emotional calming. (Side note: In real life, when your body does this naturally, it’s more like 1.5 inhales, but when I’ve taught it in therapy, clients are usually breathing very shallowly, and teaching them to do this consciously, 2.5 seems to work better – the first inhale to baseline, the second to what feels like “capacity” or a “deep breath,” and then that last little bit that “overinflates.”)
  • List 3 Things You’re Grateful For – Lots of research about this, but here’s a fun study about how gratitude reduces Repetitive Negative Thinking and thus reduces depression and anxiety. Even a single, small intervention, like listing 3 things you’re grateful for in the moment can change perspective and improve mood. 
  • If you already do EMDR, consider the Flash Technique – it’s like a quickie version of reducing SUDS, without processing the actual trauma (but has some limitations, of course). Remind me one day to do a post on what actually makes EMDR work (which isn’t bilateral stimulation).
  • Call a Thought a Thought – the simplest  of cognitive defusion strategies. Notice you’re thinking thoughts. Then say it to yourself, “I’m noticing I’m thinking XYZ,” or even “That’s just a thought.” Crazy powerful, quick, and accessible anytime. 
  • Controversial but interesting…. Take a Tylenol – Acetaminophen (paracetamol) reduces the pain of social rejection and of making tough decisions. Careful, though – it may also increase risk taking, reduce empathy, and decrease the intensity of positive experiences, as well. (And, of course, mind the risk of overdose!) 

Comment below: Share your favorite, research-based “quick tips” for clients!  

 

 

 

Obviously…


Obviously… (the false consensus effect)


This is a pretty awful word. 

The false consensus effect is a cognitive bias – it’s our tendency to see our own choices and judgments as  common and appropriate to existing circumstances. And that means, almost all the time, that we think other people really ought to be thinking, perceiving, believing, valuing, and choosing the same way that we are … obviously. 

Because we’re therapists, our job is to accept and understand the different ways that other people are thinking, perceiving, believing, valuing, and choosing. (And we don’t do this perfectly, by any stretch!)

But for a lot of people, if you aren’t thinking what’s obvious to them, you’re obviously crazy, stupid, or awful. 🙂

So, where are the places we can eliminate this word, as a way of beginning to unchain ourselves from this bias? 

 

  • We can stop using it in session, for a start. When is there a time that this word is beneficial in session? I’m guessing pretty much never. 
  • We can teach this in session, to clients. It comes up a lot in couples’ work, especially. 
  • We can work to take it out of our conversations in our non-work lives, too. 
  • And we can watch for sneaky synonyms like “of course!” 

 

 

Comment below: Now you’ll be catching yourself using this word! Post a comment about your situation! (Including if you think there ARE useful times to use it!)

 

Words of Regret


Words of Regret


Sometimes, a small change in words can make a world of difference! 

 

I know we talk about the word “Should” in therapy a lot, especially in the Albert Ellis kind of way – “shoulding all over yourself.” But there’s this one specific instance where clients seem to use “should” in a profoundly destructive and usually inaccurate way. When they regret something they have done, or haven’t done, or the way some situation went, they say: 

  • “I should have said things differently.
  • “I should have acted more quickly. 
  • “I should have been a better partner/parent/friend.

It turns out that most of the time, clients actually did the best they could with the information and resources that they had at the time. So, it’s a bit of a logical fallacy to say they should have acted differently (and certainly some other cognitive distortions in the way they imagine the difference it might have made). I have also found, though, that when they are expressing this deep, sometimes grief-filled, regret… they’re no really in the mood to talk about how unrealistic they’re being. So, sometimes I ask them to just make a tiny language change, or sometimes I just make it when I reflect it back:

  • “You wish you had said things differently.
  • “You wish you had acted more quickly. 
  • “You wish you had been a better partner/parent/friend. 

There are other words that could fit, too, but I like wish because it can be modified in terms of intensity pretty easily. “It’s the most desperate wish of your heart…” “You deeply wish that…” 

We’ll get around to talking about the specifics and the reality and all that, of course. (Side note: these shoulds/wishes are almost always much too vague, precisely because the exact right action that would have brought about the desired outcome is not knowable now, just as it was not knowable then!) In that moment, though, removing or lessening the burden of unnecessary guilt can be as simple as using language with intention. 

Comment below: When have you found that small language changes have made big impacts for clients? 

 

 

 

 

Online Resources Vol 3


Online Resources Volume 3


Here’s a new set of interesting, free, potentially useful online mental health stuff I’ve run across for clients or clinicians! If you haven’t, check out Vol 1 and Vol 2

 

  • Project Y.E.S. ​(Youth Empowerment & Support) is an anonymous program evaluation project being run by scientists at Stony Brook University in partnership with University of Texas Health Science Center at San Antonio – UT Teen Health. Free 30-minute stress-mgmt activities for teens! The idea here is that evidence-based mental health support can be SO much more widely available than it currently is!
  • These online  “pocket” memory aids  cover the basic ideas from several different types of therapy. They’re probably not useful if a client hasn’t engaged in that therapy with you, but after you’ve taught the basics, these can be a good reminder as they practice throughout the week.
  • I know there are a million CBT worksheets out there, but I quite like these from Andrew Grimmer (who I don’t know, btw! This is not a shoutout – I just came across them and find many of them more useful than resources from other, more common websites). Some are printables, others are online forms (like a chain analysis that can be filled out by a client midweek and emailed to the therapist!).
  • If you’re already familiar with ACT, these are pretty helpful technique explanations/reminders. 
  • I’m not 100% sure that I haven’t posted this before, but Now Matters Now has some great resources around suicidal ideation.
  • And here’s a great little video by Andrew Huberman describing the  “physiological sigh” – which is a great quick stress/anxiety tool. On par with the face-in-cold-water technique, but easier to do anywhere! 

Comment below: As always, share the cool, free resources you’ve found online, too! 

 

 

 

Great Books Volume 5: Contemporary and Wildly Useful Books Written by People I Know


Great Books Vol 5: Contemporary and Wildly Useful Books Written by People I Know (at least on Twitter!)


Transcend by Scott Barry Kaufman – This book is for everyone! It’s deeply humanistic and optimistic and transformational. If you thought you knew anything about Maslow’s “hierarchy of needs,” you should FOR SURE read this! It’ll both blow your mind and give you a great new metaphor for understanding human needs and actualization. Also, SBK is just this very cool, super authentic, and genuinely KIND human person. Oh, and he has the best podcast ever, too – The Psychology Podcast.

Show Your Anxiety Who’s Boss by Joel Minden – This is my favorite CBT book for clients. It’s easy to read, and the take-home message is simple and easy to remember (even though Joel knows I always roll my eyes at acronyms that are made to be cute, it turns out they are memorable!). One of my favorite things is how comprehensive it feels without turning into a long list of cognitive distortions. And I just really like the term “anxious fictions!” 

The Habit of a Happy Life: 30 Days to a Positive Addiction by Jeff Zeig. Jeff has written a lot of books, and I like all of them that I’ve read (because the way he thinks, especially about therapy, is just brilliant), but they’re not all for a very broad audience. This one, however, would be very useful for many clinicians and clients alike. If you ever read Positive Addiction by William Glasser, I’d say this is like an update version – same great concept, newer research, and I like Jeff’s writing better than Glasser’s, too! 

The Suicidal Thoughts Workbook by Kathryn Gordon – Is it weird to get really excited about a book on so heavy a topic? NO! Not for therapists, it’s not! Haven’t you lamented how few good resources there are for clients around suicide? This workbook is incredibly compassionate and thorough, gentle and practical. There’s no shying away from any difficult topics, and everything is handled with confidence in and grace for the reader. This is an indispensable resource for therapists, and I have no doubt it will be life-saving for clients. 

Brains Explained by Micah & Alie Caldwell (and sort of by their cats). Look, I know I’m an intense nerd and so you won’t like all the books I like. But if you’re one of the HUGE number of therapists who is both really interested in neuro/brain stuff but sometimes also intimidated by neuro/brain stuff, you’re going to SWOON for this book! There’s definitely enough in there that’s genuinely relevant to clinical practice to make it worth the buy on its own – but be prepared to accidentally get swept up in all the rest of it, too. It’s just so…. accessible and hilarious! And the chapters are almost bite-sized. They’re like…dessert-sized. What more could you want? (Oh, they have a fun YouTube channel, too!)

ZigZag by Michael Apter – Michael is one of my most treasured mentors. If you’ve read any of the Reversal Theory blog posts, you have also benefitted from his brilliance! He’s also written several books, but this one is the newest introduction to RT and it’s really accessible. So many more people (including your clients and yourself!) will find this book somewhere between interestingly useful and life-changing, so give it a try! 

Updated! Come As You Are by Emily Nagoski CAYA is my all time favorite book about sex!! Although it’s geared toward women, I almost always have men in relationships read it, too, especially if they’re in relationships with women. Emily is an incredible writer – she has a wild gift of taking really good, dense research and turning it into something both understandable and meaningful for the lay reader. Make sure you get the newest (revised & updated) version that was published in 2021, mostly because she says she likes it better. 

Also, CAYA has a workbook! (In fact, two cool things about the workbook. One is that I am one of the people who helped review it for initial edits, which was super fun! The second is that I’m pretty sure my husband is the reason the book exists – when we first read CAYA in 2013, before Emily was crazy famous and busy, he just emailed her to ask if she had any of the exercises in PDF, so we didn’t have to mark up the actual book and we could have 2 of each of them. So, she made them into PDFs and emailed them. Then, she put them on her website. Then, this book became a thing!)

And, yes, I’m a Nagoski superfan, so Burnout: Unlocking the Secret to the Stress Cycle (by Emily & Amelia Nagoski) makes this list, too. Incredibly useful, especially for that subset of adult female clients who grew up learning that they had to always play support roles, even unto exhaustion (and maybe developed resentment, anxiety, or low self esteem as a result). Goes along nicely with the podcast The Feminist Survival Project 2020. Just a note – both the book and the podcast lean pretty heavily liberal, but as long as I have warned my conservative clients about that, it’s been ok. 

Oh, and SURPRISE! I wrote a book, too! 😉 But you can’t have it until August! 

 

 

Comment below: What are your favorite therapy-oriented books these days? 

Crazy, Stupid, or Awful?!

 


Crazy, Stupid, or Awful?!


The foundation of couples’ work is often training them to listen. And of course, listening is actually incredibly difficult and relatively complex. For example, it involves all those difficult skills like self-soothing, holding difficult emotions, making space for the other person, accurate empathy, maximizing the use of working memory, tolerance for ambiguity, etc. And that seems overwhelming even here on this therapy blog, and it’s certainly overwhelming in session. But here’s an idea I sometimes put out in session when things start spiraling: 

You aren’t crazy, stupid, or awful and you probably didn’t marry someone who is crazy, stupid, or awful. So, there might be a misunderstanding in here somewhere. Let’s find it, shall we? 

Clients are more than likely to agree with the idea that they themselves are not crazy, stupid, or awful (and it’s nice to  validate them first, before going on to “defend” their partner). They also usually aren’t willing to say in therapy that their partner is one of those things. They at least don’t want to be married to (or in a relationship with) someone who is crazy, stupid, or awful.

This pause on our end often lets them pause on their end and create a little bit of space to hear their partner’s content differently. Yay! 

Occasionally, they will say their partner is crazy, stupid, or awful. Ok, no problem – now we know we’re in a contempt-place (in the Gottman way), and we can change gears to a process-rather-than-content level. 

 

Comment below: How do get couples to pause and refocus in session? Also, “QuotesFromSession” is a new tag – do you have any go-to session quotes that you often find useful? 

 

 

 

Preposterous Quote – Courage

There are two levels on which I want to address this preposterous quote. 

(1) I dislike, in general, inaccurate measurements. Specifically, in therapy, I dislike the idea that our own limits are not knowable. I believe that’s part of what is fundamentally useful about therapy – building accurate self knowledge and self awareness!

Look, I don’t want clients to live in a constant state of not-fulfilling-their-potential because they underestimate themselves. I don’t want them to reduce themselves to chronic-victimhood because they aren’t encouraged. I don’t want them to choose avoidance as a proxy for safety, when they could choose skills and strength instead. I don’t want them to suffer from the “untimely deadness of a too narrow existence” (Gendlin, 1973).  

I also don’t want clients to be shamed or feel shame because they actually do have limits. I want us all to know and honor the limits of our bodies, our strength, our coping. That’s when we know to access additional resources! That’s how we keep ourselves functioning for tomorrow’s challenges! 

When you’re drowning, yes…. you do usually have more oxygen available than you’re afraid you have. And use it all, please! You do usually have another half hour in you to work on that project that’s due, even though you’re really tired.  You probably do have a little more self control left over to speak kindly to your partner even though you’re stressed out from your work day. You probably do have more strength than you are afraid you have, more than you initially believe you’re capable of.

Let’s learn our REAL limits, so we can grow at our true edges. 

(2) I don’t mind the definitions of courage than rely on fear (“It’s not brave if you’re not scared”), but I really prefer the deeply existential understanding of courage – that you willingly act without knowing the outcome. And we never really know the outcome! We pretend we know the outcome, we relax into that lie sometimes, but we don’t ever really know how anything is going to turn out – our action or our inaction. That makes pretty much everything you do “courageous,” if you’re doing it willingly and acting in “good faith” (i.e., with knowledge of your own personal responsibility in living). 

 

 

Comment below: As always… your thoughts? Your definition of courage? 

Behaviorism for Parents 3


Behaviorism for Parents – Moving Up (Lesson 3)


(If you haven’t read the first two installments, find them here and here.) 

You don’t want to reward your kid for every little thing forever.

(1) First, how much does that behavior become intrinsically (or naturally) rewarding, meaning it will maintain itself over time after awhile? For example, exercise might be this way. We have to reward ourselves in the beginning to make it a habit, but once we start feeling better exercise is easier and more pleasant and our bodies feel good, so we don’t have to reward it anymore. Speaking more kindly results in nicer, easier relationships; sometimes even keeping one’s room clean ends up feeling good. If your kid starts doing a behavior with no reminders and no complaining, you can try just reducing the amount or frequency of the reward over time.

(2) You may be able to improve behavior through shaping, as described in the last post.

(3) You may want to use chaining. It’s similar to shaping, but chaining means stringing several desired behaviors together. You probably already did this at least once during potty training, because that’s a multi-behavior process (where each behavior was probably also shaped). When you first started potty training, you probably did all the work – getting to the bathroom, disrobing, setting the kid on the toilet, wiping or helping them wipe (wiping effectively is definitely one of those behaviors that needed shaping!), redressing, flushing, and washing hands. All your kid did was sit there and sometimes pee or poop. And at that time, they probably got praise or the potty song or an m&m, right? But eventually, you didn’t reward them just for peeing, they also had to flush. Then pee, flush, and pull pants up and down. All the way to being able to the whole chained process! (And, depending on how old your kids are, you probably don’t even give them m&m’s anymore -haha!)

(4) You may want to use a token economy. A token economy is especially helpful (and more convenient) when kids get older and so rewards are a little more substantial or when they can handle a little delay in their reward. (Remember, really little kids can’t make the connection even with a few minutes’ delay (this is why you brought the m&ms to the bathroom with you!), but older kids’ and teens can wait till the end of the day, week, or even more.

A token economy means that you use something symbolic (a “token”) to keep track of the rewardable behaviors, and then give the reward once they’ve added up. This could be stickers on a chart, or paper tickets that can be turned in, etc. One way to do this is just for any extra helpful chores, behaviors, etc. – for example, when a kid does a task that helps the family that’s not part of their regular responsibilities, they get a sticker. Once they get 20 stickers, they get $20. (This is more convenient than giving $1 each time.)

But if you’re using the token economy to keep track of regular chores, behaviors, responsibilities, you need to make sure that the child is regularly earning between about 60-80% of their available tokens per day. If they are earning 100% every day, it actually reduces their motivation. You can increase the difficulty of the tasks. If they are earning under 60%, they’ll also lose motivation. That means you need to reduce the difficulty of the behaviors to keep them invested in the program.

 

 

Comment below: What other behaviorism techniques might be useful for parents? 

 

If you can quit biting your nails


If you can quit biting your nails, you can do anything…


How does someone go about quitting a nail-biting habit? Admittedly, some people seem to just miraculously stop, some people never really got started, some people need a Habit Reversal Training procedure. But nail-biting is still an accessible idea to most people and it’s a common enough and acceptable enough habit that it makes it comfortable to talk about in session. 

Here’s how people think you’re supposed to stop biting your nails. 

(1) You decide you’d like to stop biting your nails. 

(2) You exercise your willpower and stop biting your nails. 

(3) The end. 

And that’s definitely NOT how it goes. 

So, what are the real steps? Something like this…

(1) You decide you’d like to stop biting your nails.

(2) You bite your nails.

(3) You notice after the fact that you bit your nails, and feel a little irritated with yourself. Your therapist explains habit formation (normalizing and depathologizing) and helps you to develop self-compassion. 

(4) You begin to notice you are biting your nails while you are biting your nails. 

(5) You make an attempt to stop, but they’re a little jagged now so you go ahead and finish biting them. 

(6) You begin to notice you are biting your nails when you start to bite your nails. You wish you had a nail file right near you. But you don’t. 

(6a) You repeat step 5. Your therapist repeats step 3. 

(6b) You get up and get a nail file. 

(7) You begin to notice that you are about to bite your nails. You wish you had a nail file right near you. But you still don’t. 

(7a) You repeat step 5. Your therapist repeats step 3. 

(7b) You get up and get a nail file.

(8) You get annoyed with always having to get up to get a nail file. 

(9) You accept that jagged nails are both bothersome and inevitable and now always carry a nail file or clippers in your purse/desk/car/etc.  

(10) You rarely bite your nails because those tools are accessible and you are aware of the need to fix nails early. You occasionally still bite your nails, and you react with self-compassion and simply manage the situation. 

 

Of course, this isn’t the only way change happens!

But this is one great way to talk about it because it emphasizes the importance of awareness, reduces emphasis on willpower (which is almost useless for meaningful, long term change), and makes central the importance of an incompatible behavior and addressing the reinforcer, which is really the foundation of change. It also addresses the impact of meta-emotion regarding the change process (e.g., how self anger, shame, etc. get in the way).

One of my favorite things about this model for explaining change is that when clients “fail” on their first homework attempt (or even later ones), I can tell them honestly that they’re making great progress. And they learn that it’s a process. 

 

Comment below: How do you talk about the change process with clients? 

 

 

 

 

 

Telephone = Telehealth


Telephone = Telehealth 


You might remember my rant about telehealth, fondly or irritably, but here is a little follow-up. One of my suggestions to clients when they begin telehealth is to mention any tech issues (e.g., lag) immediately, rather than waiting and tolerating that relational discomfort. I am willing to spend up to five minutes (but no longer!) working on a tech issue for telehealth. (Consider that, at some point, they’re paying us for IT work, which is definitely outside our boundaries of competence! Haha!) After then 5 minute mark, or after exhausting the typical fixes, I do something wild… I just call them on the phone.

Besides a large body of data indicating the usefulness of telephone consultation, and the history of telephone as the primary form of telehealth work, I came across a delightfully interesting study, with this main finding: 

Voice-only communication elicits higher rates of empathic accuracy relative to vision-only and multisense [voice and picture] communication both while engaging in interactions and perceiving emotions in recorded interactions of strangers. … Voice-only communication is particularly likely to enhance empathic accuracy through increasing focused attention on the linguistic and paralinguistic vocal cues that accompany speech. (Kraus, 2017)

That’s cool, huh?! Addresses one of the (apparently imagined!) 

