In Support of Supportive Therapy

Posted on by Psychotherapy.net Team

I am a practitioner who primarily uses cognitive and cognitive behavioral techniques. I like the structure, the science, the goals and being able to both see and measure the outcomes. My continuing education has typically been in CBT or a related subspecialty of interest. In short, I am a believer. I recently had the good fortune of being introduced to a client who taught me a new appreciation for the very non-directive and perhaps non-measurable art of being supportive.

I live in Florida and this client, like many of my clients, was retired and in her 70’s. She had no family to speak of other than a daughter who didn’t pay much attention to her other than a random call now and then. However, my client did have a dog that meant everything to her and was a powerful source of support. Though she was also under the care of a psychiatrist, my client remained depressed, isolated and lonely. My treatment plan included attempts at motivating her to become involved in social and recreational activities by expanding her support systems, and coming to some kind of terms with her absent and seemingly neglectful daughter. I had it all planned out; after all, I did specialize in an action-oriented, proven-effective and pragmatic form of psychological treatment.

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However, my client preferred discussing her dog. He liked ice cream and they had quite a full schedule of procuring it at various fine dessert emporiums around town. He had certain preferred flavors and was drawn to ice cream-related novelties including cones, sprinkles and sauces. They also had specific ice creams and treats they enjoyed while watching television and favorite procurement spots–ones they could walk to and those that required a car ride. The dog very much enjoyed his rides in the car.

As a relatively new therapist with this population I was very eager to fix what was wrong–her depression and loneliness. I was also quite eager for her to talk about her symptoms and our intervention, not ice cream. I suggested useful homework assignments and therapeutic exercises. In short, I pulled out everything from my bag of tricks. She would have none of it.

As hard as I would try to get the discussion back on track, she would invariably stick with yet another ice cream or dog tale, or both. I would bring up the daughter, she would bring up their favorite detective show. I would bring up loneliness, she would bring up the dog again. It was a dance between two partners who were not quite dancing together. I felt like I was failing her horribly by not being able to shift her to focus to her symptoms so that we might work together at alleviating her symptoms. I believed her resistance to be remarkable in its strength. I not-so-musingly wondered (silently) if I were committing insurance fraud by accepting payment for this.

I brought it up to her at one point that I wasn’t sure I was helping and asked if she wanted to pursue another avenue of treatment or another therapist? “Oh no,” was the reply, “You are helping me a lot.” So on we went dancing together-alone. I didn’t want to add a perceived abandonment to her list of difficulties.

Around the same time, I noticed I was receiving many calls from new clients in this woman’s general area. Sure enough, one by one as I met with them, they would say my client was their referral source. “So and so told me how much you help her and I just wanted to come in and talk about my son.” “So and so told me how you helped her with a depression and I wanted to see if you could help me.” Are you seeing the pattern here?

I thanked my client for the referrals when she came in and her response was, “You are welcome, you are the best therapist I’ve ever had, I tell everybody about you.” “Everybody” turned out to be the people she met at the ice cream places! Apparently the more I encouraged her to get out and get involved, the more ice cream places she and the dog visited! She chatted up whoever was there eating their ice cream and swapped stories of neglectful children, doctors, medical conditions and therapists.

So in an indirect way, I was indeed affecting her behavior, but she affected mine as well. I gained new clients from her referrals for several years after our treatment ended, and she would come back from time to time to check in. I know now that just having someone to listen and share her life with was what was important to her and I didn’t need a doctoral degree to do that, although it helped. Her meetings with me alleviated some of her loneliness and gave her a place to go, an appointment to keep, someone to talk about to the people she met at Dairy Queen. I filled a gap, I provided support, I hope I didn’t commit insurance fraud.

I now never underestimate the importance of support and of just being there. A treatment plan is great but the connection of the human spirit can truly be what heals. Ice cream helps as well! 

Treating the Physical Effects of Depression

Posted on by Psychotherapy.net Team

The quick deterioration of our bodies following severe flu, broken limb or difficult surgery is often surprising. We quickly and abruptly transition from feeling strong, energetic and balanced with a full capacity to eat, walk and climb stairs, to feeling weak, exhausted and frail with little appetite or mobility. In short, debilitated. A close relative recently had pneumonia; fortunately, the wonders of modern antibiotics brought about a quick end to the chest pain, fever, and coughing. But more than a week later, this normally athletic, fast-moving individual was having trouble climbing stairs and walking long distances. It took him weeks to regain his physical strength and overcome the fatigue that had him longing for a daily nap. Indeed, it may take several weeks or even months of physical therapy and rehabilitation programs to regain strength and stamina after the end of an acute or severe illness.

But what if the deterioration of the body is due to mental illness? What if the severely depressed individual stops eating and rarely moves from her bed in a darkened room for days at a time? What happens when anxiety is so pervasive that chronic gastrointestinal disturbances and sleep disruption result? What about a person with bipolar disorder who cycles into depression with such frequency that there is little time for recovery from the previous depression? Wouldn’t such circumstances bring about reduced nutrient intake, loss of weight due in part to loss of muscle mass, difficulty with balance, and overwhelming exhaustion—similar to that seen after a physical illness such as pneumonia or severe flu?

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Several years ago, a client with bipolar disorder who had been coming weekly to our weight-management center at a Harvard University-affiliated psychiatric hospital suddenly disappeared. Phone and email attempts to remind her of the meetings and to check on her well-being were ignored. Weeks later, she appeared and told us that she had been severely depressed and unable to get out of bed to answer the phone. She had lost weight due in part to muscle loss because of her inadequate nutrient consumption and inertia. The clinic’s exercise physiologist noted that our client’s physical stamina and balance had declined significantly, and her balance was precarious.

Fortunately, we were able to establish a meal plan and exercise routine to compensate for the days in which she was inadequately nourished and inert. But what happens to other patients whose mental illness, whether acute or prolonged, causes periods of almost total physical inactivity, inadequate nutrient intake, even lack of exposure to sun and fresh air? They may be as debilitated at the end of their episode of depression or anxiety as someone recovering from injury, infection, or a broken limb. Who recognizes their fragile physical state and takes steps to ensure their physical rehabilitation?

