Let’s Meet in the Middle

Posted on by Psychotherapy.net Team

We all want our feelings to be understood. But even if we have a significant other with whom we feel understood, we may find that we become misaligned as career and family life evolve and change. Nowhere is this more true than with professional couples and dual-career families as they take on new role-based challenges.

Recent research¹ indicates that the dynamics affecting the quality of a couple’s relationship stem from differences in motivation (approach/avoidance orientations) and patterns of interpersonal behavior. I look at both factors in the case of Meg and Paul, two highly educated professionals, each with histories of neglect in childhood. What I also consider is a style of engagement that seems well-matched to the experience and expectations of professional couples.

Couples Issues

By the time strain and conflict have become chronic, partners have often done a good deal of blaming and fault-finding with one another. It doesn’t help, but it’s almost unavoidable, as people lose their capacity to see things as they really are. Only later, after bumping up against the reality that they are stuck and that it's probably not entirely their or their partner’s fault, might they conclude that outside help, objectivity and perspective are needed.

I believe we can learn a great deal from working through our issues—their causes, course, and resolution—as couples. Doing so not only makes us happier in our couples, it makes us smarter managers, leaders and collaborators in the workplace. But of course, these truths can seem rather remote when we are in the throes of relational conflict and cannot yet see a pathway forward.

Even with awareness of our need for help, we retain the need to protect ourselves against being found lacking. We may privately hope that a therapist will take our side and that we’ll be vindicated. Couples are often ambivalent, wanting perspective but simultaneously maintaining defenses. Disarming them is about eliminating threats to emotional safety and ensuring that each person has the chance to be heard. To satisfy these conditions, we must be an empathic and assertive mediating presence.

Being heard, in this context, is more than an auditory task, and it involves more than an exchange between therapist and patient. When therapists listen actively, they provide a hearing for all three persons in the room. As the therapist and couple together reflect upon this active listening process, the couple notices how different it is than what normally happens in their exchanges at home. Thus, safety and learning depend upon how the therapist facilitates, moderates and contains the listening process.

Individual or Couples Therapy

There are times when individual therapy prior to or in addition to conjoint therapy may be indicated. When either or both members of the couple suffer from an acute mood disorder or chronic mental health problems, their capacity to participate in couples therapy may be limited. And sometimes they just can’t believe that something different and good can come from discussing their issues with their partner, not yet. But I’ve found that they’re likely to underestimate their readiness to participate in couples therapy.

In my practice, I work mostly with professional couples, the same demographic I’ve served for over 25 years in my executive coaching practice. When it comes to helping relationships, they seem to welcome an active, norm-setting agent who is willing to reign in behaviors that threaten conditions of safety and openness, or that derail productive engagement. Their basic ego strength is usually adequate. They tend to default to a practical sense of urgency to “fix” things. While their impatience and an action bias can impede progress, initially I find it helpful to leverage these attitudes to generate motivation.

They may be more skeptical and scared than they’re willing to admit, but they know they need help. They haven’t found a way to do it themselves. So, the therapist must find ways to intervene early, to validate their decision to seek therapy, and to change the way they communicate and interact. When we can model a tolerance for conflict and an ability to notice and discuss how their polarized attitudes and behaviors operate reciprocally to sustain conflict, we earn credibility. And that’s critical. Professional couples more than others will be looking for evidence that we’re competent.

Meg and Paul

When I met Paul, he was presenting with anxiety stemming from work and marriage. He was on an SSRI for anxiety and on Ritalin for ADHD. He reported a childhood replete with dysfunction and less than good-enough parenting. Raised in a small town in Alabama, he adapted by retreating to a rich imagination and creative talents, later attending a top art school in the Northeast and then settling in Brooklyn. I didn’t have to tell him his family of origin was dysfunctional. He knew it and ran as fast as he could to escape it.

Soon, it became clear that adapting at work (from artist to manager) was not nearly as challenging as making things work at home with Meg. Like Paul, Meg had a history of insecure attachment, growing up in a pastor’s home in rural Connecticut. After a failed marriage that produced two boys, she met and married Paul, who hadn’t had much success in dating or sexual intimacy. She, too, was bright and won a scholarship to an Ivy League college, but she had responded differently to childhood issues.

Meg was a fighter with an excitable temperament and a penchant for order and control. Both had suffered neglect, but Paul had taken a route of pathological accommodation and escape, while Meg had gone the way of rebellion and escape. Neither had healed the wounds of neglect. As their lives became more complicated by a third child, increased financial demands, chronic patterns of conflict and naïve hopes gave way to long-standing vulnerabilities, and each sought individual therapy.

The Circumplex Emerges

When Meg and Paul came in for their intake interview, the tension was almost immediately manifest. Sitting at either end of my six-foot sofa, they made no attempt to conceal the distance that had grown between them. I asked them to tell me what caused them to seek therapy at this time and suggested that Paul, the meeker of the two, talk first. He spoke carefully, haltingly at times, always rounding if not blunting the point of the issues he raised. I conjured an image of one navigating a minefield.

Meg sat stern-faced with arms crossed as he spoke, casting dismissive glances his way as he struggled to express himself. There was eye-rolling too, which caused me to wonder how far he got in speaking his mind at home. It was all she could do to limit her dissent to nonverbal communications as Paul spoke. Then, when it was her turn, Meg’s voice rose in angry criticism. Her first aim was to correct Paul. As she flushed with anger, Paul went pale with fear.

Her fault-finding with Paul was peppered with global accusations prefaced by “you never” and “you always.” She painted a picture of his inconsiderateness, broken promises and selfishness. Neglected as a child, she suffered it again in her marriage to Paul. Her voice rose well above the norms for my office–yes, I have such norms. So, I intervened. With a hand gesture signaling a timeout, I said, “Meg, do you have any idea how overwhelming your energy is right now?” She halted and I continued, “You’ll have to turn it down a bit if we are to communicate.”

She was taken aback and flushed from red to rose as a sudden pause prevailed. Paul sat quietly, still pale, anxiously awaiting the next steps. I can imagine the reader might wonder about the force of my presence and the effects of my behavior. Most of my clients (consulting practice) and patients (clinical practice) describe me as down-to-earth, caring, sincere and constructive. Even in my most direct moments I believe they recognize a positive intent in my face, words, and actions.

I expressed a grounded confidence. I assured them that they need not accept nor reject anything I said too quickly. I encouraged them to simply consider how it might be relevant for them. My tone with Meg and Paul was neither harsh nor timid. It was not aggressive; it was assertive. It was not out of control; it was tempered and composed. My first intervention was to invoke norms of propriety in the consulting room. This atmosphere of civility became the defining quality of dyadic communication in the therapy.

After the “flareup” was extinguished, discussion resumed. I asked how representative this episode was of the problems they’d been experiencing. They admitted that it was all too common. The difference was that at home Paul would usually not get the initial words out. Rather, Meg would define the violation Paul had committed (being late or forgetting an errand), and he would go quiet, retreat for a while, and then later try to explain himself and perhaps become defensive.

Meg would later remark on how being with Paul was like having another child. Paul didn’t agree with this characterization, but fighting it only meant extending the quarrel. So, he usually quit at this point, believing it was not worth the pain and wouldn’t change the outcome anyway. The more she played the role of his parent, the more he was cast in the role of a child.

We used the interpersonal circumplex² to consider this chronic pattern. I have found this model quite useful with couples. It plots interpersonal behavior in two-dimensional space using two axes, Dominant/Submissive and Friendly/Hostile. Using the model, we’re able to see how our expressed behavior is likely to “pull” a style of behavior from others. On the one hand, a dominant expression tends to pull a submissive response, and a submissive expressive style pulls a dominant response. On the other hand, friendly and hostile expressions seem to invite others to respond in suit. So, how did this apply to Meg and Paul?

They had been interacting in the hostile side of the circumplex, Paul from the submissive area (passive style) and Meg from the dominant area (aggressive style). We also observed that my intervention came from the friendly dominant area (assertive style). Finally, we noticed that the pause arose from the “neutral” space in the middle of the circumplex as a pause for reflection on communication style. Thus, the title of this article and my suggestion to couples that when they notice tension building, and before it becomes entrenched conflict, they tell themselves that it may be time to “meet in the middle.”

Communication Styles Chart

 Figure 2 Communication Styles (Penberthy, 2016)
 


About Motivation

Of the many ways to characterize motivation, a fundamental way of conceptualizing it is through the approach/avoidance paradigm. It’s been around since Neo-Freudian thinkers like Karen Horney, Erik Erikson and Harry Stack Sullivan, and builds upon the interpersonal point of view. It gained even more support from the observational studies of mother-infant attachment. Its central thesis is that we are essentially social beings with needs for connection and intimacy. As adults, these needs manifest in our intimate relationships with others, and also in our interdependency in the workplace.

“What we learn early in life from caregiver relationships shapes our beliefs and expectations about what is possible and probable”. When our caregivers are attentive and available, and as we and they learn how to jointly navigate nonverbally and pre-cognitively in ways that satisfy our needs, we develop a sense of trust: “I can rely on others to care, to read my behaviors, and when they fail, they don’t abandon me. No, they persist until my needs or insecurities are resolved.”

Such successes in adaptive learning and development promote an approach orientation. This includes beliefs that most problems can be solved with help, and that those with whom we share our lives at home and at work are usually willing and able to be helpful. We act from a benevolent hypothesis about others’ motivations and with optimistic beliefs about what we can do with their help. But absent this positive early-life experience, we may approach relationships with less trust and positivity, with more suspicion or doubt, and often with fears of abandonment.

Patterns of Avoidance

In the case of Meg and Paul, we observed histories of maltreatment that would understandably lead to lower expectations of what might be possible in relationships. They might look for (project) evidence of the betrayal and mistrust they experienced early in life in the contemporary behaviors of those they hoped would be there for them.

For Meg, it was an ostensibly kind and service-oriented father (pastor) who seemed to have little time and interest for her needs. He turned his attentions elsewhere, perhaps in ways that won him esteem in the eyes of those he helped. And her hopes of finding enduring love with her first husband failed. Like her father, he was “selfish.” And now, as life’s demands on Paul increased, she saw him too as neglecting her out self-interest. It was reinforced daily when he arrived home late or forgot to stop at the market.

Meg had been on alert for signs of neglect since she was a little girl, all to guard against more rejection, and she found them in her adult relationships with men. We could describe this motivational orientation as avoidance. She might ask Paul to do things, but her expectations of his delivering on these requests were very low. She was fully armed to express her anger and mistrust of him every time he fell short. In her eyes, he was breaking a promise, and she wasn’t taking it anymore. She increasingly threatened divorce in her moments of peak anger and frustration.

Paul’s mode of avoidance was more obvious. It was based on his fear of conflict learned as a child. Meg’s stern look and voice tone signaled a threat to which he reacted with an impulse to retreat. Neither he nor Meg could readily identify in the moment the fears and vulnerabilities they were replaying from childhood. They were both caught up in self-protective (defensive) routines intended to distance them from harm. That is, until in session we would enter the neutral zone represented on the circumplex model.

Noticing and suspending the visceral grip of legacy, avoidance-based emotions and motivations, adaptive approach-oriented motivations, goals, and behaviors became available. This pause simply hastened access to the approach-based responses that had been activated in Paul after Meg finally collapsed in emotional exhaustion and despair from her angry outbursts. Meg’s approach behavior was activated as she finally welcomed Paul’s concern, support, and sympathy when her aggressive energies had quieted. They both took roundabout routes to dialogue.

These, then, were the dispositional tendencies of motivation that energized their chronic patterns of conflict. The avoidance-based mindset had governed behavior with increasing frequency. I noticed that the approach-based resolution strategies were not working as often or as well. They were both feeling exhausted and discouraged. Both, especially Meg, were losing hope that things could change. Their differences in personality and behavior seemed unchanging, perhaps unchangeable.

It took concrete behavioral analysis of specific situations to shift their focus to variables that they could realistically influence or control. We had to do a great deal of situation analysis in our therapy sessions to acquire a basis of trust and positive expectations for change. We had to recognize the way they were both setting unrealistic and unattainable goals, and how they were neglecting adequate attention to the positive thoughts and behaviors that could interrupt their old routines.