Note that this research did not address the difference between voice only and face-to-face communication, which still has a lot of benefits over not being present, including client mimicry (e.g., Salazer-Kampf et al., 2020), interpersonal synchrony (e.g., Rennung & Goritz, 2016), neuroception of safety and social engagement cues (e.g., Porges, 2004), etc. So, I’m not suggesting that telephone is better than being in person together. Just that, if telehealth is necessary, phone might be an acceptable, or more than acceptable, choice!  

Comment below: Have you had great/not-so-great telephone sessions? What helped you have a good experience? 

 

 

 

 

References

Kraus, M. W. (2017). Voice-only communication enhances empathic accuracy. American Psychologist, 72(7), 644-654. doi: 10.1037/amp0000147

Porges, S. (2004). Neuroception: A subconscious system for detecting threats and safety. Zero to Three, 24(5), 19-24.

Rennung, M., & Göritz, A. S. (2016). Prosocial consequences of interpersonal synchrony: A meta-analysis. Zeitschrift für Psychologie, 224(3), 168-189. doi: 10.1027/2151-2604/a000252

Salazar Kämpf, M., Nestler, S., Hansmeier, J., Glombiewski, J., & Exner, C. (2020). Mimicry in psychotherapy – an actor partner model of therapists’ and patients’ non-verbal behavior and its effects on the working alliance. Psychotherapy Research. Advance online publication. https://doi.org/10.1080/10503307.2020.1849849

Why do we yell? (Just a theory!)


Why do we yell? (Just a theory!) 


Specifically, this idea came to me during some couples’ work. Why do people yell at each other (and this probably goes for parents/kids, too…) 

Here’s a theory I have. 

Animals vocalize in lots of ways. But when do they “raise their voices”? What does the animal research say about this? (e.g., Seyfarth & Cheney, 2003) First, there are two issues here with my reading of the literature – one is that I’m not super familiar with the comparative (i.e., animal) psyc research and the other is that animal research is always observational and about making inferences – can’t ask them any questions! Just bear that in mind. But from what I can glean, animals probably get loud in three circumstances/for three reasons:

 

  • To demonstrate aggression, especially when they feel underpowered (i.e., actual predators who are about to eat prey are sneaky and quiet, but an animal that is afraid it’s about to get killed or eaten may get loud to try to discourage a predator)
  • To sound an alarm, either to warn others of their kind that there is a danger approaching or to call for assistance
  • As part of display meant to push another animal of its kind down the social hierarchy, in a competitive way 

So, whether or not this is precisely accurate, it has been an interesting topic of conversation with my couples. I explain this idea and then make it a little human…

“Is it possible that when people raise their voices, it’s because they’re feeling underpowered and they need a show a vocal strength because their argument isn’t strong enough on it’s merit? Might they get loud because they feel like they’re in danger and actually crying for help from their partners? Or sometimes maybe they just want to diminish their partner – try to shut them down by proving they’re more important, stronger, or otherwise farther up in the hierarchy?”

Then, after there is some buy-in, I bring it to the personal/situational level: “So when you raised your voice just now (or last night, etc.), which of those reasons resonates most with your experience?”

  • Sometimes they reluctantly identify that they lost their cool because they could tell they were losing the argument. That can open the door for looking at the merits of both positions in the less-intense therapy environment. 
  • Sometimes they reluctantly identify it as feeling in danger and crying for help, and that opens a door for softer emotions from them and softer responses from their partners. 
  • Sometimes they reluctantly admit that they wanted to push their partners down, they just wanted to win. And sometimes they try to wiggle out of that by saying “I raised my voice because they just weren’t listening to me!” (Which is a sneaky way of saying the same thing… I deserved to be heard more than they deserved to be heard.) 

Yeah, no one seems to really jump enthusiastically into any of those explanations. But they give clients food for thought, sometimes they come around later or bring it up in a later session. At the very least, it prompts a discussion about the process of the conflicts, and that’s usually a therapy win! 

 

Comment below: Do you happen to know more stuff about animals (esp mammals) vocalizing loudly? I’d love to hear it! (Not including the monkeys that scream for sex – haha!) Or, how do you help couples begin to address the process rather than just the content of their conflicts? 

 

Seyfarth, R. M., & Cheney, D. L. (2003) Meaning and emotion in animal vocalizations. Ann N Y Acad Sci., 1000, 32-55. doi: 10.1196/annals.1280.004. PMID: 14766619.

Photo credit – Joshua Cotten

 

 

 

 

Reversal Theory “On The Couch”


Reversal Theory “On The Couch” 


This one’s not going to make much sense if you haven’t been following the Reversal Theory series, but if you want to check them out, here’s #1, #2, #3, and #4.

Here, as promised, are some RT-based techniques (and tweaks on classic techniques) that I’ve used in really cool and fun ways in therapy, to good effect. 

 

  • Intake Questions: Most clinical interview/intake questions are aimed at determining the client’s presenting issues and background information for diagnostic purposes. Sometimes, questions are included about clients’ expectations for therapy, their goals, and their perceived strengths.
    • RT transformation:
      • How much do you experience yourself as being serious and goal oriented? In which area of your life do you experience the best sense of “achievement”? In which area of your life do you experience that the least?
      • Playful/enjoyment; Being like others/fitting in; Being an individual/freedom; etc.
  • Cognitive Therapy: Thoughts, feelings and behavior are all connected, and that clients can overcoming difficulties and meet their goals by identifying and changing inaccurate, maladaptive thoughts. First steps are identifying maladaptive thoughts, evaluating them for accuracy/utility, and then  developing reasonable counter-thoughts, which clients tend to struggle with.
    • RT transformation:
      • The opposing nature of the RT states gives a quick, easy way to begin identifying potential, but reasonable, counterthoughts. For ex, clients often have anxiety provoking thoughts such as “this  storm is very dangerous” or “I can’t do well at this and that’s awful”. Clients tend to try to create counterthoughts in the same state, and these can be hard to swallow or not very accurate. For ex, “this storm isn’t all that dangerous” or “Maybe I am good enough at this after all”
      • Changing states creates fresh, conceivable options. For ex, “This storm is fascinating and awe-inspiring”  or “I don’t need to do well at everything to be valuable.”
  • Couples Work
    • Couples are taught to identify the RT states they are in during typical conflicts. They re-enact the conflicts in session, with an emphasis on “getting into the partner’s state” (each in turn) to improve empathy, reflection, and problem solving.
    • Techniques to help couples see from their partner’s perspective include overt state-disclosure, switching seats, mimicking partner’s posture/expression/tone, letting the partner “paint the picture,” guessing the partner’s state, and state-mapping
  • Group Work
    • This is a psychodrama-type technique I call “the gauntlet.” Two rows of 4 pairs of players (“auxiliary egos”) line up and each speak from the opposing states on the problem the protagonist has identified. The protagonist (the client who is doing the current work) “walks the gauntlet” and listens, makes comments, moves players (sit down, back up, etc.), turns the volume up and down, etc., in an improvisational way.
  • Guided Imagery
    • In the Eight Rooms technique (specific to Reversal Theory) an individual or group is instructed by a leader in a guided imagery session. The participants envision a hallway with eight rooms, four on each side. Each pair of rooms represents a pair of RT states. The participants are instructed to enter each room and fill it with colors, objects, scents, memories, and anything that helps to define each state for them. For example, a telic room may have paneling on the walls, a large clock, diplomas, and a work desk. A paratelic room may have brightly painted walls, a hammock, a tiki bar, loud music, and a bubble-machine. The participants are instructed to use as many senses as possible and not to limit themselves to ordinary furniture or objects. They are encouraged that, after the guided imagery, they will be able to use their memory of each room in order to induce the state desired at the time.

COmment below: What ways can you imagine using RT in session? 

 

 

 

Preposterous Quote – Plans

 

Frankly, this seems like a great way to alienate people and to accomplish less than you’re capable of. 

First, research is clear that sharing your individual goals (even if you don’t want help with them) improves outcomes, especially if you tell a friend or mentor. 

Second, other people can offer all kinds of support -not just encouragement and emotional support, but instrumental and tangible support! 

Third, the people who are going to be pleased by seeing your results are probably the people you want to tell, who want to help you. The people you don’t want to tell – unhelpful jerks? – aren’t going to be impressed. They’re still going be jerks.

Could we just change this one to say “Don’t tell unhelpful jerks your plans?” 

 

 

 

 

Online Resources (Vol 2)


Online Resources (Vol 2)


Here’s another installment of some free, evidence-based online resources and apps I’ve stumbled upon lately… (here’s Vol 1 if you didn’t see it)

 

  • An ebook about Getting The Most Out of Brief Therapy – could be great for clients really early on, or if they are feeling stuck.
  • This is an incredible introduction to sleep, sleep hygiene, and common sleep issues by the AMAZING Dr. Jade Wu. 
  • I like this little explanation of the R.A.I.N model of radical compassion, and it includes a 20 minute meditation. 
  • These are easy and evidence based screeners for multiple mental health conditions, like depression, anxiety, psychosis. 
  • I’m loving Dr. Russ Harris’ videos about Acceptance and Commitment Therapy! 
  • For therapists, I really like Jeff Zeig’s 5 minute therapy tip s, esp if you’re kind of existential or experiential. 
  • And here is an abnormal psyc textbook that is completely open source – it’s not my favorite abnormal book ever, and of course it’s at the undergrad level, but could be a good resource for clients

And some apps!

  • FITZ – Functional Imagery Training is an evidence based blend of imagery and motivational interviewing that shows tremendous benefits over standard habit-changing models. 
  • SmilingMind – This is an Australian meditation app – it’s really good, especially compared to the for-profit apps! 
  • UCLA Mindful – This doesn’t have the kind of sleek, fancy feeling that some of the other apps do, but it’s really good and accurate and useful, with mindfulness exercises and meditations that are similar to the ones used in research protocols. 
  • Mindfulness study – an app based on the Palouse school’s resources, which are Top Notch! Note – they mean for you to do the whole 8 week program, but who wouldn’t want to do that? It’s amazing! 

Comment below: Have you seen any of these? What do you think? Have any new, other recommendations to post? 

 

 

 

 

Behaviorism for Parents 2


Behaviorism for Parents – New Behaviors (Lesson 2)


If you haven’t read Behaviorism for Parents – The Basics, start there! 

You want behaviors done differently, or you want more complex behaviors.

(1) First, assume your kids want to behave and troubleshoot with them before assuming they are oppositional.

If your kids aren’t doing what you want them to do, make sure they CAN do it and KNOW that they are supposed to. So many instances of what parents think is “defiance” is actually a child not being capable for one reason or another, because we didn’t train them how (we just assumed they should know), or not knowing or remembering what they’re supposed to do when. Sometimes, they really didn’t hear you because they were focused on Minecraft they same way you don’t always hear your partner when you’re focused on a work email.

Kids are not shorter adults! They don’t have the same capacity for memory, sustained attention, fine motor skills, frustration tolerance, etc. as we do! Asking your kid to do the dishes is not equivalent to you doing the dishes. Kendra doesn’t wipe down the counters because she hates the feeling of crumbs in her hand and doesn’t have great coordination when she has to reach up so high. Marcus finds your “highly efficient” system for managing his multiple homework subjects too difficult to grasp and he’s already overwhelmed from struggling in Algebra 2.

Teach Kendra to hold a plate under the lip of the counter to catch the crumbs instead. Just give Marcus one big folder for homework and let him search through it at the beginning of class.

Be willing to train your kids (remember, that’s one of the main jobs of parents!) – that involves choosing behaviors they are capable of and then modeling, giving explicit instruction, doing it with them, helping while they practice, and then supervising their practice with feedback before they can do a behavior on their own!

Be willing to negotiate, or choose your battles. Is this behavior totally necessary for the family to function or for your kid to be a functioning adult? If they don’t make their bed, is it going to damage anything or just bother you? (Just bothering you isn’t a good enough reason to cause discord and stress in the family system!) If they eventually have a bed partner who wants it made, they can learn it then, can’t they?

(2) Second, you can build new or more complex behaviors through shaping.   

Shaping means starting with where your kid is (or where you are) and the making doable baby-steps toward the thing you ultimately want (successive approximations toward the goal). Sometimes this is pretty easy. If you want Jillian to make her bed, first show her how and then go through the training process (but don’t expect military corners if she’s only 6, please!), including showing, teaching, helping, and supervising. The first time she does it on her own, and it’s hot mess, just comforter pulled up and pillows askew, reward it anyway, however it is. That’s your starting point. The next day, or next week, up the ante a little. Remind her to pull up the inside sheet first – show, teach, help, supervise. Then, only reward a bed making that includes the inside sheet being pulled up. Don’t reward a bed-making if the underneath sheet is down. Just give a gentle reminder. Do the training again if need be. After another week or so, up the ante again. Remind her that all of her pillows and stuffed animals should be on the bed, at the top, facing front. Show, teach, help, supervise. Then, when she does it on her own, only reward a bed that is made with the comforter pulled up, the inner sheet pulled up, and the pillow and animals correct. Voila!  

You’ll also want to use this as your kids age, as an easy way to update their behaviors. For example, when kids are very little, they’ll need the whole training sequence to learn how to put their toys in their toybox. As they get a little older, they won’t need much training to put away toys and books, but they won’t be able to do things like “clean their room.” If you keep on top of how their capacities are increasing, you can increase the scope and complexity of their rule-following behaviors with relative ease.

Sometimes this is very hard, especially if you and your kid have gotten into a deep behavioral hole. If the behavior you have during a conflict is screaming+cursing+storming off, and the behavior you want is listening-quietly-with-a-calm-attitude-and-joining-you-pleasantly-for-dinner… there’s more work to do there than your kid will be able to do in one try, no matter how big the punishment or reward. So, even though you won’t want to do it, you will still need to reward the baby steps. That means that if your kid screams and curses, but doesn’t storm off – that behavior gets rewarded. That’s right. You heard me. After they are reliably not storming off, then you work on the cursing, then on the volume. I know it seems counterintuitive, but let me guess… you’ve already been trying it “your way” and it hasn’t gotten better, right? So, be willing to give it a try!

Note: There’s a Behaviorism for Parents Vol 3 here.

 

 

Comment: What other issues have your parent-clients had with implementing behavioral strategies at home? 

 

Misophonia


Misophonia


Misophonia, or “hatred of sound,” is characterized by selective sensitivity to specific sounds accompanied by emotional distress, and even anger, as well as behavioral responses such as avoidance.

Or, as my 8 year old says, “Just thinking about the noise makes me die! Not literally. Metaphorically.” (Because yes, we do have ‘speaking accurately’ as a family value. What can I say? I’m a psychologist and a super-nerd.) Note, she says this while holding her ears and writhing. She follows up, “It’s like the sound goes inside my ears and then it gets in my body and makes all my muscles squeeze.” She squeals, like she’s something between angry and afraid. 

Yes, my darling. I hear you. For me, it’s like the sound goes inside my ears and then scrapes down all my nerves through my spinal cord. My teeth clench and my eyes close and my neck twists and my hip flexors tighten involuntarily. My autonomic system starts kicking in, but my brain has trouble turning that into a well-labeled emotional experience – something like completely irrational, slightly panicky anger disgust that’s not quite anger because I can’t quite get the cognitions to line up right.

For my daughter, it’s the sound of rubbing the seatbelt fabric. For me, the sound of a pencil writing on paper. For my husband, the sound of a rubber ball bouncing. 

If you’ve experienced this, you probably know it by now. But you can read more about misophonia here. Though it’s experienced by tons of people, it’s pretty new in terms of research and diagnostics. There is some cool brain data about the experience. It’s difficult to categorize, but if it’s significantly impairing a client’s ability to perform their basic life roles, it could probably be diagnosed at this point as Other Specified Obsessive and Compulsive Related Disorder. Though, I imagine in a decade or so, we’ll have a whole section about sensory issues and it’ll fit better there.  

Treatment is up in the air at the moment, though physicians, audiologists, and mental health folks are working on it. In our world, definitely there’s a place for distress tolerance work and maybe exposure & response prevention. But the place I’ve done the most clinical work on misophonia is couple’s therapy, believe it or not! Oh yes, most people can tolerate the discomfort on their own, but when it’s their partner making the sound, it takes on a whole new life! 

This is an experience that needs to be handled gently and cooperatively. (I mean, like we want everything handled in couples’ therapy, honestly!) The person who does not understand this probably needs to hear some of the science from us and be assured that their partner is not just making up their distress. The distressed partner probably needs to work on their distress tolerance and be sure they aren’t using their distress as a weapon. I will say that I have found that asking for a small behavior change when it’s possible is often easier, and that couples rarely want this to be the main issue. So, if the one partner could just not chew gum, that’d be great. Or throw away all the pencils with no eraser left – they’re just pencils! Consider ways to handle this issue as quickly and pragmatically as possible. Also, use it as an opportunity to talk about legitimate partner differences in experience! 

 

 

Comment below: Do you have this experience? For which sounds? Have you had clients bring it up, ever?

Lessons from my kids books Vol 1: Percy Jackson


Lessons From My Kids’ Books Vol. 1: Percy Jackson


Lessons are EVERYWHERE, if we’re attuned to them. I just finished reading the five books in the Percy Jackson and the Olympians series by Rick Riordan. (I know this is super nerdy, but I’m always reading at least 3 books – a foundational psyc book, a book that might be useful to clients, and an easy-read book for the 2-3 minute breaks in life. Sometimes, I use that time to read the books my kids are reading, so we can engage around them. I like to have at least some of the same stories in our heads, Side note: This is a reason that reading the same books or watching the same movies as your partner can be really cool, even if they’re not what you would choose for yourself!) 

So, I’m assuming this will end up having multiple volumes. 

Ok, so these are books about teenagers who are demigods (in the Greek system) with lots of heroism and action, slight romance, and enough actually accurate mythology to make it totally worth reading. (I felt the need to write a tiny review there. I’m not completely aware of why.) 

So, here’s the lesson. Main character is chatting with Athena, goddess of wisdom, who says, “The most dangerous flaws are those which are good in moderation.” 

In this particular case, she’s speaking about the hero’s personal loyalty to friends. A virtue, of course! Unless it overtakes all other virtues. 

This is a way I often talk to clients, but especially couples. The areas in which couples are different so often become points of contention rather than celebration, and one important part of couples work is helping them to recognize and appreciate their partners’ differences.  

The flipside is that any strength can become a weakness when it gets taken to the extreme. Helping clients realize when they will benefit more from pulling back on an area of strength to keep it from becoming a weakness is just as important. We call it “falling off the cliff.” 

Examples:

  • assertiveness is great, until it alienates everyone
  • quiet acceptance is great, until it leads to resentment
  • putting your partner’s needs ahead of your own is great, until you lose your whole self or collapse from exhaustion
  • prioritizing your own needs is great, until no one can count on you
  • staying home is great, until you don’t have any friends left
  • going out is great, until you have no beer money left

Haha! See where I’m going with this? 

 

Comment below: Virtues in balance. How has that come up with your clients? 

 

 

 

Post Concussion Syndrome

 

 


Post Concussion Syndrome


Diagnostics is always more complicated then it seems – more like a DND roll than a simple symptom checklist or binary “has it” or “doesn’t have it” question. Here’s a great example:

 

Post concussion syndrome (PCS, or postconcussional syndrome) is a relatively vague set of symptoms that can continue to occur well after someone has had a head injury. The symptoms are wide and many of them are mental health symptoms, which is why it’s especially important for us to know about it. A headache is usually accompanied by symptoms like:

  • sleep problems
  • depressed mood
  • irritability
  • anxiety
  • trouble concentrating
  • difficulty with memory

Sound familiar?! YIKES! 

In fact, it’s so closely associated with other mental health conditions that 10-20% of student athletes meet criteria for it… even if they haven’t had a head injury – just because they’re stressed and somewhat sleep deprived! So, it’s important to consider all facets of this diagnostic mess!