Therapists may play a crucial role in facilitating the help these patients need to bring about an improvement in their physical as well as mental state. They may be able to encourage the patients to seek out medical attention if needed, to consult with a dietician about restoring adequate nutrient intake, or to suggest using physical therapy to restore lost muscle mass and stamina. Moreover, with the permission of the patient, it might be useful to bring the caregiver into this discussion to help make appointments with these health care specialists and to discuss ways of preventing the physical decline when or if the depression recurs. It makes good clinical sense that the psychotherapist might just be that person.    

Why Modern Clinical Psychology is in Trouble (And How Basic Empirical Research Can Help)

Posted on by Psychotherapy.net Team

I write this post as a clinical psychologist who is very concerned about my profession. Psychotherapy has, in my opinion, become of shell of its former self. Complex clinical decision-making and case formulation have been replaced by mechanical views of the therapy process. Clinical manuals rule the treatment approaches many clinicians take. These manuals provide a “paint-by-numbers” approach—a term first used by W.H. Silverman in 1996, where specific steps guide each treatment decision. There is no room for variation as each case is treated the same as every other case with a similar diagnosis. Licensed professionals are not expected to incorporate their own insights and understandings but are instead expected to just follow each step towards a predetermined goal, which is similarly lacking in any individuality.

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Even the heavily-used phrase “empirically-supported treatments” often seems devoid of any real meaning. It is supposed to reflect an understanding of clinical approaches emphasizing the scientific method. But this approach often utilizes science only in the most superficial ways.

Here’s how a typical approach to “empirically-supported treatment” works. Hundreds or even thousands of individuals who all meet the same diagnostic criteria are grouped together and specific treatment steps are applied. Members of each group are then subjected to the same sets of steps with little room for variability or individuality. There is no focus on why problems occur. Nor is there a focus on why treatment steps work. There is just a focus on finding steps that work for the largest groups and sharing those specific steps with any many clinicians as possible.

This is all much the same way that medicine is practiced. Physicians prescribe medications without necessarily knowing exactly why they work. There may be some recollection of biochemistry from medical school, but it is not necessary that physicians recall those details while following what the PDR says to prescribe.

So, implementing treatments without knowing exactly why they work is not in and of itself a problem. It is just that psychotherapy is supposed to be different. Psychotherapy is supposed to emphasize a full understanding of why people act the way they do. Freud emphasized defense mechanisms, Harlow focused on emotional attachment and Skinner highlighted reinforcement. All the most prominent names in clinical psychology, at least up until this century, recognized understanding problems to be as important as understanding specific treatment approaches.

Science used to be incorporated throughout psychotherapy. There were scientific studies of personality traits contributing to depression, anxiety, and other disorders. True scientific research guided understanding of how behaviors develop and what factors maintain them. Conflicts occurring between individuals as well as those within individuals were researched in very detailed ways. All of these issues continue to be studied but are given much less emphasis in modern clinical psychology, compared to the step-by-step therapy approaches.

Basic psychological research is the approach used for studying psychological processes. This type of research used to be emphasized much more than it is now for guiding psychotherapy. In fact, it used to be emphasized as much as clinical research. Laboratory and observational studies were used to more fully understand factors contributing to clinical issues. Basic psychological research was understood to more fully apply the scientific method than could ever be the case in clinical settings.

There are many places where I’ve seen the weakness of clinicians who have limited understanding of basic research findings. One such example is when I supervise clinical staff on behavior therapy. There is a vast amount of research, spanning decades and involving human and nonhuman subjects, showing many complex ways that behavioral constructs such as reinforcement schedules, extinction, fading and response strength function and interact with each other. But many clinicians are only familiar with the basic aspects of reinforcers increasing target behaviors. As a result, they wind up with behavioral interventions that are very, very simplistic and then they and their clients wonder why those plans aren’t working.

This is not the sort of problem that can be addressed with research only investigating general clinical interventions and generic outcomes. What is required is an understanding of the complexity of how behavioral constructs work and all the important factors involved. Clinical research just doesn’t address that. Rigid application of the scientific method addressing targeted research questions, with multiple opportunities to get findings out to clinicians “out in the field”, is what’s needed. Research funding in the social sciences is moving away from that. Hopefully, this can change.

1) Silverman, W. H. (1996). Cookbooks, manuals, and paint-by-numbers: Psychotherapy in the 90's. Psychotherapy: Theory, Research, Practice, Training, 33(2), 207. 

That’s Child Abuse

Posted on by Psychotherapy.net Team

“She can’t come today. I’m actually not really sure where she is.”

Little did I know, this would be the opening line to a new chapter in my nascent counseling career. Every therapist remembers their first child abuse report, and on an overcast day in central Massachusetts, this was about to be mine.

As the phone call continued, I learned that during a particularly heated argument, this mother had struck her daughter, and the teen had run away as a result. Although it was clear to me that mom’s blow to her daughter’s head constituted child abuse, when I consulted with my supervisor, his questioning was along an entirely different line. How long had my client been missing? Had her mother filed a missing person’s report with the police? 

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I informed him that my client had been missing for over two days, and during a second, very awkward phone call, we learned that although she had called the homes of several of her daughter’s friends, my client’s mother had not contacted the police. To my surprise, my supervisor informed me that the mother’s failure to make timely and reasonable efforts to locate her child also constituted child abuse, because being missing put my client at risk of imminent harm.

For new and seasoned clinicians alike, the line between what is and is not legally considered child maltreatment can be difficult to distinguish. Laws vary widely from state to state, and are frequently updated to reflect new findings in abuse and neglect research. The best way to familiarize yourself with your state’s laws is to read the relevant statutes yourself from beginning to end. The U.S. Department of Health and Human Services maintains an excellent search engine through which you can look up your home state’s child maltreatment laws in a matter of seconds.

