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…)

 

 

 

 

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!  

 

 

 

 

 

 

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?

 

 

 

 

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! 

 

 

 

 

 

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? 

 

 

 

 

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!  

 

 

 

 

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? 

 

 

 

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! 

 

 

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!  

 

 

 

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! 

 

 

 

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

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? 

 

 

 

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? 

 

 

 

 

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! 

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.

Connect These Dots


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


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?

 

 

 

 

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?

 

 

 

 

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?

 

 

 

 

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?

 

 

 

 

 

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!

 

 

 

 

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.

 

 

 

 

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?

 

 

 

 

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!

 

 

 

 

 

 

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!