 

 

PCS codes in ICD-10 as F07.81. Now, we probably wouldn’t want to diagnose Postconcussional Syndrome…. but we very well might want to put it in as a Rule Out or make a referral for additional testing/diagnosis with a physician or neuro specialist. 

 

We definitely want to have a question on our intakes that helps us keep this possibility in mind. For example, on my regular intake I have this question:

Have you experienced:
– chronic headache, migraine, vision changes, loss of consciousness, or dizziness?
– changes in your vision, hearing, other senses, or movement? (e.g., blurry vision, ringing in your ears, difficulty swallowing, trouble speaking, weakness or paralysis)
– difficulties with your memory, planning ability, or thinking clearly?

If so, when did you experience these symptoms and for how long?

That allows me to consider PCS, along with some other potential issues such as mild neurocognitive disorder and functional neurological symptom disorder (formerly conversion disorder). These answers can also “flesh out” other conditions, such as chronic headache associated with generalized anxiety disorder or difficulty concentrating as part of a depressive disorder. Loss of consciousness sometimes maps onto a substance use disorder. It’s a big question, but it gives lots of data and paths to follow-up on during the actual intake. 

Comment below: What are some of the diagnostically oriented questions you have on your intake? 

Psychodiversity


Psychodiversity 


Welcome to the 4th Reversal Theory blog! In this “episode,” I hope to tie all of these concepts together for you in a way that will show how Reversal Theory can be a great addition to your therapeutic repertoire – in terms of conceptualization and even treatment planning!

Popular in both the professional and lay communities is the idea that mental stability equates to mental health. However, Reversal Theory posits precisely the opposite, that people are healthiest when they exhibit the fluidity to be able to experience satisfaction in all eight states at appropriate times. As Apter (2007) says, “The reversal theory view is that a certain kind of instability is essential for a full and happy life: one should be able to pursue the satisfactions of serious achievement, but also at other times the more frivolous joys of play; one should be able to feel the warm agreeableness of bring a ‘good citizen,’ but also from time to time the keen pleasures of defiance and independence; one should be able to experience the pride of personal strength as well as, on other occasions, the comforts of modest humility” (p.187). This ability to experience all of the states and their attendant satisfactions is known as psychodiversity. Combined with an adequate frustration tolerance, a functioning internal measure of satiation, and the ability to respond effectively to situational factors, including other people, psychodiversity defines what it means to be healthy – to be able to work, love, and play effectively.

Let me give a few examples of how the concept of psychodiversity plays out in therapy…

  • Have you ever used Lazarus’ multi-modal therapy model as a way of identifying different areas of life that need to be treated for a holistic approached? What about the pie chart with physicals health, social health, spiritual health, emotional health, etc?
  • How often do clients come in complaining of being “stuck”? They often need help to get the satisfactions from a state they don’t have much practice in, or in learning how to switch states to fit their situations. 
  • All those different presentations of depression that the DSM5 can’t quite seem to cover? When the main characteristic is low self-worth, consider an autic-mastery kind of depression, where the client isn’t able to acheive the satisfaction of that state, but is in it often. When the main characteristic is boredom consider a paratelic-depression. Lack of motivation? Telic depression. Loneliness? Self-sympathy depression. Alienation? Conforming depression. This gives us a way not only to help clients learn how to derive the satisfaction from a state they’re stuck in, but also to focus more on and gain more value from switching to other states, too. 
  • Anxiety is a classic telic-disorder. The focus on danger, on the importance of success (or of not-failing), the future-orientation… And we often try to manage it in a telic way only (reducing anxiety) rather than also using the tool of switching to the paratelic state. 
  • What are the personality disorders but various combination of autic stuckness? 

I’ll do another blog post in the near future about some specific RT-based techniques and tweaks-to-techniques that I have found really helpful. In the meantime…

 

Comment below: Now that you know plenty about RT to start posing really interesting questions to yourself… how could you see this working in therapy? 

 

 

 

 

Preposterous Quote – Rules for life


These always get me riled up…


  1. Let all of your experiences influence your future… lessons learned are valuable, and ignoring them is just as likely as not to earn you repeated negative experiences. 
  2. Surround yourself with healthy, supportive people and absolutely listen to them. Your relationships are the foundation of a satisfying and productive life. Don’t alienate important others by ignoring their opinions. 
  3. Time can dull some things, but especially painful things – unprocessed – get worse with time rather than better. Regarding things like loss and grief, assume that you need to make a place for that in your life, rather than “getting over it.” 
  4. Social comparison is important – it is one of the main ways that we manage out behavior in order to be acceptable to society and generally keep things running. Competition, when you are able to admire or be inspired by those who are “better” than you, is a valuable experience in teaching you which goals you might want to pursue and how to go about improving. Comparing yourself only to yourself is a dangerous game… closed systems accumulate errors and self-destruct. 
  5. Being calm is generally more effective than being all worked up, except when your accurate anxiety can motivate you to prepare for danger, your accurate fear can motivate you to move away from danger, your accurate anger can motivate you to rectify injustice, your accurate disgust can motivate you to move away from bad influences, etc… Also, the only thing the passing of time advances by itself is your age. It doesn’t inherently help you figure things out, get wise, make better decisions, improve any skills, etc. 
  6. That level of internal locus of control is inappropriate and inaccurate. Though I am the FIRST person to say that other people and/or circumstances don’t MAKE YOU FEEL, and that most people have more control over their internal, emotional experiences than they believe they do, ignoring reality-based external stimuli is not a good recipe for functioning well in the world, building an environment that supports your growth, etc. 
  7. Smile, Frown, Laugh, Cry… Your life is meaningful and valuable even when it’s not happy or traditionally “enjoyable.” Feel free to be present for all of it. 

Comment below and give us a HEALTHY “Life Rule,” if there is such a thing! 

 

 

 

Easier, cheaper, better


Easier, Cheaper, Better


So, I was listening to news radio a few weeks ago (oh, the joys of adulthood!), to a story about electric cars. Without getting into politics or economics, let’s assume for the moment that people driving electric cars might be a good thing. Because the interesting part of this discussion was a question to the interviewee – How could the transition to most or all people driving electric cars happen? And the answer was so beautifully behavioral. In short, to get most people to drive electric cars (sooner, rather than later, when that might be all that’s available), electric cars need to be easier to buy than gas-powered cars, cheaper than gas-powered cars, and better than gas-powered cars, today. The INDUSTRY and the ENVIRONMENT need to change. Not the buyers. 

And so it is with all of our behavior changes. Shame and willpower get us nowhere. Well, that’s not quite true. Unfortunately, shame and willpower get us a tiny distance in the direction we’re headed, and then they collapse on us, leaving us typically worse off than we were before, with more shame, which leads to more undesirable behavior, and so we look more intensely for “more willpower” to get us to our behavior changes. And that system, while it fits nicely with the sort of hyper-American, Protestant-ethic model that likes to believe we can all be anything we want to be with enough will or inner strength or simple desire, is almost entirely useless. 

If we want to really change behavior in the long term, we need to think about how to make the new, desired behavior easier, cheaper, and better immediately. 

Here’s an example: Does a client want to exercise more? Preferably, we need to find a way to make that easier, cheaper, and better than not exercising, right now. 

  • What does easier mean for them? It’s going to be a challenge to make something like physical work seem like less effort than NOT doing physical effort! DO they want to try a gym? Help them find a close one, that’s on the way to or from work. (The farther away the gym is, the less often people go. ) But walking at the nearby park or exercising at home might be easier still. Is part of “easier” training their middle school age kid to do some of the laundry, so that the increase in workout clothes doesn’t feel like a burden? Does it mean getting a trainer so that they can learn to exercise in a way that’s “easier” on their knee joints? Let’s plan this in the “preparation phase” so that the benefit is immediate!
  • What does cheaper mean for them? This one usually means straight “less expensive,” but it might also mean less expensive in terms of other resources, like time spent. Would they be missing out on time with lover or kids? Could they join the exercise effort so that time isn’t missed? Walking is free, which might make it better than the gym, but it’s not cheaper than doing nothing… unless you can help them schedule their exercise at a time they might otherwise be spending money, like out to lunch or online shopping. If exercising in the morning helps them be more productive or in a better mood during the day, or sleep more restfully at night, maybe we could help them monitor that the very first week, to help “see” that additional value right away. 
  • What does better mean for them? Turns out rich folks will totally go to a far away gym as long as it’s SUPER nice! That after-workout-whirlpool is a Day 1 value and they should use it Day 1. Better health, fitness, weight loss, etc…. nice for long term goals but not helpful for that early part of the change process. Is the time-for-self they could get at the gym something that they need and want but would feel guilty about? Can we help reduce that barrier before they start, so that exercise gives them something nice right at the start? 

For long term, positive change – we don’t want to rely on willpower, and we certainly don’t want to get stuck in the shame cycle (that just leads to more Oreos, or self-criticism, or avoidance, or…). We want to change our environments to maximize the chances of following through – make the change as easy, cheap, and desirable as possible right away. If we can make it easier, cheaper, and better than the alternative, our chances are REALLY good. 

Comment below: How have you successfully used something like this model with yourself or clients in the past? Have you had the experience of thinking that a great change plan was in place, but one of these things got in the way? 

 

 

Online Resources and Apps (Vol 1)


Online Resources and Apps (Vol 1)


Honestly, I’m not a huge fan of online resources. Let me make a caveat – we’ve known for a decade that things like internet-delivered CBT can be effective for depression and anxiety (e.g., Farrer et al., 2011), and that can be a life saver for someone who doesn’t have easy access to therapy. It’s just that when I have in-person clients, I much prefer for them to have resources that we have created together or that I have made personalized for them. 

BUT… it’s 2021 and I’d have to be living under a rock to not engage with some of the really good stuff that available online and on apps. But… it’s 2021, which means the problem isn’t the availability of mental health resources/apps, but sifting through which ones are actually good! 

My requirements for resources/apps that I’ll suggest to clients are that they are (1) FREE, (2) EVIDENCE BASED (as appropriate), and worthwhile based on my actually trying them. (Like recommending books, I have an ethical problem with recommending something I haven’t fully tried). 

That said, here we go, in no particular order: 

Online resources:

Ali Mattu’s videos – You’ll have to browse around a bit to find the topic you client needs, but these are very well done and super on point from a research-based standpoint. The dive reflex episode is one of my favorites. 

Kristen Neff’s Self Compassion exercises – exactly what you think, better researched and less saccharine than Brene Brown, totally free. 

This free online course in Acceptance and Commitment therapy from Public Health Wales is pretty cool and comprehensive!

Now Matters Now is a great resource related to suicidal ideation, for clients and clinicians. 

I’m looking for some good DBT resources, btw. These videos are ok, but I’d like something more personable and more interactive. Please comment below if you know of any! 

Apps: 

Comfort Talk – this is an all-business, nothing-woowoo trainer in self hypnosis. Great research evidence! 

All of the VA apps are empirically supported and they’re nicely done. I like the CPT  and substance use apps as an adjunct to therapy sometimes, but the CBT-I (insomnia) is the one I recommend most. You don’t have to be a veteran to use them! 

Insight Timer – I’ve liked this one for a long time, mostly because of the variety of meditations that are available and the ability to search based on how much time you have. Great free alternative to apps like Calm and HeadSpace. 

Fluid – This is just a little app that lets you play with fluid dynamics (with lots of customization for time, color, etc.) It’s great for mindfulness work, and nice for clients who might otherwise fret while waiting in a line. It’s entrancing! You can see a screenshot above. 

Done– I searched HIGH and LOW for SO LONG looking for a simple, free app that would allow clients to easily track how often they do XYZ – whatever we’re working on. The free version of done is more than adequate – it’s perfect! 

 

 

 

Comment Below: What online resources or apps have you found to be helpful? Bonus if they’re free and evidence based! 

Reversing


Reversing


This is the third blog in the Reversal Theory series – if you haven’t, check out the first one here . And the second one here

 

As a reminder, Reversal Theory posits that we each have 4 different sets of states that we are in some combination of all the time – one each from Serious/Playful (also called Telic/Paratelic), Conforming/Rebellious, Mastery/Sympathy, and Self/Other (also called Autic/Alloic). So, at work you might usually be in the Serious-Conforming-Self-Mastery states, and if you are, you’re probably killing it! But, if you’re in the Playful-Rebellious-Self-Mastery states, you’re probably daydreaming about skiing and not getting much done. 

Despite the pervasiveness of the “continuum” in current psychological thinking, the ever-present bell curve, and the call for moderation in all things, the pairs of RT states do not operate this way. The bank of light switches above not chosen arbitrarily! At any given time, the light switch is positioned up or down. If pushed, it will flip to its opposite position. If not pushed hard enough, it will flip back to its original position. It does not rest in the center position. Likewise, a person is in one state of each pair or the other (this is called bistability). Bistability refers to a system which has two preferred ranges rather than one. 

A Necker cube (above) is a good example of reversing. It can be viewed sensibly in two equal but opposite ways, but there is no intermediate position and one cannot focus on the transition between the two states because it happens too quickly. Similarly, each pair of RT states functions as a “bistable” system; one is either in the serious state or the playful state, there is no stable position in between. 

So, how do we switch (or REVERSE!) our states? Three ways. 

 

Contingent reversals are the most common. A contingent reversal occurs based on an event, setting, or other environmental influence. For example, an event that is seen as threatening is likely to produce a reversal into the serious state (e.g., when one is joy-riding and then sees a police officer behind them). An event that is perceived as unfair will likely produce a reversal into the rebellious state (e.g., when a teenager is planning to go out and then is told she has been grounded). Note that it is the perception of the event which is of consequence, as events will be interpreted by different people or at different times in different ways. Another environmental factor that often produces reversals is the setting. A sports stadium may induce the playful state; a nursery may induce the sympathy state; your boss’ office may induce the serious state. Any situational event (e.g., seeing your partner smile, feeling nauseous, music playing in the background) can prompt a state reversal.

Often, the combination of many situational factors in balance determines the state one is in. For example, I may be drinking cocktails and watching football with friends (all paratelic-inducing/playful for me) and see a spider (typically a telic-inducing/serious event for me), but I might not be moved from the playful state due to the influence of the aforementioned factors. In essence, the perceived situational factors may be viewed as if on a scale, or a see-saw. Situational factors may “add up” enough to tip the internal see-saw to the opposite state, or the opposing factors may not be weighty enough, in which case I remain in the state I was in.

 

Another way that reversals are induced is through frustration. If you remember from the second blog, each state has certain kinds of satisfaction embedded within it. 

Telic -> Achievement

Paratelic -> Enjoyment

Conforming -> Fitting in

Rebellious -> Freedom

Mastery -> Power/control

Sympathy -> Care/nurturance

Self -> individualism

Other -> collectivism

 

When this satisfaction is not achieved over a period of time (which varies across times and individuals), the frustration will lead to a reversal. An example of this type of reversing is when, in the telic state, one does not feel they are making progress, cannot bring down their level of arousal, or comes to feel that what they are working toward is not worthwhile. A reversal to the paratelic state may take the form of abandoning the project in favor of something fun or distracting oneself with humor. Frustration-induced reversals may occur in the alloic sympathy state when one has heard quite enough of another’s complaining, in the negativistic state when one realizes that his/her efforts to change the system are not fruitful, or in the mastery state when one becomes exhausted with running on the treadmill.

 

The final factor in inducing reversals is known as satiation. This is hypothesized to be an internal mechanism in which a reversal is induced after a certain amount of time even when one is receiving the satisfactions of the state and in the absence of situational changes. Consider the student or retiree who, after a few hours, days, or weeks of leisure, longs for work. After a time, a loving caregiver who is content to nurture those in her household spontaneously craves some time for herself. In studies wherein participants can choose a telic-task or paratelic task for as much time as they like, will switch tasks without any seeming provocation. The process of reversing through satiation is often compared to the sleep-wake cycle, wherein the body simply recognizes that it has had enough of a certain natural and satisfying state, for reasons that are not entirely clear.

 

Those are the ways that reversals occur, and that’s plenty for this installment! Be on the lookout for #4, because it’s going to tie all of this into a very cool way of thinking about psychological wellness and therapy!

 

Behaviorism for Parents 1


Behaviorism for Parents – The Basics (Lesson 1)


I often have to teach parents about basic principles of operant conditioning and such, so I finally just wrote it up. Thought I’d share it with you. 

Thorndike’s Law: If you do something, and something good follows, you’re more likely to do that thing again. If you do something, and something bad follows, you’re less likely to do that thing again. (If this also sounds like we’re training a puppy… yes, very much yes.)

Important note: This is only for increasing or decreasing the occurrence of a behavior that already happens. We will talk about adding new behaviors (or more complex behaviors) later. Go ahead and get clients to identify a single behavior they like and one they don’t like for a single kid to use as examples for this teaching.

There are TWO WAYS for something good to follow a behavior. The first is if something pleasant is given (positive reinforcement, but you might just want to call this “reward”). So, if Jackson makes his bed in the morning, he might receive a dollar, or a sticker, or a gum drop, or extra screen time, or a curfew extension, or praise. Important note: rewards only work if they are valued by the recipient. It is a very common mistake to try to reward kids with things that we think they should care about but they really don’t.

The second way for something good to follow a behavior is for something unpleasant that already exists is taken away (negative reinforcement, but maybe you want to call it something like “reprieve.”) So, if Jackson makes his bed in the morning, he might get out of doing an unpleasant chore like washing the dishes. Same caveat – it has to matter to the kid.

Note that is has to be an overall pleasant experience, so if rewards are given grudgingly, or only after lots of nagging, etc., the overall takeaway won’t be pleasant.

SO: If Jackson likes desserts and hates folding laundry, and he makes his bed each day, and each day he gets ice cream after dinner and at the end of the week Mom hangs up his clothes instead of him, he’s much more likely to make his bed in the future.  

These two strategies – reward and reprieve – are the foundation of behavior change. Rewarding behavior you want is much, much, much more effective than trying to punish behavior you don’t want. (More on this in a moment.)

 There are TWO WAYS for something bad to follow a behavior. The first is if something unpleasant occurs (positive punishment, but you might just call it “punishment”). So, if Cinthia hits her younger sister, she gets spanked, or yelled at, or an additional chore. Important note: Punishments only work under very certain circumstances – they have to matter to the child, they have to be consistent across all settings, they have to be unemotionally delivered, and they have to be of moderate intensity. This is tremendously hard to do, especially with things like spankings. A “moderate intensity” spanking varies widely between kids and changes rapidly as they age. Also, the more often you spank, the more of a tolerance builds, and you will rapidly find yourself in a position where the hardest you are willing to spank them doesn’t matter to them anymore. And because they didn’t want to be spanked, and will resent your tyrannical exercise of control, they will begin to take much more pleasure from defying you than displeasure from being spanked and it simply won’t work anymore. Punishment (of all kinds, but certainly physical) also doesn’t get you anywhere in terms of teaching appropriate behavior. So, you don’t get better trained kids. Occasionally, you get cowed kids who seem to behave but are just waiting until they’re big enough to get away or hit back. You also teach them that aggression is the way to exercise control over other people they are bigger than. The much better choice is to choose an incompatible behavior (like listening quietly rather than shouting, telling a parent rather than hitting a sibling, etc.) and reward that behavior instead.

They second way for something bad to follow a behavior is for something pleasant to be taken away (negative reinforcement, or you may want to call it something like “payment”). If you feel you must have “negative consequences for misbehavior,” this is a much better option than punishment. So, if Cinthia hits her little sister, she has to “pay” in terms of losing allowance, an earlier curfew, losing her car or phone or screen time for a certain amount of time. There are still risks associated with this kind of use of your power – specifically that as your kids get older, they’ll just turn to friends to get the things they want – rides, borrowing phones, sneaking out, etc. – so that they aren’t dependent on you to give them the things they want.