Finally, we had to notice how different the results of our in-session problem solving were from their out-of-session efforts, and to ask ourselves why they were different. They recognized that there was little they were not able to do behaviorally if they approached it deliberately and thoughtfully. They had to own the responsibility for doing this work, and they had to recognize the payoff in doing the work, individually and as a couple.

Getting to the Point

The advantage of couples therapy for Meg and Paul was that it made them more responsible and accountable sooner. Their contributions to the problems were noticed and called out in real time. Faster-acting avenues of change became available. My observations were grounded in specific situations. It’s an approach that safeguarded them both and returned our focus to salient themes of reciprocal interaction that underlies their conflicts. Concrete "do’s and don’ts” emerged as takeaways.

They internalized a capacity for assertive problem solving that extended beyond the consulting room and their relationship, and into the workplace. Meg reported less ruminating, guilt and resentment. Paul described a growing sense of confidence and ease in his interactions with Meg. They regressed on occasion and learned how to grow from the experience. They deepened their insight and skills in the process of repairing one or two significant ruptures along the way.

“Disposition does not mean “chipped in stone.”” Their differences in temperament (Paul more laid back and Meg more intense) remained. However, both discovered a greater sense of freedom from the automatic expression of their avoidant motivations. They learned that their reactive tendencies from early life were important to notice (somatically, emotionally, cognitively, relationally). These tendencies were not to be dismissed, denied, or taken as fact; rather, they became valued as warning signs.

I accommodated their sense of practical urgency by anchoring change efforts in concrete behaviors and specific situations. In this way, they were able to more readily see the behaviors that help and hinder realization of their change goals. They learned to appraise and re-appraise their expectations for change against standards of what was realistic and achievable. In the process, they noticed how slowing down for a reflective pause could speed things up. They found reason for hope in these skilled practices.

Concluding Reflections

Each couple is unique, and the helping strategies of their therapists will vary in approach, length of treatment, and frequency and duration of sessions. Having said that, I usually tell couples that it will take us 4-6 weeks to determine if couples therapy is working for them. By then, we’ll have a good idea of what the core issues are and what is required to address them. And we’ll do that by actively engaging the couple in the process, which means they’ll be more able to make informed decisions.

Through early steps of progress in session and practical guidance for change between sessions, they acquire skills and build trust and confidence in the therapist and in each other. Guidance may be more directive in the early phase of therapy, but it becomes more non-directive as positive norms of attitude and behavior take effect. As an easier, less defensive quality of exchange becomes possible, the role of the therapist becomes more that of consultant and coach.

Couples’ gains are sometimes achieved in waves over longer periods of time (6 months or more). For others, significant change, for example restructuring relational dynamics and communications, might occur in 6-8 weeks. And when does it stop? That too varies, but insofar as our work is goal-focused, we are better able to jointly assess how they are doing, what they’ve learned, and when termination or transition to a maintenance schedule might be advisable.

My approach to helping others as a coach and therapist has always been assessment-based and goal-oriented. Goals in this sense represent purposive aims that give meaning to our actions and accomplishments. These are considerations that weigh heavily in the hearts and minds of most professionals. When these “stakes” are called out in terms of the people they want to be and what’s required to realize these aims, I’ve usually gotten their attention. And after a good deal of experimentation with new skills at home and at work, their attention is firmly planted in interpersonal space, knowing more than ever that success at home and at work is about relationships.

I have found that goals and commitments are most robust when they’re grounded in the personal truth we can only obtain from rigorous assessment. That’s why our assessment must be a joint process. Couples must play an active role in interpreting the data that I help them collect, including the patterns of behavior that I help them surface in our sessions. Couples must personally discover the power of meeting in the middle, in that neutral zone of reflection. It is there that defenses melt away and the consequential costs and benefits of change can be seen. In that way, we soon acquire a call to action—“Let’s meet in the middle”—which can give us reason to halt the cycle of escalating conflict and see things as they really are.

References

1. See for example Kuster, M., Bernecker, K., Bradbury, T. N., Nussbeck, F.W., Martin, M., Sutter-Stikel, D., & Bodenmann, G. (2015). Avoidance orientation and the escalation of negative communications in intimate relationships. Journal of Personality and Social Psychology, 109, 262-275

2. Thanks to Kim Penberthy for permission to use her version of the circumplex model: Penberthy, J. Kim (2016). Effective Treatment for Persistent Depression in Patients with Trauma Histories: Cognitive Behavioral Analysis System of Psychotherapy (CBASP). Paper presented at the meeting of Anxiety and Depression Association of America (ADAA) Conference, Philadelphia, PA.

For further information on the circumplex model, it’s history and use, see Horowitz, L., Wilson, K.R., Turan, B., Zolotsev, P., Constantino, M., & Nenderson, L. (2006). How interpersonal motives clarify the meaning of interpersonal behavior: A revised circumplex model. Personality and Social Psychology Review, 10, 67-86. 

Never Talk to a Therapist at a Party

Posted on by Psychotherapy.net Team

Building a successful therapy practice is difficult.

I was reminded of this fact at a recent dinner party. I was perched next to the food table when I struck up a conversation with a therapist friend of mine. Given my interest in the business side of therapy, I asked her about her private practice.

“How’s business going? Do you have enough clients?” I asked.

She instantly looked frustrated and she sighed. “I only had 9 clients this week; I hope business picks up soon!”

I agreed that it can be difficult to find new clients and asked, “Do you have a professional website?”

She shook her head and noted that she wasn’t very comfortable with technology. I sympathized but reassured her that building a website these days was relatively simple, even for those who are uncomfortable with software. Moreover, most web hosting companies offer free templates to design a great looking, professional site. Sites like Wix.com are a good place to start, I offered.

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“Once you have your site built, you should register with Google.”

I explained that all she had to do was create a Google business page and that this would help with her Google page ranking.

At the mention of Google page rankings, I sensed that my colleague was beginning to plan her exit. I quickly changed tacks and told her she could focus on building up her social media presence, as this would give her potential clients different ways to find her online.

“Which sites should I focus on? I don’t have a lot of time since my son was born,” she explained.

I told her to first focus on getting a profile on PsychologyToday.com and creating a business Facebook page. I suggested she could then slowly build up her LinkedIn page and populate it with therapists who could refer clients to her.

“All of these sites are important,” I noted, “but the best way to get new clients is to have positive ratings online. Create a profile on RateMDs.com and ask your clients if they would be willing to rate you.”

I reminded her that potential new clients will feel reassured contacting her if they see evidence that she has helped other clients.

My colleague seemed intrigued, so I carried on. I asked what types of clients she worked with.

“Anxiety and depression mainly. How about you?”

“Yeah, me too.”

I told her that I had struggled at first to stand out, as many of the therapists in my city also worked with anxiety and depression. To rectify this, I took the approach of specializing in working with clients that were challenging, such as those with borderline personality, substance abuse problems and eating disorders. When I would speak with my therapist colleagues, I would give them an easy to remember pitch, “I work with complex clients.” This led to several referrals because many therapists struggled with these types of clients.

I suggested to her that she could try to specialize in a specific type of anxiety, such as phobias. Many therapists advertise their comfort with a variety of mental health issues but when colleagues are considering referring clients, one needs a way of standing out. I told her she needed to keep her branding simple.
“I don’t like thinking of myself as a brand.”

I validated her concern, but I assured her that it was important to consider how you would like to be viewed by potential clients and colleagues. You want to be in control of the narrative, and one way to do that is to have a therapeutic focus that is easy to remember and is consistent across your various websites.

I suggested a few other ideas that she could consider as a way of further differentiating herself from her colleagues. For example, she could advertise her comfort in working with clients from diverse backgrounds, such as LGBTQ or military clients. I also noted that she could offer a better therapy experience for her clients, such as using a therapy management system, like Simple Practice. These types of programs allow clients to easily book sessions online or pay their bills automatically.

Similarly, she could have clients complete an intake questionnaire. This would allow her to get relevant information about clients before the first session, thereby creating a smoother process for the client.

At this point in the conversation, my friend smiled politely, as if to acknowledge how bewildering it all was. I could tell she was ready to get back to the light party banter.

I smiled back, hoping to transmit encouragement and support. I wished her well and turned my attention back to the food table.  

The Masculinity Trap: A Science-Based Response to the APA Guidelines

Posted on by Psychotherapy.net Team

Andrew was a 13-year-old boy who walked into my counseling office with a lot of issues. He had been diagnosed with a learning disorder and ADD, and his parents felt he might be depressed. Like many male clients, he would quickly decide if I as his potential counselor knew how to work with him as a male. If I did not, he would start trying to leave therapy in a few weeks or less.

After normal intake, the first thing we did together was walk outside, talking shoulder-to-shoulder. Because the male brain is often cerebellum-dependent (it often needs physical movement) in order to connect words to feelings and memories, we sat down only after our walk was finished. By then, a great deal had happened emotionally for Andrew.

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Once in our chairs, we talked with a ball in hand, tossing it back and forth, like fathers often do with children. This cerebellum and spatial involvement help the male brain move neuro-transmission between the limbic system and frontal lobe, where word centers are. We also used visual images, including video games, to trigger emotion centers, and we discussed manhood and masculinity a great deal, since Andrew, like every boy, yearns for mentoring in the human ontology of how to be a man.

I’ve seen hundreds of girls and women in my therapy practice. Few of them needed walking, physical movement and visual-spatial stimulation to help access memories, emotions, and feelings because most girls are better able to access words-for-feelings than boys and men are while sitting still. Girls and women have language centers on both sides of the brain connected to memory, emotion, and sensorial data, while the male brain mainly has word centers and word-feeling connectivity on the left side.

Without our realizing it over the last fifty years, we’ve set up counseling and psychological services for girls and women. “Come into my office,” we say kindly. “Sit down. Tell me how you feel/felt.” Boys and men fail out of counseling and therapy because we have not taught our psychologists and therapists about the male and female brain. Only 15% of new counselors are male. Clients in therapy skew almost 80% female–males are dragged in by moms or spouses, but generally find an environment unequipped for the nature of males.

Male nature, the male brain, and the need to contextualize boyhood into an important masculine journey to manhood are missing from the American Psychological Association’s new “Guidelines for Psychological Practice with Boys and Men.” While the document calls attention to male developmental needs and crises in our culture, which I celebrate as a researcher and practitioner in the field, it then falls into an ideological swamp.

Males, we are told, are born with dominion created by their inherent privilege; females (and males) are victims of this male privilege. The authors go further to discuss what they see as the main problem facing males—too much masculinity. They call it the root of all or most male issues including suicide, early death, depression, substance abuse, family breakups, school failure, and violence. They claim that fewer males than females seek out therapy or stay in therapy and health services because of “masculinity.” Never is the skewed female-friendly mental health environment discussed. The assumption that all systems skew in favor of males, not females, is so deeply entrenched in our culture today, the APA never has to prove it.

Perhaps most worrisome, the APA should be a science-based organization, but its guidelines lack hard science. Daniel Amen, Ruben and Raquel Gur, Tracey Shors, Louanne Brizendine, Sandra Witelson, Richard Haier, Laurie Allen, and the hundreds of scientists worldwide who use brain scan technology to understand male/female brain difference do not appear in the new Guidelines. Practitioners like myself and Leonard Sax, MD, PhD, who have conducted multiple studies in the practical application of neuroscience to male nurturance in schools, homes, and communities are not included.

Included are mainly socio-psychologists who push the idea that boys and men are socialized into “masculinities” that destroy male development. Stephanie Pappas on the APA website sums up the APA’s enemy; “Traditional masculinity—marked by stoicism, competitiveness, dominance, and aggression—is, on the whole, harmful.” Our job as therapists, the authors teach, should be to remove all but the ideologically sound “masculinities” from boys and men, and specifically remove masculinities that involve competition, aggression, strength, and power.

How much longer can our society and its professionals pretend we are developing a saner society by condemning the very parts of males that help them succeed, heal, and grow? In the same way that it is misogynistic to claim femininity is inherently flawed, it is misandrist to claim that masculinity is also thus.

