Tag: BackToBasics

Telehealth Arriving Rituals

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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? 

 

 

 

 

They might be an alien…

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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

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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? 

 

 

 

 

The Most Important Question – The Scrubbing Bubbles Story

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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

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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?

 

 

 

 

CLEAR thinking

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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.

 

 

 

 

Keys to Wellbeing from an Accountant

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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?

 

 

 

 

Sleep Lesson from my 8 Year Old

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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?

 

Avoidance Sucks

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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?? 

 

 

 

Behaviorism for Parents 3

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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

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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? 

 

 

 

 

 

Online Resources and Apps (Vol 1)

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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! 

Connect These Dots

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Connect These Dots

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

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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!

 

 

 

 

Affirmations

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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?

 

 

 

 

Therapeutic Apology

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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.

 

 

 

 

Easier to believe what we fear

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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!