 

Overall, the best solution is to create just a few rules for things that your kids are capable of doing that have good reasons behind them that your kids know, then rewarding those valuable behaviors with things your kids value as well.

 

Behaviorism for Parents Volume 2 and Volume 3 are now available!

 

Comment below: Where do your clients get stuck with understanding behavioral principles? 

 

 

 

Forest Wandering (A Couples’ Metaphor)


Forest Wandering (A Couples’ Metaphor)


In a perfect world, we go through life with our partners sometimes walking hand in hand, and sometimes exploring within earshot, and occasionally going off on our own but easily finding our way back to each other. Totally in sync, perfect partners know each others’ maps perfectly, and keep them continually updated. 

But sometimes, it suddenly seems like our partner is in an entirely different place – they confuse us because they don’t feel the way we expect or don’t respond how we think they will.  Sometimes that comes out like “You’re obviously wrong!” or “Stop being stupid!” or “You hurt me on purpose!” or “You should have known better!”

We entered the forest at the same place, maybe, but they’ve apparently popped out on the other side in a way different place than we have. It’s easy to imagine they’ve teleported, but it’s not true. They walked, same as us. They just walked a different path. Finding out what it was takes courage and openness. But it’s worth it, to know your partner’s landscape! 

When our partners surprise us, first we need to notice we’re surprised – sometimes that can be hard under the hurt or anger, or we’ve let it go on so long that we’re “used to it” by now because “they’re always like that.” But once we realize that they have some wildly different idea than we do, or that they seem to be acting crazy, or that this ostensibly smart/thoughtful/brave/loyal/etc person that we got together with seems to be replaced by an evil clone… we can do the work. And it’s as simple as, “I didn’t expect that [behavior, response, thought]… will you tell me how you got there?”

Simple, but not always easy. 

Rest assured – our partners VERY RARELY get replaced by evil clones. They probably aren’t crazy, malicious, or stupid. We just have to manage our own negative emotions, snap judgments, and other reactionary reactions long enough to hear it.

 

Comment below: Have you experienced this your relationship? How have you taught clients/couples to do this process? 

 

 

 

 

Preposterous Quote – Regret


Um… sort of.

First of all, after people make choices, they can frame the choice event in terms of what they chose, or in terms of what they did not choose (Valenti & Libby, 2017).

Second, the research is a little more nuanced than that. Yes, “inaction” regrets last longer and are accompanied by a stronger feeling of loss. (Also, we’re more likely to regret non-fixable than fixable situations, and women are more likely to have relationship-related regrets while men are more likely to have work-related regrets. Sorry, I hate it when research supports “stereotypes,” too!) (Morrison & Roese, 2011)

Second, to the degree that we regret more the choices we didn’t make, it’s sort of because of a cognitive fallacy. When we make a “safe” decision and it turns out well, we’re happy with the outcome. When we then find out (or even imagine!) alternative outcomes that would have been better (this is called counterfactual thinking), we feel regret (that is, regret for the thing we “didn’t do” that would have led to the better outcome) and view our own, positive outcome less positively. (Seta et al., 2015)

When we make a “risky” decision and it turns out well, we are both happy with the outcome and relieved that it didn’t turn out badly. When we make a risky decision that turns out badly, we’re unhappy with the outcome, but more likely to use the information for: 

  1. making sense of the world
  2. avoiding future negative behaviors
  3. gaining insight
  4. achieving social harmony
  5. improving ability to approach desired opportunities (presumably because we regret past passivity) (Saffrey et al., 2008)

Add all of that to hindsight bias, and this whole subject is a real mess! 

 

 

Morrison, M., & Roese, N. J. (2011). Regrets of the typical American: Findings from a nationally representative sample. Social Psychological and Personality Science, 2(6), 576–583. https://doi.org/10.1177/1948550611401756

Saffrey, C., Summerville, A., & Roese, N. J. (2008). Praise for regret: People value regret above other negative emotions. Motivation and emotion, 32(1), 46–54. https://doi.org/10.1007/s11031-008-9082-4

Seta, C. E., Seta, J. J., Petrocelli, J. V., & McCormick, M. (2015). Even better than the real thing: Alternative outcome bias affects decision judgements and decision regret. Thinking & Reasoning, 21(4), 446–472. https://doi.org/10.1080/13546783.2015.1034779

Valenti, G., & Libby, L. K. (2017). Considering roads taken and not taken: How psychological distance influences the framing of choice events. Personality and Social Psychology Bulletin, 43(9), 1239–1254. https://doi.org/10.1177/0146167217711916

 

 

 

 

 

Measuring Sticks


Measuring Sticks


Do you remember Mary Poppins’ measuring tape? When she measures Michael, it reads “Rather Stubborn and Suspicious” and when she measures Jane, it reads “Inclined to Giggle Doesn’t put things away.” And what does it say when she measures herself? “Practically Perfect in Every Way.” 

Clients come in to therapy with their own measuring sticks – and based on their own histories, experiences, biases, fears, hopes, etc. – they have a tendency to believe that their measuring stick is the RIGHT measuring stick. They’re quick to assume that their memory of the last argument, their assumption about their partner’s (or boss’ or kids’) intention, their prediction of the future is practically perfect in every way

One of the biggest and most pervasive challenges in therapy, I think, is getting clients to trade in their rulers. (After all, they’ve been using this trusty ruler since childhood, probably. It must be a good one!) Sometimes, they’ve been using “trick rulers” that just don’t measure the peril or injustice (etc.) in the world in an accurate way. (Yes! Those are real, and I want to buy one for therapy to use in a fun experiential activity, but I can’t bring myself to spend the $25!) Helping clients to recognize that maybe their genetics, physiology, past trauma, or many other factors have distorted their way of measuring may work better in a metacognitive kind of way than just helping them to measure each situation more accurately. 

Sometimes, they’re using their own ruler to judge someone else’s experience instead of using the other person’s ruler. In those cases, even if they have a super “accurate” ruler (which they probably don’t) or they took notes on the last session with their kid, or they recorded the last argument with their partner, or they pull out the email from their boss – they don’t get any close to understand the other person’s experience or intention by judging with their own rulers. 

I think a lot of this dysfunction comes from a generically nice place. When kids are little, they’re often told things like, “Don’t take Cindy’s doll. How would you feel if Cindy took your doll?” Which is probably better than not thinking about Cindy’s feelings or experience at all, but it makes the mistake of assuming that Cindy will have the same or similar experience to us. But what if we have 100 dolls and Cindy only has 2? We may damage Cindy so much, destroy the relationship, and be completely perplexed about why we’ve lost our best friend! What if we love Barbies and would treasure this stolen Barbie in a deeply forbidden, guilty way, but Cindy hates Barbies and wouldn’t really care? Then we miss an opportunity to ask Cindy if we could share or have her Barbie, Cindy misses out on an experience of altruism, we don’t get to enjoy and treasure the Barbie in a shame-free way, and we both miss out on building intimacy. 

Judging the world, and other people, solely from our own perspectives destines us for failures in empathy. Even if our measuring stick is more accurate than someone else’s. 

Comment below: How have you helped clients to use a different ruler or make theirs more accurate? 

 

 

 

 

Eight Competing Values


Eight Competing Values


This is the second installment of the Reversal Theory series. If you haven’t read the first one, check it out here. Enjoy!

OK, so we left off with the 4 pairs of states – serious/playful (also called telic/paratelic), conforming/rebellious, mastery/sympathy, and self/other (also called autic/alloic). 

Each state has a core motivational value, a range of emotions, and certain actions typically associated with it. The core value in the serious (or telic) state is achievement. When one is in the telic state and this value is being satisfied by reaching or making progress towards one’s goals, positive emotions emerge such as relief that a goal has been met or a sense of accomplishment. When this value is frustrated by a lack of progress, more negative feelings like anxiety or a sense of being overwhelmed are often present. Actions that are common to the telic state are planning, assessing risks, thinking strategically, and working diligently. Some common examples of being in the telic state might be working feverishly on a project to make a deadline, studying for an upcoming exam, or decorating the house to make it presentable for the imminent arrival of one’s in-laws.

The core value in the paratelic state is enjoyment. When one is in the paratelic state and taking pleasure in his/her current activity, excitement, fascination, and interest are common feelings. When pleasure in the current activity is thwarted, however, feelings of boredom or restlessness often emerge. Common contributions made in the paratelic state are enthusiasm, openness to new experiences, spontaneity, and creativity. Examples of being in the paratelic state include walking leisurely enjoying a sunset, working on an interesting puzzle in one’s free time, or luxuriating in the evening meal. It is important to note that it is not the activity that determines one’s state, however. One can be walking “leisurely” at sunset in order to attain the goal of pleasing their partner, or be frustrated at the leisurely pace because he/she is focused on getting home to work on a project. Likewise, in the previous example, decorating the house may be so enjoyable that the arrival of one’s in-laws may slip into the back of one’s mind.

The core motivational value of the conformist state is fitting in. This can also be expressed as the desire to do the right thing at the right time, or to do what is typically done. In the conformist state, it is a pleasant experience when one conforms and an unpleasant experience when one is not conforming. Pleasant emotions that may be experienced in the conformist state are a sense of belonging and comfort that one is doing right; unpleasant emotions may include embarrassment from not conforming or guilt from not meeting expectations. Further, actions consistent with the conforming state might be following procedures, adhering to ethics, and acting predictably. Examples of being in the conformist state may be taking pleasure in a game precisely because the rules are being followed, feeling satisfied that you “belong” in a group of coworkers, or enjoying the ceremony that marks a traditional wedding, graduation, or spiritual ritual.

In contrast, the core value of the negativistic or rebellious state is freedom. In the rebellious state, pleasure is derived by acting in way that one perceives is in opposition to external pressures or rules. Pleasant emotions experienced in the rebellious state can include independence and personal freedom, whereas unpleasant emotions may include frustration or anger at our restrictions or perceived unfairness. Actions consistent with the negativistic state may be challenging authority, behaving critically, or showing a desire for change. The rebellious state may be manifested as defiance or (despite its name) mischievousness or simply unconventionality. Enthusiastically protesting against current legislation, purposefully acting out in a residential group home, or even “thinking outside the box” at a business meeting could be examples of being in the negativistic state. Note that the same behavior may be performed in different states, based on different motivations; smoking with school friends could be enjoyed because it is not allowed, or it could be enjoyed because it allows one to fit in with the crowd.

The primary values in the mastery state are control and power. In a social interaction, this might mean desiring to have the upper hand; in a competition, this might mean being focused on winning. One could be in the mastery state with a pet, when training it; one could be in the mastery state with a piece of machinery or sports equipment, when learning to operate it. Positive emotions felt in the mastery state include pride and accomplishment and negative emotions typically center on humiliation or disappointment. In the mastery state, positive qualities that may be displayed are confidence, determination, and leadership.

The primary values in the sympathy state are caring and affection. Most often, the sympathy state has to do with people or living things. One could be in the sympathy state with a colleague when listening to their troubles or with a partner while sharing a casual Saturday afternoon picnic. One could certainly be sympathetic with a pet, lavishing it with attention. In the sympathy state, positive feelings typically include loving and feeling loved; bad feelings are those that go along with feeling unloved, such as rejection. In the sympathy state, positive attributes that one may display center around cooperation, emotional support, sensitivity, and relationship.

In the autic state, one’s primary concern is for oneself, including taking responsibility for one’s actions as well as taking care to get one’s needs and desires met. Working out at the gym to see to one’s health (self-mastery) or asking a loved one to run an errand on one’s behalf (self-sympathy) are examples of being in the autic state.  The core motivational value in the autic state is individualism, or doing the best one can for oneself. Satisfaction at doing something well or appreciation of self may be good feelings experienced in the autic state; negative feelings such as resentment or loneliness may result if one remains in the autic state too long and thus becomes isolated from others. Common actions in the autic state include attention seeking, performing to the best of one’s ability, setting and meeting personal goals, and keeping a balance between work and personal life.

In the alloic state, one’s concern is for meeting the needs or desires of others. When one tidies up the house because their partner prefers it that way, this is an example of the alloic state (other-sympathy). So is helping or coaching someone else for their growth or improvement (other-mastery). The “other” in the alloic state may be an actual other, such as a friend or child. However, the “other” may also be a group or team to which one belongs, in which case it is referred to as the extended self. The other may also be someone or a group that one identifies with, such as a hero in a movie or a favorite sports team; in this case, the other is known as the surrogate self. The basic motive in the alloic state is collectivism, caring for others or for a group more than the self as an individual. Good feelings that come from helping others or seeing others succeed are a part of the alloic state, as are the bad feelings that come from letting others down or seeing others hurting. Frequently, being a good teammate, helping, encouraging, mentoring, and giving are behaviors the alloic state might produce.

 

 

OK, good! In the next “episode,” we’ll discuss how we shift between these different states! 

 

First, do no harm.


First, do no harm. 


Despite the DoDo bird’s insistence, not all therapies are created equal. 

This won’t be a post explaining evidence based practice, or common factors, or how diagnostics should impact our therapy plans, or how psychodynamic therapy gets an undeserved reputation just because CBT is easier to manualize. (All possibilities for another day!) For today, I think it’s worthwhile to talk about how sometimes we had really interesting ideas and they turned out to be wrong. Some therapies have evidence demonstrating not just that they don’t work as well as other therapies, but that they don’t work at all or they actively damage clients! YIKES! 

Examples that might surprise you?

  • Critical Incident Stress Debriefing for PTSD
  • Grief counseling for normal bereavement
  • Relaxation treatments for panic disorder

Check this article by Scott Lilienfeld out here

 

Comment below if there’s one of those other topics you’d like me to write about, or if you have ever gotten training in any of these harmful therapies, or (heaven forbid!) you know someone who uses them. 

 

 

 

Sphere of Whelm


The Sphere of Whelm


WHELM.  

Why don’t use this word? We say “overwhelm” and “underwhelm.” Why do we never say whelm?? Probably because it’s sort of useless, as the word “whelm” technically is a synonym for overwhelm, meaning “to be submerged by.” 

::rolling my eyes:: 

I RECLAIM this now useless word for special therapeutic purposes, and like many psychological terms, will give it my own definition. I like clients to conceptualize “whelm” as just the amount that I can handle right now or saturated but not spilling over. I think of it in a similar way to being in one’s “Flow zone,” but rather than engagement or skills development, I mean it to pertain to emotion regulation. 

We all definitely know that too much stress, too big of emotions, or too much going on can lead clients to feel overwhelmed; we see them all the time. Less often (though sometimes), we see underwhelmed clients – the disillusioned nihilist, or anyone with existential ennui. And sometimes we see clients who are so numbed or checked out that they seem underwhelmed, when really they’re just shut down because of overwhelm. 

Let me suggest that we can change our level of over/underwhelm by modifying the space and time we are attending to. When clients are overwhelmed, they’ve often cast their attention out too far – too far into the future or encompassing too much “distance” (which usually means too many people). No one can handle the anxiety of a nation during a pandemic. No one can handle the regret of their whole mountain of history all at once. No one can handle the existential threat to their children for a lifetime. 

When life is too much, when we are in grief, rage, or terror – we sometimes do this naturally – bring in our spheres to just our families or ourselves, to just “getting through today” or “just what I need to do next.” We invite clients to mindfully shrink their fears when we teach them mindfulness – just what you are aware of in exactly this moment, just in your body. And sometimes clients need more – think Adler and social connectedness – sometimes depression or anxiety are presenting because we are underwhelmed. over-focused on our own troubles or discomfort, and need to widen our spheres to include other people, or a longer time perspective. 

One of my favorite ways to do this with clients is as part of a guided imagery. Creating a sort of bubble that they practice shrinking and expanding until the bubble is just encompassing their heart or encompassing the whole city, and doing that safely with me.

How do you like to? I know you you already help clients do this – you just didn’t use this fancy name. What kinds of techniques do you use to help them manage their spheres? Comment below.

Parenting is Like Holding Water


Parenting is like holding water…


This past year I’ve seen a number of families with grown children, or parents with teens or young adults. And one thing that most of them seem to have in common is the challenge of changing the relationship (and themselves!) as their kids develop. 

Of course, as infants, kids are completely dependent, and parents construct all of their experiences. As they get older, they begin to watch TV or read books that we haven’t read, to have conversations with friends and teachers that we aren’t a part of… they begin to differentiate from parents. Parents no longer know all the information, stories, experiences, memories, ideas, feelings, etc. in their kids’ heads. But often they continue to act as if they are constructing their kids’ realities, and don’t think to begin to add mutual self-disclosure to the relationship. Kids are becoming new people, and parents now need to learn who they are. As preteens and teens, of course the divide widens. Peer influences get stronger and this is sometimes when parents suddenly notice that they “don’t recognize this kid!” That’s not the kid’s fault… they’re just developing. It’s the parents (in most cases) who have not updated their maps of their kids as they have grown and changed. 

Many of the parents of teens and young adults I’ve been seeing are trying desperately to hold onto their kids, to continue to construct their realities. They’re trying to hold water. 

Imagine holding your hand under a a tiny stream of water drops. (Better yet, go do this!) When there are just a few drops, you can hold them all in your palm. When the pool of water gets bigger, if you focus on balance and negotiating the tiny changes, you can hold quite a bit for quite a while. At some point, though, the water becomes more than we can hold. At this moment, if we panic, and try to squeeze the water tightly to keep it from running over, it all squeezes out and we lose it all. This is what a lot of these parents are trying to do – hold their kids tightly because they’re afraid of losing them. 

Note that I didn’t title this “Parenting is like TRYING to hold water” …if parents can “hold them lightly,” they can’t hold onto all of their kids, but they can hold some of them, and certainly more than they can if they squeeze. 

By holding kids lightly, I don’t mean necessarily being overly permissive or just being friends. Parents still need structure – a loose, dangling hand can’t hold any water either! I mean everyday inviting your kid into a real, mutual relationship with you – that means a relationship that changes as they change! (and as you change!) And it means accepting their invitations into a real relationship, even when it’s not completely on yours terms (e.g., play time when you’d rather read, listening to music that sounds like noise, caring about “teen drama,” supporting their interests and choices even when they’re not what you would choose).

 

Comment below: What thoughts do you have about this holding water metaphor? Did you try it experientially? What metaphors do you sometimes use with parents?   

 

 

 

 

Three Rules for Couples Counseling


Rules for Couples Counseling


I have three rules for couples’ counseling. Sometimes, I say them overtly, in the first session, sometimes they come up as we go along. I don’t really think of them as “my” rules, exactly, as much as I think these are pretty well required for couples’ counseling to go well. 

(1) A true, actual, capital-R “Reality” may exist, but neither of you (nor I) actually know it and it is not knowable.

So, we will not be spending much time arguing about how things actually happened or who is Right. We will spend a lot of time talking about how you each experience(d) things and how to effective co-construct your world. (Sometimes this has to be followed up with psychoeducation about perception and memory.)

(2) Relationships aren’t fair and that’s not the goal.

We will not be measuring out love. We will not be counting resentments. You are different people and we will not compare you  (your needs, desires, pains, etc.) to each other. We will absolutely NOT be doing a tit-for-tat scenario. If you want the relationship to improve, you will have to commit to your part of the work regardless of whether the other person does their part. 

(3) Your relationship is Your relationship. 

We will not be comparing it to your parents’ relationship, or the relationships you’ve learned about from romantic comedies, the relationship your growing-up church told you that you must have, or the relationship of your best friend on Facebook. We will focus on building the relationship that works for Y’all. 

 

You’d think they run away, but they usually don’t. 🙂 

 

Comment! What kinds of rules or guidelines do you find useful working with couples?  

 

 

 

Great Books Volume 4: Books for Certain Clients


Great Books Volume 4: Books for Certain Clients


This is a list of books that are definitely accessible to clients/laypersons, but I don’t think they’re right for just anyone. 