And it is just plain wrong. Stoicism, aggression, self-reliance, and strength are helpful to human growth, healing, and self-development. Steven Pinker recently made this point when he asked the APA to revise its Guidelines, and put to rest “the folk theory that masculine stoicism is harmful.” And, a new study published in January 2019 in Psychology of Men and Masculinities, echoes Pinker, showing that boys and men who adhere to masculine training do better in life, are happier, and become better husbands, fathers, and partners.

I am an example: I was a sexual abuse victim in my boyhood, and a very sensitive boy. My ten years of healing from the abuse came as much from tapping into masculine strength as it did from expanding my sense of self in the 1970s toward the feminine. Both are good; neither is zero-sum, but I could not have healed without the very masculinity Pappas finds suspect.

Part of the problem with the APA guidelines is that, from a neuroscience point of view, masculinity is not as limited as Pappas’ assessment would have us believe. Masculinity is a social construct made of biological material, an amalgam of nature, nurture, and culture that forms an ontology in which a male of any race, creed, or ethnicity commits to developing and exercising strength, perseverance, work, love, honor, compassion, responsibility, character, service, and self-sacrifice.

What professional in the psychology field would not want to embolden these characteristics? Most fathers and mothers would want counselors to embolden them because, as the APA authors themselves point out (somewhat unaware, I think, of their self-contradiction), fathering and mentoring boys in masculine development has been proven among the most important determinants of child safety, school success, and emotional and physical health.

Not the erasure of masculinity but the accomplishment of it is required if we are to save our sons from the crises outlined in the APA guidelines. Without counselors and parents understanding how to raise and protect brain-based masculine development, boys like Andrew drift in and out of video games, depression, substances, half-love, and, often, violence.

As all of us in our profession know, the most dangerous males in the world are not those who feel powerful but, rather, those who feel powerless. “Toxic masculinity” is a convenient academic avenue for condemning males who search for strength, healing, and love by conflating things bad men do with an ontology that is necessary for human survival and thriving.

The masculine journey is not perfect and expanding what “masculine,” “male power,” and “man” mean to a given family and person is a point well made by the APA authors, but trying to hook mental health professionals into this ideological trinity of false ideas—

*masculinity is the problem, always on the verge of toxicity
*males do not need nurturing in male-specific ways because men have it all in society anyway; and
*masculinity is not an ontology, a way of healthy being, but a form of oppression,

—ignores one of the primary reasons for the existence of our psychology profession: not just to help girls, women, and everyone on the gender spectrum be empowered and find themselves, but also to help boys and men find their strength, their purpose, and their success in what will be, for them, a complex male and masculine journey through an increasingly difficult lifespan.

Sources:

Amen, D.G., et.al., “Women Have More Active Brains Than Men." August 7, 2017 Journal of Alzheimer’s Disease

Halpern, D.F., et.al., “The Science of Sex Differences in Science and Mathematics.” Psychological Science in the Public Interest. August 8, 2007

Burman, D., et.al., "Sex Differences in Neural Processing of Language Among Children." March 2007. Neuropsychologia

Benedict Carey, “Need Therapy: A Good Man Is Hard to Find.” New York Times. May 21,2011

APA Guidelines for Psychological Practice with Boys and Men

Stephanie Pappas, “APA issues first-ever guidelines for practice with men and boys.” APA Monitor. January 2019

Steven Pinker. Male Psychology: What is Wrong with APA’s Masculinity Guidelines.

Psychology of Men and Masculinities

Coalition to Create a White House Council on Boys and Men’s meta-study

Embracing Chronic Anger: A Prescription for Disempowerment

Posted on by Psychotherapy.net Team

“I’ve had a problem with anger all of my life… at work, in my relationships and everywhere in between. I was court referred because I assaulted a guy at a bar when I was drunk. That’s how I got this (pointing to the cast on his left wrist). I also took a class five years ago because I had slapped my wife. But she dropped the charges. In the past ten years, I’ve been married twice. I know my anger contributed to my divorces and I really don’t want to lose my current girlfriend.”

Anger Chose Him

Keith, a participant in one of my anger management classes, introduced himself in a deep, resonant voice. As an anger management specialist, I have offered these classes for over thirty years, with participants who have been self-referred as well as referred by their workplace, partners, friends and the courts. They have included individuals from various socio-economic levels, including professionals, blue-collar workers and students ranging in age from eighteen to seventy-five years old. Surprisingly, Keith became increasingly candid throughout the first session.

“You know, there are times I feel like maybe I was just born being angry. My father had a lot of anger too. So did his father. Maybe it’s just in my genes.” Keith described a life of chronic anger–anger that was frequent and pervasive, evidenced in his workplace, personal relationships and daily life. It entailed anger arousal not just as a situational reaction to a specific triggering event, but reflective of a general predisposition to hostility. Chronic anger encompasses “trait” versus “state” anger, which is more situational and short-lived. And like others who report issues with chronic anger, “Keith described his anger as if it chose him”, as if he was the victim of his anger and did not have free agency to choose it.

Keith, like others with chronic anger, views the world through a filter constricted by his anger. This filter inhibits self-reflection and access to more rational thought. And, like others with chronic anger, his narrowed vision, along with the rigidity of his reactions, saps his capacity to genuinely satisfy his desires and needs.

It appeared that disappointment in his life, coupled with an increased curiosity about his anger, enhanced his motivation for further exploration. The most recent arrest and being almost 40 years old also provided an impetus for his seeking help. As I later learned, he was also dealing with his father’s death two years before. Keith seemed increasingly committed to his desire to change, reflected in his active participation in the class as well as his request for individual therapy upon completing the course.

Keith, like others who exhibit chronic anger, appeared to embrace it as a core aspect of his identity. Chronic anger became a major aspect of his inner sense of sameness and continuity over time.

A Word on Identity

Consciously cultivating our identity requires that we answer the following questions:
“Who am I?” “What is my purpose?” “What kind of individual do I wish to be?” “What gives me meaning?”

Many of us fail to ask these questions of ourselves. Absent such reflection, we may subsequently become subject to a “script”, one that is defined for us by others. This script becomes the blueprint for the structure of our lives. It provides the guidelines for how we live, informing habits in how to think, feel and behave. And each time we practice these habits, we reinforce the connections in our neuronal pathways in ways that only increase our propensity for them. For this reason, it may require some life-altering event to prompt us to more fully examine what we are doing.

The self-reflection required to address these questions pits us against our fears, our sense of self-worth, and our difficulties in making decisions and choices and committing ourselves to them. Such reflection also moves us to address barriers we create regarding the opinions of others—those voiced by others as well as those we hear from the imaginary audience in our minds. It is then understandable that we may seek distraction from engaging in this daunting task–through our work, the immediate demands of our daily lives, our relationships and even our addictions. Embracing chronic anger as a major component of our identity may yet be another form of bypassing this intensely difficult challenge.

Chronic Anger

Anger, a natural emotion, stems from a perceived threat to our physical or mental well-being. Additionally, it’s a reaction to and distraction from uncomfortable negative feelings that precede it–feelings such as shame, guilt, rejection, powerlessness, inadequacy or devaluation. I’ve come to view anger, like other symptoms we may encounter, as originating from an initial impulse of self-compassion–an attempt to alleviate our suffering. Such anger hijacks our attention away from our our internal landscape and in effect offers us a temporary reprieve from enduring the intense suffering caused by these more uncomfortable feelings.

When managed in a healthy manner, we’re able to pause to take the time that is essential for understanding our anger–whether regarding our feelings behind it, our expectations or our key desires and needs. Anger can empower us to seek constructive ways to satisfy our desires and needs. It can fuel healthy assertiveness that moves us to act in ways consistent with who we are and who we wish to become.

By contrast, destructive anger moves us further away from satisfying our core desires and needs. It can lead to poor work performance, a stalled career, relational conflict, social isolation, depression, excessive guilt or shame and even the loss of one’s freedom. Additionally, extensive research shows that anger can contribute to illnesses like heart disease, high blood pressure and even back pain.

Chronic anger is one form of destructive anger. For some of us, such anger serves as psychological armor, intended to protect us from the sting of our inner pain. Such anger can be viewed as a form of “experiential avoidance,” as described by Stephen Hayes, and involves the suppression, minimization and denial of our feelings.

It is against the lack of a solid identity that individuals with chronic anger may be characterized as embodying a “negative identity,” described by Erik Erikson as an identity in opposition to what is expected of them. Lacking self-awareness and the self-reflection essential for such awareness, their default is to react. They may gravitate toward this resolution when they believe the roles their parents and society expect them to fulfill are unattainable. The psychological underpinning of this stance is reflected in the attitude “I don’t know whom I wish to be, but I certainly don’t want to be like you.”

Unfortunately for Keith and others, embracing chronic anger was a formula for disempowerment that only strengthened the tendency for anger arousal. And for Keith, like others with chronic anger, it appeared to be an outgrowth of aspects very much consistent with a negative identity.

Chronic anger has many forms. It’s reflected by the quickness to experience anger in daily life, in one’s relationships and especially with authority. Chronic anger appears in the numerous comments on the Internet, statements of opinion that are predominantly expressions of anger rather than rational argument. Such anger impairs the capacity to be civil, open, understanding or compassionate with others and ourselves. “It is a cataract that clouds our vision to the possibilities of looking for and noticing the positive in others and in ourselves”.

Chronic anger promotes disempowerment, which only furthers the propensity for anger. It undermines taking responsibility for our own lives. In doing so, it constricts the range of possibilities and minimizes the freedom for personal evolution and life fulfillment. It’s so much easier to blame others or circumstances for a difficult or painful situation and by doing so, renounce all our power to help alter our situation. In the process, however, we only further bolster our sense of victimhood. Even when others have truly contributed to our pain, embracing chronic anger may serve to protect us from the hard work of identifying and choosing alternative courses of action.

It then makes sense that individuals with chronic anger may resort to drug or alcohol use, or blame or hate others for their own misery. Certainly, such anger might foster or be a symptom of depression, especially when it is self-directed.

Furthermore, this vicious cycle of chronic anger and disempowerment fuels pessimism that inherently diminishes the capacity to envision a future without anger–a future that holds greater happiness, meaning and fulfillment. And, further, it undermines the capacity to develop an identity marked by greater individuation and resilience.

Like so many symptoms we observe in our clinical work, chronic anger is most often rooted in wounds–deeply felt hurt and trauma that have not been fully acknowledged. It is often a reaction to emotional or physical abuse, neglect, or loss. And while some studies suggest a genetic influence, as with much of personality, nurture helps determine whether these genetic predispositions are expressed. And while such anger may also originate with experiences in adulthood, being prone to chronic anger further strengthens it as a go-to reaction.

All too often, childhood trauma forms the underpinning of chronic anger. It may lead to a global sense of shame and accompanying feelings of inadequacy about oneself. This sense of shame is often the overriding and paralyzing feeling that creates a block to trusting one’s own thoughts, feelings or actions. These feelings then further weaken the capacity to engage in thoughts and behavior that would be essential for a more authentic choice in creating and living one’s identity.

The Case of Keith

Keith shared a history of physical abuse, occasionally being slapped or paddled by his father for his “bad” behavior. Like others with issues surrounding anger, he tended to minimize and deny the impact of these earlier experiences. And in doing so, he cut himself off from the range of feelings that surround such abuse. Unfortunately, a child in pain needs compassion and empathy from a caring parent but is unable to obtain it when a parent is the cause of that pain.

Keith learned to ignore his suffering by blaming himself for how he was treated. He experienced shame regarding his behavior but, more importantly, and without awareness, he experienced tremendous shame regarding the slightest surfacing of anger toward his father. As such, Keith, like others with early wounds, could describe the circumstances of early wounds as a matter of fact, but was unable to regard them as wounds–let alone be more fully in touch with the underlying emotions associated with them. “It didn’t hurt that much.” “I think I deserved it.” “That was how most parents disciplined their kids.” “I certainly wouldn’t call it abuse.”

Like others who have experienced such abuse and like many with chronic anger, these are just a few of the ways that Keith protected himself from experiencing his hurt and anger. This fear of experiencing anger with his father simply continued into his adulthood. Consequently, Keith had little awareness of how his earlier interactions and related wounds influenced his anger. “My father was a marine. He was always intensely demanding and perfectionistic. He constantly interrogated me, questioning me to justify myself, why I thought this or why I did that. He had little patience for pain or for a difference of opinion.”