Although some behaviors clearly constitute child abuse or neglect, other instances of child maltreatment are not as obvious. For example, making believable threats to kill, disfigure, or severely harm a child is considered child abuse in many states, even if the caregiver never acts on them. And many forms of punishment that may not leave physical injuries—such as excessive physical restraint and extended periods of isolation—also fall under legal definitions of child abuse. Additionally, a wide variety of parental inactions are considered child maltreatment, such as failing to establish a significant relationship with a child, failing to seek assistance with school refusal, or engaging in sexual activity with reckless disregard as to whether or not a child is present. Other unconventional forms of child maltreatment include encouraging a child to engage in criminal activity, knowingly exposing a child to sex offenders, and driving under the influence with a child in the car.

The criteria for neglect can also be difficult to navigate, as laws vary significantly from state to state. In some states, a caregiver is not considered neglectful if they are unable to meet their child’s basic needs due to financial inability, unless that caregiver has previously declined public assistance that would have allowed them to meet those needs. In other states, however, a caregiver’s failure to meet a child’s basic needs is considered neglectful regardless of the caregiver’s financial ability to meet those needs.

Similarly, there is wide variation among states in laws related to children’s exposure to illegal drug use. In some states, the issue is not directly addressed in current law, leaving mandated reporters to simply report the emotional or physical injury caused by parental substance abuse. Other states, however, have extensive and detailed legislation on this topic. For example, many states specify that child maltreatment includes knowingly exposing a child to drug paraphernalia, bringing a child to a location where drugs are manufactured, allowing a child to witness a drug sale, placing a child in a vehicle where drugs are being stored, and exposing a child to the materials necessary to manufacture drugs, even if no illicit substances are actually used or manufactured at the time the child is present.

Additionally, increased awareness about abuse to elderly, intellectually disabled, and physically disabled persons has resulted in mandatory reporting laws for these populations in several states. If it has been years since you read your state laws, I encourage you to review them the next time a client no-shows and you find yourself with an unexpected hour. You may be surprised at what has changed!

When in doubt, consult your supervisor and err on the side of caution. It’s always better to report an incident and weather the damage to your therapeutic alliance than to not report one and go home with an uneasy conscience.

In my client’s case, I was surprised at how little changed between her mother and me following my call to the Department of Children and Families. Mom was fully aware that I would be required to report her physical altercation with her daughter, so it made very little difference that her limited attempts to locate her child would also have to be reported. In fact, my call improved my client’s outcomes because being involved with DCF allowed the family to access in-home therapy resources that had been previously unavailable. Although I was terrified of alienating a family in need, reporting this mother’s struggle to discipline her teen turned out to be my most helpful intervention. 

Deliberate Practice in Psychotherapy

Posted on by Psychotherapy.net Team

Editor’s note: The following is an excerpt taken from Mastering the Inner Skills of Psychotherapy, by Tony Rousmaniere, published by Gold Lantern Books © 2018 and reprinted with permission of the author.

“Could there be a better way for therapists to acquire the inner skills of psychotherapy?” To explore this question, let’s look to other fields. Most professions have developed specific exercises that help trainees acquire the capacity necessary for professional performance. For example, musicians rehearse challenging pieces repeatedly, so they will sound effortless during the actual performance. Pilot trainees spend hours intentionally stalling their plane, so they can practice recoveries. Athletes engage in physical conditioning, so they will have improved performance in competitions. In deliberate practice, therapists use practical exercises to build their inner skills and psychological capacity to improve their psychotherapy performance.

Deliberate Practice

I lead deliberate practice workshops around the world on developing therapists’ psychological capacity. Participants who are new to the idea of psychological capacity often ask, “How can this help me be more effective with my clients?” To answer this question, let’s begin with a case example of how deliberate practice helped me with a challenging case a few years ago.

My client was a man in his early twenties. He had recently been fired from his job and was discouraged about applying for work. He struggled with depression and had started to have thoughts of suicide. His goal for our work was to improve his mood and morale so he could find new employment.

My client and I formed a good working relationship in our first few sessions. However, despite my best efforts, he did not improve. Over the following weeks his mood gradually worsened, and he became more socially isolated. The outcome monitoring software I was using indicated that he was at a high risk of deterioration and possible suicide. With the client’s consent, I recorded a video of one of our sessions and showed it to my supervisor.

When we reviewed the video together, my supervisor noticed that the client looked disassociated during our session. He said, “Notice that after you ask your client a question, his eyes glaze over and he is slow to respond? Notice how he is nodding his head but not really engaging your questions? This could be a sign that your client is experiencing so much anxiety that he is disassociating. He may be politely going along with you but not fully understanding what you are asking him or benefiting from the therapy.”

As I watched the video closely, I could see what my supervisor was pointing out. My client’s eyes were unfocused, and his speech was slow. Although he was able to follow our conversation, his comments seemed superficial or compliant, like he was going along with me rather than really expressing himself.
I was surprised that I had not seen these obvious signs of disassociation in session with my client. I had learned about disassociation years prior and had successfully helped many clients with these symptoms. “Why was I unable to help this client?”

I said, “It’s so strange that I didn’t see these symptoms in session with my client. They seem so obvious when you point them out right now.”

My supervisor replied, “I wonder if you may be having an unconscious internal reaction that is blocking your conscious awareness?”

I said, “How can I tell if I am having such a reaction?”

He replied, “They often are accompanied by thoughts, emotions, physical sensations or behavioral urges. You can look for these as signals.”

“How?” I asked.

“I’ll show you,” he replied.

Seeing in Real Time

My supervisor said, “Play the video again. Turn the volume down low so you can hear the sound of your client’s voice but not get caught up in the content of the conversation in the video.”

I did as my supervisor instructed. It felt strange to watch the video without following the content of the conversation.

He continued, “Now, try to notice any thoughts, emotions, physical sensations, or behavioral urges you may feel while watching the video.”