 

  • Barkley’s ADHD books
    • These book are filled with great behaviorally-based strategies. Only give them to conscientious clients who actually do their homework, though. (Note: This is sometimes harder to find in families with AD/HD!) If the strategies aren’t implemented well and consistently, clients will only get frustrated. You might consider a self-compassion kind of strategy if you think that might happen.
  • The Gifts of Imperfection (Brene Brown)
    • For myself, I find Brown a bit saccharine. However, there’s definitely a population of clients for whom her writing is needed and timely. Especially, it’s useful for those clients who have a very strong inner critic and who have a tendency to over-extend themselves on behalf of others. She seems to speak especially well to women. (Of note, this might be a good option for supplementing that self-compassion strategy mentioned above)
  • Come As You Are (Emily Nagoski)
    • This is, hands down, my absolute favorite book about sex, ever. Nagoski is hard science with a delightful and relational writing voice. Every client (individual and couple) I’ve ever offered this book to has had a good experience and gotten something from it. It’s incredibly validating and normalizing, and gives couples great language for talking about the dual-control model of sexuality. Really great in terms of diversity of sexual normalcy without being overwhelming, even for conservative clients.
  • Authentic Happiness (Martin Seligman)
    • I honestly didn’t like this book (or the one that came after it, about PERMA). Though I love strengths-based counseling, Seligman isn’t my kind of writer, and is a bit surface for me. BUT… this is a great book for some clients – when you want to use a strengths based approach with clients who like to do their own “research” (i.e., who tend to find too much awful stuff on google!) or those who have limited time/money to come into the office, this is a great book to give them a shared vocabulary to use with you. I’ve also found it can be really useful in couples’ work, when clients need help identifying and being aware of partners’ strengths, and for setting them on an upward trajectory, focused less on problems.
  • Twelve Rules for Life (Jordan Peterson)
    • Peterson is a controversial character, I admit. I think that’s more because he speaks in a brash and provocative, uncompromising way. But he has some good science behind him, and in it, clinical wisdom. He has a very strong grounding in Jungian psychology. His book speaks in an accessible way to the existential concepts of meaning, purpose, freedom, and responsibility. I think the reputation he has for speaking most eloquently into the lives of men (esp young men) is deserved. But the message isn’t only useful for young adult male clients. I’ve had a lot of clients enjoy and have success with this book, especially around issues of depression and demoralization.

 

Comment if you have other books to share that you’ve (1) read yourself, (2) recommended to clients, and (3) had good experiences with!

 

 

 

 

Preposterous Quotes – Winners

 

I have so many issues with this. 

Even to keep the same basic meaning, it should probably say something like “Winners are not people who never fail, but people who don’t quit until they win and then quit immediately.” Otherwise, they very likely turn into “losers” again very soon, when conditions aren’t perfect or someone else comes along who outperforms them.

Also, winners quit a lot of things – anyone who pursues everything equally doesn’t win much, if at all. We have to choose to quit most things in order to give our time, attention, effort, etc. to something we might win at. 

How worthwhile is “winning,” anyway?!

 

Comment below and Fix This Quote! 

 

 

 

 

Phrenology


Phrenology


If you aren’t familiar with phrenology, it’s a frankly brilliant pseudoscience from the early 1800’s that we completely dismiss now. But, today, I want to talk about how it’s brilliant.

The basic premise was that different parts of the brain handled different tasks/ personality structures and therefore you could determine a person’s faculties or traits by examining the shape of their skull. Of course, we know that’s not true now – growth in a certain area of the brain doesn’t make it bigger, but rather more densely populated with neural connections and/or better myelinated. But WOW… why do we summarily dismiss the outrageous assertion that the brain is an organ with many parts that serve different functions?! That’s basically the birth of neuroscience right there!

The reason I feel so passionately about phrenology (and why I like to keep a phrenology bust in my office), is because is science is always valuable, never perfect, and continually growing. And that’s a message I really, really want all of my clients (and all of us therapists) to know! Not just about science, but in the larger sense of the message “not to let the perfect be the enemy of the good.”

Comment! What’s something in psychology that we don’t really give a lot of credibility to anymore that has still helped you?

 

 

 

 

Psychological Factors Affecting Medical Conditions


Psychological Factors Affecting Medical Conditions


Psychological Factors Affecting Medical Conditions

 

  1. A medical symptom or condition (other than the mental disorder) is present.
  2. Psychological or behavioral factors adversely affect the medical condition and one of the following ways:
    1. The factors have influenced the course of the medical condition shown by a close temporal association between the psychological factors in the development or exacerbation of, or delayed recovery from, the medical condition.
    2. The factors interfere with the treatment of the medical condition (e.g., poor adherence).
    3. The factors constitute additional well-established health risks for the individual.
    4. The factors influence the underlying pathophysiology, precipitating or exacerbating symptoms or necessitating medical attention.
  3. Criterion B is not better explained by another mental disorder

Specify severity

Mild: Increases medical risk (e.g., inconsistency in taking meds)

Mod: Aggravates underlying medical condition (e.g., anxiety aggravating asthma)

Sev: Results in medical hospitalization or emergency room visit

Extr: Results in severe, life threatening risk (e.g., ignoring heart attack sxs)

***

This includes things like psychological distress (e.g., chronic overstress at work), patterns of interpersonal interaction (e.g., utilizing the sick role), coping styles (e.g., denial of seriousness), and maladaptive health behaviors (e.g., treatment noncompliance due to psychological reactance).

Remember – be careful making judgments about culturally sanctioned healing practices – if they don’t harm, don’t worry about it.

In concert with the medical diagnosis, this can be billed as F54: Psychological and behavioral factors associated with disorders or diseases classified elsewhere.

Some other diagnoses that you may consider in these situations, or in a differential diagnosis:

  • 3 Unavailability or Inaccessibility of Health Care Facilities
  • 1 Nonadherence to Medical Treatment
  • 0 Problems Related to Lifestyle

 

Here’s to treating the WHOLE person in the context of a team of health/wellness professionals!

Comment below: How have you seen psychological factors impacting clients’ physical symptoms? How have you convinced them to treat the psychological parts as well?

 

 

 

 

Not About Pedicures


It’s Not About Pedicures


I’m quite alarmed by the way that we treat self care, both for ourselves as mental health professionals, but also for our clients. We think about self care the way we think about hunger or sleep – we let ourselves get way overstressed and then we thinking that dropping off the plane in a withdrawal state or going on a self-indulgent binge is the way to somehow repair this.

(Without dismissing the importance of the basic physical health aspects – hydration, good nutrition, regular exercise, adequate sleep…) I’d like to propose a way of thinking about self care that is largely grounded in Csikszentmihalyi’s concept of Flow. The short explanation of Flow, if you’re not familiar with it, is that “zone” we get into when we’re involved in an activity that is just the right balance of challenge with our skills. It’s a balance, because if we’re engaged in things that are too easy, we get bored. If we’re engaged in things that are too difficult, we get stressed/anxious. If you’ve been in that zone, you know what I mean. In that zone, you don’t really run out of energy – the energy just seems to self-replenish.

 

 

I believe in our clinical work, we often get ourselves (or find ourselves) out of balance.

 

We take on too much – too many clients, too long of days, clients who are legitimately outside our boundaries of competence but we don’t want to admit it, expecting to have the same therapy-stamina as the most productive person in the office.

 

Or we take on too little – get into a therapeutic rut and don’t challenge ourselves to build new skills, we are in an overly systematized job and function as automatons rather than clinicians.

 

Sometimes, it’s that we feel we have no control – we’ve given up our autonomy to a harsh internship director for the sake of getting hours (oh, how you’ll regret this!), we’re so burdened by rules and paperwork that our actual clinical work is only a handful of minutes per hour or day.

 
And sometimes, it’s that we know the work isn’t meaningful – we can see that clients aren’t improving, our setting won’t allow for the care clients need, etc.

 

Real talk: if you are exhausted at the end of a perfect clinical day – engaging, moderately challenging clients with a diversity of experiences and concerns who you can have some degree of independence in working with – this might not be your calling. But I’d say that’s probably not most of us. And once you become aware of the ways your clinical work is pulling you out of Flow, you can begin to correct it!

 

Comment, please: Which way do you find yourself leaning out of Flow? How can you see this also working in clients’ lives?

 

 

 

 

Not Just For Decoration


Not Just For Decoration


I keep lots of things in my office that are not just for decoration. You might have read the post on the “useful treasures” box. This is sort of an extension of that idea, but things that I keep out in the office, either because they’re pretty, or because it’s useful for clients to see them, or because they don’t fit in the box.

 

  • Singing bowl
    • I keep a Tibetan singing bowl in the office partly because it’s just simply gorgeous. I also like to have it available to use with clients when they are learning meditation (of course), but also sometime as an “arriving” or “departure” moment, especially for client who are doing tough work, like trauma work. It can help them to have a minute to get settled in, check homework, do updates and then something to mark the transition clearly. Doing so at the end of their “deep work” also helps them to wrap up and transition back into the “real world.” I also use it sometimes when I need a super fast grounding moment between sessions.
  • Long feather for balancing
    • I have two ostrich-style feathers that sit in a cup on my desk. They’re pretty but not ostentatious and they have long, un-feathered stems. I typically have clients try to balance the feather by the stem on one fingertip. This is great for younger clients with ADHD to practice active mindfulness, it’s nice for couples as a way to not get too worked up during conflict discussions, and it’s good for many clients who need a “distractor” while they access and speak about difficult material. I’ve also let clients use the feather-end to create a sensation that they can focus on, in a DBT distress-tolerance kind of way.
  • Highlighters in many colors
    • Highlighters can do all the work of markers, don’t dry out as quickly, and obviously can be used over text as well. I use highlighters in a million ways – I’ve even printed out a list of erotic-story-words during session for a very shy client to read with her husband so she could highlight the words she feels most comfortable with him using without having to say them out loud! Also, along with the bubbles and blank paper (in my useful treasures box), highlighters are a great distraction for kids who randomly show up.
  • Phrenology bust
    • Actually Charlton (pictured above) doesn’t technically live in my office anymore, now that I share an office. But when he did, I liked to use him as an example of how we can hypothesize, gather data, and update our theories – in psychology, in therapy, and individually.
  • Jar of rocks
    • I like to keep a little clear glass jar in my office, filled with random rocks. It’s unobtrusive, and clients rarely mention it. But I like to have the rocks in case I need something to give a client as a transition object (e.g., a client with strong BPD who will be worried about abandonment) but I don’t want to give them something I actually need, use, or care about. I also occasionally give them to client who are working on habit control, as a “holder” for their motivations – so that when they are in a tempting situation, they can hold the rock. And, it’s fun to just always be on the lookout for pretty or interesting rocks!

 

Comment: What other useful things do you have in your office? Have you “pulled a MacGyver” and used something in your office for an unintended but epically useful purpose?

 

 

 

 

Connect These Dots


Connect These Dots

Connect these dots. Go ahead. Geez, at least imagine doing it!

.

.

.

.

.

.

.

.

.

.

.

.

.

.

.

Chances are one of these pictures is something like what you imagined as “the way” (or “your way”) to connect the dots, and some of them aren’t. Some might have surprised you, in a delightful way. Some of them might even feel…. wrong to you. ::Gasp!:: This isn’t a mind blowing concept – people connect dots in different ways. They perceive the same situation differently. This is just another way to demonstrate this for clients. I like it because it’s experiential and also relatively non-threatening (and super easy – you don’t need anything but what you normally have in your office to do this) The Horse & Frog pictures exercise is another way I like to do this.

I’ve recently taken this exercise to the next level in a fun way…

I made this picture (it was much harder than I expected to find the right “star level” for this activity, especially royalty free) and I printed it as a photo multiple times. I keep them in my office along with 3-4 of the metallic sharpies. I hand one photo and one sharpie to each client and tell them, “Imagine you are priest-king of an ancient civilization and create a constellation.” They do, and they obviously create different constellations. One of the bonus-features to this activity is that they typically use most of the same larger stars, but they also use different medium/background stars to complete their constellations. That gives us a way to talk about connecting the dots differently, but also things like cultural background, personal history, and perceptual differences in how they construct a narrative.

 

Comment below – I’d love to see the other ways you connect these dots, or ideas you have about bringing this concept into session! And definitely feel free to steal this!

 

 

 

 

PreposterousQuotes – BeYourself

I’m sure they meant this to be nice, but I don’t think they read it.

What a horrible reason to be yourself! Not that you are infinitely unique and valuable. Not that you have tons of creative and productive potential that no one else has. Literally, this says it’s too bad you couldn’t be any one else (implication – anyone else would be better), so you might as well be you (that’s the only choice you’ve got, so settle for being you). YUCK! 

Dr. Seuss does it better: Today You are You, that is truer than true. There is no one alive who is Youer than You! 

Carl Rogers does it WAY better: “People are just as wonderful as sunsets if you let them be. When I look at a sunset, I don’t find myself saying, ‘Soften the orange a bit on the right hand corner.’ I don’t try to control a sunset. I watch with awe as it unfolds.”

 

 

 

 

 

 

Couples Metaphor – Yoga


Yoga for Couples


Here’s a great relationship metaphor… but be aware that it might not work as well for clients who have no experience with yoga!

 

What about thinking about your relationship the way you think about your yoga practice?

 

  • 1) Set your intention. When you’re tuned in to your practice, mindfully present, your practice goes better. You know it does. When you’re just there because it’s Tuesday morning, when you’re checked out because you have a busy day ahead, when you’re there even when you know that sleeping in would have been healthier for you… your practice suffers.
    • Whether this is about the initiation of a relationship, or about a communication within a relationship you have, being mindfully aware of what you are entering into is crucial.
  • 1a) Be honest about that. It does no good to set your intention to “peace” during your yoga practice when you know you’re too worked up, or if it’s a Hot Power Flow class! You don’t need your intention to be the same as anyone else’s, and certainly not “better” than theirs (as if that’s possible).
    • In your relationship, there’s no point in setting an intention you “should” have, rather than the one you actually do have. Those “shoulds” might come from you, your history, your facebook feed, wherever. But it’s worth it to be honest with yourself about what you’re looking for.
  • 1b) Change if necessary. In addition to being honest, you want your intention to be healthy. If you’ve honestly reflected and your intention for your practice is to look better than the person next you, or to make and hold a pose regardless of your injuries… well, that’s why we set our intentions early in the practice – so we don’t waste all of that time and effort chasing something harmful.
    • Likewise, if you can tell that your intention for the relationship – or the argument – is just to win, to be “better than,” to have something you know will be nice now but damaging in the future… it’s time to rethink. Before that argument starts, preferably.

 

  • 2) Be gentle. We know that gentle stretching increases flexibility safely and – because it doesn’t cause damage – it doesn’t injure us and set us back. Similarly, gently breathing through discomfort and gently encouraging yourself to build strength go a long way toward not just finishing your practice well… but showing up the next day. Being a harsh critic has no place in yoga.
    • When communicating with your partner, always err on the side of gentleness. Clarity is important, yes. But more important is that additional damage doesn’t occur, setting the conversation back further. Going slowly, staying together, breathing through discomfort, gentle encouragement… these are powerful relationship changers, even though they aren’t dramatic.
  • 2a) Don’t expect the same “performance” every time. Every day and every practice is different. Although we tend to grow in healthy ways and make sustainable gains in yoga, what was easy yesterday may be difficult today. For many reasons, a joint may be stiff or a muscle sore.
    • Likewise, there are always multiple factors working in and around us in our relationships. While you can expect pleasant changes over time (in the context of healthy communication and such), it’s a bad idea to “microjudge” yourself or your partner. No need to hold yourself strictly accountable to being exactly the same all the time. 

 

  • 3) Don’t rush to the end. There is no “end.” There’s no winning in yoga. There’s no “being right.” It’s not a competition. It’s a practice.
    • Work slowly and gently, with the process in mind, more than the outcome. Too often, we’ve already decided the only acceptable outcome for us in advance, but then there’s no space to grow.
  • 3a) Don’t work on everything all at once. Building strength and flexibility in one area certainly benefits other areas. You’ve probably been to a yoga class that emphasized “twisting” and on another day emphasized “warrior strength.” And while that might mean that the overall
    • You needn’t cover all the

 

  • 4) Namaste. During the whole practice (and at the end), remember to honor the divine light within you, your instructor, and everyone present. It helps to maintain the growth-mindset rather than the competition mindset.
    • At the beginning, at the end, and whenever you need to in the middle of your communication – remind yourself (and maybe your partner) that this is a fully alive human being, deserving of love and respect. Remind yourself that you are, too.
  • 4a) End with peace. No matter what happens during practice, whether your legs were shaking in crescent, you fell out of tree pose, or anything else… savasana is always there.
    • Sometime when you aren’t in conflict, work out a peaceful place for yourself and your partner. Words you can say to reassure one another, something you can do together, or a place you can literally go that is “sacred” and set apart, that doesn’t involve conflict. Then, you always have something to look forward to. Even if that isn’t possible, make sure you have that for yourself, so that you can rest and recover… and come back the next day.

 

Double Triple Bonus points if you get clients to attend yoga together to enhance the metaphor!

Comment below: This metaphor seems endlessly rich to me! How can you contribute to it?

 

 

 

 

Affirmations


Affirmations


I won’t date myself by referencing the Saturday Night Live skit… well, what the hell, sure I will. It’s too classic. “I’m good enough. I’m smart enough. And doggone it, people like me.” Ah, thanks, Stuart Smalley.

Let’s talk about positive affirmations, and how to do them well.

    • Make them short and punchy. Your inner critic tends to have the vocabulary of a 6th grade bully, if you’re lucky. Your inner yoda/inner therapist/inner big sister/etc. can’t compete with that neurologically if it takes you a paragraph to say something meaningful and kind about yourself.
    • Make them accurate and defensible. No rainbows, ponies, or bullshit. Do the work of figuring out what the good things about you actually are. Make sure you have evidence, even though you won’t go through it every time (see #1). Along these same lines, don’t predict the future. Definitely replace the pop-psyc “affirmations” like “Everything will work out for me” and “I am a winner”!
    • Include your agency. There are many things you can do that you don’t do all the time. This is really helpful when you feel as though you’ve run out of the “I am ________” variety. Consider things like “I can make healthy choices” or “I’m able to hear my inner wisdom when I give myself the chance.”
    • Format them positively. This one you probably know – an affirmation should contain only positive language. This means that “I am attractive” works better than “I’m not ugly.” We want to avoid “lighting up” the parts of the brain that compete with the messaging we want to strengthen. “I’m not ugly” lights up the “ugly” networks, whether we want it to or not. So be careful with phrases like “I’m not…” or “I won’t…” or “I don’t have to…” or “I will stop…” etc. (While you’re at it, avoid language like “should” and “ought”!)
    • Check your language. Affirmations work best when they are something that becomes automatic and unconscious with exposure. So, it’s important to treat your language as carefully as hypnotic language – watch out for metaphors, descriptors, and turns of phrase that your unconscious mind may process concretely rather than abstractly (“I am a diamond; it’s time for me to shine” may bring up different associations subconsciously like hardness and impenetrability), or partially based on phrasing (“It’s easy for me to tune out the negative” can become “It’s easy for me to tune out”). This also mean things like not using the word “try” (because it implies failure at the concrete level) and words with more than one meaning like “stunning” or “pretty”. Also, be mindful of homonyms (word that sound the same) – like “a lot” (allot), peace (piece), know (no), etc. (Or even nearly the same, especially if you’re recording affirmations for a client – be mindful of your vocal differences!)

 

Bonus idea: When you’re recording the affirmations for clients, say each one out loud, and then pace yourself by saying it again in your head before you move on to the next one – this gives them time to repeat each one silently or aloud,  in their own voice.    