Keith also revealed that if anything, he was angry with himself for not measuring up. This conclusion further informed his sense of shame and inadequacy. It’s important to note that, for Keith and others like him, chronic anger served as a powerful distraction from anger that was originally self-directed. While his father was perfectionistic and highly critical, his mother was distant and not available to help protect him or validate his pain. “She was quite anxious, quiet in general, and maybe depressed, I’m not sure. I know she was fearful of my dad. She always avoided conflicts and disappeared when they arose.”

Keith’s reported that his mother was closer with his younger sister who was rarely the target of his father’s anger. His ambivalent feelings toward his mother would only later become more apparent. His parents were divorced when he was in middle school and his father remarried within a year. Only then did Keith experience some relief, as his father became preoccupied with his new wife and stepchildren.

Keith reported that during this time, he experienced a growing distance from his parents and a sense of disorientation regarding his future. He described himself as kind of “floating” throughout high school. His tendency to be angry with teachers competed with any academic interest and, subsequently, his motivation to do well in school. Lacking a more solid connection with himself, he was unable to emotionally invest either academically or in his relationships.

“Like others with chronic anger, Keith was especially sensitive to criticism in many situations”, especially those involving authority. Clearly, his early interactions left him with an increased sensitivity for perceiving threat. As he candidly admitted, his tendency toward conflicts with authority undermined his ability to succeed in school and work and his capacity to maintain friendships. “I really wasn’t motivated in school and only did the minimum to get by. I spent most of my time playing video games, hanging out with friends, and I smoked marijuana often, beginning in my freshman year.”

Keith went to college for two years, primarily because he had no idea what he wanted to do, and his father had promised to pay the tuition for the first two years. His motivation and focus hadn’t changed during this time. While he occasionally dated, his quickness to have conflicts interfered with his developing any ongoing relationships. Unlike Keith, there are certainly individuals with chronic anger who are motivated to achieve, both academically and in their pursuit of a career. For some, the full impact of their anger may not surface until they are more involved in relationships, whether personal or work related.

Keith quit school after two years and his father suggested that he join him in a property management business, but Keith knew he could never work with him. Instead, he became a realtor, primarily motivated by his belief that he could make easy money with minimal effort. Within a year, he realized that he had little patience for dealing with the clients. After that he held a variety of jobs. He gravitated toward working with computers and by the time he enlisted in my anger management class, he had been working for several years in IT.

Keith also indicated a growing anger in recent years regarding the government. He complained a great deal, even commented on the Internet, but never demonstrated his anger in more aggressive ways. He didn’t consider himself an activist but he found himself also spending a good amount of time online, following the angry chatter of various groups.

Facing the Demon

Keith represents a small fraction of men with chronic anger who ultimately seek help for their anger. I view the courageous decision to seek therapy, although prompted by pain, as stemming from self-compassion–a desire to alleviate one’s pain. And while Keith had learned to renounce his need for such compassion, he sought help when he more fully recognized how anger contributed to his suffering.

Keith had grown to view the need for compassion as reflecting weakness and as threatening to his masculinity. He had learned to believe that being a “real” man involved cultivating an identity devoid of needing such compassion. However, ignoring his need for compassion further undermined his capacity to be more fully present with his feelings, in general, as well as with his underlying desires.

When we are truly compassionate and connected with ourselves, we know how we feel, recognize our key desires, and feel anchored in an identity that provides stability with flexibility to be open to both our thoughts and feelings. By contrast, the lack of such compassion and self-reflection can make us vulnerable to self-doubt. Keith’s lack of access to his feelings reduced his capacity to notice or be compassionate to the pain reported by his partners. This is very much consistent with individuals with chronic anger and was reflected in Keith’s description of a recent anger episode with his girlfriend.

“She’s always criticizing me. She’s always telling me that I don’t care for her–like I can’t do anything right. The other day she described a conflict she had with her supervisor. After listening, I told her that maybe her supervisor was right. I mean–based on what she told me–I could see his point of view.” It became evident that Keith was more concerned with facts than with feelings. His focus on facts competed with his capacity to be empathic with his girlfriend. Understandably, validating the supervisor’s criticism was experienced by his girlfriend as a demonstration of his empathy–with the supervisor. The argument escalated with Keith cursing and demeaning her. It ended by his leaving the house for a few hours, an evening of silence upon his return and then, the next day, gradually resuming their relationship as usual.

Consistent with his experiences in past relationships, if he couldn’t “fix” his partners’ problems, he would soon experience an overwhelming feeling of inadequacy. In effect, in his personal interactions, Keith re-experienced the feelings of inadequacy as well as his self-doubts triggered in his earlier interactions with his father. Additionally, he carried into his relationship the anger he had also experienced toward his mother for her lack of availability.

“The tendency to be vulnerable and to feel controlled is part of the fallout of not living a life grounded in self-connection”. A more mature identity allows us to hear opinions that stand in opposition to our own, living a life based on an identity of anger leads to hypervigilance to protect ourselves from self-doubt and feeling influenced by others. Others’ opinions may be experienced as threatening and viewed as overbearing and controlling. It is then no surprise that individuals with chronic anger feel isolated. And it is equally understandable how such anger promotes distrust that only strengthens the avoidance of genuine intimacy.

Keith had embraced this perspective for much of his life. The more he reacted to others in this manner, the more he cultivated his sense of victimhood and, in turn, had become more prone to anger arousal. His flight from responsibility was similarly reflected in our work together, most poignantly in his initial hesitation to actually practice the skills essential for cultivating healthy anger.

Part of my approach is to have clients complete an anger log, a structured journal that helps them review an anger-provoking episode and their thoughts and feelings related to such events. The log specifically asks them to identify feelings that immediately precede their anger, the knee-jerk conclusions they make about the event, expectations they may have held before the event occurred, body sensations and key desires that feel threatened by the event.

I advocate completing the log to review as many events as possible. Doing so promotes emotional intelligence not only regarding the reviewed event, but also fosters increased mindfulness to reactions for future events. Furthermore, completing the form helps to foster emotional awareness of one’s unique “hot buttons”–personal sensitivities regarding specific desires and the past experiences that intensify their current reactions. And, as always, “I emphasize that overly intense anger most often is a residual reaction to events of early wounds”. This is poignantly highlighted when I help them recognize that “It’s happening again!” is just one of their immediate responses to a triggering event. “At that distinct moment, it is as if your emotional brain is recalling all past hurts that are in any way similar to what you are currently experiencing. This is the power of global thinking and feeling.”

I emphasized with Keith that our global emotional mind has nothing to do with our age, intelligence or even our more rational thought. It is a part of us that, without our awareness, may override our rational mind as it impacts our thinking and behavior. Completing the log serves to offer psychological distance to the experience and fosters the cultivation of the “observing self” or “witness.” This strengthens one’s ability to not feel overwhelmed by such thoughts and feelings.

Keith repeatedly did not accept this recommendation. I suggested that it would be beneficial to understand what interfered with his completing the logs. I asked if he experienced my suggested assignments as controlling. His knee-jerk response was to deny this but after a pause he then admitted, “Maybe a little.” I then responded, “That makes perfect sense–to your emotional mind. You grew up with tremendous anxiety about expressing yourself. Understandably, you experienced safety by trying to avoid conflict with your father. Your inhibitions in expressing yourself contributed to feeling controlled.”

During the following session, I asked Keith if he was open to doing an exercise. He agreed. I then handed him a blank anger log. “Make yourself physically comfortable. Look at the anger log. Imagine that you are seated where you might be completing the form. Hold the pencil to the paper without writing anything. Now, think of an event that you would review if you were to complete the log. Do that for a few moments. Now, shift your attention from the event to what you are experiencing regarding writing it. What physical sensations are you experiencing? Are you feeling calm or tense? What are your thoughts about this task?”

Keith paused for a moment to reflect. With little hesitation, he answered, “Yeah. I guess I’m angry that I have to practice these skills while others don’t have to…others had it easier. They most likely didn’t go through what I went through.” I fully acknowledged and validated this belief that, yes, others may have had it easier in so many ways. And, yes, they may not have to do these exercises to better manage their anger. And, yes, engaging in this work arouses uncomfortable feeling regarding previous wounds and hurts. I then emphasized that he could choose to stay resentful and hold on to his anger or he could take steps to change, with the potential of having a more fulfilling life. Additionally, I highlighted to him that how we manage anger involves habits in our thoughts, feelings and behaviors–habits which he can change, but only with patience, commitment and practice.

Keith’s recognition of irritation with this task presented another opportunity to discuss mourning and grieving for what he didn’t have and felt he should have had. Much of anger is about this discrepancy. As part of such mourning, I encourage clients to find a picture of themselves at an earlier age. Over time, when they are ready, I help them recall the earlier suffering of that younger self. I help them work toward being able to fully express themselves as that younger version and say things like, “It made perfect sense that you suffered, were confused and even angry with your parents,” “How you were treated was not your fault” and “I’m sorry I could not help you.”

Such mourning and grieving is an ongoing process that in many ways never ends. Rather the rawness of such experiences just becomes more emotionally muted. Through our work together, “Keith increasingly began to develop a deeper connection with himself, his feelings and his thoughts”. He became more alert to his tendency toward anger and increasingly recognized it as a signal to direct his attention to self-reflection rather than act it out. He reported one incident, having to do with a homeless person that very much reflects this growth.

“You know that homeless guy who is always on the corner. I’ve always been annoyed when I walk by him. In the past, I’d usually tell myself that he was just lazy and that he should get a job. I started to think about that. I think that I was just feeling inadequate about not being able to fix him or others like him. I also reacted to feeling he was needy, a feeling I’ve always felt uncomfortable acknowledging in myself. There’s a lot in there!”

Keith continued with therapy and gained a variety of strategies to better understand and manage his anger. He expanded his compassionate self sufficiently to recognize and admit some of the hurt he had experienced that contributed to his shame and related anger.

As often happens when treating chronic anger, improving his ability to more constructively manage his anger reduced his motivation to more poignantly mourn and grieve his childhood. However, processing the loss of his father led him to attend to his earlier years. He became increasingly able to tolerate mixed and ambivalent feelings, essential for dealing with his complex relationship with his father.

Keith demonstrated progress in that he reacted with anger less frequently and it was shorter in duration when it did occur. At one point, Keith reported that he was pleased with his improvement and that he needed to take a break. Additionally, he was also able to recognize that spending more time on grieving and mourning had been very difficult for him.

Keith returned a year later, prompted in part by an anger-arousing episode that had surprised him. While he had continued to make progress, the event had pushed hard on one of his hot buttons. It was a reminder that learning new habits requires commitment, practice and patience.

Anger in Our Culture

It’s difficult to discuss chronic anger within the therapy session and ignore the larger expressions of chronic anger that we are witnessing in society. As previously indicated, we see evidence of such anger in statements made on the Internet, supported by anonymity and increased cultural support to “tell it like it is.” We see it on newscasts revealed by the “talking heads,” each predominantly focused on getting their points across rather than having a real discussion. Clearly, the media reflects our culture, but, unfortunately, it may only further influence those who already are defined by their chronic anger–just as violent videos have been shown to have an impact primarily with adolescents who are already prone to anger.

Additionally, we see increased evidence of anger as identity as the foundational core of the hatred of the “other”, those who may be different than us–whether regarding race, religion, ethnicity, gender or sexual orientation. A moment of intense anger brings with it a tendency to demonize the other. However, when chronic, it can lead to more fully dehumanizing them as well.

Furthermore, chronic anger may foster the belief that one’s happiness can’t be achieved because of one’s very existence. It is this rigidity of identity that gives far too much power to others and distracts those with such anger from the work required to explore and identify choices that can help them to feel and become more empowered. And far more serious for all of us, are individuals who associate with others with the same tendencies or, even on their own, promote activities to teach others a “lesson.” These facts only highlight the challenge we face as clinicians dealing with chronic anger.