I tried this for a few seconds and noted that paying attention to my internal experience while simultaneously watching the video was hard. I said, “My attention keeps trying to follow what the client is saying.”

“That’s normal,” he replied, “just keep trying.”

I watched the video while trying to tune in to my internal experience. After a few moments, I noticed I was clenching my fists. I told my supervisor.

“Great,” he said, “what else do you notice?”

“My chest feels tense,” I replied.

“What else?” he asked.

“I’m holding my breath.”

“What else?”

“As I tuned in to my internal world, I realized that I was having many uncomfortable reactions I had previously not noticed”. “My legs are tense, my mouth is dry, and my palms are sweaty. There’s also a slight ringing in my ears.”

He said, “Great that you can see all of these reactions within you. Let the video keep playing so you can continue. Do you notice any thoughts? You don’t have to tell me the details, but it’s important for you to see them.”

I noticed I was having strong doubts about myself as a therapist. How could I be effective if I was having all these unconscious reactions? Was something wrong with me? Should I give up and leave the profession? I felt some shame and didn’t want to reveal the details of all these thoughts to my supervisor. Instead, I simply said, “I’m having negative thoughts about myself.”

My supervisor could probably tell that I was experiencing some shame. He looked at me with kind eyes and normalized my experience, saying, “Great that you can notice those thoughts. Self-doubt, shame, or other negative thoughts about yourself are a normal and very common response to reaching your own psychological capacity limits. Consider these thoughts to be like how an athlete will sweat or get out of breath during a tough workout. It’s just part of the process.”

He continued, “Do you notice any behavioral urges? Again, you don’t have to tell me the details. Just try to notice them within yourself.”

I noticed I felt the urge to stop following his instructions. I was glancing at the clock out of the corner of my eye and hoping our consultation would end soon. I was also surprised to notice that I was starting to feel frustrated with my supervisor. This felt awkward, as I liked him a lot personally and trusted his advice. I didn’t feel comfortable telling him all of this, so instead I just nodded my head.

My supervisor paused the video. “Congratulations,” he said, “you were able to observe your own experiential avoidance in real time as you had it. This is not easy! However, it is a very important skill for effective psychotherapy.”

I took some deep breaths. I felt shaken from this experience and a bit confused. “How can this help me with my client?” I asked.

He replied, “Your ability to be empathic and attuned with this client is being limited by the discomfort and experiential avoidance that he stirs up in you. To address this, we need to increase your ability to see your own experiential avoidance in real time. This will let you downregulate your emotional state, so you can be more empathic, attuned and helpful.”

He continued, “You know how to assess and treat disassociation. You could write a paper about it. You can perform it proficiently with many of your other clients. You could teach it to beginning trainees. However, we have discovered that your proficiency in this skill is conditional on your psychological state. When you have particularly strong experiential avoidance—such as with this client—you lose your ability to be helpful. We call this your psychological capacity threshold.”

“How can I increase my threshold?” I asked.

He replied, “By practicing therapy skills with stimuli that provoke your experiential avoidance. This is called state dependent learning. For example, this video will work well for practice. I’ll show you how.”

Engaging the Client

My supervisor said, “You are going to practice engaging the client with anxiety regulation techniques while simultaneously noticing your experiential avoidance. Do you remember the somatic anxiety regulation techniques we reviewed last week?”

I replied, “The technique where I ask the client where he notices his anxiety in his body?”

“Yes, we’ll use that,” he said, “Start the video again at low volume. Now, while watching the video, take a moment to notice your internal reactions. Raise your hand when you notice any experiential avoidance.”

After a few moments watching the video, I noticed my chest tightening and breath restricting. I raised my hand.

“Good,” he said, “now use the first technique we discussed last week.”

“Just say it to the video?” I asked.

“Yes,” he replied, “just say it to your client in the video.”

Looking at the video, I said, “Right now, where physically do you notice any anxiety in your body?” I felt strange talking to the video.

“Good,” said my supervisor, “now watch the video for about twenty more seconds while noticing your inner reactions.”

My supervisor used his watch to count down twenty seconds and then said, “Now use the anxiety regulation technique again.”

“The same one?” I asked.

“Yes,” he said, “you can play with the words if you like.”

Looking at the video, I said, “Right now, where do you notice any anxiety, physically in your body?”

“Good,” said my supervisor, “do this process again: twenty seconds of self-observation, followed by engaging the client.”

I watched the video for twenty seconds while noticing my inner reactions and then said, “Do you notice any anxiety physically in your body right now?”

“Good,” my supervisor said, “again.”

I repeated the process.
“Again,” he said.

As I repeated the process, I noticed I had conflicting feelings toward my supervisor: I was simultaneously frustrated at him and appreciative of his help.
“Again,” he said.

I repeated the process and noticed I was starting to feel fatigued.

“Okay, pause,” he said. “What did you notice while repeating the exercise?”

“It got easier,” I replied.

“Great!” he said. “”You are building your psychological capacity to engage the client” while you have experiential avoidance.”
I asked, “Why does this client provoke such a strong reaction in me?”

He replied, “We don’t know yet. I’ll give you some deliberate practice exercises to do as homework, and maybe you’ll find out.”

Doing the Homework

My supervisor said, “Between now and our next supervision session, try to do an hour of the same deliberate practice exercise we just did together. Doing these exercises on your own may be more challenging than it was here with me, so try to be patient and self-compassionate. Remember that the goal is just to notice your reactions and practice engaging the video. Do not try to change or ‘fix’ any of your reactions.”

Over the following week I did the deliberate practice homework in three sessions of twenty minutes each. Doing it myself was much harder than it had been with my supervisor. I had to fight strong urges to avoid it. I scheduled practice in the morning but put it off until the afternoon. When I sat down to practice in the afternoon, I felt tired and decided to do it the following morning. The next morning, I was tempted to put it off yet again. However, I summoned the willpower and did the exercise.