Comment below: Do you have any great examples of your favorite affirmations to share?

 

 

 

 

Childrens Melatonin


1 milligram!


I found this at my nearby Walgreens, and I was unbelievably thrilled! Children’s melatonin!

“Now, wait,” you’re saying. “That doesn’t sound like the Ellis I’ve been reading.” (And if you’ve ever heard even a small piece of my “Bad Pharma” rant, you’re especially confused.)

The reason I’m excited is NOT because I think we should be giving kids melatonin. I pretty frankly don’t think we should, at least unless all the other behavioral/psychological/family issues have been worked out and the problem is still there. Unsurprisingly, I’ve never had a family committed enough to go through that process.

Also, it doesn’t do very much, in children or adults. Here’s a meta-analysis for you – increases sleep time by 8 minutes. (It might work better in older adults?) 

I AM excited, though, because there’s an easy-to-access 1mg dosage that adults can choose. I consistently have clients asking me about using melatonin. Of course, the first thing they get is a talk about sleep hygiene and a sleep hygiene info sheet! But, if they insist that they’re going to use it, they get a secondary talk about how the typical 3mg and 5mg dosing wildly, outrageously increases the amount of melatonin in your system (I mean 50x and more!). And when we flood our bodies with something that our bodies already make, our bodies quit making it. (This is how hormonal birth control typically works, btw. And it’s why testicles shrink when men are given supplemental testosterone.) Do clients with sleep problems want to shut down their bodies’ own melatonin production?? I doubt it.

Get this – I put “melatonin supplement” in Amazon and the first option was TEN MILLIGRAMS! I’m so pleased to at least have a less insane option to point clients toward.

You may want to read the National Sleep Foundation’s article about sleep and melatonin, as well.

Comment below with sleep tips, or general pharma rants. There will be more posts to come in this area, of course!

 

 

 

 

Great Books Volume 3: Divergent Classics


Great Books Volume 3: Divergent Classics


Here’s a list of books that are well worth reading, written by fathers/mothers in the field, but that are a bit more specific (not quite so much emphasis on “how therapy works as a whole”). These tend to be a bit newer, and a bit shorter, if that has been something that’s kept you from reading along so far! You’ll see some of our favorite authors return on this list, as well…

 

  • Man’s Search for Meaning (Viktor Frankl)
    • Short and incredibly powerful. More personally beneficial than clinically useful, which is why Doctor and the Soul made the first list
  • Love is Never Enough (Aaron Beck)
    • Although this is about working with couples, it’s a good cognitive therapy text without having to read Cognitive Therapy for Depression (although that’s a good one, too). Prisoners of Hate is also awesome!
  • Sex Without Guilt (Albert Ellis)
    • Sure, there are plenty of resources to learn REBT, but why read them when you can learn it while listening to Ellis pontificate about sex five decades ago?! (There’s also an updated version which is shockingly similar to the first edition!)
  • Let Your Body Interpret Your Dreams (Eugene Gendlin)
    • Hands down, the best dream interpretation book I’ve ever read, and it also really exemplifies the down-to-the-ground humanistic, phenomenologically-oriented theory of therapy
  • Emotional Awareness (Dalai Lama and Paul Ekman)
    • A brilliant, easy-to-read dialogue that covers the basics of universal emotional experience and gives insight into the real Buddhist tradition that the West has marred
  • Behind the One Way Mirror (Cloe Madanes)
    • If you were interested in Jay Haley’s Strategies of Psychotherapy, you’ll like this case-study rich exploration of strategic family therapy
  • The Family Crucible (Carl Whitaker and Augustus Napier)
    • This would be a treatise on systems-oriented family therapy if it were a huge, boring tome. Instead it’s a lively narrative that follows one family’s journey. You may end up with more questions than answers, but that’s ok!
  • Waking The Tiger (Peter Levine)
    • The book that effectively birthed Somatic Experiencing and other body-focused trauma therapies. This is readable on a client level, but still has a good science background. May change the way you see the whole mind-body connection, not just with trauma.
  • Flow (Mihaly Csikszentmihalyi)
    • Really useful for those clients who needs more of a coaching or consultation style, or who have any kind of performance concern (professional, athletic, even relational). Very clear concept, well elaborated, easy to incorporate into your own life and into therapy
  • Gifts Differing (Isabel Briggs-Myers)
    • Great secondary text on Jung’s personality theory and great primary text on MBTI. So much more depth than what you learned in your assessment class, and it’ll give you useful constructs to work with, even if you don’t care for the actual instrument.
  • The Schopenhauer Cure (Irvin Yalom)
    • Existential classic in a very readable narrative form. Also, lots of good stuff about group therapy, all demonstrated rather than explained.
  • On Encounter Groups (Carl Rogers)
    • THE book on process groups. It’s brief and, if you’re a highlighter, prepare for more yellow than white – it’s so rich!

 

I really don’t mean to fill your bookshelves and/or drain your wallet. It’s just that they’re all SO GOOD. Comment below if you’ve read one of these and you want to recommend it for people to begin first! 

 

 

 

 

Explore Colonize Conquer


Explore, Colonize, Conquer


First, thank you to my clients (M&K) who gave birth to this metaphor with me. It has been so powerful, and not just in your lives.

When you meet another person, you aren’t just meeting another person. You’re meeting another person and all of their territory. By “territory,” I mean all of their thoughts, feelings, and neurophysiological responses that are based in the totality of their history and experiences. All of these are fundamentally different from your territory and fundamentally unknowable without that person’s willing guidance.

There are three ways to approach a new territory.

  • As a conqueror.
    • A conqueror knows what’s right and best. They force or coerce to get their own way. They take over – abolishing what was in favor of what they want. They destroy and replace. They wage war – loudly and quietly.
    • You can tell a conqueror by their actions and their language. They are forceful, uncompromising. They listen poorly (distorting) or not at all. They say things like, “yes, but…” and “But I…”
    • Everyone is a conqueror sometimes, whether you wish to think it about yourself or not. So, drop the pride and take stock. Pay attention to yourself. It’s more subtle than you think and it’s sinister. It feels right when you’re doing it. It feels…righteous. Don’t be what you don’t want to be.
  • As a colonizer.
    • A colonizer is pleased with their own way. They know they can bring good things to the new situation. Manners, refinement, worthy (if different) traditions. Changes…but only good changes (or so they protest)!
    • You can tell a colonizer by their actions and their language. They seem accommodating at first, and then you’re surprised when you’ve acquiesced. They listen, but artfully dismiss. They say things like, “I think we should…” and “how about we…”
    • Everyone is a colonizer sometimes, whether you wish to think it about yourself or not. (Oh! Therapists are SO guilty of this, so often!) So, drop the pride and take stock. Pay attention to yourself. It’s much, much more subtle than conquering. It’s (ostensibly) gentler. It feels more right. Don’t be what you don’t want to be.
  • As an explorer.
    • An explorer wants only to be exposed and educated. They do not have pre-formed opinions. They are completely open, and prepared to handle surprises gently and with curiosity and grace. They simply want to know more, hear more, understand more fully and accurately. They have no desire to change what is.
    • You can also tell an explorer by their actions and words. They make space for what is new. They ask honest questions to clarify what is new or unclear. They go slowly, without encroaching. They listen.
    • As therapists, we hope to be explorers. In relationships (romantic, familial, etc.), exploring is crucial. But it takes a lot of work, and self-management…it’s not anyone’s natural instinct.

 

In theory, you and this other person want (to some extent, at least!) to merge your borders and create “our land.” The ONLY healthy way to do this is as explorers first, then settlers – cultivating the shared land together, harmoniously.

 

 

Comment with thoughts on expanding this metaphor, or your own couples’ metaphor!

 

Office Treasures


Office Treasures


What kinds of useful treasures do you keep in your office?

Aside from the boring box of things-I-might-need-or-have-forgotten-at-home (headphones for ADHD assessment, bandaids for strange emergencies, deodorant because I’m sometimes in a rush, etc.), I have a box in my office of useful treasures that I pull out in therapy sometimes. It has mostly been populated because I really wished I had something in session and didn’t! I thought I’d share a few of those items with you:

 

  • Heart rate monitors
    • I keep two inexpensive heart rate monitors (the kinds that clip gently on clients’ index fingers) in my office, along with extra batteries. I use these in the Gottman way, when couples have a tendency to escalate (to help them see when they need a time out) and I also use them with individuals sometimes when we’re learning relaxation techniques
  • Copies of therapy-pics I’ve made
    • I like to make “take homes” for clients using stock photography, either for use in session exercises or to reinforce special ideas. I try to keep a few copies of my favorites so that I have them available and can send them home with clients
  • Bubbles
    • I use the small tubes of bubbles that are popular as kids party favors. That way it’s easy for them to be single use. The primary way I use these is to teach unpanicked breathing. Attempting to blow one large or many little bubbles is an easy way to get across the basic principle of “exhale longer than you inhale,” and clients seem to like the interactive nature of the activity. I also occasionally have couples use them when they need to discuss conflict calmly. And they’re part of my “emergency protocol” when an adult has brought a kid to session with them who I wasn’t expecting!
  • Small flag
    • I keep small plastic flags (the 10 for a dollar kind) in my office to use mostly when I am doing communication training with couples. After we’ve talked about whichever “rules” we are working on, I literally wave the flag when the rule gets broken. It makes for less of an interruption than actually interrupting, and clients seem to feel less “criticized.” (If I have a really high functioning couple, I may send them home with two flags to use during homework practice!) I will occasionally do the same thing with an individual, if we’re monitoring something together (e.g., yes-buts, self deprecation)
  • 8” inflatable beach balls
    • They take up almost no space, and (along with also being good for visiting kids), I like to use them with couples and individual trauma clients in the Bessel Van Der Kolk kind of way – creating a reciprocal, socially engaged, dynamic-yet-predictable interaction that can help to regulate the nervous system! Also, it can give clients a way to do a semi-dissociation while they talk about difficult things, kind of like how they do their best processing while knitting or petting a therapy dog. They’re the perfect size the be easy to throw and catch, even for not-very-coordinated people, but not so big that they take over the space.
  • Blank paper
    • I know, this sounds so ridiculously simple, but this is hands down the item I use most often. There are many times that I want a client to make a quick sketch, or co-create a visual metaphor with a client, or draw an explanatory diagram. I never know when that urge is going to pop up, and I really like not having to use the back of their progress note or the regular lined paper I keep I around, and not even having to get out of the chair and break the mood.

 

Comment: What do you keep in your office to use during therapy? Tell us how it works!

 

 

 

 

Slowing Way Down


Slowing Way Down


I really like having couples for double-length sessions, at least 90 minutes. There’s just SO much work to do! And how often does that dream come true? Almost never. Which is one of the reasons I use this technique, even though – I warn you! – it’s going to seem counter-intuitive.

Couples are infinitely complex and unique…except in the beginning. Because in the beginning, they all have some of the same problems. In one of those problems is a basic difficulty with saying what they mean and hearing the other person. I’m sure you had the all too common experience, to; it starts out reasonable, then there speaking over each other, saying the same things over and over, getting louder and louder. When that happens, I quietly stand up, go over to my box of supplies, and pull out a pack of index cards. Then I sit quietly, and wait for their quite confusion.

Next I hand them each one index card and a pen.

Rules are pretty simple: First, take your time – because you get the front of this one index card to save the most important things that you want your partner to hear. (It’s surprising how much event held by the size of fonts they write with during this exercise!) After you’re both done, switch cards. Read the card as many times as you need to. Quietly; no speaking. As best you can, write what your partner told you in your own words on the back. After you’re both done, switch cards.

The next step depends on your intention in using the exercise. You might take both cards, read them both and help them make corrections on their interpretations of what the other person said. You might have each of them read their partner’s interpretation, and then use a new index card to write their initial statement more clearly. If they’ve done well, and the point was mostly just to cool the temperature in the room down a little bit, you might invite them to speak again about what they’ve just written (I use a random number generator to decide who goes first).

Yes, this takes basically an entire 50 minute session. For one note card. And you know what? They usually have communicated more during that session that may have in any session before we used the technique.

Bonus: this is a relatively easy task to then assign for homework!

 

Comment below: What pitfalls can you imagine using this task with a couple you have now? How would you handle them?

 

 

 

 

Rule of Three


Rule of Three


I want to talk about the idea of false dichotomy, because they’re both so easy and so destructive.

The tendency to falsely dichotomize (AKA splitting, black-and-white thinking) has been a central issue in psychotherapy since Freud, Kernberg, and Klein. You’ve got two hands and two eyes and two brain hemispheres. There are “two sides to every story.” It so often seems like there is yes-and-no, for-or-against, right-or-wrong. Worse…. Conservative-liberal, masculine-feminine, us-them.

And that’s probably because our brains – beautiful, complex systems that they are – often use dichotomization to help us live faster in the world. (More on this in a future post.)

This happens often, and to our detriment. (Serious statisticians seem to be the only people who really know this!) Clients limit their own options, we constrain our therapeutic directions, and we stifle our diagnostics and conceptualizations.

And the trick to not falsely dichotomizing is oh-so-simple. Just make the rule of three. All questions have at least 3 answers. Don’t do an ethical decision making model without at least 3 choices of possible actions to evaluate. Put at least 3 empty bullet points on your treatment plan template. Make a deal with your consultation partner – not just playing devil’s advocate (which is a great role for them), but playing the role of horizon-broadener. When you create counterthoughts in cognitive work, make at least three. Prep all of your clinical worksheets to match. When you evaluate the “B” in the REBT method, identify at least 3 possible beliefs. When you delineate clients’ values in ACT, make 3 the minimum magic number for actions-in-pursuit-of-values. When you and a client are interpreting a dream, include at least 3 hypotheses.

Don’t worry… you won’t end up limited to just 3 and end up unwittingly stuck again. Three gets you out of falsely dichotomizing and things really open up from there.

 

Comment: When have you noticed false dichotomies in session?

 

 

 

Preposterous Quote – Moon

WARNING: PREPOSTEROUS QUOTE AHEAD!

No. No. No. If you shoot for the moon and miss, you’ll actually burn up in the atmosphere as you fall back to earth. This is a great (missed) opportunity for a cautionary tale… if you’re going to shoot for the moon (i.e., set a goal) and you don’t prepare well or have a good takeoff, you’re in for an unhappy ending. 

If we must use the metaphor, we need to shoot for the stars (i.e., have enough planning and motivation to get to the goal, preferably), on a trajectory that passes near to the moon (i.e., subgoals that would be valuable in and of themselves, in case we change course or run out of fuel), and with adequate resources (e.g., provisions and gear to last awhile, communications with support systems) so that if we shoot for the stars we may land on the moon and at least survive for awhile. 

 

 

 

Sleep Deprivation

Sleep Deprivation

Here’s a fun little (billable!) diagnosis I ran across recently. I’m always looking for just the right diagnoses to use that “get the job done” in terms of professional communication and clinical research that ALSO honor the individual’s experience by describing them faithfully. (See the previous post on Diagnosing Well). See if this one might add to your diagnostic repertoire!

 

Z72.820 Sleep Deprivation

Approximate Synonyms

  • Lack of adequate sleep

Clinical Information

  • Lack of the normal sleep/wake cycle
  • Prolonged periods of time without sleep (sustained natural, periodic suspension of relative consciousness)
  • State of being deprived of sleep under experimental conditions, due to life events, or from a wide variety of pathophysiologic causes such as medication effect, chronic illness, psychiatric illness, or sleep disorder.
  • The state of being deprived of sleep under experimental conditions, due to life events, or from a wide variety of pathophysiologic causes such as medication effect, chronic illness, psychiatric illness, or sleep disorder.

Comment: When is this truly useful and appropriate and when might you choose not to use it?

 

 

 

 

All Different


We’re All Different


I know, that’s not really news to us. Though you wouldn’t know it if you just listened your couple-clients, would you? It’s wild to me how much they expect the other to have the same personality, likes/dislikes, perspective, neurobiology, history, motives…well, you get the idea. Or rather, it’s not that I think they really expect that, but they just seem not to give it much thought?
I’d like to share an exercise with you that I use with many couples, to good effect. It asks couples to identify their differences – silly ones, serious ones, big and small – and to identify how they tolerate, accept, or celebrate those differences. (And they do at least tolerate them all, or they wouldn’t be in your office!) It gives you an opportunity to talk about how all of those are ok, and how you can even move up from tolerate to accept, or from acceptance to celebration. And it sets the stage for another important part of coupes work – each choosing to accept the other person fully while making efforts to change themselves, accepting influence from the other person and accommodating when more movement doesn’t feel possible.

 

Note: Couples, even ones who do this very well, need to continually revisit and update this information. Just as we’re different from our partners, we’re different from ourselves from last year, or ten years ago.

Bonus: This works with families, too!

Comment below if you have other techniques you’ve used to help couples or families experience each others’ differences in a gentle way.

 

 

 

 

Blank may be better…


Blank may be better…


I know there’s some kind of marketing value in having lots of “letters” behind your name and on your business card. 

But please, let’s stop the madness. 

Paying $59.99 to be a “Certified Life Coach” does not actually add anything to your practice. Becoming a “Certified XYZ Therapist” for a few hours of training that doesn’t help you do anger therapy any better than basic counseling training is a bit shameful. Mediation and anger and wellness, oh my! I’m sort of willing to go the distance on this and say that these kinds of credentials are actually unethical and misleading (APA Ethics Code 5.01 & ACA Ethics Code C.4)

Not convinced? Read this article about how a middle schooler can become a “Certified Clinical Trauma Professional” and then come back. Here’s the tl;dr…

Mental health professionals typically represent their competencies by earning a diploma and obtaining a state license to practice. Some practitioners choose to further represent their expertise by acquiring specialty certifications. We review the broader landscape of these certifications and provide a case study of a program that illustrates current problems with specialty certifications. Specifically, we demonstrate that an 8th grader with no prior mental health education or training can pass a test intended to assess expert levels of knowledge obtained from a workshop. Implications of these findings on the validity of specialty credentials and the public’s trust in them are considered.

Rosen, G. M., Washburn, J. J., & Lilienfeld, S. O. (2020). Specialty certifications for mental health practitioners: A cautionary case study. Professional Psychology: Research and Practice. Advance online publication. https://doi.org/10.1037/pro0000324

 

Let’s not chase the appearance of expertise. We don’t need to compete with 8th graders. Own your real credentials; clients will respond to your actual expertise. 

 

 

VERB Your To-Do List


VERB Your To-Do List


VERB your to-do list

I’d like to share with you a cool and random idea I had with a client that is really working for me personally.

See, I know that a lot of people, when they “can’t get motivated to do what they need to do” have maladaptive ways and reasons. They are perfectionists-who-procrastinate (and it’s worth working on their shame-related core belief), or they have their priorities all out of whack (and it’s worth taking the conversation to values and meaning), or they or maybe have subconscious resistance (and it’s worth discovering it!). Or whatever.

Some people (and I suppose I’m one of them) are just kind of internally inconsistent. I don’t always wake up in the morning with the same kind of “energy” and the kind of energy I have fluctuates during the day. Honestly, it often doesn’t matter. When it’s time to teach, it’s time to teach. When it’s time for therapy, it’s time for therapy. (Those are easy – I have internal access to my teaching and therapy energy almost all the time. I haven’t yet sorted out whether I believe that’s natural, and I just found the right occupational place for myself, or if it’s something that develops with value-oriented-time-and-practice. Or both. Or something else.) When it’s time to turn in grades, or work on a grant proposal, or have a meeting with colleagues I disagree with … I rarely have the right kind of energy, but it doesn’t really matter. It must be done.