Holding on to anger is often rooted in the need to protect ourselves from being hurt again as well as re-experiencing our past suffering. This is especially the case when this mindset becomes the foundation for one’s identity. So, while anger management strategies that focus primarily on behaviors and current knee-jerk thoughts can be effective, moving past chronic anger as one’s identity requires going deeper. It calls for helping individuals recognize and sit with the pain of grieving and mourning their past wounds. It requires that they become a witness to the suffering of their younger selves if they are to be able to live more fully and with greater emotional access in the present.

Dealing with chronic anger, as when dealing with so much of our client’s suffering, involves our sensitivity to dosage–sensitivity to the protective nature of symptoms, the degree to which they have become a part of a client’s identity and, of course, to their openness to change. For this reason, many individuals with chronic anger will never seek our services. Consequently, clinicians who address chronic anger may need to play a more active role as advocates for education and understanding of chronic anger in the courts, correctional facilities, substance abuse programs and schools.

One of my personal challenges as a therapist working with individuals with chronic anger is to “always be alert to look beyond the anger to the pain that it masks”. So, at any given moment within a session, I need to be mindful to be empathic with my client even when I find myself also focused on the pain they may cause for others. Such moments require my own comfort with anger and remembering the powerfully cohesive force that chronic anger may have in helping them to maintain their identity.     

Digital Technology and Parenting:

Posted on by Psychotherapy.net Team

As a trauma therapist I am always interested in learning about my clients’ childhood attachment patterns. Growing up with parents who were either emotionally unavailable, inconsistently responsive, frightened by or frightening to their child has a profoundly negative impact on social, behavioral, emotional, and neurological development. “Trauma-informed care” includes assessing for adverse childhood experiences and reframing clients’ subsequent “symptoms” and struggles as the inevitable by-products and coping strategies of attachment trauma. However, I am concerned that a newer version of attachment trauma has invaded even the most “loving” families. Our reliance on, and, in some cases addiction to, digital gadgets and technology has hijacked the face-to-face parent-child interactions that are necessary for consistent, sustained and secure attachment.

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Is this scenario familiar? After standing in line at the post office for fifteen minutes—a somewhat inherently traumatic experience in and of itself—I witnessed a two-year-old having a complete meltdown. Her mother’s immediate response was to hand her an iPad. In her wisdom, the child initially rejected it. In a soothing yet frustrated tone, the mother said “Use your iPad! Do you want to look at pictures? Play a game?” The child was not appeased and continued to wail. As the woman bent towards the stroller, I felt a sense of relief, assuming she was about to pick up her dysregulated child. Instead, she turned on the tablet and said with greater agitation, “look at the pictures on your screen!” After several more minutes of crying, the child realized that what she wanted and needed—to be comforted by her mother, not an inanimate object—was not going to happen. I watched as she went into collapse, emotionally shutting down and compliantly staring at the screen.

Believing her baby was now soothed allowed the embarrassed mother to comfort herself with a cellphone, tapping and swiping until it was her turn to buy stamps. In essence, they were two strangers in line together. I have seen similar scenarios countless times: in airports, malls, restaurants, and my waiting room. Preoccupied parents entranced as they stare at their iPhone, seemingly oblivious to their child’s needs. They are content to use digital gadgets as pacifiers and babysitters. They are not only modeling the excessive use of cellphones, tablets, video games, and laptops, they are actually encouraging their children to be just as hypnotized, and potentially, addicted.

At the risk of sounding old fashioned and judgmental, I believe this phenomenon is worrisome. Eye gaze, appropriate loving touch, and soothing words are the hallmark features of secure attachment. In families where there is abuse or neglect, these experiences get weaponized. Eye contact becomes a vehicle for threat or intimidation, or the neglecting parent avoids eye gaze, leaving the child feeling demeaned or invisible. Touch is either physically abusive, sexually inappropriate, or unavailable to the child. Words are bullying, shaming, hypercritical or lacking in love or support. This is why caretaker perpetration is such a betrayal and profound breach of trust.

But those three critical resources for attunement are also lost when a child is offered a screen rather than the loving and grounding experience of an available parent, which makes them feel safe, calm and connected to others. It may seem unfair to associate abuse or neglect with the disconnect that happens when a child is comforted, distracted, or cajoled by a digital appliance. But what is the long-term toll it takes on healthy attachment, affect regulation, and socialization skills? Mental health researchers and therapists alike need to assess for and explore that impact, as digital technology is not going away. Questions to consider:

  • Are kids with excessive exposure to digital gadgets less comfortable with face to face interactions and more likely to struggle socially?
  • Is it harder for them to read and accurately interpret nuanced facial expressions and body language?
  • Do these kids have a healthy ability to regulate their fluctuating or overwhelming emotional states?
  • Are these kids less likely to use relationships for soothing and comfort, and more likely to numb with endeavors that are hypnotic or dissociative?
  • Despite growing up in families that are well-meaning and financially secure, are these kids actually experiencing avoidant or insecure attachment?
  • And if they are, will they struggle with the same emotional fall-out and symptomatology as abused or neglected kids?

Since technology has made our lives much easier and resources more accessible, stakeholders may be reticent about tackling this issue head-on. I believe it is our ethical responsibility to address these dynamics with the families we treat. We must empower parents to set much stricter limits on screen time and to reconnect with the relational, face-to-face-benefits of parent-child time and family time. Many kids and teenagers need to be weaned from their overuse of digital gadgets—a kind of digital detoxification—so that they can reconnect with peers and re-access their own imaginations.

For traumatized clients, the reparative experience of secure attachment often happens within the therapeutic relationship. Therapists may need to be more mindful of addressing this issue with kids who have been overexposed to digital gadgets as a resource for comfort and soothing. They should keep technology out of the therapy room and model attunement, eye gaze and appropriate words and touch so that kids and parents alike can rediscover the power of relationship. Otherwise, the next generation risks losing the ability and the desire to be fully present with others and fully engaged in the world. 

Goldilocks and the Three Couches: Finding Your Own

Posted on by Psychotherapy.net Team

Not that anyone is necessarily keeping track, but this week marks the one-year anniversary of my relationship with Psychotherapy.net as its editor. I want to thank Victor Yalom for the opportunity, although I confused him with his father during our first phone contact. Sorry, Victor. I want to thank the able and creative staff of Psychotherapy.net for welcoming me and helping me to take ownership of this complex, but deeply rewarding position. It comes at a time in my career where I find myself at the intersection of three roles-author, clinician, and counselor-educator.

I am deeply appreciative to all of those authors, clinicians, and educators out there who have shared their stories, beliefs, and challenges along the way to becoming their best selves. To those who have written blogs, articles and have allowed me the privilege of interviewing them, I want you to know that your thoughtful contributions have been important and received by an eager audience of clinicians at all levels of training, across all theoretical disciplines and around the globe.

In the course of reviewing, editing and moving those many fine contributions forward, I am struck by the parable of Goldilocks, or was it a fairytale, I do get the two confused. Some of you have fallen into the soft welcoming couch of a particular theoretical model and have never looked back as you have become the best possible practitioner of that model that you can be. Certainly, there are seductive advantages and unpredictable disadvantages to comfort and certainty. Thomas Szasz suggested that many of us choose security over freedom. Others of you choose freedom, and whether you call it prescriptive, integrative or eclectic, are restless wanderers, forever seeking out that model, that technique, that strategy that is just the right fit. There is an equally palpable price that people pay for freedom. And finally, some of you have dedicated your careers to searching, changing and finally comfortably settling into that therapeutic couch that is just right, personally and professionally.

I thank you all and applaud you all and look forward to our shared journey together.

Lawrence C Rubin, PhD, ABPP
Editor, Psychotherapy.net

Bilingualism as a Necessary Clinical Competence

Posted on by Psychotherapy.net Team

The majority of people in the world speak more than one language, but in the United States people have primarily been monolingual. This may not be sustainable. Technology, mobile dominance, the internet, economic growth, and globalization have reconstructed our social sphere, exponentially amplifying social interaction between continental and national borders. In unprecedented ways, our world has transformed into a diverse multicultural and multinational global hub that is increasingly interconnected. An essential aspect of this global diversity includes an estimated 7,105 living languages¹. Of the more than 7 billion people on our planet, the largest portion, approximately 1.2 billion people, are first-language Chinese speakers, followed by Spanish, English, and Hindi. Countless interactions between speakers of these and many other languages happen daily, and predictably, this has steadily increased demand for bilingual psychotherapists.

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Despite the anti-immigration rhetoric prevalent in Washington, many non-English speakers continue to enter the country. In our age of technological boom and globalization, it is increasingly vital for psychotherapists to not only learn a second language but also to consider the unique and subtle implications of language differences and how an individual’s linguistic roots transect with their geographic location.

Psychotherapy, as taught in graduate programs nationwide, has recognized the need for therapists to address spirituality, religion, race, gender, ethnicity, class, gender, and sexual orientation. However, our field has only recently begun to widen its lens to address language in more depth. Language training will increasingly be not only relevant but also central in psychotherapy training curriculums as globalization, diversity, and intersections across national borders accelerate.

Psychotherapists are frequently in contact with clients whose first language is not English. The profound need for therapists to be able to communicate with non-English speaking clients already exists and is poised to expand exponentially. The most prominent language spoken in the United States after English is Spanish. Although a few graduate programs have integrated Spanish language training into their curriculum, not many recognize that this is a growing need². Currently, language training is considered supplemental, but now more than ever it must become more fundamental to training to keep up with where the world is heading.

One specific population I am passionate about working with is Spanish-speaking immigrants. They are the largest and most rapidly growing ethnic group in the United States. Not only do they underutilize mental health services, but they also tend to have high rates of mental health problems like trauma, domestic violence, depression, substance abuse, and family separations due to immigration restrictions. Research also suggests they tend to seek psychotherapy less frequently and tend not to view talk-therapy as a viable way of meeting their mental health needs, despite its demonstrated effectiveness across multiple studies, including meta-analyses.

Between 2011 to 2013, I completed my Master’s in International Counseling Psychology at the Mexico Campus of Alliant International University. I learned Spanish as I was completing my practicum in Mexico City, practicing solely with Spanish-speaking clients as well as speaking Spanish during class and supervision. We often discussed the nuances of the language differences and how they affected our work with clients, for better or worse. Toward the end of the degree, I completed a research project that covered this topic in greater depth³.

To briefly summarize, we found that in many instances participant clients described language differences as a non-issue, which should be encouraging to you, reading this, if you are considering strengthening your bilingual skills; you do not need to master a second language to make a difference.

Clients who are dominant in any other language than English are often honored by sincere and diligent attempts on the part of the clinician to learn their language. And, according to clients’ self-report (which may have been contaminated by wanting to please us, referred to broadly as research demand characteristics), language differences had unexpected clinical benefits, such as equalizing inherent power dynamics in therapy and strengthening rapport and collaboration as therapists and clients work to understand each other despite significant language differences. Predictably, in some ways, the language limitations of the therapists were also challenging and were related to clinical difficulties that we needed to creatively address with clients, such as not feeling understood by their therapists who were learning Spanish and psychotherapy simultaneously. Fast forward to today, my training has paid off; I work part-time at a non-profit called Palomar Family Counseling Service located in Escondido, California, with Spanish-speaking families.

Aside from broadening your opportunities as a psychotherapist and our field keeping up with our changing times, learning Spanish is a profound act of social justice: you can be the one decreasing the dire paucity of effective bilingual services as we take on the increasingly diverse mental health needs and challenges of clients whose languages and world views are different from ours.  

(1)  Paul, Simons & Fennig, 2013, Ethnologue: Languages of the world. Dallas, TX: SIL International.

(2) Platt, 2012, A Mexico City based immersion education program: Training mental health workers for practice with Latino communities. Journal of Marital and Family Therapy

(3) Linder, Platt, & Young, 2018¿Me explico?: Mexican client perspectives on therapy with Spanish as second language (SSL) Clinicians. Sage Research Methods.