When I started the video, I noticed a general tension throughout my body and fogginess in my mind. I kept losing track of time, so I set my phone to count down in twenty second intervals. I found it hard to say the anxiety regulation words out loud to the video. I felt awkward and had strong thoughts of shame and self-doubt. When I stopped after about twenty minutes, I felt discouraged by how much harder it had felt doing the exercise on my own rather than with my supervisor.

Two days later I did the exercise for a second time. Like my first practice session, this took considerable willpower. However, this time I had less fogginess and noticed more distinct internal experiences, including dry mouth, sweaty palms, and ringing in my ears. I felt clearer when saying the anxiety regulation words out loud. My shame and self-doubt were less pronounced. I ended the practice after about twenty minutes feeling more optimistic.

Three days later I did the exercise again. This time felt very different. As I watched the video, I noticed strong waves of tension rising from my stomach through my chest to my throat. I almost choked as I said the anxiety regulation words. The waves increased in intensity as I repeated the exercise. With surprise, I noticed tears forming in my eyes. “I felt a sharp spike in my shame and self-doubt and a strong urge to end the exercise”. However, I gathered my willpower and persisted. As I watched the video, I realized my client reminded me of times as a teenage boy when I had felt anxious and disassociated. I remembered the pain of those days, along with the social isolation and confusion. As I spoke the words of anxiety regulation to the video, I pictured saying them to myself as a teenager. I started crying out of sadness for my younger self as my shame melted into self-compassion. Resisting the temptation to stop the video, I continued with the exercise. I cried throughout the last ten minutes of the practice session.

Deliberate Practice Helped

This experience helped in multiple ways. First, my effectiveness as a therapist improved dramatically. I felt less tense and foggy sitting with the depressed young client whom I had videotaped. I was better able to help him see his own disassociation and use anxiety regulation techniques to reduce his anxiety. Over time, his mood improved, and he became more socially engaged. My effectiveness with other clients improved similarly.

Second, my morale and confidence as a therapist improved. I experienced less shame and self-doubt in my work. I felt optimistic about resolving other clinical impasses I was encountering and enthusiastic to practice more.

Third, the effects of the practice carried over to my personal life. I grew more open and engaged with my friends and family. I felt like I had further healed an old wound.

“The impact of deliberate practice on my personal life has been surprising”. I had previously done years of my own therapy, in which I had talked extensively about my teenage years. I assumed I had finished processing these old wounds. However, empathizing with this client stirred up painful memories that I had not recalled in my own therapy. Deliberate practice with my session videos helped me process those memories. After having many similar experiences myself and hearing of many from my trainees, I have come to see that deliberate practice with session videos can be a valuable tool for therapists’ personal growth. Deliberate practice helped me build my psychological capacity to be more effective with this client—and with my other clients.

Anti-Aging Psychotherapy: Dr. Ellen Langer Versus Your Green Smoothie

Posted on by Psychotherapy.net Team

The anti-aging movement is taking off at warp speed. Many people are willing to do whatever it takes to live longer, better, or both. Take me. I often start my day off with a green drink. No, I'm not talking about mixing a few avocado slices with a cucumber in a blender. No way. I'm a serious player! I'm talking about ingesting a serious organic product with nearly 100 superfoods. Yep, I said 100. I want something that packs a punch. But wait, I'm just getting warmed up. I'll often chase it with a liquid supplement sporting well over 230 other superfoods (I'm up to over 300 for those of you with a touch of OCD). I might also swallow a teaspoon of bee pollen, a whole food multivitamin, and a supplement packed with nearly 50 fruits and veggies, just for nutritional insurance.

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Since this won't fill me up, and my behavior is anything but consistent from day to day, I will often wolf down something healthy like an apple, or more likely, a food source theoretically not so healthy, such as a can of commercial soup loaded with enough sodium to keep the average NFL team bloated until Super Bowl Sunday. You might ask, "Well do you really feel like a million bucks on this regimen?" (I was hoping you wouldn't ask.) Um, truthfully, no, not really.

Some research on superfoods and antioxidants has not demonstrated longevity benefits in animals and on occasion has shortened their lives! Moreover, experts don't agree on what constitutes a superfood and what doesn’t. Take coffee and caffeine. One day the news reports they are poison, while the very next day you will hear that nothing matches their nutritional benefits. It's enough to make a therapist see a therapist!

Ditto for diets. One expert advocates a plant-based diet while another castigates you for consuming an apple loaded with sugar and recommends near zero carb lifestyle. The only remedy we know of that is almost guaranteed to extend our lives is caloric restriction, aka nearly starving yourself—and who wants to do that for the next 50 plus years? And just for the record, even some of the zealots in this arena are now backing off and claiming calorie restriction is not turning out to be the panacea we thought it was.

Okay great. So now what?

Well, what if we are all barking up the wrong tree? Enter Harvard psychologist of mindfulness fame, Ellen Langer. What if anti-aging is mainly psychological? In her landmark book Counter Clockwise: Mindful Health and the Power of Possibility, Dr. Langer shares a study she performed in 1981 that was a total game changer.

She and her colleagues took men in their seventies and eighties to a monastery in New Hampshire. The monastery was set up as if it was 1959 or 22 years earlier. The books, radio programs, television shows, and newspapers were from the 1950s. One group of men was instructed to embrace the present moment but reminisce about the era. The other group was told to pretend they actually were 22 years younger and to act as if it was actually 1959 once again. Hence, if a man was currently retired, but owned an auto repair shop in 1959, he was instructed to act and talk as if he owns the auto repair facility in the present; which again is 1959.

The results were spectacular. Although both groups of men made some anti-aging progress, the group who imagined they were younger, and acted as if it was the 50s again, made tremendous progress and literally seemed to age backward. Biomarkers of aging including strength, flexibility, vision, hearing, and cognitive abilities improved in just five days! They even looked younger. Langer reports that a group of the men gave up their canes and she was playing touch football with them by the end of their stay. Show me a green drink that can instill that kind of change and I'll say, "I'll have whatever he is drinking."