But there a lot of things that sort of fall in the middle – writing, cleaning, reading, etc. And there are some times (and I know this is a luxury, but it’s likely that you have at least some measure of it as well) when my day isn’t demandingly structured by an outside authority. And, yet – I’ve spent most of my life trying to demandingly structure my own time! (I sort of understand why, but it’s a long Family of Origin tangent.) Here’s what I do now:

I’ve chosen to group the items on my ongoing to-do list by type of energy. Generally, these are all things that don’t have hard deadlines or involve other people.

My current categories are WRITE, LEARN, CREATE, CLEAN, WORKPREP, THINK, and RUN-AROUND.

Under the WRITE category, I have things like make more blog posts and work on articles and workbooks I have in progress. The LEARN category includes reading one of my stack of not-yet-read psyc books, doing continuing education, etc. The CREATE category has more personal items – my kids’ photo books, hypnosis recordings, painting the bathroom. The CLEAN category literally just has every sub-divided space in my house listed! Under the WORKPREP title, I have things like advocacy research tasks and handouts I want to make for clients. The THINK category is where I put those random thoughts I have that I don’t have time to pursue when they pop in. And the RUN-AROUND category is everything that requires me to get in my car – typical errands.

So, when I have a bit of unstructured time, I can just check in with myself and see what kind of energy I have, then I can go to my list and choose something. I can’t tell you how much more productive I have been since I started this!

As a bonus (and this came up with a client, as well, and then also is now important in my own life…), I added REST and CONNECT categories. 

Comment below: How about you? How do you structure your own productivity when someone isn’t doing it for you? What kind of categories might you have on a verb’d to-do list?

 

 

 

 

 

Undiscovered Self Jung


Undiscovered Self (Carl Jung)


I love reading. And I’m such a psychology nerd that some of my favorite things to read are the classic texts written by the fathers and mothers of psychology and psychotherapy. So, in case you might want to read some of these – I’ll give you some glorious snippets as I come across them to entice you. (And for those who really don’t want to read these kinds of things, maybe still some good quotes to spice up your consultation meetings and help you feel psychologically erudite.) ?

Carl Jung’s The Undiscovered Self: The Dilemma of the Individual in Modern Society (1957)

This is a tiny, punchy little book! Coming in at just 112 pages, it’s pretty easy to read and fits nicely in a purse or laptop bag! Here’s one of my favorite lessons:

Individual reality can’t be expressed by statistical averages; every therapy client is a completely unique creature and needs to be treated as such.

The more a theory lays claim to universal validity, the less capable it is of doing justice to the individual facts. Any theory based on experience ins necessarily statistical; that is to say, it formulates an ideal average which abolishes all exceptions at either end of the scale and replaces them with an abstract mean. This mean is quite valid, though it need not necessarily occur in reality. … The exceptions at either extreme, though equally factual, do not appear in the final result at all, since they cancel each other out. (p. 7) … While [the average is] reflecting an indisputable aspect of reality, it can falsify the actual truth in a most misleading way. … Not to put too fine a point on it, one could say that the real picture consists of nothing but exceptions to the rule, and that, in consequence, absolute reality has predominantly the character of irregularity. … There is and can be no self-knowledge based on theoretical assumptions, for the object of self-knowledge is an individual – a relative exception and an irregular phenomenon. (p. 8) If I want to understand an individual human being, I must lay aside all scientific knowledge of the average man and discard all theories in order to adopt a completely new and unprejudiced attitude. …If the psychologist wants not only to classify his patient scientifically but also to understand him as a human being, he is threatened with a conflict of duties between the two diametrically opposed and mutually exclusive attitudes of knowledge, on the one hand, and understanding, on the other. This conflict cannot be solved by an either-or but only by a kind of two-way thinking: doing one thing while not losing sight of the other. (pp. 9-10)

That’s all I’ll give you here, but you should read it for these other gems:

  • How communism and capitalism both devalue the individual while purporting to do the opposite
  • How religion really exists through experience only, not dogma
  • The problem with ignoring your shadow and the good that can come from it
  • How art prophesies cultural shifts

 

Yes! All of that in this teensy, tiny book. Enjoy!

Comment below if you’ve read this book, or any Jung, and give your favorite quotes!

 

 

 

Just close your eyes and rest…


“Just close your eyes and rest.”


This is what we need to tell our kids, and ourselves. Trying to demand that you fall asleep, or that awful thing where you think “if I could just go to sleep NOW, I’d get 5 hours. … if I could just go to sleep NOW, I’d get 4 ½ hours…” NOT HELPFUL. Changing this language is just the beginning of the wide array of strategies we can use to help clients get restful sleep – something that’s associated with pretty much every physical and mental health measure there is! 

 

Sleep hygiene is maybe the thing that’s most applicable to virtually every client – more so even than journaling, I’d say! It’s a shame, I think, that many accessible resources for sleep hygiene are quite poor (even though they’re usually pretty accurate). I’d like to share with you the sleep hygiene handout I made for my clients – feel free to share (but, you know, obviously don’t SELL!).

 

It’s geared toward adults, but could pretty easily be modified. It doesn’t mention sleep meds (which are often antipsychotics or antianxiety meds – BEWARE; also the sleep specific meds like Ambien have some really alarming side effects!) or pharma sleep “helpers” (like antihistamines or melatonin). It also doesn’t mention some of the sleep re-set techniques for when sleep has gotten really out of control, e.g., the 24 hour re-set or the 5.5 CBT-I strategy .

 

 

Comment if you teach sleep hygiene to clients, or if you’ve learned a new sleep hygiene technique you can share! 

 

Frog: A Noble Creature


Frog: A Noble Creature


I know. Frogs don’t seem that noble. And whether they are or not, or even if the case could be made that they are (and I believe it could), that’s not even remotely the point.

You see, “Frog: A Noble Creature” is just what I title this image when I give it to one half of a couple. “Horse: A Noble Creature” is just what I title this image when I give it to the other half. See why?

(If not, tilt your head so your right ear touches your right shoulder)

It usually takes just a moment for the two of them to notice that they have the same picture. Which is good, because the point is to show them that they can’t easily see the other person’s picture the way they see it, unless they come around to the other person’s position and look from where they’re sitting.

It’s just a little introductory exercise to empathy and perspective taking, but it really seems to drive the point home better than a lecture. Here are two of my other favorites.

 

 

Comment, please! How do you explain empathy to clients? Do you know of any other optical illusions to share that would help?

Note: I hate posting images without original sourcing, and I don’t know the original source for any of these. If you do, please share!

 

 

 

 

Living fully in the moment


“Living Fully in the Moment”


I feel like that’s a thing we say a lot. So I’d like to break it down a little bit. Specifically, I’d like to talk about what living-fully-in-the-moment is NOT, because it’s not really enough to know what something is. We don’t know the shape, the fullness of something, until we find its edges.
 

What living fully in the moment is NOT:

 

  • It’s Not-Living
    • This might be “deadness,” that depressive, withdrawn un-aliveness. It can also be “stillness” or avoidance, not going-forth because of fear. It can be disconnection from the other life (people, activity) in the world through isolation, numbness, or “tuning out.” And it can be the “early death” of an unlived life – a life made too narrow by fear or unwillingness.
  • It’s Part-living (i.e., not living fully)
    • This can be a distorted existence – constricted by too-strong opinions or too-strict beliefs, by an internal critic or demanding internal parent that allows for no exploration. This can be a life lived under pressure, “obligated” in ways that the person even has difficulty articulating. This is a life lived “in bad faith,” as the existentialists say – full of blaming others and circumstances, rather than holding the freedom and responsibility for one’s own life.
  • It’s living in the not-now, not-here
    • This might be living in the future – consumed by anxiety about situations not yet arrived. Or worry for those not immediately present, who you wish you could control or keep safe, but who you don’t and can’t possess. This can be stuckness in the past – regret, guilt, and fear or repeating past mistakes. Missing out on the present and what is becoming because the gaze is focused backwards, or too far out.

Comment: What do you see as the unlived life? How have you helped clients live fully in the present?

 

 

 

 

Therapeutic Apology


The Therapeutic Apology


If you haven’t said “I’m sorry” to a client this month and meant it, you might want to check in. In real relationships, we blow it sometimes. So, if you’re having authentic, therapeutic relationships with client, apologizing will be a part of the deal. Not only is it an important part of a real relationship, it models something very important for your client. Here are some tips:

 

  • Recognize when to apologize
    • When you have violated part of the explicit or implicit contract
      • Running late, mistaken charges, delays in providing requested documentation, unclear communication, etc.
    • When you haven’t honored them well
      • Made an assumption, not listened well, gotten distracted, interrupted, followed your own agenda, etc.
    • When you made a mistake you shouldn’t have made
      • Forgotten to check their homework and they missed session time to process something that was important to them, started into a metaphor you often use but then realize it’s not well tailored to this particular client, overstepped a boundary, pushed too hard that day
      • Note: When you make a mistake that was reasonable at the time, and not due to a lack of knowledge/ethics/conscientiousness on your part, just explain it without apologizing. This is excellent modeling!

 

  • Only apologize for things you have control over (i.e., your own behavior)
    • Avoid the “habitual apology” (women are especially prone to this). That’s when you say “I’m sorry” when no offense actually occurred.
      • “I’m sorry (for taking up space in the hallway because I have a body and walk at the same time as you which is obviously not my fault)”
      • “I’m sorry (because you were speaking very softly and the air conditioner is loud so I couldn’t hear you which is obviously not my fault”
      • Resist the urge to apologize just because they don’t like something (e.g., for your email/contact policy, for ending session on time, experiencing difficult feelings, referring them appropriately)
    • Apologize for what you DID, not for what happened.
      • NO: “I’m sorry we had a misunderstanding just then.”
      • YES: “I’m sorry I wasn’t listening well just then and assumed incorrectly.”
    • Two exceptions to this rule:
      • Go ahead and say “I’m so sorry to hear that….” when something unfortunate has happened to a client. Even though sorry isn’t exactly the right word, that’s so culturally established that if you don’t say it, the moment will be really weird, and that moment is also usually moment when you need to NOT be weird, and really be attentive and present, and not explaining weird cultural, linguistic idiosyncrasies.
      • Go ahead and apologize if your administrative staff, office management/maintenance people, etc. have done something unpleasant or insensitive. The client often sort of sees them as an extension of you.

 

  • Apologize WELL.
    • No beating around the bush, be specific and own it.
      • “I’m sorry for getting distracted just then.” “I’m sorry for not listening well.” “I’m sorry for running late today.”
    • No passive aggression. Avoid giving your “reasons,” unless you’re sure they’re really reasons (not excuses) and they’re actually important to the process. In that case, be specific.
      • NO: “I’m sorry for getting distracted just then. I have a lot going on personally right now.”
      • YES: “I’m sorry for getting distracted just then. What happened was that what you said really struck a chord with me around grief, and I’m wondering now if or how grief is playing a role for you?”

 

  • Follow up.
    • They’re likely to say something like “oh, no worries” or “it doesn’t matter.” So, follow up on that with something like “thanks for you patience” or “you do matter to me, so I just wanted to let you know.”
    • Add what you’re planning to DO about it.
      • “You have my full attention now.” “Can we go back and you can describe it to me again so that I can understand better?” “I’m going to make sure I adjust your fee for the missed time today.”
      • Oh, and then DO that.

 

Comment with your own “rules” for apologizing, or a time when you have used the therapeutic apology and it’s been important.

 

 

 

 

Great Books Volume 2: Indispensable “Psychology” Books


Book List Volume 2: “Psychology” Books


Ok, I promised a follow-up post about great books by primary authors. There are too many to just do one additional post, so this one will be focused on “psychology” proper. These aren’t the most useful books, maybe, for psychotherapy, but they’re outrageously important in terms of fundamental psychological knowledge. Enjoy!

 

  • Beyond the Pleasure Principle (Sigmund Freud)
  • Psychopathology of Everyday Life (Sigmund Freud)
  • Archetypes and the Collective Unconscious (Carl Jung)
  • Principles of Psychology Volumes I and II (William James)
  • Games People Play (Eric Berne)
  • Theory of Human Motivation (Abraham Maslow)
  • Beyond Freedom and Dignity (BF Skinner)
  • The Making and Breaking of Attachments (John Bowlby)
  • The Neurotic Personality of Our Time (Karen Horney)
  • Mind: A Journey to the Heart of Being Human (Dan Siegel)
  • Change: The Principles of Problem Formation (Paul Watzlawick)
  • The Lucifer Effect (Philip Zimbardo)

I have a bunch more books I’d like to list, because I think they’ll be amazing. But I’ll practice what I preach: NEVER recommend a book you haven’t read. More to come!

Comment if there’s a book you think I missed for this post! Or if you have ever recommended a book to a client that you haven’t read and it came back to bite you! Haha!

 

 

 

 

Diagnosing Well (Rant!)


Diagnosing Well (rant!)


Diagnostics are tricky, right? We want to honor the human person, so we sort of hate the idea of diagnosing. And who wants to put clients in “a box”? Although, we need to get paid, right? And that means billable codes. What are we to do?

 

Rethink diagnosing. It honors the client when we can describe their conditions and situations in clear, useful, holistic ways. (Warning! Here comes the ranty part…) But that’s not an excuse to do it haphazardly, to give everyone adjustment disorder, or to get in the habit of using the same five diagnoses over and over. To really do it well, you might need to change the way you think and behave. You might start by trying some of these tips:

  • One of the lovely things about diagnostics is that it gives us clear definitions in order to do treatment-related research. So when you do diagnose, make it really count by accessing that research literature and translating it into effective treatment strategies, client handouts, and more.
  • Remember to use all of your specifiers! It’s no wonder we feel like we’re dumping clients into diagnostic categories if all we put is just “MDD” or “GAD.” (Remember that a few conditions, like “with Panic Attacks,” can be part of any diagnosis!)
  • Recall that “unspecified” diagnoses are really for ERs and quick intakes. Never leave one on a client’s chart. Go back and get the phenomenological data you need to update it.
  • When you give an “other-specified” diagnosis, remember to actually specify it in a brief narrative form!
  • Use your “Other Conditions” codes to paint as clear a picture as possible with your diagnosis, even when they aren’t billable (you may remember them as “v-codes”). Like these:
    • F50.4 Overeating associated with other psychological disturbances
    • F62.0 Enduring personality changes after catastrophic experience
    • F55.6 Abuse of herbal or folk remedies
  • There are more billable codes than you realize. You don’t need to use adjustment disorder for everything. Here are some fun examples:
    • F42.1 Obsessive-compulsive disorder, primarily compulsive acts
    • Z62.898 Birth of a sibling affecting child
    • Z70.8 Sex counseling
    • Oh, and if you hated that Asperger’s left the DSM-5, it’s available in the ICD-10 – F84.5. So is Dysthymia, and the Schizophrenia subtypes!

 

Let’s honor clients by doing excellent, thorough work. Maybe this will also be helpful to you? It’s a free PDF version of the Mental and Behavioral Health section of the ICD-10.

 

Leave a comment! How do YOU do diagnostics like a rock star?

 

 

 

 

Teletherapy Rant


Teletherapy Tips (but mostly rant)


(This is a bit long, and you may want to just skip to the end, where there is a client resource that you can check out!)

I’m not particularly new to teletherapy – I’ve done it for a couple of years, though only at need (for example, with a client who traveled out-of-town but in-state to care for her dying father for several weeks). Like it has for many of us, teletherapy has taken a larger role in my practice in 2020, and – as a result – I’ve solidified my relative distaste for it. It’s taken me some weeks to really get a handle on what bothers me about it, and I think I have.

 

  • It’s just not clinically appropriate for some clients.
    • For some clients, coming into the office is literally part of what is therapeutic – for depressed clients who have difficulty getting out of bed, for social anxiety clients who “feel safe” behind the screen, for clients with autism spectrum disorder whose work involves building social skills, for clients with dependent personality disorder/features
    • For some clients (those above, and those with almost any other kind of anxiety), staying sequestered at home exacerbates their symptoms. Consider how many people will have added a “with panic attacks” or “with agoraphobia” specifier to their diagnoses by the end of this time!
    • Perhaps it goes without saying, but managing potentially dangerous situations (e.g., self or other harm) via telehealth is something very few people have been adequately trained in. I have a feeling we don’t really know if we’ve been adequately trained until we’re in the moment across the screen with our client who has the scissors at their elbow.
  • Privacy/confidentiality is our responsibility, and teletherapy makes that much more difficult.
    • Privacy and confidentiality are much easier to manage in our office environments. For therapists who have moved their practice to their homes, unless they live alone, this poses significant challenges (e.g., family members hearing session, Bluetooth devices nearby allowing access to sessions). Also, when records are kept outside of the office, or moved between home and office (e.g., if you use paper records), that adds risk.
    • Probably the larger issue is that we don’t have any control over the environment that the client chooses. We can ask them to provide an optimal environment, but it becomes an ethical dilemma at some point: do we provide (suboptimal!) services when a client is, say, constantly interrupted by their kids, walking through the grocery store, or under the scrutiny of an abusive partner? Where do we draw the line and say it’s not an appropriate environment for therapy? Typically, we honor those boundaries even when clients don’t – when they sit down next to us in a church pew and start to share or even try to continue their session in the waiting room, we actively prevent that and protect their confidentiality even when they don’t.
  • We miss out on the benefit of the “sacred space.”
    • Therapy is special. When people choose to come to therapy, we are supposed to offer them something that is different from their normal lives. That’s part of what helps it to bring newness into their lives. There’s a reason that sacred spaces have existed throughout time – why you build an altar in the desert, why you go to your closet to pray, why you climb a mountain to get clarity, why indigenous healers set up holy spaces. If you think that therapy is just telling people your wise thoughts or finding interesting solutions to problems, maybe it doesn’t matter. But if you practice therapy with the intention to heal, the sacredness of the therapeutic space matters.
    • In a more scientific way, we could say that our internal states are tied to the physical spaces in which they are activated. That is the reason that one of the primary sleep hygiene rules is to only use your bed for sleep – because classical conditioning is a real thing. So, our offices – where clients choose to be disclosing and access emotions, where they feel safe, where they can bring themselves to do hard work – those offices allow clients, over time, to feel safe, disclose, access emotions, and do uncomfortable work more readily. When they do therapy from their homes, offices, cars… we lose the benefit of the therapy space.
  • For many therapists, it seems like it is more difficult for them to keep their professional boundaries.
    • The teletherapy experience seems to be convincing many therapists that they should be in text-contact with their clients much more often than they typically would be. If this is not part of a therapeutic system that a therapist has been trained in (like a Linehan-style DBT program), there are a lot of risks with extending the session beyond the session time. Beyond the risks for clients in believing that you’re always available, and then sending a crisis text while you’re unavailable, how do you take a shower, sleep restfully, or drive safely without attending constantly to the concern that a client in need might be texting you right now?
    • I’ve also been reading about and hearing about the “increased intimacy” of online therapy that some therapists are suggesting is a good thing. There are many therapists who are sharing things with clients that they never would share in face-to-face counseling, like the state of their homes and allowing clients to see them interact with their family members. Likewise, they are experiencing aspects of their clients’ lives that they wouldn’t otherwise experience. My question about this is whether those clients would choose to share those things, if they were mindful about it. Would therapists? We intentionally don’t join a client’s personal book club or speak to them when they’re at the gym. When we begin to do in-home therapy services, we get training in how to interact in a client’s personal space. While I’m sure everyone has good intentions, there’s no data about whether this is helpful or harmful to clients, and it seems to me to blur the lines that we know are helpful to clients.
    • For both of these issues, how clear are therapists being? Are we honoring our professional, ethical obligations to “clarify professional roles and obligations” and “avoid unwise or unclear commitments” (Ethical Principles of Psychologists and Code of Conduct, General Principles)? To what degree are we even maintaining a professional relationship? And make no mistake, the professional relationship is part of the healing process – we have known for a long time and continue to accumulate data that the therapeutic relationship is the primary factor in positive change (not the physician-patient relationship and not “good friendships” – the therapeutic relationship).
  • It’s harder to create a growth-promoting climate because it’s harder to use the basic Rogerian skills.
    • Silence is one of the foundational skills of therapy, and the mediation of the screen and internet connection really diminishes the effectiveness of silence… especially when the client has to ask, “Are you frozen?!” The head nods that we can use to show we’re listening while silent can be problematic; for example, they often seem like agreement to clients, so we don’t want to overuse them. The “mmm-hmming” is often either so quiet that it gets lost or so loud that it breaks the client’s rhythm because they think you want to speak.
    • Eye contact, which is also one of the most basic attending skills, is frankly impossible. If you are watching the client for facial and other non verbal cues, then they can’t see your eyes. If you look at the camera, so that it appears that you’re giving them eye contact, you can’t see them anymore. If you move your camera so far back that you can “fake it,” you’re no longer close enough to see their facial changes well. Not to mention that you need to be monitoring your tiny picture at least some of the time to at least make sure that you’re on screen, clear, and well lit.
    • Pacing is more substantially more difficult online. For one, it’s virtually impossible to see and hear clients’ breathing, which is one of the ways that you know how and when to speak in session, even if you aren’t aware that you’re attending to that. Also, the conversational lag time, even when both parties have a good connection, is unavoidable – that’s why we have to say, “Oh, sorry, you go ahead” so often.
    • Attending to nonverbals is also largely impossible. There are the issues listed above, with clarity of facial expressions and breath, but it’s unusual to be able to see more of the client’s body that you get to see in face-to-face work – wringing hands, tapping feet, holding a pillow across their torso, etc.
    • And it’s less congruent. According to Dr. Marlene Maheu, the leading teletherapy trainer in the country, from the Telebehavioral Health Institute, we need to be about 10% more expressive in order to come across the medium with the same level of engagement. That means that we are either acting (in which case our internal experience will be incongruent) or being perceived as less present (in which case the client’s experience is incongruent with our intention).
  • For me, personally, it feels less rich – the same energy isn’t there.
    • Partly, this is because I am more easily distracted and it takes more effort for me to stay fully engaged through the screen (esp in hour seven!). That may not be an issue for everyone.
    • Partly, it’s because my primary theoretical orientation is existential-experiential with a person-centered foundation, so I utilize the here-and-now and the relational process more often than other therapists might.
    • I really like how psychotherapist Erika Shershun said it, in an interview for The Bold Italic: teletherapy lacks the “refreshing and energizing resonance between two people.”