Erica Anderson on Working Therapeutically Across the Gender Spectrum

Posted on by rezendevknowfully.com

Transgender 101

Lawrence Rubin: Thank you for taking the time to speak with me this morning. Transgender issues have gained much attention in the last several years, but most therapists do not have experience working with these clients. What are some of the issues a therapist needs to know?
Erica Anderson: Thank you for this opportunity. I think it is a topic much discussed in society these days, and you're right that very few psychotherapists are trained to work with people with gender issues. One of the most important things to point out is that in years gone by, those of us in the mental health field were trained to understand gender development in a very limited, binary way, namely that one was born either male or female; "M" or "F" on their birth certificate, and then they just grew up. Puberty constituted a pretty significant change, and maybe at some point, someone would declare that they were gay, but otherwise there wasn't really much to do about the development of gender.

very few psychotherapists are trained to work with people with gender issues
What we now have come to appreciate is that gender identity exists on a spectrum, and that just as Kinsey pointed out more than half-century ago, many more people have complex sexual attractions or are bisexual than we ever thought. The same is true with gender differences. We used to think that transgender people were very rare, but in fact, people who are not binary in their gender identity or whose gender identity differs from the sex that they were assigned at birth, are in greater numbers in society than we ever really understood.

Society has become more accepting of some of these differences so more patients who are questioning their gender are coming forward to therapists. They are exploring who they are and may actually be willing to talk about some of their own self-doubts or self-realizations. So, therapists need to begin to understand how to work with such people by acquiring new knowledge, developing new skills and examining their own biases or potential biases around gender issues.
LR: Can you say more about the knowledge and skills therapists need to have when working with clients presenting with gender identity issues?
EA: The first point about knowledge is reflected in what I said a moment ago; that many people have presumed that gender really is simply a binary trait of human beings, and that is not the case. If you look at the history of human civilization, there have always been people who have not lined up in their gender identity with the sex they were assigned at birth. There have always been transgender people in society. Some of them have been acknowledged, and in some cultures, there is actually recognition of this. Many native peoples have something called "two spirit," which is a recognition of someone whose gender doesn't line up with their anatomical sex—it is a mixture of gender identities. And then there are some other cultures, in India, Brazil and Asia, where there have been transgender people recognized throughout history. We now know that, depending upon what you include in the category transgender, perhaps as many as one in 200 people in America could be said to be transgender (according to a recent study from UCLA).
LR: When we think of addressing diversity issues in counseling and therapy, we think of gender, race, age and religion. You're suggesting that within some populations, their spiritual-cultural practices may intertwine with gender identity issues?
EA: That's right and it’s a very important point here that gender identity cannot be dissected apart from the other aspects of a person. We talk these days about intersectionality and multiple identities, and that becomes acute when we then consider gender issues. This is because the experience of someone who is transgender of a certain cohort and a certain racial, ethnic or economic background might be very different from someone else whose identity is different in some of those aspects. So, it's not a situation where you can say, oh well, all transgender people are X or Y. In fact,
I say all the time, when you've seen one transgender person, you've seen one transgender person
I say all the time, when you've seen one transgender person, you've seen one transgender person. That is part of the challenge in terms of training and education in clinical practice.

One of the things I hear often is, "Oh, well, you know, coming out as transgender, well, that's like coming out as gay." Well, no, it's not. Gender identity has to do with every aspect of who you are. To equate the transition of someone who is trans from maybe being perceived as one gender into being perceived in a different way, is not exactly the same as someone who may have been closeted as a gay person and then comes out as gay and is living more openly as gay. But that's a common thought for some people who are not very well versed in these issues. It’s disturbing to some trans people to be thought of as, "Oh, well, at one point in time, you're just kind of revealing something about yourself." It's a lot more complex than that!

Beyond Binaries

LR: This suggests that clinicians need to be aware of the developmental trajectory, not just of gender, but the convergence of multiple trajectories across the lifespan that include, but are not limited to, gender.
EA: Absolutely. In fact, as we know from the traditional field of developmental psychology, people develop in lots of different ways, and that development is very uneven for most individuals through childhood and adolescence, and even into young adulthood. So, we know that we can narrow in on various aspects of development. I say all the time that everybody has their own individual developmental pathway, and that where they are at any given point in time is simply that, and it's subject to change.

The other takeaway from the emerging knowledge about transgender issues is that gender identity is something that's very fluid. So, there isn't a single narrative that explains the course of development of all transgender people. In fact, people can come to an awareness of themselves very early, in early childhood, or later in adulthood. And there's a mixture of factors in any individual case that may be contributing to those differences.
LR: It seems therefore that one of the core skills for a clinician to master is to think intersectionally—to broaden their case conceptualization and treatment planning to include these multiple converging trajectories.
EA: Exactly right, which is what makes the work so interesting for those of us who are doing it now. The evaluation process involves parsing, where we look at certain aspects of the situation, traits and historical trends of an individual, and interweave these factors. And because of the highly individual nature of gender identity, we really must listen carefully to each person, no matter what their age is. We must listen to what they say about themselves because gender, as identified by an individual, is a deeply internal and personal thing and we cannot assume that we wholly understand, in a simple way, what is going on with somebody unless we spend some time focused on it.
LR: So, one of the skills that a clinician should have is being able to move past not only binary thinking regarding sexuality and gender, but beyond binary thinking about people in general.
EA: I say all the time,
there's nothing about human beings that's binary
there's nothing about human beings that's binary. If you think about psychology as a field that has attempted to study individual differences, there's really no characteristic that is simply binary–yes or no, this or that, black or white, on or off. We're not machines. We generally think about individual differences and the intensity of various traits when we think about personality. Even in medicine, we think about laboratory studies, growth charts and laboratory ranges for all kinds of characteristics. So, there's nothing binary about human beings. But thinking about that in terms of gender requires a fundamental reordering of how we bring together all the aspects of who a person is, and a recognition that they have been evolving and changing and developing, and they're going to continue to do so.
LR: I joke sometimes with my students by saying that there are two types of people in the world, those people who believe in binaries and those who don’t.
EA: I love that. That's really cute and apt.

Words Matter

LR: Therapists not particularly trained or experienced with transgender or transitioning clients may be unsure how to start, what language or personal pronouns to use, or even how to broach the subject. What advice would you give them?  
EA: This is a big challenge for all of us, even those of us who have more experience, because society has been changing rapidly. People are bringing to these discussions whatever they've known or learned or thought they knew, as well as what information is circulating now in the world, on the Internet and in professional circles. And we don’t all mean the same thing when we use the same words. I’ve seen this evolve in my career.

I was trained on DSM II which listed homosexuality as a sexual disorder. That came out in a revision of DSM II. But today's clinicians who have been trained more in DSM-IV and DSM-5 don't think about the fact that there are huge numbers of people who are still alive who were reared in an era when homosexuality was considered shameful and a psychological disorder. I had a patient years ago who was expelled from medical school because he was arrested in a gay bar for soliciting—and that’s in my lifetime.

So, the words that we use continue to evolve. An example is "gay." You know, "gay" used to be a slur, a pejorative word. It still is in some circles. But now we have the word "queer." People are using the word "queer" all the time but don't know what anybody else means by the word. So, if somebody comes in my office—and this is a tip for therapists—and starts using some of the words that have to do with gender and sexuality, I routinely will ask them, "Well, what do you mean by that word? What do you mean by queer? What do you mean by trans? What do you mean by gender? What do you mean by attraction?"
LR: So, letting the client lead in creating the definitions, and even helping them to make peace with a definition that best fits them at that point in their life…
EA:
Dr. Seuss wrote, "You are the you-est you can be. No one is more you-er than you."
Exactly, and I love to invoke my favorite philosopher, Dr. Seuss, who wrote, "You are the you-est you can be. No one is more you-er than you." You know, we really fundamentally have to accept that people define themselves. And people who have deep-seated psychiatric disorders may be defining themselves in ways that are not helpful and maybe even toxic, but we must start there. We have to start with what's going on with someone. And there is no more significant area to do this in than gender and gender identity.

Gender Politics

LR: What if a client comes to you and doesn't broach the subject of sexuality or sexual identity or gender identity? What's the therapist's role? Is it their place to ask a pointed question? Or is it sort of a Rogerian thing, to just let the client be and go with wherever they are?
EA: As you infer, I see a lot of people who come to me because they are dealing with some of these issues that we're talking about today, but not always. I will sometimes see people who are straight who have anxiety or depression. In my long career as a psychologist I've treated people with many different conditions. I don’t assume anything about what someone wants to focus on. On my website, I have a section called "Permission to Be," where I write about my philosophy. If someone comes to me and says, "I'm coming to you because I think I'm trans, or because I am trans, or because I want to explore my gender expression and identity," then we're off to the races. By contrast some clients come to me and say, "Well, I know I'm trans. I don’t really need to deal with that. But I'm really depressed" So, it depends on the particulars of a client.

In terms of advice to other therapists, I would say, don’t assume that something having to do with sexuality or gender is a problem for someone. If it is obviously a problem and they're asking you to help them with it, help them. But if they are coming to see you for other reasons, their relationship with their gender and sexual identity doesn't necessarily require any intervention.

I want to say something else about this that I think is significant. Transsexuality, as it used to be called, was categorized as a sexual perversion, and was nested in the DSM in the section on fetishes-paraphilias. But now we're at a point where we are questioning whether it is true that everyone who has a different-than-heteronormative or cisgendered identity has a psychological problem at all. In fact, the current DSM lists "gender dysphoria" to describe those who are trans, basically. The International Classification of Diseases 11 (ICD-11) that's coming out from the WHO, will be using the term "gender incongruence," and they are taking this label out of the psychiatric section and putting it into the sexual health category.

For the first time, we’re going to see a dramatic shift in de-pathologizing transgender identity
There are several reports, including ones published by SAMHSA in 2015 and documents from the American Psychological Association concluding that differences in sexual orientation and gender identity are normal variations. There is no presumption of psychological disorder.

Interestingly, there is a task force on gender dysphoria constituted by the American Psychiatric Association. They are going to be looking at the disparity between the DSM, which does in effect pathologize trans identity, and the ICD. It is going to be a challenge to reconcile those differences. I predict that the APA will come into agreement or alignment with the rest of the world, which uses the ICD and not the DSM. For the first time, we’re going to see a dramatic shift in de-pathologizing transgender identity. And I, for one, am welcoming that change. 
LR: If a transgender client visits a therapist who's not particularly experienced in transgender issues, and presents with issues seemingly unrelated to gender such as anxiety, depression or even sexuality; is it a mistake for the therapist to assume that these other non-gender-related issues are the cause?
EA: I think assumptions of any kind about etiology are always suspect. I think we must examine our own biases and expectations. A co-occurring disorder is simply that. It may be a contributing factor to distress about gender identity. Gender dysphoria often is reflected in interpersonal conflict and anxiety, sometimes depression. But it isn't necessary to treat them separately. It also is a mistake to assume that they're related in some systematic way.
LR: Some argue that therapists need not have personal experiences similar to a client’s in order to be empathetic. How does that apply here?
EA: On the one hand, I think sometimes we take therapist-client matching a little too far. On listservs here in the Bay Area, requests for referrals to therapists usually list eight or ten characteristics that they're trying to match up. I think to myself, “whatever happened to general training and the recognition of one's competencies or limitations?” However, I also think that this is an area that one shouldn't enter cavalierly. There is a limit on the empathy that a cisgender person can have towards a transgender person. The level of complexity and the extent of personal transformation that happens when someone comes to terms with a trans identity and then embarks on a gender transition is so complete that it's hard to explain simply, and it's certainly hard to imagine.

I hear all the time lay and professional people alike, saying, "I don't understand how this person can be trans. I knew them before. There was no hint of an identity other than sex assigned at birth. I don’t understand." And I say all the time that it's not so important that you understand. What is important is that you accept that this is a deeply felt identity by this person. And if they are disclosing it to other people, they've probably been struggling with it for a long time. In fact, it's well established that, at least until now, transgender people in American society have suffered trauma and continue to suffer trauma, and some more than others. I believe that if you've been transgender for more than 15 minutes, you probably have complex trauma. And that's a joke. Thank you for laughing. Because nobody is transgender for 15 minutes or three weeks or a month. It's a long, long thing.

There's another controversy in that regard that is currently swirling. There's a term being thrown around, which is not a scientific term: rapid onset gender dysphoria. Have you heard that term?