Yes, there were minor criticisms of the study such as the fact that the results were illuminated in her book rather than published in a professional journal and no women were part of the study. Nevertheless, the quintessential question seems to be whether psychotherapists are the real anti-aging specialists. Could we become the premier movers and shakers in the quest for longevity? Should we be attempting to instill an anti-aging mindset in willing clients? Perhaps therapists ought to be at the forefront of the movement using cognitive therapy, hypnosis, guided imagery, mindfulness, and a host of related techniques to roll back the clock. Even Dr. Langer is purportedly contemplating counterclockwise rejuvenation clinics.

Should we trade in our green drinks and cupboards overflowing with vitamins, minerals, enzymes, telomere boosters, workout schedules and the next breakthrough for sessions of creative visualization from the Bill Clinton era? We can lead the charge by decorating our offices with a 1996 ambiance. When the client strolls in Adam Sandler will be on the television showcasing a key scene from the 80s classic movie “Happy Gilmore”.

Everything will go great until your 11-year-old client asks, "Why is that man on television running toward the golf ball?" You can glance at his mother and respond with, "Here, have a piece of candy, dark chocolate is a superfood."

Yeah right. At least for this week! 

The Internal Critic: Friend or Foe?

Posted on by Psychotherapy.net Team

Harsh, hurtful, degrading and depleting are just a few ways to describe the all-too-powerful words of our internal critic. We all have a critic, but the ferocity and loudness varies. As an EMDR and EFT-oriented psychotherapist, I am privileged to have a front and center view of just how universal and common the internal critic can be and the opportunity to confront that voice with my clients.

“You’re so stupid, incompetent and useless.”
“Why would you do that? You can’t do anything right.”
“That was a huge failure, you should have walked away.”
“You’re so ugly and fat.”
“You’re just not good enough.”

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Not surprisingly, my most compassionate and caring clients will say these things, never to others, but often to themselves. To put it simply, the critic is one component of our personality. The critic is also alternately referred to as an ego state, or a state of awareness. It is one member of our internal system presumably developed to help us make decisions, keep us safe and progress in life. The cohesion and integration of our system of parts varies depending upon our life experiences and relationships. Our attachment to our caregivers, experiences in school, successes, failures, mistreatment, trauma and adverse life experiences all impact the growth and development of this internal system.

Fortunately, the critic isn’t the only player on the internal mental team. Other characters may include the professional, nurturer, survivor, child, friend and parent, to name a few. The list is potentially exhaustive and unique to the individual. When working with my clients, I often reference my own rebellious teenager part that most mornings tries to induce me to skip work and sleep in. It takes a lot of energy from this professional part to push (or pull) me out of bed, but this daily internal struggle pales in comparison to the battles we have with our critic.

Through therapy, my clients begin the daunting challenge of identifying these core negative messages from the critic and discover what makes them tick. Often, I find that the critic develops at a young age, and often results from an internalization of negative messages from parents, coaches or other authority figures. I often find that the critic has good intentions and often has the same goals as the adult which is happiness, success, and safety from potential threats. Unfortunately, the critic’s approach to helping to meet these goals is ultimately misguided and damaging. After the all-too-frequent and ongoing critical barrage, my clients weaken, feel less confident, safe, secure or motivated to do the things that could otherwise propel them forward in life. The critic’s initial good intentions are inevitably thwarted, leaving clients feeling stuck, insecure, unmotivated and depleted.

So what is the therapist to do in order to befriend and redirect this formidable foe? My own therapeutic efforts begin with the practice of mindfulness—I ask clients simply become aware, to notice the voice. It helps to ask them to move to a different chair and speak the critic’s words out loud. In EFT we call this “chair work” and through this practice the client can begin to separate the critic from that part of their inner system that is not critical. By doing so, clients can better connect with the critic and begin to identify the triggers and needs of the critic that give this voice its power.

My clients notice that the critic often raises its voice prior to a challenging task, after they have made a mistake or when they fail to achieve a goal in their life (referring to when they notice it outside of the therapy office). When my client and I can hone in on those times when the critic is using a megaphone, so to speak, we are able to identify and tap into more supportive parts of their inner chorus. This often has the effect of subduing the critic—removing its bully pulpit. Doing so makes room for these other characters—the nurturer, the advocate, the cheerleader and all of those other softer and kinder empathetic elements of self that are crucial and necessary for healthy emotional survival. Calming, motivational and compassionate messages and affirmations are helpful tools which over time and hard work in therapy have helped my clients to manage, quiet and even befriend their inner critic.

By assisting my clients to increase their capacity for self-compassion, kindness and self-empathy, I have been able to help them move closer to the therapeutic goal of self-acceptance. I often ask them to consider that if self-kindness seems like a foreign concept, they think of something their nicest friend or family member might say to them, in other words, “What would ___________ tell you in this moment?” My clients will often laugh and say that they can picture their sweet grandmother comforting them during these times. In EMDR therapy, we would identify this as a new resource and the image of the grandmother’s comforting presence would come along for the therapeutic journey towards healing. Regardless of the therapeutic modalities utilized, identifying, connecting and working with the critic is crucial in helping our clients find inner peace and acceptance.
 