I know this is going to be a controversial thing to say, but in short, I think that teletherapy is the Standard American Diet of psychotherapy: it’s more convenient, it’s cheaper for the people who provide it, and it will keep you going, but it’s less nourishing and is probably causing problems down the line that we don’t even know about yet.

Of course, it’s also certainly better than nothing. For scenarios that are more like coaching, or brief solution-focused work, I think it doesn’t make much difference. If we do it well, I think it can be helpful. And I think that, in some cases, we can use it to our advantage (e.g., using the out-of-office environment to create different exposure scenarios for clients with OCD).

So, I have tried to channel these feelings into something much more productive than just a rant, and created this tip sheet  for clients doing teletherapy our scouring the internet and my professional community and finding nothing like it. Please check it out! Hopefully, you’ll find it useful and not-ranty, and be inspired to use it or make your own!

 

Thank you so much to my lovely colleague who helped me clarify these thoughts, soften my rantiness, and upgrade the usefulness of the client tip sheet.

 

 

 

Metaphors


Metaphors in Therapy


It might just be me, but metaphors are one of the most useful and most enjoyable things I do in therapy. How it develops as session moves forward…it’s so very alive! And it’s the perfect blend of co-creation, client investment, being in the here-and-now, and creating that shared vocabulary and those “inside jokes” that really solidify the relationship.

Metaphor open doors and windows. They grow into fruit-bearing stories. They are infused with energy, like water, like light, like electricity.

Here are some of my favorite, most typically-useful metaphors.

  • Therapy/life as a quest
  • Self as a house
  • Family as an ecosystem
  • Psychotherapy as physical therapy/working out
  • Relationships as a garden

Here’s the thing about metaphors. You need to be open to them – both hearing them in session and seeing them in the world. Have you ever seen the show “House?” Dr. House is an amazing diagnostician in part because he is outrageously knowledgeable and competent. But if you’ve watched the show, you know that a lot of what seems like magic happens because his brain – the sort of white noise that’s always activated – is always open. He’s got the client du jour floating in the background, always, so that when other (seemingly random) things happen, it clicks.

Once I was driving, and saw someone transporting a leather sofa in the back of their truck. I thought, “They’re lucky it isn’t raining!” But then… it became a metaphor for a client that week, who was tempting fate with her vulnerability. Another time, it was writing a stock “thank you note” that prompted a metaphor about a client’s timid, prepared communication and how it was often appreciated in the moment but then forgotten and not incorporated into her relationships.

Yes, be careful. Metaphors only go so far. Also, I know I’m providing you with some “stock” metaphors here, but the other risk is that your metaphor either doesn’t fit the client’s experience or (worse!) they make your metaphor fit their experience, and then it’s not authentic. So, please, invite them to co-create with you!

(And yes, I will do more posts that flesh out each of those metaphors, and more!)

Comment: What are your favorite therapy metaphors?

 

 

 

 

Preposterous Quote – Be Patient

CAUTION! Preposterous Quote Ahead!

Actually violates the physical law of entropy. Left alone, with just your patience, all things disintegrate, they don’t integrate. Even for things to maintain their integrity or the status quo, they have to be intentionally maintained. True for the universe writ large, but certainly true for your internal systems and relationships. If you want things to come together, patience is a nice foundation for the work you need to be doing with self compassion in yourself and your environment!

Comment with your improved version!

 

 

 

 

Focusing – Gendlin


Focusing


Recently, we talked about the 7+/-2 principle of working memory and how the brain is a pinball machine. We went on to talk about how therapy work like journaling and PCT can be effective, and how to maximize the 7 +/-2 principle in our work with clients. Which is great! And now, I want to see about taking things to a whole new dimension…

You can only THINK ABOUT  7+/-2 things at a time. Even when we’re maximizing that, clients can only experience a few of the multiple parts (e.g., thoughts, feelings, sensations) of any given situation in sequence. But you can SENSE the whole thing at once, if you allow yourself to do that and don’t rush to get ahead of yourself with words. This is called the felt sense. The felt sense (Gendlin, 1978) is different from feelings, emotions, thoughts, or regular body sensations. It is the fuzzy, unclear “gestalt” of awareness.

The felt edge is the next step that follows completely naturally from the complete felt sense and leads in the direction of more life in the body. Every natural experience has a natural next step, and only that next step will REALLY satisfy.

Hunger → eating; Arousal → orgasm; Grief → tears; Curiosity → exploration

What options do you have when you are thirsty?

Exercise? Reading a book? Vodka? Pineapple? Water? Gatorade? (Infinite options!) But which one is the one to which your thirst is leading? The BODY KNOWS.

The felt edge is like standing in patient readiness, without tension, observing all of the possible next steps and getting the sense of what feels like more life in the body.

Focusing  is the process by which we can experience the felt sense of any given problem or situation – the whole of it, at once –  and thus, approach the felt edge where we are most likely to have an awareness of the most right next movement.

The Six Steps of Focusing

  • Clearing a Space – Asking yourself: What is the main thing for me right now? Sense it, but don’t go inside
  • Felt Sense – Experience (“Feel”) the many parts of whatever it is, all together. Get a sense of what all of the problem feels like.
  • Handle – Give a name, phrase, or image to the quality of the whole felt sense.
  • Resonating – Gently go back and forth between the felt sense and the handle, patiently ensuring that you have just the right fit.
  • Asking – “What makes the problem so _____?” “What is ___ in this?” Be sure you are sensing freshly (not remembering!) the felt sense. If you get a quick answer, without feeling it in the body, let that go and stay with it.
  • Receiving – Be open, in a friendly way, to any shift in the body. This will be accompanied by some change in the whole of the problem. Accept that change gently.

 

If you want to learn more about this, you’ve absolutely got to read Focusing (Gendlin, 1978). It’ll change your life, your therapy, and your clients’ lives… guaranteed. And if you think you can’t learn something so experiential from a book…try it anyway. Focusing is all about tuning in to your own experience anyway; Gendlin’s voice through his writing may be all you need for direction.

 

Tons of other free resources and readings of Gendlin’s and The Focusing Institute here

Gendlin, E.T. (1978). Focusing (first edition). Everest House.

 

 

Comment below if you use Focusing in session, or if this is your first exposure!

 

 

 

 

 

 

Emotions for engineers


Emotions (for Engineers)


I know this is not typical, but I’d like to share with you an intensely useful metaphor that I absolutely hate. Hating it is especially difficult for me, because I made it up. It’s just not….me. But it’s wildly effective with some clients – especially the analytical, emotionally restricted, very controlled clients.

Let’s start with this: there are 6 basic human emotions. (I know, some researchers say 5, 7, or 9. Some are currently working on disputes. Of course, there are cultural, familial, and other influences. Maybe that’s a topic for another day, along with the relative absence of really good emotion lists or wheels. Today, we speak of Paul Ekman, the father of universal emotion research.)

FEAR, SADNESS, ANGER, DISGUST, JOY, INTEREST

And while I most want to write about the varieties of emotional experiencing, primary vs. secondary emotions, emotion constellations, and more, instead I’m going to tell you how I sometimes talk to people about emotions who aren’t as “into” emotions as I am. This may be because they’re truly alexithymic, because they were raised in a traditional male gender role or any of a number of cultural systems that value emotional restriction, or because they’re Vulcan. Here goes:

Think of emotions as an internal indicator about the allocation of resources in your environment. Resources could be anything – money, time, relationships, etc.

FEAR – Fear is an emotion that tells us a resource is in danger. The importance of the resource and the level of perceived danger (in intensity, closeness, and ability to deal with it) will determine whether we feel nervous (like when the resource of social status might be threatened by potentially having poor public speaking performance next week) or terrified (the resource of life/health is threatened by an oncoming 18-wheeler).

SADNESS – Sadness is the feeling we have when a resource has been lost. Again, the level of sadness we feel is determined by a few moderators like the importance of the resource (like a close family member), the irretrievability/irreplaceability (like death as opposed to a job loss), and the “realness” (e.g., we feel disappointment when we perceive a loss of something we didn’t actually have yet).

ANGER – We experience anger when resources are perceived to have been distributed unfairly. When we don’t get something that we believe that we deserve, we feel anger in response. It’s something that we can feel this as a response to someone else being unfairly resourced – an abused child being denied safety and love, the environment being destroyed through improper resource management, our kid not winning the science fair even though their project was definitely better than those other kids’.

(note: people often experience anger or something like anger as a “secondary” or “substitute” emotion when they have learned that other emotions are too painful or not acceptable to express, typically fear and/or sadness. More on this in another post, sometime.)

DISGUST – Disgust occurs when a resource is potentially threatened with corrosion or infection. This can be a physiological kind of disgust, like when we are exposed to an obviously ill person or a rotted food. It can also be when we believe our character/environment might be threatened with moral decay or infection by the presence of contemptible others.

JOY – Joy happens when we believe our resources (again, this includes all kinds of resources – money, love, status, purpose, etc.) are sufficient and safe. If we have just enough and aren’t worried, we feel contentment. We may even feel a burst of happiness or delight when we receive an unexpected resource – a winning lotto ticket or spontaneous hug. (You might prefer to use the word “happiness” for this emotion in general because you believe “joy” is tied up with purpose and meaning. Great; I support that!)

INTEREST – Interest, like all of the emotions, comes in different intensities. For example, curiosity, wonder, and awe are emotions we feel when we recognize that a resource is salient. It often combines with other emotions to tell us how salient a resource is in what way. It acts as a modifier (e.g., telling us whether something is a bit scary, pretty scary, or very scary).

 

It’s a work in progress, so comments below, especially if you have questions or ideas!

 

 

 

 

More like dancers than statues


More like Dancers than Statues 

(Introduction to Reversal Theory)


We are more like dancers than statues.

I’d like to spend a few minutes introducing you to a cool little theory that I bet you’re not familiar with. It’s called Reversal Theory and (if you’ll pardon the pun), it’s might just turn things upside down for you.

Let’s start with this – think about the theories of personality you’re most familiar with. Probably Big 5 comes to mind? Maybe Myers-Briggs? Bonus points if Allport or Eysenck popped into your mind first. Here’s the thing – most theories of personality are trait theories. They’re based on how we are, and how we stay the same. They tell us who we are, across time and situations.

Now answer this question: Do you feel like an INFP all day, every day? Aren’t there times when you’re more or less agreeable, more or less open to new experience? (And yes, while all of those theories account for slow, incremental change across the lifespan, that’s not what I mean.) I mean sometimes don’t you feel disagreeable in the morning, and more agreeable after coffee? Don’t you sometimes feel conscientious when you start working on a project and then markedly not conscientious as you slog through it for 5 hours? Don’t you sometimes feel extroverted at the beginning of a party, but just feel yourself retreating to introversion over the course of the evening? This is the aim of Reversal Theory – to give us a structure for thinking about how we are different across time and situations, rather than the same. (Don’t fret! It doesn’t do anything to diminish trait theory – all of that still counts!) 

To begin, I need you to imagine a bank of 4 light switches.

Now, I don’t want blow your mind too much right now, but in Reversal Theory, we’re not going to be thinking about traits on a continuum. We’re going to be thinking about 4 pairs of states, and each of them flips off or on like a lightswitch. (No, not like a dimmer-switch. I know the continuum is our best friend in therapy, but hang in here with me. Just wait until the end.)

Here they are:

Ok, let’s visit these one by one.

Serious-Playful

You don’t get to be serious and playful at the same time. Wen you’re in the serious state, you’re goal-oriented and future-focused. You’re focused on achieving something important and maybe on the consequences of not getting things done. When you’re driving to work for an 8am meeting with your boss to give an update on the progress of your latest project, chances are you’re in the serious state. But when it’s sunny, breezy, and 75 degrees on a Saturday afternoon, and you don’t have to rush anywhere (and also that favorite song of yours from your junior year in high school comes on the radio) – you’re probably in the playful state. In the playful state, you’re in the moment and focused mostly on enjoyment.

Conforming-Rebellious

When you’re in the conforming state, you’re focused on the value of fitting in, doing what’s right, meeting expectations. Lots of people are in the conforming state at school, work, or church. Teens are often in the conforming state, even when it doesn’t seem like it to parents (e.g., smoking to “be cool” or drinking to “fit in,” even though parents might call that rebellion!). When you’re in the rebellious state, your primary motivation is freedom, or individuality. When you spend Saturday doing whatever you want to do, or when you protest an injustice on your own behalf, or when you get a purple streak in your hair, even though your mother, husband, and coworkers might be scandalized, you’re probably in the rebellious state.

Mastery-Sympathy

In the mastery state, you’re primarily concerned with things like doing better, having control, and making progress. In the sympathy state, you’re mostly concerned with taking it easy, being gentle, love and nurturing. Chance are, if you’re at the gym, you either are in the mastery state or you’d certainly like to be. If you sometimes go to the gym for the “princess package” (a gentle swim, then the whirlpool, then the sauna, and end it with a smoothie), you’re probably in the sympathy state.  

Self-Other

The self and other states are probably what you think they are – being focused on you or being focused on someone else. These combine really naturally with the mastery and sympathy states. You might be exercising control and power over self (like when you’re at the gym), or you might be exercising control and power over someone else. For example, you might be bargaining down a salesperson for the best price and you definitely want to “come out on top” or you might really investing in beating your last high score in DoodleJump. That’s self-mastery. But what if you’re tutoring a high school student and really encouraging and empowering them to have control and mastery over themselves and their schoolwork? Any time you function as a teacher, coach, or mentor – you’re probably in the other mastery state, focused on power, control, and mastery…but for someone else. And sympathy works the same way. When you want to eat ice cream to soothe your jangled nerves, take yourself out on a date, choose to watch Netflix instead of push yourself to that deadline, you’re in the self-sympathy states. When you want to give that kind of care, love, and lenience to someone else – helping a friend in need, letting your partner sleep in – you’re in the other-sympathy states. 

Now, for each of these states, you are in one or the other of each pair at any given time. You might be more aware of one or two of them, but you’re in all four. And if you combine the states you’re in with the situation you’re in or what you’re doing, you get different and interesting results. So, you may be writing progress notes and be in the SERIOUS-conforming-self-mastery states. If you are, you’re probably killing it, getting work done, feeling great about your progress. But, if you’re in the playful-REBELLIOUS-self-sympathy state trying to work on your progress notes, I bet you’re not making any progress at all. I bet you’re sitting there, miserable, eking out a sentence at a time, wishing you were done, desperate for a massage or a margarita. See, we’re not always in the optimal states for whatever we’re doing at the moment.

OK, that’s as far as I’d like to bring you for right now. I want to give you a teaser…while you wait for the next post on this, think about what states your clients are in while they’re in session with you. Think about what states they might be in when they argue with their partners, when they’re disciplining their kids, sitting in their school desks, trying to resist peer pressure, or captivated by worried thoughts.

(If you are already in love, and don’t want to wait for the next post, buy this book.)

Comment below if you have thoughts or questions!

 

 

 

 

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!

 

 

 

 

Philodendron


All Hail the Lotus! 


There’s a reason the lotus appears on virtually every psychotherapy (and spa) website from the east to the west of the internet. Not only is the lotus beautiful, but it grows out of mud, so it makes a great therapy metaphor. And you get to quote Thich Nhat Hanh, which is always a plus.

But that is not a lotus, you notice.

Ellis, why do you have a common houseplant on your blog?

Let me introduce you to the philodendron, the underappreciated gardening-therapy metaphor. The philodendron is an ordinary, yet extraordinary, plant.

First, it can grow almost anywhere, in almost any way. It can have roots underground and/or above ground. It can get all of its needs met through the soil, through rain, or even just through the air. It changes its growth methods based on the resources available, its own maturity level, and its changing needs for nutrients and light. The philodendron can live and thrive in almost any environment.

It makes symbiotic relationships with other plant and animal life, wherever it finds itself. This includes its neighbors – nearby plants and the trees on which it sometimes grows. It also includes traditionally undesirable companions, such as ants, trading shelter for the ants’ nests in return for the ants’ protection. Oh, and they have good boundaries – their glossy leaves are a natural deterrent to many insects and larger herbivores, like deer, so they don’t get taken advantage of easily.

When it is time to grow new leaves, the philodendron first creates a small pocket of protection for the new sprout. Once it’s grown enough, this pocket is no longer needed, and it lets it go. When it does, it leaves a tiny scar – a reminder.

There are almost 500 recognized subspecies, and even philodendrons from the same subspecies will look different depending on their stage of life, the specific environment they’ve grown in, and the various resources available.

They’re happy to “stay single,” mate with other philodendrons, or hybridize with other plants. They may enjoy a full life a few feet tall, close to home at the base of a tree. Or they may grow outward, covering tropical forest floors or gloriously wild backyards. Some will grow spectacularly tall, using nearby supports to reach heights of over 1000 feet high. They’re even happy to hang out in your house.

Best of all – I found out about philodendrons because I have something of a black thumb… I don’t seem to care very well for things that don’t communicate verbally. They’re virtually indestructible. And you can trust me, because I’ve even killed aloe vera. More than once.

Now tell me, do you want your clients to be a lotus? Or to be like the incredibly hardy, adaptable, diverse, relationally competent philodendron?

Or, leave a comment with your own plant-metaphor!