Families in Transition

LR: No. Is that like acute stress disorder affecting gender?
EA: It's a term made up by parents who are concerned that their teenage children are asserting a trans identity from out of the blue. They are worried that there's some kind of social contagion going on with teenagers where it's cool to be trans. More kids are trans than ever before, and they wonder if maybe they catch it from each other. But
I can assure you, transgender identity is not something one catches. It's not infectious
I can assure you, transgender identity is not something one catches. It's not infectious.
LR: Toilet seats and door knobs won't do it?
EA: Nope, won't do it at all. Even sexual contact between two consenting adults will not affect someone with a transgender identity. But this term has been thrown around. And one of the key issues is that teenagers, as they always have, talk with each other about things that they don’t talk with their parents about. And so they're exploring this with each other. And now we have the Internet, so they're going online and finding out all kinds of stuff, and they have friends online, and so forth. They explore for a while, and they get affirmed by their peers, and they draw their own conclusions, and then maybe they tell their parents, "I think I'm trans." The parents are, in some cases, surprised. In many cases, they're not, because there were indications earlier in the life of this child. But for those who are totally surprised, they think this is a recent phenomenon. But in reality, probably it has been percolating with this child for a while, and finally they come forward.

One of the issues for us in evaluating kids, though, is to be cautious about offering medical interventions—you know, puberty blockers or hormones, certainly surgery—until we're pretty satisfied that this really is an enduring identity of this person, and that it's the right thing, it's affirming of them, and it's medical necessary. I work at the Child and Adolescent Gender Clinic at UCSF and we see kids and their families, all ages, young children, preschool children to older teenagers and young adults. And as I was saying earlier in our conversation today, there's no one narrative, there's no one pathway that explains everybody. So, we have to be cautious where there isn't an obvious track record of development of a gender different than the assigned sex. But it doesn't necessarily rule out the legitimacy of it. It may mean that we'll have to have a longer period of observation than with some other kids, where it's quite obvious to everybody that this is a trans kid.
LR: I wonder if there's a correlation in the literature between children with rapid onset transgender disorder and parental unawareness disorder?
EA: Yeah, that's a good one. Certain parents, as you were implying by your very cute comment, find it harder to accept the reality of a child whose identity is very different than what they expect. They may have somewhat rigid views of sex and gender, and they may subscribe to the dominant gender schema of binary, and they may be, as you say, unaware of the fact that gay and trans people have been around throughout human history.
LR: How can therapists help parents enter the conversation once the kid or teen begins talking about it, even though it may have been evolving for years?
EA: Some of the basic principles that have peppered our conversation so far are relevant here, and that is, as a therapist, try to avoid bringing your own bias into the situation or the conversation. Try to maintain an open mind and be focused around listening carefully to the various people. Everyone in the family—no matter what kind of family, if it's a traditional heterosexual couple with kids or whether it's any one of the many versions of "modern family"—is coming at this from a different perspective. The
older people are coming at it having grown up in an era that was less open and less aware of some of these issues
older people are coming at it having grown up in an era that was less open and less aware of some of these issues. Kids may be bringing their own perspective, which could be quite spontaneous and quite free and quite direct. And so we need to listen to each other.

The word that's often bandied around and disregarded is "transition." A trans person goes through a transition of sorts to bring their life and even their body into consistency with their identity. Everybody gets that. But everyone else around that person is also going through a transition, and it's very uneven. Some resist it, some embrace it, and some are more troubled by it than others. Literally, I've had parents of teenagers cry in the consulting room, saying, "I thought I had a daughter, and I guess I have a son, but now I'm grieving the loss of my daughter." Or the other way around, "I thought I had a son, and now I know I have a daughter, but I'm grieving the loss of my son." These are very personal and poignant moments when someone is really trying to come to terms with the reality of what's going on. It's a very tender time and we have to be kind to each other about what we're going through. 
LR: Everyone is in transition and may have been struggling to come out of their own mental closets in acknowledging and embracing that their child or their teen has been struggling for so long.
EA: Every family is different. There are some themes that are common and that are often shared, but the nuance can be so subtle and important. I had a trans teenager in my consulting room last night, and we were talking about the resistance of their mother to their identity and the struggles that this teenager has had for years with a mother who has not found it easy to accept her child on the child's terms. It was really quite a pivotal moment in my work with this young person in that they disclosed for the first time the extent of verbal abuse that their mother had given to them throughout the years. And the child's efforts to cope with this meant that they kind of shut down and are currently afraid of going forward with transition, because they’re worried that their mother is going to say, "I can't accept this," and that their father would side with the mother. And my client is saying to me, "I'm worried they're going to kick me out. They're going to kick me out of the house."
LR: So, these kids are sometimes put in the position of bearing the burden of holding the family together or reducing conflict by remaining silent? You must be so skilled as a therapist to address this once you open yourself up to the systemic and contextual nature of it.
EA: It's a challenging thing. But in the case of this young person, critical. I have to address the dynamics between the parents and between the parents and this teenager because they’re really hurting.

Complicating Issues

LR: You were just talking about transitioning, so I'm wondering if there are different clinical needs for clients who are in surgical transition as opposed to those who, for whatever reason—health, finance or choice—can't or don’t pursue surgical transition?
EA: Each of the phases of the transition has its own set of challenges. One of the things that I'm impressed with by those who get surgery is that the characteristics of the person are all-important. So, if they're healthy, have realistic expectations and a good surgeon, they have a good result and there are no consequences. That's one process. Another might be someone who has health issues, who might be a little more likely to have some kind of untoward consequence of a surgical procedure and are then frustrated afterward because their recovery is a little choppy, and maybe the result isn't exactly what they had hoped.

The differences between people are clear. Historically, surgery has been largely confined to adults 18 and over. But more and more, the trans kids that we're working with whose identity is clear at a young age and who have been on puberty blockers and cross-sex hormones as young teenagers, are getting surgery in their teenage years. This is, of course, with the full consent of their parents when everyone agrees that it's medically indicated.
These kids are being given a gift that someone in that situation a generation ago would never have had
These kids are being given a gift that someone in that situation a generation ago would never have had, which is to avoid some of the life experience in the gender they don’t want, and some of the physical changes in their body that they're not completely comfortable with. They're able to move ahead with their physical transition in such a way that by the time they're in middle to late teenage years, they're fully embodied as the person they see themselves to be and the gender that they assert. From that point on, all their experience is in that gender. So, they go to college and the people at college only know them that way. They've done their name and legal gender change, and so forth. That's a whole interesting set of patients.

By contrast, you also have people who are married, have children, have started a career or are deep into a career, and then they come to terms with who they are, and they transition. And I'm thinking of two people I’m currently working with who were assigned as male at birth. They are in their 30s and 40s, married with children, going ahead with the transition and all the complications that you would expect based on having to deal with the reaction of the spouse, the children and the people in their professional world. It's a whole different set of issues.

The Psychologist’s Role

LR: More and more, psychologists are being called on by doctors who are working with patients contemplating anything from gastric bypass surgery to—I don't know if I'm using the right word—gender reassignment?
EA: Currently, gender confirmation surgery.
LR: Thanks. These psychologists are being called on to perform evaluations to provide physicians with concrete validation that this person is psychologically ready for surgery. Do you have any recommendations for these psychologists?
EA: There are guidelines for this, we call such reports "letters of support." They're really what you and I would consider evaluation reports. They are a review of this person, their history, any co-occurring issues, and their life circumstances. In addition, as we would agree, a necessary part of this is essentially the informed consent, you know, to talk through what is going to happen with this surgery by a skilled surgeon who is well trained and experienced with this procedure. And then, does the person really understand the risks and the benefits of this surgical procedure? And what are their expectations of what it's going to be like for them after they have this surgery? I was referring to that earlier today as we were talking about how realistic the person’s expectations are about surgery.

Most people who think about gender confirmation surgery have done extensive research on it. So, I find that—maybe it's a selection bias—the people who come to me are those who are a little more sophisticated. But I must satisfy myself that they've gone through that process, and that they've asked and had answered all the questions that they have, and that they've thought through whatever the likely consequences are, and they've considered the possible unexpected consequences. And if they have, if we've done all of that, and if there isn't an outstanding psychological issue or an acute psychiatric problem, then I'm inclined to write the letter and say, yes, I recommend that this is medically necessary for this patient.

Surgeons do require such letters still, at least according to the standard of practice. There is an organization called WPATH, that has standards of care, currently in its seventh edition. These are standards of care for medical and psychological service to trans people. The 8th edition is currently under preparation. And just like everything else that we're talking about today, things are moving in the direction of de-pathologizing. The question in the future will be, "What is the purpose of the evaluation? Is it to screen for any contraindications? Is it to satisfy the psychologist and the surgeon that this person is a good candidate for this surgery?” Those are open questions as far as I'm concerned. But I do believe that because of the wide-sweeping consequences of a gender transition—and if you add into it gender surgery which is irreversible—that performing these evaluations requires serious skill and should not be done lightly.  
LR: Therapists and clinicians want to render the most competent services in a way that is correct, ethical and moral. So, it's not just laying a quick MMPI on someone and saying, "Yeah, ready to cut."
EA: Exactly.

Closing Thoughts

LR: What should therapists be wary of within themselves when working with clients who are either contemplating surgery or thinking and feeling deeply about gender identity?
EA: I have been doing a lot of thinking in the last few years about our whole paradigm of transference and countertransference, and how that might need to be adjusted for work with transgender people., I myself am transgender. I ask myself all the time, "Do I bring any bias to my work with an individual client or patient?" I try not to, of course. But, in a slightly different way, I know that some people come to see me not only because I'm a qualified psychologist, but because I'm trans. They want to know about me and will ask me personal questions which is historically seen as being out of bounds. And I wonder, how is that related to transference or not?
My inclination is that if client questions are not too deeply personal—nobody asks me about my sex life—I will answer them.
My inclination is that if client questions are not too deeply personal—nobody asks me about my sex life—I will answer them. These include questions like, "What is it like to go through hormone changes? What happens in the surgery?" And I will selectively tell them a little bit about me, because it does reassure them. It's kind of like, "Oh, yeah, she went through this, so I can do that too."

Some of the questions therapists can ask themselves could include, “What are you bringing to that discussion with someone? Do you really have empathy for what they're going through? Do you have a bias? Have you examined your perspective about this?” I think the therapeutic pitfalls are to assume that someone is too young to decide, to assume that someone is neglecting their family responsibilities if they transition and they're married with a family, to assume that someone is not going to be able to have sex if they change their body. There are a lot of potential assumptions, and we just have to be careful not to hold them because we have a bias.
LR: So, the same general concerns about countertransference, self-disclosure, presumptions and biases, but a little bit more finely tuned to the needs of clients who are in transition.
EA: I am concerned that therapists who are relatively inexperienced in this area may have a hard time parsing the co-occurring disorders. And so they might think, "Okay, we can't go ahead with hormones or anything else, or certainly not transition, until we deal with your depression. And we've got to cure all your psychological problems before I feel comfortable encouraging you to go ahead." That is, in my judgment, a mistake, and often kind of a rookie mistake. I think the literature on co-occurring disorders suggests that there are many situations where we treat concurrently, not consecutively. To pretend that we can separate aspects of a human being and treat one part and ignore the other or set aside the other for a while doesn't work very well in this area.
LR: We can’t surgically remove pieces of pathology, revealing the true issues—it is simplistic and naïve.
EA: Here's the challenge! We have inadequate empirical bases for a lot of the things that we're doing. We're doing what we're doing based on the data we do have. This includes longitudinal information we have about patients, comparing and contrasting patients who do well and patients who don’t do as well, and bringing into our work in this area what we know about other clinical challenges. If we waited until we had long-term treatment outcome studies on all these things, there would be a lot of people who would struggle.

As you know, the rate of suicidal ideation and suicide attempts is very high in trans people. So, we're going to lose a lot of people if we deny treatment to trans people until we have what the rigorous scientists consider to be adequate empirical justification for what we're doing. There is a five-year research study going on at UCSF, one of four sites for a multi-site NIH study of transgender kids and the first of its kind. But that's a five-year study. The research is looking at both medical and psychological factors having to do with how kids do when they go on puberty blockers and how kids do when they go on cross-sex hormones. And in five to ten years, we'll have some data that will help illuminate what we're doing.