Uncovering and Intervening in the Narcissistic Abuse Cycle

Posted on by Psychotherapy.net Team

“You’re an #@^ liar! I can’t believe I married such an insecure person! I deserve better,” my client, Jared, stood up screaming at his spouse Margret after she confronted him. Then, Jared stormed out of session only to return a few minutes prior to the end of our time. “Well, have you learned?” he sarcastically asked Margret. “Did she tell you how wrong you were and how you hurt my feelings?” Much to my surprise, Margret apologized to Jared. Then he sat down and gave me a look like the cat who ate the canary. They left much as they came in. Nothing that was discussed with Margret in Jared’s absence seemed to have sunk in. He still was dominating, manipulative and controlling. She was passive, voiceless and exhausted. Our hour seemed wasted. What did I witness? It felt all too familiar since narcissism was the crazy glue that held my own family tree together. That moment was a turning point for me both personally and professionally. It changed how I dealt with my family and, more importantly, opened up a career opportunity. I now specialize in personality disorders with a heavy concentration on narcissistic, borderline and antisocial individuals and their partners. Jared and Margaret are my typical clients. So, what did I observe? The typical cycle of abuse is comprised of tension building, acting-out, reconciliation/honeymoon, followed by a period of calm before the cycle begins again. However, when the abuser is also a narcissist, this downward spiral looks different. True to their personality style, the narcissist is compelled to up the ante. Narcissism changes the back end of the cycle because the narcissist, perpetually self-centered, is unwilling or perhaps incapable of admitting fault. Their need to be superior, correct and/or in charge limits the possibility of any genuine reconciliation. Instead, it is frequently the abused partner who desperately utilizes apology and appeasement while the narcissist switches into the role of victim. This switchback tactic emboldens the narcissist’s behavior even more, further convincing them of their faultlessness. Any threat to their authority repeats the cycle. This describes what I have now witnessed hundreds of times. By teaching my non-narcissistic clients this cycle, they are better able to stop it and have greater control of the downward spiral. Here are the stages in the narcissist’s cycle of abuse I have witnessed in my practice: Feels Threatened. An upsetting event occurs in which the narcissist feels threatened. It could be the rejection of sex, disapproval at work, embarrassment in a social setting, jealousy of another’s success or feelings of abandonment, neglect, or disrespect. The abused partner, aware of the potential threat, becomes nervous. They know something is about to happen and begin to walk on eggshells around the narcissist. Most narcissists repeatedly get upset over the same underlying issue whether it is real or imagined. They also tend to obsess over any perceived threat. Abuses Others. The narcissist engages in some sort of abusive behavior which can be physical, mental, verbal, sexual, financial, spiritual or emotional. The abuse is customized to intimidate the abused partner in an area of weakness, especially if that area is one of strength for the narcissist. The abuse can last for a few minutes or as long as several hours. Becomes the Victim. This is when the switchback occurs. The narcissist uses the abused partner’s reactive behavior as further evidence that they themselves are the ones being abused. The narcissist believes their referential victimization by bringing up past defensive behaviors perpetrated by the abused partner—as if it were the cause of the conflict. Because the abused partner has feelings of remorse and guilt, they accept this warped perception and try to rescue the narcissist. This might include giving in to what the narcissist wants, accepting unnecessary responsibility, placating the narcissist to keep the peace and/or acting as if the narcissist’s lies are the truth. Feels Empowered. Once the abused partner has given in or up, the narcissist once again feels empowered. This is all the justification the narcissist needs to prove that they were right in the first place. The abused has unknowingly stoked the narcissist’s already fiery ego. But every narcissist has an Achilles heel and the power they have temporarily re-claimed only lasts until the next threat. Once the narcissistic cycle of abuse is understood by the abused partner, the therapist can intervene at any point. This may include developing strategies for future confrontations, understanding how much abuse the recipient is willing and able to tolerate in the relationship, or developing an escape plan. The next time Jared exploded, Margaret immediately defused the situation through the use of diversion which stopped the cycle—at least for that moment. Recognizing and effectively intervening around the narcissistic elements of the cycle of abuse changed my practice. I transitioned from mismanaging conflict to de-escalating the tension while maintaining complete control. Couples embroiled in the cycle of narcissism benefitted in that some could remain together while others could not. Empowerment is as important for therapists as it is for the clients, particularly the ones caught up in this cycle.

How to Build an Ethical Social Media Presence

Posted on by Psychotherapy.net Team

I began my social media adventure about a year ago. I decided that I had much to share on a variety of topics, but not a wide enough medium to do so. My apprehensions were very similar to those most therapists have. How will I handle it if a person contacts me about personal issues? How can I maintain a therapeutic framework on social media? How do I balance my authenticity with the ethical demands of psychotherapy? How do I incorporate ethics, while still promoting my services and expertise?

The good news is that while these are important questions to ask and answer, we can do so along the way, while we’re learning. We can’t learn how to be an ethical psychotherapist on social media if we put off starting. Be it a Facebook page, Instagram account, Twitter, LinkedIn, YouTube-or whatever social media outlet you choose – it just may be time to start!

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Any currently practicing psychotherapist is doing so in the digital era, and this involves exploring the different opportunities that the digital realm has to offer. Among other possibilities, it may involve diving into online marketing or offering digital content in the form of webinars and e-courses. It may also means engaging with potential clients by providing them with resources for maintaining and improving their mental health. In this sense, it is about making your knowledge accessible to a wide audience in an ethical fashion that benefits your practice, your brand, and your followers.

So, how exactly do we do all this while at the same time generating ethical mental health content for our audience? The first thing to consider is establishing your boundaries by asking yourself the following questions:

  • What are you comfortable doing? Maybe you’re an exceptional writer and can create helpful blog posts on LinkedIn or on your own web page. Or, if you are a talented speaker, you can make YouTube videos or short Instagram stories to talk about a specific mental health or therapeutic topic. Tap into whatever it is that you excel in and find a social media outlet that’s a good fit for your talents and strengths.
  • What are you not comfortable doing? This looks different for everyone. For some, it might consist of posting photos of themselves or their family on social media-or showing pictures of their private practice office. For others, it might be addressing a mental health issue, because you don’t know who is receiving this information and how they are using it. Take a look at some of the big social media profiles out there, follow and analyze what they’re doing. How do you feel about their strategies?
  • How much of yourself are you willing to show to others? Whenever I write or talk about authenticity or vulnerability, I rely upon Brené Brown’s wisdom. In her latest book, Dare to Lead, she teaches us that being authentic and/or vulnerable is not synonymous with disclosing private personal information. Rather, it is about presenting yourself as vulnerable and tapping into people’s emotional needs from a place of empathy. That “authenticity sweet spot” looks and feels different for each therapist, and the only way to learn about and advertise your own is by opening yourself up to experimenting and making mistakes. And this may mean challenging yourself to step out of your comfort zone.