Hopefully it's going to confirm what we think we know about best practices with kids. We're one of the more advanced centers in terms of embracing what we call the gender affirmative model. We're very interested in affirming kids and their gender, and not putting roadblocks in their way to living authentically. We work hard to reach consensus about the truth about any individual kid, and then a consensus about what we know about this kid and what we are going to do. We ask important questions including, “What's the timing of various things? Are we holding off on things for specific reasons?” It's a very individual matter with both kids and older patients and it’s about crafting a plan for the gender journey heading towards transition. It is about trying to responsibly approach each of the potential decisions and make the best decision that we can at the time based on what we know for each patient. And that is, I think, a sound approach, but it isn't necessarily justified by empirical findings.

Gender identity isn't something that easily lends itself to measurement. Earlier, you invoked the Minnesota Multiphasic Personality Inventory (MMPI). I was at the University of Minnesota for a number of years, and I interpreted thousands of MMPIs. I don't know that we're going to ever have, at least in my career, any kind of test for who's trans and who isn't, or what level of trans-ness exists, and, oh, this means that they should proceed at this kind of pace in terms of decisions regarding medical supports for identity. 
LR: You're a transgender woman. How has your own personal journey prepared you to work as a therapist? No easy question, right?
EA: Like most of us who have been psychologists or therapists for a long time, every chapter in our lives does inform who we are and gives us insight into how life is for other people. I emphatically believe that I could not do what I do without incorporating some of what I've learned about myself and the world.
I will tell you that it is amazing to have lived as a man in society and now live as a woman in society
I will tell you that it is amazing to have lived as a man in society and now live as a woman in society. Sometimes I joke with other women and say, “I’m on our team now, and I get it. I get what it's like to be treated differently by men.” I had another interview recently in which I was “mansplained” many times. It's really hilarious when I get mansplained.

The subtlety of what I've experienced is not lost on me or some of my clients in that I know what the experiential aspects of this are, exquisitely! And although I didn't keep a careful journal of what I went through, I remember many aspects of it very, very clearly. I sometimes bring this subjective understanding into my work. I'm sure you could appreciate this. Sometimes, when my clients or patients are really struggling, I lean in, and say, "You know, I really do understand what you're going through, and I want to help you." And they realize that I'm being honest and direct about it, and it means something to them.

I'll tell you one other little anecdote which is kind of special for me. When I see trans kids at the UCSF clinic, I'll say to them, "Do you know any other trans kids?" Sometimes they shake their head, and say, "No, I don't know any other transgender kids." I'll then say, "Well, do you know any other transgender adults?" They'll shake their head, and say, "No, I don’t know any other transgender adults." I look at them and say, "Well, honey, you can't say that anymore, because I'm trans." Their eyes get big, their jaws drop. Sometimes they gasp, sometimes they break into a big smile. And it's such a sweet, special moment for me. Sometimes the parents are not surprised and other times they say, "Really?" And then they say to their child, "See, honey, you can be a doctor. You can have a good life." And I feel, in that moment, like this is a gift to me, to be there with that child.
LR: A gift to you, indeed. I was reading a book by Fred Rogers who quoted someone something along the lines of, "You're not just your age; you're every age you've ever been." And that makes me think of what you just said. You're not just your gender; you're every gender you've ever been.
EA: Yep!

Doctors Are People, Too

Posted on by Psychotherapy.net Team

John and Rebecca (pseudonyms) came into my office in tears. They were struggling with how to maintain a commitment to their medical careers while continuing to commit to their relationship and future as a married couple. They were both successfully completing their training as physicians and had promising career opportunities in their fields of speciality.

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What was unusual about this couple was their ability to articulate exactly what “The Question” is for many professional couples: Now that we know what the future holds and how much investment of time will be required of us in this profession, we feel like we may have to choose between a healthy marriage and a healthy career. In fact, that same afternoon, I had just seen another couple with completely different careers asking almost precisely the same question, but they had some trouble putting their concerns into words. John and Rebecca nailed it. In fact, they almost whispered it, leaning tentatively toward me in my softly-lit office, divulging what they both said was pretty risky to even think about, much less say out loud.…and if we have to choose, well, we don’t know if we want to do this medical thing anymore.

What I have learned about the personalities of individuals who pursue medicine as a career is that, like those in most caregiving professions, a physician’s own self-care can be last on their list. The hours, the intense fields of study, the great responsibility and risk involved in treating other human beings—these are all are ways in which the physician can potentially be set-up to fail in their personal lives. The training requires intense scheduling, curtailing and even significantly limiting social outings, and the need for sleep contributes to putting off cherished open-ended talks with a partner.

Pursuing a medical career requires sacrifice, and as a patient, I’m glad; the more well-trained my physician is, the better I feel I can rely on her assessment and treatment recommendations. At the same time, this particularly poignant and relevant discussion in my office brought up some concerns for me, first, as a couples counselor: my desire to be empathic and validating; and secondly, in a broader sense, concerns about this couple as part of the community. I want my treating physician to be not only clinically on-point but emotionally healthy. As a therapist who has counseled many people over the past decades, it has become clear that whatever one’s profession, the healthier the personal life, the more readily one can face and overcome the enormous challenges that arise in one’s professional life. If we have healthy personal relationships, someone to talk to who can be present and comfort us in times of distress, the challenges we have outside the home seem at least somewhat more tolerable.

So, in this session, I found myself experiencing a bit of an internal quandary: How much do I empathize, or do I even encourage they choose their marriage over the intense career paths that they are sure to pursue next? Knowing what I know as a couples therapist, I can guess that the road ahead will continue to be challenging, no matter what, but the fewer external pressures, the better, right? I confess a part of me wanted to jump in and champion their relationship above all else (their upcoming job offers were appealing, but would readily require at least 50-60 hour weeks). But I also was aware that their professional dreams had been hard-won (non-stop schooling since age six; postponing having children to focus on career; hundreds of thousands of dollars in student loan debt).

What I wound up doing next was listening to their concerns, their thoughts, and especially the emotions underneath, both secondary and primary emotions, and guiding them through conversations that could draw them closer together, instead of further apart. I didn’t try to change the subject or make it all better or tell them what to do but encouraged the experience of these concerns in session. Over time, they did the hard work necessary to reach their own conclusions about their career choices (they did remain in medicine), and their relationship. They risked being vulnerable with me and with one another around their feelings about choices made and unrealistic expectations. Over time they worked their way slowly back toward one another. They reached conclusions about their careers that met their own personal sweet spot: a balance between work and home that secured one another as their source of comfort and support at the end of the day.

Not all of my clients have been this “lucky.” Of course, that sweet spot can wobble a bit: misunderstandings and arguments happen. Those nagging internal questions about self-worth and existential questions about the purpose of our lives don’t magically disappear. That’s the nature of life, relationships, and making choices about our work. Physicians can often have a greater challenge, as the nature of their work requires an extraordinary commitment, along with a very small margin for error in the many decisions they make each day. But as so many of my physician-client couples have taught me, the need for their primary relationship to come “first” when it counts, serving as a source of security, comfort, and trust, means just as much—and often much more, than their medical careers.

John and Rebecca also learned that they didn’t have to choose one over the other. What they did needed to choose were ways in which they could learn to be more intentional about their relationship, building resilience to buffet the stressful nature of their work, and learning not to “use up” all of their emotional energy in the workplace. They took a risk by coming to see me; they could have been overwhelmed with the effort it took to focus on their relationship and decided not to call my office. I’m so glad they took that risk. They had the courage to admit that, as brilliant as they were, when it came to their relationship they needed a little support and guidance along the way. After all, doctors are people, too.
 

Having the Hard Conversations in Sport

Posted on by Psychotherapy.net Team

We watch what seem to be superhuman feats of athletic performance on TV and hear about the dedicated efforts and sacrifices it took for these elite performers to achieve the impossible. While these feats may, in fact, be extraordinary, the people performing them may also be struggling with real-life issues like any other individual who turns to psychotherapy. This was a major takeaway during my masters training when I studied counseling psychology with an emphasis on sports at the University of Missouri.

With a desire to delve more deeply into the complexity that exists at the intersection of mental health and athletic performance, I sought doctoral training, and am currently in my third year of the Counseling Psychology program at the University of Wisconsin-Milwaukee. I also am the mental conditioning coach at a local high school, which is how I met Brian, a football standout. I want to provide a glimpse into the lived experience of a student-athlete whose concerns fall outside of stats and figures, and instead in the realm of mental health.

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It’s 5 o’clock on Friday. Many have been looking forward to this all week, and the time has finally come. Some can’t wait to get home and unwind for the weekend, while others look forward to going out. If you’re in high school, there’s a good chance you’ll end up at a football game around 7 to watch your team play under those Friday night lights.

Society has a fascination with sports. People sit around for hours sharing their athletic feats that range from avoiding the gym class mile to their time playing in college. We’re willing to pay a lot of money to see our favorite teams play, and parents put hard-earned miles on the family car to drive their kids to practices and games. Sometimes, sports are associated with enjoyment and growth, while other times it’s fraught with pressure and anxiety. The student-athlete suiting up to hit the gridiron is exempt from neither.

“Hey coach, can we talk?”

This all too common question from a student-athlete to their coach could result in any number of conversations. Am I traveling this weekend? What’s the workout tomorrow? How’s recruiting going? Sometimes, these questions are geared toward acquiring information, while other times, they’re intended to start a conversation about something much deeper.

When Brian approached me that night, the fall chill still hanging in the air after a tough mid-season loss, I could tell the look on his face meant one of those heavy conversations was about to begin. “It’s just been really hard lately.”

Almost immediately, his eyes welled up with tears and Brian, the otherwise outspoken leader and all around tough-guy, opened up about his difficulty coping with the divorce of his parents. Things had not been alright for a while, and Brian was finding it difficult to manage the myriad of emotions that seemed to come and go without warning.

Brian opened up about expectations from coaches, parents and himself and how as a result, he was no longer having fun, wanted to quit the team and stop working out altogether. He even shared that he had previously considered taking his own life. We walked and talked for a while, and Brian shared his gratitude for having someone to listen to the painful feelings he was expressing, who saw him as a person rather than only as the blue-chip recruit the media made him out to be. Before we parted ways, Brian denied a current plan or intent to end his life, and agreed to stop by to see the school counselor on Monday.

Win or lose, the result of competition is often met with critique—from fellow athletes, coaches, and the public. Newspaper columns share stats and opinions about athletic performance, and interviews about last week’s performance are nitpicked until the next big news story hits. If the internal experience of the athlete is explored, it’s often approached from a mental performance perspective as opposed to one grounded in a genuine interest in their mental health and wellbeing.

The brutal nature of the win-loss column is characterized by attempts to tell the tale of the game, but numbers cannot always recount a personal best, or growth, or even effort. The numbers can’t tell the story of the internal battles and triumphs plaguing the minds of 1.7 million high school student-athletes nationwide.

While I may be somewhat qualified by virtue of my ongoing training in sports psychology and my years studying the complexity of optimal human performance and wellbeing, that talk with Brian could have been held by anyone with a genuine concern for who he was beneath the helmet and shoulder pads. All we did that night after a gutting loss to a cross-town rival was have a conversation. Person to person, and of course, I had the wherewithal to refer him to a professional counselor.

That night Brian had someone to talk to, and today he’s back out at practice trying to improve his skill in the game he loves, along with his mental health in the course of a painful family-life transition. We all know someone like Brian, whether that above-average skill is in sport, academics or the boardroom. They may not share their concerns with us, but those concerns may be impacting their life in a paramount way—unless we have those tough conversations.

When I think back to that conversation with Brian, I realize that the experience helped to shape the way I see the role of a sports psychologist working to improve either mental health or mental performance. It helped to deepen my belief that sometimes we need to take a step back from the game and slow down. We need to take a moment to check in with the student-athlete, who may be concerned about far more than the outcome of the next game or whether they will earn that free ride to college sports celebrity. Next time the question of, “Hey Coach, can we talk?” comes up, I’ll think back to Brian, even if the question is only about the game.