The second step is to communicate these expectations to your audience. I’ve received many direct messages on social media requesting a “mini-session”, but my disclaimer is very clear; “I do not provide therapy via Instagram. Here is my contact if you’d like to schedule an appointment.”

Another excellent resource I learned thanks to Dr. Keely Holmes is to offer a social media policy on your website. This policy might include the following:

  • The reasoning as to why you don’t accept friend requests from clients.
  • Clarification that if a client follows you on social media, you might want to briefly discuss what this entails in your next session.
  • A request to not use social media or open messaging apps to communicate, and specify which channels are allowed (e-mail, phone, etc.).
  • Clarification as to why you can’t use patient testimonials on social media or on your website.
In this digital era, where boundaries are often so easily blurred, it’s important to maintain an authentic and transparent presence with our clients. This type of document not only protects you, it also protects them.

Hopefully, these suggestions will help you to reframe your ideas about ethics in the social media era and answer a few of the questions I raised earlier on. Having a social media presence doesn’t have to be daunting. Forewarned is forearmed. It’s about being open to learning and showcasing your knowledge, skills and talent to a wide audience. Are YOU ready to take the leap?  

Helping Caregivers Find the Kid Inside

Posted on by Psychotherapy.net Team

After my father died, I became increasingly aware that my mother was suffering from dementia. She had never known how to turn on the air conditioner or the television, those were my father’s jobs. This was different. Each time I visited her, I found another piece of evidence. The kitchen table was full of crumbs and sticky from various meals; the refrigerator was full of spoiled food; her clothing had stains on it. I had no idea if she was taking her medication or not and she was not a reliable narrator. I did not want to take responsibility for my mother, but both my brother and sister were dealing with family and health issues. They did not want to know that my mother had dementia. Finally, I hired a geriatric social worker to come to the house and observe my mother for an afternoon. He verified that she had dementia and should not be left alone. I knew I had to take action. I was 55 years old, but all the feelings I had avoided during the years I was raising my children flared up again. I knew I was going to have to struggle with my feelings about my brother getting special dispensations because he is a boy; my wish to have my mother appreciate me; and anger at my mother for being so needy.

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Middle-aged caregiving is a stage of life that can be a painful re-enactment of old unresolved feelings about parents, or an opportunity to resolve them. In this stage of the life cycle, the major conflict is between acceptance and resolution of disappointments vs. repetition and holding on to old wishes. Ambivalence is central to the experience—and yet so many of us have difficulty tolerating our ambivalence. We love our parent(s) but feel angry at what we did not get from them; we want to help, but feel resentful about what we have to give up in order to do so.

Psychotherapists can help patients cope with this conflict by helping them tolerate their ambivalence, and resolve rather than repeat old patterns with parents. Patients may seek help because taking care of an elderly parent is making them depressed or angry. Of course being a caregiver may be a heavy burden under any circumstances. But many caregivers are suffering more than they have to because they are repeating dysfunctional patterns from childhood. The therapist needs to help the patient identify the dynamic that is being repeated. But, while there is a large literature about caregiver selection, there is little attention to the unconscious motives for caring for elderly parents.

These are four common patterns that make caregiving more difficult and painful.

  1. The co-dependent caregiver needs to be needed and is used to organizing her life around the chaotic moods and needs of a parent. While all caregivers have to make some sacrifices to care for their elderly parents, co-dependent caregivers sacrifice their happiness for others when it doesn’t require it. Typically, co-dependent caregivers are the children of alcoholics, drug addicts, depressed or mentally ill parents.
  2. Daddy’s girl wants to take care of her father and feels that she will do a better job than her mother. She has always felt that her relationship with her father is more special than the relationship between her parents. Caring for her father involves competing with her mother; she needs to show her mother’s inadequacy. Similarly, Mommy’s boy wants to take care of his mother in a way that his father did not. The triangular relationship, a remnant of early childhood, gets repeated in the caregiving experience.
  3. The angry/guilty child never felt loved or appreciated by her parent(s). Her caregiving is based on guilt and the guilt is a response to feeling angry. This is a repetitive cycle: the more she does to offset her guilt, the angrier she gets for giving so much to someone who never took care of her as a child.
  4. The child who was sent away or abandoned often experiences the parent’s inability or unwillingness to parent as a reaction to his/her being a bad child. For example, when parents divorce and one moves away, the child often feels that the parent left because she was bad. For some, middle-aged caregiving is an opportunity to be good and get the parent who left or sent her away to love them.

Paula is an example of a co-dependent caregiver. She complains that the time and energy she is spending caring for her mother makes her angry and depressed, but she feels she has no choice but to continue. Paula’s mother had re-occurrent breast cancer six years ago. She lives in independent housing, but her dementia is increasing. When her mother goes to the doctor, she cannot remember why she’s there. She’s safe right now, but only because Paula keeps her medication and gives it to her every day. Each time her mother is hospitalized Paula says she is going to put her in a nursing home, but she never does.

Paula says she always felt like she had to be the mother. She did the shopping and cooking because her mother was working or with a boyfriend and Paula was the oldest girl. When her parents’ marriage fell apart, Paula felt that she had to be even more grown-up.

So why is Paula taking care of her mother when her mother did not take very good care of her? Paula needs to be needed, but she’s confused about who needs her most. She is neglecting herself, her husband and her daughter in order to keep her mother out of a nursing home. Paula also cannot accept that her mother can be taken care of in a nursing home. Paula wants to feel indispensable—she wants help, but she resists changing.

Breaking this self-destructive loop requires time and patience. In my experience, the patient’s insistence that there are no alternatives can be intense because of the underlying unconscious dynamic. The patient may express rage at the therapist suggesting there are alternatives to staying in the same painful pattern, and the therapist may get frustrated at a patient who begs for help but refuses to change. Take heart and take your time.